Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy.

BACKGROUND: Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers. METHODS: Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing. RESULTS: Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers. CONCLUSIONS: Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.

The economic impact of drying off cows with a dry-off facilitator (cabergoline) compared with 2 methods of gradual cessation of lactation for European dairy farms.

An abrupt method to dry off cows has disadvantages and is considered inappropriate for current dairy cows due to welfare issues and risks for intramammary infections (IMI). A gradual cessation of lactation (by feeding or milking frequency reduction) has been the generally recommended method for drying off cows to prevent these adverse effects. However, a new alternative to the gradual approach is to abruptly stop milking at the same time as using cabergoline (CAB), a prolactin inhibitor. The aim of the study was to compare the net costs of 3 different methods of drying off cows [gradual reduction in feed (referred to as gradual feeding), gradual reduction in milking frequency (referred to as gradual milking), and abrupt cessation of milking with CAB]. A stochastic Monte Carlo simulation model, at cow level, was developed to calculate the net costs of applying these methods. All inputs for the model were based on literature information, authors' expertise, and expert knowledge. The net costs were determined by only including costs and benefits, which varied between the 3 methods. The model simulated a cow from 7 d before the day of drying off until the end of the next lactation. The likelihood of whether a cow was leaking milk early in the dry period was determined. Subsequently, it was determined whether or not the cow will get an IMI during the dry period, where the probability of getting an IMI was higher for cows leaking milk than for cows not leaking milk. If the IMI was not cured during the dry period, the cow had an IMI at calving. Also, milk production and feed requirements were modeled, and labor for applying the drying off method was included. For all methods, the net costs were calculated as the sum of costs for feed during the gradual feed reduction period, costs for applying the gradual-milking method, and the IMI costs during the dry period and lactation, minus the milk revenues during the transition from lactation to the dry period. Under default conditions, the average net cost of abrupt cessation of milking with CAB was €49.6/cow. The data showed that 90% of the net costs ranged from -€13.7 to €307.8/cow. The average net costs for gradual feeding and gradual milking were €99.1 and €71.5/cow, respectively. In conclusion, abrupt cessation of milking with CAB saved €49.5 and €21.9/cow on average compared with gradual feeding and gradual milking, respectively. This difference was mainly due to more milk returns and lower labor and IMI costs during lactation.

Skills among young and elderly laypersons during simulated dispatcher assisted CPR and after CPR training.

BACKGROUND: Dispatcher assisted cardiopulmonary resuscitation (DA-CPR) increase the rate of bystander CPR. The aim of the study was to compare the performance of DA-CPR and attainable skills following CPR training between young and elderly laypersons. METHODS: Volunteer laypersons (young: 18-40 years; elderly: > 65 years) participated. Single rescuer CPR was performed in a simulated DA-CPR cardiac arrest scenario and after CPR training. Data were obtained from a manikin and from video recordings. The primary endpoint was chest compression depth. RESULTS: Overall, 56 young (median age: 26, years since last CPR training: 6) and 58 elderly (median age: 72, years since last CPR training: 26.5) participated. Young laypersons performed deeper (mean (SD): 56 (14) mm vs. 39 (19) mm, P < 0.001) and faster (median (25th-75th percentile): 107 (97-112) per min vs. 84 (74-107) per min, P < 0.001) chest compressions compared to elderly. Young laypersons had shorter time to first compression (mean (SD): 71 (11) seconds vs. 104 (38) seconds, P < 0.001) and less hands-off time (median (25th-75th percentile): 0 (0-1) seconds vs. 5 (2-10) seconds, P < 0.001) than elderly. After CPR training chest compressions were performed with a depth (mean (SD): 64 (8) mm vs. 50 (14) mm, P < 0.001) and rate (mean (SD): 111 (11) per min vs. 93 (18) per min, P < 0.001) for young and elderly laypersons respectively. CONCLUSION: Despite long CPR retention time for both groups, elderly laypersons had longer retention time, and performed inadequate DA-CPR compared to young laypersons. Following CPR training the attainable CPR level was of acceptable quality for both young and elderly laypersons.

Three-year follow-up of sacral nerve stimulation for patients with diarrhoea-predominant and mixed irritable bowel syndrome.

AIM: Our unit has recently shown that sacral nerve stimulation (SNS) has a significantly positive short-term effect on selected patients with diarrhoea-predominant or mixed irritable bowel syndrome (IBS). The aim of the present prospective study was to evaluate the medium-term efficacy of SNS for IBS to establish whether SNS could have a future role in the treatment of IBS. METHOD: Patients with IBS who had previously been implanted with a permanent neurostimulator as part of a randomized, controlled, crossover study, were assessed for medium-term follow-up. The primary end-point was change in the IBS-specific symptom score (Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire) from baseline to 3-year follow-up. The secondary end-point was a change in the IBS-specific quality of life score (Irritable Bowel Syndrome-Impact Scale questionnaire) from baseline to 3-year follow-up. RESULTS: Of 26 patients, 20 were eligible for 3-year follow-up. The median IBS-specific symptom score was significantly lower at 3-year follow-up (30, range 13-71) than at baseline (62, 45-80) (P = 0.0001). The effect was observed in all symptom clusters within the score. Also, the median IBS-specific quality of life score was significantly improved at 3-year follow-up (52, 26-169) compared with baseline (135, 82-180, P = 0.0002). The effect was observed in all domains of the score. As per the protocol, 75% of patients were judged therapeutic successes. Seventy per cent of patients had a more than 50% reduction in daily IBS symptoms. CONCLUSION: At medium-term follow-up, SNS continues to be an effective treatment for highly selected patients with diarrhoea-predominant or mixed IBS.

Assessment of colorectal length using the electromagnetic capsule tracking system: a comparative validation study in healthy subjects.

AIM: We aimed to determine colorectal length with the 3D-Transit system by describing a 'centreline' of capsule movement and comparing it with known anatomy, as determined by magnetic resonance imaging (MRI). Further, we aimed to test the day-to-day variation of colorectal length assessed with the system. METHOD: The 3D-Transit system consists of electromagnetic capsules that can be tracked as they traverse the gastrointestinal tract. Twenty-five healthy subjects were examined with both 3D-Transit and MRI. Another 21 healthy subjects were examined with 3D-Transit on two consecutive days. RESULTS: Computation of colorectal length from capsule passage was possible for 60 of the 67 3D-Transit recordings. The length of the colorectum measured with MRI and 3D-Transit was 95 (75-153) cm and 99 (77-147) cm, respectively (P = 0.15). The coefficient of variation (CV) between MRI and 3D-Transit was 7.8%. Apart from the caecum/ascending colon being 26% (P = 0.002) shorter on MRI, there were no other differences in total or segmental colorectal lengths between methods (all P > 0.05). The length of the colorectum measured with 3D-Transit on two consecutive days was 102 (73-119) cm and 103 (75-123) cm (P = 0.67). The CV between days was 7.3%. CONCLUSION: The 3D-Transit system allows accurate and reliable determination of colorectal length compared with MRI-derived colorectal length and between days. Antegrade or retrograde capsule movement relative to this centreline, as well as the length and speed of movements, may be determined by future studies to allow better classification and treatment in patients with dysmotility.

Reliability, validity and sensitivity to change of neurogenic bowel dysfunction score in patients with spinal cord injury.

STUDY DESIGN: Psychometrics study. OBJECTIVES: The aim of this study is to investigate the validity, reliability and sensitivity to change of neurogenic bowel dysfunction (NBD) score. SETTING: Dokuz Eylül University Faculty of Medicine, Turkey. METHODS: The study included 42 patients with spinal cord injury (SCI). The reliability of NBD score was assessed by test-retest reliability and internal consistency. Cronbach's alpha coefficient was calculated to determine internal consistency. The construct validity was evaluated by exploring correlations between the NBD score and SF-36 scales, patient assessment of impact of NBD on quality of life (QoL) and the physician global assessment (PGA). The Global Rating of Change (GRC) scale was used to assess the change of NBD to investigate the sensitivity of the score to change. RESULTS: Cronbach's alpha coefficient was 0.547. In test-retest reliability analysis, high correlations between total test-retest NBD score and answers of each question were found (r=1.000, P<0.001). NBD score had a strong and significant correlation with PGA (r=0.98, P<0.000) and the impact on QoL (r=0.92, P<0.001). There was a significant negative correlation between NBD score and subscales of SF-36 (P<0.05) except physical functioning, physical role functioning and physical component summary score. There was a significant improvement in NBD scores after treatment (P=0.011). A significant positive correlation was found between GRC scale and change in total NBD score (r=0.821, P=0.007). CONCLUSION: The Turkish version of the NBD score is a valid and reliable instrument and also sensitive to change in patients with SCI.

Chronic abdominal pain in long-term spinal cord injury: a follow-up study.

STUDY DESIGN: A longitudinal postal survey. OBJECTIVES: To evaluate the prevalence and characteristics of abdominal pain in long-term spinal cord injury (SCI). SETTING: Members of the Danish SCI Association. METHODS: In 2006, a questionnaire on chronic abdominal pain and discomfort was sent to the 284 members of the Danish SCI association who had been members for at least 10 years; 203 of them responded. An almost identical questionnaire including questions on intensity and interference of pain within the past 7 days, as well as descriptors and treatment, was sent to the 178 surviving members in 2015. RESULTS: Of 130 (73%) responders, 125 answered the question on chronic abdominal pain. The mean time since injury was 30.5 (9.8) years. Chronic abdominal pain or discomfort was reported by 32.8% (41/125), and 23% (29/125) of responders had been at least moderately bothered by this in the past week. Abdominal pain or discomfort was more common in women and in those with self-reported constipation. The median intensity (numeric rating scale) was 6.0 (range 3-10) and it was often associated with autonomic symptoms. Nine (8%) of the 115 individuals who responded in both 2006 and 2015 had developed new abdominal pain or discomfort, 30 (26%) no longer reported it, and 28 (24%) reported it at both time points with a similar intensity. CONCLUSIONS: Chronic abdominal pain or discomfort is common and bothersome in long-term SCI. It has a late onset, but the prevalence and severity do not seem to further increase between 20 and 30 years following SCI.

Ageing with neurogenic bowel dysfunction.

STUDY DESIGN: Longitudinal study with postal survey. OBJECTIVES: To describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades. SETTING: Members of the Danish SCI Association. METHODS: In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires. RESULTS: Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P<0.01), the use of laxatives increased (P<0.05) and the proportion considering themselves very constipated increased from 19 to 31% (P<0.01). In contrast, the proportion suffering from faecal incontinence remained stable at 18% in 1996 and 19% in 2015. During the 19-year period, there had been no significant change in the methods for bowel care, but 22 (20%) had undergone surgery for bowel dysfunction, including 11 (10%) who had some form of stoma. CONCLUSION: Self-assessed severity of constipation increased but quality of life remained stable in a cohort of people with SCI followed prospectively for 19 years. Methods for bowel care remained surprisingly stable but a large proportion had undergone stoma surgery.

International spinal cord injury bowel function basic data set (Version 2.0).

STUDY DESIGN: International expert working group. OBJECTIVES: To revise the International Spinal Cord Injury (SCI) Bowel Function Basic Data Set as a standardized format for the collecting and reporting of a minimal amount of information on bowel function in clinical practice and research. SETTING: Working group appointed by the American Spinal injury association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS: The draft prepared by the working group was reviewed by the International SCI Data Set Committee and later by members of the ISCoS Executive and Scientific Committees and the ASIA board. The revised data set was posted on the ASIA and ISCoS websites for 1 month to allow further comments and suggestions. Changes resulting from a Delphi process among experts in children with SCI were included. Members of ISCoS Executive and Scientific Committees and the ASIA board made a final review and approved the data set. RESULTS: The International SCI Bowel Function Basic Data Set (Version 2.0) consists of the following 16 items: date of data collection, gastrointestinal and anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, defecation method and bowel-care procedures, average time required for defecation, frequency of defecation, uneasiness, headache or perspiration during defecation, digital stimulation or evacuation of the anorectum, frequency of fecal incontinence, flatus incontinence, need to wear pad or plug, oral laxatives and prokinetics, anti-diarrheal agents, perianal problems, abdominal pain and discomfort and the neurogenic bowel dysfunction score. CONCLUSION: The International SCI Bowel Function Basic Data Set (Version 2.0) has been developed.

The role of the glucuronoxylan carboxyl groups in the action of endoxylanases of three glycoside hydrolase families: A study with two substrate mutants.

BACKGROUND: Bacterial appendage-dependent GH30 glucuronoxylan hydrolases recognize the substrate through an ionic interaction of a conserved positively charged arginine with the carboxyl group of 4-O-methyl-d-glucuronic acid. One of the options to verify this interaction is preparation of enzyme mutants. An alternative approach is a chemical modification of the substrate, glucuronoxylan, in which the free carboxyl group in all residues of MeGlcA is eliminated. METHODS: In this work the carboxyl groups of 4-O-methyl-d-glucuronic acid residues of an alkali extracted beechwood xylan were esterified with methanol. A water-soluble fraction of the polysaccharide methyl ester was converted by NaBH4 reduction to the second soluble derivative, 4-O-methylglucoxylan. Specific activities of several endoxylanases (EXs) of GH families 10, 11 and 30 were determined on glucuronoxylan, and its two new uncharged derivatives. RESULTS: Elimination of the free carboxyl group from the polysaccharide did not influence activities of GH10 EXs, but resulted in 50% decrease of specific activity of GH11 EXs, and led to more than 300-fold reduction of specific activity of Erwinia chrysanthemi GH30 xylanase. CONCLUSIONS: These results confirm the crucial role of the interactions between GH30 xylanases and the MeGlcA carboxyl group for efficient cleavage of the polysaccharide. Analysis of the hydrolysis products by TLC and MS confirmed that all three types of xylanases hydrolyzed uncharged glucuronoxylans similarly as the original one. SIGNIFICANCE: The uncharged glucuronoxylan derivatives will be useful to differentiate GH30 xylanases with various degree of selectivity for glucuronoxylan, including fungal enzymes without the conserved arginine.

Does Sacral Nerve Stimulation Improve Continence Through Enhanced Sensitivity of the Anal Canal? A Pilot Study.

BACKGROUND: It has been suggested that the effects of sacral nerve stimulation against fecal incontinence involve neuromodulation at spinal or supraspinal levels. OBJECTIVE: This study aims to investigate the afferent sensory pathways from the anorectum before and during sacral nerve stimulation. DESIGN: This is an explorative study. PATIENTS: Fifteen women with idiopathic fecal incontinence (mean age, 58 ± 12.2 years) were selected. INTERVENTIONS: Cortical evoked potentials were recorded during repeated rapid balloon distension of the rectum and the anal canal both before and during temporary sacral nerve stimulation. Stimuli applied were individualized according to the subjective urge to defecate. MAIN OUTCOME MEASURES: The main outcomes measured were 1) stimulus intensity, 2) latencies and amplitudes of cortical evoked potentials, and 3) spectral content in predefined frequency bands of cortical evoked potentials. RESULTS: The median Wexner fecal incontinence score improved from 15.5 ± 3.6 before to 6.7 ± 5 during sacral nerve stimulation (p < 0.001). Sacral nerve stimulation did not affect the threshold for urge to defecate during rectal distension (p = 0.64) but reduced the threshold from stimulation of the anal canal by 50% (p = 0.03). No statistically significant differences were found in latencies, amplitudes, or spectral analysis. LIMITATIONS: This is a pilot study of limited size. CONCLUSIONS: In patients with idiopathic fecal incontinence, sacral nerve stimulation reduced the threshold for urge to defecate elicited from the anal canal, whereas supraspinal responses remained unaltered. This may suggest that sacral nerve stimulation, at least in part, acts via somatic afferent fibers enhancing anal sensation.

Cost-effectiveness analysis of sacral nerve stimulation as treatment for severe irritable bowel syndrome.

AIM: Early results from sacral nerve stimulation (SNS) for severe irritable bowel syndrome (IBS) are promising but estimates of cost-effectiveness are lacking. Our object was to perform a cost-effectiveness analysis for SNS as an alternative to no treatment of IBS. METHOD: This retrospective analysis was based on the results from a randomized controlled crossover study with a cost-utility analysis performed on patient-level data and modelling of censored data over a projected period of time of up to 20 years. The analysis was conducted on an intention-to-treat approach. For estimation of the uncertainty of the incremental cost-effectiveness ratio a bias corrected bootstrap analysis was performed. RESULTS: Cost-effectiveness was not reached for 4 years after permanent implantation (£31 270 per quality-adjusted life years), which was the upper limit for patient follow-up, but our data imply a cost-effectiveness from a 7-year perspective onwards. CONCLUSION: The study indicates the SNS treatment for IBS is cost effective from a 7-year perspective onwards.

Global audit on bowel perforations related to transanal irrigation.

PURPOSE: Transanal irrigation is increasingly used against chronic constipation and fecal incontinence in selected patients. The aims were to estimate the incidence of irrigation-related bowel perforation in patients using the Peristeen Anal Irrigation(®) system, and to explore patient- and procedure-related factors associated with perforation. METHODS: External independent expert audit on the complete set of global vigilance data related to Peristeen Anal Irrigation from 2005 to 2013. RESULTS: In total, 49 reports of bowel perforation had been recorded. Based on sales figures, this corresponds to an average risk of bowel perforation of 6 per million procedures. The latest two-year data indicate a risk of 2 per million procedures. In 29 out of 43 evaluable cases (67 %), perforation happened within the first 8 weeks since start of treatment. After 8 weeks, long-term use has an estimated risk of less than 2 per million procedures. Among patients with non-neurogenic bowel dysfunction, 11 out of 15 (73 %) had a history of pelvic organ surgery compared to 5 out of 26 (19 %) in neurogenic bowel dysfunction. In 11 of 46 (24 %) evaluable cases, burst of the rectal balloon was reported. CONCLUSION: Enema-induced perforation is a rare complication to transanal irrigation with Peristeen Anal Irrigation, which increases the benefit risk ratio in support of the further use of transanal irrigation. Increased risk is present during treatment initiation and in patients with prior pelvic organ surgery. Careful patient selection, patient evaluation and proper training of patients are critical to safe practice of this technique.

Lack of effect of sacral nerve stimulation for incontinence in patients with systemic sclerosis.

AIM: Systemic sclerosis (SSc) is a multisystem disorder of unknown aetiology leading to the deposition of excessive connective tissue in the skin, blood vessels and internal organs. Gastrointestinal involvement occurs in 90% of cases and the prevalence of faecal incontinence (FI) is 38%. This study comprises the largest case series assessing the efficacy of sacral nerve stimulation (SNS) treatment for incontinence in this patient group. METHOD: A retrospective analysis on prospectively collected data was performed on all SSc patients from our two centres who had undergone SNS for FI. RESULTS: Ten female patients of mean age of 54 (37-72) years had temporary SNS performed. The mean duration of FI was 13 (2-25) years. All had passive FI. Each patient had preprocedure anorectal physiology and endoanal ultrasound examinations documenting internal sphincter atrophy/fragmentation or reduced anal resting pressure. Overall there was no statistically significant difference (P = 0.57) in the total Wexner incontinence scores before (mean 15.1 ± 2.6 SD) and during temporary SNS procedures (mean 13.1 ± 3.6 SD). Two patients with a significant improvement went on to have permanent SNS with only one achieving a favourable outcome at 1 year. CONCLUSION: This study showed that SNS failed to reduce episodes of leakage in nine out of 10 patients with systemic sclerosis affected with incontinence.

The artificial somato-autonomic reflex arch does not improve bowel function in subjects with spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Although introduced for neurogenic bladder dysfunction, it has been suggested that the artificial somato-autonomic reflex arch alleviates neurogenic bowel dysfunction (NBD). We aimed at evaluating the effects of the reflex arch on NBD. SETTING: Denmark. METHODS: Ten subjects with supraconal spinal cord injury (SCI) (nine males, median age 46 years) had an anastomosis created between the ventral part of the fifth lumbar or first sacral nerve root and the ventral part of the second sacral nerve root. Standardized assessment of segmental colorectal transit times with radiopaque markers, evaluation of scintigraphic assessed colorectal emptying upon defecation, scintigraphic assessment of colorectal transport during stimulation of the reflex arch, standard anorectal physiology tests and colorectal symptoms were performed at baseline and 18 months after surgery. RESULTS: No significant change was observed in colorectal emptying upon defecation (median 31% of the rectosigmoid at baseline vs 75% at follow-up, P=0.50), no movement of colorectal contents was observed during stimulation of the reflex arch. Segmental colorectal transit times, anal sphincter pressures and rectal capacity did not change, and no change was seen in NBD score (median 13.5 (baseline) vs 12.5 (follow-up), P=0.51), St Marks fecal incontinence score (4.5 vs 5.0, P=0.36) and Cleveland constipation score (6.0 vs 8.0, P=0.75). CONCLUSIONS: The artificial somato-autonomic reflex arch has no effect on bowel function in subjects with supraconal SCI.

Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To evaluate the long-term effect of the sacral anterior root stimulator (SARS) on neurogenic bowel dysfunction in a large, well defined spinal cord injury (SCI) cohort. SETTING: Department of Neuro-Urology, Bad Wildungen, Germany. METHODS: Subjects undergone surgery at for SARS-SDAF (sacral deafferentation) between September 1986 and July 2011 (n=587) answered a questionnaire. In total, 277 SARS subjects were available for the baseline (recall) and follow-up comparison. RESULTS: Median age was 49 years (range: 19-80), time from SCI to surgery was 10 years (range: 0-49) and from surgery to follow-up 13 (range: 1-25). Of the responders 73% used SARS for bowel emptying. On visual analog scale (VAS) ranging from 0-10 (best), satisfaction with SARS was 10. Baseline and follow-up comparison showed a decline in the median VAS score 0-10 (worst) for bowel symptoms from 6 (range: 4-8) to 4 (range: 2-6), P<0.0001; median neurogenic bowel dysfunction score from 17 (range: 11-2) to 11 (range: 9-15), P<0.0001; median St Marks score from 4 (range: 0-7) to 4 (range: 0-5), P=0.01; and median Cleveland constipation score from 7 (range: 6-10) to 6 (range: 4-8), P<0.0001. Use of suppositories, digital evacuation and mini enema and subjects totally dependent on assistance during defecation were significantly lower after SARS. CONCLUSIONS: The SARS has the potential to be one of the few treatment methods targeting multiple organ dysfunctions following SCI.

Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury.

STUDY DESIGN: Randomized, controlled clinical trial. OBJECTIVES: Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI. SETTING: Aarhus University Hospital, Denmark. METHODS: Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of ⩾30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures. RESULTS: During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (P<0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (P<0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (P<0.01). The sBP increase was lower during TAI than during DE (P<0.05) or FC (P<0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all P<0.05). CONCLUSION: Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

A hyperactive postprandial response in the neorectum--the clue to low anterior resection syndrome after total mesorectal excision surgery?

AIM: To investigate neorectal properties regarding biomechanical, sensory and postprandial response in patients after total mesorectal excision without neoadjuvant radiotherapy in groups of no low anterior resection syndrome (LARS) patients and major LARS patients. METHOD: Patients without LARS (n = 9) and patients with major LARS (n = 23) were investigated by multimodal rectal stimulation and standard anorectal physiological tests, and results were compared. RESULTS: Patients with major LARS had an increased postprandial response with a significant increase in pressure in the neorectum after a meal compared with patients without LARS (P = 0.017). No biomechanical differences could be detected. CONCLUSION: Low anterior resection syndrome seems to be caused by physiological changes due to neural damage more than structural changes in the ano-neorectum.

Distensibility of the anal canal in patients with systemic sclerosis: a study with the functional lumen imaging probe.

AIM: Systemic sclerosis (SSc) is a generalized connective tissue disease that affects smooth muscle cells. Patients with SSc often have faecal incontinence caused by fibrotic degeneration of the internal anal sphincter (IAS). The functional lumen imaging probe (FLIP) is a novel method that allows the segmental biomechanical properties of the anal canal to be dynamically evaluated. The aim of the present study was to compare the segmental biomechanical properties of the anal canal in incontinent SSc patients and healthy controls. We hypothesized that the FLIP would reveal weaknesses of the IAS in the SSc patients. METHOD: We performed FLIP distensions, endoanal ultrasonography and standard anal manometry on 14 incontinent SSc patients [11 women, median age 60 years (range 35-80)] and 15 healthy volunteers [12 women, median age 54 years (range 33-67)]. The anal canal was divided into three parts for the biomechanical analysis: upper (surrounded by the IAS and the puborectalis), middle (IAS and external anal sphincter) and lower (external sphincter only). RESULTS: The middle anal canal was the segment most resistant to distension in all of the subjects, but it was less resistant in the SSc patients than in the controls (P < 0.01). Correspondingly, the endoanal ultrasonography showed that the IAS of the SSc patients was thinner than normal (P < 0.05), and the anal resting and squeeze pressures were lower (P < 0.05). Only minor distensibility differences were found in the upper anal canal. No changes were found in the lower anal canal. CONCLUSION: Faecal incontinence in SSc patients is associated with poor IAS function, causing increased distensibility of the middle anal canal.

Colorectal transport during defecation in subjects with supraconal spinal cord injury.

STUDY DESIGN: Clinical study. OBJECTIVES: To explore how supraconal spinal cord injury (SCI) affects colorectal emptying at defecation. Further, to relate findings to subject symptomatology expressed by bowel function scores and gastrointestinal transit time (GITT). SETTING: Aarhus University Hospital, Denmark. METHODS: Colorectal contents were marked by oral intake of (111)In-coated resin pellets. Movement of stools at defecation was assessed by comparing scintigrams performed before and just after defecation. Results from 15 subjects with SCI (14 males, median age=47 years (range: 22-74 years), SCI level: C5-Th9) were compared with those from 16 healthy volunteers (12 males, median age=31 years (range: 24-42 years)). Bowel symptoms were described from standard symptom scores, and GITT was assessed by radiopaque markers. RESULTS: Median emptying at defecation was 31% of the rectosigmoid (range: 0% to complete emptying of the rectosigmoid and 49% of the descending colon) in subjects with SCI and 89% of the rectosigmoid (range: 53% to complete emptying of the rectosigmoid and the descending colon, and 3% of the transverse colon) in the control group (P<0.01). Colorectal emptying at defecation was associated with the St Mark's fecal incontinence score (P=0.02) but not with the Cleveland constipation score (P=0.17), the neurogenic bowel dysfunction score (P=0.12) or GITT (P=0.99). CONCLUSION: Supraconal SCI results in significantly reduced emptying of stools at defecation. This is independent of changes in GITT.