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Rolleman NH, Visser IM, Klein WM, Van Putten MJAM, De Blaauw I, Botden SMBI. Feasibility and repeatability of ultrasound-guided surface electroenterography to measure colonic slow wave motility in healthy adults. BMC Gastroenterol 2024; 24:114. [PMID: 38500056 PMCID: PMC10949649 DOI: 10.1186/s12876-024-03196-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
Abstract
Surface electroenterography is a potential non-invasive alternative to current diagnostics of colonic motility disorders. However, electrode positioning in electroenterography is often based on general anatomy and may lack generalizability. Furthermore, the repeatability of electroenterography measurements is unknown. This study aimed to evaluate ultrasound-guided electrode positioning for electroenterography measurements and to determine the repeatability of those measurements. In ten healthy adults, two electroenterography procedures were performed, consisting of fasting, ultrasound-guided electrode localization and two 20-minute electroenterography recordings separated by a meal. The dominant frequency, the mean power density (magnitude of colonic motility) and the power percent difference (relative pre- to postprandial increase in magnitude) were determined. Repeatability was determined by Lin's concordance correlation coefficient. The results demonstrated that the dominant frequency did not differ between pre- and postprandial recordings and was 3 cpm, characteristic of colonic motility. The mean power density increased between the pre- and postprandial measurements, with an average difference of over 200%. The repeatability of both the dominant frequency and power density was poor to moderate, whereas the correlation coefficient of the power percent difference was poor. Concluding, ultrasound-guided surface electroenterography seems able to measure the gastrocolic reflex, but the dissatisfactory repeatability necessitates optimization of the measurement protocol.
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Affiliation(s)
- Nick H Rolleman
- Department of Pediatric Surgery, Radboud University Medical Centre- Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, Postal box 9101, The Netherlands
- Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Iris M Visser
- Department of Pediatric Surgery, Radboud University Medical Centre- Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, Postal box 9101, The Netherlands
- Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Willemijn M Klein
- Department of Pediatric Surgery, Radboud University Medical Centre- Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, Postal box 9101, The Netherlands
- Department of Medical Imaging, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Ivo De Blaauw
- Department of Pediatric Surgery, Radboud University Medical Centre- Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, Postal box 9101, The Netherlands
| | - Sanne M B I Botden
- Department of Pediatric Surgery, Radboud University Medical Centre- Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, Postal box 9101, The Netherlands.
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Hibberd TJ, Ramsay S, Spencer-Merris P, Dinning PG, Zagorodnyuk VP, Spencer NJ. Circadian rhythms in colonic function. Front Physiol 2023; 14:1239278. [PMID: 37711458 PMCID: PMC10498548 DOI: 10.3389/fphys.2023.1239278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023] Open
Abstract
A rhythmic expression of clock genes occurs within the cells of multiple organs and tissues throughout the body, termed "peripheral clocks." Peripheral clocks are subject to entrainment by a multitude of factors, many of which are directly or indirectly controlled by the light-entrainable clock located in the suprachiasmatic nucleus of the hypothalamus. Peripheral clocks occur in the gastrointestinal tract, notably the epithelia whose functions include regulation of absorption, permeability, and secretion of hormones; and in the myenteric plexus, which is the intrinsic neural network principally responsible for the coordination of muscular activity in the gut. This review focuses on the physiological circadian variation of major colonic functions and their entraining mechanisms, including colonic motility, absorption, hormone secretion, permeability, and pain signalling. Pathophysiological states such as irritable bowel syndrome and ulcerative colitis and their interactions with circadian rhythmicity are also described. Finally, the classic circadian hormone melatonin is discussed, which is expressed in the gut in greater quantities than the pineal gland, and whose exogenous use has been of therapeutic interest in treating colonic pathophysiological states, including those exacerbated by chronic circadian disruption.
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Affiliation(s)
- Timothy J. Hibberd
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Stewart Ramsay
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Phil G. Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Colorectal Surgical Unit, Division of Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | | | - Nick J. Spencer
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Wiklendt L, Mohd Rosli R, Kumar R, Paskaranandavadivel N, Bampton PA, Maslen L, Costa M, Brookes SJ, O'Grady G, Dinning PG. Inhibited postprandial retrograde cyclic motor pattern in the distal colon of patients with diarrhea-predominant irritable bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2023; 325:G62-G79. [PMID: 37162180 DOI: 10.1152/ajpgi.00114.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/08/2023] [Accepted: 05/08/2023] [Indexed: 05/11/2023]
Abstract
Patients with irritable bowel syndrome (IBS) have recurrent lower abdominal pain, associated with altered bowel habit (diarrhea and/or constipation). As bowel habit is altered, abnormalities in colonic motility are likely to contribute; however, characterization of colonic motor patterns in patients with IBS remains poor. Utilizing fiber-optic manometry, we aimed to characterize distal colonic postprandial colon motility in diarrhea-predominant IBS. After an overnight fast, a 72-sensor (spaced at 1-cm intervals) manometry catheter was colonoscopically placed to the proximal colon, in 13 patients with IBS-D and 12 healthy adults. Recordings were taken for 2 h pre and post a 700 kcal meal. Data were analyzed with our two developed automated techniques. In both healthy adults and patients with IBS-D, the dominant frequencies of pressure waves throughout the colon are between 2 and 4 cycles per minute (cpm) and the power of these frequencies increased significantly after a meal. Although these pressure waves formed propagating contractions in both groups, the postprandial propagating contraction increase was significantly smaller in patients compared with healthy adults. In healthy adults during the meal period, retrograde propagation between 2 and 8 cpm was significantly greater than antegrade propagation at the same frequencies. This difference was not observed in IBS-D. Patients with IBS-D show reduced prevalence of the retrograde cyclic motor pattern postprandially compared with the marked prevalence in healthy adults. We hypothesize that this reduction may allow premature rectal filling, leading to postprandial urgency and diarrhea.NEW & NOTEWORTHY Compared with healthy adults this study has shown a significant reduction in the prevalence of the postprandial retrograde cyclic motor pattern in the distal colon of patients with diarrhea-predominant irritable bowel syndrome. We hypothesize that this altered motility may allow for premature rectal filling which contributes to the postprandial urgency and diarrhea experienced by these patients.
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Affiliation(s)
- Lukasz Wiklendt
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Reizal Mohd Rosli
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Raghu Kumar
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | | | - Peter A Bampton
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Lyn Maslen
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Marcello Costa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Simon J Brookes
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Greg O'Grady
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
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Hyperactive Distal Colonic Motility and Recovery Patterns Following Right Colectomy: A High-Resolution Manometry Study. Dis Colon Rectum 2023; 66:579-590. [PMID: 35499821 DOI: 10.1097/dcr.0000000000002356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative ileus results in morbidity, prolonged hospitalization, and increased health care expenditure. However, the underlying abnormalities in motility remain poorly understood. Recent high-resolution manometry studies demonstrated that the distal colon becomes hyperactive with a cyclic motor pattern postoperatively, but they did not track this activity beyond 16 hours after surgery. OBJECTIVE This study used high-resolution manometry to evaluate distal colonic motility during the first 4 days after right-sided colectomy. DESIGN An observational study of perioperative high-resolution colonic manometry using a 36-sensor catheter with 1-cm resolution. SETTING A single tertiary hospital. PATIENTS Adult patients undergoing elective laparoscopic or open right-sided colonic resection. MAIN OUTCOME MEASURES Occurrence of distal colonic motor patterns during the perioperative period, defined according to a published classification system. Clinical markers of gut recovery included time to first stool, oral diet, and prolonged postoperative ileus. RESULTS Seven patients underwent perioperative manometry recordings. Hyperactive cyclic motor patterns emerged intraoperatively and peaked in the first 12 hours postoperatively, occupying 81.8% ± 3.9% of the recording. This gradually returned to normal during the first 4 days, reaching 19.0% ± 4.4% ( p = 0.002). No patient had a bowel movement before this hyperactivity resolved. High-amplitude propagating sequences were absent in early postoperative recordings, and their return temporally correlated with the passage of stool. Abnormal high-amplitude repetitive 0.5 to 1 cycle per minute activity was observed in the left colon of 1 patient with prolonged ileus. LIMITATIONS The invasive nature of recordings limited this study to a small sample size. CONCLUSIONS Cyclic motor patterns are markedly hyperactive in the distal colon after right-sided colectomy and resolve during the first 4 postoperative days. High-amplitude propagating sequences are inhibited by surgery and gradually recover. Bowel function may not return until these changes resolve. Other abnormal repetitive hyperactive patterns could contribute to the development of prolonged ileus. See Video Abstract at http://links.lww.com/DCR/B967 . MOTILIDAD HIPERACTIVA DEL COLON DISTAL Y PATRONES DE RECUPERACIN DESPUS DE COLECTOMA DERECHA UN ESTUDIO DE MANOMETRA DE ALTA RESOLUCIN ANTECEDENTES:El íleo post-operatorio produce una morbilidad significativa, una hospitalización prolongada y un aumento del gasto sanitario. Sin embargo, las anomalías subyacentes en la motilidad siguen siendo poco conocidas. Estudios recientes de manometría de alta resolución demostraron que el colon distal se vuelve hiperactivo con un patrón motor cíclico en el post-operatorio, pero no registraron esta actividad más allá de las 16 horas posteriores a la cirugía.OBJETIVO:Utilizar la manometría de alta resolución para evaluar la motilidad del colon distal durante los primeros cuatro días después de la colectomía del lado derecho.DISEÑO:Estudio observacional de pacientes sometidos a manometría colónica perioperatoria de alta resolución mediante catéter de 36 sensores con 1 cm de resolución.AJUSTE:Un solo hospital terciario.PACIENTES:Pacientes adultos sometidos a resección laparoscópica o abierta de colon del lado derecho de forma electiva.PRINCIPALES MEDIDAS DE RESULTADO:AAparición de patrones motores del colon distal durante el período perioperatorio, definidos según un sistema de clasificación publicado. Los marcadores clínicos de recuperación intestinal incluyeron, tiempo hasta la primera evacuación, dieta oral e íleo posoperatorio prolongado.RESULTADOS:Siete pacientes fueron sometidos a registros de manometría perioperatoria. Los patrones motores cíclicos hiperactivos emergieron intraoperatoriamente y alcanzaron su punto máximo en las primeras 12 horas post-operatorias, ocupando 81,8 ± 3,9% del registro. Esto volvió gradualmente a la normalidad durante los primeros cuatro días, alcanzando el 19,0 ± 4,4% (p = 0,002). Ningún paciente tuvo una evacuación intestinal antes de que se resolviera esta hiperactividad. Las secuencias de propagación de alta amplitud estaban ausentes en las grabaciones post-operatorias tempranas y su retorno se correlacionó temporalmente con el paso de las heces. Se observó actividad anormal de alta amplitud repetitiva de 0,5-1 ciclo / minuto en el colon izquierdo de un paciente con íleo prolongado.LIMITACIONES:La naturaleza invasiva de las grabaciones limitó este estudio a un tamaño de muestra pequeño.CONCLUSIONES:Los patrones motores cíclicos son marcadamente hiperactivos en el colon distal después de la colectomía del lado derecho y se resuelven gradualmente durante los primeros cuatro días posoperatorios. Las secuencias de propagación de gran amplitud se inhiben mediante cirugía y se recuperan gradualmente. Es posible que la función intestinal no regrese hasta que estos cambios se resuelvan. Otros patrones hiperactivos repetitivos anormales podrían contribuir al desarrollo de íleo prolongado. Consulte Video Resumen en http://links.lww.com/DCR/B967 . (Traducción-Dr. Mauricio Santamaria ).
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Management of Low Anterior Resection Syndrome (LARS) Following Resection for Rectal Cancer. Cancers (Basel) 2023; 15:cancers15030778. [PMID: 36765736 PMCID: PMC9913853 DOI: 10.3390/cancers15030778] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION A total of 60-80% of patients undergoing rectal resection (mostly as a treatment for rectal cancer) suffer from a variety of partly severe functional problems despite preservation of the anal sphincter. These patients are summarized under the term low anterior resection syndrome (LARS). Preoperative radiotherapy, vascular dissection and surgical excision of the low rectum and mesorectum lead, alone or all together, to a significant impairment of colonic and (neo-) rectal motility. This results in a variety of symptoms (multiple defecation episodes, recurrent episodes of urge, clustering, incontinence, etc.) which are associated with severe impairment of quality of life (QOL). METHODS This narrative review summarizes the present state of knowledge regarding the pathophysiology of LARS as well as the evidence for the available treatment options to control the symptoms resulting from this condition. RESULTS A review of the literature (Medline, Pubmed) reveals a variety of treatment options available to control symptoms of LARS. Medical therapy, with or without dietary modification, shows only a modest effect. Pelvic floor rehabilitation consisting of muscle exercise techniques as well as biofeedback training has been associated with improvement in LARS scores and incontinence, albeit with limited scientific evidence. Transanal irrigation (TAI) has gained interest as a treatment modality for patients with LARS due to an increasing number of promising data from recently published studies. Despite this promising observation, open questions about still-unclear issues of TAI remain under debate. Neuromodulation has been applied in LARS only in a few studies with small numbers of patients and partly conflicting results. CONCLUSION LARS is a frequent problem after sphincter-preserving rectal surgery and leads to a marked impairment of QOL. Due to the large number of patients suffering from this condition, mandatory identification, as well as treatment of affected patients, must be considered during surgical as well as oncological follow-up. The use of a standardized treatment algorithm will lead to sufficient control of symptoms and a high probability of a marked improvement in QOL.
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Smolilo DJ, Hibberd TJ, Costa M, Dinning PG, Keightley LJ, De Fontgalland D, Wattchow D, Spencer NJ. Stimulation of extrinsic sympathetic nerves differentially affects neurogenic motor activity in guinea pig distal colon. Physiol Rep 2023; 11:e15567. [PMID: 36636780 PMCID: PMC9837477 DOI: 10.14814/phy2.15567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/25/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023] Open
Abstract
The speed of pellet propulsion through the isolated guinea pig distal colon in vitro significantly exceeds in vivo measurements, suggesting a role for inhibitory mechanisms from sources outside the gut. The aim of this study was to investigate the effects of sympathetic nerve stimulation on three different neurogenic motor behaviors of the distal colon: transient neural events (TNEs), colonic motor complexes (CMCs), and pellet propulsion. To do this, segments of guinea pig distal colon with intact connections to the inferior mesenteric ganglion (IMG) were set up in organ baths allowing for simultaneous extracellular suction electrode recordings from smooth muscle, video recordings for diameter mapping, and intraluminal manometry. Electrical stimulation (1-20 Hz) of colonic nerves surrounding the inferior mesenteric artery caused a statistically significant, frequency-dependent inhibition of TNEs, as well as single pellet propulsion, from frequencies of 5 Hz and greater. Significant inhibition of CMCs required stimulation frequencies of 10 Hz and greater. Phentolamine (3.6 μM) abolished effects of colonic nerve stimulation, consistent with a sympathetic noradrenergic mechanism. Sympathetic inhibition was constrained to regions with intact extrinsic nerve pathways, allowing normal motor behaviors to continue without modulation in adjacent extrinsically denervated regions of the same colonic segments. The results demonstrate differential sensitivities to sympathetic input among distinct neurogenic motor behaviors of the colon. Together with findings indicating CMCs activate colo-colonic sympathetic reflexes through the IMG, these results raise the possibility that CMCs may paradoxically facilitate suppression of pellet movement in vivo, through peripheral sympathetic reflex circuits.
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Affiliation(s)
- David J. Smolilo
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Timothy J. Hibberd
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Marcello Costa
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Phil G. Dinning
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
- Department of SurgeryFlinders Medical CentreBedford ParkSouth AustraliaAustralia
- Department of GastroenterologyFlinders Medical CentreBedford ParkSouth AustraliaAustralia
| | - Lauren J. Keightley
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Dayan De Fontgalland
- Department of SurgeryFlinders Medical CentreBedford ParkSouth AustraliaAustralia
- Department of GastroenterologyFlinders Medical CentreBedford ParkSouth AustraliaAustralia
| | - David A. Wattchow
- Department of SurgeryFlinders Medical CentreBedford ParkSouth AustraliaAustralia
- Department of GastroenterologyFlinders Medical CentreBedford ParkSouth AustraliaAustralia
| | - Nick J. Spencer
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
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7
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Lin AY, Varghese C, Paskaranandavadivel N, Seo S, Du P, Dinning P, Bissett IP, O'Grady G. Faecal incontinence is associated with an impaired rectosigmoid brake and improved by sacral neuromodulation. Colorectal Dis 2022; 24:1556-1566. [PMID: 35793162 PMCID: PMC10084032 DOI: 10.1111/codi.16249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/04/2022] [Accepted: 05/20/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The rectosigmoid brake, characterised by retrograde cyclic motor patterns on high-resolution colonic manometry, has been postulated as a contributor to the maintenance of bowel continence. Sacral neuromodulation (SNM) is an effective therapy for faecal incontinence, but its mechanism of action is unclear. This study aims to investigate the colonic motility patterns in the distal colon of patients with faecal incontinence, and how these are modulated by SNM. METHODS A high-resolution fibreoptic colonic manometry catheter, containing 36 sensors spaced at 1-cm intervals, was positioned in patients with faecal incontinence undergoing stage 1 SNM. One hour of pre- and post meal recordings were obtained followed by pre- and post meal recordings with suprasensory SNM. A 700-kcal meal was given. Data were analysed to identify propagating contractions. RESULTS Fifteen patients with faecal incontinence were analysed. Patients had an abnormal meal response (fewer retrograde propagating contractions compared to controls; p = 0.027) and failed to show a post meal increase in propagating contractions (mean 17 ± 6/h premeal vs. 22 ± 9/h post meal, p = 0.438). Compared to baseline, SNM significantly increased the number of retrograde propagating contractions in the distal colon (8 ± 3/h premeal vs. 14 ± 3/h premeal with SNM, p = 0.028). Consuming a meal did not further increase the number of propagating contractions beyond the baseline upregulating effect of SNM. CONCLUSION The rectosigmoid brake was suppressed in this cohort of patients with faecal incontinence. SNM may exert a therapeutic effect by modulating this rectosigmoid brake.
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Affiliation(s)
- Anthony Y Lin
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Sean Seo
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Phil Dinning
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Discipline of Human Physiology, Flinders University, Adelaide, South Australia, Australia
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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8
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Marinello F, Pellino G, Espín-Basany E. Low anterior resection syndrome: An unavoidable price to pay to preserve the rectum? Front Oncol 2022; 12:994720. [PMID: 36313684 PMCID: PMC9614064 DOI: 10.3389/fonc.2022.994720] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Franco Marinello
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Franco Marinello,
| | - Gianluca Pellino
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Eloy Espín-Basany
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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9
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Varghese C, Wells CI, Bissett IP, O'Grady G, Keane C. The role of colonic motility in low anterior resection syndrome. Front Oncol 2022; 12:975386. [PMID: 36185226 PMCID: PMC9523793 DOI: 10.3389/fonc.2022.975386] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Low anterior resection syndrome (LARS) describes the symptoms and experiences of bowel dysfunction experienced by patients after rectal cancer surgery. LARS is a complex and multifactorial syndrome exacerbated by factors such as low anastomotic height, defunctioning of the colon and neorectum, and radiotherapy. There has recently been growing awareness and understanding regarding the role of colonic motility as a contributing mechanism for LARS. It is well established that rectosigmoid motility serves an important role in coordinating rectal filling and maintaining continence. Resection of the rectosigmoid may therefore contribute to LARS through altered distal colonic and neorectal motility. This review evaluates the role of colonic motility within the broader pathophysiology of LARS and outlines future directions of research needed to enable targeted therapy for specific LARS phenotypes.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of General Surgery, Counties Manukau District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Whangārei Hospital, Whangarei, New Zealand
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10
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Risk of Metachronous Colorectal Cancer in Lynch Syndrome: Who Needs an Extended Resection? SURGERIES 2022. [DOI: 10.3390/surgeries3030020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lynch syndrome (LS) is the most common genetic condition associated with early-onset colorectal cancer. It is inherited in an autosomal dominant fashion. The increased cancer risk is due to a germline mutation in one of the mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2) or the EPCAM gene. This leads to a deficient DNA mismatch repair mechanism, resulting in the accumulation of nucleotide changes and microsatellite instability, providing phenotypical evidence that MMR is not functioning normally. LS is associated with a high risk of early-onset colorectal cancer and recurrence. Thus, when undergoing surgery for primary colorectal cancer, extended resection should be discussed with the patient. This review provides an overview of current surgical risk-reducing strategies in LS-associated colorectal cancer. Surgical treatment for LS carriers with colorectal cancer needs to be highly individualized, based on patient and disease characteristics. Strategies are presented to guide decision making in pathologic MMR gene mutation carriers undergoing surgery for colorectal cancer.
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11
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Liao D, Mark EB, Nedergaard RB, Wegeberg AM, Brock C, Krogh K, Drewes AM. Contractility patterns and gastrointestinal movements monitored by a combined magnetic tracking and motility testing unit. Neurogastroenterol Motil 2022; 34:e14306. [PMID: 34894024 DOI: 10.1111/nmo.14306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/23/2021] [Accepted: 09/19/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ingestible wireless capsules, including the 3D-transit magnetic capsule and the wireless motility capsule (WMC), describe gastrointestinal (GI) motility from changes in position or pressure. This study aimed to combine information on contractile events in terms of position (assessed with the 3D-transit) and change in pressure (assessed with the WMC) throughout the entire GI tract. METHODS The 3D-transit capsule and WMC were combined into a single-wireless unit system. Three-dimensional space-time coordinates, pressure, and pH data from a pilot case were analyzed as the combined unit passed the GI tract. Two single and three continuous contraction patterns were defined according to pressure changes and quantified through the GI tract. KEY RESULTS The combined unit was well tolerated and provided information on contractions throughout the gut. Single contraction patterns with no significant progressive movement of the unit were most prevalent in the stomach and the rectosigmoid colon. During the continuous contraction patterns, the unit moved in an antegrade or retrograde direction. Longer distance and higher velocity were seen during antegrade than during retrograde movements. The motility indices (as measured with WMC) in combined ascending, transverse and descending colon showed a positive linear association (r = 0.7) to the capsule movements (as measured with 3D-transit). CONCLUSIONS & INFERENCES The combined system provides synchronous information about movements and gut contractions. These measurements can be used to extract more information from existing recordings and may enhance our understanding of GI motility in health and disease.
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Affiliation(s)
- Donghua Liao
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Marie Wegeberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Steno Diabetes Center North Denmark, Aalborg, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Steno Diabetes Center North Denmark, Aalborg, Denmark
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12
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Heitmann PT, Mohd Rosli R, Maslen L, Wiklendt L, Kumar R, Omari TI, Wattchow D, Costa M, Brookes SJ, Dinning PG. High-resolution impedance manometry characterizes the functional role of distal colonic motility in gas transit. Neurogastroenterol Motil 2022; 34:e14178. [PMID: 34076936 DOI: 10.1111/nmo.14178] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 04/05/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The colonic motor patterns associated with gas transit are poorly understood. This study describes the application of high-resolution impedance manometry (HRiM) in the human colon in vivo to characterize distal colonic motility and gas transit; (a) after a meal and (b) after intraluminal gas insufflation into the sigmoid colon. METHODS HRiM recordings were performed in 19 healthy volunteers, with sensors positioned from the distal descending colon to the proximal rectum. Protocol 1 (n = 10) compared pressure and impedance prior to and after a meal. Protocol 2 (n = 9) compared pressure and impedance before and after gas insufflation into the sigmoid colon (60 mL total volume). KEY RESULTS Both the meal and gas insufflation resulted in an increase in the prevalence of the 2-8/minute "cyclic motor pattern" (meal: (t(9) = -6.42, P<0.001); gas insufflation (t(8) = -3.13, P = 0.01)), and an increase in the number of antegrade and retrograde propagating impedance events (meal: Z = -2.80, P = 0.005; gas insufflation Z = -2.67, P = 0.008). Propagating impedance events temporally preceded antegrade and retrograde propagating contractions, representing a column of luminal gas being displaced ahead of a propagating contraction. Three participants reported an urge to pass flatus and/or flatus during the studies. CONCLUSIONS AND INFERENCES Initiation of the 2-8/minute cyclic motor pattern in the distal colon occurs both following a meal and/or as a localized sensorimotor response to gas. The near-absence of a flatal urge and the temporal association between propagating contractions and gas transit supports the hypothesis that the 2-8/minute cyclic motor pattern acts as a physiological "brake" modulating rectal filling.
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Affiliation(s)
- Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Reizal Mohd Rosli
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Lyn Maslen
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Lukasz Wiklendt
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Raghu Kumar
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - David Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Marcello Costa
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Simon J Brookes
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, Australia
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13
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Wells CI, Bhat S, Paskaranandavadivel N, Lin AY, Vather R, Varghese C, Penfold JA, Rowbotham D, Dinning PG, Bissett IP, O'Grady G. Potential causes of the preoperative increase in the rectosigmoid cyclic motor pattern: A high-resolution manometry study. Physiol Rep 2021; 9:e15091. [PMID: 34837672 PMCID: PMC8627120 DOI: 10.14814/phy2.15091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background Cyclic motor patterns (CMPs) are the most common motor pattern in the distal colon. This study used high‐resolution (HR) colonic manometry to quantify trends in distal colonic motor activity before elective colonic surgery, determine the effect of a preoperative carbohydrate load, and compare this with a meal response in healthy controls. Methods Fiber‐optic HR colonic manometry (36 sensors, 1 cm intervals) was used to investigate distal colonic motor activity in 10 adult patients prior to elective colonic surgery, 6 of whom consumed a preoperative carbohydrate drink (200 kCal). Data were compared with nine healthy volunteers who underwent HR colonic manometry recordings while fasted and following a 700 kCal meal. The primary outcome was the percentage of recording occupied by CMPs, defined as propagating contractions at 2–4 cycles per minute (cpm). Secondary outcomes included amplitude, speed, and distance of propagating motor patterns. Results The occurrence of CMPs progressively increased in time periods closer to surgery (p = 0.001). Consumption of a preoperative drink resulted in significantly increased CMP occurrence (p = 0.04) and propagating distance (p = 0.04). There were no changes in amplitude or speed of propagating motor patterns during the preoperative period. The increase in activity following a preoperative drink was of similar magnitude to the colonic meal response observed in healthy controls, despite the lesser caloric nutrient load. Conclusion Distal colonic CMP increased in occurrence prior to surgery, amplified by ingestion of preoperative carbohydrate drinks. We hypothesize that anxiety, which is also known to rise with proximity to surgery, could play a contributing role.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | - Anthony Y Lin
- Department of General Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Ryash Vather
- Department of Colorectal Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - James A Penfold
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - David Rowbotham
- Department of Gastroenterology and Hepatology, Auckland District Health Board, Auckland, New Zealand
| | - Phil G Dinning
- Discipline of Human Physiology, Flinders University, Adelaide, South Australia, Australia.,Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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14
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Understanding the physiology of human defaecation and disorders of continence and evacuation. Nat Rev Gastroenterol Hepatol 2021; 18:751-769. [PMID: 34373626 DOI: 10.1038/s41575-021-00487-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.
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15
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Lin AY, Varghese C, Du P, Wells CI, Paskaranandavadivel N, Gharibans AA, Erickson JC, Bissett IP, O'Grady G. Intraoperative serosal extracellular mapping of the human distal colon: a feasibility study. Biomed Eng Online 2021; 20:105. [PMID: 34656127 PMCID: PMC8520224 DOI: 10.1186/s12938-021-00944-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cyclic motor patterns (CMP) are the predominant motor pattern in the distal colon, and are important in both health and disease. Their origin, mechanism and relation to bioelectrical slow-waves remain incompletely understood. During abdominal surgery, an increase in the CMP occurs in the distal colon. This study aimed to evaluate the feasibility of detecting propagating slow waves and spike waves in the distal human colon through intraoperative, high-resolution (HR), serosal electrical mapping. METHODS HR electrical recordings were obtained from the distal colon using validated flexible PCB arrays (6 × 16 electrodes; 4 mm inter-electrode spacing; 2.4 cm2, 0.3 mm diameter) for up to 15 min. Passive unipolar signals were obtained and analysed. RESULTS Eleven patients (33-71 years; 6 females) undergoing colorectal surgery under general anaesthesia (4 with epidurals) were recruited. After artefact removal and comprehensive manual and automated analytics, events consistent with regular propagating activity between 2 and 6 cpm were not identified in any patient. Intermittent clusters of spike-like activities lasting 10-180 s with frequencies of each cluster ranging between 24 and 42 cpm, and an average amplitude of 0.54 ± 0.37 mV were recorded. CONCLUSIONS Intraoperative colonic serosal mapping in humans is feasible, but unlike in the stomach and small bowel, revealed no regular propagating electrical activity. Although sporadic, synchronous spike-wave events were identifiable. Alternative techniques are required to characterise the mechanisms underlying the hyperactive CMP observed in the intra- and post-operative period. NEW FINDINGS The aim of this study was to assess the feasibility of detecting propagating electrical activity that may correlate to the cyclic motor pattern in the distal human colon through intraoperative, high-resolution, serosal electrical mapping. High-resolution electrical mapping of the human colon revealed no regular propagating activity, but does reveal sporadic spike-wave events. These findings indicate that further research into appropriate techniques is required to identify the mechanism of hyperactive cyclic motor pattern observed in the intra- and post-operative period in humans.
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Affiliation(s)
- Anthony Y Lin
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, 1142, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, 1142, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, 1142, Auckland, New Zealand
| | | | - Armen A Gharibans
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, 1142, Auckland, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Jonathan C Erickson
- Department of Physics-Engineering, Washington & Lee University, Lexington, VA, USA
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, 1142, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, 1142, Auckland, New Zealand. .,Department of Surgery, Auckland City Hospital, Auckland, New Zealand.
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16
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Abstract
Constipation is a common challenge in pediatrics. Abdominal radiographs are frequently taken in the pediatric emergency department for diagnosis despite their inadequate reliability to detect the pathology or the degree of constipation. Misdiagnosis of constipation may cause multiple vague physician visits, deployment of emergency medical services, use of radiation, unnecessary laboratory tests, and even surgical procedures. The primary evidence-based suggestions are based on published guidelines that include management of constipation in children divided into three stages of therapy: (1) disimpaction, (2) maintenance therapy, and (3) behavior modification, and special care should be given to neonates and to children with pre-existing medical problems.
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17
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The Sphincter of O'Beirne - Part 1: Study of 18 Normal Subjects. Dig Dis Sci 2021; 66:3516-3528. [PMID: 33462748 DOI: 10.1007/s10620-020-06657-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroenterologists have ignored or emphasized the importance of the rectosigmoid junction in continence or constipation on and off for 200 years. Here, we revisit its significance using high-resolution colonic manometry. METHODS Manometry, using an 84-channel water-perfused catheter, was performed in 18 healthy volunteers. RESULTS The rectosigmoid junction registers as an intermittent pressure band of 26.2 ± 7.2 mmHg, or intermittent phasic transient pressure increases at a dominant frequency of 3 cpm and an amplitude of 28.6 ± 8.6 mmHg; or a combination of tone and transient pressures, at a single sensor, 10-17 cm above the anal verge. Features are its relaxation or contraction in concert with relaxation or contraction of the anal sphincters when a motor pattern such as a high-amplitude propagating pressure wave or a simultaneous pressure wave comes down, indicating that such pressure increases or decreases at the rectosigmoid junction are part of neurally driven programs. We show that the junction is a site where motor patterns end, or where they start; e.g. retrogradely propagating cyclic motor patterns emerge from the junction. CONCLUSIONS The rectosigmoid junction is a functional sphincter that should be referred to as the sphincter of O'Beirne; it is part of the "braking mechanism," contributing to continence by keeping content away from the rectum. In an accompanying case report, we show that its excessive presence in a patient with severe constipation can be a primary pathophysiology.
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18
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Chen JH, Collins SM, Milkova N, Pervez M, Nirmalathasan S, Tan W, Hanman A, Huizinga JD. The Sphincter of O'Beirne-Part 2: Report of a Case of Chronic Constipation with Autonomous Dyssynergia. Dig Dis Sci 2021; 66:3529-3541. [PMID: 33462747 DOI: 10.1007/s10620-020-06723-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 11/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic constipation can have one or more of many etiologies, and a diagnosis based on symptoms is not sufficient as a basis for treatment, in particular surgery. AIM To investigate the cause of chronic constipation in a patient with complete absence of spontaneous bowel movements. METHODS High-resolution colonic manometry was performed to assess motor functions of the colon, rectum, the sphincter of O'Beirne and the anal sphincters. RESULTS Normal colonic motor patterns were observed, even at baseline, but a prominent high-pressure zone at the rectosigmoid junction, the sphincter of O'Beirne, was consistently present. In response to high-amplitude propagating pressure waves (HAPWs) that were not consciously perceived, the sphincter and the anal sphincters would not relax and paradoxically contract, identified as autonomous dyssynergia. Rectal bisacodyl evoked marked HAPW activity with complete relaxation of the sphincter of O'Beirne and the anal sphincters, indicating that all neural pathways to generate the coloanal reflex were intact but had low sensitivity to physiological stimuli. A retrograde propagating cyclic motor pattern initiated at the sphincter of O'Beirne, likely contributing to failure of content to move into the rectum. CONCLUSIONS Chronic constipation without the presence of spontaneous bowel movements can be associated with normal colonic motor patterns but a highly exaggerated pressure at the rectosigmoid junction: the sphincter of O'Beirne, and failure of this sphincter and the anal sphincters to relax associated with propulsive motor patterns. The sphincter of O'Beirne can be an important part of the pathophysiology of chronic constipation.
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Affiliation(s)
- Ji-Hong Chen
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
| | - Stephen M Collins
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Natalija Milkova
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Maham Pervez
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Sharjana Nirmalathasan
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Wei Tan
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Alicia Hanman
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Jan D Huizinga
- Department of Medicine-Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, HSC-3H1F, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
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19
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Huizinga JD, Pervez M, Nirmalathasan S, Chen JH. Characterization of haustral activity in the human colon. Am J Physiol Gastrointest Liver Physiol 2021; 320:G1067-G1080. [PMID: 33909507 DOI: 10.1152/ajpgi.00063.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Contraction patterns of the human colon are rarely discussed from the perspective of its haustra. Colonic motility was analyzed in 21 healthy subjects using 84-sensor manometry catheters with 1-cm sensor spacing. Capsule endoscopy and manometry showed evidence of narrow rhythmic circular muscle contractions. X-ray images of haustra and sensor locations allowed us to identify manometry motor activity as intrahaustral activity. Two common motor patterns were observed that we infer to be associated with individual haustra: rhythmic pressure activity confined to a single sensor, and activity confined to a section of the colon of 3-6 cm length. Intrahaustral activity was observed by 3-4 sensors. Approximately 50% of the haustra were intermittently active for ∼30% of the time; 2,402 periods of haustral activity were analyzed. Intrahaustral activity showed rhythmic pressure waves, propagating in mixed direction, 5-30 mmHg in amplitude at a frequency of ∼3 cpm (range 2-6) or ∼12 cpm (range 7-15), or exhibiting a checkerboard segmentation pattern. Boundaries of the haustra showed rhythmic pressure activity with or without elevated baseline pressure. Active haustra often showed no boundary activity probably allowing transit to neighboring haustra. Haustral boundaries were seen at the same sensor for the 6- to 8-h study duration, indicating that they did not propagate, thereby likely contributing to continence. The present study elucidates the motility characteristics of haustral boundaries and the nature of intrahaustral motor patterns and paves the way for investigating their possible role in pathophysiology of defecation disorders.NEW & NOTEWORTHY Here, we present the first full characterization and quantification of motor patterns that we infer to be confined to single haustra, both intrahaustral activity and haustral boundary activity, in the human colon using high-resolution manometry. Haustral activity is intermittent but consistently present in about half of the haustra. Intrahaustral activity presents as a cyclic motor pattern of mixed propagation direction dominated by simultaneous pressure waves that can resolve into checkerboard segmentation, allowing for mixing, absorption, and stool formation.
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Affiliation(s)
- Jan D Huizinga
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Maham Pervez
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sharjana Nirmalathasan
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ji-Hong Chen
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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20
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Seo SHB, Bissett I, O’Grady G. Variable Gut Function Recovery After Right vs. Left Colectomy May Be Due to Rectosigmoid Hyperactivity. Front Physiol 2021; 12:635167. [PMID: 33708140 PMCID: PMC7940204 DOI: 10.3389/fphys.2021.635167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 01/19/2021] [Indexed: 12/11/2022] Open
Abstract
It is established that gut function recovers slower after right vs. left colectomies with higher rates of prolonged post-operative ileus (PPOI), but the reason is unclear. Development of PPOI is multifactorial. A recent manometry study in right colectomy patients showed that the distal colon becomes hyperactive after surgery with predominantly cyclic motor patterns (CMPs). In this perspective, we evaluate the hypothesis that the slower gut recovery after right hemicolectomy could be induced by a functional obstruction due to hyperactive CMPs.
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Affiliation(s)
- Sean Ho Beom Seo
- Department of Surgery, University of Auckland, Auckland, New Zealand
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21
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Wiklendt L, Costa M, Scott MS, Brookes SJH, Dinning PG. Automated Analysis Using a Bayesian Functional Mixed-Effects Model With Gaussian Process Responses for Wavelet Spectra of Spatiotemporal Colonic Manometry Signals. Front Physiol 2021; 11:605066. [PMID: 33643057 PMCID: PMC7905106 DOI: 10.3389/fphys.2020.605066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022] Open
Abstract
Manual analysis of human high-resolution colonic manometry data is time consuming, non-standardized and subject to laboratory bias. In this article we present a technique for spectral analysis and statistical inference of quasiperiodic spatiotemporal signals recorded during colonic manometry procedures. Spectral analysis is achieved by computing the continuous wavelet transform and cross-wavelet transform of these signals. Statistical inference is achieved by modeling the resulting time-averaged amplitudes in the frequency and frequency-phase domains as Gaussian processes over a regular grid, under the influence of categorical and numerical predictors specified by the experimental design as a functional mixed-effects model. Parameters of the model are inferred with Hamiltonian Monte Carlo. Using this method, we re-analyzed our previously published colonic manometry data, comparing healthy controls and patients with slow transit constipation. The output from our automated method, supports and adds to our previous manual analysis. To obtain these results took less than two days. In comparison the manual analysis took 5 weeks. The proposed mixed-effects model approach described here can also be used to gain an appreciation of cyclical activity in individual subjects during control periods and in response to any form of intervention.
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Affiliation(s)
- Lukasz Wiklendt
- College of Medicine and Public Health, Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Marcello Costa
- College of Medicine and Public Health, Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Mark S. Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Simon J. H. Brookes
- College of Medicine and Public Health, Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Phil G. Dinning
- College of Medicine and Public Health, Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
- Discipline of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
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22
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Keane C, Paskaranandavadivel N, Vather R, Rowbotham D, Arkwright J, Dinning P, Bissett I, O'Grady G. Altered colonic motility is associated with low anterior resection syndrome. Colorectal Dis 2021; 23:415-423. [PMID: 33253472 DOI: 10.1111/codi.15465] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/13/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022]
Abstract
AIM Patients frequently suffer from low anterior resection syndrome (LARS) after distal colorectal resection. The pathophysiology of LARS has not been clearly elucidated. We hypothesized that rectosigmoid resection could impair motility patterns in the distal colon, such as the rectosigmoid brake, which contribute to control of stool form and frequency. METHOD High-resolution colonic manometry was performed in patients who had previously undergone distal colorectal resection (mean 6.8 years after resection) and non-operative controls before and after a standardized meal. Symptoms were assessed using the LARS score. Propagating contractions were compared between patients with and without LARS, and controls. RESULTS Data were analysed from 23 patients (11 no-LARS; 12 LARS) and nine controls. All groups demonstrated a significant meal response. LARS patients had fewer post-prandial antegrade propagating contractions than controls (P = 0.028), and fewer retrograde propagating contractions both pre- (P = 0.005) and post-prandially (P = 0.004). Post-prandially, the LARS group had a significantly lower percentage of propagating contractions that met the criteria for the cyclic motor pattern compared to the control group (26% vs. 58%; P = 0.009). There were significant differences in antegrade and retrograde amplitude (P = 0.049; P = 0.018) and distance of propagation (P = 0.003; P = 0.002) post-prandially between LARS patients and controls. CONCLUSION Rectosigmoid resection alters the meal response following anterior resection, including impairment of the rectosigmoid brake cyclic motor pattern. These findings help to quantify the impaired functional motility after rectosigmoid resection and offer new insights into the mechanisms of LARS.
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Affiliation(s)
- Celia Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Ryash Vather
- Colorectal Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Rowbotham
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - John Arkwright
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Phil Dinning
- Department of Surgery and Gastroenterology, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
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23
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Paskaranandavadivel N, Lin AY, Cheng LK, Bissett I, Lowe A, Arkwright J, Mollaee S, Dinning PG, O'Grady G. ManoMap: an automated system for characterization of colonic propagating contractions recorded by high-resolution manometry. Med Biol Eng Comput 2021; 59:417-429. [PMID: 33496911 DOI: 10.1007/s11517-021-02316-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
RATIONALE Colonic high-resolution manometry (cHRM) is an emerging clinical tool for defining colonic function in health and disease. Current analysis methods are conducted manually, thus being inefficient and open to interpretation bias. OBJECTIVE The main objective of the study was to build an automated system to identify propagating contractions and compare the performance to manual marking analysis. METHODS cHRM recordings were performed on 5 healthy subjects, 3 subjects with diarrhea-predominant irritable bowel syndrome, and 3 subjects with slow transit constipation. Two experts manually identified propagating contractions, from five randomly selected 10-min segments from each of the 11 subjects (72 channels per dataset, total duration 550 min). An automated signal processing and detection platform was developed to compare its effectiveness to manually identified propagating contractions. In the algorithm, individual pressure events over a threshold were identified and were then grouped into a propagating contraction. The detection platform allowed user-selectable thresholds, and a range of pressure thresholds was evaluated (2 to 20 mmHg). KEY RESULTS The automated system was found to be reliable and accurate for analyzing cHRM with a threshold of 15 mmHg, resulting in a positive predictive value of 75%. For 5-h cHRM recordings, the automated method takes 22 ± 2 s for analysis, while manual identification would take many hours. CONCLUSIONS An automated framework was developed to filter, detect, quantify, and visualize propagating contractions in cHRM recordings in an efficient manner that is reliable and consistent.
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Affiliation(s)
- Niranchan Paskaranandavadivel
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
- Department of Surgery, University of Auckland, Auckland, New Zealand.
| | - Anthony Y Lin
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Leo K Cheng
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
- Vanderbilt University, Nashville, TN, USA
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland, New Zealand
| | - Andrew Lowe
- Institute of Biomedical Engineering, Auckland University of Technology, Auckland, New Zealand
| | - John Arkwright
- College of Science and Engineering, Flinders University, Adelaide, Australia
| | - Saeed Mollaee
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Phil G Dinning
- Departments of Gastroenterology & Surgery Flinders Medical Centre, Flinders University, Adelaide, Australia
| | - Gregory O'Grady
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland, New Zealand
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24
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Heitmann PT, Rabbitt P, Schloithe AC, Wattchow DA, Scott SM, Dinning PG. The relationships between the results of contemporary tests of anorectal structure and sensorimotor function and the severity of fecal incontinence. Neurogastroenterol Motil 2020; 32:e13946. [PMID: 32683767 DOI: 10.1111/nmo.13946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/24/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnostic investigations for fecal incontinence (FI) assess the structure and sensorimotor function of the anorectum. Investigations include anorectal manometry, anorectal sensory testing, pudendal nerve terminal motor latencies (PNTML), and endoanal sonography. The severity of FI and results of investigations are often discordant and the rate of symptom resolution following treatment remains <40%. High-resolution anorectal manometry (HRAM) and three-dimensional endoanal ultrasound (3D-US) have been introduced during the last decade. This study aims to assess the strength of relationships between contemporary investigation results and FI severity. METHODS Adults presenting for investigation of FI were assessed using the St Mark's FI severity score (SMIS), HRAM, anorectal sensory testing, PNTML, and 3D-US. KEY RESULTS 246 patients were included. There were significant relationships between the SMIS and HRAM (resting pressure rs = -0.23, 95% CI = (-0.34, -0.11), P < .001; squeeze pressure (rs = -0.26, 95% CI = (-0.37, -0.14), P < .001) and 3D-US (anterior EAS length rs = -0.22, 95% CI = (-0.34, -0.09), P = .001). The relationships between SMIS and HRAM had a greater effect size in those with urge-predominant symptoms (resting pressure: rs = -0.40, 95% CI = (-0.57, -0.20), P < .001, squeeze pressure: rs = -0.34, 95% CI = (-0.52, -0.12), P = .003). Overall, the variance in SMIS accounted for by anorectal investigations was 8.6% (R2 = 0.098, adjusted R2 = 0.086, P < .001). CONCLUSIONS AND INFERENCES Anorectal investigations are not strong predictors of FI severity. These findings may reflect the multifactorial, heterogeneous pathophysiology of FI, the limitations of the SMIS and anorectal investigations, and contributing factors extrinsic to the anorectum.
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Affiliation(s)
- Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Philippa Rabbitt
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Ann C Schloithe
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Queen Mary University, London, UK
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
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25
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Nocera F, Angehrn F, von Flüe M, Steinemann DC. Optimising functional outcomes in rectal cancer surgery. Langenbecks Arch Surg 2020; 406:233-250. [PMID: 32712705 PMCID: PMC7936967 DOI: 10.1007/s00423-020-01937-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Background By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention. Purpose This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted. Conclusion Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.
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Affiliation(s)
- Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Fiorenzo Angehrn
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
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26
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Anele CC, Nachiappan S, Sinha A, Cuthill V, Jenkins JT, Clark SK, Latchford A, Faiz OD. Safety and efficacy of laparoscopic near-total colectomy and ileo-distal sigmoid anastomosis as a modification of total colectomy and ileorectal anastomosis for prophylactic surgery in patients with adenomatous polyposis syndromes: a comparative study. Colorectal Dis 2020; 22:799-805. [PMID: 31943692 DOI: 10.1111/codi.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/15/2019] [Indexed: 02/08/2023]
Abstract
AIM Colectomy in patients with adenomatous polyposis (AP) syndromes demands good oncological and surgical outcome. Total colectomy with ileorectal anastomosis (TC-IRA) is one surgical option for these patients. Anastomotic leakage rates of 11% have been reported following TC-IRA. Ileo-distal sigmoid anastomosis (IDSA) is a recent modification of our practice. Our aim was to compare postoperative outcome in patients with AP following near-total colectomy with IDSA (NT-IDSA) and TC-IRA at a single institution. METHOD A prospectively maintained database was reviewed to identify patients with AP who underwent laparoscopic NT-IDSA and TC-IRA. Patient demographics, early morbidity and mortality and outcome of endoscopic surveillance were evaluated. RESULTS A total of 191 patients with AP underwent laparoscopic colectomy between 2006 and 2017, of whom 139 (72.8%) underwent TC-IRA and 52 (27.2%) NT-IDSA. The median age at surgery in the TC-IRA and NT-IDSA groups was 20 years (IQR 17-45) and 27 years (IQR 19-50), respectively. Grade II complications were comparable between the two groups. There were no anastomotic leakages in the NT-IDSA group compared with 15 (10.8%) in the TC-IRA group (P = 0.0125) and no reoperation in the NT-IDSA group compared with 17 (12.2%) in the TC-IRA group (P = 0.008). The frequency of polypectomies per flexible sigmoidoscopy was comparable between the two groups. CONCLUSION This study demonstrates that laparoscopic NT-IDSA for polyposis is associated with a significant improvement in anastomotic leakage rates and surgical outcome. It is too soon to tell whether NT-IDSA alters the need for further intervention, either endoscopic polypectomy or further surgery.
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Affiliation(s)
- C C Anele
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Nachiappan
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Sinha
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - V Cuthill
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - J T Jenkins
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - S K Clark
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Latchford
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - O D Faiz
- The Polyposis Registry, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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27
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Erickson JC, Bruce LE, Taylor A, Richman J, Higgins C, Wells CI, O'Grady G. Electrocolonography: Non-Invasive Detection of Colonic Cyclic Motor Activity From Multielectrode Body Surface Recordings. IEEE Trans Biomed Eng 2020; 67:1628-1637. [DOI: 10.1109/tbme.2019.2941851] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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28
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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29
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Wells CI, Paskaranandavadivel N, Lin AY, Du P, Penfold JA, Dinning P, Cheng LK, Bissett IP, Arkwright JW, O'Grady G. Development and feasibility of an ambulatory acquisition system for fiber-optic high-resolution colonic manometry. Neurogastroenterol Motil 2019; 31:e13704. [PMID: 31407459 DOI: 10.1111/nmo.13704] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/27/2019] [Accepted: 08/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND High-resolution colonic manometry is an emerging technique that has provided new insights into the pathophysiology of functional colorectal diseases. Prior studies have been limited by bulky, non-ambulatory acquisition systems, which have prevented mobilization during prolonged recordings. METHODS A novel ambulatory acquisition system for fiber-optic high-resolution colonic manometry was developed. Benchtop validation against a standard non-ambulatory system was performed using standardized calibration metrics. Clinical feasibility studies were conducted in three patients undergoing right hemicolectomy. RESULTS Pressure profiles obtained from benchtop testing were near-identical using the ambulatory and the non-ambulatory systems. Clinical studies successfully demonstrated ambulatory data capture with patients freely mobilizing postoperatively during continuous recordings of >60 hours. The occurrence (P = .56), amplitude (P = .65), velocity (P = .10), and extent (P = .12) of colonic motor patterns were similar to those obtained in non-ambulatory studies. CONCLUSIONS A novel ambulatory system for high-resolution colonic manometry has been developed and validated. This technique will facilitate prolonged ambulatory recordings of colonic motor activity, assisting with investigations into the role of colonic motility in disease states.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Anthony Y Lin
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - James A Penfold
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Phil Dinning
- Discipline of Human Physiology, Flinders University, Adelaide, South Australia, Australia
| | - Leo K Cheng
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - John W Arkwright
- Department of Computer Science, Engineering and Mathematics, Flinders University, Adelaide, South Australia, Australia
| | - Greg O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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30
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Gunn D, Fried R, Lalani R, Farrin A, Holloway I, Morris T, Olivier C, Kearns R, Corsetti M, Scott M, Farmer A, Emmanuel A, Whorwell P, Yiannakou Y, Sanders D, Mclaughlin J, Kapur K, Eugenicos M, Akbar A, Trudgill N, Houghton L, Dinning PG, Ford AC, Aziz Q, Spiller R. Treatment of irritable bowel syndrome with diarrhoea using titrated ondansetron (TRITON): study protocol for a randomised controlled trial. Trials 2019; 20:517. [PMID: 31429811 PMCID: PMC6700805 DOI: 10.1186/s13063-019-3562-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/08/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Irritable bowel syndrome with diarrhoea (IBS-D) affects up to 4% of the general population. Symptoms include frequent, loose, or watery stools with associated urgency, resulting in marked reduction of quality of life and loss of work productivity. Ondansetron, a 5HT3 receptor antagonist, has had an excellent safety record for over 20 years as an antiemetic, yet is not widely used in the treatment of IBS-D. It has, however, been shown to slow colonic transit and in a small randomised, placebo-controlled, cross-over pilot study, benefited patients with IBS-D. METHODS This trial is a phase III, parallel group, randomised, double-blind, multi-centre, placebo-controlled trial, with embedded mechanistic studies. Participants (n = 400) meeting Rome IV criteria for IBS-D will be recruited from outpatient and primary care clinics and by social media to receive either ondansetron (dose titrated up to 24 mg daily) or placebo for 12 weeks. Throughout the trial, participants will record their worst abdominal pain, worst urgency, stool frequency, and stool consistency on a daily basis. The primary endpoint is the proportion of "responders" in each group, using Food and Drug Administration (FDA) recommendations. Secondary endpoints include pain intensity, stool consistency, frequency, and urgency. Mood and quality of life will also be assessed. Mechanistic assessments will include whole gut transit, faecal tryptase and faecal bile acid concentrations at baseline and between weeks 8 and 11. A subgroup of participants will also undergo assessment of sensitivity (n = 80) using the barostat, and/or high-resolution colonic manometry (n = 40) to assess motor patterns in the left colon and the impact of ondansetron. DISCUSSION The TRITON trial aims to assess the effect of ondansetron across multiple centres. By defining ondansetron's mechanisms of action we hope to better identify patients with IBS-D who are likely to respond. TRIAL REGISTRATION ISRCTN, ISRCTN17508514 , Registered on 2 October 2017.
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Affiliation(s)
- David Gunn
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ron Fried
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rabia Lalani
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ivana Holloway
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tom Morris
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Olivier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rachael Kearns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Maura Corsetti
- Nottingham Digestive Diseases Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Scott
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Adam Farmer
- Royal Stoke Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Anton Emmanuel
- University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Whorwell
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Yan Yiannakou
- County Durham and Darlington Foundation Trust, University Hospital of North Durham, Durham, UK
| | - David Sanders
- Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Mclaughlin
- Salford Royal NHS Foundation Trust, Salford Royal University Hospital, Manchester, UK
| | - Kapil Kapur
- Barnsley Hospital, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Maria Eugenicos
- Western General Hospital Edinburgh, NHS Lothian, Edinburgh, UK
| | - Ayesha Akbar
- London North West Healthcare NHS Trust, St Mark’s Hospital, London, UK
| | - Nigel Trudgill
- Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Lesley Houghton
- St James’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Phil G. Dinning
- Discipline of Surgery and Gastroenterology, Flinders Medical Centre, Flinders University, Adelaide, South Australia Australia
| | | | - Qasim Aziz
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Robin Spiller
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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31
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Wells CI, O'Grady G, Bissett IP. Colonic Electromechanical Abnormalities Underlying Post-operative Ileus: A Systematic and Critical Review. J Neurogastroenterol Motil 2019; 25:36-47. [PMID: 30504526 PMCID: PMC6326204 DOI: 10.5056/jnm18030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 06/20/2018] [Accepted: 07/21/2018] [Indexed: 12/25/2022] Open
Abstract
Post-operative ileus (POI) is an inevitable consequence of major abdominal surgery, and may be prolonged in up to 30% of patients. Ileus is commonly presumed to result from paralysis of the GI tract, though there is little direct evidence to support this view. The aim of this review is to systematically search and critically review the literature investigating post-operative colonic electrical and mechanical activity. MEDLINE and Embase databases were systematically searched for articles investigating post-operative colonic motor or electrical activity in human patients. Nineteen original articles investigating post-operative colonic motor or electrical activity were identified. Most studies have used low-resolution techniques, with intermittent recordings of colonic motility. Numerous studies have shown that colonic electrical and motor activity does not cease routinely following surgery, but is of abnormal character for 3–6 days following laparotomy. One recent high-resolution manometry study identified hyperactive cyclic motor patterns occurring in the distal colon on the first post-operative day. Low-resolution studies have shown colonic slow waves are not inhibited by surgery, and are present even in the immediate post-operative period. Recovery of normal motility appears to occur in a proximal to distal direction and is temporally correlated with the clinical return of bowel function. No studies have investigated motility specifically in prolonged POI. Future studies should use high-resolution techniques to accurately characterise abnormalities in electrical and mechanical function underlying POI, and correlate these changes with clinical recovery of bowel function.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand.,Department of Surgery, Auckland District Health Board, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand.,Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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32
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Dinning PG. A new understanding of the physiology and pathophysiology of colonic motility? Neurogastroenterol Motil 2018; 30:e13395. [PMID: 29971850 DOI: 10.1111/nmo.13395] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In recent years, high-resolution manometry has been used in an attempt to gain a greater insight into the physiology/pathophysiology of colonic contractile activity in healthy adults and patients with colonic motility disorders. New colonic motor patterns have been identified and characterized, however, the clinical significance of these findings remains undetermined. PURPOSE This review will assess the current literature on colonic high-resolution manometry and determine if this procedure has advanced our understanding of colonic motility. The limitations, future directions, and the potential of this technique to assess the effects of treatment upon colonic motor patterns will also be discussed.
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Affiliation(s)
- P G Dinning
- The Department of Gastroenterology & Surgery, Flinders Medical Centre & the College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
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33
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Vather R, O'Grady G, Lin AY, Du P, Wells CI, Rowbotham D, Arkwright J, Cheng LK, Dinning PG, Bissett IP. Hyperactive cyclic motor activity in the distal colon after colonic surgery as defined by high-resolution colonic manometry. Br J Surg 2018; 105:907-917. [PMID: 29656582 DOI: 10.1002/bjs.10808] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/18/2017] [Accepted: 11/21/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Recovery after colonic surgery is invariably delayed by disturbed gut motility. It is commonly assumed that colonic motility becomes quiescent after surgery, but this hypothesis has not been evaluated rigorously. This study quantified colonic motility through the early postoperative period using high-resolution colonic manometry. METHODS Fibre-optic colonic manometry was performed continuously before, during and after surgery in the left colon and rectum of patients undergoing right hemicolectomy, and in healthy controls. Motor events were characterized by pattern, frequency, direction, velocity, amplitude and distance propagated. RESULTS Eight patients undergoing hemicolectomy and nine healthy controls were included in the study. Colonic motility became markedly hyperactive in all operated patients, consistently dominated by cyclic motor patterns. Onset of cyclic motor patterns began to a minor extent before operation, occurring with increasing intensity nearer the time of surgery; the mean(s.d.) active duration was 12(7) per cent over 3 h before operation and 43(17) per cent within 1 h before surgery (P = 0.024); in fasted controls it was 2(4) per cent (P < 0·001). After surgery, cyclic motor patterns increased markedly in extent and intensity, becoming nearly continuous (active duration 94(13) per cent; P < 0·001), with peak frequency 2-4 cycles per min in the sigmoid colon. This postoperative cyclic pattern was substantially more prominent than in non-operative controls, including in the fed state (active duration 27(20) per cent; P < 0·001), and also showed higher antegrade velocity (P < 0·001). CONCLUSION Distal gut motility becomes markedly hyperactive with colonic surgery, dominated by cyclic motor patterns. This hyperactivity likely represents a novel pathophysiological aspect of the surgical stress response. Hyperactive motility may contribute to gut dysfunction after surgery, potentially offering a new therapeutic target to enhance recovery.
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Affiliation(s)
- R Vather
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - A Y Lin
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - P Du
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - C I Wells
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - D Rowbotham
- Department of Gastroenterology, Auckland District Health Board, Auckland, New Zealand
| | - J Arkwright
- Department of Computer Science, Engineering and Mathematics, Flinders University, Adelaide, South Australia, Australia
| | - L K Cheng
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - P G Dinning
- Human Physiology, Flinders University, Adelaide, South Australia, Australia.,Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - I P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Affiliation(s)
- Gunnar Steineck
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Oncology and Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Bull
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Fei Sjöberg
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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Wells CI, O’Grady G, Bissett IP. Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms. World J Gastroenterol 2017; 23:5634-5644. [PMID: 28852322 PMCID: PMC5558126 DOI: 10.3748/wjg.v23.i30.5634] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/29/2017] [Accepted: 07/22/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO). METHODS A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken. RESULTS No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors. CONCLUSION Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.
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