Rectoanal Inhibitory Reflex Research Articles

Does Water-Perfused Catheter Overdiagnose Anismus Compared to Balloon Probe?

Background: The purpose of this study was to compare the manometric assessment of straining effort as if to defecate and rectoanal inhibitory reflex obtained with a rectosphincteric balloon probe and with a waterperfused catheter in the same subject. Methods: Twelve healthy volunteers underwent two manometric assessments of anal sphincter function and electromyographic (EMG) surface recordings, one with a rectosphincteric balloon and one with a water-perfused catheter, 7 days apart in random order. Results: Increased EMG activity in the external anal sphincter in the midst of the rectoanal inhibitory reflex ( P < 0.001) and during straining for defecation ( P < 0.001) was more frequently observed with the perfused system than with the balloon probe. There was a discrepancy between the EMG activity of the external anal sphincter and the anal pressures during straining recorded with the perfused system. Duration of the reflex elicited by rectal distension with 10 and 20 ml of air was significantly greater with the rectosphincteric balloon than with the perfused catheter ( P = 0.02 and P = 0.05, respectively). Conclusion: Water instilled in the anal canal by the perfused system induces artifacts in EMG recording and active anal contractions. These artifacts and induced contractions could lead to an erroneous diagnosis of anismus, particularly if pelvic floor EMG is only taken into account for the diagnosis of anismus.

Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence

Biofeedback is a nonsurgical treatment that reportedly produces good results in 65-75% of fecally incontinent patients. However, previous studies have not ruled out nonspecific treatment effects. It is also unknown whether biofeedback works primarily by improving the strength of the striated pelvic floor muscles or by improving the rectal perception. We aimed to 1) evaluate the efficacy of biofeedback in formed-stool fecal incontinence, 2) assess the relative contribution of sensory and strength retraining to biofeedback outcomes, and 3) identify patient characteristics that predict a good response to treatment. Twenty-four patients with frequent (at least once a week) solid-stool incontinence were provided with three to four biofeedback sessions. They were taught to squeeze in response to progressively weaker rectal distentions. Patients were re-evaluated by anorectal manometry and symptom diary 3 months after completing training and by diary and interview 6-12 months after training. Seventeen (71%) were classified responders; 13 became continent and four reduced incontinence frequency by at least 75%. Clinical improvements were maintained at 12-month follow-up. At 3-month follow-up, responders had significantly lower thresholds for perception of rectal distention and for sphincter contraction, but squeeze pressures did not significantly differ from those of nonresponders. Baseline measures that predicted a favorable response were sensory threshold (50 ml or less), urge threshold (100 ml or less), lower threshold for sphincter contraction, and lower threshold for the rectoanal inhibitory reflex; neither anal squeeze pressure nor severity of incontinence predicted treatment outcome. In solid-stool fecal incontinence biofeedback training effects are robust and seem not to be explained by expectancy or nonspecific treatment effect. Sensory retraining appears to be more relevant than strength training to the success of biofeedback.

Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence

OBJECTIVES: Biofeedback is a nonsurgical treatment that reportedly produces good results in 65–75% of fecally incontinent patients. However, previous studies have not ruled out nonspecific treatment effects. It is also unknown whether biofeedback works primarily by improving the strength of the striated pelvic floor muscles or by improving the rectal perception. We aimed to 1) evaluate the efficacy of biofeedback in formed-stool fecal incontinence, 2) assess the relative contribution of sensory and strength retraining to biofeedback outcomes, and 3) identify patient characteristics that predict a good response to treatment. METHODS: Twenty-four patients with frequent (at least once a week) solid-stool incontinence were provided with three to four biofeedback sessions. They were taught to squeeze in response to progressively weaker rectal distentions. Patients were re-evaluated by anorectal manometry and symptom diary 3 months after completing training and by diary and interview 6–12 months after training. RESULTS: Seventeen (71%) were classified responders: 13 became continent and four reduced incontinence frequency by at least 75%. Clinical improvements were maintained at 12-month follow-up. At 3-month follow-up, responders had significantly lower thresholds for perception of rectal distention and for sphincter contraction, but squeeze pressures did not significantly differ from those of nonresponders. Baseline measures that predicted a favorable response were sensory threshold (50 ml or less), urge threshold (100 ml or less), lower threshold for sphincter contraction, and lower threshold for the rectoanal inhibitory reflex; neither anal squeeze pressure nor severity of incontinence predicted treatment outcome. CONCLUSIONS: In solid-stool fecal incontinence biofeedback training effects are robust and seem not to be explained by expectancy or nonspecific treatment effect. Sensory retraining appears to be more relevant than strength training to the success of biofeedback.

Fecal incontinence after minor anorectal surgery.

Fecal leakage after open lateral internal anal sphincterotomy for chronic anal fissure is common, but underreported. The aim of this study was to prospectively assess the physiologic and morphologic effects of sphincterotomy, comparing continent and incontinent patients after surgery. This group was further compared with an unselected group of patients presenting with incontinence after hemorrhoidectomy. Between January 1997 and June 1999, 23 patients were prospectively followed up through internal sphincterotomy with conventional and vector volume anorectal manometry, parametric assessment of the rectoanal inhibitory reflex, and endoanal magnetic resonance imaging. Fourteen continent patients were compared with 9 incontinent postoperative cases, 9 patients referred with incontinence after hemorrhoidectomy, and 33 healthy volunteers without anorectal disease. Significant differences were noted between continent and incontinent postsphincterotomy cases for all resting conventional and vector volume parameters and for some squeeze parameters. Although there was a significant reduction in postoperative high pressure zone length at rest, there were no differences between the postoperative groups. There was an increase in sphincter asymmetry of 6.7 percent (+/- 3.5 percent) in incontinent postsphincterotomy patients and a decrease of 2.8 percent (+/- 3.2 percent) in continent cases. Significant differences were noted for resting parameters between incontinent postsphincterotomy and posthemorrhoidectomy patients, with a higher resting sphincter asymmetry in the latter group. The area under the rectoanal inhibitory curve was smaller in postsphincterotomy incontinent patients when compared with continent cohorts over the distal and intermediate sphincter zones at rest with a reduced latency of inhibition. There was no difference in the magnetic resonance images of the sphincterotomy site between incontinent and continent postsphincterotomy cases and no posthemorrhoidectomy case had evidence of sphincteric damage. There are complex significant differences in the postoperative physiology of patients undergoing lateral internal sphincterotomy who become incontinent when compared with those who maintain continence. These physiologic changes are not reflected in detectable morphologic sphincteric differences. It is unknown whether these changes predict for long-term incontinence, and it is suggested that postoperative incontinence after minor anorectal surgery is not necessarily related either to a preexisting sphincter defect or inadvertent intraoperative sphincter injury.

Rectoanal inhibition and rectocele: physiology versus categorization.

Some authors divide rectoceles into those with chronic evacuatory difficulty and normal genital position (type 1) and those with associated pelvic organ prolapse (type 2). This study assessed whether there are physiological differences between these two clinical rectocele types. Female patients were assessed by conventional anorectal manometry, vector manometry, parametric assessment of the rectoanal inhibitory reflex (RAIR), and defecography. Subjects included 33 volunteer controls without anorectal disease, 14 patients with type I rectocele, and 26 patients with type II rectocele. Significant differences were noted for resting pressure measurements (maximal resting anal pressure and vector volume) between rectocele types and between type I patients and controls. Significant differences were noted for squeeze parameters (maximal squeeze pressure and vector volume) only between rectocele types. There were minimal differences in parameters of the RAIR, with a reduced slope of inhibition in the proximal sphincter for both rectocele groups and a reduced maximal inhibitory pressure in the intermediate and distal sphincter of type 1 rectocele patients. There were no differences in transient excitation of the pressure wave during the RAIR reflex to account for pressure variations with no measured differences in rectocele depth (type 1, 2.87 +/- 0.7 cm; type 2, 2.84 +/- 1.4 cm) There are few physiological differences between the different clinical categories of rectocele patients based on the presence or absence of associated genital prolapse.

Gastrointestinal transit and anorectal manometry in children with colonic substance P deficiency.

Severe intractable constipation in children may be associated with a reduction of substance P (SP)- containing fibers in colonic circular muscle. The aim of this study was to characterize gastrointestinal transit (GIT), anorectal manometry (ARM) and electromyographic (EMG) changes in these children. Seromuscular laparoscopic biopsies of the colon were obtained from 35 children with severe constipation. Immunofluorescent staining for SP and vasoactive intestinal peptide (VIP) were then performed on these specimens. The cohort of patients studied included a SP-deficient group (SPD, n = 25) who had reduced numbers of SP-immunoreactive nerve fibers. The other group consisted of patients with normal staining for both SP and VIP (SPN, n = 10). Gastrointestinal transit studies (gastric emptying, orocecal and colonic transit) suitable for analysis were available for 17 patients (SPD, n = 9 and SPN, n = 8). The colon was divided into segments and radioactivity counts in each segment were expressed as a percentage of the total colonic count at each time point (6, 24, 32 and 48 h). The geometric center (GC), ARM, EMG, clinical and demographic data characteristics of both groups of patients were compared. There were no differences in demographic data, gastric emptying, orocecal transit or geometric center of transit in the colon between the two patient groups. The ARM and EMG studies suggested that the SPN group have a higher mean threshold volume of balloon distension required to initiate a rectoanal inhibitory reflex, and a higher incidence of anismus; however, this did not reach statistical significance. These data suggest a trend that the SPN patients have a greater problem with obstructive defecation and abnormal rectal sensation than those with SPD. We were unable to confirm any defect in colonic transit in the SPD patients compared with the SPN group.

ANORECTAL MANOMETRY IN PAEDIATRIC PATIENT WITH BOWEL DYSFUNCTION

Introduction: Bowel dysfunction in children presented as abdominal distension, colic, constipation or soiling is common. Besides conventional history and physical examination plus abdominal radiograph, suction rectal biopsy is usually required to rule out Hirschsprung’s disease. We adopted the manometric measurement in the assessment of the children with bowel dysfunction and see whether it helps to manage the problem.Method: Patients were placed in a calm environment and a microtransducer probe was used to measure the anal pressure. Rectoanal inhibitory reflex was measured with a balloonless method using room air injection as trigger. A conventional anal sphincter pressure profile was measured in several different directions in selected cases.Results: We have performed 74 measurements from 1996 till now. The procedure was well tolerated by most of the children. Positive rectoanal inhibitory reflex excluded the presence of Hirschsprung’s disease and spared the patients from invasive suction rectal biopsy. Anal dyskinesia was diagnosed with a negative rectoanal reflex plus presence of ganglion in suction rectal biopsy, and bowel management programs could be applied. The anal pressure profile generated important information as a functional assessment of the sphincter integrity especially for those patients received anorectal surgery.Conclusion: Anorectal manometry is a very useful and noninvasive adjunct in the management of bowel dysfunction in children.

Quantitation of Defecation Function Using Radionuclide Artificial Stool in Children with Chronic Constipation*

We aimed to investigate the value of scintigraphically determined evacuation fraction (EVF) as an objective follow-up criterion in medically treated children with chronic constipation, and to evaluate the relation between patients' symptoms and rectal emptying rate. Thirty children (m: 22, f: 8, mean age: 8.9 +/- 0.9 year) suffering from chronic constipation were assessed by scintigraphic evacuation study. All patients underwent anal manometric and scintigraphic examinations before their therapy was started. During 3 months, they received conventional laxative treatment for constipation, and scintigraphic studies were repeated in 20 of 30 patients. Scintigraphic examinations consisted of instillation of artificial stool into the rectum up to the volume impending rectal evacuation, and acquisition of pre- and post-evacuation images. EVF values were then calculated from the images using a fixed region of interest. All of the patients had high resting anal canal pressure (75 +/- 12 mmHg) and had positive rectoanal inhibitory reflex. In 14/20 patients (70%) who benefited from therapy, mean EVF changed from 43.6% to 62.2% (p < 0.001), while decreasing in 6120 who did not benefit. The volume arousing rectal evacuation was significantly lower at the second scintigraphic study (261 +/- 98 ml) than the first study (354 +/- 138 ml) (p < 0.05). As a conclusion: 1) EVF was low in chronically constipated children, 2) it was improved after conventional laxative treatment and, 3) radionuclide EVF determination may be a useful method for follow-up.

Quantitation of defecation function using radionuclide artificial stool in children with chronic constipation.

We aimed to investigate the value of scintigraphically determined evacuation fraction (EVF) as an objective follow-up criterion in medically treated children with chronic constipation, and to evaluate the relation between patients' symptoms and rectal emptying rate. Thirty children (m: 22, f: 8, mean age: 8.9 +/- 0.9 year) suffering from chronic constipation were assessed by scintigraphic evacuation study. All patients underwent anal manometric and scintigraphic examinations before their therapy was started. During 3 months, they received conventional laxative treatment for constipation, and scintigraphic studies were repeated in 20 of 30 patients. Scintigraphic examinations consisted of instillation of artificial stool into the rectum up to the volume impending rectal evacuation, and acquisition of pre- and post-evacuation images. EVF values were then calculated from the images using a fixed region of interest. All of the patients had high resting anal canal pressure (75 +/- 12 mmHg) and had positive rectoanal inhibitory reflex. In 14/20 patients (70%) who benefited from therapy, mean EVF changed from 43.6% to 62.2% (p < 0.001), while decreasing in 6120 who did not benefit. The volume arousing rectal evacuation was significantly lower at the second scintigraphic study (261 +/- 98 ml) than the first study (354 +/- 138 ml) (p < 0.05). As a conclusion: 1) EVF was low in chronically constipated children, 2) it was improved after conventional laxative treatment and, 3) radionuclide EVF determination may be a useful method for follow-up.

Effect of acute changes in sacral nerve stimulation amplitude on anorectal function in faecal incontinence

Sacral nerve stimulation improves faecal continence. Preliminary evidence suggests that the effect may be mediated via altered rectal and anal smooth muscle activity, as well as facilitation of external sphincter contraction. Clinical benefit however, appears unrelated to whether stimulation amplitude is above or below that required to produce threshold perineal sensation. Formal evaluation of the effect of different levels of stimulation has not been undertaken. This study aimed to assess the effect of varying stimulation amplitude on pelvic floor motor and sensory function in patients permanently implanted for faecal incontinence. Three female patients with passive faecal incontinence secondary to internal sphincter weakness, rendered continent with a permanently implanted sacral nerve stimulating electrode and pulse generator a mean of 19 months previously, were assessed. Patients underwent a series of anorectal physiological tests whilst stimulating amplitude was altered but all other stimulation parameters were kept constant. Baseline studies were initially performed at the stimulation amplitude providing continence over recent months for individual patients. Amplitude was then initially reduced, and then increased, in increments of 0.2 V, initially down to zero, and then to the maximal tolerated stimulation amplitude, at which pain was felt. Anorectal physiological testing was repeated 10 min after adjustment to each new amplitude of stimulation. Procedures were well tolerated by all patients. There were no significant differences in any of the physiological variables measured dependent upon intensity of stimulation between zero and the maximum tolerated stimulation. The recto-anal inhibitory reflex was unaltered in the one patient in whom it was demonstrable prior to stimulation. Acute changes in stimulation amplitude alone do not produce acute measurable differences in standard anorectal physiological variables. The clinical benefits of sacral nerve stimulation for faecal incontinence are not mediated primarily by improvement in anal canal pressures or alteration of anorectal sensation. Trials of different stimulation parameters over weeks or days may be necessary to demonstrate other functional differences.

Effect of reinforcing qi and moistening intestine oral liquid on anorectal manometry of asthenia type constipation patients

To study the change of anorectal manometry in asthenia type constipation patients and effect of reinforcing Qi and moistening intestine oral liquid (RQMI) on it. The fotal of 135 cases were divided into healthy group, RQMI treated group, Maren pill (MRP) treated group and prepulside (PPS) treated group, their anal maximal voluntary squeeze pressure, rectoanal contraction reflex, rectoanal inhibitory reflex, defecation reflex, rectal volume sensory threshold and rectal maximal tolerable volume were observed. The rectal sensory function of patients weakened obviously and anal sphincter reactivity reduced as compared with those of healthy person (P < 0.01), and both were improved by RQMI treatment (P < 0.05). RQMI is superior to MRP and prepulside in improving anorectal dynamic abnormality in constipation patient of asthenia type.

Anorectal physiologic testing for bowel dysfunction in patients with spinal cord lesions.

Bowel dysfunction is common in patients with spinal cord lesions. This study aims to determine whether there are any discriminatory findings at anorectal physiologic testing in patients with spinal cord lesions. Twelve consecutive patients (6 females) with significant spinal cord lesions who had mixed symptoms of constipation, fecal impaction, and fecal incontinence were evaluated by perfusion manometry and pudendal nerve terminal motor latency. None of the patients had a sphincter defect as evaluated by endoanal ultrasonography. The median age was 54 (range, 40-87) years. Eight (67 percent) of them had had traumatic spinal cord injuries. Other spinal cord lesions included spina bifida, syringomyelia, arachnoid cyst, and spinal cord ischemia after abdominal aortic aneurysm repair. In patients with spinal cord lesions, the mean (range) resting anal canal pressure and maximum squeeze anal canal pressure were 46 (10-100) mmHg and 76 (30-120) mmHg respectively compared with 62 (50-70) mmHg, and 138 (100-180) mmHg, respectively, in healthy controls. Eleven (92 percent) patients had prolonged pudendal nerve terminal motor latency (9 bilateral and 2 unilateral) whereas rectoanal inhibitory reflex was abolished in all 9 patients tested. Spinal patients with severe bowel symptoms tended to have lower anal canal pressures than healthy controls. Pudendal netropathy and impaired rectoanal inhibitory reflex are common and may be important in the pathogenesis of bowel dysfunction in patients with spinal cord lesions.

The use of unilateral gluteus maximus muscle for the management of fecal incontinence following anorectal surgery

A dynamic unilateral gluteoplasty sutured as a U-shaped sling around the anal canal was carried out in 9 patients with fecal incontinence, including 8 males and one female ranging in age from 6 to 46 years (mean, 13.9 years). All had previous anorectal surgery: in four cases a Swenson's operation for congenital megacolon, in 2 cases a pull-through procedure for high anorectal anomalies, in 2 cases for a failed sphincteric repair, and in one case to correct rectal prolapse. Morbidity was limited to minor wound infection and postoperative dermatitis (4 cases). Seven patients achieved an improvement in their continence score. Overall continence score was 5–6 (mean, 4.0; SD = 1.4) preoperatively and 2–6 (mean, 4.0; SD = 1.4) postoperatively, a difference which was statistically significant (p = 0.006). Maximum resting pressure and maximum squeeze pressure were improved. None of the patients could retain 200 ml saline in their rectum preoperatively, while 6 patients could do so postoperatively. Rectoanal inhibitory reflex was positive in 2 patients preoperatively and in 6 postoperatively. In conclusion, unilateral dynamic gluteoplasty is an effective option for improving continence with no mortality and minimal morbidity in patients who previously had anorectal surgery, reserving the other gluteus muscle for use in a second attempt if first operation fails.

Clinical evaluation and management of neurogenic bowel after spinal cord injury.

To assess the state of the neurological bowel in spinal cord injured (SCI) patients, design and apply a program for the comprehensive management of neurogenic bowel and evaluate outcome. Out-patient in a Rehabilitation Service. Thirty-eight SCI patients, 12 (32%) with complete lesions of more than 5 years duration. Observational, longitudinal and prospective. Pre and post intervention. Pre and post SCI intestinal function was evaluated clinically prior to beginning program. The presence of GI symptoms were studied. Laboratory work-up included colonic transit time (CTT), anorectal manometry and recto-colonoscopy. An intestinal program was designed, in order to achieve an effective and efficient evacuation in a predictable and socially acceptable time, to avoid short and long term complications and eliminate inadequate intestinal evacuation habits. Pre and post SCI difficulty in intestinal evacuation (DIE) was increased (from 2.6% to 26.3%). The most frequent GI symptom was abdominal distention (53%). Colonic inertia was present in 49% of CTT, internal anal sphincter pressure was normal or increased in 77% and rectoanal inhibitory reflex was present in 88%. With the intestinal program, the incidence of DIE was reduced to 8.8%, manual extraction (ME) was reduced from 53% to 37%. Excellent and good results were obtained in 56% of the patients. The proposed intestinal program is effective in the rehabilitation of SCI patients with neurogenic bowel. It is essential to initiate these physiological and safe procedures as soon as possible after sustaining the injury; this will lead to better results and to the elimination of inadequate intestinal maneuvering in the future Spinal Cord (2000) 38, 301 - 308.

Coloanal motor coordination in association with high-amplitude colonic contractions after pharmacological stimulation.

The rectoanal inhibitory reflex facilitates defecation by relaxation of the internal anal sphincter during rectal distention by gas or stool. Defecation is sometimes preceded by high-amplitude propagated contractions (HAPCs). Our objective was to seek evidence for motor coordination between human colonic and anal sphincter functions. As part of a study of alpha2 modulation of colonic and anal motor functions in 32 healthy volunteers, we studied the relationship between high HAPCs and anal sphincter pressure with colonic manometry, barostat, and a Dent sleeve in the anal canal. Twenty-two HAPCs were observed; in 19/22 HAPCs there was optimal positioning of the Dent sleeve to assess the anal sphincter. Eighteen of 19 HAPCs occurred postprandially; 14 HAPCs occurred after administration of yohimbine, three after clonidine, and one before any drug administration. Seven followed experimental balloon distention. Anal sphincter relaxation occurred (14 +/- 4 s) before the recorded onset of HAPC in the descending colon and 88 +/- 7 s before the arrival of the HAPC in the rectum. After or during the HAPCs, anal sphincter pressure decreased by 40 +/- 4% and increased by 56 +/- 8% in the postrelaxation phase. The close temporal association between anal sphincter relaxation and onset of HAPC in the descending colon suggests a coloanal reflex that may facilitate defecation during mass movements independently of the rectoanal inhibitory reflex.

Coloanal motor coordination in association with high-amplitude colonic contractions after pharmacological stimulation

OBJECTIVE: The rectoanal inhibitory reflex facilitates defecation by relaxation of the internal anal sphincter during rectal distention by gas or stool. Defecation is sometimes preceded by high-amplitude propagated contractions (HAPCs). Our objective was to seek evidence for motor coordination between human colonic and anal sphincter functions. METHODS: As part of a study of α 2 modulation of colonic and anal motor functions in 32 healthy volunteers, we studied the relationship between high HAPCs and anal sphincter pressure with colonic manometry, barostat, and a Dent sleeve in the anal canal. RESULTS: Twenty-two HAPCs were observed; in 19/22 HAPCs there was optimal positioning of the Dent sleeve to assess the anal sphincter. Eighteen of 19 HAPCs occurred postprandially; 14 HAPCs occurred after administration of yohimbine, three after clonidine, and one before any drug administration. Seven followed experimental balloon distention. Anal sphincter relaxation occurred (14 ± 4 s) before the recorded onset of HAPC in the descending colon and 88 ± 7 s before the arrival of the HAPC in the rectum. After or during the HAPCs, anal sphincter pressure decreased by 40 ± 4% and increased by 56 ± 8% in the postrelaxation phase. CONCLUSIONS: The close temporal association between anal sphincter relaxation and onset of HAPC in the descending colon suggests a coloanal reflex that may facilitate defecation during mass movements independently of the rectoanal inhibitory reflex.

Anorectal manometry during the neonatal period: its specificity in the diagnosis of Hirschsprung's disease.

In this study the reliability of anorectal manometry (ARMM) in Hirschsprung's disease (HD) in the neonatal period is evaluated. ARMM was performed in 59 patients (age ranging between 2 to 90 days) in whom HD was suspected. Rectal biopsy was performed in 23 newborn whose rectoanal inhibitory reflex (RAIR) was not identified in the ARMM study and in 13 RAIR-positive newborn due to strong clinical signs supporting HD or persistence of symptoms during their follow-up. Other RAIR-positive patients were followed up to 4 months to 3.5 years and no problems were encountered. Among the 36 newborn with rectal biopsies, if the results were compared to ARMM studies, there were one false-positive and two false-negative results. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ARMM in the diagnosis of HD are 91.6%, 95.6%, 84.6% and 91.6% respectively. We conclude that ARMM can be used as a screening test in patients in whom HD is suspected during the neonatal period, but for definitive diagnosis it must be combined with other diagnostic tests.

Anorectal dysfunction following low anterior resection for rectal carcinoma: a comparison between handsewn and stapled anastomosis

Sphincter-saving resection for rectal carcinoma is frequently accompanied by anorectal dysfunction (increased stool frequency and varying degrees of faecal incontinence). Although numerous reports regarding this dysfunction have been published, the exact mechanism is still controversial. The purpose of the present study was to compare the functional results of low anterior resection (LAR) for rectal carcinoma following handsewn and stapled anastomosis. The patients with rectal carcinoma were divided into two groups: LAR with handsewn anastomosis (HS) (n = 15), and LAR with stapled EEA (U.S. Surgical Corporation) anastomosis (EEA) (n = 16; four with 28 mm stapler, 12 with 31 mm stapler). Sixteen patients with carcinoma of sigmoid colon who received high anterior resection (HAR) were taken as the control group. Anorectal functional study was performed preoperatively and post-operatively at 1 week and another after 6 months, whereas routine clinical assessment was carried out preoperatively and 6 months post-operatively. The post-operative maximal resting pressure was significantly reduced in both HS and EEA groups, while a tendency to recovery was observed in the HS and 28 mm stapler group 6 months later. A significant decrease in rectal capacity was noted in the EEA group. The return of rectoanal inhibitory reflex was observed in 67% of the HS group and 37.5% of the EEA group. Although clinically increased stool frequency was experienced in both HS and EEA groups, continence was significantly worse in the EEA group. LAR for rectal carcinoma results in impaired anorectal function, which might present clinically with increased stool frequency and minor faecal soiling. The former may be due partially to reduced neorectal capacity, while the latter may be due to internal anal sphincter dysfunction, possibly because of damage to innervation.

Slow-transit constipation: solitary symptom of a systemic gastrointestinal disease.

Autonomic neuropathy is thought to play a role in the pathogenesis of slow-transit constipation, but other gastrointestinal organs may also be involved, even if they are symptom-free. We investigated whether motility in gastrointestinal organs other than the colon was impaired in patients with slow-transit constipation and whether the autonomic nervous system was involved. Twenty-one consecutive patients (18 females; median age, 46 years) with severe chronic constipation (< or = 2 defecations/week and delayed colonic transit time) were studied. Autonomic neuropathy function was tested with esophageal manometry, gastric and gallbladder emptying (fasting and postprandial motility) by ultrasonography, orocecal transit time (H2-breath test), colonic transit time (radiopaque markers), and anorectal volumetric manometry. The integrity of the autonomic nervous system was assessed by a quantitative sweat-spot test for preganglionic and postganglionic fibers, tilt-table test, and Valsalva electrocardiogram R-R ratio. Esophageal manometry showed gastroesophageal reflux or absence of peristalsis in five of the seven patients examined. Gallbladder dysmotility (i.e., increased fasting, postprandial residual volume, or both) was observed in 6 of 14 (43 percent) patients. Gastric emptying was decreased in 13 of 17 (76 percent) patients. Orocecal transit time was delayed in 18 of 20 (90 percent) patients; median transit time was 160 (range, 90-200) minutes. Median colonic transit time was 97 (range, 64-140) hours. Anorectal function showed abnormal rectoanal inhibitory reflex and decreased rectal sensitivity in 11 of 19 (58 percent) patients. Signs of autonomic neuropathy of the sympathetic cholinergic system were found in 14 of 18 (78 percent) patients. Only one of nine patients had vagal abnormalities detected with the Valsalva test and four of five patients with a history of orthostatic hypotension had a positive tilt-table test. Slow-transit constipation may be associated with impaired function of other gastrointestinal organs. More than 70 percent of patients with slow-transit constipation present some degree of autonomic neuropathy. Severe constipation may be the main complaint in patients with a systemic disease involving several organs and possibly involving the autonomic nervous system. This should be considered in the management of such cases.

Is Electrostimulation of the Pelvic Floor an Effective Treatment for Neurogenic Faecal Incontinence?

Background: This study was designed to evaluate the results of electrostimulation of the pelvic floor for faecal incontinence. Methods: Twenty-four patients with neurogenic (n = 20) or idiopathic (n = 4) incontinence were treated on 12 occasions. Twenty were women, and the mean age was 63 years (range, 26-85 years). The result was evaluated at 3 and 12 months with a validated questionnaire and anorectal manometry. Results: Eleven patients (46%) reported improvement after 3 months, and the Miller's incontinence score was reduced (P < 0.01). Resting pressures, rectal compliance, and the length of the high-pressure zone were unchanged, but squeeze pressures tended to decrease. A lower threshold was seen for the rectoanal inhibitory reflex (RAIR) (P < 0.01), and the saline infusion test tended to show improved retention (P = 0.07). Nine of 13 patients followed up for 1 year claimed improvement. The most pronounced subjective improvement was seen in patients with moderate incontinence. Conclusions: Electrostimulation was successful in a substantial proportion of the patients. The threshold for RAIR was lowered, and the saline infusion test tended to improve, but variables reflecting sphincter competence did not improve. Moderate incontinence was prognostically favourable, and electrostimulation might therefore be an alternative to surgery in this group.