Sphincter Integrity Research Articles

Local excision followed by postoperative radiation therapy

The management of distal rectal cancer is in evolution. Although abdominoperineal resection has been long regarded as the definitive treatment of distal rectal cancer, it is associated with significant morbidity--loss of anorectal function with a permanent colostomy and a high incidence of sexual and genitourinary dysfunction. To overcome these limitations, innovative efforts are underway studying the feasibility and efficacy of a variety of sphincter-preserving operations, usually in combination with radiation therapy and chemotherapy. Local excision procedures with adjuvant therapy represent one such treatment strategy that attempts to optimize local control and survival with preservation of sphincter integrity. This article summarizes the current role of local excision and postoperative irradiation and chemotherapy for patients with carcinoma of the rectum.

Perineal examination as a predictor of underlying external anal sphincter damage.

To assess the relation between perineal inspection and sphincter integrity in parous women. Prospective observational study. District general hospital. Fifty-seven consecutive parous women attending a gynaecology clinic for problems unrelated to the pelvic floor. A detailed history of bowel function and mode of delivery obtained; the perineum inspected to determine the presence and position of scarring, and anal endosonography performed. In 19 women with an intact perineum on inspection, endosonography showed perineal scarring in five, with both perineal and sphincter scarring in three. Four had urge faecal incontinence. Three patients had a perineal tear only on inspection, but this group was too small for analysis and was discounted. Nine had an episiotomy scar only. Endosonography demonstrated perineal scarring in four, and combined perineal and sphincter scarring in two; one woman in this group had urge faecal incontinence. Twenty-six women had episiotomy and perineal tears on inspection. Endosonography revealed underlying perineal scarring in five women, with combined perineal and sphincter scarring in 14; six women in this group had urge faecal incontinence and one passive incontinence for flatus. Sonographically the scarring was anterior and circumferential rather than radial, and mostly left-sided, whereas on inspection episiotomy and perineal scarring were right sided. A normal perineum on clinical examination does not exclude underlying sphincter damage. The incidence of sphincter damage increases significantly when an episiotomy scar is associated with a perineal tear.

Endosonographic assessment of postpartum anal sphincter injury using a 120 degree sector scanner

Obstetric injury is the principal cause of faecal incontinence in women. We describe use of a 120 degrees sector ultrasound probe to assess integrity of the anal sphincters in primigravid women. Eighty-eight women were successfully studied 6 weeks following vaginal delivery. Anal vector manometry and pudendal nerve studies were abnormal in 54 (61%), of whom 41 (71%) were symptomatic (urgency of defaecation, incontinence to flatus or faeces). The sonographic pattern of the anal sphincters described with a 360 degrees probe was reproduced. Forty-eight abnormal scans were reported by two radiologists with a kappa statistic of 0.65. Sphincter defects were found in 11 asymptomatic women. We conclude that anal endosonography has an important role screening for and diagnosis of postpartum anal sphincter defects. Use of a 120 degrees sector ultrasound probe may prove a cost-effective means of increasing the availability of this technique.

Organ preservation in anal and rectal cancers.

For the past 10 to 15 years, radiation therapy and chemotherapy have played an increasingly important role in the treatment of various gastrointestinal malignancies, most prominently in anal and rectal cancer. Critical issues in the care of patients with anal and rectal cancer include not only local control and survival but organ preservation as well. For patients with carcinoma of the anal canal, external-beam irradiation with 5-fluorouracil and chemotherapy with mitomycin C have replaced surgery as primary therapy. Current studies are optimizing this therapy. In contrast, the management of distal rectal cancer is in evolution. Although the abdominoperineal resection has been long regarded as the definitive treatment of distal rectal cancer, it is associated with substantial morbidity (loss of anorectal function with a permanent colostomy and a high incidence of sexual and genitourinary dysfunction). As an alternative, treatment programs utilizing sphincter-preserving procedures with radiation therapy and chemotherapy are under active investigation. In selected patients, these strategies appear promising, and there have been reports of satisfactory local control and survival, as well as preservation of sphincter integrity.

Intestinal transit time in patients after total proctocolectomy and ileoanal pouce is related to sphincter integrity but not plasma PYY levels: [formula omitted], P. Staab, G.J. Blatchford, M.A. Christensen, A.G. Thorson, J.S. Thompson, S.D. Lanspa, P.G. Meade, R.A. Cali, P.M. Falk, S.M. Sentovich, T.E. Adrian. Depts. of Surgery, Biomedical Sciences and Gastroenterology, Creighton University and Dept. of Surgery, University of

Intestinal transit time in patients after total proctocolectomy and ileoanal pouce is related to sphincter integrity but not plasma PYY levels: [formula omitted], P. Staab, G.J. Blatchford, M.A. Christensen, A.G. Thorson, J.S. Thompson, S.D. Lanspa, P.G. Meade, R.A. Cali, P.M. Falk, S.M. Sentovich, T.E. Adrian. Depts. of Surgery, Biomedical Sciences and Gastroenterology, Creighton University and Dept. of Surgery, University of

Endoluminal ultrasound is preferable to electromyography in mapping anal sphincteric defects

Assessment of complex sphincteric defects in patients with fecal incontinence by digital rectal examination and intraoperative dissection can be difficult in the presence of excessive scarring. Adjunctive investigation such as endoluminal ultrasound (ELUS) and needle electromyography (EMG) may provide objective evidence of the nature and extent of the sphincteric defects. In a series of 11 patients, ELUS of the anal canal with a 10-MHz transducer (focal zone of 1-4 cm) accurately detected defects in the external anal sphincter (EAS) in seven of seven patients, defects in the internal anal sphincter (IAS) in eight of eight patients, and integrity of both sphincters in two patients. These findings were confirmed by needle EMG of the EAS alone in five patients, by operative findings at a perineal sphincteroplasty operation in six patients, and by both in two patients. ELUS was associated with less pain than was needle EMG (pain score 4 vs. 10, 10 being most painful) and provided high-resolution radial images of both the EAS and the IAS. Thus, ELUS seems preferable to EMG in mapping anal sphincteric defects and can be a useful anatomic adjunct to physiologic studies of anorectal function in patients with fecal incontinence.

Lower Esophageal Sphincter Integrity Is Maintained During Succinylcholine-Induced Fasciaculations in Dogs With ???Full??? Stomachs

During succinylcholine-induced muscle fasciculations, gastroesophageal barrier pressure in fasted adult dogs (n = 10) was compared by esophageal manometry with that in the same dogs with full stomachs. After fasting, fasciculations did not increase significantly either mean intragastric pressure (4.7 +/- 1.3 mm Hg before; 5.2 +/- 1.7 mm Hg during) or lower esophageal sphincter pressure (35.4 +/- 21.4 mm Hg before; 40.6 +/- 17.5 mm Hg during). Filling the dogs' stomachs with 300 mL of saline significantly increased both mean intragastric pressure (from 3.8 +/- 2.2 to 7.4 +/- 1.4 mm Hg) and mean lower esophageal sphincter pressure (from 20.2 +/- 6.8 to 28.6 +/- 14.8 mm Hg). Fasciculations did not produce a further increase in either mean intragastric or mean lower esophageal sphincter pressure. Most importantly, in all animals, under all conditions, gastroesophageal barrier pressure remained positive (range, 6.0-65.5 mm Hg) and therefore served as a barrier to passive regurgitation.

Pouch Surgery — The Importance of the Transitional Zone

Patients with preservation of the transitional zone of the anal canal have less leakage and less need to wear pads than patients who have had mucosectomy. There is a significant difference in mean maximum resting pressure between patients that have had anal transitional zone preservation and mucosectomy. With preservation of the anal transitional zone, a mean maximum resting pressure of 57.6±3.8 mmHg was obtained compared with 47.3±4 mmHg in the mucosectomy group. Preservation of the resting pressure is dependent on preservation of internal anal sphincter integrity. The integrity of the sphincter is injured during mucosectomy due to anal dilation. Other factors affecting continence and stool frequency, such as diet, antidiarrheal medications, stool consistency and compliance, when examined were found to be unrelated factors.

Urogenital Diaphragm Raising Maneuver

The urogenital diaphragm raising maneuver, a procedure to facilitate membranous urethral surgery, is described. The technique shortens operating time by permitting easy identification and exposure of the severed urethral ends, thus, allowing for precise re-establishment of urinary tract continuity. Selective membranous urethral surgery can be performed with ease, preserving external sphincter integrity. This maneuver represents an advance over any other technique by almost eliminating the risk of stenosis, urinary fistula and incontinence owing to failure of precise reapproximation of the membranous urethra.