Fiorella Anzini

Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders

AIM To prospectively assess the efficacy and safety of stapled trans-anal rectal resection (STARR) compared to standard conservative treatment, and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR. METHODS Thirty patients (Female, 28; age: 51 ± 9 years) with rectocele or rectal intussusception, a defecation disorder, and functional constipation were submitted for STARR. Thirty comparable patients (Female, 30; age 53 ± 13 years), who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol, were assessed. Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment. A responder was defined as an absence of the Rome III diagnostic criteria for functional constipation. Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients, respectively. RESULTS After STARR, 53% of patients were responders; during conservative treatment, 75% were responders. After STARR, 30% of the patients reported the use of laxatives, 17% had intermittent anal pain, 13% had anal leakage, 13% required digital facilitation, 6% experienced defecatory urgency, 6% experienced fecal incontinence, and 6% required re-intervention. During macrogol therapy, 23% of the patients complained of abdominal bloating and 13% of borborygmi, and 3% required digital facilitation. No preoperative symptom, defecographic, or manometric finding predicted the outcome of STARR. Post-operative defecography showed a statistically significant reduction (P < 0.05) of the rectal diameter and rectocele. The post-operative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified, and that rectal compliance was reduced (P = 0.01). CONCLUSION STARR is not better and is less safe than macrogol in the treatment of defecation disorders. It could be considered as an alternative therapy in patients unresponsive to macrogol.

Intraluminal pH and Oesophageal Motility in Patients with Gastro-Oesophageal Reflux

The effect of intraluminal pH on motor activity of the lower oesophageal body was studied in patients with pathological gastro-oesophageal reflux. Liquid boluses with a pH range of 6.98-1.1, infused in the distal oesophagus of 21 patients during manometric recording of motor activity, elicited either secondary peristalsis or simultaneous contractions. Acid pH did not affect the threshold of distension required to elicit secondary peristalsis. Oesophageal responses to volumes of instillate did not differ in patients with normal and abnormal acid clearing test, nor in patients with a negative and positive acid perfusion test.

Effect of Bombesin on Lower Esophageal Sphincter Pressure in Humans

Intravenous infusion of bombesin in humans results in increased serum gastrin levels and increased lower esophageal sphincter pressure. To differentiate a gastrin- from a nongastrin-mediated mechanism, the effect of intravenous bombesin infusion on lower esophageal sphincter pressure was studied in 5 healthy subjects and in 5 antrectomized patients. Lower esophageal sphincter pressure was recorded by three continuously perfused catheters with side-openings located 5 mm apart. Blood samples were taken at regular intervals during the study periods to assay gastrin and pancreatic polypeptide. Manometric tracings and blood samples were coded and evaluated blindly. Lower esophageal sphincter pressure increased during bombesin infusion both in normal and antrectomized subjects. The increase had a delayed onset and persisted after discontinuation of bombesin. No correlation was found between lower esophageal sphincter pressure and serum gastrin or pancreatic polypeptide values. These data indicate that the effect of bombesin on lower esophageal sphincter pressure is not gastrin or pancreatic polypeptide mediated.

Muscular and neuromuscular esophageal motor alterations in Steinert's myotonic dystrophy

• ABNORMAL GASTROINTESTINAL TRANSIT IN RATS WITH CHRONIC ILEITIS. V M Pifieiro-Carrero, C Sullivan, NAli , J Goldhill, T Shea-Donohue. Departments of Pediatrics and Medicine, USUHS, Bethesda, MD. Patients with Crohns disease often complain of postprandial abdominal pain and early satiety, These symptoms may contribute to the anorexia and poor oral intake seen in these patients. We have previously demonstrated that acute ileitis eausas marked alterations in intestinal myoelectric activity. Our objective was to further investigate intestinal motility in an animal model of chronic ileitis. METHODS: Inbred female Lewis rats (180 220g) were sensitized with a s.c. injection of trinitrnbenzene sulfonic acid (TNBS, 2.5 rag) mixed with incomplete Freunds adjuvant or adjuvant alone. Seven days later, TNBS (100 mg/kg) in 50% ethanol or saline (1 ml) was given intraluminally 30 cm proximal to the ileocecal junction. The rats were studied 3 or 7 days later. Small intestinal transit (SIT, geometric center) and gastric emptying (GE, % emptied from stomach) were determined by measuring the progress of an 5= IG bolus (0.2 mL) of Cr (5 p_Ci/rat). After 25 min, the rats were sacrificed and the intestine was divided into 10 equal segments and counted..RESULTS: In TNBS-treated rats, microscopic findings on day 3 included mucosal atrophy, edema of lamina propria and PMN infiltration. By day 7, rats had developed thickened bowel wall, adhesions, intestinal perforation (33%) and histologic findings of lymphocytic infiltration and circular muscle hypertrophy. GE was reduced by 44% at 3 days but returned to normal by day seven. SIT was delayed on both days.