Documenti di Didattica
Documenti di Professioni
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Coloi eclal
Disease
9 Springer-Verlag1988
Symposium
Proctography
Participants: D.C.C. Bartolo, Bristol; C. I. Bartram, London; O. Ekberg, Lund; F.-T. Fork, Malmo;
I. Kodner, St. Louis; J. H. C. Kuijpers, Nijmegen; P. H. G. Mahieu, Brussels; P.J. Shorvon, London;
G.W. Stevenson, Hamilton; N. Womack, London
Moderator: I. G. Finlay, Glasgow
Introduction
Moderator Mr. Finlay: Over the past decade
there has been increasing interest in the pathophysiology of the anorectum, particularly in disorders of function such as incontinence, prolapse,
obstructed defaecation and solitary rectal ulcer
syndrome. Manometry and electromyography of
the anal canal and pelvic floor have been used
predominantly by enthusiasts for research purposes. Subsequently techniques to visualise the
anorectum have been introduced and the term
proctography has been used to describe the
dynamic radiography study of this area. The technique has evolved in different ways in each centre
and the purpose of this symposium is to bring
together that experience so that we might determine whether patterns of technique, patient selection and clinical application are emerging. A
series of questions relating to these aspects has
been put to a group of experts all active in the
field to determine the present state of knowledge
and reproducibility of the technique.
Technique: What is your technique? Please define
and comment on any variations such video,
integrated or spot film proctography.
Mr. Bartolo: We have employed three differing
techniques according to the type of information
required.
a) Evacuation proctography. No bowel preparation is used since it is deemed more physiological
to observe anorectal morphology without prior
preparation. Fifty millilitres of dilute barium
sulphate is introduced into the rectum to coat the
rectal wall. A semi-solid paste is made up with
68
Sion, and not true defaecation. Video is used as it
is convenient and cheap, does not involve higher
radiation as does cine, and allows video mixing of
other electrical inputs for integrated examinations. Spot films are taken simply to provide a
better record of some interesting feature, as slide
reproduction from video is poor.
Dr. Fork and Dr. Ekberg: Patients are pretreated
with Pico-Salax | In order to delineate small
bowel loops in the pelvis, 150ml of barium
contrast m e d i u m is given orally, one hour before
defaecography. Filling of the loops down to the
terminal ileum is checked fluoroscopically.
Ordinary physiological conditions during
defaecography are simulated by injecting 300 ml
of a thick barium paste (Mixobar oesophagus |
Astra) into the rectum with a caulking gun. This is
done with the patient in the left lateral position.
By placing a tampon soaked in iodine contrast
m e d i u m in the vagina the precise location of the
posterior fornix is readily identified radiographically in female patients.
The patient is then seated on a radiolucent
toilet placed in a remote control stand. Wedges
are used. Single films are obtained together with
videotape recordings. The images are centred over
the rectum and pelvis during resting, straining
and squeezing using lateral views. Thereafter a
further volume of thick barium paste is injected
and completing video and single films are obtained with the patient in the posteroanterior
projection.
Dr. Kodner: Our technique involves mixing
methyl cellulose with barium sulphate to thicken
it to a consistency approximating stool. Approximately 200 cc of thickened barium is instilled into
the rectum under fluoroscopic control to fill the
rectosigmoid. The patient is then seated on a
water-filled ring placed on a bed pan situated on
top of a wooden box and defaecation is then
observed by fluoroscopy from a lateral position.
The examination is recorded on videotape and
selected spot films are obtained by the radiologist.
The position of the rectosigmoid in relation to the
sacral promontory must be documented. The
rectum is observed for movement during defaecation. It is important to examine the rectum from
the sacral promontory to the level of the coccyx.
It is difficult to see the air-tissue interface at the
anus because of the extremes of contrast, and in
some cases actual prolapse of the rectum has been
missed. One should also look for motion of the
69
centrated suspension of barium can be injected
before the paste [5]. In females a barium-soaked
gauze can be placed in the vagina.
We have designed a special commode [3, 5, 7]
acting as a filter. This commode consists of several
rubber air rings filled with water, secured on top
of each other and lined by a disposable plastic
bag.
Profile views are taken by videotape or
preferably by ampliphotography using a 100 m m
camera, 0.6 m m focus, and a voltage of 117 kV at
a rate of 1 or 2 frames per second. Standard films
(24
cm) are taken at rest, during squeezing
and straining.
Professor Stevenson and Dr. Shorvon: A wooden
commode has been constructed furnished with a
solid pine seat (plywood produces artefactual
lines), and mounted on wheels. Metal hooks are
attached to the sides of the upright fluoroscopy
table so that the c o m m o d e can be moved with
remote table movement for easier centring. A
plastic rod with radio-opaque centimetre markings is mounted in the mid line below the seat for
accurate measurements in this plane. Two copper
plates (4 m m thick), one being shaped to the
curve of the buttocks and the other square,
provide radiological infiltration, to avoid 'flare'.
No bowel preparation is given, and a contrastsoaked tampon is inserted into the vagina in
female patients. Barium paste as described by
Mahieu et al. [5] is introduced with an orthopaedic cement gun and disposable plastic syringe.
A mixture of barium and petroleum gel is
smeared on the skin at and posterior to the external anal orifice to mark the skin. The examination is recorded on video, and four or five
105 m m films are taken with the patient at rest,
during squeezing or lifting and straining during
and at the end of defaecation.
Certain modifications of the technique are frequently used. In patients who have difficulty in
evacuation liquid barium is often used alone and
a second examination with paste is performed
only if the liquid has been successfully expelled.
In patients with suspected enterocele or sigmoidocele the small bowel and sigmoid colon are
first opacified with barium. Anteroposterior and
oblique views are taken in patients with unusual
radiographic findings, and the c o m m o d e is on
wheels to facilitate this.
70
having found that plywood produced artefactual
lines. A plastic rod with radio-opaque centimetre
markings is m o u n t e d in the midline below the
seat for accurate midline measurements. Copper
plates shaped to the curvature of the buttocks
were used to avoid flare.
c) Contrast material: Dr. Mahieu advocates that
the m e d i u m must be semi-solid in an attempt to
simulate faeces. He uses 150 mls of 100% weight
per volume barium suspension with 400 mls of
water. This is beaten and gradually mixed with
100 grams of potato starch and beaten with a
whisk until a smooth paste is obtained. A pistol
injector is then required to place this thick paste
into the rectum. While the injector is being
withdrawn, injection is continued to outline the
anal canal. For improved coating of the rectal
mucosa, 50 mls of a concentrated suspension of
barium can be injected before the paste. Professor
Stevenson and Dr. Shorvon use the same technique but employ an orthopaedic cement gun to
introduce paste into the rectum. Dr. Bartolo and
Dr. Womack both use a semi-solid paste by
mixing barium with dehydrated potato. The
Swedish group use 300 mls of thick barium paste
(Mixobar oesophagus astra) placed into the rectum using a caulking gun. Dr. Bartram and Dr.
Kuijpers both use a liquid barium solution, while
Dr. Kodner uses 200 cc of thickened barium.
d) X-ray technique: All contributors used video
to make this a dynamic investigation including
selected spot films. Dr. Mahieu takes profile views
by ampliphotography using a 1 0 0 m m camera
0.6 m m focus and a voltage of 117 kV at a rate of
1 or 2 frames per second. Standard films (24x
30 cm) are taken at rest, during squeezing and
straining. Dr. Bartolo also uses ampliphotography
with a voltage of 125 kV from a 100 m A generator
to give a short exposure at a rate of 1 frame per
second. Each frame is numbered automatically
enabling the sequence to be analysed in detail. He
distinguishes evacuation, standard and video
proctography. Standard proctography provides a
static picture of the anorectal angle and its relationship to the pubococcygeal line taken at rest,
during a maximal sphincter contraction and
whilst the subject strains. Dr. Kodner noted that
his examination required 1 min 40 s of exposure
time with an irradiation dose calculated to be 270
millirads. This compares with 750 millirads for a
routine barium enema.
Although the technique used by the other
contributors was less extensively described, Dr.
Fork and Dr. Ekberg commented that they would
71
41
28
36
23
29
Puborectalis accentuation 49
Anterior rectal wall
24
prolapse
Perineal descent only
13
Solitary ulcer only
5
Megarectum
4
47%
19%
9%
6%
4%
15%
72
Table 3. Resultsofdefaecography(117 patients)
No. of FeMales Age (years)
patients males
mean and
range
Rectal prolapse
Constipation
Faecal incontinence
Solitaryulcer
syndrome
9
59
31
18
6
51
25
12
3
8
6
6
49 (19-68)
45 (19-77)
58 (44-81)
30 (19-64)
mal", which may well be fallacious as the variability within an asymptomatic population will
not be established. We have recently reviewed 20
patients who were carefully screened to exclude
any defaecatory abnormality [13]. Ten male and
ten female patients were questioned to exclude a
history of frequency, excessive straining, incontinence with a normally formed stool and examined proctoscopically to exclude significant
haemorrhoids. Their mean age was 58 years
(range 38-70 years).
Dr. Fork and Dr. Ekberg: Control patients. We
have not been able to examine asymptomatic
volunteers.
Dr. Kodner: We have studied very few control
patients and would rely on the sophisticated study
done by Professor Stevenson at McMaster University to define the spectrum of normal findings.
We do recognise that there are levels of internal
intussusception seen even in completely asymptomatic patients. The most important issue is,
therefore, to define the indication for surgical
correction of the anatomical abnormalities seen
on defaecography.
Dr. Kuijpers: We have used control studies after
sphincter repair as normals. In these patients the
anal sphincters only were damaged, and repair
resulted in complete restoration of faecal continence. Needless to say, they were all young
women. However, in later studies we detected that
sphincter rupture was accompanied by denervation in at least 20-30%. So the need for normal
studies is growing more and more.
Dr. Mahien: Between 1978 and 1982 we studied a
series [5] of 56 patients whose defaecograms were
considered normal: 8 were made in asymptomatic
patients, 27 in patients with a functional colopathy, and 21 in patients with first-degree
haemorrhoids. Proctoscopy revealed no other
abnormalities. The 56 patients included 22 men
and 34 women with a mean age of 47.5 years
(range 17-80 years).
Professor Stevenson and Dr. Shorvon: Because a
number of abnormal findings were being seen
unexpectedly we studied 47 normal adult individuals (25 men and 23 women). Nearly half
(44% men, 45% women) had an intussusception
73
and 77% of the women had an anterior rectocele
which was moderate to large in 9 of the 23 patients. Mean pelvic descent in women was 2.0 cm
and 1.9 cm in men. Respectively, 23% and 20%
had a descent of more than 3 cm. Four patients
had an open anal canal at rest without incontinence (see below for further details) [14].
Mr. Womack: Integrated pressure - EMG
Proctography has been performed in 23 control
subjects (18 females and 5 males, median age 45
years, range 35-68 years). These subjects were
volunteers who had been admitted to hospital for
surgical procedures. They were all free from
anorectal symptoms at the time of the investigation and had no significant history of previous
anorectal symptoms or surgery. Nine female
subjects had been admitted for hysterectomy (6
for menorrhagia, 3 for localised neoplasia, none
for uterine prolapse). Others required treatment
for varicose veins (2), duodenal ulcer (2), gallstones (2), breast lumps (2), and non-specific
upper abdominal pain (1). The males required
admisstion for treatment of inguinal hernia (2),
hiatus hernia (1), duodenal ulcer (1) and renal
colic (1).
Moderator Mr. Finlay: Primarily for ethical
reasons, there is a paucity of information in
control patients. For example, Dr. Mahieu has
studied only 8 truly asymptomatic patients
despite performing over 1000 examinations. It is
for this reason that the study by Professor Stevenson is extremely important. It will now be necessary to reconsider our criteria of a normal
proctogram. In particular, he has demonstrated
that a degree of perineal descent, rectocele and
even intussusception may occur in asymptomatic
subjects. Thus there is clearly a danger that a
proctogram in isolation may be over-interpreted.
It may be that as further information is gained
from integrated studies, using EMG and pressure
monitoring, the important factors which distinguish
symptomatic from non-symptomatic patients may
be identified.
Dr. Fork and Dr. Ekberg: During resting conditions the anorectal angle in normal patients
measures 70~
~ mean 114 ~ During defaecation, this increases to 110~
~ mean 135 ~
Normally the anal canal opens symmetrically and
attains the form of a cone, being wider cranially.
This is seen in both lateral and anteroposterior
projections. The initial event is a widening in the
anterior aspect of the upper third of the anal
canal. The contrast medium in the rectum is then
emptied by contraction of the rectum. This is
usually seen as a simultaneous contraction of the
entire rectum, and only occasionally as a peristal-
74
MeanValueatRest
30"
~ 20. ~
._~
92 ~
MeanValueDuringStraining
137 o
~ AtRest
Strainin~~
-~-
"a
~ lO,
65- 75- 85- 95- 105- 115- 125- 135- 145- 155ValueoftheAnomctalAngleInD~n~s
Fig. 1. Anorectal angle in 56 normal patients at rest and during straining. After Mahieu et al. [5]
tic wave. The evacuation of the rectal content in
these cases is complete. There is often a folding
tendency of the lower rectal mucosa, seen as a
mucosal impression, about 5 mm thick, on the
barium column. The indentation moves a few
centimetres in a distal direction. During defaecation there is a concomitant descent of the pelvic
floor by 2 to 8 cm (mean 4 cm) as seen on the
lateral rectal films.
Dr. Kodner: We have defined our criteria for a
normal defaecogram or proctogram as follows:
(a) an increase in the anorectal angle on straining;
(b) relaxation of the puborectalis muscle on
straining; (c) wide opening of the anal canal; (d)
total evacuation of rectal contents; (e) normal
resistance of the pelvic floor; (f) maintenance of
the rectal fixation at the sacral promontory during
straining; (g) absence of internal intussusception.
Dr. Kuijpers: Although we have not done a study
in normal subjects, we have our definitions of a
normal defaecography. The anorectal angle at rest
is about 85-90 ~. In older people, especially
women, it may be increased to 95-100 ~ It decreases to 75-80 ~ during squeezing and increases
to about 135 ~ during straining.
Barium is excreted without difficulty in 5 to
10 s. The posterior rectal wall remains fixed to the
anterior sacral surface over its full length. The
anorectal junction descends about 3 cm. Rectal
configurations generally remain straight, but
small rectal wall invaginations may occur at different levels. Asymptomatic rectoceles are common in older women.
Dr. Mahieu: We prefer the term of "defaecography" instead of "proctography" because defaecography more clearly implies that a physiological function (defaecation) is examined under
75
contracts. Although to my knowledge this has not
been conclusively demonstrated, I would agree
that in a normal study there is the appearance of
a contraction wave.
All participants agree that the measurement of
the anorectal angle is inexact because the configuration of the lower rectal wall is variable.
Anorectal angle therefore, at best, must be an
approximate measurement.
Enumerate the radiological abnormalities
observed on proctography
Fig. 2. Grading of mucosal prolapse and intussusception.
Grades 1 and 2 involve folds of mucosa of 3 mm or less in
thickness. For grades 3 and above the folds are of greater than
3 mm. In grade 5 the circumferential fold impinges on the internal and orifice, in grade 6 extends into the anal canal and in
grade 7 prolapses externally
76
sistent posterior indentation during evacuation
suggests puborectalis contraction, but this is infrequent and usually the anal canal shows a Vshaped configuration. This is associated with slow
evacuation, of more than 30 s, which is often incomplete.
Anterior rectocele formation may be regarded
as a normal variant in females. When present, the
rectocele collapses down onto the anal canal at
the end of evacuation. This can be difficult to
distinguish from intra-anal intussusception. However, the dividing line is any movement into the
anal canal. Any fold that prolapses into the anal
canal is abnormal and implies intussusception.
Dr. Fork and Dr. Ekberg: There appear to be us
to be least eight features which indicate abnormality.
b) Internal proccidentia:
This is a condition in which a circular indentation
in the barium column is seen 6-1 l cm above the
internal anus. The indentation progresses and
deepens to form a ring pocket. This may reach up
to, into or through the anal canal. In the latter
case it is referred to as a rectal prolapse. The
thickness of the intussusception varies between 2
and 4 cm in anteroposterior diameter and is
usually deeper anteriorly than posteriorly.
g) Faecal incontinence:
Patients with uncontrolled loss of faecal material
under resting conditions are suffering from faecal
incontinence. Radiographically the anorectal
angle at rest can be seen to be increased. This
condition is evident on lateral radiograms.
c) Enterocele:
This is a condition observed in patients in whom
a deep rectogenital fossa is seen on lateral films. It
is diagnosed as an increased distance between the
vagina and the rectum. This space may or may
not contain small bowel loops, i.e. forming an
enterocele.
d) Rectocele:
This condition is seen as a forward bulging involving the anterior aspect of the rectum. A
rectocele may sometimes have a considerable
depth.
e) Retention of barium:
This is a fairly uncommon finding in patients in
whom there is residual contrast medium within
77
obvious forceful straining by the patient during
the defaecography. The patient with the descending perineum syndrome can be shown on
defaecography to have exaggerated motion of the
perineum. Measurements on plain films and with
perineometer have proved to be more accurate.
Patients with rectocele have been observed many
times on defaecography to also have internal
intussusception of the rectum. The internal intussusception is probably a significant component of
the condition referred to as rectocele. We have
found that patients treated surgically for intussusception of the rectum who have had refractory
rectoceles have in fact not needed additional
surgery to correct the rectocele.
I
possibly be better called pelvic floor outlet obstruction since we are not sure of the primary
defect. A very prominent posterior intendentation
and anterior distortion of the low rectum is seen
even during straining to defaecate. The normal
straightening seen from relaxation of the pelvic
floor and sphincter mechanism does not occur.
The rectal ampulla does not empty in spite of
78
[1
Fig. 6. Rectal intussusception. The typical funnel-like configuration of internal intussusception, created by prolapse of both
the anterior and posterior rectal wall. Protrusion through the
anal canal as in complete rectal prolapse does not occur (reprinted with permission of Digestive Disease)
79
thin folds seen on the films. Full-thickness intussusception can be intrarectal, intra-anal or
external (rectal prolapse).
2. Outpocketing of the rectal wall which protrudes
anteriorly or posteriorly during evacuation.
3. Intermittent or permanent paradoxal imprint of
the puborectalis sling during evacuation, consecutive to a lack of coordination in the pelvic
floor muscle activity.
4. Pelvic floor descent at rest or during straining
(the anorectal junction should not drop more
than 3.5 cm in a normal subject during defaecation [13, 15, 18].
5. Widening of the anorectal angle at rest or
during straining.
6. Permanent opening of the anal canal and
eventual unvoluntary loss of contrast m e d i u m
injected in the rectal lumen.
Professor Stevenson and Dr. Shorvon: The radiological abnormalities that can occur on proctography are observed during various phases of
the examination. Thus they include features at
rest and during different manoeuvres.
a) At rest: Abnormal anorectal junction position, abnormal anorectal angle, reduced canal
length or open canal, incontinence. Flat rectal
floor, small or large volume rectum.
b) Squeezing: Failure to elevate the pelvic floor,
failure of canal to close, failure of increase in
puborectalis impression, separate indentation of
puborectalis and posterior parts of levators.
Unusually prominent puborectalis. Failure of
abnormal anorectal angle or sphincter appearances to return to normal.
c) Straining: Failure to descend or abnormal
descent, failure of puborectalis to relax (real or
inhibition?), incontinence, prolapse or rectocele or
enterocele. Postero-lateral pouches (these are seen
as mid-rectal posterior bulges and represent
lateral herniations of the rectal mucosa through
the levators in patients who habitually strain).
d) Evacuation: Failure to relax the puborectalis or
paradoxical tightening of puborectalis. Delay in
opening or incomplete opening of sphincter.
Intussusception with or without obstruction to
defaecation, and with or without rectocele formation. Enterocele or sigmoidocele formation is
shown by separation of rectum and vaginal
tampon. If opacified prior to the procedure, sigmoid colon or small bowel can be seen prolapsing
into the gap.
80
What correlations do radiological abnormalities
have with the various disease entities studied?
Mr. Bartolo: Persistent puborectalis impression is
the commonest finding in slow transit constipation. This is usually accompanied by failure of
evacuation so should not be over-interpreted
since it may reflect lack of rectal awareness. A
normal defaecatory response will accordingly not
ensue. Rectal intussusception is the commonest
abnormality associated with perineal descent of
more than 3 cm on straining. In our experience
the remaining patients with descent have either
a rectocele or prolapse of the anterior rectal wall.
Failure to open up the anorectal angle is rarely
seen in this group but dynamic studies with
simultaneous electromyography may show paradoxical contraction of the sphincter muscles
despite apparent relaxation on radiological screening. Such findings may have important bearing on
the pathogenesis of pelvic floor descent and
obstructed defaecation.
Rectoceles are c o m m o n findings in women
with obstructive symptoms, yet in some patients
in whom they are associated with intussusception,
rectoceles have been repaired by combined anterior and posterior rectopexy [19] with little improvement in obstructive symptoms. This suggests
that they are more likely to be manifestations of a
weakened pelvic floor than the primary cause of
obstructive symptoms. Proctography usually
reveals abnormalities which correlate with the
presenting symptoms, but unfortunately all too
frequently the demonstration of a specific abnormality does not readily translate into a particular
therapy in which correction of the pathology
yields a satisfactory clinical result.
Dr. Bartram: We have used evacuation proctography in the investigation of constipation to determine which patients have a defaecatory disorder.
In 13 women with severe constipation [20] there
was gross delay in evacuation, with six being
unable to expel any barium. These patients
represent the most severe end of the spectrum of
the spastic pelvic floor. In a larger study of 58
consecutive patients with idiopathic constipation
[21] a more representative range of patients was
investigated. The only significant differences from
normal were the time taken for evacuation and
the amount of barium remaining in the distal
rectum. Fifteen of the 20 controls evacuated
within 20 s, whereas 45 of the 58 patients took
Fig. 8. Proctogram in a female patient with refractory idiopathic constipation. Note the pelvic floor descent from continued straining, poor opening of the anal canal associated
with delayed and incomplete evacuation - typical findings of
sphincter dysfunction
81
Table 4. Indications for defaecography
Longstandingconstipation with forceable straining
Sensation of incomplete rectal evacuation
The need for digital manoeuvres in order to evacuate the
rectum
Significantsensation of pelvic pressure and pain
Variable degrees of incontinence in conjunction with a background history of constipation
82
intra-anal or intra-rectal intussusception. Dyskinetic contraction of the puborectal muscle was
recognised in only four cases (9%) and was associated with intra-anal rectal intussusception in
only one case. Self-digitation was admitted by one
third of the patients.
Professor Stevenson and Dr. Shorvon: The symp-
Table 5. The incidences of radiological abnormalities in control, constipated, incontinent, and solitary rectal ulcer syndrome
(SRUS) subjects
Rectocele
Controls
n=23
Constipation
n=59
Incontinence
n=31
SRUS
n=18
13%
22%
13%
6%
0%
4%
0%
0%
6%
17%
14%
6%
0%
3%
37%
16%
11%
0%
45%
28 %
Total intussusception
4%
43%
56%
84%
2.5
( 1.5-3.0)
3.0
( 1.7-5.3)
4.2
(1.5-5.4)
2.3
( 1.0-3.3)
93
(86-108)
132
(120-145)
96
(86-132)
124
(106-160)
121
(90-152)
145
(116-166)
96
(88-122)
134
(92-160)
83
and the solitary ulcer patients (p < 0.05) than the
constipated patients. There was a correlation between the presence of an intussusception and the
anteroposterior diameter of the anal canal during
voiding, with the patients with more advanced
degrees of intussusception having greater anteroposterior diameters. This resulted in the anal canal
diameters being significantly greater in the incontinent patients (p <0.001) and the solitary ulcer
patients (p <0.001) than in the control subjects.
The anorectal angles at rest and during voiding
were similar in the control, constipated and solitary ulcer subjects, but both the rest (p<0.001)
and during voiding (p <0.001) angles were significantly wider in the incontinent patients than
in the control subjects.
Moderator Mr. Finlay: All contributors have
emphasised the ability of the technique to identify
prolapse and intussusception. This would appear
to be the only clinical entity which can be
identified with certainty. Although perineal
descent, rectocele, posterior pelvic floor hernia
and puborectalis paradox have been observed by
all the participants, the clinical significance of
these findings has yet to be determined with
certainty.
It is clear that the aetiology and nature of
"puborectalis paradox" has yet to be elucidated.
Indeed, there is still no uniformity of nomenclature for this clinical entity. It has been called
outward obstruction constipation, obstructed defaecation or spastic pelvic floor syndrome. Dr.
Kuijpers has indicated that he would now favour
electromyography for the diagnosis of this clinical
entity rather than the use of videoproctography.
Further study using integrated manometry, EMG
and videoproctography may help to shed light on
the pathophysiology of this condition.
Several contributors indicated that these
features rarely occur in an individual patient in
isolation. Indeed, there is considerable overlap,
such that they may all be components of a single
clinical entity. In this respect, one might speculate
that idiopathic faecal incontinence is the end
stage of that disease process.
9
4/9
6
5/5 a
5
AR physiology
basal squeeze
Anal eanalp
Pudendal n 1at.
96 + 14
77 + 18
65 +_ 16
2.26+0.15
70_+ 10 mm Hg
2.83 +0.034
84
Surgery may be contemplated, and it is then vital
to know if there is a gross defaecatory disorder
present. If so, then simply resecting part of the
colon will not help for the same reasons that
laxatives or bulk forming agents will not [20].
Unfortunately the results of puborectalis division
have not been encouraging, so that as yet no
sphincteric surgery has been developed with
which to correlate proctographic findings.
Proctography therefore has a role in patients
with solitary ulcer syndrome and severe constipation, to identify those with difficulty in evacuation
in whom surgery might not be beneficial. It is of
limited value in patients with incontinence. Pelvic
floor descent at rest, a widely open anal canal
with a vertical rectum are typical appearances of
incontinence due to neuromuscular damage. The
anatomical configuration pre- and post-surgery
has been used to define the changes after a
postanal repair.
I have performed a few examinations on
patients who have had surgery during infancy for
congenital anomalies. These have not proved
valuable in assessing residual sphincteric function,
and other imaging techniques such as computerized tomography would be recommended
[24].
85
Dr. Mahieu: The results of defaecography determine the choice between medical or surgical
treatment.
a) Mucosal prolapse is usually treated with satisfactory results by elastic ligature. External prolapse and intra-anal intussusception are not
always detected by clinical a n d / o r endoscopic
examination; defaecography is much more sensitive [10]. These conditions, when radiologically
proven, can be treated surgically (Orr-Loygue
rectopexy).
It is difficult to make the diagnosis of intrarectal full-thickness intussusception without
defaecography. Once made we prefer medical
treatment (diet, prevention of excessive straining).
b) Dyskinetic puborectalis sling. Medical treatment (kinesitherapy) is preferred.
b) Descending perineum syndrome. We have no
great experience of postanal repair and have
used biofeedback and kinesitherapy.
d) Incontinence. We would perform a postanal
repair for idiopathic incontinence and direct
sphincter repair in post-traumatic incontinence.
e) Solitary ulcer syndrome of the rectum. We
have operated by rectopexy only on those patients
presenting with external prolapse and intra-anal
rectal intussusception. The operation is usually
followed by rapid healing of the ulcer after 2 to 3
months. Intrarectal intussusception is not yet
proven to be an indication for surgery.
Professor Stevenson and Dr. Shorvon: We have
learned a great deal about the normal and abnormal appearances of defaecation, but the application of this knowledge to treatment is in its
infancy. The finding of impaired relaxation of
puborectalis is being experimentally treated with
biofeedback methods of retraining but we do not
yet have reportable results. When sphincter and
puborectalis tone are impaired but not absent in
patients with incontinence, biofeedback techniques
are also tried. Large rectoceles are usually obvious clinically and small ones are normal. Enteroceles have been found that were clinically
unsuspected as a cause of obstructed defaecation.
One result of our normal study is that intrarectal
intussusception is a normal event (at least seen on
defaecography) and should not be considered as a
reason for surgical treatment unless at least of
grade 5 or more.
that should be widely available to surgeons dealing with anorectal conditions. It can demonstrate
lesions which, although clinically occult, are the
cause of m u c h discomfort to the patient. Its main
influence on treatment must, therefore, be to
improve diagnosis and aid selection of the correct
treatment for the patient. A further role is the
reinvestigation of patients after treatment. This
provides the opportunity to determine if the treatment has achieved its intended object and allows
appropriate refinement of the treatment regime if
this is found to be necessary.
Integrated pressure - E M G proctography is a
more complex and time-con~suming procedure
that is best suited to centres with a specialist
interest. It provides more detailed information
about the pathophysiology of disease entities,
leading to a greater knowledge of a condition and
its aetiology. It is, therefore, more than a simple
diagnostic procedure. In addition to the contributions to patients' management referred to
above it is thought that a better understanding of
the causes of, and interrelationships between, the
conditions studied may allow earlier diagnosis
and treatment at a stage in the aetiology before
irreversible changes in the pelvic floor and anal
sphincter musculature have become severe.
86
How useful has proctography been in the study
of the pathophysiology of particular conditions?
Mr. Bartolo: Proctography has been particularly
useful in elucidating the pathophysiology in patients with incontinence. Perineal descent and the
anorectal angle can be measured together with
detecting occult or overt rectal prolapse. As far as
the constipation and obstructed defaecation syndromes are concerned, we do not understand the
pathophysiology. Moreover, we do not know
whether the observed abnormalities on proctography are cause or effect. To elucidate these
disorders it is important to document abnormalities of structure and correlate them with function.
This allows an objective assessment before and
after surgical procedures. The 18 patients described above with obstructed defaecation and
rectal intussusception all had their anatomic
abnormalities corrected by abdominal rectopexy,
yet only four achieved a successful result. Clearly
the intussusception is unlikely to have been the
cause of the obstructive symptoms. We do not
know how commonly rectal intussusception
progresses to complete rectal prolapse. Longitudinal proctographic studies should indicate how
frequently this occurs.
When the puborectalis fails to relax and the
rectal contents are retained, one cannot necessarily infer an inappropriate reflex response, since
the patient may lack rectal awareness. Moreover
there may be no desire to defaecate, or embarrassment may prevent evacuation. Alternatively
the volume of contrast may be too small or fail to
stimulate rectal contraction. To try and elucidate
these factors we try to fill the rectum until
sensation is perceived. Where interpretation is
difficult, we use simultaneous electromyography
and manometry to improve the assessment of the
aetiology of outlet obstruction.
Although proctography has helped our understanding there remain great gaps in our comprehension of the pathophysiology of pelvic floor
disorders. In isolation, proctography makes a
small contribution, but together with other physiological tests we can establish global assessment
of the patient's defaecatory function. Careful
audit of such evaluations in relation to the
outcome of treatment regimens may in the long
term improve our knowledge of the pathophysiology.
Dr. Bartram: Evacuation proctography gives a
unique view of the configuration of the rectum
87
obstruction is treated with techniques of biofeedback described by Han Kuijpers.
If a patient is incontil~ent with internal intussusception or prolapse of the rectum the sphincter
and pudendal nerves are evaluated with manometry and electromyography. If the pudendal
nerves are intact continence will be restored after
fixation of the rectum. This has been documented
by manometric studies and proctography in
some cases to demonstrate continued fixation of
the rectum.
88
Table 7. The increase in intrarectal pressure and change in anorectal angle associated with voiding and attempted voiding in constipated patients and control subjects
Increase in intrarectal
pressure on attempted
voiding (cm water)
Controls
Constipation
Voided
Failed to void
(n = 11)
(n = 16)
(n = 7)
(n = 9)
60 (50-140)
114 (30-225)"
120 (80-215)
100 (30-225)
Strain
93 (86-108)
95 (86-120)
102 (92-120)
93 (86-110)
132 (120-145)
112 (92-120)
118 (108-138)
110 (92-114) b
Values are medians and range. "Significantlydifferent to controls,p < 0.01. b Significantlydifferent to "voided", p < 0.01
Increase in intra-rectal
pressure during voiding
(cm water)
Controls
SRUS
SRUS with mucosal
ulceration
SRUS without mucosal
ulceration
(n = 9)
(n = 18)
60 (50-140)
95 (60-210) a
(n= 11)
100(71-210) a
(n = 7)
65 (60-95) b
c) Idiopathic faecal incontinence: Rectal intussusception, two thirds of which were clinically occult,
was demonstrated in 59% of patients with idiopathic faecal incontinence. The intussusception
distended the anal canal and the resulting anteroposterior diameter correlated inversely ( R s =
-0.54, p < 0 . 0 0 1 ) with the basal anal canal pressure. This suggests anal canal distension m a y be
the cause of the internal sphincter damage that
has been previously demonstrated in this condition [27].
Moderator Mr. Finlay: It is apparent that we still
do not understand the pathophysiology of any o f
these conditions. M a n y of the contributors have
indicated that they believe these components to
be secondary features, often an as yet unidentified
primary event. In this respect it is of interest to
note from a recent report that 72% of patients
with obstructed defaecation attributed their symptoms to childbirth. A further 20% implicated a
hysterectomy in the onset o f symptoms [28]. It is
of particular interest that each clinical feature
appears to overlap, suggesting an interrelationship perhaps between all o f these events. As one
might expect proctography appears to have raised
more questions than it has provided answers. A
foundation however has been laid upon which we
might build in terms of defining the pathophysiology of these pelvic floor disorders, followed by the
assessment of various modes of treatment.
References
89
3. Mahieu P, Pringot J, Vanheuverzwyn R, Goncette L (1981)
Les prolapsus du rectum. Apport du lavement baryt6 et de
la d&rcographie. Acta Gastroenterol Belg 44:502-512
4. Mahieu P (1983) La drfrcographie. Description d'une
technique simiplifire et apport diagnostique. Ann
Gastroentrrol Hrpatol 19:345-350
5. Mahieu P, Pringot J, Bodart P (1984) Defecography: I.
Description of a new procedure and results in normal
patients. Gastrointest Radiol 9:247-251
6. Bartram C, Mahieu P (1985) Radiology of the pelvic floor.
In: Henry M and Swash M (eds) Coloproctology and the
pelvic floor. Butterworths, London, pp 151-186
7. Mahieu P (in press) La drfrcographie. Technique
d'imagerie de la drfrcation et de ses drsordres fonctionnels. Encycl Mrd-Chir (Paris)
8. Womack NR, Williams NS, Holmfield JHM, Morrison
JFB, Simpkins KC (1985) New method for the dynamic
assessment of anorectal function in constipation. Br J Surg
72:994-998
9. Bartolo DCC, Read NW, Jarratt JA, Read MG, Donnelly
TC, Johnson AG (1983) Differences in anal sphincter
function and clinical presentation in patients with pelvic
floor descent. Gastroenterology 85:68-75
10. Mahieu P, Pringot J, Bodart P (1984) Defecography: II.
Contribution to the diagnosis of defecation disorders.
Gastrointest Radiol 9:253- 261
11. Womack NR, Williams NS, Holmfield JHM, Morrison
JFB (1987) Pressure and prolapse - the cause of solitary
rectal ulceration. Gut 28:1228-1233
12. Womack NR, Williams NS, Holmfield JHM, Morrison
JFB (1987) Anorectal function in the solitary rectal ulcer
syndrome. Dis Colon Rectum 30:319-323
13. Bartram CI, Turnbull GK, Lennard-Jones JE (1987)
Evacuation proctography: an investigation of rectal expulsion in 20 subjects without defecatory disturbance.
Gastrointestinal Radiol 13:72- 80
14. Shorvon PJ, McHugh S, Somers S, Stevenson GW (1987)
Defaecography findings in young healthy volunteers. Gut
28:A1361-1362
15. Mahieu P (in press) Defecography: a radiological method
for evaluation of anorectal disorders. In: Margulis AR,
Burhenne HJ (eds) Alimentary tract roentgenology. CV
Mosby, St. Louis
16. Kuijpers JHC, Bleijenberg G, de Morree H (1986) The
spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: a radiological
study. Int J Colorect Dis 1:44-48
17. Kuijpers JHC, Bleijenberg G (1985) The spastic pelvic
floor syndrome. A cause of constipation. Dis Colon
Rectum 28:669- 672
18. Mahieu P, Bartram CI (1985) Apport de la radiographie
l'rtude des troubles de la drfrcation. Acta Gastroenterol
Belg 48:11-20
19. Nicholls RJ, Simson JNL (1986) Anteroposterior
rectopexy in the treatment of solitary rectal ulcer syndrome without overt rectal prolapse. Br J Surg 73:
222-226
20. Turnbull GK, Lennard-Jones JE, Bartram CI (1986)
Failure of rectal expulsion as a cause of constipation: why
fibre and laxatives sometimes fail. Lancet ii:767-769
21. Turnbull GK, Bartram CI, Lennard-Jones JE (in press)
Radiological studies of rectal evacuation in adults with
idiopathic constipation. Dis Colon Rectum
Addresses of participants
Mr. D. C. C. Bartolo, MS, FRCS, Department of Surgery
Bristol Royal Infirmary, Bristol BS 2 8HW, UK
Dr. C. I. Bartram, Department of Radiology, St. Mark's
Hospital, City Road, London EC1V 2PS, UK
Dr. O. Ekberg (jointly with Dr. Fork), Department of
Diagnostic Radiology, University of Lund, Malmo General
Hospital, S-214 01 Malmo, Sweden
Dr. F.-T. Fork, Department of Diagnostic Radiology, University of Lund, Malmo General Hospital, S-214 01 Malmo,
Sweden
Dr. I. Kodner, The Jewish Hospital of St. Louis, 216 South
Kingshighway Boulevard, P.O. Box 14109, St. Louis, Mo,
63178, USA
Dr. J. H. C. Kuijpers, Katholieke Universiteit Nijmegen, Sint
Radboudziekenhuis, Algemene Chirurgie, Geert Grooteplein zuid 14, NL-6500 HB Nijmegen, The Netherlands
Dr. P. H. G. Mahieu, Service de Radiologie, Institut Chirurgical de Bruxelles, Universite Catholique de Louvain, Square
Marie-Louise 59, B-1040 Bruxelles, Belgium
Dr. P. J. Shorvon (jointly with Professor Stevenson), Department of Radiology, Central Middlesex Hospital, Acton
Lane, Park Royal, London NW10 7NS, UK
Professor G. W. Stevenson, Chairman, Department of Radiology, McMaster University, 1200 Main Street West,
Hamilton, Ontario L8N 3Z5, Canada
Mr. N. Womack, The London Hospital Medical College,
Surgical Unit, The London Hospital, Whitechapel, London
E1 1BB, UK
Address of moderator
Mr. I. G. Finlay, Consultant Surgeon Glasgow Royal Infirmary, Glasgow G4 0SF, Scotland, UK
Col6['eclal
Disease
9 Springer-Verlag 1988
Original articles
Sympathetic nervous influence on the internal anal sphincter
and rectum in man
A. Carlstedt ~, S. Nordgren ~, S. Fasth ~, L. Appelgren 2 and L. Hult~n
1Department of Surgery and 2 Department of Anaesthesiology, University of G6teborg, G6teborg, Sweden
91
i::
Lt
HGN
Motility recordings
Rectal motility was studied by means of a volume recording
device. A polyethylene bag, 12 cm long, and wide enough to
prevent complete expansion at maximal rectal relaxation, was
mounted on an 18 Ch polyethylene tube introduced via the
anus and placed in the lower part of the rectum. The polyethylene tube was connected to an air-reservoir. The pressure
in the rectal balloon was kept at 20 cm water by means of a
water-reservoir draining into the air-reservoir. The water-
~/~.. ~
Fig. 1. Schematic illustration showing the sympathetic innervation of the rectum and the internal anal sphincter. Abbreviations: HGN, hypogastric (presacral) nerves; LCN, lumbar colonic nerves
75
Anal pressure
50
(mmHg)
25
0
Rectal volume
50
(ml)
100
150
i|
EDA
(Mepivacaine,2%, lOml)
Time (min),
0
10
15
20
92
Anal pressure
mmHg
80
ml
200
60
150
40
100
20
50
Rectal volume
Nerve stimulations
Stimulation of the HGN was accomphshed by use of a hookelectrode on intact nerves or Unilaterally after nerve division.
The distal cut ends of the LCN were put on silver ring
electrodes for subsequent electrical stimulation.
Unidirectional square wave pulses were delivered from a
Grass stimulator, model S 5 E. Stimulation frequency was 5 or
10 Hz corresponding to the upper range of the physiological
discharge rates in postganglionic nerves. Voltage was kept at
8-20 V. The stimulation threshold of these nerve fibres was
determined by varying the pulse duration between 0.5 and
l0 ms.
Results
EDA
EDA
Fig. 3. Anal pressure and rectal volume before and 15 min after EDA in eight patients
Anal pressure
ImmHg)
100]
"]
"~-~'-
- -
50
Resting conditions
Anal pressure (n = 15) as r e c o r d e d u n d e r general
anaesthesia a n d m u s c l e relaxation was 5 2 +
13 m m H g ( m e a n + SD). The IAS exhibited spontaneous r h y t h m i c contractions at a f r e q u e n c y o f
8 - 1 0 / m i n , s u p e r i m p o s e d on ultra slow waves
( 0 . 5 - 1 / m i n ) . Rectal v o l u m e varied c o n s i d e r a b l y
b e t w e e n the patients. M e a n v o l u m e was 8 7 +
23 m l ( m e a n + SD). S p o n t a n e o u s motility in the
r e c t u m was generally absent.
Rectal
at 20(ml)cmVOlUmeH20 500 t
5ms
a i
-J--,
Anal pressure
100]
(mmHg)
50
Rectal volume
(ml)
60 -]
80 1
100
(5ms, 10V)
~
( 10ms,20V)
J ,
~ ,
93
Anal
pressure
(mmHg)
8ot
Discussion
6O
401
Rectal
volume
(ml)
50
-"N,,,j_..~---~
100
5Hz,O.5ms, IOV lOHz, lOms,20V
stim.
HGN
Time,(min)
Fig. 6. Effect o f H G N s t i m u l a t i o n in one p a t i e n t with a pred o m i n a n t anal relaxation o n h i g h intensity stimulation. In this
case H G N also elicited a w e a k rectal relaxation
Anal
pressure
(mmHg)
so
25
Rectal
volume
(ml)
70t
120
170-t
LCN
stim.
Time
(rain)
5Hz,5ms,8V
IOHz, l O m s , 2 0 V
. . . .
94
which is in accordance with previous animal
observations [1-4, 10, 11]. Reports on the effects
of HGN stimulation in man are sparse and
contradictory. While Rankin and Learmonth [6]
reported an anal contraction, studies by Shephard
and Wright [7] and more recently by Lubowski
et al. [8] showed that HGN stimulation invariably
caused a relaxation of the IAS. A possible explanation for the variation in results may be that
the stimulation parameters used both by Shepard
and Wright [7] and Lubowski etal. [8] were
subthreshold (pulse duration 0.5-1 ms). Moreover, due to the short-lasting stimulations used in
both investigations (3-30 s), the sphincter contraction often occurring after a preceding relaxation might have been overlooked.
As mentioned above it is likely that the anal
contraction on HGN-stimulation is mediated
through an alpha-adrenergic transmission. The
pathways and receptors involved in the intitial
relaxation on HGN stimulation in the present
experiments cannot be determined in an in vivo
study in man. Direct activation of inhibitory betaadrenergic receptors on the IAS may be one
explanation for this effect as suggested by Lubowski et al. [8]. This is supported by in vitro
experiments on h u m a n sphincteric muscle, which
have revealed the presence of beta-receptors on
the IAS [17-19]. Furthermore, there is pharmacological evidence, in vivo, of an inhibitory betaadrenergic influence on human IAS [16]. Secondly
antidromic activation of afferent fibres in the
HGN may cause a relaxation of the IAS via
activation of sacral spinal reflexes. Such reflexes
have been described by Langley and Andersson
[1]. A third possible mechanism may be a release
from adrenergic nerve terminals of a second
neurotransmitter with inhibitory action. It has
thus been suggested that ATP may be released
from sympathetic nerves, modulating the effect of
noradrenaline [20].
Unlike the colon, in which the sympathetic
innervation is mainly inhibitory [21], recent
studies [12] have revealed an excitatory alphaadrenergic innervation to the rectum in the cat. In
our experiments efferent stimulation of the HGN
elicited rectal contractions (sphincter-like effect)
in some experiments and relaxation (colon-like
effect) in others. The HGN thus seems to exert a
dual effect on the rectum, which has not been
previously shown in man.
Most previous investigations on the extrinsic
innervation of the IAS show that the motor
supply to the sphincter is provided by sympathetic fibres in the HGN, although reports from
supported by grants
from the Swedish Medical Research Council (17 X-03117),
from the University of GOteborg, from Gtteborgs L~tkaresallskap and from Assar Gabrielsson's Fund.
References
1. Langley JN, Anderson HK (1895) On the innervation of
the pelvic and adjoining viscera. J Physiol 18:67-105
2. Garrett JR, Howard ER, Jones W (1974) The internal anal
sphincter in the cat: a study of nervous mechanisms
affecting tone and reflex activity. J Physio1243:153-166
3. Bouvier M, Gonella J (1981) Nervous control of the
internal anal sphincter of the cat. J Physiol 310:457-469
4. Carlstedt A, Fasth S, Hulttn L, Nordgren S (in press) The
sympathetic innervation of the internal anal sphincter and
rectum in the cat. Acta Chir Scand
5. Frenckner B, Ihre T (1976) Influence of autonomic nerves
on the internal anal sphincter in man. Gut 17:306-312
6. Rankin FW, Learmonth JR (1930) Section of the sympathetic nerves of the distal part of the colon and rectum
in the treatment of Hirschsprung's disease and certain
types of constipation. Ann Surg 92:710-720
7. Shepard J, Wright PG (1968) The response of the internal
anal sphincter in man to stimulation of the presacral
nerve. Am J Dig Dis 13:421-427
8. Lubowski DZ, Nicholls RJ, Swash M, Jordan MJ (1987)
Neural control of internal anal sphincter function. Br J
Surg 74:668-670
9. Learmonth JR, Markowitz J (1929) Studies on the function
of the lumbar sympathetic outflow. Am J Physiol 89:
686-691
10. Mizutani M, Nakayama S (1986) Role of lumbar colonic
nerves on internal anal sphincter motility in dogs. Ital J
Gastroenterol 18:134-139
11. Rayner V (1979) Characteristics of the internal anal
sphincter and the rectum of the vervet monkey. J Physiol
286:383-399
12. Hedlund H, Fasth S, Hulttn L (1984) Efferent sympathetic
nervous control of rectal motility in the cat. Acta Physiol
Scand 121:317-324
13. Lyren~is E, Abrahamson H, Dotewall G (1985) Effects of
beta-adrenoceptor stimulation on recto-sigmoid motility in
man. Dig Dis Sci 6:536-540
95
14. Gagnon DJ, Devroede G, Belisle S (1972) Excitatory
effects of adrenaline upon isolated preparations of human
colon. Gut 13:654-657
15. Fasth S, Hult6n L, Nordgren S, Akervall S, Oresland T (in
press) Manovolumetry - a new method for investigation of
anorectal function. Gut
16. Gutierrez JG, Shah AN (1975) Autonomic control of the
internal anal sphincter in man. In: Van Trappen G (ed)
Fifth International Symposium of Gastrointestinal
Motility. Typoff Press, pp 363-373
17. Parks AG, Fishlock DJ, Cameron JDH, May H (1969)
Preliminary investigation of the pharmacology of the
human internal anal sphincter. Gut 10:674-677
18. Friedmann CA (1968) The action of nicotine and catecholamines on the human internal anal sphincter. Am J Dig
Dis 13:428-431
Coloi'ectal
Disease
9 Springer-Verlag 1988
Abstract. Rectoanal
manovolumetry
during
graded isobaric rectal distension was carried out
in 12 w o m e n with severe constipation classified as
slow transit constipation (Arbuthnot Lane's disease).
The resting anal sphincter pressure, the rectoanal
inhibitory reflex and the rectal capacity were all
normal. While the distension volumes required to
elicit sensation of rectal filling a n d an urge to
defaecate were within normal limits in all patients
the distension pressures required to elicit such
sensations fell outside the 95% limits of variation
of control subjects in 4 patients. All patients were
subsequently subjected to colectomy and ileorectal anastomosis. Patients with normal rectal
sensory function had a satisfactory functional
result after colectomy, whereas the four patients
with blunted sensation did not improve. These
findings suggest that rectoanal m a n o v o l u m e t r y
with determination of the distension pressures
required to elicit rectal sensation is an important
preoperative measure to be used in patients with
severe constipation for selection of patients suitable for colectomy and ileorectal anastomosis.
97
rectoanal
reflex inhibition
50
Weight transducer
(Rectal
volume)
Pressure transducer
<
(Anal pressure)
E_
200
~ E
1OOi
rectal c o n t r a c t i o n
~n
i
Distension pressure
(5-80cm
H20)
i
4s
initial volume
~nal prooe
60s
final volume
Rectal distension
Fig. 1. A Schematic illustration of the method used for anorectal manovolumetry, and B a recording from a normal subject. The
pre-set distension pressure and the corresponding volume in the balloon recorded at 4 s (initial volume) were used to determine
sensory thresholds. For further details see Methods
Rectoanal manovolumetry
Rectal volume, rectal sensation, anal pressure and rectoanal
reflex inhibition were studied by a technique allowing simultaneous recording of rectal volume and anal pressure in
response to graded isobaric rectal distension [13]. The rectoanal manovolumetry device illustrated in Fig. 1A, consists of
two main units: (1) an adjustable reservoir system reflecting
rectal volume which also effects rectal distension by means of
a high compliance balloon inflated with constant pre-set
pressures, (2) a unit for anal pressure recording. The investigation was performed as series of distensions with 5 cm water
increments from 5 cm water to 80 cm water and the sensory
thresholds for sensation of rectal filling and appreciation of
urge for defaecation were assessed, see Fig. 1. The threshold
distension pressure and rectal volume for eliciting rectoanal
reflex inhibition was also determined. A rectal contraction was
defined as the occurrence of a shortlasting decrease of rectal
volume following the initial rapid volume expansion at a
distension pressure of 25 cm water. Rectal capacity was defined as the volume in the balloon recorded at a pressure of
40 cm water exerted for 60 s. (Final volume at 40 cm water,
60 s = rectal capacity, Fig. 1 B).
Results of the studies were compared with 24 matched
control subjects, all women (mean age 39.8, range 25-63
years) with normal bowel function and without a history of
anorectal disease. The statistical significance of data compared
in this study was evaluated using the Wilcoxon rank test for
unpaired data and Fischer's exact test. Whenever data were
positively skewed log-transformation was performed to obtain
the 95% limits of variation. The study was approved by the
Ethical Committee of the University of G6teborg.
Operative procedures
Abdominal pain, bloating and nausea were dominating symptoms in two patients. To confirm that these symptoms also
were related to the colonic disorder a diverting loop ileostomy
was performed as a first stage operation. Both patients became
free of symptoms during a 4 and 12 months period, respectively, and a colectomy with ileorectal anastomosis was subsequently performed. Eight patients had a colectomy and ileorectal anastomosis performed as a one-stage procedure. In two
patients the operation was done in two stages, a diverting loop
ileostomy being closed 10 weeks later. The ileorectal anastomosis was in all cases constructed at the level of the promontory.
Postoperative complications
One patient had an anastomotic leakage with a pelvic abscess
which resolved on conservative treatment. Four patients were
laparotomized for small bowel obstruction caused by adhesions and an extensive small bowel resection had to be
performed in one of these patients.
Follow up
All patients have been followed up in the out-patient clinic on
a regular basis. Mean length of the follow-up was 3.4 years,
range 12 months to 6 years.
Results
Outcome of surgery
D e t a i l s o f t h e c l i n i c a l r e s u l t s a p p e a r i n T a b l e 1.
E i g h t o f t h e 12 p a t i e n t s s t a t e d t h a t t h e y h a d r e l i e f
from their symptoms
and from constipation
having daily evacuations without need of laxatives o r e n e m a . T h e s t o o l f r e q u e n c y , r a n g i n g f r o m
98
Table 1. Details of patients treated by colectomy and ileorectal anastomosis for severe constipation
Case
Age at
onset
Age at
operation
Previous problems
or operation
Preoperative
bowel habits
Postoperative
bowel habits
Length of
follow-up
years
Subsequent problems
or operations
30
53
Moschkowitz operation;
colectomy (CRA)
Enema
Unchanged
SBO laparatomy x 3
with division of
adhesions
Childhood
36
Sigmoid resection;
colectomy (CRA)
Enema
Unchanged
40
58
Enema
Childhood
26
Colectomy (CRA)
1-2/2 weeks
laxatives
1/day
Puberty
31
Ovarian cystectomy;
hysterectomy;
sigmoid resection
Enema
4-6/day
Puberty
50
Cholecystectomy;
colectomy (CRA)
1/week
laxatives
Unchanged
Continent ileostomy
25
29
Anorexia nervosa;
endogenous depression;
gastropexy (volvulus)
Enema
1/day for
6 months;
enema after
rectopexy
Abdominal rectopexy
for complete rectal
prolapse; SBO with
100 cm jejunal
resection
Puber~
26
Sigmoid resection;
Caecopexy
Enema
2-3/day
Intermittent anal
pain; anal stretch x 3
Childhood
39
1/2 weeks
laxatives
1/day
10
Puber~
27
Moschkowitz operation;
left-sided hemicolectomy
Enema
Unchanged
11
Childhood
31
I/2 weeks
laxatives
1-3/day
12
Childhood
62
Enema
3-4/day
Awaiting ileostomy
Table 2. Results of anorectal manovolumetry in women with severe constipation and normal controls
Constipation (n = 12)
Resting anal sphincter pressure
(mm Hg)
Thresholds for rectoanal
reflex inhibition
Controls (n = 24)
n.s.
n.s.
n.s.
233.8__+39.7 (175-310)
n.s.
p < 0.05
n.s.
47.1+ 6.9(10-80)
170.0_+ 18.7 (90-275)
27.1__+ 1.9(15-60)
117.8_ 11.0 (24-292)
p < 0.01
n.s.
All results expressed as means + SEM (range). Statistical analysis by the Wilcoxon rank test for unpaired data
99
Rectoanal manovolumetry
300.
250.
200.
9
150 9
100 -
50.
,o
,'~
,o
;~
3o
3'5
,;o
5o
Distension pressure, cm H 2 0
Fig. 2. Clinical outcome of colectomy and ileorectal anastomosis as related to first sensation of rectal filling. The shaded
area shows the 95% interval of variation for normal women.
Note that the four patients who did not improve had a markedly blunted sensation
300,
m
250
200
150
100
50
20
40
60
80
Fig. 3. Clinical outcome of colectomy and ileorectal anastomosis as related to threshold of urge to defaecate. Shaded area
95% interval of variation for control subjects.Note that the distension pressures are increased in patients who turned out to
be failures
tion of filling in the four patients who did not
improve after colectomy. Moreover, a considerably higher distension pressure was required to
elicit a sensation of urge to defaecate in these
patients than in the controls whereas patients with
satisfactory postoperative function fell within the
95 % limits of variation of the controls (Fig. 3).
100
and it has been suggested that the constipation is
a manifestation of a systemic disease [5]. Nevertheless, patients often suffer from constipation
and abdominal symptoms to such an extent that
surgical intervention is considered justified. The
present study shows evidence that the assessment
of rectal sensory function might be of predictive
value for the selection of patients who may
benefit from colectomy and ileorectal anastomosis
which appears to be the common operation
employed for the condition.
The resting anal pressure in the constipated
patients did not differ from controls. This is in
keeping with a recent report by Roe et al. [10] on
patients with slow transit constipation but contradictory to other studies on similar patients where
both raised pressures [5] and low pressures [14, 15]
have been reported. The reason for the conflicting
results is obscure especially so as the patients in
these series appear to be rather homogenous. In
accordance with other reports [10, 14] the
threshold volumes required to elicit recto-anal
reflex inhibition were within normal limits indicating that the intramural neurones involved in
this response [16] are intact in patients with slow
transit constipation. The reflex rectal contraction
following distension was observed less often in
constipated patients than in controls. A decreased
rectal motility on distension was also noted by
Read et al. [14] in a substantial number of constipated patients. These findings might suggest a
motility disorder in the rectum that contributes to
the constipation by preventing an efficient
squeezing of rectal contents towards the anal
canal.
It has been shown by Hurst [17] that balloondistension of the rectum causes a sensation that is
interpreted as a desire to pass wind or motion,
contrasting to the vague abdominal sensation of
discomfort or pain felt at distension of the colon.
In four of the patients the distension pressure
required to elicit rectal sensation was significantly
higher than in the controls both as regards the
sensation of filling and the urge to defaecate. In
contrast the threshold volumes associated with
perception of rectal sensation did not differ from
those recorded in the controls. This observation is
in keeping with other reports [10, 14] suggesting
that rectal sensation as assessed by the volume at
which rectal filling is first appreciated is not
significantly affected in patients with slow transit
colon. In contrast the report by Baldi et al. [18]
states that a larger volume than normal was
required to evoke initial awareness of rectal filling. Read et al. [14] presented evidence that in
101
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
References
1. Smith B (1973) Pathological changes in the colon produced by anthraquinone purgatives. Dis Colon Rectum
16:455-458
2. Krishnamurthy S, Schuffier MD, Rohrmann CA, Popell
CE (1985) Severe idiopathic constipation is associated
with a distinctive abnormality of the colonic myenteric
plexus. Gastroenterology 88:26-34
3. Hinton JM, Lennard-Jones JE (1968) Constipation: definition and classification. Postgrad Med J 55:720-723
4. Hughes ESR, McDermott FT, Johnson WR, Polglase AL
(1981) Surgery for constipation. Aust NZ Surg 51 : 144-151
5. Watier A, Devroede G, Duvanceau A, Alderrahman M,
Dugnay C, Forand MC, T6treault L, Arhan P, Lamarche
J, Elhilali M (1983) Constipation with colonic inertia. A
manifestation of systemic disease? Dig Dis Sci 28:
1025-1033
6. Goligher JC (1984) Surgery of the anus, rectum and
colon, 5th edn. Balli6re - Tindall London, pp 335-345
7. Preston DM, Hawley PR, Lennard-Jones JE, Todd IP
(1984) Results of colectomy for severe idiopathic constipa-
18.
19.
20.
21.
Colol'eetal
Disease
9 Springer-Verlag 1988
103
Methods
Results
Patients
Macroscopic observations
Four to six months after surgery, colonoscopy with ileoscopy was performed in all patients and controls. The neoterminal ileum was carefully examined over 30 cm and multiple biopsies were obtained 4 cm above the anastomosis, in
the area where the intraoperative biopsies had been taken.
The biopsies were obtained from normal-appearing mucosa as
well as from lesions. Ileocolonoscopy with biopsy was repeated
six months later. All patients gave informed consent for the
various procedures.
Pathological studies
The operative specimens and the per- and postoperative
biopsies were submitted to routine microscopy, enzyme histochemistry and immunohistochemistry. Routine microscopy
(H.E. staining) on Bouin fixed, paraffin embedded semiserial
sections was performed for diagnostic purposes and for the
assessment of the presence and the extent of microscopic
inflammation. Enzyme histochemistry involved the staining of
6 Nn cryostat sections of freshly frozen tissue specimens for
acid phosphatase (ACP) and adenosine triphosphatase (ATP)
according to a modified metal salt method [8, 9]. This
technique was used to distinguish further between various
types of dendritic cells involved in the inflammation. Immunohistochemistry was performed on serial frozen sections using
an indirect immunoperoxidase method. Six gm thick sections
of the freshly frozen biopsies were dried overnight at -20 ~
and fixed in acetone for 30 min at room temperature. Serial
sections were incubated for 30 rain with the following monoclonal antibodies:
OKT3 (CD code CD3) reactive with T ceils; OKT8 (CDs)
defining cortical thymocytes and probably cytotoxic/suppressor T cells; OKT4-Leu 3 a (CD,) defining helper/inducer Tcells; HLA-DR reacting with the common framework of
human MHC class II antigens; B1 (CD2o) reacting with all Bcells; and Leu7 for natural killer cells. The monoclonal
antibodies were obtained from Ortho Pharmaceutical Co.,
Raritan, NJ, USA (OKTJOKTs/OKT4),from Becton-Dickinson, San Francisco, Ca (Leu-7, Leu-3a and HLA-DR) and
from Coulter Immunology, Hialeah, F 1a (B0.
For the immunohistochemical
bound (S) immunoglobulins on
cytoplasmic (C) immunoglobulins
embedded sections, an unlabeled
(PAP) procedure was performed
clonal antibodies to human IgA,
Copenhagen, Denmark).
Microscopic observations
Routine microscopy. R o u t i n e m i c r o s c o p i c e x a m ination o f the o p e r a t i v e s p e c i m e n s c o n f i r m e d the
diagnosis o f C r o h n ' s disease in all nine cases
o p e r a t e d for this disease. Ileal a n d colonic resection m a r g i n s r e v e a l e d no signs o f m i c r o s c o p i c
i n f l a m m a t i o n in eight o f these nine cases. In one
patient, i n f l a m m a t o r y lesions were p r e s e n t at the
ileal resection m a r g i n .
The biopsies o b t a i n e d d u r i n g the o p e r a t i o n in
the ileal s e g m e n t left behind, were n o r m a l in
eight o f these nine patients. Microscopic signs o f
i n f l a m m a t i o n (i.e. a n increased cellular infiltrate
in the l a m i n a p r o p r i a c o m p o s e d o f p o l y m o r p h s
a n d l y m p h o c y t e s ) w e r e p r e s e n t in the biopsies o f
one patient. This was the s a m e p a t i e n t in w h o m
the ileal resection m a r g i n s h o w e d an i n f l a m m a t o r y reaction.
No i n f l a m m a t o r y lesions consistent with
C r o h n ' s disease were f o u n d in the o p e r a t i v e
specimens f r o m the control patients. All the intrao p e r a t i v e ileal biopsies f r o m these patients w e r e
normal.
All biopsies o b t a i n e d d u r i n g the follow-up
endoscopies in p a t i e n t s with C r o h n ' s disease
showed u n e q u i v o c a l m i c r o s c o p i c signs o f i n f l a m m a t i o n i.e. b l u n t i n g a n d irregularity o f the villi,
superficial m u c o s a l defects, a n d a focal i n f l a m m a tion o f the l a m i n a p r o p r i a (3). Similar lesions
were not o b s e r v e d in the biopsies f r o m the control
patients.
Immunohistochemistry
A positive staining for H L A - D R or M H C class II
antigens was o b s e r v e d o n small intestinal epi-
104
Fig. 1. Early postoperative biopsy from a patient with Crohn's disease. MHC class II antigens are not expressed by the epithelial
cells (e), and the cellular infiltrate in the lamina propria (Lp) is minimal ( x 200)
Fig. 2. Microphotograph of small intestinal biopsy showing epithelial cells and lamina propria cells. Magnification x 200. Stained
for MHC class II antigens. This is a biopsy from a patient with postoperative recurrence of Crohn's disease obtained during a second follow-up ileoscopy. MHC class II is expressed by the epithelial cells (arrows) as well as by the lamina propria cells. The central
lacteal is dilated. Its endothelial lining is negative for MHC class II (arrowhead)
Fig. 3. a Intraoperative biopsy from a patient with Crohn's disease stained for OKT4. The villus shows a normal configuration and
the number of lamina propria lymphocytes (L+ arrows) is normal (x200). b Intraoperative biopsy from a patient with Crohn's
disease stained for OKTs. Intraepithelial lymphocytes are clearly visible (arrows)
105
thelial cells, on capillary endothelial cells from the
lamina propria and the submucosa and on numerous round and irregularly shaped inflammatory
cells of the lamina propria in the intraoperative
biopsies from the patients with Crohn's disease.
Similar findings were obtained in the biopsies
from the control patients. The positively staining
irregular cells were mainly present in the villi in a
subepithelial position.
The endoscopic biopsies obtained from patients with Crohn's disease during follow-up colonoscopy 4 to 6 months after the operation
showed either no or only weak positive staining
for MHC class II antigens on the small intestinal
epithelial cells (Fig. 1). A clear and strong positive
epithelial staining pattern reappeared in the postoperative biopsies obtained one year after the
operation. The postoperative biopsies from the
control patients obtained at the same intervals
showed always a normal positive staining for
MHC class II on the epithelial cells. Endothelial
cells and lamina propria cells remained positive
for MHC class II in the postoperative biopsies
from the patients with Crohn's disease and from
the control patients (Fig. 2).
Intraepithelial lymphocytes were mainly
OKT8 +, HLA-DR negative cells in all biopsies.
Only rare OKT4 +, HLA-DR-intraepithelial lymphocytes were observed. No differences were seen
between the biopsies from patients with Crohn's
disease and from the controls.
Table 1. Lamina propria lymphocytes in Crohn's disease of
ileum
T,
m~
T,/T~
Intraoperative biopsies
19.8 4.3 16.7_+5.2 1.2_+0.4
Early postoperativebiopsies 21.5+4.6 18.7+5.0 1.1_+0.3
Late postoperativebiopsies 24.3___4.7 19.8+ 5.7 1.2_0.5
Lymphocytesare expressed as number of cells per 100 lamina
propria cells (+ SEM)
Lamina propria lymphocytes were BI+B lymphocytes as well as OKT~+T lymphocytes and
Leu-7 + natural killer cells in all biopsies.
Few B1 stained lymphocytes were present,
except in areas adjacent to or in lymphoid aggregates. No differences were observed between
the various groups of biopsies. Leu-7 + cells were
also rarely observed.
OKT4 +, Leu-3a + and OKT8 + lamina propria
lymphocytes were present in all intraoperative
and postoperative biopsies. The absolute number
of these cells expressed as number of cells per 100
lamina propria cells was increased in the early
and late postoperative biopsies from patients with
Crohn's disease when compared with the controls
(Fig. 3). But the OKT4/OKT8 ratio remained
unchanged (see Table 1).
An increase of immunoglobulin-containing
plasma cells was observed mainly in the postoperative biopsies from the patients with Crohn's
disease. The relative number of IgA, IgM and
IgG-containing cells expressed as a percentage
per 500 lamina propria cells remained unchanged
except for a relative increase of IgM-containing
cells. Surface immunoglobulin presenting cells
were rare except adjacent to or in lymphoid
follicles.
Enzyme histochemistry
HLA-DR positive irregular cells were observed
mainly in the lamina propria of the villi of the
ileal biopsies immediately underneath the epithelial basement membrane. Enzyme histochemistry
demonstrated that these cells formed a heterogeneous population composed of a mixture of
cells showing either strong membrane adenosine
triphosphatase (ATPase) activity but weak cytoplasmic acid phosphatase activity or strong ACP
activity but no detectable ATPase activity.
Table 2. Enzymehistochemistry
Results
Crohn's Disease
ATPase+cells
ACPase+cells
Controls
Intraoperative
biopsies
Postoperative
biopsies
Intraoperative Postoperative
biopsies
biopsies
25 4.2
15+_1.2
28 + 2.3
10_+2.3
12.5_+2.9
14 + 2.6
15 2.6
12 4.2
Positive lamina propria cells in the ileum expressedper 500 lamina propria cells (+ SEM). The biopsies of Crohn's patients contain
significantlymore HLA-DR+,ATPase+dendriticcells than the biopsies of normal controls(p < 0.001)
106
Fig. 4. Intraoperative biopsy from a patient with Crohn's disease stained for a acid phosphatase and b for ATPase showing the
presence &numerous ATPasepositive macrophageshigh in the lamina propria (arrows),and a positivebrush border staining
Discussion
107
11.
References
19.
3.
4.
5.
6.
7.
8.
9.
10.
12.
13.
14.
15.
16.
17.
18.
20.
108
21. Geboes K, De Vos R, Rutgeerts P, Desmet V, Yantrappen
G (1987) Light microscopic and ultrastructural immunocytochemical study of Whipple's disease. Gastroenterology
92:1401
22. Scott H, Solheim BG, Brandtzaeg P, Thorsby E (1980)
HLA-DR like antigens in the epithelium of the human
small intestine. Scand J Immunol 12:77-82
23. Cerf-Bensussan N, Quaroni A, Kurnick JT, Bhan AK
(1984) Intraepithelial lymphocytes modulate la expression
by intestinal epithelial cells. J lmmunol 132:2244-2252
24. Unanue ER, Allen PM (1986) Comment on the finding of
Ia expression in nonlymphoid cells. Lab Invest 55: 123125
25. Brandtzaeg P, Baklien K (1977) Intestinal secretion of IgA
and IgM: a hypothetical model in immunology of the gut.
Ciba Foundation Symposium 46 (new series). Elsevier,
Excerpta Medica North-Holland, Amsterdam, Oxford,
New York, pp 77-108
Col6i'ec/al
Disease
9 Springer-Verlag 1988
1Department of Surgery, S6dersjukhuset, Stockholm and Departments of 2Ontology, 3Surgery and 4 Pathology,
University of Uppsala, Akademiska sjukhuset, Uppsala, Sweden
squamous cell carcinomas derived from the squamous epithelium and the so-called cloacogenic
carcinomas derived from a transitional epithelium
in the anal canal should be considered as a single
entity since they apparently behave in a similar
way clinically and their prognoses are identical
[4-9].
The purpose of the present study was to
compare the natural history of different histological types and gradings in relation to sex, age,
site, staging and survival in an unselected population-based series in order to assess the proportion
of the various subtypes and their clinical importance. A simplified pathological subclassification using clearly defined and easily identified
criteria was used.
Patients and m e t h o d s
Patients
In order to obtain an unselected and representative series,
data on all patients with diagnosed rectal and anal carcinomas
(International Classification of Diseases, ICD 8, No 154) who
were residents of the Swedish counties of Stockholm, Uppsala,
Kopparberg, V~istmanland and J~mtland (totally approximately 2.5 million inhabitants) between January 1978 and
December 1984 were gathered from: (1) the diagnostic files of
all surgical and oncological departments in the counties, and
(2) the Cancer Registries of the Uppsala and Stockholm health
care regions. In this way, 177 patients with a neoplasm in the
anus were identified. There were 166 patients with a tumour
of an epidermoid type, five were adenocarcinomas, four
malignant melanomas, one basal cell carcinoma and one
leiomyosarcoma. Of the 166 patients, two could not be
included in the study due to insufficient pathological material.
Histopathological evaluation
Microscopic material from all 164 patients was re-evaluated
by one experienced pathologist (EW) without knowledge of
110
111
the original classification, the clinical course or the location of
the tumour.
Formalin-fixed and paraffin-embedded blocks of all carcinomas were cut in 4 ~tm thin sections and stained with hematoxylin-eosin and/or van Gieson's stain and examined by light
microscopy. In most instances, multiple, well preserved
tumour areas were available. On the basis of their histological
pattern, the turnouts were classified into two types: squamous
(71 cases) or cloacogenic (basaloid, transitional cell, 93 cases)
carcinomas.
To secure a diagnosis of squamous carcinoma, the whole
tumour, including all individual tumour cells, had to display a
squamous differentiation. Most of these tumours, but not all,
contained areas with keratinization and pearl formation. All
squamous carcinomas were subgrouped as follows, [1] well
differentiated tumours in which all the turnout cells were
attached to each other and the borders between tumour tissue
and surrounding stroma were sharp and always evident, [2]
moderately differentiated tumours which displayed signs of
tumour cell dissociation and the borders between the tumour
aggregates and the stroma were less evident, and [3] poorly
differentiated tumours, which were identified by the ability of
the tumour cells to dissociate diffusely in the stroma tissue
(Figs. 1-3). Thus, the subgrouping of the squamous carcinomas was exclusively based on the degree of dissociation of the
turnout cells. Parameters such as atypia (cell polymorphism),
frequency of mitotic figures, presence of keratinization and
pearl formation and degree of lymphocytic infiltration in the
tumour stroma were not evaluated.
Tumours classified as cloacogenic carcinomas were
mainly built up of transitional epithelioid cells. They were
subgrouped as follows; grade I-tumours consisted of transitional epithelioid cells with an obvious and distinct cell
palisading in the periphery of the tumour aggregates. Grade
II-tumours were characterized by a partial, but not total, loss
of the peripheral cell palisading. Grade III-tumours were
identified by the total loss of peripheral cell palisading on the
tumour buds. Cloacogenic carcinomas disclosing no squamous
differentiation and thus composed entirely of transitional
epithelioid cells were classified as subtype A, and tumours with visible squamous differentiation, mostly with
signs of keratinization and pearl formation, were designed
subtype B (Figs. 4-6). The histopathological grading and subtyping of the cloacogenic carcinomas used in the present study
is regarded as a simplified modification of the Klotz et al.
histological classification of 1967 [2].
Tumour staging
Tumour size and localisation were prospectively evaluated for
all cases referred to Akademiska sjukhuset, Uppsala. The
same information was collected retrospectively from the diagnostic files of cases not referred to this hospital. The upper
limit of the anal canal was at the ano-rectal junction and the
border between the perianal region and the anal canal was at
the anal verge. The outer border of the perianal region was
Treatment
During the time period, the majority of the patients were
treated either at the Departments of Surgery and Oncology,
Akademiska sjukhuset, Uppsala, the Karolinska sjukhuset,
Stockholm or Srdersjukhuset, Stockholm, respectively. Except
in cases with a small, superficially located tumour, which was
excised locally, primary treatment was radiation, usually in
combination with chemotherapy (bleomycin [12], bleomycin
with vincristine or bleomycin with 5-fluoro-uracil with cyclophosphamide). In Stockholm during the first 3-4years,
surgery was then usually performed, whereas in Uppsala [12]
and in Stockholm during the last 1-2 years, surgery was only
performed in cases of insufficient response to radiation. Cases
not referred to these hospitals were treated in many different
ways. Some elderly patients as well as the single case identified at routine autopsy did not obtain any specific therapy.
Of the 23 patients with a perianal tumour, 12 (52%) were
treated with irradiation with or without chemotherapy alone,
one patient with irradiation with chemotherapy followed by a
rectal excision and nine patients with local excision. One 91
year old woman with inguinal node metastases was only
treated palliatively.
Of the 50 squamous cell carcinomas in the anal canal,
four (8%) patients were operated locally and six (12%) underwent a rectal excision. The majority (31 (62%) patients) were
treated with irradiation (with or without chemotherapy), and
19 of these did not have additional major surgery. Nine
patients were only treated palliatively or received no specific
therapy. Of 91 cloacogenic carcinomas, six (7%) were locally
operated, 16 (18%) patients underwent radical excision of the
rectum and 36 (39%) were irradiated, sometimes combined
with chemotherapy as their sole treatment. Twenty-three
(25%) patients received a combined therapy of irradiation with
or without chemotherapy followed by major surgery. Ten
(11%) patients received no therapy or only palliation because
of advanced age, disseminated disease and/or poor general
condition.
Figs. 1-3. Illustration of squamous cell carcinomas with various degrees of differentiation. 1 Well differentiated tumour with
regular sheets of tumour cells and sharp borders between tumour tissue and stroma component. 2 Moderately differentiated tumour
in which some single cells or small aggregates of turnout cells are diffusely spread in the stroma and 3 poorly differentiated tumour
with obvious signs of pronounced tumour cell disintegration. Hematoxylin-eosin stains x 160
Figs. 4-6. Picture of cloacogenic carcinomas with various morphology. 4 Grade I tumour built up of regular tumour aggregates
with distinct cell palisading. 5 Grade II tumour with partial but not total loss of the peripheral cell palisading and 6 Grade Ill
tumour with partly disintegrated tumour cells without identified cell palisading. Hematoxylin-eosin stains x 160
112
Statistical analysis
Results
The majority (15/23, 65%) of the perianal tumours were small (T1). Only two (9%) of the
patients had inguinal lymph node metastases at
diagnosis and none had generalized disease (Table 2).
Most of the anal canal carcinomas were more
advanced tumours, i.e. primarily in stage T3 (67
cases, 48%) or T4 (22 cases, 16%) (Table2).
Cloacogenic carcinomas and squamous cell carcinomas had approximately the same distribution
in the different T-stages and there was an equal
distribution of male and female patients. The
T-stage could not be assessed in two cases.
Inguinal node metastases were rare in stages
T1-T2 (5 cases, 10%). Twenty percent (11/55) of the
T3 tumours had inguinal node metastases at diagnosis; this figure was 61% (11/18) in advanced
cases (T4). It should be noted that due to the
retrospective nature of part of this material the N
stage could not be properly assessed in 16 cases
Perianal
Differentiation/subtype
Men
Women
All
Men
Women
All
All
Squamous cell
Well
Moderate
Poor
12
9
2
1
9
5
3
1
21
14
5
2
11
0
3
8
39
5
13
21
50
5
16
29
71
19
21
31
0
-
2
2
-
21
70
91
93
17
2
22
40
39
42
39
44
2
2
-
12
11
23
32
109
141
164
Cloacogenic
IB
II A
II B
IIIA
Total
Anal canal
Total
113
Table 2. Tumour stage
Perianal
T1NoMo
Anal canal"
Squamous
Cloacogenic
All
Squamous
Cloacogenic
All
14
15
10
14
T2
14
17
31
T3
T4
2
-
2
-
9
3
33
4
42
7
TaNxMo
T2
.
-
T~
T4
8
1
4
3
12
4
TaN+ Mo
T2
0
1
1
0
2
1
3
1
T3
T4
TaN0-+Ma
T2
T3
T4
2
1
2
4
4
5
50
89
139
21
23
10
I
@
O"
"~ 0s
9
,b
(8}
ca_
12
24
36
Time (months)
48
60
114
10
10
t
(5)
o 0.5
"~ 0.5
)3)
(3)
(71
h(4)
o-
12
24
36
Time (monthsl
48
.>
12
24
36
Time (months)
(7)
&
(11)
'B 05
ii
48
j.
L
i
24
36
Time (monfhs]
6 119)
!8)
,i-
60
(11)
)11
m_
12
&
)41
ca_
60
10
{[
'~ 05
46
(31
10
60
12
,1,
24
J6
Time (months)
48
60
Fig. 11. Probability of survival in 139 patients with an epidermoid carcinoma of the anal canal according to clinical stage.
T1-4 NOMO (n = 94, []
Ez), T1-2 NOMO (n = 45, A
z~),
T3-4 NOMO (n=49, 9
--), T1-4 NXMO (n= 16, 9
o),
T1-4 N + M O (n--19, 9
~), T1-4, N O - + , M1 (n=10,
9 . 9
115
10
(12)
ez
>
I 16
"G 05
Estimation variable
Univariate
Multivariate
Step
Entering
)~
)~2
p
(values in the
final model)
Stage
(T1-2 vs T3-4)
9.59
9.59
Differentiation
(well + moderate
versus poor)
7.75
9.78
(11
(21
a_
12
24
36
1.8
60
Time (months)
Fig. 12. Probability of survival in 89 patients with an epidermoid carcinoma of the anal canal without known metastases,
according to primary treatment. T1-2 NOMO, primary radiotherapy with or without chemotherapy (n = 29, o
9 or
surgery (n = 14, 9
9 and T3-4 NOMO radiotherapy with
or without chemotherapy (n= 38, []
[]) or surgery (n= 8,
9
m)
Sex
3.79
6.42
Localization
7.91
7.03
"
Table 4. Additional prognostic information by sex and histological subtype within the cloacogenic carcinomas - a multivariate analysis in non-disseminated cases
Estimation variable
Univariate
Multivariate
Step
Entering
)d
)~2
p
(values in the
final model)
Stage T1
T2
T3
T4
Ref
0.63
1.86
3.58
7.59
Sex
8.90
4.34
9.40
4.12
Subtype
(A vs B)
~ p<0.01; by<0.05
116
Table5. Additional prognostic information given by sex,
localization and histological type - a multivariate analysis in
non-disseminated primary anal carcinoma
Estimation variable
Univariate
Multivariate
Step
Entering
X2
Z2
p
(values in the
final model)
Differentiation
well + I
moderate + II
poor+III
Ref.
5.05
15.28
8.77
20.11
b
a
Stage T1
T2
T3
T4
Ref
0.41
2.30
4,20
7.97
4.40
b
c
Sex
9.78
9.91
Discussion
117
differentiation revealed independent prognostic
information.
Besides the importance of histopathologic subgroup and stage for prognosis, we also noted a
clear correlation between sex and prognosis with
a considerably less favourable course for men
than for female patients. Such a difference has
not been reported before. The reason for the
difference is not known. Neither is it known why
the distribution of sexes within certain histopathological subgroups was so uneven.
An unselected population-based material
provides the most accurate way of truly assessing
parameters such as age and sex distribution and
the proportion of different histopathological subgroups and their possible clinical importance.
Due to the retrospective nature of part of a
population-based study, other factors such as the
incidence of, for example, lymphatic node metastases and, particularly, the importance of treatment can be less accurately assessed. This heterogeneity in treatment should be remembered when
correlating the pathological picture with clinical
behaviour and prognosis.
The unselected nature of this material is reflected in a higher median age of tumours in the
anal canal (68 years) than in previous, usually
hospital-based, series (50-60 years, [4, 5, 18, 19]).
The median age corresponds well with the figures
(66 years) in the Cancer Incidence of Sweden
1970-1983. Furthermore, the n u m b e r of larger
(more advanced) tumours appears to be considerably higher in this series than in previously published series [7, 18, 20], although it should be
remembered that staging procedures have varied
considerably. In the present series, two of three
tumours in the anal canal were larger than 4 cm
in diameter, whereas in previous series only between 1/5 to 2/5 of the tumours were of a
comparable size.
In contrast, this series does not have a higher
incidence of inguinal metastases or distant metastases [9, 19]. Similar to previous series there was a
marked predominance for female patients (3.5 : 1).
This figure is somewhat higher than in most
previous series (2-3 : 1) [4, 21].
In spite of a higher median age and larger
tumours in this series, the overall prognosis was
not less favourable. The reported 5-year survival
rates are usually in the order of 45 to 55% [2, 5,
22], although a recent series by Merlini and
Eckert from Switzerland noted only 20% 5-year
survivors [23]. In that series composed of 106
patients, it was found that the tumours were more
Perianal tumours
118
References
1. Harrison EG, Bearhs OH, Hill JR (1966) Anal and perianal malignant neoplasms: pathology and treatment. Dis
Colon Rectum 9:255-267
2. Klotz RG, Pamukcoglu T, Souilliard DH (1967) Transitional cloacogenic carcinoma of the anal canal. Cancer 20:
1727-1745
3. Beahrs OH (1979) Management of cancer of the anus. Am
J Radiol 133:791-795
4. Beahrs OH, Wilson SM (1976) Carcinoma of the anus.
Ann Surg 184:422-428
5. Singh R, Nime F, Mittelman A (1981) Malignant epithelial tumours of the anal canal. Cancer 48:411- 415
6. Bohe M, Lindstr6m C, Ekelund G, Leandoer L (1982)
Carcinoma of the anal canal. Scand J Gastroenterol 17:
795- 800
7. Frost DB, Richards PC, Montague ED, Giacco GG,
Martin RG (1984) Epidermoid cancer of the anorectum.
Cancer 53:1285-1293
8. Dougherty BG, Evans HL (1985) Carcinoma of the anal
canal: a study of 79 cases. Am J Clin Pathol 83:159-164
9. Adam YG, Efron G (1987) Current concepts and controversies concerning the etiology, pathogenesis, diagnosis,
and treatment of malignant tumors of the anus. Surgery
101:253-266
10. Papillon J, Mayer M, Montbarbon JF, Gerard JP,
Chassard JL, Bailly C (1983) A new approach to the
management of epidermoid carcinoma of the anal canal.
Cancer 51:1830-1837
11. Spiessel B, Schiebe O, Wagner G (1982) UICC - TNM
Atlas. Springer, Berlin Heidelberg New York
12. Glimelius B, Phhlman L (1987) Radiation therapy of anal
epidermoid carcinoma. Int J Radiat Oncol Biol Phys 13:
305-312
13. Peto R, Pike MC, Armitage P, Breslow NE, Cox DR,
Howard SV, Mantel N, MacPherson K, Peto J, Smith PG
(1977) Design and analysis of randomized clinical trials
requiring prolonged observations of each patient. II Analysis and examples. Br J Cancer 35:1-39
14. Cox DR (1972) Regression models and life tables. J R Stat
Soc B 26:103-110
15. Grinvalsy HT, Helwig ET (1956) Carcinoma of the anorectal junction I. Histological considerations. Cancer 9:
480-488
16. Morson BC, Dawson JM (1979) Gastrointestinal pathology, 2nd edn. Blackwell Scientific Publications, Oxford,
pp 741-753
17. Serota A, Well M, Russell W, Wollman J, Wilson S (1981)
Anal cloacogenic carcinoma. Arch Surg 116:456-459
18. Boman BM, Moertel CG, O'Connell JH, Scott M, Weiland
LH, Beart RW, Gunderson LL, Spencer RJ (1984) Carcinoma of the anal canal: a clinical and pathologic study
of 188 cases. Cancer 54:114-125
19. Cummings BJ (1982) The place of radiation therapy in the
treatment of carcinoma of the anal canal. Cancer Treat
Rev 9:125-147
20. Nigro ND (1984) An evaluation of combined therapy for
squamous cell cancer of the anal canal. Dis Colon Rectum
27:763-766
21. Goldman S, Ihre Th, Seligsson U (1985) Squamouscell carcinoma of the anus. Dis Colon Rectum 28:143-146
22. Golden GT, Horsley JS (1976) Surgical management of
epidermoid carcinoma of the anus. Am J Surg 131:
275-280
23. Merlini M, Eckert Ph (1985) Malignant tumors of the
anus. A study of 106 cases. Am J Surg 150:370-372
24. Greenall MJ, Quan S, Stearns M, Urmacher C, DeCosse J
(1985) Epidermoid cancer of the anal margin. Am J Surg
149:95-100
25. Stearns MW, Quan SH (1970) Epidermoid carcinoma of
the anorectum. Surg Gynecol Obstet 131:953-957
26. Nielsen OV, Jensen SL (1982) Cancer ani i Danmark
1943-1973. I. Carcinoma planocellulare a n i - diagnose,
behandling og prognose. Ugeskr Laeger 144:851-856
Accepted: 20 January 1988
Dr. Sven Goldman
Department of Surgery
SOdersjukhuset
Box 38100
S- 100 64 Stockholm
Sweden
Col6ree/al
Disease
9 Springer-Verlag 1988
Dietary factors have been implicated in the aetiology of colorectal cancer [1]. Prime candidates for
such a role are dietary fats [2] and fibre-depleted
diets [3]. Results from epidemiological studies
have so far been inconclusive with respect to
which exact dietary component is important in
this disease. Similarly, dietary studies in experimental models of colon cancer have also been
inconclusive although dietary factors have been
shown to modify the disease, with fats increasing
tumour yields and incidence [4] and fibre generally reducing these parameters [5]. Of particular
interest are the reports of elemental diets conferring protection against experimental colon
cancer by reducing incidence, numbers of colonic
tumours and improving survival [6-9]. The
mechanism of this protection can be variously
attributed to intestinal mucosal hypoplasia [10,
11], the cholesterol-free nature of such diets [7]
and the effects on gut flora and faecal sterols [12].
Further, u
has been reported to cause a
reduction in biliary secretions in man [13] and
this effect may be of relevance in the animal
model. The purpose of this study was to investigate whether dietary Vivonex exerts its protective
effect against experimental colon cancer by a
liver-mediated mechanism.
Materials and methods
A total of 240 female Wistar rats (weight range 80-100 g) were
randomly allocated to three dietary groups: (A) Vivonex I-IN
powder (Norwich Eaton plc, Woking, Surrey), (B) Vivonex
kiN with 0.05% added cholesterol and (C) standard laboratory
powdered diet (MRC Formula 41B, E Dixon & Co, Ware,
Herts) and served as controls. Diets, the main constituents of
which are detailed in Table 1, and water were provided ad
libitum. All animals then received a colon cancer-producing
regimen of dimethylhydrazine (DMH) at a dose of 40 mg/kg
BW, s.c., once weekly for five weeks. The animals were housed
120
Table 1. The main dietary constituents of three experimental
groups
Dietary
components
Energy KCals/kg
Carbohydrates %
Protein %
Fat %
Fibre %
Vivonex HN
3,750
79.1
2.5
0.33"
0
Vivonex HN
+ 0.05 %
Cholesterol
41B
Control
diet
3,750
79.1
2.5
0.33 a
0
3,580
49.7
12.7
3.12 b
4.8
110//
//
100/
>
_J
ol
90-
iI
80-
(D
0~
70-
~
o
VChol
60-
50-
40-
~o
l'S
20
TIME
io v
2's
IN
3'o
3'5
4o
WEEKS
Fig. 1. The changes in median total liver lipids with time in the
three dietary groups
5"0-
/ /
4"5-
//o
._1
.J
4-0-
E
VChol
(Z 3-5I.iJ
LIJ 3 " 0 -
C>
"12"5-
Results
The results for changes in total liver lipids, cholesterol and phospholipids and the development of
total colonic neoplasms with time in the three
dietary groups are illustrated in Figs. 1, 2, 3 and 4
respectively.
In control animals the total liver lipids remained unchanged over the 40week period
(Fig. 1) and this was associated with an increase
in both the % incidence and median number
(Table 2) and the development of colonic neoplasms with time (Fig. 4). In contrast, in the
Vivonex-fed group there was an upward trend in
total liver lipids with time (Fig. 1). These lipids
were significantly higher (p values < 0.01) over
the whole study period than in the control group
and associated with significantly fewer (p values
< 0.05) and significantly slower (p < 0.001) development of colonic neoplasms with time (Fig. 4).
Total liver lipids in the Vivonex+cholesterol
group fell between the curves for the other two
groups (Fig. 1) being significantly higher over the
41B
2-0
1'o
,5
2'o
TIME
2'5
IN
3'o
40
WEEKS
15-0 /
oV
//
1.5
o~
?
~Q.
--1
0
Q.
m
0"1-
//
12"5....
"-~
~- - ////
VChol
10.0-
7"5-
~~176
418
5.0
ib
1%
2'o ,%
TIME
s'o
s%
20
IN WEEKS
121
Table 2. The changes in % incidence and median numbers of colonic neoplasms with time in the three dietary groups
Weeks
10
15
20
25
30
35
40
Vivonex + Cholesterol
Controls
Incidence
%
Median (range)
Neoplasms/group
Incidence
%
Median (range)
Neoplasms/group
Incidence
%
Median (range)
Neoplasms/group
0
20
20 c
30 d
70
100
80
0 (0-0)
0 (0-1)
0 (0-1)"
0 (0-3)~
1 (0-3)"
2 (1-4)"
1 (0-3)"
0
10
30"
50 b
50 b
80
100
0 (0-0)
0 (0-2)
0 (0-3) a
1 (0-5)"
1 (0-4)"
2 (0-5)"
2 (1-5)"
10
50
90
100
100
90
100
0 (0-1)
I (0-3)
2 (0-18)
4 (1-11)
4 (1-13)
7 (0-13)
12 (2-22)
" p < 0.01; bp < 0.02; cp < 0.005; dp < 0.002 compared to controls
Table 3. Changes in the incidence of small bowel neoplasms
with time in the three dietary groups
Weeks
10
15
20
25
30
35
40
Vivonex
Vivonex +
Cholesterol
Controls
0
0
0
20
20
10
20
0
0
40
0
0
20
10
0
10
10
10
50
30
40
13041 B
120-
60-
z
~- 50z
o
0
40-
VCho[
30-
..a,
20-
jJ
" \,
.J
10O.J
10
15
20
25
30
TIME IN WEEKS
35
40
122
References
1. Armstrong B, Doll R (1975) Environmental factors and
cancer incidence and mortality in different countries, with
special reference to dietary practices. Int J Cancer 15:
617-631
2. Wynder EL, Reddy BS (1983) Dietary fat and fibre and
colon cancer. Semin Oncol 10:264-272
123
3. Burkitt DP (1971) Epidemiology of cancer of the colon
and rectum. Cancer 28:3-13
4. Reddy BS, Maeura Y (1984) Tumour promotion in AOM
induced carcinogenesis in female F334 rats: influence of
amount and source of dietary fat. J Natl Cancer Inst 72:
745 -750
5. Freeman HJ, Spiller GA, Kim YS (1980) A double blind
study on the effects of differing purified cellulose and
pectin fibre diets on 1,2-dimethylhydrazine-induced rat
colonic neoplasia. Cancer Res 40:2661 - 2665
6. Castleden WM (1977) Prolonged survival and decrease in
intestinal tumours in dimethylhydrazine-treated rats fed a
chemically defined diet. Br J Cancer 35:491-495
7. Cruse JP, Lewin MR, Ferulano GP, Clark CG (1978) Cocarcinogenic effects of dietary cholesterol in experimental
colon cancer. Nature (London) 276:822-825
8. Fleiszer D, Murray D, MacFarlane J, Brown RA (1978)
Protective effect of dietary fibre against chemically induced bowel tumours in rats. Lancet ii:552-553
9. Fleiszer DM, Murray D, Richards GK, Brown RA (1980)
Effects of diet on chemically induced bowel cancer. Can J
Surg 23:67-73
10. Janne P, Carpentier Y, WiUems G (1977) Colonic mucosal
atrophy induced by a liquid elemental diet in rats. Am J
Dig Dis 22:808-812
11. Morin CL, Ling V, Bourassa D (1980) Small intestinal and
colonic changes induced by a chemically defined diet. Dig
Dis Sci 25:123-128
12. Crowther JS, Drasar BS, Goddard P, Hill MJ, Johnson K
(1973) The effect of a chemically defined diet on the faecal
flora and faecal steroid concentration. Gut 14:790-793
13. Nelson LM, Carmichael HA, Russell RI, Atherton AT
(1977) Use of an elemental diet (Vivonex) in the management of bile acid-induced diarrhoea. Gut 18:792- 794
14. Christie WW:(1973) The isolation of lipids from tissue. In:
Christie WW (1973) Lipid analysis. Pergamon Press, Oxford, p 30-41
15. Stabler F, Gruber W, Stinshoff K, Roschlau P (1977) Eine
praxisgerechte enzymatische Cholesterin-Bestimmung.
Med Lab 30:29-37
16. Takayama M, Itoh Smagasaki T, Tanimizu I (1977) A new
enzymatic method for determination of serum cholinecontaining phospholipids. Clin Chim Acta 79:93-98
17. Russell RI (1975) Elemental diets. Gut 16:68-79
18. Tatsuta M, Yamamura H, Ishi H, Ichii M, Noguchi H,
Baba M, Taniguchi H (1985) Effect of a chemically
19.
20.
21.
22.
23.
24.
25.
26.
27.
Col6i'eeial
Disease
9 Springer-Verlag 1988
Abstract. In a p r o s p e c t i v e r a n d o m i s e d trial, 43
patients with b l e e d i n g h a e m o r r h o i d s were allocated to receive either a b u l k laxative with
injection o f p h e n o l (5%) in arachis oil (20 patients) ( G r o u p 1), or a b u l k laxative a l o n e (23
patients) ( G r o u p 2). T r e a t m e n t was given b y one
a u t h o r a n d patients were assessed " b l i n d " b y the
other at 6 weeks, 3 m o n t h s a n d finally at 6
months. At 6 weeks 12 (48%) in G r o u p 1 a n d 12
(57%) in G r o u p 2 were still bleeding (NS; 3(2=
0.54). At 3 m o n t h s 10 (40%) in g r o u p 1 a n d 6
(35%) in g r o u p 2 (NS; X2=0.10), a n d at 6 m o n t h s
10 (43%) in g r o u p 1 a n d 7 (47%) in g r o u p 2 were
still bleeding (NS; ;(2 =0.04). N o significant difference in b l e e d i n g at 6 m o n t h s after either
injection s c l e r o t h e r a p y with b u l k laxative or b u l k
laxatives alone was found.
Results
There were 28 m e n a g e d b e t w e e n 20 a n d 79 years
( m e a n 47.8 years) a n d 15 w o m e n aged b e t w e e n
24 a n d 65 years ( m e a n 42.2 years).
N o patient r e p o r t e d u n t o w a r d side effects
f r o m injections. Six patients could not tolerate
sterculia and were given i s p a g h u l a as an alternative b u l k laxative within 4 days o f stopping the
former. All the patients a d m i t t e d to taking the
b u l k laxative regularly.
O n e patient in G r o u p 2 was s u b s e q u e n t l y
f o u n d to h a v e a sigmoid a d e n o m a a n d a n o t h e r
patient in G r o u p 2 did not attend for follow-up at
125
Table 1. Changes in denominator in Groups 1 and 2
Randomisation
6 weeks
3 months
6 months
2 lost follow-up
Group 1
20
> 24
f
Group 2
23
25
4 bleeding
worse
~ 21
/ I ~ 23
1 bleeding
worse
> 17
1 lost follow-up
1 sigmoid adenoma
15
1 lost follow-up
] C - ~ o u p 1 E~dklaxative& injection
80
[]
60,
% bleeding
,0.
~i
801(:0.
0/52
6/52
3/12
6/12
% bleeding ! t
[]
[]
% not bleeding
1
0/52
6/52
3/12
6/12
126
Acknowledgement. We
References
1. Anon (1975) Outpatient treatment of haemorrhoids. Br
IVied J 1:651
2. Graham-Stewart CW (1962) Injection treatment of haemorrhoids. Br Med J 1:213-6
3. Greca F, Hares MM, Nevah E, Alexander-Williams J,
Keighley MRB (1981) A randomised trial to compare
rubber band ligation with phenol injection for treatment
of haemorrhoids. Br J Surg 68:250-2
4. Sim AJW, Murie JA, Mackenzie I (1981) Comparison of
rubber band ligation and sclerosant injection for first and
second degree haemorrhoids. Acta Chir Scand 147:71720
5. Cheng FCY, Shum DWP, Ong GB (1981) The treatment
of second degree haemorrhoids by injection, rubber band
ligation, maximal anal dilatation, and haemorrhoidectomy:
a prospective clinical trial. Aust N Z J Surg 51:458-62
6. Leicester RJ, Nicholls RJ, Mann CV (1981) Infrared
coagulation: a new treatment for haemorrhoids. Dis Colon
Rectum 24:602-5
7. Gartell PC, Sheridan RJ, McGinn FP (1985) Out-patient
treatment of haemorrhoids: a randomised clinical trial to
compare rubber band ligation with phenol injection. Br J
Surg 72:478-479
8. Hunt PS, Korman MG (1981) Fybogel in haemorrhoid
treatment. Med J Aust 2:256-8
9. Moesgaard F, Nielsen ML, Hansen JB, Knudson JT
(1982) High fibre diet reduces bleeding and pain in
patients with haemorrhoids. Dis Col Rectum 25:454-6
10. Webster DJT, Gough DCS, Craven JL (1981) The use of
bulk evacuant in patients with haemorrhoids. Br J Surg
65:291-2
11. Broader JH, Gunn IF, Alexander-Williams J (1974) Evaluation of a bulk forming evacuant in the management of
haemorrhoids. Br J Surg 61:142-4
12. Keighley MRB, Buchmann P, Minervini S, Arabi Y,
Alexander-Williams J (1979) Prospective trials of minor
surgical procedures and high fibre diet for haemorrhoids.
Br Med J 2:967-9
13. O'Callaghan JD, Matheson TS, Hall R (1982) In-patient
treatment of prolapsing piles: cryosurgery versus MilliganMorgan haemorrhoidectomy. Br J Surg 69:157-9
Accepted: 23 February 1988
Mr. R. J. Nicholls
Consultant Surgeon
St. Thomas' Hospital
London SE1 7EH
UK
Col61"eclal
Disease
9 Springer-Verlag 1988
How I do it
Abstract. Local recurrence of rectal adenocarcinoma is mainly due to failure to remove all the
tumour. A method is described for the routine
detection of involvement of the circumferential
(lateral) resection margin. Current definitions of
the length of the rectum are inadequate for the
assessment of the risk of local recurrence as the
rectum frequently extends higher than 15 cm. Use
of the term recto-sigmoid should be replaced
clinically by sigmoidoscopic measurement of the
height of a tumour and pathologically by its
anatomical relationship to the level of peritoneal
reflection, i.e. lower or upper segment of the
rectum or the sigmoid colon. Tumours above the
peritoneal reflection (upper segment) are at risk
of circumferential resection margin involvement
due to their retroperitoneal component. The
amount of tissue excised varies considerably from
surgeon to surgeon. Meticulous attention to the
clearance of the tumour at the circumferential
resection margin is essential if local recurrence
rates are to be reduced. A trial of postoperative
radiotherapy should be instigated based on the
pathologist's identification of patients at high risk
of local recurrence.
128
Method
129
130
131
References
1. Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local
recurrence of rectal adenocarcinoma due to inadequate
surgical resection. Histopathological study of lateral tumour
spread and surgical excision. Lancet 2:996-999
2. Heald RJ, Ryall RDH (1986) Recurrence and survival after
total mesorectal excision for rectal cancer. Lancet 1:
1479-1482
3. Williams PL, Warwick R (eds) (1980) Gray's anatomy, 36th
edn. Churchill Livingstone, London
Col6i'ee/al
Disease
9 Springer-Verlag 1988
Rare disorders
Abstract. R e c t a l v a r i c e s r e p r e s e n t a r a r e c o n d i t i o n
e v e n in c a s e s o f p o r t a l h y p e r t e n s i o n . A c a s e o f
b l e e d i n g a n o - r e c t a l v a r i c e s p r e s e n t i n g as t h e first
m a n i f e s t a t i o n o f p o r t a l h y p e r t e n s i o n is r e p o r t e d .
T r e a t m e n t b y s c l e r o t h e r a p y w a s successful.
Case report
A 90-year-old woman with chronic cardiac failure was admitted as an emergency with massive rectal bleeding. Eight
133
Table 1. Rectal varices reported in the literature
Comment
Authors
Case
Bleed- Therapy
number ing
Yes
1
1
1
2
4
No
Yes
Yes
Yes
Yes
1
2
No
Yes
Death (hemorrhagy)
Colonic resection
No treatment
No treatment
Ligation of varices
Mesenterico-caval shunt
Cryotherapy
Ligation of varices
No treatment
134
References
1. Lebrec D, Benhamou JP (1985) Ectopic varices in portal
hypertension. Clin Gastroenterol 14:105-121
2. Nivatvongs S (1985) Suture of massive hemorrhoidal
bleeding in portal hypertension. Dis Col Rect 28:
878-879
3. Marti M-C (1982) La maladie hemorroidaire et son traitement. Rev Med Suisse Romande 102:359-368
4. Hamlyn AN, Morris JS, Lunzer MR, Puritz H (1974)
Portal hypertension with varices in unusual sites. Lancet
II:1531-1534
5. Mashiah A (1981) Massive bleeding from hemorrhoidal
varices in portal hypertension. JAMA 246:2323-2324
6. Jacobs DM, Bubrick MP, Onstad GR, Hitchcock CR
(1980) The relationship of hemorrhoids to portal hypertension. Dis Col Rect 23:567-569
7. Berson H, Woringer M (1961) Varices coliques chez une
malade ayant subi une ligature de la veine cave inferieure.
J Radio142:416
Col6i ec/al
Disease
9 Springer-Verlag 1988
Current practice
Is the Kock pouch still a viable option?
A. M. Vernava, III. and S. M. Goldberg
Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota, USA
Development
The continent ileostomy was initially described by
Kock in 1969 to provide a continent alternative for
ileostomates and thereby obviate many of the
physical and psychosocial difficulties which accompany a conventional eversion ileostomy [1].
His initial considerations were revolutionary and
included an internal ileal reservoir for storage, a
nipple valve to maintain continence and the
elimination of a protruding stoma and external
appliances. To the extent that the operation provided continence, he and others were immensely
successful. Many authors, including Kock, report
almost universal improvement in the quality of
General complications
136
Table 1. Current complicationsfollowingcontinent ileostomy
Pouch ileitis
Nipple valve slippage
Fistulae
Stomal stricture
Nipple prolapse
Stomal necrosis
Complicationsrequiring revisional
surgery
15-30%
3-25 %
0-10%
@ 10%
4-6%
?
12-25%
teric stripping has resulted in a small but unspecified n u m b e r of patients with ischaemic necrosis of the nipple valve. Further modification of
the technique by Kock [6] and Skinner [11],
including the use of the less traumatic TA55,
removal of the distal 10 staples prior to engagement of the stapler and less aggressive mesenteric
stripping has resulted in a reduction in the incidence of this difficult problem. The precise
impact of stomal necrosis on current stabilisation
techniques is difficult to assess since most current
authors do not report this complication.
Stomal stricture
It is not the purpose of this paper to describe current operative techniques for the construction of a
continent ileostomy; these are well documented
elsewhere [6, 8, 12]. However, the authors would
like to make several points which have been stressed
137
The contemporary indications for continent ileostomy are essentially those for restorative proctocolectomy and include ulcerative colitis and polyposis coli (Table 2). An occasional patient with
another condition such as multiple colo-rectal
carcinoma may also benefit from the construction
of a Kock pouch. As alluded to earlier, the ileoanal reservoir has provided for many patients an
opportunity for restoration of the normal defaecation pathway and is now the preferred alternative
to conventional ileostomy [14, 15]. However, the
ileo-anal reservoir is not suitable for all patients
who require proctocolectomy. Impaired continence
and even patient preference are instances when
restorative proctocolectomy would be unsuitable.
In these patients the Kock pouch provides a
continent alternative to conventional ileostomy.
In addition the continent ileostomy provides an
acceptable therapeutic alternative to the resection
of 50 cm of small intestine in the patient with a
failed ileo-anal reservoir. The incidence of failure
of the ileo-anal reservoir, due to either pelvic
sepsis or a poor functional result, is between 5%
and 15% [14, 15]. An excellent description of the
technique used to convert an ileo-anal reservoir to
a continent ileostomy can be found in the article
by Hulten [16].
Contraindications
Ulcerative colitis
Impaired continence
Patient preference
Polyposis coli
Impaired continence
Patient preference
ment of the bowel at the time of operation account for the small number of patients with
Crohn's disease who undergo the continent ileostomy. Most authors would disagree with Bloom's
contention that patients having quiescent Crohn's
disease are suitable candidates for conversion to a
continent ileostomy [17]. Relative contraindications to the continent ileostomy include obesity
owing to mesenteric shortening, advanced age
and insufficient motivation.
Conclusion
138
improvement in the operative results of the continent ileostomy using contemporary surgical
techniques.
The answer to the question "Is the Kock
pouch still a viable option?" is therefore unequivocally yes. Recent advances in surgical technique and postoperative care'qaave decreased the
incidence of complications tO acceptable levels
when performed by experienced surgeons. Patients unsuited to restorative proctocolectomy and
those 5-15% of patients who have failed after
restorative proctocolectomy may desire a continent option. The Kock pouch still offers a
valuable alternative to conventional ileostomy in
these patients.
References
1. Kock NG (1969) Intra-abdominal "reservoir" in patients
with permanent ileostomy. Preliminary observations on a
procedure resulting in fecal continence in five ileostomy
patients. Arch Surg 99:223-231
2. Kock NG, Myrvold HE, Nilsson LD (1980) Progress
report on the continent ileostomy. World J Surg 4:143-8
3. Kock NG, Myrvold HE, Nilsson LO, Philipson BM (1981)
Continent ileostomy. An account of 314 patients. Acta
Chir Scand 147:67-72
4. Gerber A, Apt MK, Craig PI~ (1984) The improved
quality of life with the Kock continent ileostomy. J Clin
Gastroenterol 6:513-7
5. Mcleod RS, Fazio VW (1984) Quality of life with the
continent ileostomy. World J Surg 8:90-5
6. Kock NG, Brevinge H, Philipson BM, Ojerskog B (1986)
Continent ileostomy. The present technique and long term
results. Ann Chir Gynaecol 75:63-70
A nnouncement
Tripartite Meeting
The meeting will be held from 19 to 22 June 1989 at the Metropole Hotel, National Exhibition Centre, Birmingham, England.
For further information contact:
Great Britain: Ms. Judy Cook, Sections Office, Royal Society
of Medicine, 1 Wimpole Street, London W1M 8AE, UK.
Mr. R. H. Grace, FRCS, Consultant Surgeon, The Royal Hospital, Wolverhampton WV2 1BT, UK.
Colonic & Rectal Surgery, Royal Australasian College of Surgeons, College of Surgeons' Gardens, Spring Street, Melbourne
3000, Victoria, Australia.
138
improvement in the operative results of the continent ileostomy using contemporary surgical
techniques.
The answer to the question "Is the Kock
pouch still a viable option?" is therefore unequivocally yes. Recent advances in surgical technique and postoperative care'qaave decreased the
incidence of complications tO acceptable levels
when performed by experienced surgeons. Patients unsuited to restorative proctocolectomy and
those 5-15% of patients who have failed after
restorative proctocolectomy may desire a continent option. The Kock pouch still offers a
valuable alternative to conventional ileostomy in
these patients.
References
1. Kock NG (1969) Intra-abdominal "reservoir" in patients
with permanent ileostomy. Preliminary observations on a
procedure resulting in fecal continence in five ileostomy
patients. Arch Surg 99:223-231
2. Kock NG, Myrvold HE, Nilsson LD (1980) Progress
report on the continent ileostomy. World J Surg 4:143-8
3. Kock NG, Myrvold HE, Nilsson LO, Philipson BM (1981)
Continent ileostomy. An account of 314 patients. Acta
Chir Scand 147:67-72
4. Gerber A, Apt MK, Craig PI~ (1984) The improved
quality of life with the Kock continent ileostomy. J Clin
Gastroenterol 6:513-7
5. Mcleod RS, Fazio VW (1984) Quality of life with the
continent ileostomy. World J Surg 8:90-5
6. Kock NG, Brevinge H, Philipson BM, Ojerskog B (1986)
Continent ileostomy. The present technique and long term
results. Ann Chir Gynaecol 75:63-70
A nnouncement
Tripartite Meeting
The meeting will be held from 19 to 22 June 1989 at the Metropole Hotel, National Exhibition Centre, Birmingham, England.
For further information contact:
Great Britain: Ms. Judy Cook, Sections Office, Royal Society
of Medicine, 1 Wimpole Street, London W1M 8AE, UK.
Mr. R. H. Grace, FRCS, Consultant Surgeon, The Royal Hospital, Wolverhampton WV2 1BT, UK.
Colonic & Rectal Surgery, Royal Australasian College of Surgeons, College of Surgeons' Gardens, Spring Street, Melbourne
3000, Victoria, Australia.
Answers: (1) Failure to distend a narrowed segment in the very distal sigmoid colon, where the mucosal
folds are therefore more prominent - the so called "crumpled paper" or "tacked down" appearance.
Note the normal mucosa through this segment. (2) Pericolic disease which has adhered to the sigmoid
colon preventing complete distension. (3) (a) adjacent abscess (diverticular disease); (b) adjacent
inflammation (Crohn's disease); (c) adhesions (previous operation); (d) tumour (primary extracolonic invasion or mural metastatic deposits). (4) There are no sigmoid diverticula and hence a
diverticular abscess would be very atypical. Adhesions involving the colon would similarly be extremely
atypical. There is no "mass effect" indenting the colon to indicate an adjacent tumour. On the lateral
film anterior to the rectum is an atypical small bowel loop (outlined with air) and the combination of
the large bowel signs and this loop strongly suggests Crohn's disease. (5) Small bowel study.
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