Rectal Pouch Research Articles

Light and electron microscopic study of the hindgut of the ant (Formica nigricans, hymenoptera): II. Structure of the rectum.

The rectum of the ant Formica nigricans is composed of six ovoid rectal papillae inserted into a rectal pouch. The wall of the rectal pouch is made up of a flat epithelium of simple rectal cells lined by cuticle, and surrounded by a circular muscle layer. Each rectal papilla is comprised by a simple columnar epithelium of principal cells facing the lumen, and a simple cuboid epithelium of secondary cells towards the hemolymph; a group of 20-25 slender junctional cells lies laterally between both epithelia enclosing an intrapapillar sinus. The muscle layer of the rectal wall also surrounds the base of the papillae. Principal cells do not exhibit extensive infoldings at the apical and basal plasma membranes. Lateral membranes, in contrast, develop highly folded mitochondria-scalariform junction complexes enclosing very narrow intercellular canaliculi between adjacent cells. These canaliculi open to wider intercellular sinuses that ultimately drain into the intrapapillar sinus at the sites of entry of tracheal cells. The lateral plasma membranes do not link to the apical or basal plasma membrane, thus originating a syncytium throughout the principal cells. The apical plasma membrane of secondary cells shows invaginations in relation with an apical tubulovacuolar system, bearing portasomes to the cytoplasmic side of the membrane. Secondary cells unite by convoluted septate junctions, and basolateral infoldings are also developed. These ultrastructural traits, some of them different from those found in other insects, are discussed and examined in relation to their role in water and solute absorption. A route for rectal transport in F. nigricans is proposed.

Preoperative Enzymo-Histochemical Diagnosis of Dysganglionoses Associated with Anorectal Malformations (ARM) with Recto-Vestibular and Recto-Perineal Fistula

The posterior sagittal anorectoplasty (PSARP) is widely recognized as the best technique available today for the surgical treatment of anorectal malformations (ARM). However, different retrospective studies on the functional results of PSARP in the treatment of ARM have shown different postoperative degrees of constipation. In particular, even in patients with normal sacrum, about 70% of operated ARM with vestibular fistula and about 50% with perineal fistula can be complicated by fecal constipation and pseudoincontinence. In order to identify preoperatively whether ARM patients present abnormal innervation patterns of rectal pouch and fistula (as reported by Holschneider et al [7]), we decided to study suction rectal biopsies performed by introducing SBT-100 rectal suction biopsy tool into the fistula at 6, 4, 3 and 2 cm from the meatus. To date, this approach has been adopted in 22 ARM cases (15 females and 7 males, age range 7 days-4 years), 6 of them with recto-vestibular fistula and 13 with recto-perineal fistula. Biopsies were frozen in isopentane at liquid nitrogen temperature and cryostatic sections were studied by acetylcholinesterase (AChE), succinic-dehydrogenase (SDH) and alpha-naphthyl-esterase (ANE) enzymo-histochemical techniques. The results concerning the innervation-type of fistula and proximal rectal pouch were confirmed by the biopsies obtained during PSARP. Our overall incidence of rectal innervation intrinsic disorders was 81.82%. In particular, all our cases of vestibular fistula presented associated dysganglionoses. The incidence of associated Hirschsprung's disease was high, corresponding to 18% of cases. Our results suggest that the high frequency of constipation in low forms of ARMS depends on primary intestinal neuronal malformations and it cannot be ascribed to a denervation secondary to rectal dissection and to PSARP procedure. We propose the introduction of this type of preoperative enzymo-histochemical diagnosis in ARM cases because it can select those patients with severe associated dysganglionoses. In our opinion, if this diagnosis is available preoperatively, PSARP can be performed without using abnormally innervated structures and reducing postoperative functional complications.

Analysis of 1,992 patients with anorectal malformations over the past two decades in Japan

Background/Purpose: This report describes the results of a group study of the Japanese Study Group of Anorectal Anomolies (JSGA) to determine the relative incidence of specific types of anorectal anomaly in Japan, and includes discussion of rectourethral fistula regarding the relationship between the levels of the fistula and blind end of the rectum, low type deformity, rare types, and associated anomalies. Methods: A total of 1,992 patients (1,183 boys and 809 girls) registered from 1976 to 1995 were analyzed. Results: High-type deformities accounted for 26.0% of cases, intermediate 10.7%, low 57.2%, miscellaneous 4.5% and unclassified 1.8%. The most frequent deformity was male anocutaneous fistula (n = 364), followed by male rectourethral fistula (n = 333), and female anovestibular fistula (n = 241). There were 42 rectovesical fistulas in boys and 93 rectocloacal fistulas in girls. Covered anus complete occurred at the same frequency (10.1% of low deformities) as covered anal stenosis. In rectourethral fistula, the blind end of the rectum lay at or above the level of the P-C line in 40.3% of cases, at or above the M line in 39.6% and at the vicinity of the I line in 20.2%, respectively. There was no parallel relationship between the site of the fistula opening and the level of the rectal pouch. The overall incidence of patients having one or more associated anomalies was 45.2%: 70.6% in high deformity, 60.7% in intermediate, and 31.3% in low. The rate of association of Down's syndrome with deformities without fistula (40.3%) was significantly higher than with deformities with fistula (0.3%). Conclusions: Rectovesical fistula and covered anus complete were not infrequent deformities in this series. We consider that at least 20% of rectourethral fistula should be categorized as intermediate or low deformity from the viewpoint of the position of there rectal pouch. A significant preponderance of Down's syndrome in the deformities without fistula suggests that further investigation of associated anomalies in comparison with other congenital diseases may provide insights into the pathogenesis of anorectal malformation in the field of molecular genetics.

Longterm outcomes and quality of life after Z-shaped anastomosis for Hirschsprung’s disease

Background: Z-shaped anastomosis is one of the modifications of Duhamel’s procedure that was designed to eliminate the blind rectal pouch and to achieve complete resection of the colorectal septum. It has been the most widely performed operation in Japan for many years. The longterm postoperative function of evacuation and quality of life of the patients are considered important to evaluate this procedure. Methods: At Kyushu University Hospital, from 1963 to 1997, 127 patients with Hirschsprung’s disease underwent Z-shaped anastomosis. As a result, 122 out of 127 patients (96%) survived. The present status and symptoms, and anorectal functions, including a manometric study and barium enema, were evaluated during the clinical followup. Results: A total of 99 of the 122 surviving patients (81%) were available for this study, and the mean postoperative period was 16 years. Evacuation scores in all patients were as follows; excellent, 62.2%; good, 28.6%; fair, 8.2%; and poor, 1.0%. The percentage of the patients who showed severe symptoms was 4.1% for diarrhea, 3.1% for constipation, 5.1% for incontinence, and 7.1% for soiling. The evacuation score improved chronologically and tended to reach a plateau at 10 to 15 years after operation, at which time 73% of the patients showed excellent outcomes and 95% were satisfactory (good or excellent). The appearance of a sense of defecation and an increase in the pressure difference between the anal canal and the rectum substantially contributed to the improvement in the defecation score. The appearance of the rectosphincteric reflex, including the atypical one, was seen in 40.5% of patients, but the appearance of a reflex did not seem to be related to the clinical status of defecation. Twenty-two of 30 patients older than 20 years were married, and 8 patients had children. Conclusions: The evacuation scores of in-patients undergoing Z-shaped anastomosis improved with age and were satisfactory (good or excellent) in most patients at least 10 years after operation. Most of the patients adapted to a normal social life.

The discovery and a study of the adventitia rectalis, a fibrous layer of the rectal wall

In sacral anoplasty, it is frequently found that an outer layer of the rectal wall, which resembles the structure of the taenia bands of the colon, limits the elasticity of the rectum making it different from the small intestine, hence preventing the rectal stump from being advanced to reach the perineum. Results of autopsy studies on 40 human babies and 40 dogs showed that a special collagenous fibrous layer called adventitia rectalis was found to limit the free expansion of the rectal wall. This was responsible for keeping the rectum a straight tubular shape with a fixed volume. This tissue plays an important role in bowel movement by defining a threshold of intrarectal pressure in the bowel reflex of defecation and by transmitting the expulsive force from the abdomen above down to the anal opening. This discovery may explain why (1) in Hirschsprung's disease, the preservation of the rectal wall in Soave's or Rehbein's procedure or partial preservation in Duhamel's operation will preserve better bowel function; (2) in atresia ani, rectal tapering results in better bowel control than rectal pouch amputation; and (3) in sacral anoplasty, multiple releasing incisions of adventitia rectalis at different levels will lengthen the rectal stump to about double its original length to reach the perineal incision, and the divided fibers will soon regenerate.

The anterior sagittal approach for high imperforate anus: A simplification of the mollard approach

High imperforate anus is a complex anomaly that requires a combination of careful preservation of native structures and precise anatomic reconstruction for optimal results. Previously the authors used an anterior perineal approach derived from the technique described by Mollard, with generally satisfactory results. The present report describes the authors' refinement of the technique to avoid skin flaps and to construct a shorter, more normal anal canal. The perineal approach, via an anterior sagittal incision, usually is combined with a transverse suprapubic laparotomy. The technique includes division of the external sphincter and longitudinal muscle fibers anteriorly, simple dilatation of the puborectalis, and division of the fistula close to the urethra, with preservation of the internal sphincter. The rectal pouch is brought down to the level of the puborectalis, without tapering, and the anoderm is brought up to the level of the rectal pouch to construct a shorter anal canal with a normal anorectal angle. This technique maximally preserves internal sphincter function, preserves specialized anoderm for the anal canal, and avoids extensive pelvic dissection and division of the levator sling. It also facilitates repair in the neonatal period, which may be optimal for long-term continence. The authors have used this technique in five patients, with good anatomic and short-term functional results. The authors believe that the technique provides optimal preservation of native tissues; only minimal destruction and dissection are required for reconstruction.

The rectoanal relaxation reflex and continence in repaired anorectal malformations with and without an internal sphincter-saving procedure

From 1985 to 1994, 27 patients with high- or intermediatetype imperforate anus who underwent anorectoplasty were studied for postoperative function, particularly with respect to the rectoanal relaxation reflex and continence. Fourteen of the patients had a rectourogenital fistula and were treated with posterior sagittal anorectoplasty using the fistular end as the neoanus (internal sphincter-saving). Nine patients had a blind rectal pouch and received posterior sagittal anorectoplasty using the trimmed bowel end for reconstruction of the neoanus (incomplete internal sphincter-saving). The other four had Rehbein's mucosa-stripping endorectal pull-through combined with anterior sagittal anorectoplasty (none internal sphincter-saving). A positive rectoanal relaxation reflex was found in 8 of 14 (57.1%), 7 of 9 (77.8%), and 3 of 4 (75%), respectively. It appears that the internal sphincter-saving procedure is not essential for the development of the rectoanal relaxation reflex. Compensation or adaptation most likely contributes to the presence of the rectoanal relaxation reflex, and perhaps to postoperative continence.

Innervation patterns of the rectal pouch and fistula in anorectal malformations: A preliminary report

The innervation patterns of the rectal pouch and fistula of 52 children with anorectal malformations were investigated. Posterior sagittal anorectoplasty was used for intermediate and high anomalies; for the latter it was combined with an abdominal approach. Perineoproctoplasty was performed for low anomalies. The specimens were investigated by acetylcholinesterase staining, lactate dehydrogenase, and succinyldehydrogenase reaction. They consisted of fistula material only in 23 patients and of parts of the rectal pouch in 29. Fourty-four patients (84.6%) had follow-up, and information on bowel movements and continence was obtained after a mean of 3.3 years. Abnormal innervation patterns were found in 96% of the specimens. All fistulas were found to be aganglionic, including the adjacent part of the rectum involving the internal sphincter equivalent. Classical aganglionosis was found in 31% of the rectal pouch specimens, hypoganglionosis in 38%, neuronal intestinal dysplasia (NID) type B in 14%, and dysganglionosis in 10%. All patients with severe constipation or soiling at the time of follow-up had some histopathological correlation. Of the 25 patients for whom the specimens had consisted of rectal pouch material, nine (31%) had severe constipation. All four patients with a low-type malformation who had follow-up and pathological innervation patterns in the rectal pouch suffered from severe constipation; this was true of only five of the 19 children with intermediate or high malformations ( P < .05). However, numerous pathological innervation patterns had been identified in patients who had normal bowel function at the time of follow-up. It is concluded that partial denervation of the rectum may not be the only cause in the pathogenesis of constipation after posterior sagittal anorectoplasty and perineoproctoplasty. The high frequency of neuronal intestinal malformations in the rectal pouch may be related to the higher frequency of bowel disturbances in patients with low malformations, in whom the resection was less radical. However, the clinical course is not necessarily related to specific histopatological findings. In the authors' opinion, the recommendation to use the distal rectal pouch and parts of the fistula in the reconstruction of anorectal malformations should be reconsidered.

Hirschsprung's disease: One surgeon's experience in one institution

The clinical experience of 137 patients treated by one pediatric surgeon at HanYang University Hospital over 12 years was analyzed. The sex ratio was 3.6:1 with male predominance. Neonatal Hirschsprung's disease (HD) occurred in 70 cases (51.1%). One hundred fourteen cases (83.2%) were short-segment and 23 cases (16.8%) were long-segment disease, of which 4 cases were total colon aganglionosis. Symptoms were abdominal distension, vomiting, constipation, and delayed passage of meconium. Family history was noted in 4 cases: 3 involved siblings and 1 involved relatives. All patients were male and had short-segment diseases. There were 3 pairs of monozygotic twins discordant for HD. Seventy-seven two-stage Duhamel operations were performed at the age of 121 ± 41.3 days. Primary Duhamel operations were performed on 30 children. Anorectal myectomies were performed on 12 cases of short rectal aganglionosis. The incidence of enterocolitis was 25.5% preoperatively and 10.1% postoperatively. Complications after the Duhamel operation were intestinal obstruction (3), wound disruption (4), and septum reformation (3) with fecaloma formation in the blind rectal pouch. Bowel function was normalized within 3 months in 77.3% and within 1 year after operation in 91.6%. Duhamel operation with a GIA stapler after preliminary colostomy could be done at the age of 104 days on average with good functional results and with acceptable morbidity. Primary Duhamel operation could be done safely on the patients whose conditions were diagnosed after 90 days of life with good results. There was no mortality after Duhamel operation.

Urinary diversion in females

Permanent urinary diversions are performed in the majority of patients after cystectomy for bladder carcinoma. An ileal conduit is the most common incontinent stoma created but long-term follow-up shows that up to 80% of patients may develop deterioration in the upper renal tract, stomal problems, pyelonephritis, urolithiasis or electrolyte abnormalities. Continent stomas require intermittent self-catheterization to empty their reservoirs, which are created from detubularized ileal or colonic bowel segments. Long-term follow-up is awaited with continent urinary diversions but the absence of a continually worn collection device is of major benefit to patients. The risk of developing colonic carcinoma and metabolic disturbances has detracted from the use of ureterosigmoidostomy as a common form of diversion, but recently the augmented valved rectum and the sigma rectal pouch have been described to minimize the metabolic changes previously described.

Reconstruction of urinary andgastrointestinal tracts in total pelvic exenteration: Experience at columbia-presbyterian medical center

To examine the effectiveness of and complications from total pelvic exenteration (TPE) with maintenance of urethral and anal sphincter function for locally invasive tumors of the pelvis. A retrospective review of 4 patients who have undergone TPE with urethral and anal sphincter preservation at Columbia-Presbyterian Medical Center in the last 2 years was performed with attention to perioperative morbidity and mortality, disease-free status, and need for further operative procedures. Two patients had colorectal adenocarcinoma, 1 had squamous cell carcinoma of the cervix, and 1 had prostate sarcoma. All had urinary tract reconstruction with orthotopic neobladder creation, and 3 of 4 had primary low rectal anastomoses for gastrointestinal reconstruction. One patient underwent creation of a J rectal pouch. One of 4 patients had received radiation therapy for the disease prior to surgery. There was no operative or perioperative mortality. Two of 4 patients required reoperation, 1 in the immediate postoperative period for repair of a left ureteral stricture, and the other 13 months postoperatively for repair of a rectal-neobladder fistula. With a mean follow-up of 25 months (range, 21 to 43 months), 3 of 4 patients are alive and free of disease. All living patients are continent of urine and 2 of 3 are continent of stool. Our experience confirms that TPE can be effective in controlling a variety of locally advanced pelvic tumors and can be performed in conjunction with simultaneous genitourinary and gastrointestinal reconstruction with minimal morbidity.

Results in the treatment of anorectal malformations with special regard to the histology of the rectal pouch.

The results of surgery for anorectal malformation (ARM) in 536 children treated between 1962 and 1993 are presented. Before 1985, patients underwent an abdominoperineal pullthrough for high and intermediate type of ARM, whereas cut-back procedures or perineoproctoplasty were performed in low type. Since 1985, we have changed our policy and performed a modified posterior sagittal anorectoplasty (PSARP) for intermediate type of ARM, eventually combined with an abdominal mobilization for high type. Perineoproctoplasty was reserved for low type of ARM. Data of 143 patients of Group 1 and 85 patients of Group 2 were available for follow-up. Continence was compared using a clinical score. Good or fair continence was found in 82% of patients operated on before 1985 (low type 85% good, 15% fair, intermediate type 17% good, 50% fair, high type 12% good, 37% fair), comparing to 93% in children treated after 1985 according to the new regimen (low type 88% good, 6% fair, intermediate type 59% good, 35% fair, high type 43% good, 47% fair). Liquid stools and inability to retain bowel contents were the main problem in the older series, whereas incontinence could often be attributed to constipation with overflow incontinence in the recently treated group of patients. Analysis of the innervation of fistula and distal rectal pouch in a prospective study comprising 40 of our most recent patients showed normal innervation in only 5% of patients, whereas 66% had neuronal intestinal malformations (NIM) including aganglionosis, NID and hypoganglionosis.(ABSTRACT TRUNCATED AT 250 WORDS)

A new look at an old operation for aganglionosis

Since 1980, the authors have operated on seven infants with total colon Hirschsprung's disease using the long Duhamel procedure. All infants were given an ileostomy when the diagnosis was made, and the long Duhamel procedure was performed between 6 and 24 months of age. This operation is the standard Duhamel procedure except that the sigmoid and descending colon form the fecal reservoir (as in the Martin variation of the Duhamel operation). A covering loop ileostomy was made in all the patients, and it was closed within 5 months; two infants had one episode of enterocolitis, 1 to 9 months after closure. The seven infants have had follow-up for 1 to 13 years; all are alive and well. The children are continent and toilet trained (age not with-standing); they have up to 10 formed stools per day. Two had some soiling at night. Whereas in the past the Duhamel procedure (in which a too-long anterior rectal pouch was left) often resulted in the formation of a fecal impaction, this does not occur when the material passing through the anus is at best semiliquid. With no long side-to-side anastomosis, the procedure is simple and complications are few.

Constipation is a major functional complication after internal sphincter-saving posterior sagittal anorectoplasty for high and intermediate anorectal malformations

Anorectal function was clinically, manometrically, and radiologically followed-up in 40 patients who underwent an internal sphincter-saving posterior sagittal anorectoplasty in 1984 to 1989. The functioning internal sphincter was manometrically verified in 83% ( 33 40 ) of the patients. Soiling related to sphincter insufficiency was found in only 4 of the 33 patients with a functioning internal sphincter; 5 of the 7 patients without an internal sphincter had soiling. Symptomatic constipation was found in 73% ( 24 33 ) of the patients with a functioning internal sphincter, but in only 28% ( 2 7 ) of the patients without this structure. Constipation was not associated with a stenotic anal outlet in any patient. On anorectal manometry, there was no statistical difference in basal anal pressures and internal sphincter reflex threshold values between constipated and nonconstipated patients. Histologically, ganglion cells were found in the proximal anal canal in all cases. The radiological size of the rectal pouch before closure of the protecting colostomy had a positive correlation with the severity of constipation. Medical treatment with diet and bulk-laxatives (13 patients) or with stimulant laxatives and occasional enemas (11 patients) successfully relieved constipation in 24 patients. In 2 patients, the symptoms were refractory to medical treatment and a resection of the megarectum was required. In conclusion, the preservation of the internal sphincter in patients with high or intermediate anorectal anomalies gives a good fecal continence outcome, but is associated with a high incidence of symptomatic constipation.

The use of a long split rectal tube to aid in pull-through procedures for imperforate anus

Problems with loss of correct orientation of the pull-through rectal pouch during posterior sagittal anorectoplasty (PSARP) for high imperforate anus can occur during laparotomy after perineal closure is complete. A simple modification of the de Vries-Peña technique is described that facilitates preservation of orientation and precise anatomical neomuscle construction. A slotted rubber tube preserves correct anatomical orientation of the neorectal pouch and allows accurate construction of the muscle complex around the tube.

The atonic baggy rectum: A cause of intractable obstipation after imperforate anus repair

Three children with successful imperforate anus repairs had chronic, intractable obstipation and recurrent fecal impaction refractory to diligent medical therapy. All had massive stool-filled rectums up to 14 cm in diameter on abdominal radiographs. They responded well to resection of the baggy atonic rectum with low anterior anastomosis. The massively dilated atonic rectal pouch in some children with repaired imperforate anus can demonstrate abnormal motility characterized by poor peristalsis and propulsion. This results in recurrent obstipation, impaction, and soiling refractory to the usually successful medical management.

Carcinoma of the rectal pouch following restorative proctocolectomy

A case of adenocarcinoma developing in the pouch following restorative proctocolectomy is presented. This seems to be the third reported in the literature. The carcinoma developed from the remnants of precancerous rectal mucosa left in the muscular rectal cuff. The patient had been suffering from ulcerative colitis for 17 years prior to the development of the malignancy. He presented with features of subacute intestinal obstruction. Diagnosis was by sigmoidoscopic examination of the pouch and biopsy. He was treated with abdominoperineal resection of the pouch and rectum, followed by chemotherapy.

Anterior perineal approach and three-flap anoplasty for imperforate anus: Optimal reconstruction with minimal destruction

Despite progress in the treatment of imperforate anus, anal stenosis, rectal prolapse, and other late complications may still arise. In 1987, we described the three-flap anoplasty for the treatment of rectal prolapse following pull-through operations. Since 1986, we have performed 14 three-flap anoplasties in combination with an anterior perineal rectal pull-through for primary treatment of imperforate anus. The mean age at definitive repair was 4.4 months (range, 0 to 14 months). Eleven of the 14 primary pull-through procedures could be performed through a perineal approach only. There were no deaths. At a mean follow-up of 24.2 months, none of the patients has developed prolapse, and only one has had a temporary stenosis. Three children are already fully continent, and soiling is absent in 12. All have a good sphincter tone. Although it is too early to evaluate long-term results, it appears that the three-flap anoplasty prevents mucosal prolapse through the interposition of a skin-lined anal canal. Moreover, a combination of this technique with the anterior perineal approach provides an excellent exposure with minimal dissection of the perineal and pelvic musculature and allows for easy and safe pull-through of the rectal pouch, making an abdominal counterincision unnecessary in most cases. It reproduces at the same time a normal anatomy while taking advantage of all existing structures.

Derm Detective: The Rectal Pouch: A Safer Alternative to Rectal Tubes

Derm Detective: The Rectal Pouch: A Safer Alternative to Rectal Tubes

The Rectal Pouch: A Safer Alternative to Rectal Tubes

Caring for a patient who is incontinent of stool consume enormous amounts of nursing time and energy. And, despite frequent linen changes and meticulous skin care, progressive irritation and breakdown may still result. A common approach to the problem is inserting a large Foley catheter into the patient's rectum and inflating the balloon to keep it in place-a practice that can damage the rectal sphincter and the mucous membranes. A safer alterna-