International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019).

At present, natural orifice specimen extraction surgery (NOSES) has attracted more and more attention worldwide, because of its great advantages including minimal cutaneous trauma and post-operative pain, fast post-operative recovery, short hospital stay, and positive psychological impact. However, NOSES for the treatment of gastric cancer (GC) is still in its infancy, and there is great potential to improve its theoretical system and clinical practice. Especially, several key points including oncological outcomes, bacteriological concerns, indication selection, and standardized surgical procedures are raised with this innovative technique. Therefore, it is necessary to achieve an international consensus to regulate the implementation of GC-NOSES, which is of great significance for healthy and orderly development of NOSES worldwide.

International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer.

In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, better cosmetic and psychological effect have been described in colorectal surgery. Despite significant decrease in surgical trauma of NOSES have been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three rounds of discussion by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-term progress of NOSES worldwide.

On the etiology of the electric activity of the external anal and urethral sphincters.

UNLABELLED: In a previous study, the external anal sphincter (EAS) in dogs, known to consist of skeletal muscle fibers, was proved to contain bundles of smooth muscle fibers in between as well. OBJECTIVE: Cause of electric activity in the external anal and urethral sphincters is not known; the current study investigated this point. MATERIAL AND METHODS: Slices from external anal and urethral sphincters of 21 cadavers (12 male, 9 female). Eighth were fully and mat wide neonates, 13 were adults, were stained with hematoxylin and eosin, Masson's trichrome and succinic dehydrogenase, and examined microscopically. Eighteen healthy volunteers, electromyography activity of their external anal and urethral sphincters was recorded at rest, on coughing, after pudendal nerve block and after drotaverine administration, (a smooth muscle relaxant). Anal and urethral pressures were also measured. RESULTS: Microscopic studies have shown that both external anal and urethral sphincters were formed of bundles of smooth muscle fibers present in between the skeletal muscle fibers. Bilateral pudendal nerve block did not abolish the external anal or the urethral sphincters electromyography activity at rest, or on coughing, and did not cause significant anal or urethral pressure changes (p > .05). Drotaverine administration lead to disappearance of the electromyography activity and significant decline of the anal and urethral pressures (p < .05). The results were reproducible when the tests were repeated in the same subject. CONCLUSION: Histologic examination revealed the presence of smooth muscle fibers, between the skeletal fibers of the external anal and urethral sphincters. Evidence suggests that the smooth muscle fibers are the source of the electric activity of the sphincters and might explain some physiologic phenomena such as the external anal contraction on rectal distension or on coughing.

Tunica albuginea reefing: a novel technique for the treatment of erectile dysfunction.

BACKGROUND: "Tunica albuginea (TA) reefing" is a modification of Shafik's "TA overlapping" operation. Both techniques are based on the fact that in venogenic erectile dysfunction patients, the TA exhibits degenerative and atrophic collagen and elastic fibers causing its subluxation and flabbiness. This had led to loss of the veno-occlusive mechanism of the TA and venous leakage during erection. AIM: Reefing of the redundant tissue by bilateral excision of an ellipse of the TA provides a more effective correction of the TA and achieves a good support of the corpora cavernosa during tumescence. MATERIAL AND METHODS: The study included 24 patients with a mean age of 33.5 ± 1.7 SD years. Intracorporal pressure was measured preoperatively and postoperatively. After penile degloving, an ellipse was excised from both lateral aspects of the penile shaft, extending from the glans penis to its root, and the two edges of each wound were reefed by continuous Dexon suture. RESULTS: The TA ellipses were taken as biopsies and revealed degenerative changes when stained with hematoxylin and eosin and Masson's trichrome stain. Postoperatively, there was an intracorporal pressure increase (p < .01) in 20 out of 24 patients of the study and a decrease in 4 out of 24. Six months after operation, the patients showed significantly (p < .01) improved scores for the domain of erectile function over the preoperative scores. CONCLUSION: The reefing operation corrects the TA flabbiness to a greater extent, lends more support to corporal tissue, and improves the veno-occlusive mechanism.

Ileocecal junction: anatomic, histologic, radiologic and endoscopic studies with special reference to its antireflux mechanism.

AIM: The aim of the study was to perform histomorphologic, endoscopic, and radiologic studies of the ileocecal junction (ICJ). A clearer understanding of the anatomical structure of the ICJ may shed some light on its function. METHODS: Histomorphologic studies were performed in 18 cadavers and radiologic in 22 and endoscopic in 10 healthy volunteers. Morphologic studies were done with the help of a magnifying loupe: histologic sections were stained with hematoxylin and eosin and Masson's trichrome. The ICJ was studied radiologically using the method of small bowel meal. Endoscopic study was done under controlled air inflation using a video endoscope. RESULTS: A nipple (1.5-2 cm long) with transversely lying stoma protruded from the medial wall of the cecum. A fornix was found on each side. The nipple stoma was surrounded by two lips: upper and lower. A mucosal fold started at both angles of the stoma and extended along the cecal circumference. It was marked on the outer cecal aspect by a groove. CONCLUSION: The ileocecal nipple is a muscular tube with a transversely lying stoma and is suspended to the cecal wall by a "suspensory ligament". The morphologic structure of the ileocecal nipple was confirmed endoscopically and radiologically. The ileocecal nipple was closed at rest and opened upon terminal ileal contraction to deliver ileal contents to the cecum. It evacuated the barium periodically into the cecum. The ileocecal nipple structure seems to be adapted to serve the function of cecoileal antireflux.

MRI anatomy of the anal region.

PURPOSE: The aim of this study was to identify the normal anatomy of the anal region on magnetic resonance images. METHODS: T1-weighted turbo spin-echo images of anal sagittal sections, anal coronal sections, and oblique anal transverse planes were obtained with a body coil in 60 normal volunteers (30 women and 30 men, aged 19-25 years) at rest in the supine position. RESULTS: T1-weighted images showed fat spaces and muscles simultaneously, allowing visualization of 7 image layers, including the mucosa, submucosa, anal smooth muscle, inner (intersphincteric) space, vertical levator, outer (intersphincteric) space, and external anal sphincter. The anal smooth muscle was derived from the rectal smooth muscle, and the inner space originated from the perirectal space. The outer space lay between the vertical levator and the external sphincters. The puborectalis did not have a longitudinal portion. The deep, superficial, and SC sphincters were 3 separate muscle bundles. The perianal spaces had a complex interconnection. CONCLUSIONS: Multiplanar body-coil MRI studies can show anorectal fat spaces and musculature simultaneously, allowing fat spaces and musculature to serve as mutual referents. The results of imaging of the anal region with this method are different from previous imaging descriptions and may provide a more accurate and systemic description of the anal region structures than was previously available.

A study of an anatomic-physiological cecocolonic sphincter in humans.

We hypothesized an anatomical/physiological sphincter and investigated this hypothesis in current communication. The histomorphologic and morphometric studies were carried out in 14 cadavers and radiologic studies in 20; endoscopy studies were done in 16 healthy volunteers. Longitudinal sections along cecum, cecocolonic junction, and ascending colon were stained with H & E and Masson's trichrome stain. Morphometry study of musclethickness of cecum, cecocolonic junction, and ascending colon, radiological examination by method of small bowel barium meal administration, and endoscopic study by pancolonoscopy were studied. A cecocolonic fold was identified 2-2.5 cm distal to ileocecal nipple. It extended along gut circumference, shelf-like, and was marked by a shallow groove on outer aspect of colon. Microscopically, cecocolonic fold consisted of mucosa, submucosa, and muscularis externa. The circular muscle layer was thicker than that of cecum or ascending colon. Branching cells with ovoid nuclei representing probably intestinal cells of Cajal were identified in muscularis externa. Also morphometric study showed that circular muscle layer was significantly thicker than that of cecum or ascending colon, whereas longitudinal muscle exhibited no significant difference. Radiologic studies demonstrated narrowing at cecocolonic junction, which became wider on cecal contraction and narrower or closed on colonic contraction. Endoscopically, cecocolonic junction was narrow due to presence of cecocolonic fold, which exhibited spontaneous contractions. Our findings suggest an "anatomic" sphincter at cecocolonic junction as evidenced histomorphometrically, radiologically and endoscopically. Detection of interstitial cells of Cajal in cecocolonic fold postulates possible existence a pacemaker in cecocolonic fold, a point that needs further study.

Effect of severe stress on the gastric motor activity: canine study of mechanism of action.

BACKGROUND: Increased gastric motility was observed during restraint stress in animals; however, mechanism of action could not be traced in literature. We investigated the hypothesis that high levels of stressful cutaneous stimuli induce increase of gastric motor activity through a reflex action. METHODS: Gastric tone (GT) was assessed in 14 dogs by barostat system consisting of balloon-ended tube connected to strain gauge and air-injection system. Tube was introduced into stomach and its balloon inflated with 150 mL of air. Thermal cutaneous stimulation (TCS) was performed by thermal plate applied to skin. Temperature was raised in increments of 5 degrees C up to 107 degrees C and GT was simultaneously assessed by recording balloon volume variations expressed as percentage change from baseline volume. Test was repeated after separate anesthetization of skin and stomach. RESULTS: TCS up to mean temperature of 48.7 +/- 1.1 degrees C effected significant decrease of GT, but significant increase beyond this temperature. Twenty minutes after individual anesthetization of skin and stomach, TCS produced no significant change in GT. CONCLUSION: TCS up to certain degree effected GT decrease, whereas TCS beyond this degree augmented the GT. These effects seem to be mediated through reflex action as evidenced by their absence on individual anesthetization of the suggested 2 arms of the reflex arc: skin and stomach; we call this reflex "cutaneo-gastric reflex." The reflex may have the potential to serve as an investigative tool in diagnosis of gastric motor disorders provided further studies are performed to reproduce current results.

An electrophysiologic study of female ejaculation.

Opinions vary over whether female ejaculation exists or not. We investigated the hypothesis that female orgasm is not associated with ejaculation. Thirty-eight healthy women were studied. The study comprised of glans clitoris electrovibration with simultaneous recording of vaginal and uterine pressures as well as electromyography of corpus cavernous and ischio- and bulbo-cavernosus muscles. Glans clitoris electrovibration was continued until and throughout orgasm. Upon glans clitoris electrovibration, vaginal and uterine pressures as well as corpus cavernous electromyography diminished until a full erection occurred when the silent cavernosus muscles were activated. At orgasm, the electromyography of ischio-and bulbo-cavernosus muscles increased intermittently. The female orgasm was not associated with the appearance of fluid coming out of the vagina or urethra.

Colosigmoid junction: morphohistologic, morphometric, and endoscopic study with identification of colosigmoid canal with sphincter.

To study the anatomical structure of the colosigmoid junction, 15 cadaveric specimens were studied morphologically, another 15 histologically, and a morphometric study was done in 10 specimens. Specimens consisted of the descending colon, sigmoid colon, and the colosigmoid junction. Histologic specimens were stained with hematoxylin and eosin and Masson's trichrome stain. Morphometric studies used an image analysis system. The colosigmoid junction was investigated endoscopically in 18 healthy volunteers. A narrow segment having a mean length of 5.2 +/- 1.1 cm was identified both externally and internally between the descending and sigmoid colon. We called this segment the colosigmoid canal. Mucosal folds were found crowded in the colosigmoid canal, the lower end of which formed a nipple and was surrounded by a fornix. Histologically, the colosigmoid canal mucosa showed multiple folds. Its circular muscle was thicker than that of the descending or the sigmoid colon and confirmed morphometrically. The longitudinal muscle was thicker in only 4 of 10 specimens. Both the narrowing and the mucosal crowding were verified endoscopically. The colosigmoid junction is the narrow segment between the descending and the sigmoid colon. Histologic, morphometric and endoscopic studies indicated the presence of a sphincter in the colosigmoid canal. A colosigmoid sphincter is suggested to control the passage of colonic contents from the descending colon to the colosigmoid canal as well as to prevent reflux of sigmoid contents into the descending colon.

Percutaneous perineal electrostimulation induces erection: clinical significance in patients with spinal cord injury and erectile dysfunction.

OBJECTIVES: Approximately one third to one half of the penis is embedded in the pelvis and can be felt through the scrotum and in the perineum. The main arteries and nerves enter the penis through this perineal part of the penis, which seems to represent a highly sensitive area. We investigated the hypothesis that percutaneous perineal stimulation evokes erection in patients with neurogenic erectile dysfunction. METHODS: Percutaneous electrostimulation of the perineum (PESP) with synchronous intracorporeal pressure (ICP) recording was performed in 28 healthy volunteers (age 36.3 +/-7.4 y) and 18 patients (age 36.6 +/- 6.8 y) with complete neurogenic erectile dysfunction (NED). Current was delivered in a sine wave summation fashion. Average maximal voltages and number of stimulations delivered per session were 15 to 18 volts and 15 to 25 stimulations, respectively. RESULTS: PESP of healthy volunteers effected an ICP increase (P < 0.0001), which returned to the basal value upon stimulation cessation. The latent period recorded was 2.5 +/- 0.2 seconds. Results were reproducible on repeated PESP in the same subject but with an increase of the latent period. Patients with NED recorded an ICP increase that was lower (P < 0.05) and a latent period that was longer (P < 0.0001) than those of healthy volunteers. CONCLUSION: PESP effected ICP increase in the healthy volunteers and patients with NED. The ICP was significantly higher and latent period shorter in the healthy volunteers than in the NED patients. PESP may be of value in the treatment of patients with NED, provided that further studies are performed to reproduce these results.

Effect of thermal cutaneous stimulation on the gastric motor activity: study of the mechanism of action.

AIM: To investigate the mechanism of action of thermal cutaneous stimulation on the gastric motor inhibition. METHODS: The gastric tone of 33 healthy volunteers (20 men, mean age 36.7 +/- 8.4 years) was assessed by a barostat system consisting of a balloon-ended tube connected to a strain gauge and air-injection system. The tube was introduced into the stomach and the balloon was inflated with 300 mL of air. The skin temperature was elevated in increments of 3 degree up to 49 degree and the gastric tone was simultaneously assessed by recording the balloon volume variations expressed as the percentage change from the baseline volume. The test was repeated after separate anesthetization of the skin and stomach with lidocaine and after using normal saline instead of lidocaine. RESULTS: Thermal cutaneous stimulation resulted in a significant decrease of gastric tone 61.2% +/- 10.3% of the mean baseline volume. Mean latency was 25.6 +/- 1.2 ms. After 20 min of individual anesthetization of the skin and stomach, thermal cutaneous stimulation produced no significant change in gastric tone. CONCLUSION: Decrease in the gastric tone in response to thermal cutaneous stimulation suggests a reflex relationship which was absent on individual anesthetization of the 2 possible arms of the reflex arc: the skin and the stomach. We call this relationship the "cutaneo-gastric inhibitory reflex". This reflex may have the potential to serve as an investigative tool in the diagnosis of gastric motor disorders, provided further studies are performed in this respect.

Vaginal response to clitoral stimulation: identification of the clitorovaginal reflex.

OBJECTIVE: To investigate the hypothesis that glans clitoris (GC) penile buffeting effects contraction of the vaginal musculature and seems to increase arousal of the penis during coitus. STUDY DESIGN: The response of the vaginal wall to GC electrical and mechanical stimulation was recorded in 26 healthy women (aged 36.8 +/- 6.7 years). The test was repeated after individual anesthetization of the GC and vagina using lidocaine gel and after application of bland gel instead of lidocaine. RESULTS: The 2 vaginal electrodes recorded, at rest, slow waves followed or superimposed by action potentials. Wave parameters were similar from the 2 electrodes. Electrical or mechanical GC stimulation effected a significant increase in vaginal electromyographic (EMG) activity and pressure (p < 0.01). GC stimulation, while the vagina or GC had been separately anesthetized, produced no significant change, but there was a response following application of bland gel. CONCLUSION: GC stimulation effected an increase in vaginal EMG activity and pressure and presumably indicated vaginal wall contraction. This action seems to be a reflex and is mediated through the clitorovaginal excitatory reflex. Vaginal wall contraction during coitus appears to effect penile arousal and, consequently, female sexual stimulation.

Study of the response of the penile corporal tissue and cavernosus muscles to micturition.

BACKGROUND: The reaction of the corpora cavernosa (CC), the corpus spongiosum (CS), the bulbocavernosus (BCM) and ischiocavernosus (ICM) muscles to passage of urine through the urethra during micturition is not known. We investigated the hypothesis that the passage of urine through the urethra stimulates the corporal tissue and cavernosus muscles. METHODS: In 30 healthy men (mean age 42.8 +/- 11.7 years), the electromyographic activity (EMG) of the CC, CS, BCM, and ICM were recorded before and during micturition, and on interruption of and straining during micturition. These tests were repeated after individual anesthetization of urethra, corporal tissue, and cavernosus muscles. RESULTS: During micturition, the slow wave variables (frequency, amplitude, conduction velocity) of the CC and CS decreased while the motor unit action potentials of the BCM and ICM increased; these EMG changes were mild and returned to the basal values on interruption or termination of micturition. Micturition after individual anesthetization of urethra, corporal tissue and cavernosal muscles did not effect significant EMG changes in these structures, while saline administration produced changes similar to those occurring before saline administration. CONCLUSION: The decrease of sinusoidal and increase of cavernosus muscles' EMG activity during micturition apparently denotes sinusoidal relaxation and cavernosus muscles contraction. Sinusoidal muscle relaxation and cavernosus muscles contraction upon micturition are suggested to be mediated through a 'urethro-corporocavernosal reflex'. These sinusoidal and cavernosus muscle changes appear to produce a mild degree of penile tumescence and stretch which might assist in urinary flow during micturition.

Inguinal canal dilatation: a novel technique for the repair of failed testicular descent despite hormonal treatment.

Treatment of the undescended testicle (UT) after it failed to descend on hormonal therapy is surgical. Spermatic cord elongation may impair testicular function, particularly in cases in which cord integuments or veins have to be divided to provide an extra cord length. A factor that might impede testicular descent is presence of a narrowed or obliterated inguinal canal. We investigated the hypothesis that dilatation of a narrowed or obliterated inguinal canal might assist spontaneous testicular descent. Twenty-six boys (age 3.6 +/- 0.8 years) with unilateral UT and failed hormonal treatment, whose UT was located at deep inguinal ring, were included in the study. Through an inguinal incision, the inguinal canal was dilated, spermatic cord adhesions divided, hernial sac, if present, excised, and skin closed. Testicular descent into the scrotum occurred in 22 patients within 4.2 +/- 1.3 months. The remaining four patients were reoperated on by Fowler-Stephens orchiopexy after 14 months. A technique is presented for the treatment of the UT after failure to respond to hormonal treatment. It consisted of clearing the testicular pathway of any adhesions and dilating the narrowed inguinal canal. The technique is simple, easy, and does not interfere with the testicle or spermatic cord.

Effect of micturition on clitoris and cavernosus muscles: an electromyographic study.

We investigated the hypothesis that passage of urine through urethra stimulates corporal tissue and cavernosus muscles. Electromyographic (EMG) activity of corpora cavernosa (CC), bulbocavernosus muscle (BCM), and ischiocavernosus muscle (ICM) was recorded in 27 healthy women before and during micturition. These tests were repeated after individual anesthetization of urethra, corporal tissue, and cavernosus muscles. During micturition, slow wave variables of CC decreased and motor unit action potentials of the BCM and ICM increased. These EMG changes returned to basal values on micturition interruption or termination. Micturition after individual anesthetization of the urethra, corporal tissue, and cavernosus muscles did not effect significant changes in these structures. Decreased EMG activity of CC and increased activity of cavernosus muscles during micturition apparently denotes corporal tissue relaxation and cavernosus muscles' contraction. The latter two actions occurring on micturition are suggested to be mediated through a reflex called "urethro-corporocavernosal reflex" and effect a mild degree of clitoral tumescence.

The electromyographic activity of the external and internal urethral sphincters and urinary bladder on vaginal distension and its role in preventing vaginal soiling with urine during sexual intercourse.

BACKGROUND/AIM: We investigated the hypothesis that external (EUS) and internal (IUS) urethral sphincters and urinary bladder (UB) respond to penile thrusting (PT) of vagina in a way that prevents urinary leakage during coitus. METHODS: Vaginal condom was inflated with air in increments of 50-300 ml and EMG of EUS and IUS and vaginal pressure were recorded; test was repeated after anesthetization of vagina, UB, EUS, and IUS. RESULTS: Vaginal distension effected reduction of vesical pressure but increase of IUS EMG until the 150 ml distension was reached, beyond which more vaginal distension caused no further effect; EUS EMG showed no response. Vaginal distension while vagina, UB, EUS, and IUS had been separately anesthetized, produced no change. CONCLUSION: Vaginal balloon distension appears to effect vesical relaxation and increased IUS tone. This seems to provide a mechanism to avoid urine leakage during coitus and to occur through a reflex we term 'vagino-urethrovesical reflex'.

Electromyographic lag time and opening time: two novel noninvasive methods to investigate patients with anal outlet obstruction and their response to treatment.

Methods in use can diagnose anal outlet obstruction but not degree of obstruction. We introduced two novel noninvasive methods of diagnosing and evaluating the degree of anal outlet obstruction: pelvic floor electromyographic lag time and opening time. Pelvic floor electromyographic lag time measured time interval between start of pelvic floor muscle relaxation and start of anal outlet flow. Opening time calculated time lapse between start of rectal contraction and start of anal outlet flow. We investigated the hypothesis that pelvic floor electromyographic lag time and opening time can be used as investigative tools in diagnosing and evaluating degree of anal outlet obstruction. Thirty-one patients with anal outlet obstruction and 26 healthy volunteers were studied. Electromyography of external anal sphincter and anal and rectal pressures were recorded on rectal balloon distension until balloon was expelled. Pelvic floor electromyographic lag time and opening time were measured. Mean opening time and pelvic floor electromyographic lag time of the anal outlet obstruction patients showed significant increase compared to those of healthy volunteers. Pelvic floor electromyographic lag time was longer than opening time in both patients and controls, but the difference was not significant. Biofeedback effected improvement in 24 of the 31 patients. Thus, two novel investigative tools -- opening time and pelvic floor electromyographic lag time -- in diagnosis of anal outlet obstruction are presented. They exhibited significant increase in anal outlet obstruction patients over the healthy volunteers. There was no significant difference between pelvic floor electromyographic lag time and opening time readings.

Effect of urethral stimulation on vesical contractile activity.

BACKGROUND: We investigated the hypothesis that urethral stimulation effects vesical contraction. METHODS: Vesical pressure response to urethral balloon distension with normal saline in increments of 1 mL was recorded in 26 healthy volunteers (17 men, 9 women; mean age, 36.9 +/- 9.7 SD years) before and after individual anesthetization of the urinary bladder and urethra. Urethral distension was effected by a 6F balloon-ended catheter introduced per urethra. Vesical pressure was measured by means of a microtip catheter. RESULTS: Vesical pressure recorded gradual increase on increase of urethral balloon distension. Bladder response was maintained as long as urethral distension was continuous. The response showed no significant difference when we distended different parts of the male or female urethrae. Urethral distension after individual vesical and urethral anesthetization effected no change in the vesical pressure. CONCLUSIONS: Urethral distension produced a vesical pressure increase that presumably denotes vesical contraction. Vesical contraction on urethral stimulation by distension is suggested to be mediated through a "urethrovesical stimulating reflex" that seems to facilitate vesical contraction. Provided further studies to be performed in this respect, the reflex may prove to be of diagnostic significance in micturition disorders.