Sampling reflex: pathogenic role in functional defecation disorder

BACKGROUND

The sampling reflex is necessary to begin defecation or flatulence. It consists of a simultaneous rectoanal inhibitory reflex (RAIR) mediated by relaxation of the internal anal sphincter and rectoanal excitatory reflex (RAER) mediated by contraction of the external anal sphincter. The aim of this study was to evaluate the sampling reflex in patients with functional defecation disorder (FDD).

METHODS

A prospective cohort study was conducted on 58 obstructed defecation syndrome (ODS) patients with FDD. All 58 patients and 20 controls were evaluated with anorectal manometry to study the sampling reflex. Quantitative RAIR (total duration of reflex; maximal amplitude of relaxation; residual pressure at the lowest point of the RAIR) and RAER data (maximal amplitude of contraction; duration) were obtained. The straining test on manometry was considered positive for FDD if there was a muscle contraction/lack of relaxation or an insufficient pressure gradient for the passage of feces. Defecography was performed on all the patients with assessment of the anorectal angle and persistence or increase of puborectalis indentation.

RESULTS

Fifty (86.2%) FDD patients had an altered sampling reflex, showing incomplete/short duration of RAIR and excessive contraction/duration of RAER. More specifically, there was a correlation between a positive straining test and a short total duration of RAIR (ρ 0.92) as well as with excessive duration of RAER (ρ 0.89). There was also a correlation between lack of muscle relaxation on defecography and short total duration of RAIR ((ρ 0.79) and between lack of muscle relaxation on defecography and excessive duration of RAER (ρ 0.83). Altered maximal amplitude relaxation had the highest sensitivity in detecting impairment of RAIR (87.9) while maximal amplitude contraction had the highest sensitivity in detecting impairment of RAER (89.6). High residual pressure at the lowest point of RAIR had the highest specificity in detecting impairment of RAIR (80.0) while RAER duration had the highest specificity in detecting impairment of RAER (77.7).

CONCLUSION

The sampling reflex is impaired in patients with FDD. This finding provides an important insight into the pathogenesis of obstructed functional defecation.

Pelvic floor rehabilitation for defecation disorders

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Different perception of chronic constipation between patients and gastroenterologists

BACKGROUND

There is a certain number of subjects that consider themselves to be constipated (self diagnosed constipation; SDC). The Rome Criteria separate FC from IBS-C, but some SDC patients do not meet the Rome criteria (no Rome Constipation; NRC). Our aims were to evaluate the percentage of SDC subjects with a diagnosis of FC and IBS-C and to compare demographic and clinical features, symptoms, and quality of life in the different SDC groups (FC, IBS-C, NRC).

METHODS

During a 2-month period, 934 patients and 980 accompanying persons (AP) were asked to complete a survey. The presence of FC or IBS-C was assessed. SDC subjects were invited to record the stool consistency (Bristol scale) and to fill in the Constipation Severity Index (CSI), obstructed defecation syndrome (ODS) and patient assessment of constipation-quality of life (PAC-QoL). The use of laxatives and enemas was evaluated.

KEY RESULTS

The probability of the ROME III criteria being present was higher in SDC compared with no-SDC (OR 20.5). NRC was present in 13.5% of the SDC. In the patients' group the agreement between a diagnosis of Rome III and SDC was good (K 0.62), whereas in the AP it was moderate (K 0.56). NRC showed lower mean values of ODS, CSI and PAC-QoL, higher Bristol scale and a lower use of laxatives and enemas compared to IBS-C and FC. No differences were found between IBS-C and FC.

CONCLUSIONS AND INFERENCES

The Rome III criteria identify subjects with a greater clinical impact, but separation of FC and IBS-C does not seem justified.

Transverse loop colostomy and colonic motility

BACKGROUND

The motility of the defunctionalized colon, distal to transverse loop colostomy, has never been studied "in vivo." The aim of our study was to evaluate the influence of transverse loop colostomy on colonic motility.

METHODS

Thirteen patients were examined before stoma closure by means of clinical evaluation and colonic manometry; we studied both the right and distal colon in both fasting and fed patients in order to detect motor activity.

RESULTS

Quantitative and qualitative manometric analyses showed that the diverted colon had motor activity even if no regular colonic motor pattern was observed. The spreading of aboral propagated contractions (PCs) was sometimes recorded from the right colon to the distal colon. The response of the proximal and distal colon to a standard meal, when compared to fasting values, increased more than 40 and 35 %, respectively. Stool and gas ejections from the colostomy were never related to a particular type of colonic motility: Motor quiescence such as PCs was chaotically related to stool escape.

CONCLUSIONS

In conclusion, motility of the defunctionalized colon is preserved in patients with transverse loop colostomy.

Faecal soiling: pathophysiology of postdefaecatory incontinence

AIM

Passive postdefaecatory incontinence is poorly understood and yet is an important clinical problem. The aim of this study was to characterize the pathophysiology of postdefaecatory incontinence in patients affected by faecal soiling.

METHOD

Seventy-two patients (30 women, age range 49-79 years; 42 men, age range, 53-75 years) affected by faecal passive incontinence with faecal soiling were included in the study. Two patient groups were identified: Group 1 comprised 42 patients with postdefaecatory incontinence and Group 2 had 30 patients without incontinence after bowel movements. After a preliminary clinical evaluation, including the Faecal Incontinence Severity Index (FISI) score and the obstructed defaecation syndrome (ODS) score, all patients of Groups 1 and 2 were studied by means of endoanal ultrasound and anorectal manometry. The results were compared with those from 20 healthy control subjects.

RESULTS

A significantly higher ODS score was found in Group 1 (P < 0.001). Endoanal ultrasound revealed a significantly diffuse thinning of the internal anal sphincter (IAS) in Group 2 (P < 0.02) with a linear relationship between signs of IAS atrophy and the FISI score (ρs 0.78; P < 0.03). Anal resting pressure (Pmax and Pm ) was significantly lower in Group 2 (P < 0.04). The straining test was considered positive in 30 (71.4%) patients in Group 1, significantly greater than in Group 2 (P < 0.01). A significantly higher conscious rectal sensitivity threshold (CRST) was found in Group 1 patients (P < 0.01).

CONCLUSION

The ODS score, a positive straining test and high CRST values suggest that postdefaecatory incontinence is secondary to impaired defaecation.

Obstructed defaecation: what is the role of rehabilitation?

AIM

The study was designed to evaluate the results of rehabilitative treatment in patients suffering from obstructed defaecation.

METHOD

Between January 2008 and July 2010, 39 patients (37 women, age range 25-73 years; and two men, aged 57 and 67 years) affected by obstructed defaecation were included in the study. After a preliminary clinical evaluation, including the Obstructed Defaecation Syndrome (ODS) score, defaecography and anorectal manometry were performed. All 39 patients underwent rehabilitative treatment according to the 'multimodal rehabilitative programme' for obstructive defaecation. At the end of the programme, all 39 patients were reassessed by clinical evaluation and anorectal manometry. Postrehabilition ODS scores were used to categorize patients arbitrarily into three classes, as follows: class I, good (score ≤ 4); class II, fair (score > 4 to ≤ 8); and class III, poor (score > 8).

RESULTS

After rehabilitation, there was significant improvement in the overall mean ODS score (P < 0.001). Thirty (76.9%) patients were included as class I (good results), of whom eight (20.5%) were symptom free. Five (12.8%) patients were considered class III. A significant postrehabilitative direct correlation was found between ODS score and pelvic surgery (ρ(s) = 0.54; P < 0.05). Significant differences were found between pre- and postrehabilitative manometric data from the straining test (P < 0.001), duration of maximal voluntary contraction (P < 0.001) and conscious rectal sensitivity threshold (P < 0.02).

CONCLUSION

After rehabilitation, some patients become symptom free and many had an improved ODS score.

Obstructed defecation: the role of anorectal manometry

BACKGROUND

The aim of the study was to evaluate the clinical usefulness of anorectal manometry (AM) in patients affected by obstructed defecation (OD).

METHODS

Between January 2007 and December 2010, 379 patients (287 women and 92 men) affected by OD were evaluated. After a preliminary clinical evaluation, defecography and AM were performed. The results were compared with those from 20 healthy control subjects.

RESULTS

Overall anal resting pressure was not significantly different between patients and controls. Maximal voluntary contraction (MVC) data were significantly lower when compared with those of controls (P < 0.01). The straining test was considered positive in 143 patients. No significant difference was noted between patients and controls in maximal tolerated volume data. Patients had a significantly higher conscious rectal sensitivity threshold than controls (P < 0.02).

CONCLUSIONS

A positive straining test, low MVC and impaired rectal sensation are the main abnormalities detected by AM in patients with OD.

Self-perceived normality in defecation habits

BACKGROUND

Available information on normal bowel habits was mainly gathered by means of telephone interviews or mailed questionnaires.

AIMS

We undertook a prospective study to evaluate the defecatory habits in subjects perceiving themselves as normal concerning this function.

SUBJECTS AND METHODS

A questionnaire (4-week diary with "yes-no" daily answers to six questions concerning bowel habits) was distributed to 204 subjects perceiving their defecation behaviour as normal.

RESULTS

The completed questionnaire was returned by 140 subjects. No significant differences were found between sexes or age groups for any variable, even though straining at stool and feeling of incomplete and/or difficult evacuation showed a trend to increase with age. No subject had less than three bowel movements per week or more than three per day. The percentage of symptoms linked to an abnormal defecatory behaviour was well below 10%. Fifty-five percent of subjects reported at least one parameter of abnormal functioning; the most frequent was straining at stool and the rarer was the manual manoeuvres to help defecation.

CONCLUSIONS

In normal subjects the prevalence of symptoms considered in Rome II criteria as part of an abnormal defecatory behaviour (in more than 25% of defecations) is well below 10%, manual manoeuvres are almost never used to help defecation, and the frequency of defecations is at least three per week.

Different anal pressure profiles in patients with anal fissure

BACKGROUND

A consistent debate exists about the association between anal fissure and hypertonic anal canal. The aim of this study was to determine if the manometric findings in patients with chronic anal fissures varied according to the topography of the fissure.

PATIENTS AND METHODS

Seventy-three outpatients (52 men, 71%) with chronic anal fissures and nine healthy volunteers (5 men, 55%) were examined. Patients were classified according to the topography of the anal fissures: posterior midline (group A), anterior midline (group B), and lateral position (group C). We use computerized anorectal manometry to evaluate anal resting pressure, maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance.

RESULTS

In Group A, the mean pressure was higher than that of controls (p<0.05), and the resting pressure 2 cm from anal verge was higher than that of other groups and controls (p<0.05). Normotonic anal canal was found in 49.1% of patients in group A, in 66% of those in group B and in 57.1% of those in group C. Four elderly patients (7%) of group A had a hypotonic anal canal. No differences were found regarding maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance between patients and controls.

CONCLUSIONS

Patients with chronic anal fissures may have several anal pressure profiles. The anal canal is often normotonic. Fissures with hypertonic or normo-hypotonic anal canal need different therapies.

Case report: colonic manometry reveals abnormal propulsive behaviour after anterior resection of the rectum

Anterior resection of the rectum is a frequent surgical procedure. However, abnormal bowel habits following this procedure are frequently reported. The functional evaluation of these patients is usually limited to the anorectal area. By means of colonic manometry, we have evaluated a patient with frequent urge for defecation and increased bowel frequency following anterior resection of the rectum with straight coloanal anastomosis and almost normal anorectal function. Analysis of the tracing revealed a reduction of contractile segmental activity and much more high-amplitude propagated contractions than which occur in healthy subjects. These high-amplitude propagated contractions, representing the manometric equivalent of mass movements, were always in association with urge for defecation and, sometimes, with loose stools. High-amplitude simultaneous contractions were also observed. We feel that the surgical resection of a potential physiological brake may be responsible for these observations.

Multimodal rehabilitation for faecal incontinence: experience of an Italian centre devoted to faecal disorder rehabilitation

BACKGROUND

Sphincter exercises and biofeedback therapy have been used to treat faecal incontinence but results have been unpredictable and standards of treatment have not yet been established. The aim of this study was to retrospectively evaluate the effects of a new multimodal rehabilitation model on faecal incontinence.

METHODS

All of the rehabilitative procedures are guided by manometric data. Primary study outcome criteria were the determination of changes or deterioration in incontinence, failure to achieve full continence and/or presence of faecal urgency. The clinical outcome was designed according to the Jorge-Wexner incontinence score.

RESULTS

Between 1997 and 2001, one hundred forty-nine incontinent patients (85 F and 64 M; age range, 41-73 years; mean age, 60.6 years) underwent multimodal rehabilitation at our outpatient unit. The overall mean incontinence score had significantly improved after treatment ( p<0.001), and 58 patients (38.9%) were symptom free. No patient reported any deterioration in incontinence. Faecal urgency persisted in 23 patients (15.4%).

CONCLUSION

In conclusion, multimodal rehabilitation, using manometric study, can modify the incontinence score.

Gastric emptying in myotonic dystrophic patients

BACKGROUND

Myotonic dystrophy is often associated with digestive symptoms that can precede the clinical appearance of skeletal muscle involvement. Although motility disorders may be observed in these patients at any level of the gastrointestinal tract, upper gastrointestinal symptoms have up to now usually been considered to be due to oesophageal rather than gastric dysmotility.

AIMS

To evaluate: a) gastric emptying in myotonic dystrophic patients without dyspeptic symptoms, and b) relationship between gastric emptying and severity and duration of the disease.

PATIENTS AND METHODS

Gastric emptying was evaluated in 11 non-dyspeptic dystrophic patients and in 22 healthy volunteers by means of computerised ultrasound scan, assessing the variation in the antral area over time after ingestion of a meal.

RESULTS

The final emptying time was higher in patients than in healthy volunteers (373' +/- 35' vs 270' +/- 47'; p < 0.001). Basal and maximal post-prandial antral areas were similar in the two groups. There was a significant correlation between gastric emptying and the duration of the disease (rs = 0.62; p = 0.04). No relationship was found between gastric emptying and severity of the disease.

CONCLUSIONS

Gastric emptying may be abnormally delayed in myotonic dystrophy patients, even in absence of dyspeptic symptoms. This delay is correlated with duration but not with severity of the disease. However there is no difference in either basal or maximal postprandial antral areas between myotonic dystrophy patients and healthy volunteers.

Stapled mucosal prolapsectomy for haemorrhoidal prolapse with Lone Star Retractor System

This technical note presents a variation of the stapled mucosal prolapsectomy for haemorrhoidal prolapse using the Lone Star Retractor. Our experience highlights the simplicity and usefulness of the technique which is based on the complete eversion of the prolapse carried out by the Lone Star Retractor, without using any kind of proctoscope and without stretching the anal sphincters. Postoperatively, rectal bleeding occurred in 4.7% of 127 cases, 9.8% of the patients complained of faecal urgency and only 3.9% had severe anal pain. None had faecal incontinence. This method simplifies the making of the purse-string suture as well as the use of the suturing device and achieves satisfactory clinical results.

Correlation between DNA content and p53 deletion in colorectal cancer

OBJECTIVE

To find out whether tumour DNA content correlates with allelic loss of p53 and other pathological features in primary colorectal carcinomas.

DESIGN

Ongoing prospective study.

SETTING

University hospital, Italy.

SUBJECTS

128 patients who had undergone radical resections for colorectal carcinoma.

INTERVENTIONS

Flow cytometric measurement of tumour DNA content and detection of allelic loss on the short arm of chromosome 17 by Southern blot (restriction fragment length polymorphism) analysis in fresh tumour specimens.

MAIN OUTCOME MEASURES

Correlation between DNA ploidy and deletion of p53, as well as between these two genetic events and clinicopathological variables.

RESULTS

Interpretable DNA histograms were obtained for 122 tumour specimens. Forty-three tumours (35%) were diploid and 79 (65%) aneuploid. The diploid tumours were significantly more common in the proximal colon (from the caecum to the splenic flexure) than in the distal colon (from the descending colon to the rectum) (p = 0.002). The allelic state on the short arm of chromosome 17 was evaluated in 80 heterozygous patients. Forty-four tumour specimens (55%) showed deletion of 17p. Allelic loss of p53 was significantly more common in the distal and rectal tumours than in the proximal ones (p < 0.0001). Aneuploidy was more common among those tumours which had shown deletion of p53 than in those that had not (p = 0.0008).

CONCLUSIONS

DNA aneuploidy was significantly associated with the deletion of the p53 gene. This suggests that the functional loss of p53 may favour the growth and establishment of an aneuploid cell population within tumours. Tumours of the proximal and distal colon differ in their genetic nature.

Pelvic floor dyssynergia and bimodal rehabilitation: results of combined pelviperineal kinesitherapy and biofeedback training

Dyschezia may be caused by pelvic floor dyssynergia, which takes place when a paradoxical contraction or a failure to relax the pelvic floor muscles occurs during attempts to defecate. The aim of our study was to set up a new bimodal rehabilitation programme for pelvic floor dyssynergia, which combined pelviperineal kinesitherapy and biofeedback, and to evaluate the results of this treatment. Thirty-five patients (age range: 28-64 years; mean age: 42.5 years) from the outpatient unit of the Clinica Chirurgica of the University of Florence, Italy, and an age-matched group of 10 healthy control subjects (age range: 31-59 years; mean age 45.7 years) with normal bowel habits and without any defecatory disorders, were studied. The 35 patients were symptomatic for dyschezia without slow colonic transit and had been diagnosed as being affected by pelvic floor dyssynergia. No evidence of any organic aetiology was present but all demonstrated both manometric and radiological evidence of inappropriate function of the pelvic floor. All of the patients underwent bimodal rehabilitation, using the combined training programme Clinical evaluation, computerized anorectal manometry and defecography were carried out 1 week before and 1 week after a completed course in bimodal rehabilitation. The control group underwent manometric and defecographic examination. Their results were compared with those of the 35 patients before and after training. After the programme, all 35 patients had a very significant increase in stool frequency (P < 0.001), while laxative and enema-induced bowel movements had become significantly less frequent (P < 0.001). After bimodal rehabilitation, computerized anorectal manometry showed some peculiar results. Resting anal canal pressure had increased but not significantly. Pre-programme values that indicated a shorter duration ("exhaustio") of maximal voluntary contraction than found in the controls had returned to normal values. The rectoanal inhibitory reflex (RAIR), with incomplete relaxation, which had been shorter than that of controls, became normal by the end of the rehabilitation. All RAIR parameters were significantly different especially when pre- and post-treatment values were compared (P < 0.001). No differences were found as regards rectal sensation parameters and rectal compliance between those before or after bimodal rehabilitation. Defecographic pretreatment X-ray films showed indentation of the puborectalis and poor anorectal angle (ARA) opening, at evacuation, with trapping barium of at 50%. After pelviperineal kinesitherapy and biofeedback training, the indentation had disappeared and the ARA had become significantly larger (P < 0.001) during evacuation. No differences were found after rehabilitation, when both were compared with those of controls. The pelvic floor descent was also significantly deeper (P < 0.001) than before the start of the programme. The bimodal rehabilitation technique can be considered a useful therapeutic option for functional dyschezia as shown by our clinical evaluations, manometric data and defecographic reports.

Character of the invasive margin in colorectal cancer: does it improve prognostic information of Dukes staging?

PURPOSE

The clinical significance and prognostic value of the histopathologic parameters used in both the Dukes and Jass classifications were evaluated to select those with an independent effect on survival after radical surgery for colorectal cancer.

METHODS

The depth of local spread (limited to the bowel wall or extended beyond it), the number of metastatic lymph nodes (none, 1-4, more than 4), the character of the invasive margin (pushing or infiltrating), and the presence or absence of conspicuous peritumoral lymphocytic infiltration were assessed in 235 patients who had undergone radical resection for colorectal cancer. The influence of these variables on survival was studied by univariate and multivariate analysis.

RESULTS

No significant difference in survival was found between patients with conspicuous peritumoral infiltrate and those without it; moreover, multivariate analysis failed to show any independent prognostic value for either lymphocytic infiltration or depth of local invasion. However, the character of the invasive margin and the number of metastatic lymph nodes were identified as the only variables with any independent importance on survival. Based on these data, a new prognostic model may be proposed; it uses the character of the infiltrative margin as a discriminating factor among patients within the lymph node-negative (Dukes A and B stages) and lymph node-positive (Dukes C1 and C2 subsets) groups. A good prognosis for Dukes A, B, and C1 patients was associated with pushing tumors; C1 and C2 patients with infiltrating tumors had a poor prognosis. On the whole, the new prognostic model has allowed for the placement of 59.6 percent of our patients into groups that provide a confident prognosis. The clinical outcome of Dukes A and B patients with infiltrating tumors is still uncertain.

CONCLUSIONS

The character of the invasive margin is an important prognostic factor in colorectal cancer. The association of this parameter with the traditional Dukes classification may provide additional useful prognostic information and aid in the selection of those patients who could most benefit from adjuvant therapy.

[A case of primary hepatic carcinoid. A report of its surgical resolution]

Primary hepatic carcinoid tumors are extremely rare; conversely, the liver is the most frequent site of metastases from gastrointestinal carcinoids. Clinically, primary lesions are characterized, in most cases, by the absence of an overt endocrine syndrome. Histologic findings and immunohistochemical demonstrations of chromogranin and neuron specific enolase, generally, enable the neuroendocrine origin of these neoplasms to be established. Prognosis after surgical treatment of primary hepatic carcinoids seems to be more favorable when compared with other hepatic carcinomas.

[The 3rd national workshop on defecography: the functional radiology of (neo) rectal ampullae (ileal reservoir, colo-anal anastomosis, continent perineal colostomy)]

A survey was made in 13 Italian centers with a questionnaire concerning the (a) indications, (b) postoperative complications, (c) functional results and (d) diagnostic imaging modalities related to the making of an ileal or colonic (neo) rectum. Ulcerative colitis (100%), familial polyposis (61.5%) and Crohn's disease (15.3%) were the most common indications for an ileal pouch; rectal cancer (7.96%), chronic inflammatory diseases (15.3%), diverticulosis, rectal prolapse, redundant colon and imperforate anus (7.6% each) were the most common indications for a colonic pouch. Postoperative complications included pelvic abscess (14%), sinus tract/dehiscence (10%) and bowel obstruction (9%). When compared with the S and W variants, the J-shaped ileoanal pouch proved superior because urgency and fecal retention rates were lower (18.4% vs. 44.4% and 23% vs. 28.6%, p < 0.01 and p < 0.05, respectively), despite slightly more frequent staining episodes (15.8% vs. 11.1%; p < 0.05). As for colonic ampullae, fecal retention and provoked evacuation were more frequent in the J pouch and after gracileplasty; urgency and incontinence in the straight colo-anal anastomosis (33.3% vs. 22.2% and 41.6% vs. 33.3%, respectively). The functional outcome was assessed by anal endosonography (available in 4/13 centers), defecography and anorectal manometry. Abnormal findings included: (a) reduced capacity, barium leakage, anal gaping, sphincter damage (urgency and incontinence); (b) barium retention, pouch dilatation, split evacuation, knobs and strictures (fecal retention).

Anterior rectocele and anorectal dysfunction

The two types of anterior rectocele, "distension" of Type 1 rectocele (T1R) and "displacement" or Type 2 rectocele (T2R), have different anatomical, clinical and therapeutic profiles. The aim of this study was to assess anorectal function in patients with distension or displacement rectocele. Three groups of female patients and one group of healthy female subjects were studied. Both the 10 Group 1 subjects, who had been diagnosed as having T1R, and 10 Group 2 women who had been diagnosed as having T2R, were symptomatic for digital evacuation of the rectum. The 10 Group 3 females had complained of sever idiopathic constipation but had no defecatory disorders. The control group was made up to 10 healthy volunteers. All patients and controls underwent clinical evaluation, colonic transit time (CTT), computerized anorectal manometry (CAM), and defecography. Bowel movements and clinical evaluation were similar for both rectocele groups. In Group 1, CAM detected significantly higher anal pressure (P < 0.05) and more impaired rectoanal inhibitory reflex (RAIR) (P < 0.01) in comparison to the other patients and controls. In Group 2, the lowest anal pressure (P < 0.001) was noted but RAIR was normal. Defecographic results, at rest and during evacuation, showed a significantly (P < 0.001) higher anorectal angle and a more abnormal pelvic floor descent in Group 2 than in the other study groups and controls. Therefore, peculiar anorectal function was present in patients with anterior rectocele. A pelvic floor dyssynergia was noted in the distension rectocele group, while a fall of the pelvic floor was noted in the displacement rectocele group.

[Giant mesenteric fibromatosis: a case report]

The fibromatoses represent a broad group of fibroblastic proliferations characterized by infiltrative growth and a tendency toward recurrence but, unlike malignant fibrous tumors, they do not metastasize. Mesenteric fibromatosis arising from the mesentery of the small bowel is rare. It may be sporadic or may occur in association with polyposis coli and other soft tissue tumors as a component of Gardner's syndrome. We report a case of mesenteric fibromatosis in a 52-year-old man with no evidence of Gardner's syndrome. The neoplasm occupied the whole abdominal cavity, weighing 12 kg, with the greatest diameter being 50 cm. Histological findings (i.e moderate degree of cellularity, lack of nuclear pleomorphism and mitotic figures) allowed to rule out malignancy. Surgical removal is actually the only effective treatment for mesenteric fibromatosis. Excision must be as wide as possible in order to prevent local recurrence. Until now, no satisfactory results have been obtained with external radiotherapy. More recently, anti-inflammatory drugs have been used in the management of this tumor.

Long-term ambulatory enterogastric reflux monitoring. Validation of a new fiberoptic technique

A new technique for the long-term ambulatory detection of enterogastric and nonacid gastroesophageal reflux has been conceived, developed, and validated. It is based on the use of a fiberoptic sensor that utilizes the optical properties of bile. In vitro studies have shown good precision, good stability, sensitivity of 2.5 mumol/liter bilirubin concentration, as well as a useful working range of 2.5-100 mumol/liter bilirubin concentration. In vivo studies have been performed in 29 subjects. Simultaneous gastric aspirations have allowed a comparison of fiberoptic system measurements both with spectrophotometric analysis and bile acid concentrations of corresponding gastric juice samples. Linear correlations were shown between fiberoptic assessment and both spectrophotometric and bile acid concentration findings (P < 0.01). Simultaneous assessment of reflux with the fiberoptic system and cholescintigraphy has shown a 92.9% concordance as regards the presence or absence of reflux. Present results imply that the fiberoptic system is an important tool for the understanding of the clinical relevance of enterogastric and nonacid gastroesophageal reflux.

[Esophageal motor abnormalities, gastroesophageal reflux and duodenogastric reflux in patients with Raynaud's disease]

Twenty-four patients with Raynaud's phenomenon, without ARA criteria for classification, were examined, after clinical history, by means of esophageal manometry, combined gastric and esophageal pH-monitoring, endoscopy. The results showed in these patients a high incidence of esophageal motor abnormalities (66.6%), of gastroesophageal reflux (50%), and of duodenogastric reflux (45.8%).

Usefulness of combined gastric and esophageal pH monitoring in detecting gastroesophageal alkaline and mixed reflux

96 patients with 'typical' symptoms of gastroesophageal reflux were studied by means of combined gastric and esophageal pH monitoring. The aim was to assess the incidence of 'alkaline' and 'mixed' gastroesophageal reflux episodes as well as 'acid' reflux and their reciprocal relationship with esophagitis. 'Alkaline' gastroesophageal reflux was defined whenever the pH in the esophagus rose above 7, but only when there was a simultaneous or immediately previous rise of gastric pH to similar alkaline values resulting from duodenogastric reflux. 'Mixed' gastroesophageal reflux was defined whenever the pH in the esophagus dropped to 5.5-4.5, but only when there was a simultaneous or immediately previous rise of gastric pH above 4 related to duodenogastric reflux. Our data suggest that 'alkaline' gastroesophageal reflux is a rare phenomenon while 'mixed' gastroesophageal reflux episodes are present in 21% of these patients. 87% of patients with mixed reflux had esophagitis. Until analytical studies of refluxed material are available to clarify its composition, combined gastric and esophageal pH monitoring seems a useful test to correctly interpret the 'alkaline' and 'mixed' gastroesophageal reflux.

Anorectal physiology after anterior resection and pull-through operation

Sensory and motor investigations have been performed in normal subjects, in patients who had undergone low anterior resection of the rectum and in patients following Bacon-type pull-through operation. The electromechanical relationship has been clearly defined in the anal sphincter activity. The motor findings, the threshold for sensation and its quality in the patients following low anterior resection were similar to those of the controls. Following pull-through operation the anorectal inhibitory reflex is frequently replaced by a contraction of the sphincteric zone. But, sometimes, this reflex is preserved as well as a fine discriminatory sensation. These data suggest that at least some of the mechanisms of anal sphincter continence have been preserved even after complete excision of the rectum.