Discrepancies in anal manometric pressure measurement--important or inconsequential?

PURPOSE: Maximum resting and squeeze pressures have been the most widely employed parameters for manometric assessment of the anal sphincters. However, a single maximum value may not always be the best assessment. METHODS: The aim of this study was to compare mean and maximum resting and mean and maximum squeeze pressures in a large sample population. All manometric pressure profiles were reviewed by a single individual blinded to the patient's age and diagnosis. RESULTS: Four hundred sixty-six patients with a measurable high-pressure zone were included in this study. The study population was comprised of 279 females and 186 males. A significant difference was found between mean (56.26 mmHg) and maximum (79.2 mmHg) resting pressures (P < 0.01) and also between mean (81.25 mmHg) and maximum (119.50 mmHg) squeeze pressures (P < 0.01). A significant difference (P < 0.01) was also observed when compared by length of the high-pressure zone. CONCLUSION: The measurement, documentation, and reporting of mean resting and mean squeeze pressures provide a better perspective of anal manometric results, since the two sets of values are significantly different (P < 0.01), regardless of the anal canal length. Therefore, these data support the standardized evaluation of both mean and maximum pressures in individual patients and in published series.

Optimization of sphincter function after the ileoanal reservoir procedure. A prospective, randomized trial.

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: high-pressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17-69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (delta = 2.6) in Group 1 and from 0.2 to 2.0 (delta = 1.8) in Group 2 (P = 0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P > 0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.

Ileal pouch-anal anastomosis: is preoperative anal manometry predictive of postoperative functional outcome?

PURPOSE: The aim of this study was to determine the value of preoperative anal manometry in predicting post-operative continence. METHODS: Anal manometry was performed in 73 consecutive patients before ileal pouch-anal anastomosis (IPAA) surgery (m1), before loop ileostomy closure (m2), and at a follow-up of one (m3) and two (m4) years. Mean and maximum resting and squeezing pressures were documented at each occasion. One year after surgery, pressures were correlated (r) with an incontinence score. RESULTS: A significant (P < 0.05) decrease in mean resting pressures was observed after IPAA (m1 = 66 mmHg; m2 = 42.8 mmHg), followed by a significant (P < 0.05) improvement of mean resting pressure after loop ileostomy closure (m3 = 53.8 mmHg; m4 = 54.7 mmHg). Mean squeezing pressures did not change (P > 0.05) at any time during the study (m1 = 114 mmHg; m2 = 102.9 mmHg; m3 = 103.4 mmHg; m4 = 95.8 mmHg). There was no correlation between preoperative mean resting pressure and postoperative (mI) incontinence score. CONCLUSION: Anal manometry showed a characteristic trend in internal anal sphincter injury after IPAA followed by recovery after ileostomy closure. However, it failed to prove helpful in the prediction of clinical outcome. Thus, although this study supports the continued use of manometry in a research setting, it challenges the value of routine manometry in a clinical context.

Colon trauma--clinical staging for surgical decision making. Analysis of 119 cases.

A retrospective study is presented of 119 patients admitted to the Central Hospital of the Venezuelan Institute of Social Security, in Caracas, between 1982 and 1990, with the diagnosis of colon trauma. Several parameters including age, etiology, time elapsed between the accident or assault and hospital admission, preoperative and postoperative hemoglobin and diastolic blood pressure, associated lesions, procedure practiced, complication rate, and hospital mortality are reviewed. The second and third decades of life appear most often involved. Most patients reached the hospital within the first four hours of the accident or assault. Anemia, sustained diastolic hypotension, and number of organs involved in addition to the colon were important prognostic factors for complications. Apparently the surgical procedure, with simple suture or resection, mostly without "protective" colostomy, was not very relevant. Hospital mortality was 2.4 percent. A staging system based on clinical conditions for decision making in the operating room was used in an attempt to inject some objectivity into the surgical approach.

Socialized medicine or state-ruled medicine: the Venezuelan dilemma.

The economic crisis in which Venezuela is living, caused by the fall in oil prices, has forced the government to reorganize its medical services. A central administrative organ, the National Health Service, has been created. It seeks to develop a social medicine directed at the less favored classes of the population. Notwithstanding the continuously rising costs of private medicine, which, until now, the government has permitted without restrictions, the shadow of government intervention looms ominously over private practice, where subemployment of doctors already exists, along with the growing tendencies of insurance companies to impose economic conditions. The Venezuelan Medical Federation, which, by law, groups all Venezuelan doctors, has began a battle on two main fronts: against the State intervention and against the insurance companies who hope to benefit at the expense of the already underpaid doctors.

Histoclinical basis for a new classification of hemorrhoidal disease.

The present classification of first, second, and third grade hemorrhoids only reflects variation in size of a normal human tissue and does not relate to "hemorrhoidal disease." Cross-sections and coronal sections of the anal canal in 32 fetuses, with ages ranging from 28 to 38 weeks of development, were studied and the following fundamental facts were found: in the lumen of the anal canals of fetuses, there are prominences of mucosa formed by conjunctive and muscular tissue, arterial and venous vessels and glands, arranged without following any particular pattern, which resemble similar formations found in the adult that protrude equally in the inside of the canal, known as hemorrhoids. The muscular tissue, smooth or striated, is grouped in bundles, and bunches of collagen fibers of homogeneous, nonfragmented, and regular aspect are found between them. Blood vessels have an ample lumen with a defined structure of collagen tissue as well as muscular tissue in its walls. Prominences of mucosa are connected to the remainder of the intestinal wall by defined conjunctive thick, nonfragmented fibers, that permit firm adherence. In healthy adults, the findings were similar but there was an evident degenerative process in the collagen fibers. In 100 surgical specimens of hemorrhoidectomies, the histologic investigation demonstrated a severe inflammatory reaction that especially affected the blood vessel wall and conjunctive tissue, which probably produced an ischemic lesion of the mucosa that could condition the onset of a vascular thrombosis, allowing displacement of the mucosa and its protrusion through the anus. The files of 815 patients suffering from hemorrhoidal disease were also studied. The main physical findings were bleeding, thrombosis of the internal hemorrhoidal plexus, prolapse of the anal cushions, or a combination of these. The authors propose to classify hemorrhoidal disease as bleeding, prolapsing, thrombotic, and mixed hemorrhoidal disease, aiming toward a rational treatment.