Anal sphincter size measured by endosonography in healthy volunteers. Effect of age, sex, and parity

The anal sphincter muscles consist of the circular internal and external sphincters together with the sling-shaped associated puborectalis muscle. Ten men, 10 women with no vaginal deliveries, and 10 women with one or more vaginal deliveries were studied with anal endosonography using a 7 MHz multiplanar endoprobe. The thickness of the internal sphincter and the thickness, length, and cross-sectional area of the external sphincter were measured and related to age, sex, and parity. Reproducibility was assessed by similar measurements on different days in 10 volunteers. Anal sphincter size was the same in men and women and was not affected by the number of child births. Internal sphincter muscle thickness increased with age. Anal manometry and electromyography with an anal sponge were performed in all volunteers but the results did not correlate to any of the anal sphincter dimensions. Our conclusion is that although there are some limitations, endosonography can be used to determine the size of the anal sphincter muscles.

[Surgical interventions in ulcer diseases in Denmark. A questionnaire study]

Surgical practice in the treatment of peptic ulceration in Denmark is illustrated by means of a questionnaire. The percentage of replies was 96. The investigation reveals that the predominant method of elective surgery for duodenal ulceration is still proximal gastric vagotomy rather than vagotomy+antrectomy. In elective surgery for prepyloric ulcer, vagotomy+antrectomy is employed most frequently and for elective operation for gastric ulcer partial gastric resection. In operative interventions for complications of ulceration such as haemorrhage and perforation, the operative strategy appears to be determined by the difficult current possibilities for training in ulcer surgery to a not inconsiderable extent, rather than to be based on a rational scientific basis as the definitive intervention here is replaced to a great extent by minor interventions such as simple undersewing of a bleeding gastric ulcer followed by H2-blocker treatment and simple closure of a perforated duodenal ulcer.

The colon in carbohydrate malabsorption: short-chain fatty acids, pH, and osmotic diarrhoea

Short-chain (C2-C6) fatty acids (SCFA) are the major anions in colonic contents and the result of anaerobic fermentation of mainly saccharides. The effects and regulation of saccharide fermentation were studied in vitro and in vivo. In vitro faecal incubation was used to study the effects of lactose, glucose, and galactose and of pH on SCFA formation. Changing the pH to below 5 or above 11 abolished SCFA formation in the faecal incubates; in the pH 5-9 interval SCFA production was high, with only minor pH dependence. Adding glucose, galactose, or lactose to the incubation system increased SCFA production, but at high saccharide concentrations (100-300 mmol/l) SCFA formation was inhibited by the pH change. In vivo disaccharide malabsorption with increasing doses of lactulose caused a decrease in faecal pH to less than 5, values inhibitory to fermentation, before the appearance of carbohydrate in faeces. In 6 of 12 volunteers diarrhoea occurred suddenly and was caused by malabsorbed non-fermented carbohydrate. The six other volunteers had a gradual increase in faecal output with lactulose dose and developed diarrhoea before the appearance of saccharide in faeces. The intake of lactulose tolerated before diarrhoea ensued varied between individuals, with the majority having diarrhoea of more than 11/day at 160 g lactulose per day. At this dose SCFA absorption was estimated to be in the range 550 to 1150 mmol/day.

Dynamic anal manometry: physiological variations and pathophysiological findings in fecal incontinence

A recently developed technique for dynamic anal manometry was used to study 40 healthy volunteers and 23 patients with fecal incontinence. Seven parameters of anal function were measured. Intraindividual variation of the parameters was studied in 5 females and 5 males. The results of dynamic anal manometry were compared with standard pull-through static anal manometry and correlated well. During opening of the anal sphincter at rest, compliance increased with increasing distension. Males had higher maximal closing pressures during squeeze and lower anal compliance during squeeze than females. There was no sex differences of the sphincter measurements at rest. Age had little effect, and gender had no effect on the measurements. With standard anal manometry, 6 of 23 patients with fecal incontinence both had maximal resting pressure and maximal squeeze pressure within the normal range. When dynamic anal manometry was used, all 23 patients showed one or more abnormal values. The method of dynamic anal manometry provides an opportunity for a more thorough assessment of anal sphincter function than previous manometric methods.

Viscous fluid retention: a new method for evaluating anorectal function

The ability to retain viscous fluid in the standing position was tested in 22 patients with fecal incontinence, 11 patients with constipation, and 26 control subjects. Viscous fluid was introduced into the rectum in increments of 50 ml. The examination was stopped when the patient complained of discomfort or the viscous fluid leaked. Eighteen of 22 patients with fecal incontinence leaked fluid, while none of the control subjects and only four of the constipated patients did so. Patients with fecal incontinence retained significantly less viscous fluid than did control subjects, whereas no difference was found between patients with constipation and control subjects. Rectal sensation from distention with air was tested in the patients as well as in the control group. The following volumes and pressures at each sensation were measured: 1) earliest defecation urge (EDU), 2) constant defecation urge (CDU), and 3) maximum tolerable volume (MTV). Patients with fecal incontinence had lower volumes than control subjects at all sensations, while patients with constipation had higher volumes at earliest defecation urge and at constant defecation urge. Rectal compliance was higher in patients with fecal incontinence than in control subjects, whereas patients with constipation did not differ from control subjects. Regression analysis showed a linear relationship between viscous fluid retention and the maximum tolerable volume and also between viscous fluid retention and rectal compliance. No difference in the ability to retain viscous fluid between male and female control subjects was found; regression analysis of viscous fluid retention in relation to age revealed decreasing volumes with increasing age. Day-to-day variation of the ability to retain viscous fluid was tested in eight persons, and reproducibility was found to be good.

Treatment of anal incontinence by an implantable prosthetic anal sphincter

Twelve patients with anal incontinence due to neurologic disease or failure of previous incontinence surgery underwent implantation of an artificial anal sphincter. The system used was a modification of the AMS 800 artificial urinary sphincter. In two patients, infection necessitated removal of the system, and in four patients, eight revisional procedures had to be performed because of mechanical failure. After various modifications of the system, especially reinforcement of the closing mechanism of the cuff, only one case of mechanical failure has occurred. Erosion through the anal canal did not occur. Among 10 patients with the system in function for more than 6 months, the result was considered excellent in 5, with only occasional leakage of flatus, good in 3, who occasionally leaked liquid feces and flatus, and acceptable in 2, in whom the cuff obstructed defecation. It is concluded that implantation of an artificial anal sphincter is a valid alternative to permanant colostomy in patients with anal incontinence due to neurologic disorders and in patients in whom other types of incontinence surgery have failed.

Comparison of different staining methods for polyvinylidene difluoride membranes

Several new staining methods for polyvinylidene difluoride membranes, including mercurochrome, silver and dimethylaminoazobenzene isothiocyanate staining were compared with Coomassie Brilliant Blue and gold staining. Of these, Coomassie was most versatile and completely compatible with ensuing microsequencing, immunostaining or other visualization methods, while gold and silver staining were more sensitive. Mercurochrome allows selective detection of sulfhydryl-containing proteins while dimethylaminoazobenzene isothiocyanate staining may allow quantitation of sequenceable protein.

Advances in the surgical management of anal incontinence

The standard treatments for traumatic and idiopathic faecal incontinence have for the last 10-15 years been sphincter reconstruction and pelvic floor repair, respectively. Results of the treatment of traumatic sphincter lesions have in general been satisfactory, whereas the results after prolonged follow-up of pelvic floor repair for idiopathic anal incontinence seem less convincing. Incontinence due to neurological disorders cannot always be treated by local procedures on the anal sphincter or pelvic floor. This has led to the investigation of a number of other surgical procedures with the aim of re-establishing faecal continence. These include transposition of striated muscles, primarily the gracilis and gluteus maximus, implantation of neuromuscular stimulators, implantation of artificial sphincters and implantation of neuroprosthesis. These new techniques, which are also applicable in patients with traumatic and idiopathic anal incontinence where local reconstructive procedures have failed, are reviewed in this chapter in the light of our present state of knowledge.

Anal endosonographic findings in the follow-up of primarily sutured sphincteric ruptures

Twenty-four women with primary suture of an obstetric tear of the anal sphincter were examined with anal endosonography a median of 12 (range 3-18) months after delivery. Endosonography was normal in ten patients, of whom one was incontinent. The examination showed a defect in the external anal sphincter in 13 patients; six of these were incontinent, two of whom had normal findings on palpation. An isolated internal sphincter defect was found in a continent patient. Since anal endosonography causes no more discomfort than digital examination, it may be useful to identify patients who would benefit from surgical reconstruction of the anal sphincter.

Fat and gastric acid secretion

To evaluate the importance of the terminal carboxyl group of the oleic acid molecule in the inhibition of gastric acid secretion, 6 normal persons were stimulated twice with duodenal perfusates containing either 20 mM oleic acid or 20 mM oleyl alcohol. Oleic acid significantly inhibited the gastric acid secretion stimulated by pentagastrin (100 ng/kg/h) and increased the levels of secretin in plasma. The effect of oleyl alcohol was insignificant. It is concluded that the carboxyl group of the fat molecule has an important role in the inhibition of gastric acid secretion, and the effect could in part be attributable to the release of secretin into plasma.

Anorectal pressure gradient in patients with anal incontinence

Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used (P less than 0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used (P less than 0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.

Risk of recurrence and reoperation after resection for ileocolic Crohn's disease

To evaluate possible risk factors for recurrence after primary resection of ileocolic Crohn's disease, the clinical course of 48 consecutive patients operated on over a 27-year period were reviewed. Median follow-up was 10 years (range, 3-27 years). The probability of not having a recurrence and the probability of not undergoing a second resection were 0.476 (+/- 0.191, 95% confidence limits) and 0.701 (+/- 0.180), respectively, after 10 years. None of the possible risk factors examined--sex, age at the primary resection, length of preoperative history, length of bowel involvement, failure of preoperative medical treatment, and residual microscopic disease at resections lines--significantly influenced the risk of recurrent disease (P greater than 0.05, log-rank test); however, there was a trend towards a higher risk of recurrence for the patients who had received medical treatment preoperatively. In the present study it was not possible to identify any factors that influenced the risk of recurrence.

Endosonography of the anal sphincter: findings in healthy volunteers

Knowledge of the normal sonographic features of the anal canal is essential for the detection of anal carcinomas, anal sphincteric defects, or other anal abnormalities with endosonography. The anal sphincters consist of the circular smooth muscle fibers of the internal sphincter and the circular striated muscle fibers of the external sphincter together with the sling-shaped puborectalis muscle. Anal endosonography was performed in 14 healthy women with normal anophysiologic examinations. The procedure was performed during electromyographic registration in five. A radial 7-MHz probe and a multiplane 7-MHz probe were used, and transverse and longitudinal images were obtained. On transverse images, the internal anal sphincter was visualized as a circular hypoechoic band, which on longitudinal images was seen in continuity with the muscularis layer of the rectal wall. The external anal sphincter was seen as a thicker circular echogenic band just outside the internal sphincter. The puborectalis muscle sling, which is the medial part of the levator and muscle, was visualized in the upper anal canal and had the same echogenic appearance as the external sphincter. Our experience in volunteers provides information about the normal sonographic features of the anal canal as depicted on anal endosonography with high-frequency probes. The results suggest the procedure may be a useful diagnostic tool in detecting pathologic conditions in the anal canal.

Attachment sites of primary binding proteins L1, L2 and L23 on 23 S ribosomal RNA of Escherichia coli

The attachment sites of the primary binding proteins L1, L2 and L23 on 23 S ribosomal RNA of Escherichia coli were examined by a chemical and ribonuclease footprinting method using several probes with different specificities. The results show that the sites are confined to localized RNA regions within the large ribonuclease-protected ribonucleoprotein fragments that were characterized earlier. They are as follows: (1) L1 recognizes a tertiary structural motif in domain V centred on two interacting internal loops; the main protein interaction sites occur at the internal loop/helix junctions. (2) The L2 site constitutes a single irregular stem/loop structure in the centre of domain IV where non-Watson-Crick pairing is likely to occur. (3) L23 recognizes a tertiary structural motif involving a single terminal loop structure and part of an adjacent internal loop at the centre of domain III. Each of the three primary binding proteins, whose presence is essential for ribosomal assembly, has been associated with important ribosomal functions: L1 lies in the E-site for deacylated tRNA binding while L2 and L23 have been implicated in the P and A substrate sites, respectively, of the peptidyl transferase centre. Moreover, each of the protein sites, but particularly those of L2 and L23, lies at the centre of RNA domains where they can maximally influence both the assembly of secondary binding proteins and the function of the RNA region.

Experimental studies on the development and propagation of shock waves created by the interaction of short Nd:YAG laser pulses with a titanium target. Possible implications for Nd:YAG laser phacolysis of the cataractous human lens

The formation and propagation of shock waves created by the interaction of high powered Nd:YAG laser pulses with a titanium target are photographed and analyzed. The titanium target is located at the distal end of a probe, similar to an irrigation/aspiration probe used in cataract surgery, and the Nd:YAG laser is delivered by a cladded 300 microns quartz fiber. This device, and the results of this study, are being applied to develop a device for fragmenting nuclear material for cataract extraction.

Emergency haemorrhoidectomy compared with incision and banding for the treatment of acute strangulated haemorrhoids. A prospective randomised study

OBJECTIVE

To find out if incision and banding was as effective as emergency haemorrhoidectomy in the treatment of strangulated haemorrhoids.

DESIGN

Prospective randomised study.

SETTING

Glostrup Hospital, Copenhagen, Denmark.

SUBJECTS

30 patients with uncomplicated acute strangulated haemorrhoids.

INTERVENTIONS

Milligan-Morgan haemorrhoidectomy or incision, evacuation of blood clot, and application of elastic bands.

MAIN OUTCOME MEASURE

Amount of analgesia required, length of stay in hospital, and incidence of complications.

RESULTS

Patients treated by incision and banding required significantly less opioid analgesia and spent significantly fewer days in hospital than those treated by haemorrhoidectomy, but two of them required emergency haemorrhoidectomy because the bands had slipped.

CONCLUSIONS

Incision and banding is a reasonable alternative to emergency haemorrhoidectomy provided that it is done correctly, but long term follow up is needed before a final conclusion can be drawn.