[Possibilities in the preservation and restoration of anal continence]. / Az analis continentia megórzésének és helyreállításának lehetóségei.

The preservation of anal continence and the improvement of the patients' quality of life in general are primary objectives of colorectal surgery. Earlier the loss of the entire rectum, colon required a definitive stoma. This review describes surgical procedures designed to preserve anal continence. This paper also describes operative techniques designed to improve impaired sphincter function. Total extirpation of the mesorectum reduces local recurrence of rectal tumours. At the same time, this operation requires formation of the anastomosis low, at the level of the levator muscle. Low colorectal or coloanal anastomoses are associated with higher incidence of suture leakage and poor functional outcome. The distance between anastomosis and anal verge was less than 7 cm in 249 sphincter-sparing rectal resections performed during the examined 6-year period in our institute. Different techniques to perform anastomoses were applied, the prevalence of suture leakage and the functional results are analysed. Restorative proctocolectomy has dramatically improved the treatment of familial polyposis and ulcerative colitis with rectal involvement. Although proctocolectomy is necessary to cure the disease, acceptable faecal continence can be achieved by creating ileoanal anastomosis with ileal reservoir. We discuss our results after 43 operations. Weakness of the sphincter apparatus is the most common cause of continence problems. Occasionally, the sphincter is no longer suitable for reconstruction because of extensive damage or denervation. In such cases, the levator muscles or--if neither these are of acceptable quality--the gluteus maximus muscle can be used to repair the external sphincter. Anterior levator plasty involves tightening the levator plate by suturing its arches together between the rectum and the vagina. This procedure enhances the resistance of the sphincter barrier primarily by increasing functional sphincter length. The functional outcome of this procedure was acceptable in two-thirds of the 52 operations. Post anal repair was performed only in 3 patients. This method comprises reinforcing the levator plate through an access between the external and the internal sphincters. When the levator plate is unsuitable, bilateral gluteus plasty can be performed to increase the strength of sphincter muscles. As the gluteus is a striated muscle it can improve only the of the external sphincter function. Therefore this procedure can restore acceptable continence to hard stool only. This is demonstrated by our clinical experience obtained in 10 patients.

[Isolated gastroduodenal Crohn's disease: a case report]. / Izolált gasztroduodenális Crohn betegség: esetismertetés.

Although it can involve any segment of the gastrointestinal tract, Crohn's disease confined to the gastroduodenum is extremely rare. We report the story of a 20-years old male patient admitted for pyloric obstruction that developed despite medical treatment. Clinical manifestations necessitated operative treatment; Polya-gastrectomy was performed. Histology identified Crohn's disease and inflammatory changes as the cause of pyloric obstruction. Postoperative recovery was uneventful. The lesson of this case is, that if duodenal Crohn's disease would have been recognized preoperatively, gastrectomy could have been avoided. We review the literature and discuss treatment options for gastroduodenal Crohn's disease.

Modulation by GABA(B) and delta opioid receptors of neurally induced responses in isolated guinea-pig taenia coli and human colonic circular muscle.

The GABA-ergic and opioid modulation of neurally induced muscle responses was studied in isolated guinea-pig taenia coli and human colonic circular muscle, using identical field stimulation parameters (rectangular pulses of 0.5 ms duration, 9 V x cm(-1) intensity, trains of 3 pulses at 0.5 Hz, repeated every 1/3/5 min). The stimulation-induced contractions were inhibited in both preparations by GABA and baclofen; the IC50 values in human colonic circular muscle were approximately 100 and 31.0 microM, respectively. In guinea-pig taenia coli, the inhibition by 10(-4) M GABA was dose-dependently reversed by 10(-4)-10(-3) M of GABA(B) receptor antagonist CGP 35348; antagonism by phaclofen was less effective in the same concentration range. In human colonic circular muscle, inhibition by 3 x 10(-5) M baclofen was fully reversed by 10(-3) M CGP 35348. With the exception of caecum, the delta 2 opioid receptor agonist deltorphin II was a potent inhibitor in human colonic circular muscle. 10(-8) M Deltorphin caused a 74.4 +/- 9.6% (n = 4) inhibition which was reversed by 10(-6) M of delta receptor selective peptide antagonist BOC-Tyr-Pro-Gly-Phe-Leu-Thr(OtBu). Deltorphin II was ineffective in guinea-pig taenia coli even at 10(-6) M; the same concentration caused an 84.3 +/- 7.9 (n = 4) inhibition in human preparations. It is concluded that: 1) GABA-ergic modulatory mechanisms are present both in human colonic circular muscle and guinea-pig taenia coli; 2) the GABA receptors involved are of type B; and 3) delta opioid receptor-mediated modulation functions only in human colonic circular muscle in regions other than the caecum.

[Treatment of anal fistulas]. / Az analis fistula kezelése.

The authors describe the traditional operative technique for correction of anal fistulae and analyse the outcome of surgical treatment. During a 5-years period between 1994 and 1998, 286 patients underwent surgery for anal fistula in the department--more than one--third of this population presented with recurrent disease. During the operation, the extrasphincteric segment of the anal fistula is excised and the margin of the sinus is marsupialized. Introducing a rubber band through the sinus tract eliminates lesions that penetrate the sphincter. As the tied band shears through the encircled sphincter muscle, the rate of transsection is controlled individually, by adjusting the tightness of the rubber band as necessary. The inner opening of the fistula is often difficult to identify and consequently, excision may be incomplete. This is a serious pitfall that commonly leads to recurrence. According to the authors' experience, flushing the fistula tract with hydrogen peroxide is the most effective methods for pinpointing the inner meatus. Using this technique, postoperative recurrence was detected in 30 patients (10%). Moderate impairment of anal continence had been observed in 57 patients (20%); however, this never progressed to permanent incontinence.

[Unusually large stromal tumor of the rectum causing obstruction]. / Obstrukciót okozó szokatlan nagyságú stromális rectum tumor.

A male, 74 years old patient with perineal, sacral pain and with defecation disorders attended the outpatient clinic of HIETE. The origine of the complains was a retrorectal, fist like, rectum narrowing tumor. The tumor was covered by normal mucosa from rectal side. Preoperative examinations--endoscopy, CT, MRI transrectal US--detected a tumor with size 7 x 6 x 5 cm, growing from the muscular wall of the rectum, with no connection with the surrounding tissues. Deep biopsy revealed malignant mesenchymal tumor. After preoperative irradiation abdominoperineal rectum amputation was performed. The recovery was uneventful. The definitive hystological examination proved a gastrointestinal stromal tumor (GIST). This type of tumor rarely occurs in the large intestine or in the rectum, that why the publishing can be interesting.

Clinical significance and application of anorectal physiology.

During the last decade, interest in anorectal disorders has increased continuously. This review presents the results of Hungarian authors' contributions to a better understanding of anorectal physiology over the last 10 years. It has been demonstrated that the surgical technique of pelvic floor reconstruction can be refined and surgical complication rates reduced through the analysis of anal basal pressure components and exploration of internal anal sphincter function. Objective assessment of anal continence (distinguishing continent from incontinent patients) is a consistent problem in clinical practice. The balloon-retaining test, a special application of manometry, facilitates evaluation of anorectal function in incontinent patients. Constipation is an extremely common symptom. Surgical treatment of these ailments should not be regarded as a first-choice therapy. Disordered defecation due to anismus can be identified by defecometry, and can eventually be treated by biofeedback training. The data presented here demonstrate the enormous impact of sophisticated diagnostic techniques on the therapeutic options in treatment of anorectal diseases.

Manometric evaluation of incontinent patients.

The relationship between symptoms and manometric data was studied in incontinent patients. Conventional anal manometry, the rectal saline infusion test and the balloon-retaining test were performed in 27 control subjects (M:8, F:19; mean age: 47 yr) and in 40 incontinent patients (M:5, F:35; mean age: 49 yr). The correlation coefficient between the clinical degree of continence/incontinence and the maximum anal basal tone, squeeze pressure and the pressure increment during squeeze was -0.74, -0.74 and -0.57, respectively. Discriminatory values of > 40 mmHg for maximum basal pressure and > 92 mmHg for squeeze pressure could identify continent patients with 96%, and incontinent patients with 88% accuracy. The uncontrollable evacuation of a balloon, progressively filled with water at 60 ml/min, before the maximum tolerable sensation level was reached, was related to the degree of clinical incontinence. Also the maximum retained volume and the interval between the first sensation volume and the maximum retained volume ("perceived rectal capacity") were related to the clinical symptoms: r = -0.72 and -0.71, respectively. The balloon-retaining test proved to be superior to the rectal saline infusion test for the determination of the severity of incontinence. The saline infusion test, however, was found to be more adequate to identify minor defects of continence. Thus, the manometric assessment of anorectal continence should consist of routine anal manometry, the rectal saline infusion test and the balloon-retaining test. Some important clinical implications are discussed.

The trigger for rectal filling sensation.

In order to evaluate whether rectal volume, weight or pressure is the main trigger for rectal sensation, their respective values were determined at each of the rectal filling sensation thresholds (first, constant, urge, maximum) in 12 adult control subjects. The rectal balloon was filled at 60 ml/min in sitting position using water (twice), air and mercury consecutively. Pressure values were corrected for the elastic properties of the balloon, while the volume of inflated air was recalculated taking into account the prevalent rectal pressure and temperature. The results obtained using water, air and mercury demonstrated a constant relationship between a given rectal sensation level and the pressure recorded in the distending balloon, but not its volume or weight. Pressure values recorded at each sensation level were constant during repeated determinations of rectal sensation, the volume of rectal distension increased, probably because the rectum had already been dilated by previous testing. Balloon distension using air with the patient in the lateral position were found to be most practical for routine evaluation of rectal sensation. It is therefore concluded that any disturbance of rectal sensation will be reflected by changes in pressure and not by changes in the volume needed to produce a given sensation level. The location of the receptors involved has to be elucidated, but it seems that the pelvic floor can be excluded since the weight of the rectal contents was not related to sensation.

Valvular colonic sphincter substitutes. An experimental study in dogs.

Three types of colonic sphincter substitutes were placed at an abdominal colostomy in dogs. Simple valve construction (8) was based on orthograde intussusception of the colon over 3.5 cm. In calibrated valves (6) the intraluminal pressure was increased by reducing the diameter of the overlying muscle coat. Reverse smooth muscle plasties (5) and simple colostomies (5) served as controls. Immediately after construction highest pressure (50 +/- 8.9 mm Hg) was obtained in calibrated valves. After 1 month the pressure dropped to 20 mm Hg, but remained stable thereafter. Although valvular constructions cannot maintain high pressure, they may be useful as substitutes for the internal anal sphincter by filling up the lumen so that the action of a surrounding striated muscle ring becomes more effective.

The internal anal sphincter can not close the anal canal completely.

We determined the maximum closing capability of the internal anal sphincter muscle ring in vitro and in vivo. The internal sphincter, 4 to 6 mm thick, cannot close the anal canal hermetically, not even during maximal contraction. The blood-filled anal cushions have to fill up an intrasphincteric gap of at least 7 to 8 mm in diameter.

The internal anal sphincter: mechanisms of control and its role in maintaining anal continence.

The human IAS has particular structural and functional characteristics. This smooth muscle constantly generates rhythmic electrical slow waves, but no action potentials. The slow waves are linked to calcium fluxes and both are essential for mechanical activity, i.e. the ASPW. The IAS is pharmacologically characterized by the presence of alpha excitatory and beta inhibitory adrenergic receptors. Cholinergic drugs have an indirect effect through the release of an inhibitory neurotransmitter, very probably VIP, from NANC nerves. The myogenic activity of the IAS is enhanced by its extrinsic sympathetic innervation. Thus, at rest, the IAS is in a state of partial tetanus and contributes approximately 55% of the MABP. Because the IAS ring cannot be completely closed, the anal mucosa and the haemorrhoidal plexuses fill the gap. By compressing these tissues, the IAS perfectly closes the anal canal to retain not only solids but also fluid stool and gas. Acute rectal distension and rectal activity, mainly through intramural pathways, induce reflex IAS relaxation, permitting the rectal contents to be sampled by receptors in the upper anal canal while continence is temporarily maintained by EAS activity and by expansion of the haemorrhoidal cushions. There is a correlation between the volume of rectal distension and the parameters of IAS relaxation. At maximal IAS relaxation, ASPW are absent, indicating the completeness of the inhibition. Although this RAIR is not essential for defecation, insufficient relaxation may be implicated in constipation. Hyperactivity of the IAS resulting in a high MABP and AUSPW has been considered both as a cause and as an effect in haemorrhoids and anal fissure. Continence for fluids and gas is impaired if IAS activity is decreased (i.e. a low MABP), either by direct trauma or by damage of its sympathetic innervation. Severe faecal incontinence will develop when the contractility of both the IAS and the EAS is affected.

[Initial experience with ultrasonic examination of the rectum]. / Kezdeti tapasztalataink a rectum ultrahang vizsgálatával.

The authors report their initial results obtained by the use of transrectal sonography in examination of known or suspected rectal and perirectal masses. 42 patients were examined with commercially available endosonographic probes. 22 patients had known rectal cancer. 13 patients underwent surgical exploration. Malignant infiltration of perirectal fat were detected as accurately with US as with histology in 9 cases. Lymph node involvement was accurately identified in 11 cases. They recommend this new technique for the assessment of invasion of rectal tumours and lymph node involvement, for postoperative follow-up and for examination of benign diseases of the rectum.

Biofeedback defaecation training for anismus.

Anismus, paradoxical external sphincter function, spastic pelvic floor syndrome, rectoanal dysnergia, abdomino-levator incoordination for abdominopelvic asychronism, are all due to paradoxical contraction of the striated sphincter apparatus during voiding and is characterised by prolonged and excessive straining at stool. Biofeedback is the treatment of choice and has to be introduced at an early stage. We present the results of an ambulatory approach based on the integration of simulated balloon defaecation with small (50 ml) as well as constant rectal sensation volume, defaecometry and anal manometry. The pathophysiology visualised by the patient's own anorectal pressure recordings on the screen of a personal computer is explained and corrected. Sixteen patients were treated and followed for at least 1 year. Manometric data were normal except for an increased minimum residual pressure and rectal compliance. Nine patients could not evacuate a 50 ml bolus initially. Simulated defaecation became possible in seven out of these nine patients when the bolus was increased up to the individual constant rectal sensation volume. Two patients could not evacuate this volume either, while defaecation was made much less laborious in the other seven patients. Paradoxical contraction was immediately corrected in 7/16 cases. Also, as an immediate, objective benefit of a single training session, improved defaecation of a 50 ml bolus was observed in 11 patients. This effect was preserved after 6 weeks in nine cases; symptomatic recurrence did not occur in these patients during follow-up. This method of defaecation training has many advantages as compared with sphincter training using EMG electrodes eventually performed in the absence of a desire to defaecate or in lying position.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraobserver variation in the radiological measurement of the anorectal angle.

Seven experts drew the rectal axes of 18 representative proctographic images on two occasions, with a 1-year interval, in order to assess intraobserver variation in the determination of the anorectal angle (ARA). Intraobserver variation (6%) and interobserver variation (17%) were smallest when the central rectal axis was used to determine the ARA. A strong relation was found between inter- and intraobserver variation (r = 0.77). Intraobserver variation tended to be rather small for pictures made during straining, but a relation with the magnitude of the ARA was not found. Although none of the seven experts could reproduce the rectal axes with less than or equal to 10% variation in all 18 pictures, redrawing of the central rectal axis delivered less than or equal to 10% variation in 86% of determinations. It is concluded that intraobserver variation is influenced by the expertise of the investigator, the method of analysis, and the anorectal configuration to be analyzed. Radiologic assessment of the ARA may yield reliable data on the dynamics of the anorectum if performed by a single investigator on x-ray films that allow confident analysis.

Observer variation in the radiological measurement of the anorectal angle.

Determination of the anorectal angle (ARA) and the position of the pelvic floor is, theoretically, very important in understanding the mechanisms of anorectal continence and defaecation. The variability in the measurement of the ARA was analyzed. Nine experts drew ther rectal axis either as a line along the posterior wall of the distal rectum or as the central axis of the rectal lumen on the outlines of 18 representative proctographic images. The standard deviations and ranges of the mean values of each ARA were comparable but large in both methods. On average, the S.D. was 8 degrees and the range value about 23 degrees. Inter-observer variation was not related to the magnitude of the ARA, but rather to the anorectal configuration. Drawing a line along the posterior distal rectal wall is difficult when it is irregular or when the puborectalis impression is indistinct. The central rectal axis is difficult to draw when the junction between the upper and lower rectum is ill defined or when the outlines of the distal rectum are asymmetric e.g. by the presence of a rectocele. Thus, the variability of both methods was not strongly interrelated (r = 0.68 for the median values). It is concluded that, in general, radiologic assessment of the ARA is not reliable enough for comparative investigation of the dynamics of the anorectum.

[Defecometry: determination of objective parameters of defecation]. / Defecometria: a székelés objektív paramétereinek meghatározása.

A method is presented for the identification and analysis of constipation due to difficult evacuation of rectal content. This condition--which has not been elucidated by former techniques--was identified in 5 out of the 19 constipated patients by this new method. Disturbed defecation was characterized by prolonged evacuation of the simulated stool and the greater work performed during this process. The cause of this phenomenon was the paradox movement of the pelvic floor, i.e. contraction instead of relaxation. The results' highlight: the excessive straining can induce a neuromuscular damage to the pelvic floor. The clinical importance of this method lies in the clarification of the principle, that the therapy of this condition must be initiated as early as possible.

Defecometry. A new method for determining the parameters of rectal evacuation.

The parameters of defecation, i.e., maximum rectal pressure increase during straining, duration of effective evacuation, and the work performed to evacuate a simulated stool, can be quantified by defecometry, a new method to evaluate the defecation act. Simultaneous anal pressure records demonstrate the nature of the sphincter activity during simulated defecation. The test was performed on 19 patients with constipation and on 14 controls. Five patients could not evacuate the simulated stool, while five others could, but more laboriously than the remaining nine patients whose defecation was comparable with the controls. Laborious defecation is characterized by longer duration and more performed work during evacuation. Every patient with difficult or ineffective evacuation had sphincter contraction during defecation, whereas this phenomenon was not observed in patients with normal defecation. Defecometry permits more adequate identification and characterization of the outlet-obstruction-type constipated patients than the simple balloon expulsion test and the analysis of sphincter activity during straining with empty rectum in lateral decubitus. Early diagnosis and treatment of patients with outlet obstruction is important to avoid late neuromuscular damage to the pelvic floor.

A new balloon-retaining test for evaluation of anorectal function in incontinent patients.

The balloon-retaining test consists of progressive filling of a compliant intrarectal balloon in a patient in the sitting position. The pressure inside the balloon is monitored and the patient is asked to retain the balloon as long as possible and to report first, constant, and maximal tolerable sensation levels. A balloon is used to simulate semisolid and solid stool. This test is a more realistic approach to the evaluation of fecal continence than the rectal saline infusion test and anal manometry. The test evaluates the rectal reservoir function, sensation, and sphincter competence simultaneously; however, the real rectal distensibility and compliance must be determined by compliance measurement until the maximal tolerable level for patients in a reclining position is reached. This test also permits objective evaluation of the effect of different treatments in incontinent patients.

The composition of anal basal pressure. An in vivo and in vitro study in man.

The maximal anal basal pressure (MABP) was measured with probes of 0.3, 1, 2 and 3 cm diameter in 21 subjects, 60 years old, without anal pathology. The components of MABP were analyzed by inducing a maximal internal sphincter (IS) relaxation, taking pressure measurements in the conscious state and during narcosis with curarization. In seven cases pressure measurements were done on isolated anorectum after abdominoperineal rectum amputation. MABP increases with probe diameter before as well as during anaesthesia with curarization. The contribution of the striated sphincter tonic activity is constant within the range of probe diameters used. At rest, i.e. when the 0.3 cm diameter pressure recording probe is used, 30% of MABP is made up by striated sphincter tonic activity, 45% of it is due to nerve induced IS activity, 10% to purely myogenic IS activity and 15% can be attributed to the expansion of the haemorrhoidal plexuses. Although MABP is mainly based on active forces generated by the smooth and striated sphincter apparatus, the presence of the anal cushions is essential for perfect anal continence, as they have to fill the gap within the IS ring to hermetically close the anal canal. The global IS activity, contributing 50-60% of MABP at rest, can completely be inhibited by a maximal rectoanal inhibitory reflex. Stretching of passive elements starts at 1 cm anal distension, but steeply increases thereafter, accounting for 65% of the MABP at 3 cm anal distension. It is deduced that optimal stool diameter is about 2 cm.