Conceptos actuales de patología anorrectal funcional / Current concepts in functional anorectal disorders

The purpose of the present article is to highlight relevant aspects of anorectal pathology, mainly fiber resistant constipation, fecal incontinence and fecal soiling. A high percentage of patients with fiber resistant constipation correspond to dyssynergic defecation cases. In addition, most patients with dyssinergia and slow colonic transit return to normal after correction of the dyssyinergic condition. For these reasons, the current recommendation is to consider the evaluation of dyssynergic defecation as the initial diagnostic approach in patients with laxative-resistant constipation. Rectal hyposensitivity is an important pathophysiological mechanism involved in both constipation and fecal incontinence. About 80% of fecal incontinence cases present multiple pathological mechanisms, including sphincter insufficiency, rectal hyposensitivity, poor rectal emptying and impaired rectal compliance. Soling and seepage are usually in the context of poor rectal emptying and not in the context of sphincter insufficiency.

El siguiente artículo pretende destacar aspectos relevantes en patología anorrectal funcional, principalmente constipación resistente a fibra, incontinencia fecal y ensuciamiento. Entre los pacientes con constipación resistente a fibra, un alto porcentaje corresponde a defecación disinérgica. Además, la mayoría de los pacientes con defecación disinérgica y tránsito colónico enlentecido normalizan el tránsito tras mejoría de la disinergia. Por estos motivos, la recomendación actual es la evaluación de defecación disinérgica como primera estrategia diagnóstica en los pacientes con constipación refractaria a laxantes. La hiposensibilidad rectal es un mecanismo importante en casos de constipación e incontinencia fecal. Alrededor de 80% de los casos de incontinencia fecal tienen múltiples mecanismos descritos, incluyendo insuficiencia esfinteriana, hiposensibilidad rectal, mal vaciamiento rectal y alteraciones de la complianza rectal. El ensuciamiento suele estar en el contexto de mal vaciamiento rectal y no en el contexto de insuficiencia esfinteriana.

Nerve-sparing radical hysterectomy: time for a new standard of care for cervical cancer? / 부인종양

No abstract available.

Conventional versus nerve-sparing radical surgery for cervical cancer: a meta-analysis / 부인종양

OBJECTIVE: Although nerve-sparing radical surgery (NSRS) is an emerging technique for reducing surgery-related dysfunctions, its efficacy is controversial in patients with cervical cancer. Thus, we performed a meta-analysis to compare clinical outcomes, and urinary, anorectal, and sexual dysfunctions between conventional radical surgery (CRS) and NSRS. METHODS: After searching PubMed, Embase, and the Cochrane Library, two randomized controlled trials, seven prospective and eleven retrospective cohort studies were included with 2,253 patients from January 2000 to February 2014. We performed crude analyses and then conducted subgroup analyses according to study design, quality of study, surgical approach, radicality, and adjustment for potential confounding factors. RESULTS: Crude analyses showed decreases in blood loss, hospital stay, frequency of intraoperative complications, length of the resected vagina, duration of postoperative catheterization (DPC), urinary frequency, and abnormal sensation in NSRS, whereas there were no significant differences in other clinical parameters and dysfunctions between CRS and NSRS. In subgroup analyses, operative time was longer (standardized difference in means, 0.948; 95% confidence interval [CI], 0.642 to 1.253), while intraoperative complications were less common (odds ratio, 0.147; 95% CI, 0.035 to 0.621) in NSRS. Furthermore, subgroup analyses showed that DPC was shorter, urinary incontinence or frequency, and constipation were less frequent in NSRS without adverse effects on survival and sexual functions. CONCLUSION: NSRS may not affect prognosis and sexual dysfunctions in patients with cervical cancer, whereas it may decrease intraoperative complications, and urinary and anorectal dysfunctions despite long operative time and short length of the resected vagina when compared with CRS.

Rectal hyposensitivity and functional anorectal outlet obstruction are common entities in patients with functional constipation but are not significantly associated

BACKGROUND/AIMS: The causes of functional anorectal outlet obstruction (outlet obstruction) include functional defecation disorder (FDD), rectocele, and rectal intussusception (RI). It is unclear whether outlet obstruction is associated with rectal hyposensitivity (RH) in patients with functional constipation (FC). The aim of this study was to determine the association between RH and outlet obstruction in patients with FC. METHODS: This was a retrospective study using a prospectively collected constipation database, and the population comprised 107 patients with FC (100 females; median age, 49 years). We performed anorectal manometry, defecography, rectal barostat, and at least two tests (balloon expulsion test, electromyography, or colon transit time study). RH was defined as one or more sensory threshold pressures raised beyond the normal range on rectal barostat. We investigated the association between the presence of RH and an outlet obstruction such as large rectocele (> 2 cm in size), RI, or FDD. RESULTS: Forty patients (37.4%) had RH. No significant difference was observed in RH between patients with small and large rectoceles (22 [44.9%] vs. 18 [31%], respectively; p = 0.140). No significant difference was observed in RH between the non-RI and RI groups (36 [36.7%] vs. 4 [30.8%], respectively; p = 0.599). Furthermore, no significant difference in RH was observed between the non-FDD and FDD groups (19 [35.8%] vs. 21 [38.9%], respectively; p = 0.745). CONCLUSIONS: RH and outlet obstruction are common entities but appear not to be significantly associated.

Study of the density of ganglion cells in the terminal bowel of rats with anorectal malformations

PURPOSE: To study the ganglion cells (GC) in the terminal bowel of rats with ethylenethiourea (ETU) induced anorectal malformations (ARM). METHODS: The animals were divided into three groups: Group A - normal fetuses from pregnant rats that were not administered ETU; Group B - fetuses without ARM born from pregnant rats that were administered ETU and Group C - fetuses with ARM born from pregnant rats that received ETU. ETU was administered on the 11th day of pregnancy at the dose of 125 mg/kg body weight by gastric gavage. The rats had cesarean section on the 21st day of gestation. The fetuses’ terminal bowel tissue was analyzed by immunohistochemistry to demonstrate ganglion cells. RESULTS: Statistically significant differences were found between groups A, B and C regarding ganglion cell densities. Group A had the highest cell density, followed by Group B and the lowest density was found in Group C. CONCLUSION: Ganglion cell densities are decreased in the terminal bowel of rats with ARM.

OBJETIVO: Estudar as células ganglionares (CG) no intestino terminal de ratos portadores de anomalia anorretal (AAR) induzida pela etilenotiouréia (ETU). MÉTODOS: Os animais foram distribuídos em três grupos: Grupo A - fetos normais, obtidos de ratas grávidas às quais não foi administrada ETU; Grupo B - fetos não portadores de AAR obtidos de ratas grávidas às quais foi administrada ETU e Grupo C - fetos portadores de AAR obtidos de ratas grávidas às quais foi administrada ETU. A ETU foi administrada no décimo primeiro dia de gestação na dose de 125 mg/Kg, por gavagem. As ratas foram submetidas à laparotomia e histerotomia para retirada dos fetos no vigésimo primeiro dia de gestação. O intestino terminal dos fetos foi retirado e analisado por imunohistoquímica para pesquisa de CG. RESULTADOS: Foram encontradas diferenças estatisticamente significantes entre os grupos A, B e C quanto à densidade de CG. O grupo A apresentou a maior densidade, seguida pelo grupo B, e a menor densidade foi encontrada no Grupo C. CONCLUSÃO: Existe uma menor densidade de CG no intestino terminal de ratos portadores de AAR.

Total Mesorectal Excision and Preservation of Autonomic Nerves / 대한소화기학회지

The procedure of total mesorectal excision (TME) becomes a gold standard for the treatment of rectal cancer. The reason is the marvelously low incidence of local recurrence after TME even without other adjuvant treatment, which has been reported by several independent groups. Although controversy still exists about the role of TME in upper rectal cancer, it is now widely accepted for cancers of the middle and lower third. There are number of histopathological evidences that cancer cells can spread distally several centimeters from the lower margin of cancer, and cancer bearing lymph nodes are found in the distal portion of the mesorectal tissues far from the cancer. Therefore, the distal clearance of mesorectum should be peformed downwardly to the level of pelvic diaphragm (puborectalis) and the rectum is divided within a few centimeters from the pelvic floor musculature. TME defines an en-bloc procedure, along the plane between parietal and visceral pelvic fasciae. If the dissection plane is breached, the chance of visceral pelvic fascia tearing is raised and mesorectal tissue might reside in the pelvis. There are problems in auditing the procedure. As many surgeons agree, this procedure requires a learning curve. Theoretically, the autonomic nerves run between the visceral and parietal pelvic fasciae since the nerves must be preserved to make visceral fascial envelop. Any patient who become incontinent or impotent after the surgery should have received decorticating surgery other than TME. Thus, the high quality of TME should fulfill two clinical measurements: absence of impotence or incontinence and at least single digit, 5-year, cumulative recurrence rate regardless of adjuvant therapy.

Congenital megacolon: diagnosis using size of sub-mucosal nerve trunk as a criteria.

Cholinergic hyperinnervation in submucosa of aganglionic segment of Hirschsprung's disease has been described. However, objective measurement of the nerve fibers was insufficiently reported. OBJECTIVES: To study the amount and size of hypertrophic submucosal nerve trunks in the aganglionic segment of Hirschsprung's disease, semiquantitatively and evaluate the possibility of using the size as objective diagnostic criteria. MATERIAL AND METHOD: Thirteen specimens from aganglionic segments from Hirschsprung's disease and six specimens from the age-matched control subjected without colonic innervation disorders were studied with the S-100 immunohistochemical technic. The submucosal nerve trunks were counted per ten HPF and measured in width, semiquantitatively. Fiber sizes were stratified into small (<20 micrometers), medium (20-40 micrometers), and large (>40 micrometers). Maximum fiber size in each specimen was also recorded. RESULTS: Average density of submucosal nerve trunk in the aganglionic segment and the control were 12.5 and 3.4 fibers per ten HPF, respectively. The large nerve trunks were detected in 12 of 13 aganglionic specimens and none was detected in the controls. The maximum fiber size in aganglionic segments was 78.2 micrometers, compared to 24.1 micrometers in the control group. The sensitivity and specificity to set the presence of hypertrophic nerve trunk, larger than 40 micrometers as a diagnostic criteria for Hirschsprung's disease were 92.3 and 100 per cent, respectively. The data suggest the use of this size as an objective diagnostic criterion, which may be valuable in rectal suction biopsy specimens.

Neonatal Hirschsprung's disease.

Since the classic description of this disease by Harold Hirschsprung's. In 1886 just over a century ago, there has been a marked evolution in the diagnostic modalities, understanding of the pathophysiology, unraveling of genetic association and the treatment approach of this disease. Recent research on the molecular biology of the disease has bestowed us with a clearer understanding of the pathogenesis of the disease. Genetic deletions have been identified which explain the familial incidence of 3.6%-7.8%, and in some kindreds the inheritance rate approaches 50%. Improvement in the diagnostic approaches has evolved from full thickness rectal biopsy (under GA) to suction rectal biopsy. The development of the histochemical staining for acetylcholinesterase, allows rapid identification in the lamina propria of hypertrophied extrinsic nerve fibers which have proliferated in the absence of intrinsic ganglion cells. Frozen sections now permit screening for normal ganglia in the myenteric plexus from seromuscular biopsies during the definitive pull-through procedures or leveling colostomy. This service, however, requires significant infrastructure and an expert pathologist, not widely available. Hirschsprung's disease (HD) variants like intestinal neuronal dysplasia(IND), hypoganglionosis are better identified and treated with availability of histochemical staining. The three-stage procedure till date remains the gold standard; however, increasingly, the world over, two stage and even single stage procedures are being tried. In the era of minimally invasive surgery, perineal pull through procedure has been attempted with or without laparoscopic assistance.

Retroalimentación biológica y su aplicación clínica / Clinical applications of biofeedback

Antecedentes: La incontinencia fecal constituye un serio problema social que afecta a todos los grupos de edad. Su tratamiento es tan complejo como desconocido. Métodos: Efectuamos un estudio longitudinal, prospectivo, experimental, entre 47 pacientes consecutivos que presentaban incontinencia total por un periodo de 55.4 ñ 7.6 meses (intervalo: seis meses a 21 años), con 2.4 ñ 0.2 episodios de incontinencia (intervalo: 1-7 por día). A todos se les efectuó cuestionario para validar el diagnóstico de incontinencia, historia clínica completa, laboratorio, colon por enema, rectosigmoidoscopia, sensibilidad rectal, manometría rectoanal, y retroalimentación biológica sin instrumentación electrónica. Veintiún sujetos normales sirvieron como grupo control. Resultados: Los pacientes con incontinencia fecal presentaron disminución de la sensibilidad rectal (p<0.01) y alteraciones en el reflejo recto anal inhibitorio espontáneo. Todos obtuvieron curación completa en un periodo de 4 ñ 0.5 meses (intervalo: 15 días a 15 meses) y fueron seguidos por uno a ocho años. Conclusiones: La nueva modalidad de retroalimentación biológica aquí descrita no utiliza ningún instrumento electrónico. La curación y el tiempo de curación de los pacientes no solamente es comparable, sino superior a lo hasta ahora informados. Puede ser reproducido, con el entrenamiento adecuado, por mayor número de médicos en cualquier centro y condicionar, por tanto, un beneficio significativo en la calidad de vida de un mayor número de pacientes

Dor anal e retal / Anorectal pain

O objetivo deste trabalho é trazer aos colo-proctologistas e clínicos a importância da correta interpretaçäo da dor ano-retal na clínica diária. Por vezes, esta é täo característica que se torna patognomônica de determinada afecçäo. É descrita detalhadamente a inervaçäo do reto e canal anal e, a partir daí, säo definidos dois tipos polares de dor nesta regiäo: a cutânea ou superficial e a visceral ou profunda. A sensaçäo dolorosa depende de dois componentes: a percepçäo através de mecanismo fisiológico e a reaçäo através de mecanismo basicamente psicogênico. Säo atualizadas, ainda, as características da dor ano-retal em variadas afecçöes, desde as inflamatórias, varicosas, tumorais, até complexas nevralgias que, por vezes, se constituem em verdadeiras psicoses