Transrectal ultrasonography: relationship with anorectal manometry, electromyography and sensitivity tests in irritable bowel syndrome

Irritable bowel syndrome is the most frequently diagnosed disorder in gastroenterology. It has been demonstrated with specialized motility studies that these patients compared to healthy subjects show changes in rectoanal electrical and mechanical activity and in rectoanal sensitivity. However, until now no report has been published on morphological alterations in the rectum or the internal anal sphincter. Twenty-five consecutive patients with irritable bowel syndrome (mean age 32, range 17–47 years; 24 females) were evaluated prospectively by transrectal ultrasonography, rectal sensitivity studies, and recordings of both electrical and mechanical activity of the distal rectum and internal anal sphincter during a 2-h interdigestive period. Ten healthy volunteers (mean age 34.5, range 19–50 years) served as a control group. Paired and non-paired Student's two-tailed t test and linear regression analysis were used. It was shown that muscle thickness of the rectum during rest (4.7±0.1 mm) was correlated neither with its rectal spike amplitude (0.73±0.1 mV) nor with rectal spike frequency (17.06±3.6 spike/2 h). In addition, the diameter of the internal anal sphincter (1.2±0.1 mm) was correlated neither with its resting pressure, nor with frequency (17.1±3.2/2 h), duration (14.9±1.5 s), or amplitude (14.1 ±1.9 mmHg), of inhibition of the spontaneous rectoanal inhibitory reflex. No correlation was found between ultrasonographic parameters and rectal distension variables (r=0.03). This study demonstrates for the first time morphological anorectal changes in patients with irritable bowel syndrome compared to healthy subjects, in addition to showing that morphological changes are independent of physiological ones. Therefore both transrectal ultrasonography to determine anorectal morphology and electromanometry to assess anorectal function are important measures in the evaluation of patients with irritable bowel syndrome. Accepted: 21 November 1997     

Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices

Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1)coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Francisco, California, May 2 to 6, 1982.     

直肠粘膜下局部浸润麻醉在PPH术中的临床观察

目的评价直肠粘膜下局部浸润麻醉在痔上粘膜环切术中的应用。方法观察分析50例应用直肠粘膜下局部浸润麻醉和骶管麻醉患者PPH中或术后的不良反应及并发症,并与50例应用单一骶管麻醉实施PPH术的患者进行比较。结果两组患者麻醉效果均达到手术要求。两组患者术中牵拉反应及术后下腹部疼痛、尿潴留等并发症的发生率间差别有显著性意义（P〈0.05）。结论骶管麻醉实施PPH效果肯定,在此基础上再加用直肠粘膜下局部浸润麻醉,可减少术中或术后不良反应及并发症,提高麻醉效果。     

SHH/BMP4信号在肛门直肠畸形肠神经系统发育中的作用研究

目的研究不同类型先天性肛门直肠畸形(ARM)胎鼠直肠末端肠神经系统(ENS)发育程度,探讨SHH/BMP4在其发育过程中的作用。方法利用全反式维甲酸(ATRA)诱导大鼠产生肛门直肠畸形胚胎,孕20d剖宫取胎,应用免疫组织化学方法检测对照组和高、低位ARM组直肠末端神经元特异性烯醇化酶(NSE)及骨形态发生蛋白4(BMP4)的表达;反转录-聚合酶链反应(RT-PCR)方法检测各组直肠末端SHH/BMP4mRNA的表达差异。结果对照组肠壁肌间及黏膜下神经丛可见NSE和BMP4抗体染色阳性细胞,ARM高位组与ARM低位组、对照组比较,阳性细胞的平均光密度(MOD)值明显降低,差异均有统计学意义(P<0.05);ARM低位组和对照组相比,阳性细胞的MOD值略降低,差异有统计学意义(P<0.05)。在ARM直肠末端SHH和BMP4基因表达呈正相关(P<0.01,r=0.884),对照组与ARM组相比较,BMP4和SHHmRNA的表达水平明显高于ARM组,差异均有统计学意义(P<0.05),不同ARM组之间比较,高位ARM组的表达水平显著减弱低于低位ARM组,差异也有统计学意义(P<0.05)。结论①不同类型ARM胎鼠直肠末端ENS发育程度存在差异,不仅与闭锁的位置密切相关,还可能与BMP4基因的表达水平有关。②过量的ATRA可能抑制了SHH/BMP4信号表达,干扰了直肠ENS的正常发育。     

直肠癌组织中PgP蛋白和p16蛋白的表达及临床意义

目的探讨PgP和p16蛋白在直肠癌组织中的表达情况及临床意义。方法应用MaxVisionTM免疫组化的方法对71例直肠癌及癌旁组织进行PgP和p16蛋白检测。结果 PgP的总阳性率为84.51%(60/71)。PgP的阳性表达与直肠癌的淋巴结有无转移有关,与癌组织的分化程度、浸润深度与伴不伴有神经浸润无关。其中低分化腺癌(93.33%,28/30)高于高分化腺癌(82.61%,19/23)、中分化腺癌(72.22%,13/18,P>0.05)。淋巴结无转移组93.48%(43/46)明显高于淋巴结转移组68%(17/25,P<0.05)。伴有神经浸润组85.71%(24/28)与不伴有神经浸润组(83.72%,36/43,P>0.05)两者之间差异无统计学意义。癌组织浸润到浆膜外脂肪组织(87.5%,21/24)高于浸润到肠壁全层(84.21%,32/38),高于浸润到肠壁肌层(77.78%,7/9,P>0.05)。p16蛋白的总阳性率为(64.79%,46/71)。p16蛋白的阳性表达与淋巴结有无转移及组织的分化程度无关,与伴不伴有神经浸润及癌组织的浸润深度有关。其中其低分化腺癌(73.33%,22/30)高于高分化腺癌(60.87%,14/23)和中分化腺癌(55.56%,10/18,P>0.05)。淋巴结转移组(17/25,68%)与淋巴结无转移组(29/46,63.04%)两者之间差异无统计学意义(P>0.05)。不伴有神经浸润组(79.07%,34/43)明显高于伴有神经浸润组(42.86%,12/28,P<0.05)。癌组织浸润到肌层(88.89%8/9)高于浸润到全层(71.05%,27/38),明显高于癌组织浸润到浆膜外脂肪组织(45.83%,11/24,P<0.05)。结论 PgP和p16蛋白的阳性表达与直肠癌的某些临床病理指标相关,可作为对判断直肠癌的恶性程度,预测肿瘤侵袭转移,评估预后的良好指标。     

肛管直肠损伤34例诊治分析

目的探讨肛管直肠损伤的诊断与治疗。方法收集1994年10月至2008年10月我院经治的34例肛管直肠损伤的病历资料,对其受伤原因,诊治经过及预后进行分析。结果全组行非手术治疗5例,手术治疗29例。其中,单纯腹部手术6例,腹部手术加延期肛门括约肌修复手术5例,单纯肛门括约肌修复术5例,取异物手术6例,清创引流7例。全组无手术死亡病例。术后并发症发生率为13．8％。结论详细询问受伤经过、仔细观察病情、及时肛门指诊和进行控制感染的手术与保护肛门功能的手术是肛管直肠损伤诊断与治疗的基本原则。     

Conservative management of rectal perforation after nerve sparing endoscopic extraperitoneal radical prostatectomy (NS EERPE) in a patient with a past history of polypectomy

Introduction

Rectal polypectomy causes thinning (or even perforation) of the rectal wall in addition to thermic injury at the polypectomy site.

Case report

We present a rare case of spontaneous rectal perforation after uncomplicated nerve sparing endoscopic extraperitoneal radical prostatectomy in a patient with a previous history of rectal polypectomy at the perforation site. The patient could be treated conservatively. There was complete healing of the fistula without any effect on functional results. This Conservative therapy for such rectal perforations is indicated if the patient''s general condition remains stable without any signs of infection.

Conclusions

Polypectomy is an important risk factor for rectal perforation during nsEERPE. Adequate time interval should be given to allow healing and avoid adding further thermal wall damage which may obscure healing leading to complications like fistula. Conservative therapy for small missed rectal perforations constitutes an attractive, feasible and non invasive treatment entity. Following this principle we have not faced this complication in following similar cases.     

A novel technique for nonoperative removal of round rectal foreign bodies

Extraction of rectal foreign bodies is challenging. The medical literature confirms the diversity of the problem and equally some ingenious solutions, the majority of which requires either an anesthetic agent or a laparotomy to remove them. This case report presents a simple nonoperative technique to deal with one such situation.     

Metastatic Merkel Cell Carcinoma in the Rectum: Report of a Case

Merkel cell carcinoma is a rare, aggressive skin malignancy of neuroendocrine origin with predominant occurrence in the elderly males. Approximately 50 percent of patients with Merkel cell carcinoma develop distant metastasis at some point during the disease course; hence, Merkel cell carcinoma always has a poor prognosis. Distant metastasis has never been disclosed in the rectum to the best of our knowledge. We present a 76-year-old male with clinical manifestation of massive hematochezia and final diagnosis of metastatic Merkel cell carcinoma in the rectum. We conclude that radical resection of rectal metastatic Merkel cell carcinoma is important in the management strategy of a patient with recurrence and lymph node metastases. Presented at the meeting of the Taiwan Surgical Association, Linkou, Taoyuan, Taiwan, March 25 and 26, 2006.     

Rectum dose reduction and individual treatment plan optimization for high-dose-rate prostate brachytherapy

PURPOSE: Different doses and techniques used in high-dose-rate (HDR) prostate brachytherapy make it difficult to define universal quality parameters. The aim of this study was to develop individual, objective parameters for the evaluation of an HDR brachytherapy plan for prostate radiation. METHODS: Fifty-three patients who received an HDR brachytherapy boost after external radiation were analyzed in this study. Brachytherapy was performed with a (192)Ir source after ultrasound-guided, transperineal metal needle application followed by removal of the ultrasound probe to reduce organ dose levels at the anterior rectum wall. The rectum and prostate locations as well as the dose at the anterior rectum wall were estimated under the anatomical conditions of HDR prostate brachytherapy. The doses at the organs at risk (rectum and urethra) were analyzed for several parameters, which were compared to values of former patients before the start of treatment. In cases of major deviations, modifications of the treatment plan were performed before starting the treatment. RESULTS: Deflating of the water balloon led to an increase of the space between the anterior rectal wall and the dorsal margin of the prostate (mean, 6mm; 1-10mm). The dose of the introduced "virtual rectum," represented by the ventral surface of the ultrasound probe, in the treatment plan correlated to dose measurements in the rectum. Pretreatment evaluation and comparison of the established individual quality parameters led in two cases to a treatment plan modification. CONCLUSIONS: This method allows a fast and objective individual brachytherapy treatment plan evaluation and improvement.