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It has been postulated that reduction in anal resting pressure following low anterior resection is due to intraoperative injury to the internal anal sphincter during transanal passage of the stapling device or damage to its nerve supply in the course of rectal mobilization. The aim of this study was to assess the relative importance of either mechanism. Fourteen dogs had a standard segment of colon and distal rectum excised. Colorectal reconstruction was performed using either a low stapled EEA (U.S. Surgical Corporation, Norwalk, CT) colorectal anastomosis (n = 7) or a handsewn anastomosis (n = 7). Anorectal manometry was performed preoperatively and again on the 10th postoperative day. Resting anal pressure was significantly reduced after EEA anastomosis (mean +/- SEM: before, 49 +/- 3 mm Hg; after, 20 +/- 4 mm Hg; P less than 0.001) and handsewn anastomosis (mean +/- SEM: before, 46 +/- 4 mm Hg; after, 35 +/- 4 mm Hg; P less than 0.01). Postoperative resting pressures were also significantly reduced (P less than 0.05) following EEA anastomosis when compared with the handsewn group. This study suggests that damage to the innervation of the internal anal sphincter during rectal mobilization and further direct injury to the sphincter during transanal instrumentation both contribute to the fall in anal resting pressure observed following low anterior resection.
Dis Colon Rectum 1992 May
PMID:Mechanism of sphincter impairment following low anterior resection. 841 74

Fecal incontinence at night may be a disturbing consequence of ileal pouch-anal anastomosis (IPAA). The hypothesis was that decreases in anal canal resting pressure occur as sleep deepens and that the decreases are more profound in pouch patients with incontinence than in controls. Using a sleeve catheter assembly for recording intraluminal and canal pressure and polysomnographic recordings of sleep stages, progressive decreases in anal canal resting pressure with deepening sleep occurred in 11 healthy controls (mean +/- SEM: 57 +/- 3 mm Hg to 43 +/- 3 mm Hg: P less than 0.05) and in 11 patients after IPAA (55 +/- 3 mm Hg to 42 +/- 4 mm Hg; P less than 0.05). Minute-to-minute variations in mean pressure were also found in both controls and IPAA patients, and they were greater at night in patients (P less than 0.05), except during rapid eye movement (REM) sleep. In three patients, resting pressure during REM sleep decreased markedly to 31 +/- 8 mm Hg. This decrease plus the variations in pressure during REM sleep led to incontinence. In conclusion, decreases in anal resting pressure coupled with marked minute-to-minute variations in pressure during sleep occurred in controls and in patients after IPAA and, when profound, led to nocturnal fecal incontinence in some patients.
Dis Colon Rectum 1992 Feb
PMID:Influence of sleep on anal sphincteric pressure in health and after ileal pouch-anal anastomosis. 173 15

A surgical aphorism has long held that the omentum is the "watchdog of the abdomen." However, detractors believe that leaving the omentum behind after colectomy precipitates later small bowel obstruction. A retrospective comparison was made between a group of 406 patients (Group I) having omentectomy with proctocolectomy and ileoanal anastomosis and a group of 239 patients (Group II) having a similar procedure without omentectomy. Follow-up in this series of 645 patients was 4.3 +/- 2.1 years (mean +/- SEM). No difference was present in the rate of partial small bowel obstruction or complete small bowel obstruction between Group I patients (32 percent partial, 12 percent complete) and Group II patients (29 percent partial, 12 percent complete; P greater than 0.1). However, a better outcome with regard to postoperative sepsis and sepsis requiring operation was apparent in Group II patients retaining the omentum (4 percent and 3 percent, respectively) than in Group I patients (10 percent and 8 percent, respectively), in whom the omentum was removed (P less than 0.01). As this experience would support, we urge surgeons to "let sleeping dogs lie" and, when possible, retain the omentum when performing colectomy or proctocolectomy.
Dis Colon Rectum 1991 Jul
PMID:Let sleeping dogs lie: role of the omentum in the ileal pouch-anal anastomosis procedure. 190 21

Although stool consistency is considered to be an important component of anorectal continence, its effect on rectal emptying has never been quantitated. In 12 healthy volunteers and 12 patients after ileal pouch-anal anastomosis (IPAA) (46 +/- 5 months after the operation; mean +/- SEM), perfused anal manometry was performed; movements of the anorectal angle were quantitated scintigraphically; and rectal capacity and compliance were measured by air insufflation of an intrarectal balloon at three infusion rates. The efficiency of rectal evacuation of three consistencies (5 percent, liquid; 7.5 percent semisolid gel; 11.25 percent solid gel; w/w) of Tc99m labeled artificial stool (aluminum magnesium silicate gel) was quantitated by gamma camera imaging. No abnormalities of pelvic floor function were demonstrated in either controls or patients. The mean neorectal capacity and compliance of patients with IPAA did not differ from control, (capacity; IPAA: 215 +/- 22 ml vs. control; 245 +/- 29 ml; compliance; IPAA: 5.5 +/- 0.7 ml/cm H2O vs. control; 6.6 +/- 0.7 ml/cm H2O; P greater than 0.05). In controls, the percentage of the 7.5 percent consistency evacuated (81 +/- 5 percent, mean +/- SEM) was significantly more than the percentage evacuation of either the 5 percent consistency (67 +/- 7 percent) or the 11.25 percent consistency (77 +/- 2 percent) (P less than 0.05). After IPAA, the mean overall percent evacuation of the three stool consistencies was significantly less than control (52 +/- 6 percent after IPAA; 75 +/- 5 percent control, P less than 0.05). However, there was no significant difference in neorectal emptying between the liquid, the semisolid gel and the solid gel (56 +/- 6, 55 +/- 6, 51 +/- 9 percent, respectively, P greater than 0.1). We concluded that in healthy subjects but not in patients after IPAA, stool consistency affected the efficiency of evacuation of enteric content.
Dis Colon Rectum 1991 Jan
PMID:The effect of stool consistency on rectal and neorectal emptying. 199 15

A simple method of defecation radiography using video recording of evacuation of a suspension of radiopaque barium sulfate in ten normal volunteers to establish physiologic parameters is described. Clinical perineal descent and defecographic measurement have been performed. The anorectal angle (ARA) was, on the average, 90.00 +/- 4.76 degrees (SEM) at rest and 111.00 +/- 5.02 degrees (SEM) during evacuation. The width of the anal canal (W) was, on the average, 1.29 +/- 0.13 cm (SEM). The duration of sphincteric relaxation (SRT) was, on the average, 4.50 +/- 1.04 sec (SEM), with a total average evacuation time (TET) of 12.00 +/- 3.54 sec (SEM). The authors confirm the effectiveness of defecographic techniques and recommend the standardization of the method to have an unequivocal interpretation of the obtained data.
Dis Colon Rectum 1990 Aug
PMID:Evaluation of normal subjects by defecographic technique. 237 27

A comparison, based on results from anal manometry and continence, was made between eight patients after circular stapled ileal J-pouch-anal anastomosis without mucosectomy (Js) and seven patients after endoanal mucosal proctectomy and hand-sewn ileal pouch-anal anastomosis (Jm). The mean and range from ileostomy closure were 3.5 months (1.5 to 12) and 21.7 months (13 to 32), respectively. The mean maximum resting pressure (MRP) ( +/- SEM and range) was 81.3 mm Hg ( +/- 6.0 and 61 to 112.5) and 50.0 mm Hg ( +/- 6.2 and 17 to 62.5), respectively, for the Js and Jm groups (P less than .003). None of the Js patients experienced leakage or wore a pad, while in the Jm group 14 percent experienced minor leakage during the day and 28 percent at night. Seventy-one percent of the Jm group wore a pad at some point. Anal sphincter resting pressures and continence were better in the Js group. The improvement in MRP resulted from avoidance of injury to the internal and sphincter during dilatation and mucosectomy and the maintenance of a normal anal canal that allowed for proper closure.
Dis Colon Rectum 1989 Nov
PMID:Internal anal sphincter function after total abdominal colectomy and stapled ileal pouch-anal anastomosis without mucosal proctectomy. 280 22

Six patients with prolapsing hemorrhoids and 12 control subjects had assessment of anorectal pressure and external sphincter electromyography performed over a prolonged period under ambulant conditions. Patients with prolapsing hemorrhoids demonstrated greater degrees of sampling responses, 12.9 +/- 1.9/hour, vs. 7.4 +/- 2.0/hour (mean +/- SEM) in controls (P less than .05). Ultraslow wave and giant ultraslow wave activity were seen frequently in the patient group occupying more than 30 percent of recording. The external sphincter demonstrated much greater electrical activity (spike potentials) in patients with hemorrhoids than in controls both by day, 24.9 +/- 11.0/10 min vs. 12.8 +/- 3.2/10 min (P less than .02), and by night, 7.4 +/- 2.6 min vs. 1.6 +/- 1.3/10 min (P less than .03). Sleep electrical activity in the presence of hemorrhoids did not differ significantly from that of controls during waking, 7.4 +/- 2.6/10 min vs. 12.8 +/- 3.2/10 min (P less than .1). No difference in phasic and periodic rectal motor activity was noted between patient and control groups. This demonstrates the application of prolonged assessment of anorectal motility and external sphincter activity in a patient group. Abnormalities previously documented in patients with hemorrhoids using conventional manometric tests were confirmed. In addition, evidence of increased external sphincter function during waking and sleep may have implications in the pathophysiology of this disorder.
Dis Colon Rectum 1989 Nov
PMID:Prolonged ambulant assessment of anorectal function in patients with prolapsing hemorrhoids. 280 26

Regeneration of rectal mucosa after rectal mucosectomy and ileoanal anastomosis (IAA) could jeopardize the long-term safety of the procedure. The aim of this study was to determine if rectal mucosal regeneration occurred after IAA. Pathologic specimens of the IAA and surrounding rectal muscular cuff were obtained from 29 patients who had required IAA excision 17 +/- 2 months (mean +/- SEM, range, 2 to 48 months) following construction. Multiple (greater than or equal to 6) coronal and sagittal sections of each specimen were made and examined histologically. The rectal muscle cuff was bound to ileal serosa by dense fibrous tissue. Small islets of residual rectal mucosa were identified between the denuded rectal cuff and the ileal pull-through in four patients (14 percent) and at the ileoanal anastomosis in two patients (7 percent). Active rectal mucosal disease, dysplasia, or reepithelialization of the denuded rectal muscle were not seen. It is concluded that small islets of rectal mucosa may remain after IAA. Up to four years after IAA, however, no evidence of rectal mucosal regeneration could be documented.
Dis Colon Rectum 1987 Jan
PMID:Does rectal mucosa regenerate after ileoanal anastomosis? 380

In this study we report the effects of flurbiprofen and prostaglandin E2 on anastomotic tensile strength, collagen synthesis, and collagenolytic activity which are in a particularly fine balance in colonic healing. Colonic anastomoses were fashioned in 150 Sprague-Dawley rats which were allocated to receive either 20 mcg prostaglandin E2 in 1 ml saline, 1 ml saline alone (control) intraperitoneally for three days post-operatively, or oral 2.5 mg/kg flurbiprofen daily. Anastomotic bursting pressures, collagen content and collagenolytic activity were measured at three, six, and ten days. It was found that prostaglandin E2-treated animals had significantly weaker anastomoses at three days (102 +/- 6.1 mm Hg; m +/- SEM) compared with the control (126 +/- 7.3; P less than 0.02) or flurbiprofen group (128 +/- 4.6; P less than 0.01) with no differences at six and ten days. Collagen levels were higher in flurbiprofen-treated rats at three days (9.7 +/- 0.2 micrograms hydroxyproline/mg tissue) compared with the control (8.1 +/- 0.4 micrograms/mg; P 0.01) or prostaglandin E2 group (7.2 +/- 0.5 micrograms/mg; P 0.001). These differences were unchanged at six days but were not statistically different at ten days. Collagenolytic activity showed no differences in the three groups during the study. It is concluded that flurbiprofen enhances colonic healing with improved collagen synthesis without affecting collagenolytic activity.
Dis Colon Rectum 1984 Nov
PMID:Prostaglandins in colonic anastomotic healing. 649 5

Random stool samples were obtained from 14 ileal pouch-anal anastomosis (IPAA) patients 43 +/- 5 (mean +/- SEM) months after surgery, and the concentrations of individual short-chain fatty acids (SCFAs) were determined by gas liquid chromatography. Stool frequency was determined from a diary recorded for 15 days prior to stool sampling. The frequency, amplitude, and duration of phasic contractions (PCs) within the pouch following infusion of a physiologic concentration of SCFAs and normal saline randomly into the pouch of six IPAA patients were determined manometrically. The mean total SCFA concentration after IPAA did not differ significantly from normal stools (83 +/- 20 mM after IPAA vs. 97 +/- 10 mM for controls; P > 0.05). In the IPAA patients, regression analysis demonstrated an inverse relationship between stools per day and total SCFA concentration (r = 0.73; P < 0.001). Moreover, no change in frequency (3.0 +/- 0.9 vs. 3.2 +/- 0.8 PCs/30 minutes), amplitude (26 +/- 5 vs. 25 +/- 4 mmHg), or duration (23 +/- 3 vs. 26 +/- 2 seconds) of PCs was found after SCFA infusion compared with saline control (P > 0.1). These findings demonstrate that SCFAs are present in ileal pouch effluent and that stool frequency may be related to fecal SCFA concentration. Also, the normal contractile response of the terminal ileum to SCFAs does not occur in the ileal pouch.
Dis Colon Rectum 1993 Mar
PMID:Fecal short-chain fatty acid concentrations and effect on ileal pouch function. 844 26


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