功能性便秘患儿肛门内括约肌检测的临床意义

目的探讨功能性便秘患儿肛门内括约肌结构及功能的改变以及内括约肌厚度与临床症状严重程度的关系。方法对中国医科大学附属盛京医院2008年6—12月间收治的35例功能性便秘患儿（便秘组,其中合并失禁者17例）进行肛门直肠测压和肛管内B超检测,并与同期住院治疗的23例经检查排除消化道和内分泌疾病患儿（对照组）进行对照．采用儿童便秘临床症状评分标准（65分法）评估症状的严重程度。结果便秘组与对照组相比．直肠感知阈值明显增加[（42．4±19．5）ml比（29．1±15．6）ml,P〈0．05）;引起肛门内括约肌松弛反射的最低充气量明显增高[（55．6±31．6）ml比（30．5±13．8）ml,P〈0．05）;肛门内括约肌明显增厚[（3．8±1．7）mm比（2．5±1．0）mm,P〈0．05）;但两组肛管静息压[（170．8±62．3）mmHg比（161．3±51．1）mmHg]的差异无统计学意义（P〉0．05）。便秘组患儿临床症状评分为（9．3±4．3）分：肛门内括约肌厚度与临床症状评分呈正相关（r=0．407,P=0．015）;与患儿年龄、性别及病程则无相关性（均P〉0．05）。结论功能性便秘患儿肛门内括约肌结构与功能均会发生改变。肛门内括约肌厚度在一定程度上可以反映便秘症状严重程度。     

A study of motor and sensory evoked potentials in chronic cauda equina compression of the dog

Previous experimental studies have shown the effects of acute compression of the spinal cord and peripheral nerve roots. Recently, however, a few studies of chronic compression of the cauda equina in animal models have been reported. The purpose of this study was to determine the long-term electrophysiologic changes resulting from chronic compression of the cauda equina in dogs. An animal model of lumbar spinal stenosis was prepared according to Delamarter's method. Four experimental groups, each containing six dogs, were studied. One group underwent only laminectomy of the sixth and seventh lumbar vertbrae; these animals served as controls. In the three other groups, a laminectomy was performed and the cauda equina was constricted by 25%, 50%, and 75%, respectively, to produce chronic compression. Weekly neurologic examinations were carried out, and the neurologic deficits were graded using a modified Tarlov system. Sensory, and motor evoked potentials were recorded preoperatively, immediately after constriction, and at 2 weeks and 1, 2, and 3 months postoperatively. The animals in the control group showed no changes in sensory or motor evoked potentials. The dogs in which the cauda equina had been constricted by 25% showed no neurologic deficits and only mild changes in sensory and motor evoked potentials. The dogs in which the cauda equina had been constricted by 50% showed mild initial motor weakness, and major changes in the evoked potentials. The dogs in which the cauda equina had been constricted by 75% showed significant weakness, paralysis of the tail, and urinary incontinence; all dogs were partially recovered by the 3rd month, but all still showed neurogenic changes in the evoked potentials. Sensory and motor evoked potentials revealed neurologic abnormalities before the appearance of neurologic signs and symptoms. Constriction of more than 50% was the critical point that resulted in complete loss or reduction of the evoked potentials and in neurologic deficits. Dogs in which motor and sensory evoked potentials recovered also showed gradual disappearance of neurologic symptoms and signs. Recovery of motor evoked potentials in particular was associated with complete disappearance of neurologic symptoms and signs. For accurate prognosis in cases of chronic cauda equina compression, a combined diagnostic study of sensory and motor evoked potentials is recommended.     

Botulinum toxin in the treatment of refractory constipation associated with anal sphincter hypertonicity: A pilot prospective study in Chinese children (CME paper)

Objective: Idiopathic constipation in children can be difficult to manage with conventional therapies. The present study aimed to evaluate the efficacy of adjunctive botulinum toxin injection in children attending our regional centre with refractory idiopathic constipation associated with internal anal sphincter hypertonicity. Methods: Children suffering refractory constipation after a minimum of 3 months bowel training, dietary and laxative treatments were evaluated by anorectal manometry. Those with idiopathic anal sphincter hypertonicity (resting pressure > 60 mmHg with normal recto‐anal reflex) were recruited for botulinum toxin injection. Pretreatment evaluation also included bowel‐function score and the degree of megarectum as measured transpubically by ultrasound. Each child received 60 units of Botox^® intrasphincterically under general anaesthesia. Follow‐up evaluations were carried out at 6 weeks and 6 months. Results: Eleven Chinese children, mean age 6.1 years, underwent botulinum toxin treatment. The mean sphincter pressure decreased from 73 mmHg to 55 mmHg and the mean symptom score improved from 2.5 to 6.3 (P = 0.003, Wilcoxon signed rank‐sum test). The mean rectal diameter decreased from 3.7 cm to 3.4 cm. Findings were sustained at 6 months with no treatment complications. Conclusion: Botulinum toxin intrasphincteric injection is a safe, non‐invasive and effective adjunct to conventional therapies in managing children with refractory idiopathic constipation associated with sphincter hypertonicity. Timely definitive therapy to facilitate pain‐free habitual defecation plays an important role in these children in their potty training, as demonstrated by the sustained ‘sphincterotomy’ effects outlasting the transient toxin paralysis.     

Rhythmic pressure variations in urethra and anal canal: Investigations in healthy fertile female volunteers

Ten healthy fertile female volunteers underwent one hour continuous urethral and anal canal pressure recordings. The recordings showed a median maximum urethral pressure (mMUP), of 74.0 cm H₂O and a median maximum anal canal pressure (mMAP) of 50.0 cm H₂O. The anal canal pressure variations (APV) showed the same frequency domains as found in the urethra ranging from 0.001 to 0.03 Hz. The APV amplitude was correspondingly diminished and the two pressure tracings were out of phase indicating the urethral pressure variations (UPV) and APV to be separate intrinsic spontaneous activities of the urethra and anal canal. Twenty-six months prior to the present study the women had a similar urethral pressure recording. Comparison of the mMUP, maximum urethral closure pressure (mMUCP), and UPV frequency and amplitude showed no difference between the two periods. The intraindividual variation was lower than the interindividual variation meaning that the individual woman had rather stable urethral pressures, whereas there was a considerable variation between the women. The rhythmic UPV frequencies and amplitudes were stable during the two year period. Consequently the study underlines the consistency of urethral pressure. The comparative investigations of urethral and anal pressure add evidence to our pressure statements that they originate from smooth muscle activity.     

Adenocarcinoma in the anal canal associated with a fistula: Report of a case

Adenocarcinoma in the anal canal associated with an anal fistula is extremely rare, and in most cases its origin is difficult to ascertain because the primary sites have already been destroyed before any diagnosis of malignancy is able to be made. We report herein the case of a 62-year-old man found to have papillary adenocarcinoma with partial mucinous carcinoma associated with an anal fistula. The tumor was not exposed to the mucosal surface of the anal canal or rectum and an abdominoperineal resection was carried out. Macroscopic findings suggested that the tumor had developed from the anal fistula; however, the tumor showed a positive result when tested for O-acetylated sialic acids. This test also proved positive in the mucus of normal rectal mucosa, but not in the mucus of the anal glands. We speculated that the results of these tests may indicate that this tumor could have originated from the rectal mucosa, from where it migrated into the anal fistula.     

Prevalence and correlations of anal incontinence and constipation in Taiwanese women

Anal incontinence and constipation are not only physically and psychologically disabling symptoms but also a significant social and public health problem. The epidemiology of anal incontinence and constipation from community-bases remains largely unknown, especially in Asian women. This study is a continuation of a previous survey taken on the epidemiology of urinary incontinence and overactive bladder in Taiwanese women by using a second questionnaire (correlation coefficient for symptoms, r=0.87; P<0.05). We evaluated the prevalence and potential risk factors associated with anal incontinence and constipation in the general population. Of the 1,584 (2.92%) women sampled, 1,253 (79.1%) were successfully interviewed at home. The prevalence of fecal incontinence and flatus incontinence was 35 (2.8%) and 107 (8.6%), respectively. There were 306 (24.5%) participants who reported constipation. However, according to the current medical criteria for constipation, the prevalence of constipation was only 2.7%. The prevalence of anal incontinence did not increase after the age of 65 years (9.7%, including 3.5% of elderly women with fecal incontinence and 6.2% of elderly women with flatus incontinence). The prevalence of constipation significantly increased in the women aged 65 years and over (self-reported prevalence: 32.4%, fitted in medical criteria for constipation: 8.3%). Our results demonstrated that constipation shares some of the same risk factors, namely, symptoms of uterovaginal prolapse, prior gynecologic surgery, and overactive bladder that predispose women to the occurrence of anal incontinence. The questionnaire needs a higher discriminatory capacity, and a longitudinal study should be conducted to clarify this conflict further.     

Anatomy of the rectum and anal canal

Diseases of the rectum and anal canal, both benign and malignant, account for a very large part of colorectal surgical practice in the UK. This article emphasizes the surgically relevant aspects of the anatomy of the rectum and anal canal.     

Quantitative assessment of anal canal sensation in patients undergoing low anterior resection for rectal cancer

To determine the influence of anal canal sensation on anal function after low anterior resection (LAR) for rectal cancer, anal canal sensation was quantitatively evaluated before and after LAR by measuring anal mucosal electrosensitivity (AMES), and the relationship between AMES and postoperative anal function was explored. Sensory thresholds 1, 2, and 3 cm from the anal margin were recorded in 21 patients who underwent LAR for rectal cancer (LAR-I) before, then 1 and 4 months after their operation. Another 14 patients who had been followed up for more than 1 year (LAR-II) after LAR and 21 control subjects were also studied. The median preoperative sensory thresholds in the LAR-I group were higher than those in the controls, though the differences were not significant. The sensory thresholds in the LAR-I group 4 months after LAR were lower than those preoperatively, but they did not significantly differ from those in the LAR-II and control groups. Although the postoperative sensory thresholds did not correlate with postoperative anal function, the preoperative sensory thresholds were higher in patients who were experiencing episodes of fecal incontinence 4 months after their operation. These results suggests that the preoperative measurement of AMES is useful for identifying patients who are likely to have a poor quality of continence after LAR.     

病理性肛裂组织切除治疗慢性肛裂疗效观察

目的 探讨病理性肛裂组织切除治疗慢性肛裂的疗效。方法 回顾分析2019年9月至2020年4月在我院接受病理性肛裂组织切除手术46例慢性肛裂患者的临床及随访资料,观察患者手术时间、术中出血量、术后并发症情况、术后疼痛评分、手术前后肛管静息压变化及临床疗效。结果 本组患者手术时间（35.91±12.35）min,术中出血量（7.33±3.48）mL。术后出现尿潴留4例（8.70%）,切口感染1例（2.17%）,未出现切口出血、肛门失禁等并发症。术后24 h疼痛评分（3.43±0.91）分,术后48 h疼痛评分（3.00±0.73分,术后72 h疼痛评分（2.22±0.76）分,术后1周疼痛评分（0.67±0.63）分。术前肛管静息压（19.86±2.24）kPa,术后3周肛管静息压（10.396±1.97）kPa,差异具有统计学意义（P=0.000）。创面愈合时间为（24.26±5.14）d。本组患者治愈42例（91.30%）,好转4例（8.70%）,有效率100%。中位随访时间8.2个月,无复发病例。结论 病理性肛裂组织切除术治疗慢性肛裂安全、有效。     

The anatomy of the rectum and anal canal

Diseases of the rectum and anal canal, both benign and malignant, account for a very large part of colorectal surgical practice in the UK. This article emphasizes the surgically-relevant aspects of the anatomy of the rectum and anal canal.     

Sentinel lymph node biopsy for squamous cell carcinoma of the anal canal

Background: The current Trans‐Tasman Radiation Oncology Group (TROG) protocol for T1 and T2 anal cancers is combination chemotherapy and radiotherapy excluding the inguinal region from the field. Several centres worldwide irradiate both inguinal regions as there is a small incidence of involvement with early stage tumours. The presence of inguinal lymph node metastases is not accurately detected using clinical and most radiological assessment modalities. We have developed a method of sampling the sentinel node in the groin using established node mapping techniques. Methods: A combination of radio‐labelled Antimony Sulphide and Patent Blue dye injected around the anal cancer enable identification of the sentinel node in the groin, using a gamma probe and direct visualization of the blue node. Results: This technique has been used in four patients. A groin sentinel node was identified and removed in three of these, with pathological assessment excluding metastatic disease in the inguinal region. The fourth patient had a sentinel node mapped to a meso‐rectal node. This was not sampled. Conclusions: The application of this effective technique will allow accurate staging of anal cancers to better plan future treatment regimes.     

Auditory evoked potential index: a quantitative measure of changes in auditory evoked potentials during general anaesthesia

We describe a novel index derived from the auditory evoked potential, the auditory evoked potential index, and we compare it with latencies and amplitudes related to clinical signs of consciousness and unconsciousness. Eleven patients, scheduled for total knee replacement under spinal anaesthesia, completed the study. The initial mean (SD) value of the auditory evoked potential index was 72.5 (11.2). During the first period of unconsciousness it decreased to 39.6 (6.9) and returned to 66.8 (12.5) when patients regained consciousness. Thereafter, similar values were obtained whenever patients lost and regained consciousness. Latencies and amplitudes changed in a similar fashion. From all parameters studied, Na latencies had the greatest overlap between successive awake and asleep states. The auditory evoked potential index and Nb latencies had no overlap. The consistent changes demonstrated suggest that the auditory evoked potential index could be used as a reliable indicator of potential awareness during propofol anaesthesia instead of latencies and amplitudes.     

U形肌袢成型重建原位肛门治疗低位直肠癌和肛管癌

目的在Miles术式的基础上,采用U形肌袢成型重建原位肛门治疗低位直肠癌和肛管癌。方法为72例低位直肠癌和肛管癌患者实施保留耻骨直肠肌双重U形肌袢成型重建原位肛门,同时建立直肠角和直肠瓣的新术式。结果本组72例,于术后4~6d开始出现便意感,1个月左右排便有自控意识,排便次数1~2次/日。1年内,优41例,良19例,差12例。结论本术式是在Miles术式基础上完成重建肛门,能彻底切除肿瘤,重建肛门排便功能良好,生活质量满意。     

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females

Aim Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy. Method Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap. Results Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance. Conclusion Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.     

肛管腺癌49例的临床特点及其治疗

目的 探讨肛管腺癌的临床特点和治疗方法。方法 回顾性分析我院1965年1月至2002年3月间收治的肛管腺癌共49例的临床资料。结果 男女比例1．3：1，平均年龄52岁，中位年龄56岁。肛门出血、便条变细和肛门肿物是最常见的症状。36．7％伴有慢性肛周疾病史。治疗后中位随访时间66个月。局部复发和腹股沟淋巴结转移各7例，肺转移2例，锁骨上淋巴结转移和纵隔转移各1例。单纯手术组、单纯放化疗组、综合治疗组（腹会阴联合切除加术后辅助放化疗）和无局部治疗组患者的3年总生存率分别是41，3％、20．0％、56．3％和15．0％，5年总生存率分别是34．4％、0、37．5％和0。结论 早期诊断是改善肛管腺癌预后的最基本保证，综合治疗是目前疗效较好的治疗手段。     

Irritable bowel syndrome and chronic constipation in patients with endometriosis

Aim The aim of this study was to evaluate how many patients with endometriosis have concomitant irritable bowel syndrome (IBS) and/or constipation according to the Rome III criteria. Furthermore, the value of an additional gastroenterological consultation with therapeutic advice was evaluated. Method Patients with proven endometriosis were included in a prospective, single‐centre study. A questionnaire was undertaken regarding IBS and chronic constipation. Patients with symptoms consistent with the Rome III criteria for IBS were referred to our gastroenterological outpatient clinic. Results In total 101 patients were included. Endometriosis was diagnosed surgically in 97% and visually in the vagina in 3%. Fifteen per cent of the patients with endometriosis also had IBS and 14% of the patients with endometriosis had functional constipation without IBS. Of the 22 patients finally presenting to the gastroenterologist, five had a significant stenotic rectosigmoid lesion and were treated surgically. The remaining 17 patients were treated conservatively. Defecation symptoms improved in 86% and pain was reduced in 64%. Conclusion In patients with endometriosis, 29% also had IBS or constipation. Referral to a gastroenterologist resulted in improvement of defaecation in 86%, and 64% reported a reduction in the degree of pain.