Anal Channel Research Articles

The Optimum Surgical Methods at Disease Hirschsprung’s in Adults.

The Purpose: perfect the results of the surgical treatment disease Hirshprung’s (DH) in adult operations with using abdominally -anal resection of the rectum with voiding functionning division of the colon in anal channel.

Comparative estimation of a pain syndrome in patients after combined operations for coexistent pathology of anal channel and rectum with application of modern and standard surgical technologies

Objective. Comparative estimation of the pain syndrome in patients with concomitant pathology of anal channel and rectum after performance of combined operations, using modern high-frequency electro-surgical and radio-surgical apparatuses, as well as conventional scalpel.
 Materials and methods. The results of surgical treatment of 689 patients with concomitant pathology of anal channel and rectum, using apparatuses of a high-frequency electro-surgery and radio-wave surgery, were analyzed, using the pain syndrome estimation on 1-7th postoperative day. The patients were distributed into 4 investigation groups and a control group, consisting of 112 patients, operated on using metallic conventional surgical scalpel.
 Results. The pain syndrome on the first postoperative day was mostly expressed in patients of control group, for anesthesia they needed (4 ± 1) ml of 2% solution of promedol, while the patients of the first, third and fourth groups investigated, in which, accordingly, apparatus of radio-wave surgery «Surgitron» and high-frequency electro-surgical apparatuses «EFA» and «KLS Martin» were used, needed for anesthesia (2 ± 1) ml of 2% solution of promedol. While application of the electro-surgical high-frequency apparatus «ERBE ICC 200» the necessity for the 2% solution of promedol for anesthesia have constituted (3 ± 1) ml.
 Conclusion. Combined operations, using modern apparatuses of high-frequency electro-surgery and radio-wave surgery give significantly better results, than application of conventional surgical metallic scalpel, because it produces significantly reduced pain syndrome due to thin layer of coagulation necrosis, promoting formation of delicate elastic cicatrix and preventing development of cicatricial strictures of anal channel in postoperative period.

Anal ultrasonography in monitoring and postoperative evaluation of anorectal malformations

Objectives: We aimed to describe anal ultrasound for monitoring anorectal malformations. Methods: A descriptive and retrospective study of patients diagnosed and/or intervened with anorectal malformations rated by anal ultrasonography, between 2016-2017, was performed. We employed a transducer of 10 megahertz to identify the anatomy of the anal channel. Results: Eight patients, 5 men and 3 women were included, with a mean of 8.37 years old (range, 3-11). Three patients had a diagnosis of an anterior anus (not operated). Surgery was performed in 5 patients: 2 had a rectourethral fistula, 1 had a rectovesical fistula, and 1 had a rectovestibular and a perineal fistula. The most significant ultrasound findings were partial absence of the anterior part of the external sphincter, internal sphincter hypertrophy in the middle channel, and absence of internal sphincter in the median and high channel plus the absence of external sphincter in the anterior region. These results belonged to a patient with clinical incontinence and to 2 patients that were previously diagnosed with an anterior anus. Conclusions: Anal ultrasonography is a non-invasive method, economic, and feasible to be performed without anesthesia. It offers useful anatomical information to establish the best therapeutic option. Its main limitation is the unfeasibility of carrying it out on patients under 3 years old.

Хірургічне лікування поєднаної патології анального каналу і прямої кишки з використанням сучасних високочастотних електрохірургічних та радіохірургічних апаратів

Мета. Покращення результатів хірургічного лікування пацієнтів з поєднаною патологією анального каналу (АК) і прямої кишки (ПК) шляхом застосування високочастотних (ВЧ) електрохірургічних (ЕХ) апаратів «ERBE ICC 200», «ЕФА», «KLS Martin» та апарата радіохвильової (РХ) хірургії «Surgitron» і їх порівняльна характеристика.
 Матеріали і методи. Проаналізовані результати лікування 564 пацієнтів з поєднаною патологією АК і ПК з використанням ВЧ ЕХ апаратів «ERBE ICC 200», «ЕФА», «KLS Martin» та апарата РХ хірургії «Surgitron».
 Результати. Дослідженням встановлено, що застосування ВЧ ЕХ апаратів «ERBE ICC 200», «ЕФА», «KLS Martin» та апарата РХ хірургії «Surgitron» зменшує тривалість операції до (20 ± 5) хв, об’єм інтраопераційної крововтрати до (20 ± 10) мл, потребу в наркотичних аналгетиках до (2 ± 1) мл, строки стаціонарного лікування до (5 ± 1) доба.
 Висновки. Використання ВЧ ЕХ апаратів «ERBE ICC 200», «ЕФА», «KLS Martin» та апарата РХ хірургії «Surgitron» забезпечує скорочення тривалості операції, зменшення об’єму крововтрати під час операції, інтенсивності больового синдрому в післяопераційному періоді, а також незначну глибину некрозу тканин (від 0,055 до 0,43 мм), що обумовлює хороший косметичний результат операції.

Диференційований підхід до вибору способу дислокації тонкокишкового трансплантата в порожнину малого таза

Мета. Покращити результати реконструктивно-відновних операцій після колектомії з наднизькою передньою резекцією прямої кишки шляхом оптимізації методів забезпечення вільної дислокації тонкокишкового трансплантата в порожнину малого таза.
 Матеріали і методи. Розроблені нові способи дислокації тонкокишкового трансплантата під час виконання реконструктивно-відновних операцій після колектомії з наднизькою передньою резекцією прямої кишки, мукозектомії хірургічного анального каналу, які передбачають мобілізацію кореня брижі тонкої кишки, пересічення судинної аркади верхньої брижової артерії (ВБА) та прямих її судин. Зазначені способи використано у 32 пацієнтів у комплексі з відомими методами в складних анатомічних умовах залежно від анатомічних особливостей брижі тонкої кишки, розташування відрізка клубової кишки, архітектоніки ВБА.
 Результати. Ускладнень в ранньому післяопераційному періоді, обумовлених дислокацією тонкокишкового трансплантата в порожнину малого таза, у оперованих пацієнтів не спостерігали. В пізньому післяопераційному періоді у 1 (3,1%) пацієнта виник ішемічний резервуарит, який не був пов’язаний з особливостями техніки дислокації.
 Висновки. Розроблені нові способи дислокації тонкокишкового трансплантата після резекції термінальної ділянки клубової кишки сприяють збільшенню його довжини та покращенню мобільності. Диференційований підхід до використання розроблених нових способів дислокації тонкокишкового трансплантата в комплексі з відомими методами забезпечував переміщення трансплантата в порожнину малого таза в складних анатомічних умовах, обумовлених зменшенням довжини термінальної ділянки клубової кишки, без натягу брижі тонкої кишки, суттєвого ризику виникнення його ішемії та некрозу.

Сучасні хірургічні технології у лікуванні пацієнтів з поєднаною патологією анального каналу і прямої кишки

Мета. Покращення результатів хірургічного лікування пацієнтів з поєднаною патологією анального каналу і прямої кишки шляхом застосування високочастотного електрохірургічного апарата «KLS Martin».
 Матеріали і методи. Проаналізовані результати лікування 50 пацієнтів з поєднаною патологією анального каналу і прямої кишки з використанням високочастотного електрохірургічного апарата «KLS Martin».
 Результати. Застосування високочастотного електрохірургічного апарата «KLS Martin» зменшувало тривалість операції до (15 ± 5) хв, об’єм крововтрати до (20 ± 10) мл, потребу в наркотичних аналгетиках до (2 ± 1) мл, строки стаціонарного лікування до (4 ± 1) доба.
 Висновки. У разі використання високочастотного електрохірургічного апарата «KLS Martin» скорочується тривалість операції, зменшується об’єм крововтрати під час операції, а також інтенсивність больового синдрому в післяопераційному періоді. Після застосування зазначеної електрохірургічної технології глибина некрозу тканин незначна - (0,192 ± 0,12) мм, чим забезпечується косметичність операції.

Лікування поєднаної патології анального каналу і прямої кишки з використанням електрохірургічного високочастотного апарата «ЕФА»

Мета. Покращення результатів хірургічного лікування хворих з поєднаною патологією анального каналу і прямої кишки шляхом використання електрохірургічного високочастотного апарата «ЕФА».
 Матеріали і методи. Проаналізовано результати лікування 114 пацієнтів з поєднаною патологією анального каналу і прямої кишки з використанням електрохірургічного високочастотного апарата «ЕФА».
 Результати. Встановлено, що у разі використання електрохірургічного високочастотного апарата «ЕФА» тривалість операції зменшується до (25 ± 5) хв, об’єм крововтрати - до (20 ± 5) мл, потреба в наркотичних аналгетиках - до (3 ± 1) мл, тривалість стаціонарного лікування - до (6 ± 1) доба.
 Висновки. Використання електрохірургічного високочастотного апарата «ЕФА» приводить до скорочення тривалості операції, зменшення об’єму є інтраопераційної крововтрати, інтенсивності больового синдрому в післяопераційному періоді. Після використання даної хірургічної технології глибина некрозу тканин незначна - (0,254 ± 0,18 мм), чим забезпечується косметичність операції.

Застосування високочастотного електрохірургічного апаратА “ERBE ICC 200” для лікування пацієнтів з поєднаною патологією анального каналу і прямої кишки

Реферат
 Мета. Покращення результатів хірургічного лікування пацієнтів з поєднаною патологією (ПП) анального каналу і прямої кишки шляхом використання апарата високочастотної електрохірургії (ВЧЕХ) “ERBE ICC 200”.
 Матеріали і методи. Проаналізовані результати лікування 164 пацієнтів з ПП анального каналу і прямої кишки з використанням апарата ВЧЕХ “ERBE ICC 200”.
 Результати. Встановлено, що при використанні апарата ВЧЕХ “ERBE ICC 200” зменшуються тривалість операції - до (20 ± 5) хв, об’єм крововтрати - до (15 ± 5) мл, потреба в наркотичних аналгетиках до (2 ± 1) мл, тривалість стаціонарного лікування - до (5 ± 1) доба.
 Висновки. Застосування апарата ВЧЕХ “ERBE ICC 200” приводить до скорочення тривалості операції, зменшення крововтрати під час операції, а також інтенсивності болю в післяопераційному періоді. Використання даної хірургічної технології забезпечує незначну глибину некрозу тканин - (0,286 ± 0,15) мм та косметичність операції.

Використання сучасних мініінвазивних хірургічних технологій у лікуванні поєднаної патології анального каналу і прямої кишки

Мета. Покращити результати хірургічного лікування пацієнтів з поєднаною патологією анального каналу і прямої кишки за рахунок використання апарата радіохвильової хірургії «Surgitron».
 Матеріали і методи. Проаналізовані результати лікування 236 пацієнтів з поєднаною патологією анального каналу і прямої кишки з використанням апарата радіохвильової хірургії «Surgitron».
 Результати та їх обговорення. Дослідженням встановлено, що використання апарата радіохвильової хірургії «Surgitron» зменшує тривалість операції до (15 ± 5) хв, об’єм крововтрати – до (20 ± 10) мл, потребу в наркотичних аналгетиках – до (2 ± 1) мл, тривалість стаціонарного лікування – до (4 ± 1) день.
 Висновки. Застосування апарата радіохвильової хірургії «Surgitron» скорочує тривалість операції, зменшує крововтрату під час операції, а також інтенсивність болю в післяопераційному періоді. Використання цієї мініінвазивної технології забезпечує незначну глибину некрозу тканин – (0,2 ± 0,1) мм і косметичність операції.

SURGICAL TREATMENT OF THE COMBINED NON-NEOPLASTIC PATHOLOGY OF THE ANAL CHANNEL AND RECTUM

PURPOSE. To evaluate the results of surgical treatment of hemorrhoids in combination with other pathologies of the rectum and anal canal. MATERIALS AND METHODS. 331 patients are operated in clinic concerning non-neoplastic surgical pathology of the anal channel (AC) and the rectum (R) from 2012 to 2015. The probed group (PG) was 159 (48,0±2,7%) patients who underwent combined surgical treatment of hemorrhoids and other pathology AC and R. Control group (CG) was 172 (52,0±2,7%) patients who underwent hemorrhoidectomy. RESULTS. The average duration of surgery in PG was 28±5 min, in CG - 19±3 minutes (p>0.05). The amounts of long-term postoperative complications in the PG was 4,4±1,6/, in the CG - 2,3±1,1% (p> 0,05).The average duration of hospitalization in the PG was 5,1±1,0 days, in СG - 3,2±1,0 days (p> 0,05), the duration of rehabilitation in the PG was 20,3±3,2 days, in CG -15,1±2,0 days (p>0,05). CONCLUSION. Existence of the pathology of AC and R in combination with hemorrhoids is the indication to the combined surgical treatment. The increation in the duration ofsurgery, postoperative complications, duration of hospitalization and rehabilitation in the PG compared with the CG are not statistically significant. Simultaneous surgical treatment of hemorrhoids and other pathologies AC and R relieves the patient from having to perform repeated surgery and its possible complications.

Aspiration drainage in the prevention of postoperative septic complications in rectum sphincter-sparing abdominoperitoneal resection

Aim. Explore the effectiveness of the double-barreled drainage tube «tube in tube», mounted by the developed technique after rectum sphincter-sparing abdominoperitoneal resection due to cancer.
 Methods. The data of 52 patients with rectal tumors who underwent rectum sphincter-sparing abdominoperitoneal resection in two surgical wards over the past 4 years were analyzed. At the surgery, the colon was brought down together with anal channel mucosa excision and bringing down the colon mucosa to the anal channel. Rectum sphincter-sparing abdominoperitoneal resection was finished in all patients by placing a double-barreled drainage tube of the original construction to the retroperitoneal part of the cavity of the true pelvis by an original method via the anterior abdominal wall incision. No one-step intestinal stoma was exteriorized in any of the patients.
 Results. The average duration of postoperative hospital stay was 17 days; in patients who underwent non-hybrid operation (50 of 52 patients) - 15.3 bed-days. Postoperative complications occurred in a total of 11 (21.1%) patients, and the rate of septic complications was 1.9%, which is lower compared to published data. It is worth noticing that the use of our original method of pelvic cavity draining totally excludes peritoneal fistula formation and facilitates post-operative care.
 Conclusion. The proposed method of pelvic cavity draining at rectum sphincter-sparing abdominoperitoneal resections might be effective, as is associated with lower chance of purulent and septic complications. It excludes the possibility of perineal fistula formation, facilitates the post-operative period management.

PP‐4 ANORECTAL MALFORMATIONS

Background:Anorectal malformations (ARM) are infrequent anatomic defects with a prevalence of 1 each 5000 alive newborns. Most of the patients repaired of this illness have some degree of constipation or fecal incontinence. There are few reports about manometric studies and biofeedback treatment in patients with anorectal malformations.Objectives:To evaluate of our population's anorectal functionality late after surgery by anorectal manometry; To study the response to diet, toilet training, and/or biofeedback.Methods:Anorectal manometry was done in 39 patients with ARM and 35 of them received combinated treatment of diet, toilet training and biofeedback. Age: 6 to 17 years old. Mean age: 8.05 years. Descriptive study. From april 2004 to april 2015. 14 patients had high malformations(36%), 18 had low malformations(46%) and 7 had cloaca(18%). Inclusion criteria: children over 6 years of age with anorectal malformation operated using Peña's technique (postsagittal anorectoplasty). Exclusion criteria: patients with neurological disorders that do not non‐compliant with study and treatment indications.Results:Average resting pressure was 28 mmHg(High level 25,5 and Low level 29,8 mmHg), range between 7 and 51 mmHg. Squeezing pressure between 29 and 120 mmHg(mean:69mmHg). Combined treatment of diet, toilet training, and biofeedback was succesfull to get total continence in 22 patients (4 cloacas, 10 high malformations and 8 low malformations), partial continence in 6(all low) and without response in 3(1 low, 1 high and 1 cloaca); 2 patients archived continence only with toilet training and 2 were lost in follow up(T.Fisher: 0,1). In high ARM 8 had positive(+) rectoanal inhibitory reflex(RAIR) and 6 negative(¬). In cloacas it was (+) in 3, (¬) in 3 and doubtful in 1. In low ARM 15(+), 2 (¬) and 1 doubtful. Reflex was obtained with 20 to 60cc of air(mean 31,36). The RRAI duration was 10 to 17 seconds(mean: 13 seconds). From 22 total continent, RAIR was (+) in 13, (¬) in 7 and hazardous in 2. All 6 partially continent had (+) RAIR; and from 3 incontinent, 2 had (+) RAIR and 1 (¬). From succesfully treated, 10 showed low resting pressures at the anal channel and 12 had normal pressures. Squeezing pressure was normal in 35 and negative in 4.Conclusions:1) RAIR was (+) in most of low malformations, while in high and cloacas only nearly half of them were (+). 2) RAIR and resting pressures at the anal channel were not useful to predict treatment success. 3) Malformation Height was not significant to determine patients outcome. 4) Combined dietary, toilet training and biofeedback therapy was effective for achievement of fecal continence in most of our population.

Stapled Hemorrhoidopexy With Longo Process in the Treatment of 3rd and 4th Degree Internal Hemorrhoids and Rectal Mucosal Prolapsus: A Prospective Study

Background: The hemorrhoid surgery done with a circular stapler is becoming increasingly common in recent years. Longo process first described in 1998 is a stapled hemorrhoidopexy (SH) makes transverse mucosal-submucosal rectal resection in the anal channel using the circular stapler. In this study Longo process was used the treatment of 3rd and 4th degree internal hemorrhoids and rectal mucosal prolapsus. Materials and Methods: Between January 2012-January 2015, at Diyarbakir Gazi Yasargil Training and Research Hospital General Surgery Clinic, a total of 18 patients with complaints of 3rd and 4th degree internal hemorrhoids and mucosal rectal prolapse were included in this prospective study. Circular stapler method using the procedure for proplase & hemorrhoids (PPH03) kit (Ethicon PROXIMATE® PPH) was applied to all cases. Results: Patients’ average pain score was 2 on a Visual Analogue Scale of 10. Most patients have no pain at all immediately after surgery. Symptom were bleeding in 2 patients, pain in 12 patients, and gas passing in 4 and constipation in 10 patients. Patients were followed for a median of 14 months. In 6 patients, pain was observed which responded to medical treatment, symptomatic skin pile was found in 4 patients. None of the patients had septic complication, incontinence and evidence of anal stenosis. Conclusion: hemorrhoidectomy with Longo is easily used acceptable treatment due to shorter healing process and less pain.

Аспирационное дренирование в профилактике послеоперационных гнойно-септических осложнений при брюшно-анальной резекции прямой кишки

Aim. Explore the effectiveness of the double-barreled drainage tube «tube in tube», mounted by the developed technique after rectum sphincter-sparing abdominoperitoneal resection due to cancer. Methods. The data of 52 patients with rectal tumors who underwent rectum sphincter-sparing abdominoperitoneal resection in two surgical wards over the past 4 years were analyzed. At the surgery, the colon was brought down together with anal channel mucosa excision and bringing down the colon mucosa to the anal channel. Rectum sphincter-sparing abdominoperitoneal resection was finished in all patients by placing a double-barreled drainage tube of the original construction to the retroperitoneal part of the cavity of the true pelvis by an original method via the anterior abdominal wall incision. No one-step intestinal stoma was exteriorized in any of the patients. Results. The average duration of postoperative hospital stay was 17 days; in patients who underwent non-hybrid operation (50 of 52 patients) - 15.3 bed-days. Postoperative complications occurred in a total of 11 (21.1%) patients, and the rate of septic complications was 1.9%, which is lower compared to published data. It is worth noticing that the use of our original method of pelvic cavity draining totally excludes peritoneal fistula formation and facilitates post-operative care. Conclusion. The proposed method of pelvic cavity draining at rectum sphincter-sparing abdominoperitoneal resections might be effective, as is associated with lower chance of purulent and septic complications. It excludes the possibility of perineal fistula formation, facilitates the post-operative period management.

Diagnostics Features and Results Estimation of Chronic Colostasis Investigation in Children

The purpose of the research is the applications of various methods of research and study of their results at chronic colostasis in children. Material and Methods: In the Republican Research Centre of Emergency Medical Care in Tashkent since 2006 till the present time in the branch of children’s surgery, 75 children were treated with chronic colostasis at the age of from 3 months till 14 years. With the purpose of the confirmation of the diagnosis, the children were examined according to the standards accepted at the centre: USG, coprological analysis, identification of the intestinal microflora, rectal manual examination, colonofibrocopy, histological investigation of the colon biopsies samples, roentgenocontrast investigation of the colon irrigography, multisliced computed tomography (MSCT) of the colon, definition of anal muscles contractile function. Results and Discussion: In 35 (46.7%) studied children, there was diagnosed dolichosigma, in 14 (18.7%) —dolichocolon or dolichomegacolon, in 14 (18.7%)—Hirschsprung’s disease, in 1 (1.3%)—congenital narrowing of the anal channel, in 1 (1.3%)—Pair’s syndrome, in 10 (13.3%)—functional constipations. Conclusions: Any of known methods at the isolated application does not give absolute reliance of correctness of verification of the diagnosis, especially in heavy cases, at a divergence of clinical findings and data of the patient investigation. Each of methods has the restrictions at application and interpretation of results. The examination of children with chronic constipations should be complex and gradual, and at the subsequent diagnostic stage, the clinician should determine individually in each concrete case.

An unusual case of mesalazine intoxication: Oral and rectal overloading of the rectal suppository form

Drugs containing 5-acetylsalicylic acid (5-ASA) have been commonly used for inflammatory bowel diseases for more than half a century, but no case about overdose of suppository form of mesalazine which was taken both orally and rectally has been reported in the related literature up to now. In the present case, a 20-year-old male patient who took 14.5 g of mesalazine rectally and orally for suicide purpose is discussed. He was an ulcerative colitis patient and depressed about his illness and routine life traffic. Although it was hard for him to take the suppository form orally because of its bad taste and structure, he took it with the help of water. In the patient's colonoscopy, diffuse hyperemia and edema extending from the anal channel to the proximal rectal mucosa and a 1.5 cm diameter ulcer expanding from anal channel through the rectum were identified. No pathology was found in the upper gastrointestinal endoscopy. Routine laboratory examination was performed and no abnormality was identified in the patient's total blood account, biochemical parameters and full-urine examination. In the control rectoscopy applied to the patient 15 days later, recovery of the ulcer was observed and he was discharged to be followed in the psychiatry clinic.

OC30.02: Changes in the female anal channel during voluntary squeeze assessed by vaginal ultrasound

Objective: Several mechanisms are believed to be in play maintaining anal continence, one of them being voluntary squeezing using the pelvic muscles. Here we study the effect of squeeze on the anal channel position and dimensions. Method: 20 healthy 0-gravida and 24 women with anal incontinence were recruited after written consent for 3D vaginal ultrasound measurements of angles and diameters during rest and squeeze. The anovaginal angle was defined as the angle between the posterior vaginal wall and the anterior wall of the channel assessed in a sagittal section. The anorectal angle was defined as the angle between the posterior wall of the anal channel and that of the rectal wall above the level of the puborectal muscle. Diameter and area of the mucosa were measured in the middle of the anal channel (lower level) and at the level of the puborectal muscle (upper level). Results: The 0-gravida had a mean age of 26 years with an incontinence score 0 on a scale 0–24. The incontinent women had a mean age of 59 years and their score was mean 11 (range 3–22). The ultrasound measurement results are presented in the table. Conclusion: Voluntary squeeze augments the bend of the anal and rectal tube at the level of the puborectal muscle and compresses the mucosal cuff at this level in young 0-gravida women. In incontinent women of a higher age, the anal tube is straighter, the mucosal cuff in the lower anal channel is smaller, and the effect of squeeze is less prominent or lacking.

OC30.03: The impact of first delivery on the levator hiatus and the urogenital hiatuxs

Objective: Several mechanisms are believed to be in play maintaining anal continence, one of them being voluntary squeezing using the pelvic muscles. Here we study the effect of squeeze on the anal channel position and dimensions. Method: 20 healthy 0-gravida and 24 women with anal incontinence were recruited after written consent for 3D vaginal ultrasound measurements of angles and diameters during rest and squeeze. The anovaginal angle was defined as the angle between the posterior vaginal wall and the anterior wall of the channel assessed in a sagittal section. The anorectal angle was defined as the angle between the posterior wall of the anal channel and that of the rectal wall above the level of the puborectal muscle. Diameter and area of the mucosa were measured in the middle of the anal channel (lower level) and at the level of the puborectal muscle (upper level). Results: The 0-gravida had a mean age of 26 years with an incontinence score 0 on a scale 0–24. The incontinent women had a mean age of 59 years and their score was mean 11 (range 3–22). The ultrasound measurement results are presented in the table. Conclusion: Voluntary squeeze augments the bend of the anal and rectal tube at the level of the puborectal muscle and compresses the mucosal cuff at this level in young 0-gravida women. In incontinent women of a higher age, the anal tube is straighter, the mucosal cuff in the lower anal channel is smaller, and the effect of squeeze is less prominent or lacking.

Haemorrhoids are associated not with hypertrophy of the internal anal sphincter, but with hypertension of the anal cushions.

A combined manometric and ultrasonographic study of the internal anal sphincter was carried out in 20 patients with haemorrhoids and 20 age-matched normal controls. Mean(s.e.m.) basal anal pressure was significantly higher in patients than in controls, 62(4) versus 45(6) cmH2O (P less than 0.05), although there were no significant differences in mean maximum basal and squeeze pressures. During rectal distension 90 per cent of patients showed no reduction in anal pressure in the outermost anal channel, although the internal sphincter electromyogram was suppressed and the external sphincter electromyogram did not necessarily increase above baseline. The mean(s.e.m.) maximum residual pressure was significantly higher in patients, 70(6) versus 45(6) cmH2O (P less than 0.05). Direct pressure measurement in anal cushions exhibited abnormally high median pressure in patients compared with controls, 35 versus 10 cmH2O (P less than 0.001). Pressures recorded during coughing and straining were also significantly higher in patients than in controls (P less than 0.001). Ultrasonographic study of the anal canal revealed a clear image of the internal sphincter, the thickness of which could easily be measured. The mean(s.e.m.) thickness of the sphincter was not significantly different, 2.3(0.2) versus 2.1(0.1) mm, between patients with haemorrhoids and controls (P = 0.18). The absence of any significant differences in the internal sphincter thickness between normal subjects and patients with haemorrhoids suggests that the high anal pressure in patients with haemorrhoids is of vascular origin.

Anogenital electrical stimulation as treatment of urge incontinence in children.

To evaluate retrospectively the result of anogenital afferent stimulation (AGAS) in neurological healthy children with therapy-resistant urge incontinence. The study included 48 children (24 girls and 24 boys, 5-14 years old) with a diagnosis of bladder instability verified by cystometry in all. Anogenital afferent stimulations were applied using a battery-powered dual constant-current stimulator. The children were stimulated continuously at 10 Hz for 20 min once or twice daily and if required the children and/or the parents continued to apply the treatment at home. For home stimulation a single (anal) channel stimulator was used. The patients were instructed to stimulate for 20 min at maximum intensity two to three times a week until the effects were optimal. The outcome was evaluated retrospectively by comparing voiding/incontinence diaries obtained before and at the follow-up 6-12 months after the end of treatment. AGAS was applied at the clinic for a median (range) of 9 (4-20) times. Thirty-one children continued with home stimulation for another 25 (5-96) sessions. At the follow-up, 18 children were cured and another seven improved, with a leakage score of less than half that before treatment. The treatment was well tolerated by most children. Anogenital afferent stimulation is an effective, potentially curative treatment in children with severe urge incontinence. Home stimulation is a well accepted adjuvant to treatment at the clinic and improves the outcome.