Morphometry of the aging female rat urethra

Muscles in the limbs change with age, but the aging process of urethral muscles is unknown. Therefore, we compared smooth and striated muscle content in the female rat urethra in young (12 month) and old (32 month) animals, using immunochemical techniques. All the striated skeletal fibers at both ages contain slow myosin. Urethral diameter does not change with age (young, 1.44±0.08 mm; old, 1.46±0.10 mm,n=5), nor does the external sphincter width (young, 0.088±0.016 mm; old, 0.080±0.017 mm,n=5). Neither smooth nor skeletal muscle volume in the urethra is changed with age (skeletal: young, 20.72±2.94%; old, 19.95±2.35%. Smooth: young, 22.26±2.98%; old, 26.75±2.35%,n=5). The external striated sphincter is separate and distinct from the pubococcygeal region of the levator ani muscle, but is closely apposed to another layer of longitudinally oriented fibers into the vaginal musculature. The morphometric analysis shows no difference in urethral architecture in aging female rats.EDITORIAL COMMENT: This paper presents a well planned experimental animal model looking specifically at the morphologic characteristics of the aging female rat urethra. Although this information cannot be directly transferred and applied to our knowledge of the aging human female urethra, such research is extremely important. Hopefully, understanding the structure and function of the urethra in other animals will clarify the same in humans. This type of research is critical in finding an appropriate animal model for basic science research in female urology.     

Antitoxin's effect on tetanus toxin induced sphincter pupillae paralysis in the rabbit

Summary The effectiveness of antitoxin in preventing tetanus toxin's blockage of acetylcholine release from the cholinergic nerves of the rabbit iris was tested by injecting purified tetanus toxin into the anterior chamber, and by injecting horse antitoxin at various time intervals either into the anterior chamber, intravenously, or into the anterior chamber and intramuscularly.The results indicate that antitoxin is ineffective in preventing the development of sphincter pupillae paralysis once it is induced by tetanus toxin, prior to appearance of the symptoms.The efficacy of antitoxin treatment depends on the administration of an optimal therapeutic dose.Neither the rate of development, nor the rate of recovery from the maximal pupillary paralysis are altered by antitoxin treatment.The severity, the duration, and the time of complete recovery from the paralysis are directly related to the time antitoxin treatment begins.     

How to diagnose MSA early: the role of sphincter EMG

Summary. Multiple system atrophy (MSA) is a degenerative disease manifesting a combination of parkinsonism, cerebellar, pyramidal, and autonomic (including urinary, sexual and anorectal) dysfunction. It is pathomorphologically defined, but lacks a definitive clinical diagnostic test. In patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the majority of patients in all the different forms of the disease in most studies, including patients who, as yet, have no urological or anorectal problems. Patients with Parkinson’s disease (PD) as a rule do not show marked sphincter EMG abnormalities in the first five years of the disease. Thus, abnormal spontaneous activity or marked motor unit potential changes in sphincter muscles are helpful in distinguishing MSA from PD in the first five years after the onset of symptoms and signs, and from pure autonomic failure, as well as from cerebellar ataxias, if other causes for sphincter denervation have been ruled out. EMG does not distinguish MSA from progressive supranuclear palsy. How early in the course of MSA these abnormalities become significant enough to support diagnosis remains to be established by prospective studies.     

Characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver,sphincter, and gallbladder in patients with sphincter of Oddi spasm

The major objectives of this project were to establish the pattern of basal hepatic bile flow and the effects of intravenous administration of cholecystokinin on the liver, sphincter of Oddi, and gallbladder, and to identify reliable parameters for the diagnosis of sphincter of Oddi spasm (SOS). Eight women with clinically suspected sphincter of Oddi spasm (SOS group), ten control subjects (control group), and ten patients who had recently received an opioid (opioid group) were selected for quantitative cholescintigraphy with cholecystokinin. Each patient was studied with 111–185 MBq (3–5 mCi) technetium-99m mebrofenin after 6–8 h of fasting. Hepatic phase images were obtained for 60 min, followed by gallbladder phase images for 30 min. During the gallbladder phase, 10 ng/kg octapeptide of cholecystokinin (CCK-8) was infused over 3 min through an infusion pump. Hepatic extraction fraction, excretion half-time, basal hepatic bile flow into the gallbladder, gallbladder ejection fraction, and post-CCK-8 paradoxical filling (>30% of basal counts) were identified. Seven of the patients with SOS were treated with antispasmodics (calcium channel blockers), and one underwent endoscopic sphincterotomy. Mean (±SD) hepatic bile entry into the gallbladder (versus GI tract) was widely variable: it was lower in SOS patients (32%±31%) than in controls (61%±36%) and the opioid group (61%±25%), but the difference was not statistically significant. Hepatic extraction fraction, excretion half-time, and pattern of bile flow through both intrahepatic and extrahepatic ducts were normal in all three groups. Gallbladder mean ejection fraction was 9%±4% in the opioid group; this was significantly lower (P<0.0001) than the values in the control group (54%±18%) and the SOS group (48%±29%). Almost all of the bile emptied from the gallbladder refluxed into intrahepatic ducts; it reentered the gallbladder after cessation of CCK-8 infusion (paradoxical gallbladder filling) in all eight patients with SOS, but in none of the patients in the other two groups. Mean paradoxical filling was 204% (±193%) in the SOS group and less than 5% (P<0.05) in both the control and the opioid group. After treatment, six of the SOS patients had complete pain relief and one, partial pain relief. The basal tonus of the sphincter is variable in patients with SOS, and allows relatively more of the hepatic bile to enter the GI tract than the gallbladder. Due to simultaneous contraction of the sphincter and gallbladder in response to CCK-8, most of the bile emptied from the gallbladder refluxes into intrahepatic ducts, and reenters the gallbladder immediately after cessation of hormone infusion. The characteristic features of gallbladder filling, emptying, and paradoxical refilling with cholecystokinin provide objective parameters for noninvasive diagnosis of SOS by quantitative cholescintigraphy.     

Endoscopic sphincterotomy for stenosis of the sphincter of Oddi

BACKGROUND: Sphincter of Oddi dysfunction (SOD) is one of the causes of postcholecytectomy syndrome and biliary pain. Endoscopic sphincterotomy (EST) is recommended in some cases for patients refractory to conservative treatment. By the Milwaukee classification, patients with biliary pain can be divided into three groups. Group I patients show all the objective signs suggestive of a disturbed bile outflow-i.e., elevated liver function tests, dilated common bile duct (CBD), and delayed contrast drainage during endoscopic retrograde cholangio pancreatography (ERCP). Group II patients have biliary-type pain along with one or two of the criteria from group I. Group III patients have only biliary pain, with no other abnormalities. This study confirms the effectiveness of EST for the relief of symptoms in group I patients (papillary stenosis). METHODS: Between 1989 and 1999, we treated eight patients clinically diagnosed as having group I papillary stenosis by EST. Their ages ranged from 52 to 73 years. In addition to biliary pain, all patients were found to have dilated CBD, elevated enzyme levels, and delayed contrast drainage at ERCP. None of the patients had CBD stones or other causes of obstruction. Sphincter of Oddi manometry was not performed. RESULTS: EST was successfully performed in eight patients. Each patient had a very large papilla. A false orifice was found in one patient. In five patients, endoscopic cannulation of the bile duct was very difficult. The use of a long, tapered catheter and guidewire papillotomy was necessary in four patients. A precut papillotomy was performed in one patient. All patients achieved resolution of their symptoms after EST. There were no complications. The average length of the follow-up period was 26 months. CONCLUSIONS: SOD is a real entity that continues to pose a diagnostic dilemma. EST is an effective and safe modality for the treatment of papillary stenosis (group I patients). SOD manometry is not necessary before EST in group I patients.     

Early discharge after external anal sphincter repair

PURPOSE: The aim of this study was to describe an accelerated-stay program for repair of the external anal sphincter. METHODS: Twenty consecutive patients undergoing overlapping repair of the external anal sphincter were included in the study. Effect parameters were length of hospitalization and complications within 30 days after the operation. Surgery was performed during the period of March 1993 to May 1997. The accelerated-stay program included preoperative information, no premedication, a surgical procedure without colostomy, single-dose prophylactic antibiotics, paracetamol for analgesia, free oral fluid and food immediately after the operation supplemented by laxatives, and enforced mobilization. Follow-up by questionnaire was performed at a median of 14 (range, 4–52) months after the operation. RESULTS: Median hospital stay was one day. Fifteen patients were discharged the day after surgery and 5 patients stayed for 48 hours after the operation. There was no 30-day morbidity, and no patient received a colostomy in conjunction with the sphincter repair. Fourteen of 19 patients available for follow-up reported a significantly improved functional result compared with preoperative state. CONCLUSION: We have described a safe accelerated-stay program (24 to 48 hours) for overlapping repair of external anal sphincter.     

A population-based study of rectal cancer: permanent colostomy as an outcome

Purpose: The objectives of this study are to describe the utilization of surgery and of radiotherapy in the treatment of newly diagnosed rectal cancer in Ontario between 1982 and 1994, and to describe the probability of permanent colostomy at any time after the diagnosis of rectal cancer, as an outcome of the treatment of newly diagnosed rectal cancer.

Methods and Materials: Electronic records of rectal cancer (International Classification of Diseases code 154) from the Ontario Cancer Registry (n = 18,695, excluding squamous, basaloid, cloacogenic, and carcinoid histology) were linked to surgical records from all Ontario hospitals, and radiotherapy (RT) records from Ontario cancer centers. Procedures occurring within 4 months of diagnosis, or within 4 months of another procedure for rectal cancer, were considered part of initial treatment. Multivariate analyses controlled for age, sex, and year of diagnosis.

Results: Resection plus permanent colostomy was performed in 33.1% of cases, whereas local excision or resection without permanent colostomy was performed in 38.2%. Multivariate logistic regression demonstrated higher odds ratios (OR) for resection plus permanent colostomy in all regions of Ontario relative to Toronto. The OR for postoperative RT following local excision or resection without permanent colostomy varied among the regions relative to Toronto (e.g., OR Ottawa = 0.59, OR Hamilton = 0.76, OR London = 1.25). The relative risk (RR) of colostomy conditional upon survival within 5 years from diagnosis varied among regions relative to Toronto (e.g., RR Ottawa = 1.21, RR Hamilton = 1.20).

Conclusions: There is regional variation in the utilization of resection with permanent colostomy, and in the utilization of postoperative RT among cases not undergoing permanent colostomy. Regions with higher initial rates of resection plus permanent colostomy continue to experience higher probability of permanent colostomy 5 years after diagnosis of rectal cancer. Higher initial rates of permanent colostomy may be malleable to interventions aimed at improving overall outcomes.     

影响低位直肠癌手术保肛相关因素的研究

目的分析影响低位直肠癌手术保肛的相关因素。方法将341例低位直肠癌患者按是否施行保肛手术而分为APR组和SP组，对两组病例临床资料（包括肿瘤下缘距肛缘的距离、患者年龄、性别、BMI）及病理资料（包括肿瘤周径、肿瘤位置、肿瘤大体分型、分化程度和Dukes分期）进行比较分析。结果APR组肿瘤下缘距肛缘距离显著小于SP组，肿瘤周径小于1／2周、1／2～3／4周、大于3／4周及全周四者保肛率依次下降（P〈0．01），对于肿瘤周径小于1／2周者，肿瘤主体位于后壁、侧壁及前壁者三者保肛率依次下降，但无明显统计学意义（P〉0．05）。肿瘤大体分型中，肿块型、溃疡型及浸润型三者保肛率依次下降（P〈0．05），肿瘤病理呈高、中、低分化癌者三者保肛率逐渐下降（P〈0．01），低位直肠癌Dukes A、B、C、D期四者保肛率呈逐渐下降趋势。青年人、男性、BMI≥23的患者其保肛率显著低于中老年人、女性及BMI〈23的患者（P〈0．05）。结论肿瘤下缘距齿状线或肛缘的距离是低位直肠癌手术保肛最主要的影响因素，肿瘤周径、肿瘤病理分期、肿瘤主体位置、肿瘤大体分型、肿瘤分化程度及患者的性别及BMI等均可对低位直肠癌手术保肛产生影响。     

Conservative Management of Rectal Adenocarcinoma by Radiotherapy

Purpose: The aim of this study was to analyze the experience of Centre GF Leclerc for conservative and curative treatment by radiotherapy of low rectal cancer.

Patients and Methods: A total of 151 patients received radiotherapy alone for rectal adenocarcinoma with curative intent. They were clinically staged according to size (T1 < 3 cm, and T2 > 3 cm) and depth of infiltration (A = superficial, and B = impaired mobility and T3 fixed). Over the past 6 years, rectal ultrasound (US) has been used systematically, compared with computed tomographic scan and magnetic resonance imaging when needed. Intracavitary contact X ray was given to 129 patients (69%), and brachytherapy in 45 of 151. External radiotherapy was used in 34 cases (22.5%).

Results: Complete response was obtained in 93%. Local failures were observed in 50 cases (28%); two occurred in pelvic nodes after intracavitary X rays. Size (tumors > 3 cm) and alteration of mobility significantly influenced the rate of local failure (p = 0.009 and 0.007). The addition of external radiotherapy in patients with poor prognostic factors improved the local control rate. A total of 39 patients with recurrence were amenable to salvage surgery. After salvage treatment, the local control rate was 82% with unlimited follow-up. The 5-year actuarial survival rate was 57%, with a specific survival of 66%. There was no difference in local control or survival according to differentiation of the tumors and distance between anal margin and the inferior level of the lesion. Severe late effect (grade 3) was 3.8%. The sphincter preservation was obtained in 104 of 124 cases (84%). The sphincter function was judged to normal in 102 of 104 patients (98%).

Conclusion: Intracavitary contact X ray is the treatment of choice for clinical Stage T1A rectal tumors. External radiotherapy significantly improved the results of treatment of tumors > 3 cm. Clinical staging and transrectal ultrasound allows a safe selection of indications. Radiotherapy alone may be proposed for selected cases as an alternative to mutilating surgery for small rectal adenocarcinoma.     

山莨菪碱等对Oddi括约肌作用的临床测压研究

目的 用经胆道镜Oddi括约肌压力测定方法观察临床常规剂量吗啡、硝酸甘油、西沙必利、硫酸镁、山莨菪碱对Oddi括约肌作用及相互间拮抗作用。方法 选择术后患者70例,分7组;对照组1、硝酸甘油组、西沙必利组、吗啡组、对照组2、硫酸镁组和山莨菪碱组。用经胆道镜压力测定方法,测十二指肠压力、Oddi括约肌基础压力及收缩幅度和胆总管压力。结果硝酸甘油组Oddi括约肌基础压力及收缩幅度下降了(23.07±24.18)和(20.72±26.10)mmHg(P<0.05),西沙必利组下降了(14.99±19.94)和(19.44±24.33)mmHg(P<0.05),吗啡组增加了(15.40±15.44)和(47.90±32.08)mmHg(P<0.05);硫酸镁组下降了(7.40±24.17)和(71.74±66.84)mmHg(P<0.05),山莨菪碱组下降了17.00±17.49和85.34±70.49mmHg(P<0.05)。结论 临床常规剂量硝酸甘油、西沙必利可以降低Oddi括约肌基础压力及收缩幅度,临床常规剂量吗啡有升高Oddi氏括约肌基础压力及收缩幅度的作用,而硫酸镁、山莨菪碱可以拮抗吗啡对Oddi氏括约肌的作用。