Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM： TO evaluate the status of anorectal function after repeated transanal endoscopic microsurgery （TEN）. METHODS： Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large （〉 1 cm） polyps in the remaining rectum （range： 6-20 cm from the anal edge）. All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a question- naire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maxi- mum squeeze pressure, maximum tolerable volume （MTV） and rectoanal inhibitory reflexes （RAIR） were recorded. The integrity and thickness of the internal anal sphincter （IAS） and external anal sphincter （EAS） were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life （QoL）. RESULTS： All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38±5 mmHg to 19±3 mmHg （38±5 mmHg vs 19±3 mmHg, P = 0.000） and MTV from 165± 19mLto60± 11mL（165± 19mLvs60± 11 mL, P = 0.000） at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg （38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057） and 159 ± 19 mL （165 ± 19 mL vs 159 ± 19 mL, P = 0.071）, respectively, at month 6 after TEM. Maximal squeeze pressure de- creased from 171 ± 19 mmHg to 62 ± 12 mmHg （171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000） at week 2 after operation, and returned to normal values by postoperative month 3 （171 ± 19 vs 166 ± 18, P = 0.051）. RAIR were absent in 4 patients preoperatively and in 12 （χ2 = 4.947, P = 0.026） patients at month 3 after surgery. PAIR was absent only in 5 patients at postoperative month 6 （χ2 = 0.141, P = 0.707）. Endo- sonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary inconti- nence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm （1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000） at postoperative month 3 and increased to 1.8 ± 0.5 mm （1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239） at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm （3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510） at month 3 and then increased to 3.6 ± 0.4 mm （3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123） at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 pa- tients. With regard to the QoL, the physical and mental health status scores （SF-36） were 56.1 and 46.2 （50 in the general population）, respectively.CONCLUSION： The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.

Effect of 5-HT1 agonist (sumatriptan) on anorectal function in irritable bowel syndrome patients

AIM： To evaluate the effect of sumatriptan, a selective 5-HT1 agonist, on anorectal function in irritable bowel syndrome （IBS） patients. METHODS： Twenty-two IBS patients selected according to the Rome II criteria （F 15, M 7; mean age 29.3±6.8, range 22-44 years） were examined. The study was blind, randomized and placebo-controlled with a crossover design. Anorectal manometry and rectal balloon distension test were performed before and after the administration of placebo and sumatriptan. RESULTS： The administration of sumatriptan caused a significant increase in the resting anal canal pressure from 9.2±2.0 kPa to 13.1±3.3 kPa （P〈0.0001） connected with the increase in the anal sphincter length and high pressure zone. After sumatriptan injection a remarkable increase in the threshold for the first sensation from 27±9 mL to 34±12 mL （P〈0.05） and urge sensation from 61±19 mL to 68±18 mL （P〈0.01） was observed. Sumatriptan did not affect either the volume evoking the rectoanal inhibitory reflex or the results of the straining test. CONCLUSION： 5-HT1 receptors participate in the regulation of anorectal function. Elucidation of the role of 5-HT1 receptors in the pathophysiological mechanisms of IBS may have some therapeutic implications.

Referral for anorectal function evaluation is indicated in 65% and beneficial in 92% of patients

AIM: To determine the indicated referrals to a tertiary centre for patients with anorectal symptoms, the effect of the advised treatment and the discomfort of the tests.METHODS: In a retrospective study, patients referred for anorectal function evaluation (AFE) between May 2004 and October 2006 were sent a questionnaire, as were the doctors who referred them. AFE consisted of anal manometry, rectal compliance measurement and anal endosonography. An indicated referral was defined as needing AFE to establish a diagnosis with clinical consequence (fecal incontinence without diarrhea, 3rd degree anal sphincter rupture, congenital anorectal disorder, inflammatory bowel disease with anorectal complaints and preoperative in patients for re-anastomosis or enterostoma, anal fissure, fistula or constipation). Anal ultrasound is always indicated in patients with fistula, anal manometry and rectal compliance when impaired continence reserve is suspected. The therapeutic effect was noted as improvement, no improvement but reassurance, and deterioration.RESULTS: From the 216 patients referred, 167 (78%) returned the questionnaire. The referrals were indicated in 65%. Of these, 80% followed the proposed advice. Improvement was achieved in 35% and a reassurance in 57% of the patients, no difference existed between patient groups. On a VAS scale (1 to 10) symptoms improved from 4.0 to 7.2. Most patients reported no or little discomfort with AFE. CONCLUSION: Referral for AFE was indicated in 65%. Beneficial effect was seen in 92%: 35% improved and 57% was reassured. Advice was followed in 80%. Better instruction about indication for AFE referral is warranted.

Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry

BACKGROUND The quality of life in patients who develop low anterior resection syndrome(LARS)after surgery for mid-low rectal cancer is seriously impaired.The underlying pathophysiological mechanism of LARS has not been fully investigated.AIM To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively.METHODS Patients diagnosed with mid-low rectal cancer were included.The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure.Anorectal functions were assessed by threedimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery.RESULTS The study population consisted of 24 patients.The total LARS score was decreased at 6 mo compared with 3 mo after surgery(P<0.05),but 58.3%(14/24)lasted as major LARS at 6 mo after surgery.The length of the high-pressure zone of the anal sphincter was significantly shorter,the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in allpatients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focalpressure defects of the anal canal were detected in 70.8% of patients, and those patients had higherLARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spasticperistaltic contractions from the new rectum to anus were detected in 45.8% of patients, whichwere associated with a higher LARS score at 3 mo postoperatively (P < 0.05).CONCLUSIONThe LARS score decreases over time after surgery in the majority of patients with mid-low rectalcancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spasticperistaltic contractions from the new rectum to anus postoperatively, might be the majorpathophysiological mechanisms of LARS.

Therapeutic effect of different treatment methods on functional anorectal pain

Objective： To observe the clinical efficacy of oral traditional Chinese medicine （Jiaweitiaoqi decoction）, electroacupuncture, biofeedback, and combined treatment on functional anorectal pain （FAP）. Methods： A total of 200 patients with FAP were randomly divided into 4 groups, with 50 patients in each group. Group 1 was given oral Jiaweitiaoqi decoction; group 2 was given electroacupuncture at the lumbosacral acupoints; group 3 was given biofeedback training; and group 4 was given combined treatment. The numeric rating scale （NRS）, Short Form-36 （SF-36） quality of life scale, static pressure of the anal canal, and maximum systolic pressure were observed in the 4 groups. Results： The observation indices of the 4 groups were all improved after treatment compared with those before treatment, and the fourth group showed the most obvious improvement. Regarding NRS scores, the static pressure of the anal canal, and maximum systolic pressure, group 4 had lower values than the other 3 groups （P 〈 0.05 for all）. In the SF-36 quality of life score, group 4 showed a higher value than the other 3 groups （P 〈 0.05）. Conclusion： Non-drug therapy including acupuncture and physical exercise can enhance the clinical efficacy of single Chinese medicine in the treatment of FAP .

Action mechanism of Zhitong Rushen Decoction in treating functional anorectal pain based on network pharmacology

Objective:Network pharmacology method was adopted in this study to screen the target of Zhitong Rushen Decoction of the treatment to Functional Anorectal Pain(FAP)and explore its mechanism of treatment.Methods:Chemical components and selected targets related to the ten traditional Chinese medicine(TCM)herbs were searched through the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform(TCMSP).Through GeneCards database,OMIM database,disease targets of FAP were searched.R language was used to screen the common targets between drugs and disease,and then the interaction network diagram of the targets was constructed by String.Cytoscape3.7.0 was applied to construct the active ingredients-targets interacted network.GO enrichment analysis and KEGG enrichment analysis of targets were based on R language.Results:Four main chemical components including quercetin,wogonin,fisetin and kaempferol were screened,and four key targets including ESR1、NOS2、PGR and CHRM3 were identified.In GO enrichment analysis,66 molecular function entries,1040 biological process entries,26 cell component entries were obtained.KEGG pathway enrichment analysis showed that zhitong rushen decoction played a therapeutic role in functional anorectal pain by regulating AGE-RAGE signaling pathway in diabetic complications,Bladder cancer,Estrogen signaling pathway,HIF-1 signaling pathway.Conclusion:Zhitong rushen decoction for the treatment of functional anorectal pain may be related to its multi-component effect on multiple targets and multiple signaling pathways,providing theoretical basis for further study of active ingredients and mechanism of action.

Thirty-six cases of functional anorectal pain treated with heat-sensitization moxibustion

Objective To explore the clinical effects of heat-sensitizing moxibustion on functional anorectal pain. Methods Thirty six patients with functional anorectal pain were treated with moxibustion on heat-sensitive acupuncture points.The heat-sensitized points include Chángqiáng（长强 GV l）, Cìliáo（次髎 BL 32）, Yāoshū（腰俞 GV 2）, and local perianal points. A course of treatment consisted of treatment at each heat-sensitized point for 15 min once per day for 10 days. The therapeutic effects were observed after continuous treatment for 3 treatment cycles. Results Twelve cases were cured, eleven cases had effective results, and 3 cases were ineffective. The total effectiveness rate was 91.7%. The visual analog scale（VAS） total score was 6.1±1.52 before treatment and was 1.63±1.05 after treatment, showing a statistically significant difference（P〈0.01）. Conclusion Heat-sensitization moxibustion can significantly relieve functional anorectal pain.

Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy

BACKGROUND Severe chronic radiation proctopathy(CRP) is difficult to treat.AIM To evaluate the efficacy of colostomy and stoma reversal for CRP.METHODS To assess the efficacy of colostomy in CRP,patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled.Patients with tumor recurrence,rectal-vaginal fistula or other types of rectal fistulas,or who were lost to follow-up were excluded.Rectal bleeding,hemoglobin(Hb),endoscopic features,endo-ultrasound,rectal manometry,and magnetic resonance imaging findings were recorded.Quality of life before stoma and after closure reversal was scored with questionnaires.Anorectal functions were assessed using the CRP symptom scale,which contains the following items:Watery stool,urgency,perianal pain,tenesmus,rectal bleeding,and fecal/gas incontinence.RESULTS A total of 738 continual CRP patients were screened.After exclusion,14 patients in the colostomy group and 25 in the conservative group were included in the final analysis.Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L(P < 0.001) in the conservative group.All14 patients in the former group achieved complete remission of bleeding,and the colostomy was successfully reversed in 13 of 14(93%),excepting one very old patient.The median duration of stoma was 16(range:9-53) mo.The Hb level increased gradually from 75 g/L at 3 mo,99 g/L at 6 mo,and 107 g/L at 9 mo to111 g/L at 1 year and 117 g/L at 2 years after the stoma,but no bleeding cessation or significant increase in Hb levels was observed in the conservative group.Endoscopic telangiectasia and bleeding were greatly improved.Endoultrasound showed decreased vascularity,and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall.Anorectal functions and quality of life were significantly improved after stoma reversal,when compared to those before stoma creation.CONCLUSION Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP.Stoma can be reversed,and anorectal functions can be recovered after reversal.

Sphincter preservation for distal rectal cancer - a goal worth achieving at all costs?

To assess the merits of currently available treatment options in the management of patients with low rectal cancer, a review of the medical literature pertaining to the operative and non-operative management of low rectal cancer was performed, with particular emphasis on sphincter preservation, oncological outcome, functional outcome, morbidity, quality of life, and patient preference. Low anterior resection (AR) is technically feasible in an increasing proportion of patients with low rectal cancer. The cost of sphincter preservation is the risk of morbidity and poor functional outcome in a significant proportion of patients. Transanal and endoscopic surgery are attractive options in selected patients that can provide satisfactory oncological outcomes while avoiding the morbidity and functional sequelae of open total mesorectal excision. In complete responders to neo-adjuvant chemoradiotherapy, a non-operative approach may prove to be an option. Abdominoperineal excision (APE) imposes a permanent stoma and is associated with significant incidence of perineal morbidity but avoids the risk of poor functional outcome following AR. Quality of life following AR and APE is comparable. Given the choice, most patients will choose AR over APE, however patients following APE positively appraise this option. In striving toward sphincter preservation the challenge is not only to achieve the best possible oncological outcome, but also to ensure that patients with low rectal cancer have realistic and accurate expectations of their treatment choice so that the best possible overall outcome can be obtained by each individual.

Observation on Curative Effect of Self-made Wubeizi Decoction Combined with rhaFGF in Promoting Postoperative Wound Healing in Patients with Anal Fistula

[Objectives]To explore the curative effect of Self-made Wubeizi Decoction combined with recombinant human acidic fibroblast growth factor(rhaFGF)in promoting postoperative wound healing in patients with anal fistula.[Methods]A total of 82 patients with anal fistula who underwent anal fistula resection+use of setons in Luodian Hospital during January and March of 2020 were randomly divided into observation group and control group with 41 cases in each group.The control group was given rhaFGF external application regimen,and the observation group was treated with Self-made Wubeizi Decoction on the basis of the control group.After 3 weeks of treatment,the differences in curative effects of TCM syndromes were compared between the two groups.Besides,the changes in TCM symptom scores,inflammatory mediators[interleukin-12(IL-12),tumor necrosis factor-α(TNF-α),interferon-γ(IFN-γ)],anorectal functions[anal resting pressure(ARP),maximal systolic pressure(MSP)and maximum tolerated volume(MTV)of the anal canal],quality of life[GQOLI-74 scores]were compared.[Results]After 3 weeks of treatment,the total effective rate of the observation group was significantly higher than that of the control group(P<0.05);the levels of TCM symptom scores,IL-12,TNF-α,IFN-γ,ARP,MSP,and MTV in both groups were significantly lower than those before treatment,and these levels in the observation group was significantly lower than that in the control group at the same time(P<0.05).The GQOLI-74 scores of both groups were significantly higher than those before treatment,and the observation group was significantly higher than the control group(P<0.05).[Conclusions]The Self-made Wubeizi Decoction combined with rhaFGF therapy has a significant effect in promoting postoperative wound healing in patients with anal fistula.It can effectively inhibit the local inflammation of patients,facilitate the recovery of anorectal function and improve the quality of life,thus has high clinical application value.

Efficacy evaluation of electroacupuncture at Dong’s points combined with biofeedback in the treatment of functional anorectal pain

Objective:To investigate the clinical effect of electroacupuncture combined with biofeedback on functional anorectal pain.Methods:Sixty patients diagnosed functional anorectal pain were divided into three groups by random number table,namely electroacupuncture group,biofeedback group,and combination group,with 20 patients in each.In the electroacupuncture group,the electroacupuncture at Dong’s points Sānqí(三其穴),including Qímén(其门),Qíjiǎo(其角),and Qízhéng(其正),and Línggǔ(灵骨),Dàbái(大白),Chángmén(肠门)of both sides was given;in the Biofeedback group,the biofeedback therapy was adopted;in the combination group,the electroacupuncture and biofeedback therapy were used.All patients were treated once a day,30 min each time,10 consecutive treatments as one treatment course,and the therapeutic effect was evaluated after 3 treatment courses.The observation indexes after the intervention:Visual analogue Scale(VAS)score,SF-36 Quality of Life Scale score,Self-rating Anxiety Scale(SAS)score,Self-rating Depression Scale(SDS)score,Anorectal manometry,Clinical efficacy,and patients’adverse reactions.Results:After treatment,the pain of patients in the three groups was alleviated than that before treatment,VAS score,SAS score,SDS score,and anorectal pressure were decreased(P<0.05),and SF-36 Quality of Life Scale score was increased(P<0.05).After treatment,in the combination group,the VAS scores,SAS scores,SDS scores,and Anal-rectal pressure scores were lower than those in the other two groups(P<0.05),and SF-36 Quality of Life Scale scores were higher than those in the other two groups(P<0.05),the total effective rate was 80.0%(16/20),which was significantly higher than that of the electroacupuncture group(55.0%,11/20)and the biofeedback group(40.0%,8/20)(both P<0.05).No adverse reactions occurred in all three groups.Conclusion:Electroacupuncture at Dong’s points combined with biofeedback therapy has a significant effect on functional anorectal pain.The combined application of electroacupuncture and biofeedback therapy has a synergic action,and the analgesic effect is better than that of only using electroacupuncture or biofeedback therapy.

Evaluation of pelvic visceral functions after modified nerve-sparing radical hysterectomy

Background Nerve-sparing radical hysterectomy （NSRH） was developed in an attempt to minimize complications after radical hysterectomy.Since 2008,a modified NSRH-nerve plane-sparing radical hysterectomy （NPSRH） has been developed at the Cancer Hospital,Chinese Academy of Medical Sciences.The aim of this study was to investigate the role of NPSRH in improving postoperative pelvic visceral dysfunctions.Methods Eighty-three patients with International Federation of Gynecology and Obstetrics （FIGO） stage IB1-IIA2 cervical cancer received NPSRH （the study group） from January 2008 to October 2012.One hundred and sixty-six patients who underwent conventional radical hysterectomy （CRH） were randomly selected as the control group.Age,pathological type and stage were matched between the two groups.The safety of surgery was assessed by duration of operation and blood transfusion rate.Postoperative short-term bladder function was analyzed by duration of catheterization.Long-term bladder,anorectal and sexual function were evaluated with questionnaires.Results Seventy-eight patients （94.0%） in the NPSRH group and one hundred and sixty patients （96.4%） in the CRH group completed the study.Median follow-up time was 31.9 months and 31.0 months respectively （P=0.708）.There was no significant difference between the two groups in terms of age,body mass index,FIGO stage,pathologic type,preoperative and postoperative therapy （P 〉0.05）.The blood transfusion rate shared no difference between two groups （P=0.364）.The operation time in the NPSRH group was significantly longer than CRH group （P 〈0.01）.But the duration of catheterization and hospitalization in the NPSRH group was significantly reduced compared with CRH group （P 〈0.01）.In addition,the incidence of long-term urinary frequency,urinary incontinence,urinary retention,straining to void,constipation and diarrhea was significantly lower in the NPSRH group （P 〈0.05）.However,there was no significant difference regarding sexual function （P 〉0.05）.Conclusions The current evidence indicated that NPSRH improved long-term bladder function compared to CRH.Moreover,it may improve long-term anorectal function as well.

Sensory threshold for defecation and its correlation with pelvic organ prolapse:An exploration of related factors

Objectives This research aimed to investigate changes in defecation sensory threshold and related factors in patients with posterior vaginal wall prolapse.Methods A total of 214 patients with pelvic organ prolapse were recruited between October 2019 to January 2021.All patients underwent a defecation sensory threshold examination,physical examination,and pelvic floor ultrasound examination.Factors related to the defecation sensory threshold were analyzed.Results(1)Among the participants,57 patients(26.6%)had a defecation sensory threshold of more than 90ml.Patients with a threshold>90ml showed higher scores of defecation dysfunction in the Constipation Scoring System(CSS)score(p=0.003)and higher scores of constipation in the Colorectal-anal Distress Inventory 8(CRADI-8)score(p=0.002).(2)The defecation sensation threshold positively correlated with the Ap point(r=0.448,p<0.001),the Bp point(r=0.345,p=0.009),the area of the levator-ani hiatus measured by transvaginal ultrasound(r=0.403,p=0.002),and parity(r=0.355,p=0.007).Conclusions Patients diagnosed with pelvic organ prolapse commonly experience an increased threshold of defecation sensation.Elevated thresholds were associated with more frequent constipation symptoms.Additionally,the severity of posterior pelvic prolapse positively correlated with the defecation sensory threshold.