Transanal endoscopic microsurgery in the treatment of select rectal cancers or tumors suspicious for cancer

Background: This study describes a personal experience with the use of transanal endoscopic microsurgery to facilitate surgical access, and to determine the ability of this technique to reduce the need for major abdominal procedure and prevent the need for a temporary or permanent colostomy in select patients with known or suspected rectal cancer. Methods: The subjects of this study were 43 patients with rectal cancer or tumors who had a high likelihood of malignancy. The 24 men and 19 women comprised two groups: patients with known cancer (n = 16) and patients with tumors suspicious for cancer (n = 27), six of whom proved to have invasive malignancy. The tumors ranged in size from 1 to 7 cm (average, 3.5 cm). The tumors inferior level in the rectum ranged from –1 to 21 cm (average, 6.5 cm). Eleven patients known to have rectal cancer were treated with preoperative radiation or chemoradiation. By ordinary standards, 22 patients would have received an abdominal perineal resection; 14 patients would have qualified for abdominal sphincter–preserving operations; and 7 patients were indeterminate. Full-thickness local excisions were disk excisions (n = 23), hemicircumferential excisions (n = 19), and sleeve resection (n = 1). The ages of the patients ranged from 30 to 91 years (average, 66.7 years). Results: In this study, 90% avoided a major abdominal operation (39/43), and 90% avoided an abdominal perineal resection of the patients (20/22). The complications were as follows: mortality (n = 10), morbidity (n = 9), minor wound separation (n = 6), and major wound separation (n = 3). Two of these complications were rectovaginal fistulas: the one in a 91-year-old patient who presented with a fistula and the other in a 77-year-old patient who presented with a previously irradiated and incompletely excised cancer. A single instance of locally recurrent cancer required an abdominal perineal resection. There were no other recurrences. Overall, three patients required a stoma (7%). Conclusion: Transanal endoscopic microsurgery promises to offer a safe and effective option for the selective treatment of patients with rectal cancer after preoperative chemoirradiation, and for the management of tumors suspicious for rectal cancer. Transanal endoscopic microsurgery used selectively can reduce the need for major abdominal surgery and colostomy.     

经直肠内修补术治疗直肠前庭瘘

女婴因会阴部感染继发直肠前庭瘘在我国较为常见。结合我院手术治疗６５例患儿随诊情况，对经直肠内修补术的手术方式，手术年龄，手术要点及术式的优点进行了阐述，提出了经直肠内修补术手术简单，不损伤肛门括约肌及会阴部正常结构，愈合后外阴部不遗留疤痕，是可以推荐的一种手术方式。     

Evaluation of results of the prostigmine-morphine test with quantitative hepatobiliary scintigraphy: a new method for the diagnosis of sphincter of Oddi dyskinesia

Attempts have long been made to use the prostigmine-morphine provocation test for the selection of postcholecystectomy patients suffering from sphincter of Oddi (SO) dyskinesia. Since the whole procedure is based upon the evaluation of subjective complaints, this test has frequently been criticized. To improve the diagnostic value of this method, we have visualized SO spasms during prostigmine-morphine provocation by means of quantitative hepatobiliary scintigraphy (QHBS). Twenty-two cholecystectomized patients with typical postprandial biliary pain were included in this study. In the first series of studies, QHBS with technetium-99m 2,6-diethylphenylcarbamoylmethyl-diacetic acid was performed in each patient 2 days before prostigmine-morphine provocation. The time to peak activity (T _max) and the half-time of excretion (T _1/2) over the liver parenchyma (LP), hepatic hilum (HH) and common bile duct (CBD), and the duodenum appearance time (DAT), were determined and served as control values. In the second series of experiments, sphincter spasms were evoked by prostigmine-morphine administration and visualized by means of QHBS. The same parameters were evaluated and serum levels of aspartate aminotransferase (AST) were determined simultaneously at regular intervals. In 12 patients who responded to prostigmine-morphine provocation with typical biliary pain and a significant AST elevation (Nardi positive group) the hepatobiliary scintigram demonstrated a marked biliary obstruction.T _max andT _1/2 over the LP, HH and CBD were significantly increased, while DAT was significantly longer relative to the corresponding data obtained without provocation. Four of the remaining ten patients indicated atypical abdominal pain during prostigmine-morphine provocation, but the AST level remained unchanged in all ten (Nardi negative group). In this group, QHBS revealed a slower, but free transpapillary flow of the tracer: althoughT _1/2 over the LP, HH and CBD appeared to be significantly higher than without provocation,T _max did not change and an obstructive pattern was not detected on the hepatobiliary scintigram. When QHBS parameters determined during prostigmine-morphine provocation were compared for the Nardi positive and Nardi negative groups, with the exception ofT _max over the LP they were significantly different. QHBS combined with the prostigmine-morphine provocation test proved to be a useful non-invasive method for the detection of pathological sphincter spasms in patients with SO dyskinesia. Application of this method is therefore strongly recommended in the diagnosis of SO dyskinesia.     

Cholescintigraphy in the diagnosis and assessment of benign papillary stenosis

Benign papillary stenosis (BPS) is an uncommon condition, the diagnosis of which is often difficult. In this report cholescintigraphy with technetium-99m diethyl-acetanilido-iminodiacetic acid has been evaluated for the diagnosis of BPS, as well as for assessing the effect of treatment by endoscopic sphincterotomy (ES). In 12 patients with BPS, cholescintigraphy was performed before and after ES and the findings compared with those in ten controls. Time-activity curves from regions over the liver and bowel were generated. A significant difference was found in respect of the time for maximum activity (T _max) over the liver before and after ES. The time for occurrence of bowel activity (T _excr) also showed significant differences before and after ES. Considering both T _max and T _excr mean values plus two standard deviations in the control group, all BPS patients would have been detected and there would have been no false-positives among the controls. It is concluded that cholescinitgraphy should be used in the diagnosis of BPS. The method has high sensitivity and should be applied as an early diagnostic procedure to exclude BPS in patients with clinical suspicion of the disorder. The method can also be used for assessment of endoscopic treatment (ES). Correspondence to: B. Persson     

Effects of buprenorphine on motor activity of the sphincter of Oddi in man

Summary Buprenorphine, (Temgesic), a N-cyclopropylmethyl derivative of oripavine, is both an agonist and antagonist of morphine. Its effect on the motility of the sphinceter of Oddi (SO) in humans have been investigated by endoscopic manometry (EM). Buprenorphine leads to a significant decrease in the amplitude of SO contraction waves without altering other parameters. Thus, it has no morphine-like effect on SO motility, but it does act like a partial antagonist of morphine in reducing the amplitude of SO contraction waves.     

Oddi括约肌测压及内镜下十二指肠乳头切开术对Oddi括约肌运动功能障碍诊治的意义

目的：对60例胆囊切除术后复发腹痛患者进行Oddi括约肌测压研究，并探讨内镜下十二指肠乳头切开术（EPT）对Oddi括约肌基础压升高患者疗效。方法：用低顺应性灌注系统，三通道测压导管，观察Oddi括约肌基础压、Oddi括约肌基础收缩幅度、频率和传播方式。对Oddi括约肌基础压＞6．32kPa（35mmHg）者，随机分为两组，一组予以EPT治疗，另一组作为对照，并随访其疗效。结果：Oddi括约肌测压异常发生率为46．7％。Oddi括约肌基础压升高者，EPT治疗后，随访3～18个月，有效率为91．7％，明显高于对照组（P＜0．05）。结论：Oddi括约肌测压对Oddi括约肌运动功能障碍（SO）的诊断具有较高价值。测压发现Oddi括约肌基础压升高患者EPT可获得满意的长期疗效。     

腹腔镜下全直肠系膜切除保肛术治疗超低位直肠癌

目的探讨腹腔镜下全直肠系膜切除保肛术治疗超低位直肠癌的可行性及临床疗效。方法对24例超低位直肠癌患者的临床资料进行回顾性分析。结果手术顺利，无转为开腹，平均手术时间260min（150-300min），平均术中出血60ml（30-80m1），术后1～2d胃肠功能恢复，平均住院时间11d（7～15d），术中及术后无并发症。24例均随访6～12个月，未发现肿瘤复发及腹壁套管穿刺孔肿瘤种植。结论腹腔镜下全直肠系膜切除保肛术具有出血少、恢复快等特点，安全可行。     

Direct Effect of Thyroxine on Pig Sphincter of Oddi Contractility

Sphincter of Oddi (SO) motility has an important role in the regulation of bile flow. SO function disturbances (stenosis or dyskinesia) may prevent normal bile flow and thus enhance the probability of common bile duct (CBD) stone formation. Previously we have shown that there is an increased prevalence of diagnosed hypothyroidism in CBD stone patients, compared with gallbladder stone patients or age-, sex-, and hospital-admission-adjusted controls. The present study was done to test the hypothesis that thyroxine directly effects the SO. The specificity of the effects of thyroxine were studied by comparing with triiodothyronine (T₃), progesterone, cortisone, estrogen, and testosterone. For ex vivo studies three or four successive 1 to 1.5-mm SO rings were prepared from each pig and placed between two hooks in oxygenated physiologic salt solution at 37°C. SO contraction was measured with isometric force displacement transducers and registered on a polygraph. Each SO ring was stimulated with KCl (125 mM), acetylcholine (ACh; 10 or 100 M) and histamine (Hist; 10 or 100 M) with and without thyroxine (10^-10 or 10 ^-8 M), T₃ (10^-9 or 10^-7 M), progesterone (1 M), cortisone (1 M), estrogen (1 M), or testosterone (1 nM) in the medium. KCl, ACh, and Hist induced strong contractions in the SO rings. The addition of thyroxine did not influence significantly the KCl-induced contractions, but the ACh- and Hist-induced contractions decreased by a mean of 37–44% (P < 0.001) and 54–56% (P < 0.001), respectively, as compared to the contractions without thyroxine. Triiodothyronine had a similar inhibitory effect to thyroxine, whereas cortisone, estrogen, and testosterone had no effect. Progesterone decreased the KCl-, ACh-, and Hist-induced SO contractions. In conclusion, physiological concentrations of thyroxine have an inhibitory effect on receptor-mediated ACh and Hist, but not on the nonspecific KCl-induced SO contraction ex vivo. The inhibitory effect is similar in thyroxine and triiodothyronine. Of the steroid hormones, only progesterone nonspecifically ameliorates SO contractions ex vivo. Because the effect of thyroxine on the SO is prorelaxing, the lack of thyroxine may result in an increased tension of the SO.     

术前新辅助放化疗在低位进展期直肠癌治疗中的价值

目的:探讨术前新辅助放化疗对直肠癌切除及保肛的价值.方法:选择22例低位进展期直肠癌患者(TNMⅡ期和Ⅲ期)进行术前新辅助放化疗:放疗每周5 d,每次1.8～2.0 Gy,总剂量45～50 Gy,疗程4～5周,同时持续口服卡培他滨1 250 mg·m-2·d-1化疗至手术.放疗结束后4～6周进行手术,术后给予FOLFOX4方案4～6个疗程.结果:21例施行了保留肛门的直肠癌根治术(95.5%),1例施行了Miles手术.其中术后肛门排便功能优者占81.0%,局部复发率仅为4.5%.结论:术前新辅助放化疗对低位进展期直肠癌确实能达到肿瘤降期、局部复发率降低、提高手术切除率和保肛成功率等目的,是治疗低位进展期直肠癌的一种有效辅助方法.     

An intracellular study of perineal and hindlimb afferent inputs onto sphincter motoneurons in the decerebrate cat

Summary The external urethral sphincter (EUS) and external anal sphincter (EAS) are striated muscles that function to maintain urinary and fecal continence respectively. This study examines the short-latency synaptic input from a variety of cutaneous perineal and muscle/cutaneous hindlimb afferents to the motoneurons innervating these muscles. Intracellular recordings from anti dromically identified EUS and EAS motoneurons provided records of the postsynaptic potentials (PSPs) produced by electrical stimulation of peripheral afferents in decerebrate or chloralose anesthetized cats. Excitatory postsynaptic potentials (EPSPs) were produced in most EUS and EAS motoneurons by stimulation of ipsilateral and contralateral sensory pudendal (SPud) and superficial perineal (SPeri) cutaneous nerves. The shortest cen tral latencies in the study (1.5 ms) suggest that there are disynaptic excitatory, in addition to tri-and oligosynap tic, connections within these reflex pathways. EPSPs mixed with longer latency inhibitory potentials (E/I PSPs) were observed in both motoneuron populations but were found more frequently in EAS motoneurons. These E/I PSPs were evoked more often from contralat eral afferents than from ipsilateral afferents. Cutaneous nerves innervating the hindlimb had weaker if any synaptic effects on sphincter motoneurons. Stimulation of ipsilateral hindlimb muscle nerves rarely produced PSPs in EUS motoneurons and had weak synaptic actions on EAS motoneurons. In 2 of 22 animals (both decerebrate), large inhibitory potentials predominated over early small EPSPs suggesting that inhibitory pathways from these afferents to sphincter motoneurons can be released under certain circumstances. The relation between the segmental afferents to EUS and EAS motoneurons and the neural circuitry influencing them during micturition and defecation are discussed.