Transanaler rektaler Verschiebelappen (rectal advancement flap) versus mukosaflap mit internusnaht im management komplizierter fisteln des anorektums Eine prospektive klinische und manometrische studie

A prospective study was carried out on 55 patients with complicated anal fistulas (41 transsphincteric, 5 suprasphincteric and 9 rectovaginal) to evaluate the value of two sphincter-conserving techniques with primary occlusion of the internal ostium and endorectal advancement flap (group A, n=34) or mucosal flap (group B, n=21). Ten of the patients had Crohn's disease. Both techniques consist in one-stage fistulectomy without drainage of the intersphincteric space. The inflamed proctodeal and granulation tissue was carefully cleared. The site of the former primary orifice of the fistula was adapted by means of two or three peranally performed single stitches. The peranally applied suture included the layers of the internal anal sphincter muscle only. A mobilized flap of rectal wall (group A) and rectal mucosa and submucosa (group B) about 4 cm × 3 cm in size was stitched below the muscular sphincter. The perianal part of the wound was left to heal by second intention. Postoperatively there were 16 cases of suture leakage (23.5% in group A, and 38% in group B), and 19 patients (26% or 47% in both groups) had to have revision surgery because of recurrent fistula or sutur leakage; 2 patients (3.6%) developed incontinence with intermittent fecal soiling. Complete incontinence was not observed in any patient. No significant difference in clinical and functional results was determined between the two groups.

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Transanaler rektaler Verschiebelappen (rectal advancement flap) versus mukosaflap mit internusnaht im management komplizierter fisteln des anorektums Eine prospektive klinische und manometrische studie

Zusammenfassung Bei 55 Patienten mit komplizierten Analfisteln (41 transsphinktere, 5 suprasphinktere, 9 rektovaginale Fisteln) wurde eine prospektive Studie zur Bewertung von 2 sphinktererhaltenden Techniken mit primärem Verschlu des inneren Fistelostiums and anschlieender Deckung durch einen endorektalen Verschiebelappen (Gruppe A, n=34) oder Mukosalappen (Gruppe B, n=21) durchgeführt. Zehn Patienten hatten M. Crohn. Beide Techniken bestehen aus einer einzeitigen Fistulektomie ohne Drainage des Intersphinkterraumes. Das entzündlich veränderte Procdodealdrüsen- und Granulationsgewebe wurde vorsichtig mit dem scharfen Löffel entfernt. Der Ort der früeren Primäröffnung der Fistel wurde mit zwei bzw. drei peranal angelegten Einzelknopfnähten verschlossen. Die peranal gelegte Naht umfate die Schichten des M. spincter ani internus. Ein mobilisierter Rektumwandlappen (Gruppe A) oder ein Mukosa-Submukosalappen (Gruppe B), in einer Gröe von ca. 4×3 cm wurde versetzt und über den muskulären Verschlu gedeckt. Der perianale Teil der Wunde heilte sekundär. Postoperativ trat bei 16 Fällen eitle Nahtinsuffizienz auf (23,5% in Gruppe A, 38% in Gruppe B). Neunzehn Patienten (26% gegenüber 47% in beiden Gruppen) erforderten eine erneute Operation aufgrund von wiederkehrenden Fisteln oder Nahtinsuffizienzen. Zwei Patienten (3,6%) entwickelten eine Inkontinenz in Hinblick auf intermittierendes Stuhlschmieren. Eine völlige Störung der Kontinenz wurde in keinem Fall beobachtet. Ein signifikanter Unterschied zwischen beiden Gruppen war weder in klinischen noch in den funktionellen Ergebnissen zu ermitteln.

     

Dysphagia in Parkinson's disease: Pharyngeal manometry and fiberoptic endoscopic evaluation

ObjectiveDysphagia is a common symptom in Parkinson's disease (PD) and it represents a negative prognostic factor because of its complications. This study is to evaluate pharyngeal dysphagia for boluses of various consistencies with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Pharyngeal High-Resolution Manometry (PHRM) in a group of PD patients, making a comparison between the information provided by the two exams.MethodsGroup of 20 patients affected by PD was selected and initially subjected to a qualitative evaluation of the swallowing performing FEES. Subsequently, they were evaluated by PHRM to identify quantitative measures associated with pressures expressed by pharyngeal organs during swallowing. Values obtained in the study group were compared with those recorded in a group of 20 healthy subjects.ResultsStudy showed that Pmax (the maximum pressure elicited by the single pharyngeal muscle structures involved in swallowing) was significantly lower than the control group (p<0.05) for all the boluses and consistency tested, in particular for the Tongue base and the Cricopharyngeal muscle. Pmean pre-swallowing pressure (represents the mean value of a contraction in which basal and maximal pressure where normally calculated) was significantly higher compared to normal subjects for the Tongue base and the Cricopharyngeal muscle (p<0.05). Mean intra-swallowing pressure was higher for the Velopharynx and the Cricopharyngeal muscle, but lower for the tongue base. Pmax and Pmean at PHRM were altered independently to the degree of dysphagia detected at FEES, and they did not correlate either with the location of the residue or with the type of bolus. Images displayed at the FEES, found the corresponding biomechanical explanations in the PHRM, which also allowed us to quantify the extent of the dysfunction, through the calculation of the pressures generated in the various structures studied.ConclusionPHRM is particularly useful in the early detection of dysphagia, when FEES may still show no evidence of abnormal swallowing.     

Pyloric motor abnormality in patients with infantile hypertrophic pyloric stenosis

There are no published data of manometric studies of pyloric motor function in patients with infantile hypertropic pyloric stenosis (IHPS). The present study attempted to examine the characteristics of motor abnormality of the pylorus in five children with IHPS. Using a transducer-built-in manometric catheter cannulated through the pylorus under fluoroscopy, the pressure in the pyloric canal was recorded continuously over 3 h during fasting. Clusters of high-amplitude spastic contractions of over 300 mmHg were recorded at intervals. The frequency was 1–3/min (mean 1.7 cpm) and the duration was 7–15 s. These periodic spastic contractions were suppressed temporarily for 20–30 min after intravenous injection of 0.01 mg/kg atropine. After pyloromyotomy, these spastic contractions decreased remarkably in amplitude, but there were no changes in frequency. It is concluded that the underlying motor abnormality observed in hypertrophied pyloric muscle is clusters of high-amplitude contractions, although more precise measurements of basal pyloric pressure are needed to explore the pathophysiology of IHPS in detail. The effect of pyloromyotomy may be related to the decrease in high-amplitude contractions. Accepted: 26 May 1998     

食管裂孔疝伴胃食管反流病的胃食管动力学研究

目的:探讨食管裂孔疝(HH)伴胃食管反流病(GERD)患者与单纯HH及GERD患者之间的内镜、24h食管pH监测、食管测压、胃动力学检查之间的相关性.方法:经胃镜确诊的HH伴GERD患者61例,同期内镜确诊单纯HH患者28例,GERD患者30例,在一周内进行24h食管pH监测、食管下端括约肌(LES)压力测定及胃磁图测定胃半排空时间.结果: GERD中pH监测诊断同内镜诊断相符合占83.52%,不符合占16.48%.24h pH监测中,HH伴GERD组患者的总反流时间、卧位反流时间及立位反流时间百分比均显著高于GERD组和HH组,GERD组显著高于HH组;HH伴GERD组LESP显著低于HH组和GERD组,HH组LESP显著低于GERD组;HH伴GERD组LESL显著短于GERD组,HH伴GERD组和HH组LESL无显著差异,HH组LESL显著短于GERD组;HH伴GERD组LESR显著高于HH组和GERD组,HH组LESR显著高于GERD组;HH伴GERD组胃排空延缓者显著多于HH组,但与GERD组无显著差异,GERD组胃排空延缓者显著多于HH组.     

Frequency of abnormal esophageal acid exposure in patients eligible for bariatric surgery

BackgroundObesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery.MethodsData collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux.ResultsEsophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P<.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring.ConclusionFrequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.     

Intraoperative Sphincter of Oddi Manometry in Patients with Gallstones

In seven patients operated on with cholecystectomy for simple gallstones, sphincter of Oddi manometry was performed during surgery. The sphincter was localized as a zone with elevated base-line pressure and phasic contractile activity. Mean value of the amplitude was 90 mm Hg; wave duration, 4 sec; frequency, 5/min; and base-line pressure, 10 mm Hg. No activity was seen in the antrum or duodenum. The plotting of peak-to-peak intervals in a histogram showed that these were evenly distributed around 6 sec or at integrated multiples of this value. This indicates that the sphincter of Oddi is paced. The origin of the pacing is not yet established.     

Internal anal sphincter

The internal anal sphincter, the smooth muscle component of the anal sphincter complex, has an ambiguous role in maintaining anal continence. Despite its significant contribution to resting anal canal pressures, even total division of the internal anal sphincter in surgery for anal fistulas may fail to compromise continence in otherwise healthy subjects. However, recently reported abnormalities of the innervation and reflex response of the internal anal sphincter in patients with fecal incontinence indicate its significance in maintaining continence. The advent of sphincter-saving surgery and restorative proctocolectomy has re-emphasized the major contribution of the internal anal sphincter to resting pressure and its significance in preventing fecal leakage. The variable effect of rectal excision on rectoanal inhibitory reflex has led to a reappraisal of the significance of this reflex in discrimination of rectal contents and its impact on anal continence. Electromyographic, manometric, and ultrasonographic evaluation of the internal anal sphincter has provided new insights into its pathophysiology. This article reviews advances in our understanding of internal anal sphincter physiology in health and disease.     

肛门直肠测压在先天性巨结肠及巨结肠同源病中的应用进展CSCD

Anorectal manometry (ARM) is a non-invasive clinical tool of detecting anorectal rectal motion reflexes with a pressure detection device. It has been widely employed for diagnosing and treating Hirschsprung’s disease and allied disorders due to the advantages of mini-invasiveness, non-radioactivity, rapidness and convenience. However, its diagnostic value has remained controversial. This review summarized the application of ARM in recent years and discussed its shortcomings to help better diagnose the diseases, evaluate the prognosis, improve patient quality-of-life and provide new rationales for in-depth ARM researches. © 2022, Journal of Clinical Pediatric Surgery. All rights reserved.