The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome

BACKGROUND

The aim of the present study was to assess the relationship between symptoms of obstructed defecation and findings on magnetic resonance (MR) defecography in males with obstructed defecation syndrome (ODS).

METHODS

Thirty-six males with ODS who underwent MR defecography at our institution between March 2013 and February 2016 were asked in a telephone interview about their symptoms and subsequent treatment, either medical or surgical. Patients were divided into 2 groups, one with anismus (Group 1) and one with prolapse without anismus (Group 2). The interaction between ODS type and symptoms with MR findings was assessed by multivariate analysis for categorical data using a hierarchical log-linear model. MR imaging findings included lateral and/or posterior rectocele, rectal prolapse, intussusception, ballooning of levator hiatus with impingement of pelvic organs and dyskinetic puborectalis muscle.

RESULTS

There were 21 males with ODS due to anismus (Group 1) and 15 with ODS due to rectal prolapse/intussusception (Group 2). Mean age of the entire group was 53.6 ± 4.1 years (range 18-77 years). Patients in Group 1 were slightly older than those in Group 2 (age peak, sixth decade in 47.6 vs 20.0%, p < 0.05). Symptoms most frequently associated with Group 1 patients included small volume and hard feces (85.0%, p < 0.01), excessive strain at stool (81.0%, p < 0.05), tenesmus and fecaloma formation (57.1 and 42.9%, p < 0.05); symptoms most frequently associated with Group 2 patients included mucous discharge, rectal bleeding and pain (86.7%, p < 0.05), prolonged toilet time (73.3%, p < 0.05), fragmented evacuation with or without digitation (66.7%, p < 0.005). Voiding outflow obstruction was more frequent in Group 1 (19.0 vs 13.3%; p < 0.05), while non-bacterial prostatitis and sexual dysfunction prevailed in Group 2 (26.7 and 46.7%, p < 0.05). At MR defecography, two major categories of findings were detected: a dyskinetic pattern (Type 1), seen in all Group 1 patients, which was characterized by non-relaxing puborectalis muscle, sand-glass configuration of the anorectum, poor emptying rate, limited pelvic floor descent and final residue ≥ 2/3; and a prolapsing pattern (Type 2), seen in all Group 2 patients, which was characterized by rectal prolapse/intussusception, ballooning of the levator hiatus with impingement of the rectal floor and prostatic base, excessive pelvic floor descent and residue ≤ 1/2. Posterolateral outpouching defined as perineal hernia was present in 28.6% of patients in Group 1 and were absent in Group 2. The average levator plate angle on straining differed significantly in the two patterns (21.3° ± 4.1 in Group 1 vs 65.6° ± 8.1 in Group 2; p < 0.05). Responses to the phone interview were obtained from 31 patients (18 of Group 1 and 13 of Group 2, response rate, 86.1%). Patients of Group 1 were always treated without surgery (i.e., biofeedback, dietary regimen, laxatives and/or enemas) which resulted in symptomatic improvement in 12/18 cases (66.6%). Of the patients in Group 2, 2/13 (15.3) underwent surgical repair, consisting of stapled transanal rectal resection (STARR) which resulted in symptom recurrence after 6 months and laparoscopic ventral rectopexy which resulted in symptom improvement. The other 11 patients of Group 2 were treated without surgery with symptoms improvement in 3 (27.3%).

CONCLUSIONS

The appearance of various abnormalities at MR defecography in men with ODS shows 2 distinct patterns which may have potential relevance for treatment planning, whether conservative or surgical.

Postoperative MR Defecography following Failed STARR Procedure for Obstructive Defecation Syndrome: A Three-Centre Experience

Aim. To describe the abnormalities at MR imaging and related complaints in patients with poor outcome after STARR procedure. Materials and Methods. The medical records of 21 symptomatic patients from centre 1, 31 patients from centre 2, and 63 patients from centre 3 were reviewed with regard to findings at MR defecography and related symptoms. Results. Regardless of the centre, most relevant imaging features and related complaints were (a) impaired emptying (82.11%), related complaint ODS; (b) persistent rectocele >2 cm and intussusception (39.3%), split evacuation and digitation; (c) pelvic organ descent on straining (39.8%), prolapse sensation; (d) small neorectum and loss of contrast (32.5%), urgency and incontinence; (e) anastomotic stricture and granuloma (28.4%), pain; and (f) nonrelaxing puborectalis muscle (19.5%), tenesmus. Less frequent findings included rectal pocket formation (5.6%) and rectovaginal sinus tract (1.6%). Patients were referred to MR imaging with an average time interval of 5 ± 2, 4 ± 1, and 2 ± 1 years in the three centres, respectively, and only rarely by the same surgeon who performed the operation: 1/21 (4.8%) in centre 1, 3/39 (7.7%) in centre 2, and 9/63 (14.3%) in centre 3. Conclusion. Most surgeons involved in STARR operation with subsequent poor outcome do not rely on MR imaging.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

MR-defecography in obstructed defecation syndrome (ODS): technique, diagnostic criteria and grading

BACKGROUND

The aim of this study was to evaluate the use of a magnetic resonance (MR)-based classification system of obstructive defecation syndrome (ODS) to guide physicians in patient management.

METHODS

The medical records and imaging series of 105 consecutive patients (90 female, 15 male, aged 21-78 years, mean age 46.1 ± 5.1 years) referred to our center between April 2011 and January 2012 for symptoms of ODS were retrospectively examined. After history taking and a complete clinical examination, patients underwent MR imaging according to a standard protocol using a 0.35 T permanent field, horizontally oriented open-configuration magnet. Static and dynamic MR-defecography was performed using recognized parameters and well-established diagnostic criteria.

RESULTS

Sixty-seven out of 105 (64 %) patients found the prone position more comfortable for the evacuation of rectal contrast while 10/105 (9.5 %) were unable to empty their rectum despite repeated attempts. Increased hiatus size, anterior rectocele and focal or extensive defects of the levator ani muscle were the most frequent abnormalities (67.6, 60.0 and 51.4 %, respectively). An MR-based classification was developed based on the combinations of abnormalities found: Grade 1 = functional abnormality, including paradoxical contraction of the puborectalis muscle, without anatomical defect affecting the musculo-fascial structures; Grade 2 = functional defect associated with a minor anatomical defect such as rectocele ≤ 2 cm in size and/or first-degree intussusception; Grade 3 = severe defects confined to the posterior anatomical compartment, including >2 cm rectocele, second- or higher-degree intussusception, full-thickness external rectal prolapse, poor mesorectal posterior fixation, rectal descent >5 cm, levator ani muscle rupture, ballooning of the levator hiatus and focal detachment of the endopelvic fascia; Grade 4 = combined defects of two or three pelvic floor compartments, including cystocele, hysterocele, enlarged urogenital hiatus, fascial tears enterocele or peritoneocele; Grade 5 = changes after failed surgical repair abscess/sinus tracts, rectal pockets, anastomotic strictures, small uncompliant rectum, kinking and/or lateral shift of supra-anastomotic portion and pudendal nerve entrapment.

CONCLUSIONS

According to our classification, Grades 1 and 2 may be amenable to conservative therapy; Grade 3 may require surgical intervention by a coloproctologist; Grade 4 would need a combined urogynecological and coloproctological approach; and Grade 5 may require an even more complex multidisciplinary approach. Validation studies are needed to assess whether this MR-based classification system leads to a better management of patients with ODS.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis)

Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome

OBJECTIVE

There is no objective means to assess the obstructed defaecation syndrome (ODS), to allow evaluation of outcome or to compare the efficacy of treatment including surgery. The study aimed to validate a disease-specific index to quantify severity to allow assessment of the results of treatment in clinical trials, to permit comparison between them.

METHOD

Seventy-six patients with ODS and 30 healthy controls entered the study after proctologic and ano-rectal physiological investigation. Hirschsprung's disease and slow transit constipation were excluded. An eight-item questionnaire with four or five possible answers was administered by two independent researchers at two different times. The ODS score was the sum of all points with a maximum possible of 31 points. Agreement between the two operators was evaluated by the Kappa coefficient for each single item. The coefficient of repeatability (CR) was assessed by the Bland and Altman plot. The internal consistency was evaluated by the Crohnbach-alpha test. A cluster analysis was carried out on each clinical finding. The Mann-Whitney U-test was used to compare median ODS score between patients and controls.

RESULTS

The ODS score of the two operators was normally distributed and strongly correlated (r = 0.89). The correlation coefficient between the score assigned to each item by two operators ranged from 0.79 to 0.98. The degree of agreement between the operators was good and the two methods were reproducible (CR = 3.13). There was a significant difference between the mean ODS score for patients and controls (t = 20.70, P < 0.001). The Crohnbach alpha value for internal reliability was +0.513. Cluster analysis showed a different profile between cluster 1 (a nonhomogenous group including rectocoele, intussusception or perineal descent), and cluster 2 (pelvic dysynergia).

CONCLUSION

The ODS score offers a validated severity of disease index in grading the severity of disease and monitoring the efficacy of therapy.

Correlation between urodynamics and perineal ultrasound in female patients with urinary incontinence

AIMS

We performed urodynamics and perineal ultrasound in female patients with urinary incontinence to assess morphology and function of the bladder base-urethra complex and of the detrusor muscle, and to find the correlation between these investigations in the diagnosis of (a) bladder neck and urethral hypermobility and (b) detrusor overactivity; we wanted to compare the tolerabililty of the urodynamic investigation and of the perineal ultrasound.

METHODS

We considered 66 female patients referred to our outpatient clinic for urinary incontinence; we also studied 14 healthy control patients. After accurate case-history collection and physical examination, urodynamic investigation and perineal ultrasound were performed, with recording of parameters specific to both investigations. The statistical analysis was performed by ANOVA, Bonferroni post hoc test, and Spearman correlation test. The tolerability index between the diagnostic investigations performed was assessed by a 3-point scale suggested by the patient.

RESULTS

In patients with stress incontinence the posterior urethro-vesical angle, the angle of urethral inclination, and the proximal pubo-urethral distance are significantly different under stress compared to the resting phase; in patients with urge incontinence, the detrusor wall is thicker and is accompanied by an increase in opening detrusor pressure and detrusor pressure at maximum flow; it is also accompanied by detrusor overactivity with increased urethral functional length. Increased urethral functional length is suggested on axial US images by alteration of its normal characteristic target-like appearance with four concentric rings of different echogenicity. In all cases the tolerability of perineal ultrasound has been higher than that of urodynamics.

CONCLUSIONS

There is a good correlation between urodynamic and perineal ultrasound in the diagnosis of bladder neck and urethral hypermobility; perineal ultrasound can also be useful in the diagnosis of urge incontinence. Functional compressive urethral obstruction can be diagnosed on the basis of the ultrasound aspect of the urethral sphincter.

Anal endosonography: a survey of equipment, technique and diagnostic criteria adopted in nine Italian centers

BACKGROUND

Anal endosonography (AES) has become an essential part of the pre-operative diagnostic workup in both organic and functional anal diseases.

METHODS

Nine Italian centres with an average volume activity of >10 exams/week each were surveyed with the aim of determining the concordance with respect to indications for the procedure and interpretation of the results.

RESULTS

Overall, anal sepsis, faecal incontinence and anorectal tumours were the more common indications for AES while evacuation dysfunctions and anal pain were not always considered indications. All centres use the same diagnostic criteria for simple and complicated perirectal sepsis and sphincteric defects, but adopt different classifications for stage 1 and stage 2 anal tumours. Participants agreed in that lymph-node staging by AES is less precise than tumour staging, especially after chemoradiation therapy.

CONCLUSIONS

A list of recommendations and guidelines based on the groups's experience has been produced for those radiologists and coloproctologists interested in the use of AES and accreditation of their centres.

Evacuation sonography

BACKGROUND

Because of the drawbacks of defecography (radiation hazard and lack of standardization), a new method by introital sonography is described to assess the evacuation phenomenon in women as an alternative to contrast radiographic studies.

METHODS

Ten consecutive women (mean age, 41 years; range, 33-50; mean parity, 2; range, 1-4) without evacuation disturbances (history and physical examination) nor prior pelvic surgery underwent hypoechoic contrast-enhanced evacuation sonography in the squatting position and fluoroscopic defecography, when appropriate, within a 10-minute interval.

RESULTS

Both techniques gave clear images of anal neck opening and funneling. While ultrasonography underestimated anorectal junction mobility, it showed soft tissue details (flap valve) not seen at defecography. Other advantages with sonography included lack of radiation hazard and prolonged observation time.

CONCLUSIONS

Evacuation sonography may be useful as an alternative to defecography for research purposes and for screening of evacuation dysfunctions in women.

Dynamic imaging of pelvic floor with transperineal sonography

Real-time transperineal sonography has enhanced the appreciation of morphology and dynamics of the pelvic floor. Standard images are obtained from longitudinal and axial planes by placing the transducer between the vagina and rectum. This fast, effective, noninvasive and inexpensive examination represents the preferred initial diagnostic imaging tool for women with pelvic floor dysfunctions, such as prolapse and incontinence.

Measurement of the anorectal angle by defecography for the diagnosis of fecal incontinence

We assessed the reliability of anorectal angle (ARA) measurement as an index of fecal incontinence. The "posterior" ARA was measured at rest, squeezing, and straining in 69 continent and 82 incontinent subjects all complaining of various evacuation dysfunctions. The two groups were homogeneous with regard to sex distribution (48.6% vs. 51.4% men and 44.7% vs. 55.3% women, n.s.) and age (56.5 +/- 10.2 vs. 59.3 +/- 9.7 years, n.s.). The incidence of rectal prolapse was the same in the two groups (40 each). The intraobserver agreement index from two independent measurements (Pearson's correlation coefficient), age, and gender interaction [T2 Hotelling test in multivariate analysis of variance (ANOVA)] and the most discriminating category of ARA measurement (Fisher's F test in ANOVA) were calculated. In addition, the relationship between ARA and severity of incontinence was assessed by the eta coefficient. Pearson's correlation coefficient was between 0.78 and 0.98 (P < 0.01). The mean ARA differed significantly between the continent and incontinent subjects (104.5 +/- 10.3 degrees vs. 116.2 +/- 23.6 degrees at rest, 84.5 +/- 14.2 degrees vs. 95.1 +/- 20.1 degrees on squeezing, and 133.7 +/- 21.7 degrees vs. 141.7 +/- 25.9 degrees on straining; T2 0.066, P < 0.05 in multivariate ANOVA). No interaction was noted between groups and gender (T2 = 0.023; F = 1.11, n.s.). Resting ARA was shown by ANOVA to be the most discriminating index (F = 9.4 P < 0.01) between the two groups. Overall, ARA measurement was correlated with the severity of fecal incontinence (eta coefficient: 0.894 at rest; 0.811 on squeezing; 0.695 on straining); its accuracy was 79%, the false-positive rate was 15.3% and the false-negative rate 26.5%. Irrespective of the underlying abnormality, namely rectal prolapse, ARA measurement by defecography can: (a) be reinterpreted reliably by the same observer and (b) differentiate continent from incontinent subjects.

Motor evoked potentials recorded from external anal sphincter by cortical and lumbo-sacral magnetic stimulation: normative data

Electrophysiological activation of the motor pathways can be obtained by electrical or magnetic stimulation. The latter has the great advantage of being painful and able to stimulate deeply situated nervous structures. Only a few reports describe responses obtained from pelvic floor muscles and external anal sphincter (EAS) by transcranial and lumbo-sacral magnetic stimulation. Our purpose is to present normative data of motor evoked responses from EAS in a group of healthy subjects (age range 19-80 years) using a standardized protocol of magnetic stimulation. Nine females and 7 males, with a mean age of 52.63 years, were included in this study. They had no known neurological and gastrointestinal disease. Magnetic shocks were delivered by a Magstim 200 (Novametrix) and a circular coil, centered on the vertex and on the lumbo-sacral region. Electromyographic recordings were taken from EAS using needle electrodes. The cortical magnetic stimulation was performed in two conditions: at rest and during a mild contraction of pelvic floor muscles. The mean values of motor evoked potentials (MEPs) latencies after cortical stimulation were 26.92+/-3.01 ms at rest and 23.31+/-2.70 ms during facilitation. Motor latency after lumbo-sacral root stimulation was 6.09+/-1.43 ms. The MEPs from EAS are easily obtained and stably reproducible in normal subjects. It can be suggested also as a useful adjunct in the assessment of faecal incontinence.

Dynamic imaging of the normal pelvic floor

PURPOSE

To provide quantitative data by a modern cross-sectional imaging technique (CT) for defining normal physiological values of pelvic floor structures.

PATIENTS AND METHODS

Twenty seven subjects, 7 males, 20 females, aged 20-75 yrs (mean 46.3 +/- 5 yrs) without pelvic floor or defection dysfunction underwent Direct Coronal (DC) CT scanning of the pelvis with the patient seated instead of lying. Scans obtained at rest and on straining were compared by bony landmarks. Three anatomical compartments, i.e. anterior, middle and posterior, were identified by two planes drawn tangential to the ischial foramina and the ischial tuberosities, respectively. Measurements of (1) Levator ani muscle length (mm); (2) Levator-anal angle (degrees); (3) Rectal floor-to-ischial line distance (mm) and (4) Supra/Infralevator spaces (square cm) were independently performed twice by two radiologists. The statistical analysis included calculation of intra and interobserver agreement (correlation coefficient). The differences between the means of the resting and straining values from each compartment (Student's t test) and the correlation between parameters (Pearson's coefficient) to evaluate whether resting values allowed a prediction of those on straining were determined.

RESULTS

DC scans of diagnostic quality were obtained in all but two patients (92.5%). Both intra- and interobserver agreement indices were always greater than 80% (except for a 0.63 value by one observer obtained in the infralevator space from the anterior compartment at rest). A significant difference between the resting and straining values of all parameters was noted in the three compartments. At rest the levator ani muscle length was significantly shorter and the supralevator space smaller in the posterior compartment (48.3 +/- 7.9 mm vs 48.8 +/- 7 mm vs 42.6 +/- 9.4 mm, P < 0.05 and 70.6 +/- cm2 vs 66.9 +/- 11.5 cm2 vs 27.2 +/- 4.8 cm2, P < 0.01 anterior, middle and posterior respectively). On straining, these two parameters increased by +42% and +17.8%, respectively, in the same compartment, while the most pronounced variation of the infralevator space occurred in the middle compartment (-51.1%). The increase in the supralevator space correlated with a decrease in the rectal floor-to-ischial line distance and widening of the levator-anal angle (r = -0.64, P < 0.01 and 0.48, P < 0.05, respectively). A close correlation between resting and straining values was observed in all parameters, especially in the supralevator space in the three compartments (r = 0.82, 0.93 and 0.88, P < 0.01).

CONCLUSIONS

Direct Coronal CT scanning showed that on straining the posterior component of the levator ani muscle, i.e. the coccygeus muscle, undergoes "physiological overstretching" and the supralevator space acts as a "compliant cavity", whose behaviour can be predicted at rest.

[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).

[Defecography in the diagnosis of fecal incontinence: an analysis of the receiver operating characteristic (ROC)]

Two groups of patients with altered bowel habit and pelvic floor dysfunction, but comparable epidemiologic characteristics (i.e. n = 105 each; mean age and SD 47.3 +/- 15.8 yrs vs. 54.9 +/- 16.7 yrs; range 15-80 yrs vs. 9-88 yrs; F/M ratio 28:1 vs. 2.6:1) with the exception of the absence (or presence) of fecal incontinence, were examined with defecography, taking into account criteria other than anorectal angle values and anorectal junction mobility. At the Receiver Operating Characteristic (ROC) analysis a "barium leak sign", occurring either at rest or on straining was found to be a highly reliable index of fecal incontinence (specificity: 100% and 92-93%, respectively, intraobserver agreement K value = 0.82, Z = 21.58, p < 0.001). A false negative rate of 14.2% was limited to "minor" incontinence only, i.e., incontinence to gas and/or occasional staining episodes. In the search for an etiologic diagnosis, useful adjunctive criteria included (a) anal diameter > 10 mm at rest; (b) poor stop test (inability to interrupt the barium stream); (c) rectal diameter > 6.5 cm and < 4 cm (abnormally increased and reduced compliance, respectively). Defecography is a useful diagnostic tool in fecal incontinence and should precede anal endosonography, manometry and electromyography for proper therapeutic decision-making and in risk conditions, e.g., in the patients about to undergo elective pelvic surgery.

[Kohlrausch's plica (plica transversalis recti): localization, morphology, function]

The plica transversalis recti (K Kohlrausch's plica or Houston's valve) shows a preferential double (52%) rather than triple (38%) localization and is absent in as much as 16% of cases. It is alternatively found on the left and right sides, 3-4 and 8-9 cm from the anal margin respectively. Both its detection rate and radiographic features depend on the technique used as follows: (a) 92%, contour indentation and/or linear filling defect, 4 to 5 mm thick at barium enema studies; (b) 67%, the same as in (a) plus 1/3 narrowing of the maximum diameter at defecography; and (c) 90%, two opposite and overlapping folds at coronal CT. Evidence is given that neither organic nor functional anorectal conditions affect the radiographic appearance of the fold, its likely role being to fix the proximal margins during the expulsion of feces.

[The coronal anatomy of the pelvis at rest and under straining]

Twenty-five subjects with no pelvic floor dysfunctions at defecography were examined with direct coronal CT scans of the pelvis at rest and on straining. Three compartments with different characteristics were delimited by two planes-the anterior one being tangent to the ischiatic foramen and the posterior one to the ischial tuberosities. At rest, the average length of the levator ani muscle and the surface of the supralevator space were significantly lower posteriorly than in the other two compartments (48.3 mm +/- 7.9; 48.8 mm +/- 7; 42.6 mm +/- 9.4, p < 0.05 and 70.6 cm2 +/- 7.5; 66.9 cm2 +/- 11.2; 27.2 cm2 +/- 4.8, p < 0.01, respectively). On straining, maximum muscle lengthening occurred posteriorly, as indicated by similar average values (63.7 mm +/- 12.7; 63.3 mm +/- 9.5 and 60.5 mm +/- 14) and the corresponding increase (+12.5%) in the supralevator space occurred in the middle compartment (73.8 cm2 +/- 7.6; 75.3 cm2 +/- 11.6 and 30.2 cm2 +/- 5.2). To conclude, our method proved reliable enough (intra- and interobserver correlation index > 80%) and promising for future clinical applications and studies of pelvic floor dysfunctions.

[The National Workshop on Defecography: anorectal deformities with a functional origin (prolapse, intussusception, rectocele)]

The nonoperative treatment--i.e., rubber band ligation and sclerotherapy--of mucous rectal prolapse, rectocele and intussusception is much less expensive than conventional surgery (Lit. 325,000 vs. 6,500,000, p < 0.0001 on the average). Symptom relief, however, has been reported in 0 to 57% of cases only, according to current literature. A possible cause is represented by improper management from misdiagnosis, relying on clinical findings only, overestimating mucous prolapse in 36.37% of cases and underestimating intussusception in 14.22% of cases (with respect to defecography). Defecography is a cost-effective method (average cost: Lit. 37,000) potentially reducing failure rate after the surgical repair of rectal prolapse.

Straight ileo-anal anastomosis with myectomy as an alternative to ileal pouch-anal anastomosis in restorative proctocolectomy

Restorative proctocolectomy with various types of reservoir is widely used in the elective surgery of ulcerative colitis and familial adenomatous polyposis. Both, advantages and disadvantages of this procedure are well known and documented. Straight ileo-anal anastomosis (IAA) yields unsatisfactory clinical results due to the lack of storage capacity of the distal ileum and the frequency of bowel movements related to high pressure ileal waves. In an attempt to create an alternative to the above procedures, we have performed a straight ileo-anal anastomosis with two rectangular (10 cm x 1 cm) myectomies down to 2 cm, above the anastomotic line. The two myectomies are spaced at 120 degrees to each other and to the mesenteric border of the ileal loop. The rationale of this approach is to reduce the peristaltic drive of the ileum by weakening the muscular wall. This study presents the results in three patients operated on with this new method in the last year.

[National working team report on defecography]

A questionnaire concerning defecography was submitted to 5 national experts in order to: 1) quantify the demand and 2) develop a consensus report. The demand is currently 2-8 exams week and the most frequent indication (70%) is obstructed defection, with/without constipation. The highest discriminatory capabilities was exhibited by the following variables: a) the anorectal angle (ARA) on straining and b) the distance from the pubococcygeal line (PCL) on squeezing (101.2 degrees +/- 15 vs. 120.6 degrees +/- 13, p < 0.05 and 27.4 mm +/- 15 vs. 2.4 mm +/- 7, p = 0.005, respectively) in chronically constipated patients (mean age: 60 years) when compared to the control group; and c) PCL on squeezing and at rest (35.5 mm +/- 20 vs. 2.4 mm +/- 7, p = 0.005 and 38.9 mm +/- 18 vs 18.4 mm +/- 17, p < 0.05, respectively) in patients with severe incontinence with respect to healthy subjects. While sensitivity and positive predictive values of the test were highest (97 and 98% respectively) for rectocele, specificity ranked first (92%) in anal gaping.

Functional radiology of the ano-rectal region

Chronic constipation is probably the most common symptom resulting in a referral of patients for a dynamic radiologic investigation of the GI tract. The primary usefulness of defecography in chronic constipation is to provide details about the dynamic phenomenon of evacuation which cannot be elicited by any other medical technique. It is employed to demonstrate or rule out the presence of an anatomical deformity (prolapse, rectocele, intussusception) and/or a localized dysfunction (outlet obstruction, rectal inertia) of the distal GI tract. Defecography can distinguish between a grossly obstructed pattern and an overtly normal one, but a definitive diagnosis is made by manometry and electromyographic studies. On the other hand, it should be noted that a failure to show abnormalities by defecography does not necessarily imply a normal anorectal function. A better understanding of anorectal physiology is expected in the future from combined video-pressure studies, which will provide the exact timing between the pressure drop and barium passage through the distal colon.

Proctocolectomy and stapled ileo-anal anastomosis without mucosal proctectomy

The present study compared the outcome of a small series of patients (7 cases) who underwent total proctocolectomy without mucosal proctectomy and stapled ileal pouch-anal anastomosis made at the apex of the anal transitional zone, with our previous experience (17 cases) in which the ileal pouch was anastomosed at the dentate line after mucosectomy. Though not statistically significant, our limited experience showed excellent clinical results with better continence and discriminating ability of flatus from faeces in the former group. The resting anal pressure profile was not changed postoperatively. The operation time was significantly reduced compared with our previous approach which was a time-consuming procedure. There was an indication that risk of complications (pelvic sepsis and haemorrhage) was less.

[Dynamic radiologic study with video recording of the oral and pharyngeal stages of normal deglutition]

The upsurge of interest in dynamic radiology of the oral pharyngeal phases of deglutition can be explained by: (a) the increased survival-rate in neuromuscular diseases; (b) the improved results in head and neck surgery and radiotherapy; (c) the awareness of the existence of a "silent" form of dysphagia. This paper is aimed at divulgating the radiological dynamic investigation of deglutition by videorecording, and at assessing the findings of a study on 119 consecutive non-dysphagic patients (55 males and 64 females; mean age 54 years) as a control group for future studies on dysphagic patients. Seventy-nine out of 119 subjects (66.4%) were found to be normal. Various abnormalities were observed in the remaining 40 (33.6%), such as barium penetration in the subepiglottic or supraglottic space (20 cases), dysmotility of the epiglottis (14 cases), transient and mild cricopharyngeal muscle dysfunction (17 cases), diverticula (6 cases). Further studies are needed to evaluate the true significance and implication of these findings in asymptomatic patients. Finally, a more widespread use of this method is hoped for, in order to establish its diagnostic and clinical efficacy.

[Colpocystographic study of female genital prolapse and urinary stress incontinence (author's transl)]

Colpocystography consists of a static and dynamic study of the opacified pelvic viscera (bladder, vagina, rectum) in lateral projection. This method is non traumatic and easy to perform. It is an useful diagnostic complement in the evaluation of bladder, uterine, rectal prolapse and urinary stress incontinence.

[Oblique tomography (55 degrees) in chest disease (author's transl)]

Conventional lung tomography may not clearly reveal the component of a pathologic mass at a hilum. Oblique cuts proved to be superior in the visualization of enlarged lymph nodes, parenchymal shadows and great fissures. Several cases are presented.

[Chronic eosinophilic pneumonia (author's transl)]

The clinical and radiologic findings of the chronic eosinophilic pneumonia are presented. A personal observation of one case is reported. This should be the first in the Italian roentgenologic literature. The importance of radiology in the diagnosis and in the evolution of the disease is stressed.

[Radiologic evaluation of bronchial asthma (author's transl)]

The physiopathologic and anatomic findings of bronchial asthma are shortly reviewed. A description follows of the radiologic patterns based on personal experience. Only seldom the radiologic investigations provide the possibility to reach the correct diagnosis of bronchial asthma. But they always complete the clinical evaluation and allow the demonstration of the numerous and frequent complications which influence the evolution and prognosis of the disease.

[The correlation between radiological and haemodynamic pictures in the diagnosis of pulmonary hypertension in chronic obstructive diseases (author's transl)]

A comparison between the radiographical findings and the haemodynamic data was made in 53 cases of chronic bronchial obstruction. The results were used in an assessment of the reliability of standard chest X-rays in the diagnosis of pulmonary hypertension. Reference is also made to quantitative indices. Several cases are presented by way of example.

[Radiological evaluation of neurogenic bladder]

A method that can be profitably employed in the clinical and functional evaluation of nevrogenic bladder is illustrated and discussed. It is primarily based on retrograde and micturition urethrocystography and urography with high doses of contrast medium.

[Radiologic patterns of pulmonary edema in chronic pulmonary diseases (author's transl)]

Three atypical patterns of cardiac failure and pulmonary edema, as frequently seen in chronic obstructive pulmonary diseases, are described; I. regional; II. miliary-like; III. Swiss-cheese like. Their importance in early diagnosis of pulmonary edema is discussed in the light of a review of a series of 98 patients whose pulmonary function was also investigated. Examples and statistical data are drown from this series.

[Radiologic and clinico-functional correlations in chronic lung diseases during congestive heart failure]

Two groups of patients were studied with serial correlated radiological functional analysis. Each group had a previous history of chronic obstructive pulmonary disease; however, on admission, only one group exhibited the clinical signs of this superimposed disease. The results of this research showed that chronic pulmonary disease is better defined by functional studies while cardiac failure (even in early stages) is always revealed by radiological examination.