次侧切术治疗期肛裂前后肛门直肠压力对比分析

目的 :探讨次侧切开内括约肌治疗肛裂术前、术后肛门直肌压力的变化。方法 :采用自行设计的次侧方内括约肌切开加双缘结扎术治疗 期肛裂 6 0例 ,测定手术前后肛门直肠压力 ,并与 6 0例正常人肛压比较 ,评价新术式治疗 期肛裂的临床疗效及其对肛门功能的影响。结果 :显示术后患者肛管静息压显著降低 ,与术前比较有显著性差异 (P <0 .0 1) ,与正常人比较无显著性差异 (P>0 .0 5 ) ;肛管最大收缩压与术前及正常人比较无显著性差异 (P>0 .0 5 )。结论 :次侧方内括约肌切开加双缘结扎术能有效地解除内括约肌痉挛 ,从根本上消除高肛压 ,从而彻底治愈肛裂 ,而且不影响肛门功能。     

Infusion manometry and detection of sphincteric function of crural diaphragm

The principles of infusion manometry in the measurement of lower esophageal sphincter (LES) pressure were laid down in the mid-1960s by L.D. Harris and his coworkers. Dodds and his colleagues were largely responsible for the improvements and advent of the low-compliance manometry. Using side-hole manometry, it is possible to detect accurate LES pressure that correlates with the strength of the antireflux barrier. The LES pressure as measured by the side-hole manometry, shows respiration-induced pressure oscillations. These pressure oscillations were initially thought to be due to the influence of abdominal and thoracic pressures on the LES. However, it was later pointed out that these pressure oscillations were due to the relative motion of the point pressure sensor (side hole of the manometric catheter) and the LES during respiration. Recent studies suggest that active contraction of the crural diaphragm during inspiration is responsible for the pressure oscillations observed in the cat LES pressure tracings. The use of the sleeve device in the measurement of LES pressure during contraction of the diaphragm has been described recently. Using the principles of manometry and sleeve device, it is now possible to identify two lower esophageal sphincters: the smooth muscle LES, traditionally known as the LES, and crural diaphragm, which we have referred to as the external lower esophageal sphincter. The purpose of the following paper is to summarize the general principles of the infusion manometry in the measurement of intraluminal pressure, specifically the LES pressure. The recently developed technique of detection of the sphincteric function of the crural diaphragm by the sleeve device will be discussed. In the last paragraph the limitations of manometry in detection of the muscular contractile activity are described.     

芬太尼／哌替啶致Oddi括约肌痉挛的探讨

２００例择期胆囊切除＋术中胆道造影患者分二组；芬太尼１７ｕｇ／ｋｇ静注（Ｆ组，ｎ＝１００）、哌替啶１ｍｇ／ｋｇ静注。评价两种麻醉性镇痛药致Ｏｄｄｉ括约肌痉挛的发生率，结果：８例病人造影剂不能通过Ｏｄｄｉ括约肌、十二指肠不显影，胆总管下端显示“鸟嘴样”或“假结石”影像，后者３例病人胆总管探查阴性，静注纳络酮０．４ｍｇ后，全部病例造影剂顺利进入十二指肠。结论：硬膜外麻醉辅用小剂量芬太尼／哌替啶时Ｏｄｄ     

Functional role and histological demonstration of nitric-oxide-mediated inhibitory nerves in dog sphincter of Oddi

Abstract Nitric oxide (NO) plays an important physiological role in regulating gastrointestinal motility. Involvement of endogenous NO was evaluated in the response to non-adrenergic, non-cholinergic (NANC) nerve stimulation of the dog sphincter muscle of Oddi. Transmural electrical stimulation (TES), nicotine (10^?5M) and K⁺ (10 mM) produced only a relaxation in the sphincter muscle strips contracted with substance P, which was not potentiated by atropine. The TES-induced relaxation was abolished by tetrodotoxin (3 times 10^?7 M) and oxyhaemoglobin (1.6 times 10^?5 M), but not affected by atropine (10^?7 M), propranolol (10^?7 M), phentolamine (10^?7 M), indomethacin (10^?6 M), chole-cystokinin (CCK, 10^?8 M) and vasoactive intestinal polypeptide (VIP, 10^?8 M). The relaxation was also abolished by treatment with N^G-nitro-L-arginine (L-NA, 10^?5 M), an NO synthase inhibitor. Nicotine produced a transient relaxation, which was abolished by tetrodotoxin, hexamethonium (10^?5 M) and L-NA, but not affected by atropine and N^G-nitro-D-arginine (D-NA, 10^?5 M). The addition of K⁺ elicited a transient relaxation, which was abolished by tetrodotoxin and L-NA. The inhibitory effects of L-NA were antagonized by L-arginine (10^?3 M). The presence of neurons containing nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase was histochemically demonstrated in the sphincter of Oddi. These findings may indicate that TES, nicotine and K⁺ liberate NO from NANC inhibitory nerve which is involved in the relaxation of the dog sphincter of Oddi. The muscular tone does not seem to be regulated by cholinergic nerves under the experimental conditions used.     

Risk factors for anal sphincter tears: the importance of maternal position at birth

Objective  To assess the role of birth position in the occurrence of anal sphincter tears (AST).
Design  Observational cohort study.
Setting  South Hospital in Stockholm, a teaching hospital with around 5700 births per year.
Population  Among all 19 151 women who gave birth at the South Hospital during the study period 2002–05, 12 782 women met the inclusion criteria of noninstrumental, vaginal deliveries.
Methods  Data on birth position and other obstetric factors were analysed in relation to occurrence of AST.
Main outcome measure  Third- and fourth-degree AST.
Results  AST occurred in 449 women (3.5%). The trauma was more frequent in primiparous (5.8%) than in multiparous women (1.7%). The highest proportion of AST was found among women who gave birth in lithotomy position (6.9%), followed by squatting position (6.4%). Logistic regression analyses showed that lithotomy (adjusted OR 2.02, 95% CI 1.58–2.59) and squatting positions (adjusted OR 2.05, 95% CI 1.09–3.82) were associated with a significantly increased risk for AST. Other major risk factors for anal sphincter trauma were primiparity (adjusted OR 3.29, 95% CI 2.55–4.25), prolonged second stage of labour >1 hour (adjusted OR 1.52, 95% CI 1.11–2.10), infant birthweight more than 4 kg (adjusted OR 2.12, 95% CI 1.64–2.72) and large infant head circumference (adjusted OR 1.57, 95% CI 1.23–1.99).
Conclusion  Lithotomy and squatting position at birth were associated with an increased risk for AST also after control for other risk factors.     

Oddi括约肌狭窄的诊治体会

目的 探讨Oddi括约肌狭窄的诊断及治疗方法.方法 对1990年至2005年间45例Oddi括约肌狭窄的临床资料进行回顾性分析.结果 45例中有27例术前进行过磁共振胆胰管造影（MRCP）检查,8例获得诊断;25例切开十二指肠行括约肌成形术,术后病理证实为Oddi括约肌狭窄;20例经ERCP确诊,并行内镜括约肌切开术.因MRCP的广泛使用,2000年后Oddi括约肌狭窄的术前诊断率明显提高,2000年前为2/27,2000年后为6/18（χ2=4.79,P＜0.05）.内镜括约肌切开术术后胰腺炎发生率为3/20,经十二指肠Oddi括约肌成形术术后胰腺炎发生率为4/25（χ2=0.01,P＞0.9）.结论 MRCP是诊断Oddi括约肌狭窄理想的非损伤性检查;内镜括约肌切开术是治疗Oddi括约肌狭窄的有效方法.     

电针足三里穴对人体幽门运动功能影响的研究

应用内镜测压术,检测电针足三里穴前后部分健康成人和胃、十二指肠疾病患者幽门括约肌压力参数变化。结果表明:电针足三里穴对幽门括约肌压力波参数的影响主要表现为升高低振幅波和降低高振幅波,与电针非经穴点的单纯抑制效应有显著区别。提示电针足三里穴有兴奋和抑制幽门括约肌功能的双相调节效应。     

Vesico-anal influences in healthy intact humans: Quantificated by responses in the external anal sphincter following transcranial cortical stimulation

EMG responses in the external anal sphincter (EAS), the rectus abdominis muscle (RA), and the anterior tibial muscle (TA) were recorded following single magnetic transcranial cortical stimulations (TCCS) in seven healthy volunteers. The responses in the EAS differed from the responses in the other muscles. They had comparatively long durations ranging from 1 to 2 seconds, no inhibitory periods were observed, and there was no tendency for habituation to occur following a limited number of stimuli. The responses recorded in the EAS were used as test responses in order to evaluate the excitability changes in the EAS motoneurons occurring during bladder filling. Cystometries with filling rates of 15, 50 and 200 ml/min were done. During these cystometries TCCS were applied repeatedly, with constant strength, after each 50 ml of filling up to bladder capacity. The responses following TCCS changed in a highly reproducible way during bladder filling. After 100–200 ml of filling, the responses had longer latencies, diminished sizes, and shorter durations. When the filling reached a level 50–150 ml below capacity, the responses in most subjects again became greater and the latencies shorter. The changes were believed to be physiological. It was concluded that the EAS motoneurons are under both inhibitory and facilitatory influence during bladder filling in intact healthy humans. Facilitatory influences are often observed when the bladder is filled close to capacity. At lower bladder volumes the observed influence is always inhibitory. A decrease in the EMG activity of the EAS during filling cystometry should consequently not be regarded as a pathological response.     

Rectal sensorimotor characteristics in female patients with idiopathic constipation with or without paradoxical sphincter contraction

Patients with chronic constipation fulfilling the Thompson criteria can show paradoxical sphincter contraction. Aim of this study was to evaluate rectal sensorimotor characteristics in patients with constipation with or without paradoxical sphincter contraction. Thirty female patients with chronic constipation and 22 female controls were investigated with anal manometry and rectal barostat. Paradoxical sphincter contraction was shown with manometry as a paradoxical increase of anal pressure during straining. Visceral sensitivity and compliance were tested by intermittent and continuous pressure-controlled distension. Patients were classified according to their sensations and compliance into normal, hypersensitive, reduced compliant, insensitive or excessive compliant rectum. Postprandial rectal response (PRR) and phasic volume events (PVEs) were registered for 1 h after a 600-kCal meal. Paradoxical sphincter contraction was found in 13 (43%) patients. In these patients, rectal sensitivity scores were higher (P = 0.045) than in patients without paradoxical contractions, but rectal compliance was not different. In 90% of patients an abnormal rectal sensitivity or compliance was found: excessively compliant in 35%, reduced compliant in 10%, hypersensitive in 27% and hyposensitive in 17%. Both patients with constipation (11%; P = 0.042) and controls (25%; P = 0.002) exhibited the presence of a postprandial rectal response. This response was not significantly different between idiopathic constipation, paradoxical sphincter contraction and controls. Patients with rectal hypersensitivity had lower response than other patients (P = 0.04). Patients with constipation had fewer basal PVEs compared controls (P = 0.03). Postprandial PVEs increased in both patients (P = 0.014) and controls (P < 0.001). Postprandial rectal response and PVE were not different in patients with or without paradoxical sphincter contraction. A total of 90% of female patients with idiopathic constipation show an abnormality in rectal sensation or compliance. The postprandial rectal response was comparable between patients with constipation and controls, however, PVEs were diminished. Patients with paradoxical sphincter contraction had higher rectal sensitivity but an unaltered compliance and postprandial rectal response. Future trials should investigate whether the classification of rectal abnormalities in patients with constipation has clinical importance.     

Botulinum toxin injection inhibits myogenic tone and sympathetic nerve function in the porcine internal anal sphincter

Objective Botulinum toxin is an effective treatment for anal fissure, though there is a lack of agreement over the optimal site for its injection. This reflects our current ignorance of its mechanism, and whether it has any action on the nerves of the internal anal sphincter (IAS). This study set out to resolve this issue through use of a pig model. Materials and methods Eight pigs were studied in pairs: one of each pair received a botulinum toxin injection into the anal sphincter, whilst the other acted as its control. Manometry was performed every two weeks under anaesthesia. Pigs were slaughtered at between four and six weeks after injection and the properties of the IAS compared in vitro. Results Whilst maximum anal resting pressure (MARP) increased slowly in control pigs during the experimental period, reflecting weight gain, a fall was observed in treated pigs. In vitro, IAS strips from control pigs generated 400 mg of spontaneous tone per gram of tissue (± 45; standard error), compared to 250 (± 25) mg/g tissue from treated pigs (P < 0.01). Electric Field Stimulation at 50Hz produced 150 (± 22) mg contraction/gram tissue in IAS strips from control pigs compared to 53 (± 13) mg/g tissue in treated pigs (P < 0.0005). This contractile response was blocked by guanethidine. Conclusion Botulinum toxin has a significant action on the IAS. It reduces myogenic tone and contractile responses of this tissue to sympathetic nerve stimulation. Further studies are required to clarify its mechanism of action more precisely.