Anal Sphincter Function Research Articles

Short-course preoperative radiotherapy combined with chemotherapy in resectable locally advanced rectal cancer: local control and quality of life

The authors sought to evaluate the clinical outcome after preoperative short-course radiotherapy (SC-RT) for locally advanced resectable rectal cancer in terms of local control (LC) and quality of life (QoL). Patients with locally advanced rectal cancer enrolled between 1997 and 2008 in an observational study of preoperative SC-RT were analysed. The treatment algorithm was neo-adjuvant chemotherapy (CT) administered for four cycles, followed by preoperative SC-RT administered 1 week after chemotherapy completion, delivering 20 Gy in five fractions over 1 week. Immediately in the following week surgery was performed. The adjuvant 5-FU-based CT was planned for pathological stage UICC≥II. LC, overall survival (OS), disease-free survival (DFS), early and late complications (RTOG scale) were analysed. All patients completed the EORTC QoL (C-30 and C-38), Faecal Incontinence QoL, and International Index of Erectile Function questionnaires (IIEF). A total of 67 patients were analysed. Chemotherapy and radiotherapy were well tolerated. At the pathological analysis, stable disease was obtained in 24 patients (36%), reduction of disease stage in 34 patients (50.7%), and progression in nine cases (13.3%). Adjuvant chemotherapy was indicated in 21 patients. Two locoregional recurrences, both within the radiotherapy volume, were observed, resulting in a 5-year LC of 97%. The 5-year DFS was 84%, with mean time to systemic progression of 24 months. After a mean follow-up of 114 months, the 5-year OS rate was 67%. Late toxicity >grade II was observed in 9% of patients. High anterior resection (AR) patients had significantly better scores than low AR or abdomino-perineal resection (APR). A total of 89% of the patients treated with conservative surgery had regular anal sphincter function. In male patients undergoing AR or APR, erectile dysfunction was found in 47% and 75% of the cases, respectively. Preoperative SC-RT combined with chemotherapy for locally advanced resectable rectal cancers was well tolerated. This treatment resulted in favourable LC, OS, low rates of toxicity and satisfying QoL.

Drug treatment for faecal incontinence in adults.

Faecal incontinence (leakage of bowel motions or stool) is a common symptom which causes significant distress and reduces quality of life. To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities. We searched the Cochrane Incontinence Group Specialised Register of Trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearching of journals and conference proceedings (searched 21 June 2012) and the reference lists of relevant articles. All randomised or quasi-randomised controlled trials were included in this systematic review. Two review authors independently screened abstracts, extracted data and assessed risk of bias of the included trials. Sixteen trials were identified, including 558 participants. Eleven trials were of cross-over design. Eleven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea, following ileoanal pouch or rectal surgery, or due to use of a weight-reducing drug). Two trials were amongst people with weak anal sphincters, one in participants with faecal impaction and bypass leakage, and one in geriatric patients. In one trial there was no specific cause for faecal incontinence.Seven trials tested anti-diarrhoeal drugs to reduce faecal incontinence and other bowel symptoms (loperamide, diphenoxylate plus atropine, and codeine). Six trials tested drugs that enhance anal sphincter function (phenylepinephrine gel and sodium valproate). Two trials evaluated osmotic laxatives (lactulose) for the treatment of faecal incontinence associated with constipation in geriatric patients. One trial assessed the use of zinc-aluminium ointment for faecal incontinence. No studies comparing drugs with other treatment modalities were identified.There was limited evidence that antidiarrhoeal drugs and drugs that enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. Loperamide was associated with more adverse effects (such as constipation, abdominal pain, diarrhoea, headache and nausea) than placebo. However, the dose may be titrated to the patient's symptoms to minimise side effects while achieving continence. The drugs acting on the sphincter sometimes resulted in local dermatitis, abdominal pain or nausea. Laxative use in geriatric patients reduced faecal soiling and the need for help from nurses.Zinc-aluminium ointment was associated with improved quality of life, with no reported adverse effects. However, the observed improvement in quality of life was seen in the placebo group as well as the treatment group.It should be noted that all the included trials in this review had small sample sizes and short duration of follow-up. 'Risk of bias' assessment was unclear for most of the domains as there was insufficient information. There were no data suitable for meta-analysis. The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which use the recommendations and principles set out in the CONSORT statement, and include clinically important outcome measures, are required.

Imaging the course of a hypoplastic cerebellum in a spina bifida newborn

We report about a spina bifida patient with myelomeningocele at the lumbar level L5, extensive Chiari malformation type II with vermal herniation reaching to C6 with downward pontine shift, and a severe hypoplastic cerebellum. Chromosomal diagnostic tests showed no abnormalities. The infant experienced severe central apneas successfully treated with oxygen therapy and caffeine medication; functional motor level was established at L5 with sparse anal sphincter function. After surgical intervention (myelomeningocele repair and ventriculoperitoneal shunt placement), these abnormalities significantly improved on radiological imaging; the preoperative hypoplastic, almost undetectable, cerebellum developed to a fair sized cerebellum. Apneas disappeared over time and the patient showed further developmental improvement. Herein, we illustrate and discuss the changes of the cerebellar volume before and after neurosurgical intervention.

LE TRAITEMENT CHIRURGICAL DES FISTULES ANALES

In this study the authors report the surgical treatment result of 300 cases of anal fistula, performed during 5 years. The mean age is 37 years (16 - 71 years). Males were prevalent (83%). Intersphincteric and low transsphincteric are the most frequent fistula. Fistulotomy alone was performed in 41%, and slow fistulotomy in 59%. There was no mortality, whereas the morbidity rate was 9,3% and include 4% of recurrence and 1,7% of transient anal incontinence, 1,3% of anal pruritus, 1,3% of anal exuding, and 1% of postoperative bleeding. The preoperative evaluation of anal sphincter function and the respect of the fistulotomy principles are guaranties of satisfactory results.

Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy

To date fistulotomy is still the treatment of choice for patients with a transsphincteric fistula passing through the lower third of the external anal sphincter, because it is a simple, effective and safe procedure with a minimal risk of incontinence. However, data suggest that the risk of impaired continence following division of the lower third of the external anal sphincter is not insignificant, especially in female patients with an anterior fistula and patients with diminished anal sphincter function. It has been shown that ligation of the intersphincteric fistula tract (LIFT) is a promising sphincter-preserving technique. Therefore, we questioned whether LIFT could replace fistulotomy in patients with a low transsphincteric fistula. A consecutive series of 22 patients with a low transsphincteric fistula of cryptoglandular origin underwent LIFT. Continence scores were determined using the Rockwood Fecal Incontinence Severity Index. Median follow-up was 19.5months. Primary healing was observed in 18 (82%) patients. In the four patients without primary healing, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulotomy with preservation of the external anal sphincter. The overall healing rate was 100%. Six months after surgery, the median incontinence score was not changed significantly. Low transsphincteric fistulae can be treated successfully by LIFT, without affecting faecal continence. Division of the lower part of the external anal sphincter is no longer necessary in the treatment of low transsphincteric fistulae, which is essential for patients with compromised anal sphincters.

Repeated Transanal Endoscopic Microsurgery Is Feasible and Safe

The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade malignant lesions in the low and middle rectum are well recognized. This study examined the feasibility and safety of a repeated TEM procedure. Patients who underwent a repeat TEM for excision of rectal lesions, either for involved resection margins or for local recurrence, between the years 2000 and 2010, were identified. Rectal lesion characteristics were retrieved. Mean operative times, length of hospital stay, and intra- and postoperative complications were compared between primary and repeated procedures. The postoperative histopathology reports were reviewed, and the adequacy of resection was determined. All patients completed a questionnaire based on the Wexner score for anal sphincter function evaluation. Fourteen patients (3 female, 11 male) underwent a repeat TEM operation during the study period. All procedures were completed endoscopically. Indications for repeated TEM were involved margins in 12 patients and recurrence of benign tumor in 2. Mean operative time, mean length of hospital stay, and rate of postoperative complications were similar for primary and repeated TEM procedures (62.5 ± 17 versus 55 ± 23 minutes, P=.181; 1.7 ± 1.3 versus 1.7 ± 1.12 days, P=.99; and 35.7% versus 21.4%, P=.66, respectively). The Wexner score was comparable at baseline and after the first and the second TEM procedures (1.5 ± 2.3, 1.5 ± 2.3, and 3.3 ± 3.1, respectively; P=.188). No cases of fecal incontinence following a repeat TEM were documented. Repeated TEM is feasible and safe and may be appropriate for selected patients.

Functional New Sphincter Ani Reconstruction by Using Neurovascualr Antropylorus Transposition After an Anorectal Excision

See Article on Page 7-11 Receptors for the external sphincter response are supposed to lie in the rectal mucosa or near the mucosa. The external sphincter is only supplied by somatic pudendal nerves from the second sacral nerve. The levator ani and the pubolrectalis muscles are found to be supplied by multiple direct branches from the sacral nerves S2 to S4 [1]. If the sphincter muscle is divided at the level of the puborectaslis sling, the patient will be incontinent. Several kinds of traumas, colorectal diseases, congenital anomalies, neurologic diseases and other miscellaneous conditions cause fecal incontinence. Anal incontinence may not be a life-threatening disease, but it is often disabling. A permanent colostomy is often preferable in cases of end-stage anal incontinence, but many patients with a stoma hope to improve their quality of life with a new functional anal sphincter and without a stoma [2]. For cases in which the anal sphincter muscles have been destroyed, several measures, such as gracilis muscle transfer, gluteus maximus transposition and an artificial sphincter, can be used for supplementing the sphincter mechanism. The main drawback of a cross-innervated skeletal muscle neosphincter is the limited range of muscle transposition because of its considerably fragile vascular pedicle. Another disadvantage is the low pressure, which is insufficient to hold stools in the neorectum, especially in the cases of gracilis muscle transfer. Goldsmith reported eight cases of a pedicled gastric pyloric valve transposition to provide a new sphincter ani in a human being [3]. Twenty-five percent of the patients had serious complications of pelvic sepsis and transplant necrosis. Manometric studies were done preoperatively on patients with anal sphincter damage and after pyloric valve transposition. Manometric data demonstrated that six cases had tolerable anal continence. Goldsmith insisted that a vascularized pyloric valve supplied by the gastroepiploic artery within the omental pedicle could serve as a replacement for an excised anal sphincter. He also commented that the operation would have to be done by an experienced surgeon. In a real operation, when the omental pedicle is long, maintaining an effective blood supply is not easy. Schwabegger reported functional sphincter ani reconstruction using free latissimus dorsi muscle transfer with coaptation to the pudendal nerves in dogs [4]. He concluded that a free graft with nerve coaptation seemed to be superior to any pedicled muscle flap. A cadaveric study for neoanal reconstruction showed the feasibility of pyloric valve transposition with pudendal nerve anastomosis. Anastomosis between the distal portion of the anterior branch of the vagus nerve of the pylorus and the inferior rectal nerve was also feasible. However, in my opinion, the problem of a pedicled flap can be fixed by using a free pyloric valve graft with microanastomosis of vessels and nerves. I suggest that if one is able to do a free graft of a new microvascular anastomosis between the gastroepiploic vessel of the pyloric valve and the internal pudendal vessel, the blood supply to the valve will be effectively maintained. The pudendal nerve contains sensory, sympathetic and parasymphathetic fibers. A nerve coaptation close to the transplanted muscle allows rapid muscle reinnervation, with an estimated regeneration of 1 mm per day. During the intervening period, external stimulation might prevent muscle atrophy. A good portion of a well-vascularized muscular pyloric valve can be positioned as a circular physiologic contractile ring with optimal vascular and nerve supplies around the anal canal. However, even though a new anal sphincter would provide good continence, constipation and incomplete evacuation must continue to be considered. In conclusion, we are not given a validated quality of life in human trial data to evaluate the true effect of anal sphincter replacement. However, we are eager to develop an easy and effective treatment to restore anal incontinence without the need for colostomy diversion.

Autologous growth factors used for the treatment of recurrent fistula-in-ano preliminary results

Dear Sir, The risk of postoperative complications such as fistula recurrence or incontinence increases in patients with recurrent fistulas and high transsphincteric and suprasphincteric fistulas [1, 2]. Due to the large number of postoperative complications, in recent years, there have been some attempts to treat this disease conservatively. Methods of treatment include tissue adhesives and plugs that close the internal orifice as well as autologous growth factors that are present in the platelet-rich plasma and used as “natural glue” to close the lumen of the fistula. Autologous platelet-rich plasma (APRP) is platelet concentration derived from centrifuged full blood collected from a patient right before surgery. The platelet-rich plasma (PRP) obtained using the Gravitational Platelet Separation III System (GPS® III, Biomet Merck, UK) constitutes 10 % of the original volume of the collected blood and more than 90 % of its mass is made of platelets. Platelet-rich plasma preparation is administered to the fistula tract following curettage (Fig. 1). We report our experience with the GPS® System in 2 patients with anal fistula. Fig. 1 Autologous platelet-rich plasm administration to fistula tract A 50-year-old male underwent surgery for recurrent suprasphincteric posterior horseshoe fistula at our unit. At a time of surgery curettage of the fistula tract was performed, and then a GPS® III preparation was administered to the fistula tract. The patient was discharged home 2 days after surgery. Fourteen days after surgery, the patient presented at the ward due to an inflammatory infiltration. Two months after surgery, a follow-up examination revealed fistula recurrence. A 37-year-old male with recurrent intersphincteric anterior fistula-in-ano, and with a narrow, transsphincteric branch running towards the puborectalis loop also underwent surgical treatment at our unit. At a time of surgery, the main tract of the fistula was removed and APRP (GPS® III) was administered to the narrow lateral tract following curettage. The patient was discharged home on postoperative day 3. No recurrence of the fistula was reported within the 6-month follow-up period. The first experiences with using growth factors were related to the treatment of patients with chronic skin ulcers [3]. At present, indications for using APRP therapy are being expanded. APRP is used in burn units and for the treatment of non-healing wounds. There are also reports of using APRP for the treatment of tendon injuries, muscle injuries, degenerative lesions of tendons and joints and bone voids, mainly in maxillofacial surgery. APRP therapy is also offered by aesthetic surgery centres, where it is used to fill deep wrinkles. In the healing process, thrombin stimulates platelet alpha-granules to release growth factors which, through appropriate stem cell receptors, stimulate stem cell differentiation. Reports of using autologous growth factors for the treatment of fistula-in-ano date back to the late 1990s. In 1999, a paper on the treatment of patients with recurrent fistula-in-ano was published [2]. It described a group of 30 patients with complex fistulas, rectovaginal fistulas and vesicorectal fistulas. The cure rate was 60 %. A similar cure rate was reported by Cintron et al. [1]. In the literature, there are reports of using APRP as an element of multi-stage treatment of fistula-in-ano. The first stage involves inserting a loose seton through the fistula tract in order to drain and heal any local inflammatory lesions. The second stage involves APRP administration, which resulted in fistula healing in as many as 75 % of patients [4]. Hagen et al. [5] used the two-stage method, and in 2009 they published the results of administering APRP to 10 patients with high transsphincteric fistulas. The first stage of treatment involved draining the fistula tract and then closing the internal opening with a patch of mucous membrane and filling the tract with APRP. After almost 2 years of follow-up, fistula recurrence was observed in 10 % of the patients. Available publications include papers that present small groups of patients, different types of fistulas qualified for APRP treatment and different methods of surgery. However, the results are encouraging since this method has no negative effect on anal sphincter function.

Anorectal function after partial intersphincteric resection in ultra‐low rectal cancer

To investigate the feasibility and efficacy of intersphincteric resection (ISR), in terms of postoperative anorectal function, for ultra-low rectal cancer in mainland China. A total of 43 patients who consecutively underwent curative partial ISR for ultra-low rectal cancer between 2006 and 2009 were enrolled in the study. Defaecatory function was assessed, using detailed questionnaires, 3, 6 and 12 months after surgery. The Wexner score was used to assess faecal continence, and anal manometry studies were performed to analyse anal sphincter function. Overall defaecatory function was assessed as being satisfactory in 41 of 43 patients. Twelve months after surgery, the mean Wexner score was 4.0 ± 3.6. Anal manometry studies showed a significant change at 3 months and further, gradual, improvement over the following year. During the postoperative period, maximum squeeze pressure reached a normal value of 174.1 ± 19.5 mmHg (P = 0.041) by 6 months and resting pressure was 42.4 ± 5.6 mmHg by 12 months, which was close to the preoperative level (P = 0.038). Because of the satisfactory recovery of defaecatory function and good oncological results, partial ISR may be recommended as an effective sphincter-preserving operation for patients with ultra-low rectal cancer.

Comparative study of anal acoustic reflectometry and anal manometry in the assessment of faecal incontinence

Anal acoustic reflectometry (AAR) is a reproducible technique providing a novel physiological assessment of anal sphincter function. It may have advantages over conventional anal manometry. The aims of this study were to determine the ability of AAR and anal manometry to identify changes in anal sphincter function in patients with faecal incontinence (FI) and to relate these changes to the severity of FI. Women with FI underwent assessment with AAR and anal manometry. All patients completed the Vaizey FI questionnaire and were classified according to symptom type (urge, passive or mixed) and integrity of the anal sphincters. The ability of AAR and anal manometry to correlate with symptom severity was evaluated. AAR was compared with anal manometry in detecting differences in anal sphincter function between symptomatic subgroups, and patients with and without a sphincter defect. One hundred women with FI were included in the study. The AAR variables opening pressure, opening elastance, closing elastance and squeeze opening pressure correlated with symptom severity, whereas the manometric measurements maximum resting pressure and maximum squeeze pressure did not. Unlike anal manometry, AAR was able to detect differences in anal sphincter function between different symptomatic subgroups. [corrected]. An anal sphincter defect was not associated with a significant change in anal sphincter function determined by either AAR or anal manometry. In the assessment of women with FI, AAR variables correlated with symptom severity and could distinguish between different symptomatic subgroups. AAR may help to guide management in these patients.

Use of a spiral rectal diaphragm technique to control anal sphincter incontinence in a cat

A 10-year-old castrated male domestic shorthair cat was examined for a mass involving the right anal sac region. The mass was diagnosed as a fibrosarcoma, and resulted in progressive tenesmus, requiring repeated resection. Surgical removal of the fibrosarcoma was performed on 4 occasions, including complete resection of the anal sphincter muscles and portions of the rectum. A perineal urethrostomy was required during the third surgical procedure secondary to tumor invasion of the preputial tissues. To reduce involuntary loss of feces, the remaining rectal wall was rotated approximately 225° prior to surgical closure during the second, third, and fourth surgical procedures. This procedure created a natural spiral diaphragm within the rectal lumen. The elastic spiral barrier reduced inadvertent fecal loss and facilitated fecal distention of the terminal portion of the colon, allowing the patient to anticipate the impending passage of feces and to use the litter tray on a daily basis. With complete loss of the terminal portion of the rectum and anal sphincter muscles, spiraling the rectum created a deformable threshold barrier to reduce excessive loss of stool secondary to fecal incontinence. On the basis of the positive outcome in this patient, this novel technique may be a useful option to consider for the treatment of cats with loss of anal sphincter function.

Effect of repeat acute injury on contractile function of the external anal sphincter in an animal model

Our aim was to estimate the physiologic effects of early repeat transection and repair on the contractile properties of the external anal sphincter (EAS) in a rat model. Eighty young female rats underwent anal sphincter transection and repair. After 7 days, they were randomized to repeat sphincter transection (injury-injury, n = 40) or sham operation (injury-sham, n = 40). Thereafter, the anal sphincter complex was dissected, mounted, and analyzed for contractile function 7 days, 21 days, 3 months, or 6 months after the second operation. Contractile function was also determined in 40 age-matched unoperated controls (n = 10 for each time point). Statistical analysis was performed using analysis of variance (ANOVA) with Tukey-Kramer adjustment for multiple testing. P ≤ 0.05 was considered significant. Although single injury (injury-sham) resulted in modest compromise of sphincter function, repeat injury (injury-injury) resulted in profound impairment of twitch tension, maximal tetanic responses, and maximal electrical-field stimulation (EFS) induced-force generation at 7 days. After single injury, parameters of contractile function returned to baseline uninjured levels by 21 days. In contrast, sphincter function remained reduced 21 days after repeat injury. Contractile function of sphincters from both injury-sham and injury-injury animals were no longer impaired at 3 and 6 months. In this animal model, repeat injury and repair of the EAS 7 days after the initial injury resulted in prolonged compromise of EAS function compared with single injury. Nevertheless, contractile function of the double-injured sphincter fully recovered with time, resulting in no long-term impairment.

Effects of Scleroderma Antibodies and Pooled Human Immunoglobulin on Anal Sphincter and Colonic Smooth Muscle Function

Patients with systemic sclerosis (SSc) have impairments in gastrointestinal smooth muscle function. The disorder has been associated with circulating antibodies to cholinergic muscarinic the type-3 receptor (M(3)-R). We investigated whether it is possible to neutralize these antibodies with pooled human IgGs (pooledhIgG). We studied the effects of IgGs purified from patients with SSc (SScIgGs) on cholinergic nerve stimulation in rat colon tissues. We also examined the effects of SScIgGs on M(3)-R activation by bethanechol (BeCh), M(3)-R occupancy, and receptor binding using immunofluorescence, immunoblot, and enzyme-linked immunosorbent analyses of human internal anal sphincter (IAS) smooth muscle cells, before and after administration of pooledhIgG. Functional displacement of M(3)-R occupancy by the SScIgGs was compared with that of other IgGs during the sustained phase of BeCh-induced contraction of intact smooth muscles from rats. SScIgG significantly attenuated neurally mediated contraction and acetylcholine release in rat colon as well as BeCh-induced sustained contraction of the IAS smooth muscle. In immunofluorescence analysis, SScIgG co-localized with M(3)-R. In immunoblot and enzyme-linked immunosorbent analyses, M(3)-R loop-2 peptide and human IAS SMC membrane lysates bound significant amounts of SScIgG, compared with IgGs from healthy individuals and pooledhIgG. Binding was attenuated significantly by application of pooledhIgG, which by itself had no significant effect. Incubation of samples with pooledhIgG, or mixing pooledhIgG with SScIgG before administration to tissues, significantly reduced binding of SScIgG, indicating that pooledhIgG prevents SScIgG blockade of M(3)-R. In studies of rat and human tissues, pooled human IgG prevent and reverses the cholinergic dysfunction associated with the progressive gastrointestinal manifestations of SSc by neutralizing functional M(3)-R antibodies present in the circulation of patients with SSc.

Transvaginal resection of a rectal gastrointestinal stromal tumor

We herein report a case in which a rectal gastrointestinal stromal tumor (GIST) was resected transvaginally. The patient, a 45-year-old female, had a rectal GIST on the anterior wall of the lower rectum. The tumor was within 6 cm of the anal verge, a location which would normally require performing an ultra-low anterior resection using the Double Staple Technique, and a diverting stoma. To minimize the invasiveness of treatment and to reduce the postoperative morbidity, a transvaginal resection was performed. Under general anesthesia, the posterior vaginal mucosa was incised vertically. The tumor was then excised en bloc with the overlying rectovaginal septum and rectal mesenchymal tissue. The defect was repaired primarily, and a diverting stoma was not required. The procedure was uncomplicated, and the patient was discharged home with an intact anal sphincter function and no abdominal incisions. In female patients, transvaginal resection of low anterior rectal lesions may provide a minimally invasive alternative to the traditional ultra-low anterior resection.

Treatment of carcinoma of the anal canal at Groote Schuur Hospital

Chemoradiation is the treatment of choice for squamous carcinoma of the anal canal, resulting in the same local control rates as surgery but with the advantage of organ function preservation. We aimed to review all cases of anal canal carcinoma treated at Groote Schuur Hospital between 2000 and 2004 and to assess treatement outcome. The records for 31 patients presenting during this period were reviewed. Patient and tumour characteristics were recorded. Twenty-six patients were treated with chemoradiation. Local failure-free, colostomy-free and overall survival were calculated using the Kaplan-Meier method. Compared with the literature, the median patient age was younger and the stage was more advanced in this study. The complete response rate for all stages with chemoradiation was 80%. The local failure-free survival at 5 years was 60.7%. Colostomy-free and overall survival at 5 years were 59.2% and 65.6%, respectively. The patients presented with locally advanced disease. Chemoradiation is effective treatment for this group of patients and the majority avoid a permanent colostomy as they preserve anal sphincter function.

Short-Term Effects of Neoadjuvant Chemoradiotherapy on Internal Anal Sphincter Function

Neoadjuvant chemoradiotherapy is recommended in the treatment of locally advanced rectal cancer. Studies have suggested that chemoradiotherapy adversely affects anorectal function. However, the functional implication and the underlying neuromyogenic changes involved in radiation-induced damage are poorly understood. This study evaluated the functional changes following chemoradiotherapy on the internal anal sphincter. This article describes an in vitro study on the internal anal sphincter collected from patients undergoing abdominoperineal resection or proctectomy. Five patients were treated by surgery alone (control group), and 6 received preoperative chemoradiotherapy (treatment group). Sphincter strips were mounted in organ bath, and the responses to electrical field stimulation and drugs were monitored. The study was performed at the University of Oxford. The end points of this study were to investigate whether chemoradiotherapy has any significant effects on internal anal sphincter function and, subsequently, to establish the type of injury induced. Chemoradiotherapy strips developed similar tone, but significantly lower spontaneous activity (p = 0.001) than controls. Electrical field stimulation induced relaxation, followed by contraction. At 50 Hz, electrical field stimulation produced 25.6 ± 4.9% (mean ± SE) of maximum relaxation followed by a contraction of 5.5 ± 0.9% of basal tone in chemoradiotherapy strips i9n comparison with 47.0 ± 6.2% (p = 0.009) and 17.7 ± 4.0% (p = 0.007) in controls. Relaxation was significantly attenuated by N-nitro-L-arginine. Significant differences were found in responses to carbachol (p = 0.018) and phenylephrine (p = 0.022), but not to sodium nitroprusside. This work was limited by the relatively small number of patients enrolled, because of the difficulty of finding human tissue for laboratory studies, and the lack of long-term results. Chemoradiotherapy significantly impairs internal anal sphincter function and intrinsic nerves seem more susceptible than smooth muscle. The exclusion of anal canal from the radiation field is recommended, when oncologically safe.

Sphincter-preserving surgery after preoperative radiochemotherapy for T3 low rectal cancers

The aim of this study was to evaluate the feasibility and the effectiveness of preoperative radiochemotherapy followed by total mesorectal excision (TME) and sphincter-preserving procedures for T3 low rectal cancer. Patients with rectal cancer and T3 tumors located within 1-6 cm of the dentate line received preoperative radiochemotherapy. Concurrent 5-fluorouracil-based radiochemotherapy was used. Radical resection with TME and sphincter-preserving procedures were performed during the six to eight weeks following radiotherapy. Survival was analyzed using the Kaplan-Meier method. The anal function was evaluated using the Wexner score. The clinical response rate was 83.5%, overall downstaging of T classification was 75.3% and pathological complete response was 15.3%. The anastomotic fistula rate was 4.7%. A median follow-up of 30 months showed the local recurrence rate to be 4.7% and the distant metastasis rate to be 5.9%. The three-year overall survival rate was 87%. The degree of anal incontinence as measured using the Wexner score decreased over time, and the anal sphincter function in the majority of patients gradually improved. Preoperative radiochemotherapy was found to improve tumor downstaging, reduces local recurrence, increase the sphincter preservation rate, and is therefore of benefit to patients with T3 low rectal cancer.

The Effects of Age and Childbirth on Anal Sphincter Function and Morphology in 999 Symptomatic Female Patients With Colorectal Dysfunction

Conflicting data exist on the contributions of advancing age and childbirth on the structure and function of the anal sphincter. This study aimed to examine the relative contributions of age and childbirth in a large cohort of women referred for investigation of symptoms of colorectal dysfunction (fecal incontinence and constipation). This study was conducted at a specialist surgical colorectal investigation unit in a university teaching hospital. Retrospective analysis was performed on prospectively collected demographic, symptom profile, and physiologic data from 3686 female patients. Strict exclusion criteria were applied, leaving 999 patients for univariate, multivariate, and logistic statistical modeling. The effects of independent variables alone and in combination on anal sphincter pressures (resting and squeeze increment) and the presence of sphincter defects (internal and external) were expressed as regression coefficients and odds ratios. Median age was 42 years (range, 16-88), and parity was 2 (range, 0-11); 16% were nulliparous. Three hundred sixty patients had fecal incontinence, 352 had constipation, and 287 had combined symptoms. Anal resting tone decreased with age by 0.66 cm H2O per year, and by 4.3 cm H2O per birth, and was associated with both internal and external anal sphincter defects (p = 0.0001 for both). Squeeze increment pressures decreased by 0.3 cm H2O per year, and by 3.8 cm H2O per birth; decreased pressures were, however, only significantly associated with external anal sphincter defects (p = 0.0001) as a result of childbirth. Cesarean delivery was protective against both reduced anal pressures and sphincter defects. Pudendal nerve terminal motor latencies increased bilaterally with age and with vaginal delivery; the impact of both was greater on the left nerve. Rectal sensation was unaffected by age or parity. Aging predominantly affects anal resting pressures; childbirth, particularly instrumental delivery, is detrimental to the structure and function of the external sphincter.

Investigation of anal sphincter function following Mainz pouch type II urinary diversion after radical cystectomy

Our aim was to evaluate the anal sphincter function following cystectomy with urinary diversion of Mainz pouch II. Seventy-six patients were involved in our survey, and the cohort was for two groups divided. The first group was a retrospective review of 40 patients with examination of the state of continence. Comparative examinations on anal sphincter function and the quality of life survey were carried out. The second group consisting of 15 patients underwent a prospective investigation including rectal manometry in both the pre- and postoperative periods. Measurements of resting anal sphincter pressure (RASP), maximal anal closing pressure (MACP) and the function of the recto anal inhibitions reflex were taken. In the first part of our investigation, 80% of the patients were considered as continent. There were no significant differences observed between RASP values in the cases of continent as well as of incontinent patients (79.2 ± 2 vs. 73.6 ± 68.4 mmHg, p = 0-53); however, the MACP values of the continent patients were significantly higher (204.3 ± 22.8 vs. 117.3 ± 14 mmHg, p = 0.001). In the course of the second experiment, both the RASP (86.3 ± 18.7 vs. 76.1 ± 13.9 mmHg p = 0.0049) and the MACP (232.2 ± 53.8 vs. 194.1 ± 74.5 mmHg, p = 0.0054) were detected as decreasing in the case of the incontinent group. A decrease in rectal sphincter function is responsible for incontinence following Mainz pouch type II diversion, and this dysfunction can be correlated with the surgery. Ureterosigmoideostomy is therefore considered as a useful method of urinary diversion only in selected cases with proven good sphincter function.

Increased rectal wall stiffness after prostate radiotherapy: relation with fecal urgency

Late anorectal toxicity is a frequent adverse event of external beam radiotherapy (EBRT) for prostate cancer. The pathophysiology of anorectal toxicity remains unknown, but we speculate that rectal distensibility is impaired due to fibrosis. Our goal was to determine whether EBRT induces changes of rectal distensibility as measured by an electronic barostat and to explore whether anorectal complaints are related to specific changes of anorectal function. Thirty-two men, irradiated for localized prostate carcinoma, underwent barostat measurements, anorectal manometry, and completed a questionnaire prior to and 1 year after radiotherapy. The primary outcome measure was rectal distensibility in response to stepwise isobaric distensions. In addition, we assessed sensory thresholds, anal pressures, and anorectal complaints. External beam radiotherapy reduced maximal rectal capacity (227 ± 14 mL vs 277 ± 15 mL; P < 0.001), area under the pressure-volume curve (3212 ± 352 mL mmHg vs 3969 ± 413 mL mmHg; P < 0.005), and rectal compliance (15.7 ± 1.2 mL mmHg(-1) vs 17.6 ± 0.9 mL mmHg(-1) ; P = 0.12). Sensory pressure thresholds did not significantly change. Sixteen of the 32 patients (50%) had one or more anorectal complaints. Patients with urgency (n = 10) had a more reduced anal squeeze and maximum pressure (decrease 29 ± 11 mmHg vs 1 ± 7 mmHg; P < 0.05 and 31 ± 12 mmHg vs 2 ± 8 mmHg; P < 0.05 respectively) compared with patients without complaints, indicating a deteriorated external anal sphincter function. Irradiation for prostate cancer leads to reduced rectal distensibility. In patients with urgency symptoms, anal sphincter function was also impaired.