Defecation Reflex Research Articles

Lubiprostone Improves Distal Segment-Specific Colonic Contractions through TRPC4 Activation Stimulated by EP3 Prostanoid Receptor

Background: Prokinetic agents are effective in increasing gastrointestinal (GI) contractility and alleviating constipation, often caused by slow intestinal motility. Lubiprostone (LUB), known for activating CLC-2 chloride channels, increases the chloride ion concentration in the GI tract, supporting water retention and stool movement. Despite its therapeutic efficacy, the exact mechanisms underlying its pharmacological action are poorly understood. Here, we investigated whether LUB activates the canonical transient receptor potential cation channel type 4 (TRPC4) through stimulation with E-type prostaglandin receptor (EP) type 3. Methods: Using isotonic tension recordings on mouse colon strips, we examined LUB-induced contractility in both proximal and distal colon segments. Quantitative real-time polymerase chain reaction (qRT-PCR) was conducted to determine mRNA levels of EP1-4 receptor subtypes in distal colonic muscular strips and isolated myocytes. The effects of a TRPC4 blocker and EP3 antagonist on LUB-stimulated contractions were also evaluated. Results: LUB showed significant contraction in the distal segment compared to the proximal segment. EP3 receptor mRNA levels were highly expressed in the distal colon tissue, which correlated with the observed enhanced contraction. Furthermore, LUB-induced spontaneous contractions in distal colon muscles were reduced by a TRPC4 blocker or EP3 antagonist, indicating that LUB-stimulated EP3 receptor activation may lead to TRPC4 activation and increased intracellular calcium in colonic smooth muscle. Conclusions: These findings suggest that LUB improves mass movement through indirect activation of the TRPC4 channel in the distal colon. The segment-specific action of prokinetic agents like LUB provides compelling evidence for a personalized approach to symptom management, supporting the defecation reflex.

Physiology of lower gastrointestinal tract.

The lower gastrointestinal (GI) tract, formed from the midgut and hindgut, encompasses the colon, rectum and anal canal. The aim of this review is to provide an overview of the anatomy and physiology of the lower GI tract. Literature review on anatomy and physiology of the lower GI tract, including normal motility and phases of defecation. It derives its blood supply from the superior and inferior mesenteric arteries while it is innervated by the extrinsic autonomic (the thoracolumbar and sacral nerves) and the intrinsic enteric nervous system. The colon has four layers: mucosa, submucosa, muscularis externa and serosa. The anal canal ends in the internal and external anal sphincters (EASs) involved in continence and defecation. The lower GI tract is predominantly involved in digestion, absorption, defecation and protection. Defecation is a complex process that requires inter-neural (enteric and autonomic nervous systems), neurohormonal and neuromuscular coordination. It has four phases which include basal, pre-expulsive, expulsive and end phase. High-propagating contractions in the colon propel stool to the rectum leading to rectal distention and the recruitment of the recto-anal inhibitory reflex. Once able, the EAS, under full conscious control, is then relaxed allowing stool to be evacuated. Other defecation reflexes include the gastrocolic, gastroileal and coloanal reflexes. Recent advances provide novel techniques to investigate motility patterns including high-resolution manometry protocols with automated assessments, magnetic resonance imaging techniques for defecography, wireless motility capsules and fecobionics.

A brief physiology and pathophysiology of the anorectum based on the Integral Theory paradigm.

The remit of this review is confined to the experimental scientific works and surgeries based on the Integral Theory paradigm. The video abstract summarizes the anorectal function, how ligaments cause dysfunction and cure of fecal incontinence and obstructed defecation by ligament repair. Anorectal function is reflex and binary, with cortical and peripheral components. The same three oppositely acting reflex muscle forces which open and close the bladder, contract against the pubourethral (PUL) and uterosacral (USL) ligaments: (I) to close the anorectum for continence when the puborectalis muscle (PRM) contracts forwards; (II) to open the anorectum prior to evacuation when the PRM relaxes; (III) to stretch the rectum in opposite directions to support the anorectal stretch receptors "N" to prevent premature activation of the defecation reflex, (fecal urgency). Weak or loose PULs or USLs may cause dysfunction of closure, of evacuation, and inability to control the defecation reflex (fecal urgency). Repair of the PUL and USL can improve or cure these dysfunctions. The perineal body (PB) acts as an anatomical support for the distal vagina, anorectum and external anal sphincter (EAS). It serves as an anchoring point for the forward action of the pubococcygeus muscle (PCM), which tensions the anterior rectal wall during closure and defecation. Bladder and bowel dysfunction have a similar pathogenesis, ligament laxity, mainly pubourethral and uterosacral, with added PB damage for anorectal dysfunction. PB damage can cause obstructive defecation and descending perineal syndrome (DPS). Repair of damaged PUL and USL can restore the closure and evacuation functions of both bladder an anorectum. DPS can be cured by repair of the PB's suspensory ligaments, deep transversus perinei.

Prevalence of Manasikahetu (Psychological factors) in patients suffering from Ajirna (Indigestion)

In Ayurveda, digestive power is compared to fire and is also called Agni. The weakening of digestive power () by various reasons, lead to dyspepsia or indigestion and the state called as . Different symptoms like abdominal distension and hard stools detrimentally affect the lives of patients suffering from , often leading to psychological disturbances.Study focuses on the elucidation of the prevalence of psychological issues in patients suffering from .Descriptive data of 100 pre-diagnosed patients, showing definite relation to causative factors was analyzed using numbers and percentages. Chi square test was also used to correlate the data.: This cross-sectional observational study included the pre-diagnosed patients of Ajirna, from the age group of 20 to 60 years. A structured and pilot-tested 14 item questionnaire was used to collect data.: In our study, 67% of the patients suffered from chronic indigestion, and 33% from acute indigestion. patients were majorly affected by hard stools (89%), abdominal distension (85%), and incomplete defecation or bloating (54%). Other noteworthy factors are 72% of the patients showed excessive water intake per day and restraining from defecation reflex (70%). Almost 90% of the population was sentimental, with 76% was short-tempered and 72% restraining the crying reflex. The frequent emotional breakdown was noticed in 71% of the patients, and 40% suffered from grief regularly.Our study suggests the correlation of chronic digestive problems with psychological factors () in patients. Therefore, treatment of along with associated psychological ailments will be crucial for effective outcome.

Medical rehabilitation of children operated on for anorectal malformations

Surgery to correct anorectal malformations is only one of the stages in the complex treatment of children with malformations of the anorectal area. The optimal choice and technique of surgical correction of the defect and the absence of postoperative complications will certainly contribute to obtaining good functional results. Nevertheless, the final result is largely determined by the quality of rehabilitation measures in the immediate and long-term postoperative period. Medical rehabilitation is aimed at normalizing the passage of feces and the tone of the rectal sphincter and pelvic floor muscles, restoring the defecation reflex, and reducing astheno-vegetative disorders. Rehabilitation measures should be carried out continuously until the newly formed rectum reaches normal function.

Modulation of the autonomic nervous system by one session of spinal low-level laser therapy in patients with chronic colonic motility dysfunction.

Patients with a defecation disorder may not evoke a normal defecation reflex, or the reflex may be excessive, as a dysfunction of the spinal autonomic nervous system. Treatment with various forms of lumbar and sacral neuromodulation have shown symptom improvement, but potential changes in autonomic functioning are rarely studied. Here we evaluate the effects on autonomic function of a single session of low-level laser therapy (LLLT) on the lumbar and sacral spine in 41 patients with chronic gastrointestinal motor dysfunction. The LLLT protocol used red LED light at a wavelength of 660 nm for 10 min and infrared LED light at a wavelength of 840 nm for 10 min, followed by infrared laser light at a wavelength of 825 nm for 10 min. Effects on the autonomic nervous system were assessed by measuring heart rate variability (HRV) changes. Respiratory Sinus Arrhythmia (RSA) and Root Mean Square of Successive Differences (RMSSD) were used to quantify parasympathetic reactivity; the Baevsky’s Stress Index (SI) reflected sympathetic activity while the ratios SI/RSA and SI/RMSSD were used to show shifts in autonomic dominance. The results indicate that lumbar and sacral neuromodulation using light arrays reduced, whereas stimulation by the laser probes significantly increased parasympathetic activity. The light arrays increased whereas the laser probes significantly decreased sympathetic activity (SI). The entire protocol shifted the autonomic balance toward parasympathetic activity. The comparison of actual vs. sham neuromodulation proved that the change in HRV parameters was due to actual light stimulation and not due to the arrays and probe touching the skin. In conclusion, a single session of LLLT markedly affects autonomic nervous system activity reflected in changes in HRV which is only possible by generating activity in the spinal autonomic nerves. These results warrant a study into the effects of LLLT on restoring autonomic dysfunction in chronic refractory colonic motility disorders.

Assessment of defecation disorders using high-resolution MRI-defecography.

The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders. 44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T. MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases. As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.

Effects of Sacral Nerve Stimulation on Neuronal Nitric Oxide Synthase in the Colon and Sacral Cord of Rats With Defecation Disorder After Spinal Cord Injury

This study aimed to determine the effects of sacral nerve electrical stimulation (SNS) on neuronal nitric oxide synthase (nNOS) in the colon and sacral cord of rats with defecation disorder after spinal cord injury (SCI). Rats with severe SCI (T10) were used as models and randomly divided into an SCI group and an SNS group. After 14 days of treatment, the intestinal transport function was assessed. Finally, the differences in nNOS immunoreactive cells, protein levels, nNOS mRNA, and NO content in the colon and sacral cord tissues were estimated using immunohistochemistry, Western blot, real-time polymerase chain reaction, and nitrate reductase method. The intestinal transport function of the SNS group was superior to that of the SCI group (P < 0.05). The average optical density of nNOS immunoreactive positive cells in the SCI group were significantly increased compared with those in the sham group. The content of NO of the SCI group significant increased compared with those of the sham group and the SNS group (both P < 0.01). The nNOS mRNA and protein expression was higher in the SCI group than in the sham group (P < 0.01), while that in the SNS group was significantly lower than that in the SCI group. SNS could reduce nNOS expression in the colon and sacral cord of SCI rats. This reduction may be an important neuromodulation mechanism for SNS to improve defecation reflex and promote the recovery of intestinal transit function.

The anorectal defaecation reflex: a prospective intervention study.

AimOur hypothesis is that there may be a neural pathway with sensory afferent neurons in the anal canal that leads to rectal contraction to assist defaecation. We aimed to compare rectal motility between healthy participants with or without anal anaesthesia.MethodThis prospective intervention study consisted of two test sessions: a baseline session followed by an identical second session. During each session we performed the anal electrosensitivity test, the rectoanal inhibitory reflex test and rapid phasic barostat distensions. Prior to the second session, participants were randomly assigned to receive either a local anal anaesthetic or a placebo.ResultsWe included 23 healthy participants aged 21.1 ± 0.5 years, 13 of whom received an anal anaesthetic and 10 a placebo. All participants showed a transient rectal contraction during the first test session, which decreased significantly after anal anaesthesia (18.6 ml vs. 4.9 ml, p = 0.019). The maximum rectal contraction was comparable to the baseline results in the placebo group. Furthermore, the electrosensitivity at the highest centimetre of the anal canal correlated with the maximum rectal contraction (r = −0.452, p = 0.045).ConclusionAll healthy study participants display an involuntary, reproducible rectal reflex contraction that appears to be innervated by afferent nerves in the proximal anal canal. The rectal reflex contraction appears to play a role in defaecation and we therefore refer to this phenomenon as the anorectal defaecation reflex. Knowledge of the anorectal defaecation reflex may have consequences for the diagnostics and treatment of constipation.

Functional constipation in children

Constipation is one of the most common nosologies that a pediatric gastroenterologist deals with during outpatient visits. In the vast majority of children with constipation the problem is functional in nature. According to studies published in the Russian Federation, the frequency of constipation in children accounts for about 25–30%. The joint clinical guidelines of the European and North American Societies of Pediatric Gastroenterologists, Hepatologists and Nutritionists for the management of children with functional constipation were published in 2014. The national guidelines for the diagnosis and treatment of functional constipation are based on these guidelines. According to the clinical guidelines, the 2006 Rome III criteria should be used to establish the diagnosis of functional constipation in children. In May 2016, the Rome IV criteria that provide separate diagnostic criteria for infants and children under 4 years of age and children over 4 years and teenagers were adopted. A group of children with symptoms of constipation, who have already had toilet skills at the time of diagnosis, was identified among infants and children under 4 years of age. The presence of anxiety symptoms or refractory constipation (constipation that does not resolve within 3 months while taking adequate therapy) is considered an indication for use of additional examination methods, including instrumental ones. The manifestation of constipation is often associated with a change in eating habits - the period of introduction of complementary feeding in infants or the beginning of going to a day-care centre, inadequate fluid intake. The onset of constipation often coincides with the period of the development of hygiene skills (potty training). The voluntary stool retention by a child who is trying to avoid painful defecation experiences is the main mechanism for the development of constipation. The aim of functional constipation treatment is to soften the stools, which facilitates painless defecation and ensure that there is an urge to defecate. Clinical examples of the treatment of patients with functional constipation and chronic colonic stasis, functional constipation and encopresis are provided. The outcome of the treatment of functional constipation is to ensure painless defecation and the development of a stable defecation reflex. The drug therapy for functional constipation is based on the use of laxatives. Dietary advice and behavioral therapy also play an important role.

Modern technologies of medical rehabilitation of children with chronic constipation

Medical rehabilitation of children with chronic constipation is a complex system of measures, including: rational nutrition, drug therapy, physiotherapy, physical therapy, massage, et. The main tasks of medical rehabilitation are: normalization of the passage of fecal masses, tone of the sphincter apparatus of the rectum and pelvic floor muscles, restoration of the defecation reflex and reduction of astheno-vegetative disorders. The article describes the methods of physiotherapy used in the treatment of chronic constipation in combination with diet, daily routine, medication, physical therapy and massage: amplipulstherapy, interference therapy, percutaneous electroneurostimulation, high-intensity magnetic therapy, transcranial electrostimulation. Balneotherapy methods are widely used: internal and external application of mineral waters, as well as heat treatment and peloid therapy. Natural and artificial physical factors are assigned differentially, taking into account the type of intestinal motility disorders. One of the promising areas of modern physiotherapy is the study of the combined and combined use of two physical factors that increase the effectiveness of the program of medical rehabilitation of children with chronic constipation. Methods of medical and psychological correction are of great importance in the medical rehabilitation of children with chronic constipation.

Optimizing Autonomic Function Analysis via Heart Rate Variability Associated With Motor Activity of the Human Colon.

The parameters of heart rate variability (HRV) can non-invasively assess some autonomic activities, and HRV is influenced by many bodily actions. Although parasympathetic activity is the primary driver of colonic propulsive activity, and sympathetic activity a major inhibitor of colonic motility, they are rarely measured and almost play no role in diagnosis of colon motor dysfunction or in standard treatments. Here we set out to optimize HRV analysis of autonomic nervous system changes related to human colon motility. The electrocardiogram and impedance were recorded in synchrony with colonic motor patterns by high-resolution manometry. Respiratory sinus arrhythmia (RSA), root mean square of successive differences of beat-to-beat intervals (RMSSD), the Baevsky Index or Sympathetic Index (SI), and the ratios of SI/RSA and SI/RMSSD were shown to indicate a marked increase in parasympathetic and withdrawal of sympathetic activity during the high-amplitude propagating pressure waves (HAPWs). Strong associations were seen with HAPWs evoked by a meal and rectal bisacodyl indicating a marked increase in parasympathetic and withdrawal of sympathetic activity during the gastrocolic reflex and the defecation reflex. When HAPWs occurred in quick succession, parasympathetic activation (RSA and RMSSD) occurred in a rhythmic fashion. Hence, during propulsive motor patterns, an overall shift in autonomic activity toward increased parasympathetic control was shown to be reflected in HRV. HRV assessment may therefore be valuable in the assessment of autonomic dysfunction related to colonic dysmotility.

A35 ASSOCIATIONS BETWEEN AUTONOMIC DYSFUNCTION, COLONIC DYSMOTILITY AND ABSENT DEFECATION REFLEXES IN PATIENTS WITH CHRONIC REFRACTORY CONSTIPATION

Abstract Background A defecation reflex involves sensory information from the colon sent to the central nervous system which results in propulsive motor patterns in the colon through programmed neural activity from the autonomic nervous system. Neurological causes of constipation are recognized but specific neurological pathways that contribute to pathophysiology of the disease is underexplored. Diagnosis and treatment usually do not involve the autonomic nervous system. Aims Our objective was to assess autonomic dysfunction and abnormal defecation reflexes as a possible cause of chronic constipation. Methods Defecation reflexes were assessed by high-resolution colonic manometry through balloon distention, meal intake, and rectal bisacodyl. Specific heart rate variability (HRV) parameters were used to assess general orthostatic autonomic reactivity, and autonomic functioning during high resolution colonic manometry, in 14 patients with chronic refractory constipation considered for surgery. Results All patients had a unique combination of motility, reflex ability and HRV profiles. Patients overall did not generate HAPWs or had lower HAPW amplitude and lower propulsive activity compared to healthy individuals. Half of the 14 patients were tested to have high sympathetic tone based on Baevsky’s stress index prior to HRCM, and 11 of the patients had sympathetic hyper-reactivity and/or low parasympathetic reactivity to at least one type of colonic stimulation during HRCM. Abnormal autonomic tone or autonomic reactivity to colonic stimulation was present in all four patients with absence of the vagosacral defecation reflex. Five of the seven patients with absence of the sacral defecation reflex showed high sympathetic tone or high sympathetic reactivity to stimulation. Only two patients had abnormality in coloanal coordination and this was associated with low parasympathetic reactivity to stimulation in both patients. Conclusions The assumption that colonic resection was needed to remove an inert colon was wrong in most patients, but most patients had some form of reflex abnormality. Sympathetic dominance far outweighed parasympathetic dysfunction. Incorporation of assessments of defecation reflexes and autonomic nervous system activity into diagnosis of chronic refractory constipation provides a comprehensive pathophysiological understanding of specific defective neurological pathways contributing to dysmotility. This forms the basis for our individualized treatment efforts through sacral neuromodulation. Funding Agencies CIHR

A232 AUTONOMIC FUNCTION ANALYSIS VIA HEART RATE VARIABILITY ASSOCIATED WITH PROPULSIVE MOTOR PATTERNS OF THE HUMAN COLON

Abstract Background Although parasympathetic activity is the primary driver of colonic propulsive activity, and sympathetic activity a major inhibitor of colonic motility, they are rarely measured and almost play no role in diagnosis of dysfunction or standard treatments. Aims Our aim was to develop assessment of autonomic nervous system activity associated with the major propulsive motor patterns, an essential part of defecation reflexes in the human colon orchestrated by neural reflexes. Methods One hundred and forty-five motor patterns were recorded from eleven healthy volunteers using high resolution colonic manometry (HRCM) with concurrent electro- and impedance cardiography to evaluate changes in parameters of heart rate variability (HRV). Results High-amplitude propagating pressure waves (HAPWs) that often start in the proximal colon, traverse distally and end with anal sphincter relaxation, were associated with a 8.2% (P&amp;lt;0.02) increase in the respiratory sinus arrhythmia (RSA) value, a 24.6% increase in the root mean square of successive differences of beat to beat intervals (RMSSD), indicated a strong parasympathetic reactivity that subsided within 2 min of termination of the HAPW (Figure 1). The measure of sympathetic reactivity to motor patterns was best reflected by the Baevsky Stress Index (or Sympathetic Index, SI) that reduced by 45% (P&amp;lt;0.02). We developed a measure of autonomic balance, the SI/RSA ratio that changed from 18.8 to 8.7 (54%; P&amp;lt;0.01) during motor activity and recovered to 16.1 immediately after (P&amp;lt;0.005). The SI/RMSSD reduced by 65% (P&amp;lt;0.01). When HAPWs occurred in quick succession, the parasympathetic activity showed rhythmicity at the HAPW frequency that slowly terminated when motor activity stopped. During motor activity, the heart rate did not significantly change. Conclusions The major propulsive motor pattern of the human colon, the HAPW as measured by HRCM that is part of the major defecation reflexes, is associated with marked changes in parasympathetic and sympathetic activity that is reflected and measurable as heart rate variability parameters. This opens the way to evaluate autonomic dysfunction in patients with colon motor disorders. Funding Agencies CIHRNSERC, Farncombe Institute

A235 EFFECTS OF SACRAL PHOTOBIOMODULATION ON THE AUTONOMIC NERVOUS SYSTEM IN PATIENTS WITH COLONIC DYSMOTILITY

BackgroundPatients with chronic refractory constipation show colon dysmotility, including impaired coordination of descending colon-sigmoid colon-rectum-anal sphincter motor functions; this may involve slow colonic transit and colo-anal dyssynergia. Impaired neuronal communication between the sacral defecation center and the distal colon may be causative. In addition, patients with lumbosacral neurological conditions (with lower back pain) may not be able to evoke an effective defecation reflex.AimsTo evaluate if a single therapeutic session of sacral low-level laser therapy (LLLT) would affect the autonomic activity in patients with chronic constipation as revealed by changes in heart rate variability, and to report a multi-session treatment case study.MethodsIn 41 patients with chronic constipation, one session of LLLT was executed, using red LED light at a wavelength of 660 nm for 10 minutes and infrared LED light at wavelength of 840 nm for 10 minutes followed by infrared laser light with wavelength of 825 nm for 20 minutes, while measuring the electrocardiogram. One patient received this treatment 8x over 3 weeks.ResultsThe lumbar-sacral light array treatment showed a significant decrease in parasympathetic activity (RSA & RMSSD) whereas pure sacral laser light treatment showed a significant increase in parasympathetic activity (RSA & RMSSD) as well as a reduction in sympathetic activity (Baevsky’s stress index: SI) (table). A single session of LLLT was also executed during HRCM in 8 patients with some but not all showing evoked colonic motility. Before COVID-19 shutdown, one patient was successfully treated. With a history of chronic constipation without ability to have spontaneous bowel movements for 5 years, symptoms improved from 13 to 8 (on a 20 scale) and quality of life improved from 1.5 to 2.5 (on a 0–4 scale) after 8 sessions. Sympathetic reactivity from supine to standing markedly reduced, from highly elevated measured as the Baevsky index from 55 to 153 s-2 it improved from 42 to 75 s-2 upon standing after 4 sessions. Parasympathetic reactivity did not change.ConclusionsA single session of sacral LLLT markedly affected autonomic nervous activity reflected in changes in HRV. The LLLT is likely affecting the sacral defecation center through peripheral nerves entering and exiting the spinal cord including the dorsal root ganglia. LLLT treatment of a patient with inability to generate spontaneous bowel movements, resulted in ability to have complete evacuations associated with marked reduction in sympathetic reactivity during the supine-standing test, after 4 LLLT sessions. Funding AgenciesCIHRFarncombe Family Digestive Health Research Institute

Modern Opportunities of Medical Rehabilitation of Children with Chronic Constipation

This article reviews the methods of medical rehabilitation used in the complex treatment of children with chronic constipation. Medical rehabilitation of children with chronic constipation is a complex system of measures that include rational nutrition, medication therapy, physiotherapy, kinesotherapy, massage, etc. The main objectives of the medical rehabilitation of children with chronic constipation are normalization of the passage through the intestines, improvement of tone of the pelvic floor muscles, restoration of the defecation reflex. The article describes the methods of physiotherapy used in the treatment of chronic constipation in children in combination with diet, daily regimen, drug treatment, physiotherapy exercises and massage: amplipulse therapy, interference therapy, ultrasound therapy, percutaneous electroneurostimulation, fluctotuorization, high-intensity magnetic therapy, transient transduction. The methods of balneotherapy are widely used: the internal and external use of mineral waters, as well as heat therapy and peloidotherapy. Natural and artificial physical factors are assigned differentially, taking into account the type of intestinal motility disorder. One of the promising directions of modern physiotherapy is to study the combined and combined use of two physical factors that increase the effectiveness of the medical rehabilitation program for children with chronic constipation. Methods of medical and psychological correction are of great importance in the medical rehabilitation of children with chronic constipation. The medical rehabilitation of children with chronic constipation is carried out taking into account the individual program of medical rehabilitation of the child, which makes it possible to increase the efficiency of medical rehabilitation and the patient’s quality of life.

Transperineal Intracath Meconiolysis and Evacuation Technique of "Distended" Bowel Evacuation for One-Stage Laparoscopic Anorectoplasty for High Anorectal Malformations in Males.

Introduction: One-stage anorectoplasty provides maximum potential for "normal" defecation reflexes right at birth and avoids complications and problems of colostomy. One-stage laparoscopic anorectoplasty (OSLARP) for rectourinary fistula (RUF) is restricted by distended bowel obscuring the working space for laparoscopy. This study describes transperineal intracath meconiolysis and evacuation (TIME) technique for OSLARP in the treatment of RUF in neonates. Materials and Technique: High male anorectal malformation (ARM) admitted from January 2016 to March 2019 were included in the study. Diagnosis of level of ARM was made on the basis of invertogram. Patient presenting with lethal comorbidities were excluded who underwent colostomy. The technique involved placement of a 16G intracath in the perineum through the site of future neo-anus, which was identified using muscle stimulator. Meconiolysis and evacuation was done using warm saline and 2% N-acetyl. The creation of enough abdominal space was achieved after evacuation and two working instruments were placed in paraumbilical positions. The laparoscopic dissection and division of fistula was done as followed in standard laparoscopic anorectoplasty. Results: Seventeen patients were selected for TIME technique but on laparoscopy 2 patients had severe necrotizing enterocolitis hence they underwent laparoscopy-assisted high sigmoid colostomy. Fifteen patients underwent OSLARP successfully. Mean weight was 2.5 ± 0.4 kg, mean gestational age was 36 ± 5 weeks, and mean age of presentation was 3.5 ± 1 days after birth. The TIME technique was successful decompressing bowel in all the patients. Out of 15 patients of OSLARP, 14 had rectoprostatic urethral fistula and 1 had rectovesical fistula. Mean total operative duration of OSLARP was 46 ± 15 minutes. Patients who could be followed for 3 years had good results in terms of continence and bowel movements. Discussion: TIME technique is a very simple and effective way to overcome the problem of associated colonic distention in neonatal one-stage laparoscopic anoplasty.

The Defecation Reflex Assessed by High-Resolution Colonic Manometry.

The Defecation Reflex Assessed by High-Resolution Colonic Manometry.

Roles of the noradrenergic nucleus locus coeruleus and dopaminergic nucleus A11 region as supraspinal defecation centers in rats.

We previously demonstrated that administration of norepinephrine, dopamine, and serotonin into the lumbosacral defecation center caused propulsive contractions of the colorectum. It is known that the monoamines in the spinal cord are released mainly from descending neurons in the brainstem. In fact, stimulation of the medullary raphe nuclei, the origin of descending serotonergic neurons, enhances colorectal motility via the lumbosacral defecation center. Therefore, the purpose of this study was to examine the roles of the noradrenergic nucleus locus coeruleus (LC) and dopaminergic nucleus A11 region in the defecation reflex. Colorectal motility was measured with a balloon in anesthetized rats. Electrical stimulation of the LC and A11 region increased colorectal pressure only when a GABAA receptor antagonist was injected into the lumbosacral spinal cord. The effects of the LC stimulation and A11 region stimulation on colorectal motility were inhibited by antagonists of α1-adrenoceptors and D2-like dopamine receptors injected into the lumbosacral spinal cord, respectively. Spinal injection of a norepinephrine-dopamine reuptake inhibitor augmented the colokinetic effect of LC stimulation. The effect of stimulation of each nucleus was abolished by surgical severing of the parasympathetic pelvic nerves. Our findings demonstrate that activation of descending noradrenergic neurons from the LC and descending dopaminergic neurons from the A11 region causes enhancement of colorectal motility via the lumbosacral defecation center. The present study provides a novel concept that the brainstem monoaminergic nuclei play a role as supraspinal defecation centers.NEW & NOTEWORTHY The present study demonstrates that electrical and chemical stimulations of the locus coeruleus or A11 region augment contractions of the colorectum. The effects of locus coeruleus and A11 stimulations on colorectal motility are due to activation of α1-adrenoceptors and D2-like dopamine receptors in the lumbosacral defecation center, respectively. The present study provides a novel concept that the brainstem monoaminergic nuclei play a role as supraspinal defecation centers.

Novel method for restoration of anorectal function following spinal cord injury via nerve transfer in rats

ObjectivesNerve transfer has been developed to restore partial function after serious nerve injuries, for example, restoring bladder control after spinal cord injury (SCI). Our aim here was to establish a preclinical proof-of-concept model using nerve transfer for restoring anorectal function after SCI.SettingWe used laminectomy to model SCI, and bilateral spinal ventral and dorsal nerve root anastomosis to re-establish connectivity to the anorectal musculature.MethodsMultidisciplinary methods were used to assess the anatomical and functional integrity of the alternative spinal-to-anorectal nerve circuit. Adult rats were used to establish the model. Bilateral anterior and posterior L5 nerve roots were surgically matched with anterior and posterior of S1 nerve roots by microscopic anastomosis to establish an artificial rectal reflex arc with complete sensory and motor pathways. Twelve weeks later, we used retrograde nerve tracing and neurohistomorphological analysis to assess anatomical integrity of the new artificial rectal reflex arc. Anorectal manometry was used to assess the function of the new nerve circuit.ResultsRetrograde tracing with recombinant attenuated pseudo rabies virus indicated that the new neural pathway was successfully established to the anorectal musculature after experimental SCI. Toluidine blue-stained sections of the anastomosis site revealed normal-appearing nerve fiber morphology and regeneration, and transmission electron microscopy revealed myelinated axons. Anorectal manometry revealed significant anorectal functional recovery.ConclusionThese results suggest that our model is a feasible first step in developing an alternative reflex pathway after laminectomy at L4 to S2 and shows promise for effective restoration of anorectal function.