Usefulness of anorectal and endovaginal 3D ultrasound in the evaluation of sphincter and pubovisceral muscle defects using a new scoring system in women with fecal incontinence after vaginal delivery.

PURPOSE: This study aims to evaluate pubovisceral muscle and anal sphincter defects in women with previous vaginal delivery and fecal incontinence and to correlate the findings with the severity of symptoms using the combined anorectal and endovaginal 3D ultrasonography with a new ultrasound scoring system. METHODS: Consecutive female patients with previous vaginal delivery and fecal incontinence symptoms were screened. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale, and the extent of defects was assessed by an ultrasound score based on results of anorectal and endovaginal 3D ultrasound. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale. RESULTS: Of 84 women with previous vaginal delivery and fecal incontinence, 21 (25%) had intact pubovisceral muscles and anal sphincters; 63 (75%) had a pubovisceral muscle or anal sphincter defect, or both. Twenty-eight (33%) had a pubovisceral muscle defect [23% with an external anal sphincter (EAS) defect or combined EAS/internal anal sphincter defects; 11% with intact anal sphincters]. Thirty-five (42%) had intact pubovisceral muscles and an anal sphincter defect. Compared with women with intact pubovisceral muscles/anal sphincter defects, patients with pubovisceral muscle defects had significantly higher incontinence scores and significantly higher ultrasound scores indicating more extensive defects. Incontinence symptoms correlated positively with the ultrasound score, measurements of sphincter defects, and area of the levator hiatus. CONCLUSIONS: Evaluation of both pubovisceral muscles and anal sphincters is important to identify defects and determine treatment for women with fecal incontinence after vaginal delivery. The severity of fecal incontinence symptoms is significantly related to the extent of defects of the pubovisceral muscles and anal sphincters.

Use of Biofeedback Combined With Diet for Treatment of Obstructed Defecation Associated With Paradoxical Puborectalis Contraction (Anismus): Predictive Factors and Short-term Outcome.

BACKGROUND: Numerous studies have described the use of biofeedback therapy for the treatment of anismus. Success rates vary widely, but few data are available regarding factors predictive of success. OBJECTIVE: Our aim was to evaluate short-term results of biofeedback associated with diet in patients with obstructed defecation because of anismus and to investigate factors that may affect the results. DESIGN: Patients were identified from a single-institution prospectively maintained database. SETTINGS: This study was conducted in a tertiary hospital. PATIENTS: Consecutive patients who had obstructed defecation associated with anismus and were treated with biofeedback associated with diet were eligible. INTERVENTIONS: Each patient underwent anal manometry and/or dynamic anal ultrasound. Patients with anismus and were treated with biofeedback associated with diet. MAIN OUTCOME MEASURES: Patients classed as having a satisfactory response to therapy and those classed as having an unsatisfactory response were compared with regard to sex, age, Cleveland Clinic Florida constipation score, functional factors (anal resting and squeeze pressures and reversal of paradoxical puborectalis contraction on manometry), and anatomic factors in women (history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery). RESULTS: A total of 116 patients were included (75 women and 41 men). Overall, 59% were classed as having a satisfactory response (decrease in constipation score, >50%). Patients with satisfactory responses to biofeedback plus diet did not differ from those with unsatisfactory responses with regard to clinical, anatomic, and physiological factors. LIMITATIONS: This was not a randomized controlled trial. CONCLUSIONS: Biofeedback combined with diet is a valuable treatment option for patients with obstructed defecation syndrome associated with anismus, and more than half of our patients of both sexes achieved a satisfactory response. Improvement was not related to reversal of paradoxical contraction of puborectalis muscles at manometry. Patient sex, age, previous anorectal surgery, anorectal manometry pressures, and vaginal delivery, menopause, and hysterectomy in women did not significantly affect outcome.

Use of dynamic 3-dimensional transvaginal and transrectal ultrasonography to assess posterior pelvic floor dysfunction related to obstructed defecation.

BACKGROUND: New ultrasound techniques may complement current diagnostic tools, and combined techniques may help to overcome the limitations of individual techniques for the diagnosis of anorectal dysfunction. A high degree of agreement has been demonstrated between echodefecography (dynamic 3-dimensional anorectal ultrasonography) and conventional defecography. OBJECTIVE: Our aim was to evaluate the ability of a combined approach consisting of dynamic 3-dimensional transvaginal and transrectal ultrasonography by using a 3-dimensional biplane endoprobe to assess posterior pelvic floor dysfunctions related to obstructed defecation syndrome in comparison with echodefecography. DESIGN AND SETTING: This was a prospective, observational cohort study conducted at a tertiary-care hospital. PATIENTS: Consecutive female patients with symptoms of obstructed defecation were eligible. INTERVENTION: Each patient underwent assessment of posterior pelvic floor dysfunctions with a combination of dynamic 3-dimensional transvaginal and transrectal ultrasonography by using a biplane transducer and with echodefecography. MAIN OUTCOME MEASURES: Kappa (κ) was calculated as an index of agreement between the techniques. Diagnostic accuracy (sensitivity, specificity, and positive and negative predictive values) of the combined technique in detection of posterior dysfunctions was assessed with echodefecography as the standard for comparison. RESULTS: A total of 33 women were evaluated. Substantial agreement was observed regarding normal relaxation and anismus. In detecting the absence or presence of rectocele, the 2 methods agreed in all cases. Near-perfect agreement was found for rectocele grade I, grade II, and grade III. Perfect agreement was found for entero/sigmoidocele, with near-perfect agreement for rectal intussusception. Using echodefecography as the standard for comparison, we found high diagnostic accuracy of transvaginal and transrectal ultrasonography in the detection of posterior dysfunctions. LIMITATIONS: This combined technique should be compared with other dynamic techniques and validated with conventional defecography. CONCLUSIONS: Dynamic 3-dimensional transvaginal and transrectal ultrasonography is a simple and fast ultrasound technique that shows strong agreement with echodefecography and may be used as an alternative method to assess patients with obstructed defecation syndrome.

How much of the internal sphincter may be divided during lateral sphincterotomy for chronic anal fissure in women? Morphologic and functional evaluation after sphincterotomy.

BACKGROUND: Sphincterotomy is used to treat chronic anal fissure, but the length of the sphincterotomy is associated with incontinence. OBJECTIVE: We used 3-dimensional anal ultrasonography to determine the proportion of the internal anal sphincter that may be divided during lateral internal sphincterotomy in women without predisposing them to a high risk of fecal incontinence. DESIGN AND SETTING: This was a prospective, observational cohort study conducted at a tertiary-care hospital. PATIENTS: Women treated for chronic anal fissure with high anal resting pressure and no symptoms of fecal incontinence were selected. Asymptomatic women recruited from different departments of the same hospital served as controls to provide reference values for anal canal measurements. INTERVENTION: Patients underwent a standardized technique of lateral internal sphincterotomy. MAIN OUTCOME MEASURES: Three-dimensional ultrasonography was used to measure sphincter lengths. Continence was assessed with the Cleveland Clinic Florida (Wexner) score. The relationship between the extent of the surgically divided portion of the internal anal sphincter and the continence score was evaluated. RESULTS: Successful healing was achieved in all patients within 2 months. Follow-up continence scores were significantly correlated with the extent of sphincter division. The proportion of patients with a continence score of 0 was significantly greater in patients in whom sphincter division was less than 25% in comparison with patients with a division of 25% or more. Anal canal and sphincter lengths in patients after sphincterotomy did not significantly differ from those in asymptomatic women. LIMITATIONS: The study is limited by its nonrandomized nature and the lack of preoperative ultrasound assessment. CONCLUSIONS: Based on data from this study, the safe extent of division is less than 25% of the total sphincter length, which in women corresponds to less than 1 cm.

Anatomic characteristics of anal fistula on three-dimensional anorectal ultrasonography.

BACKGROUND: Surgery for anal fistula is often associated with continence disorders due to the transection of sphincter muscles. Extensive knowledge of anal canal anatomy and anal fistula can help prevent this outcome. OBJECTIVE: This study aimed to correlate the anatomical conformation of the anal canal, the fistula track, and the internal opening according to sex and hemicircumference (anterior vs posterior) by use of 3-dimensional ultrasonography. METHODS: One hundred sixty-five patients with fistula were evaluated with 3-dimensional ultrasound and grouped according to sex, fistula type, internal opening, and track position. Fistulas were transsphincteric in 128 subjects and intersphincteric in 37 subjects. The study measured the external and internal anal sphincter, the puborectalis, the distance from the internal opening to the distal edge of the external and internal sphincter, the length of the internal and external sphincter compromised by the track, and the percentage of compromised muscle. RESULTS: The anal canal muscles were longer in males. The distance from the internal opening to the internal sphincter was greater for the posterior hemicircumference. The point where the fistulous track crossed the anterior external sphincter was similar for the 2 sexes, but the percentage of compromised muscle was greater in females. The point where the fistulous track crossed the internal sphincter was similar for the 2 sexes, but the percentage of compromised internal sphincter was greater in males for the posterior hemicircumference. The study was limited by the absence of testing for interobserver and intraobserver agreement. CONCLUSION: The anal canal muscles are longer in males and the pectinate line is asymmetrical. In females, the percentage of compromised external sphincter was greater in the anterior hemicircumference because of the shorter external sphincter, whereas in males the percentage of compromised internal sphincter was greater in the posterior hemicircumference.

The role of 3-dimensional anorectal ultrasonography in the assessment of anterior transsphincteric fistula.

PURPOSE: The aim of this study was to evaluate the role of 3-dimensional anorectal ultrasonography in the choice of surgical technique according to the position of the fistulous tract in patients with anterior transsphincteric anal fistula. METHODS: A total of 33 patients (18 male) with anterior transsphincteric fistulas were evaluated by ultrasonography. The length of the external and internal anal sphincters, the position of the internal opening, the length of the compromised sphincter, and the percentage of sphincter muscle to be transected during surgery were measured, compared between sexes, and used in planning the surgery. Postoperative incontinence symptoms were quantified with a Wexner score. RESULTS: The external and internal sphincters were longer and the position of the internal opening was higher in males. The position where the tract crossed the external sphincter was in both sexes, but the percentage of compromised muscle was higher in females because of the smaller length of the external sphincter. Seton placement followed by fistulotomy or advanced flap repair were indicated in 11 of 18 males and 13 of 15 females as the tract crossed the external sphincter above 50.0%. The mean postoperative follow-up was 12 months. Overall, minor fecal incontinence symptoms were identified in 16 (48.0%) patients. Of these, 11 (73.0%) females and 5 (28.0%) males had a mean incontinence score of 2.9 and 3.0, respectively. CONCLUSIONS: Three-dimensional ultrasonography was shown to be useful in the preoperative assessment of anterior transsphincteric fistulas by quantifying the length of muscle to be transected, contributing to the choice of a safe treatment approach and to the reduction of the rate of postoperative continence disorders.

Effect of soluble fiber or fructooligosaccharide supplementation upon trinitrobenzenesulphonic acid induced colitis in rats.

PURPOSE: To evaluate the effect of soluble fiber or fructooligosaccharide (FOS) supplementation upon trinitrobenzene sulphonic acid (TNBS)-induced colitis in rats. METHODS: 64 Wistar rats were given water, soluble fiber or FOS intragastrically during 14 days prior to colitis induction with TNBS (n=48) or rectal enema with water (n=16; control group). On the 7th or 14th day following colitis induction the rats were weighed and euthanized in order to determine the colon weight/length ratio and macroscopic and microscopic scores. RESULTS: On the 7th day following colitis induction the body weight had decreased significantly, the colon weight/length ratio had increased and macroscopic and microscopic colon lesions were observed. On the 14th day following colitis induction no difference in body weight was observed, in spite of the persistence of macroscopic and microscopic lesions and increased colon weight/length ratio. Supplementation with soluble fiber or FOS did not revert colon lesions or any of the study parameters. Supplementation with FOS, but not with fiber, was associated with increased colon weight/length ratio on the 14th day. CONCLUSION: Supplementation with soluble fiber or FOS produced no significant impact on TNBS-induced colitis in rats.

[Importance of the tridimensional ultrasound in the anorectal evaluation]. / Importância do ultra-som tridimensional na avaliação anorretal.

BACKGROUND: Anorectal endosonography is actually the main image exam to evaluate some anorectal diseases. AIM: To show the three-dimensional endosonography importance in the anal canal anatomic evaluation and the anorectal diseases diagnosis. METHODS: Seventy four anorectal ultrasound were performed, 23 normal individuals (13 women) and 51 patients (33 women) with benign and malignant diseases. All the patients were examined with a 3-D equipment with 360 degrees transducer. Normal individuals were evaluated in midline sagittal plane concerning to the length of the anal canal, the internal anal sphincter, the external anal sphincter and the anatomic defect in the anterior quadrant. RESULTS: There were no differences in the anal canal and the internal anal sphincter length between men and women. Otherwise, the external anal sphincter length is longer in men and the anatomic defect is longer in women. In those with anorectal diseases, 11 sphincter injuries, 8 anal fistulas, 7 abscess, 1 perirectal endometriosis, 1 pre-sacral cyst, 3 anal canal and 10 rectal malignant neoplasias were diagnosed. The surgical findings confirmed the ultrasound diagnosis in all the patients. CONCLUSION: Three-dimensional endosonography demonstrated the anatomic differences between male and female anal canal, justifying the larger incidence of pelvic floor disorders in female patients. It was possible to diagnose the anorectal diseases, in multi-plane, with high spatial resolution, adding also important informations about the therapeutic decision. Such characteristics become it similar to nuclear magnetic resonance with intra-rectal coil, with the advantages to be easier, quicker, low cost and better tolerated.

[Histologic analysis of colonic anastomotic healing, in rats, under the action of 10% Aroeira-do-sertão (Myracrodruon urundeuva fr. all.) enema]. / Análise histológica da cicatrização da anastomose colônica, em ratos, sob ação de enema de Aroeira-do-sertão (Myracrodruon urundeuva fr. all.) a 10%.

PURPOSE: Evaluate, from a histologic view point, the action of the aqueous extract of aroeira-do-sertão on the healing of colonic anastomosis, in Wistar rats. METHODS: There were used 48 Wistar rats, males, with average weight of 320g, distributed in two groups, with 24 animals, each. All animals were subjected to a complete transverse section of the descending colon, followed by colonic anastomosis. The rats on group A received daily post-operative enemas of carboxymethylcellulose (CMC) based vehicle. The animals on group B received post-operative enemas of 10% aqueous extract of aroeira-do-sertão in CMC based vehicle, until the date of euthanasia. On days 3, 7, 14 and 21 of the experiment, six rats in each group were subjected to removal of a colonic segment, including the anastomosis, destined to histological evaluation and qualitative analysis of inflammatory and healing cell response. RESULTS: The morphologic analysis reveals a significant difference between groups, on day 7 (ñ < 0.05), when the group studied showed lower score than the control group. The collagen deposition on the aroeira group was lower, on days 3, 7 and 14 (ñ < 0.05), compared to the control group. CONCLUSION: The aqueous extract of aroeira-do-sertão has anti-inflammatory action. It also has inhibitory effect on collagen deposition during the phases of inflammation and fibroplasia of the healing process of colonic anastomoses, in Wistar rats, but in advanced phases (day 21) the healing process is similar to that in the animals of the control group.

[Tensional and morphologic analysis of the colonic anastomosis on 10% acetic acid induced colitis, in Wistar rats, treated with 10% aroeira-do-sertão (Myracrodruon urundeuva fr. all.) aqueous extract]. / Análise tensional e morfológica da anastomose colônica na colite induzida por ácido acético a 10%, em ratos Wistar, tratados com extrato aquoso de aroeira-do-sertão a 10% (Myracrodruon urundeuva fr. all.).

PURPOSE: Verify, from a morphologic and tensional view point, the effect of the 10% aqueous extract of aroeira-do-sertão on the colonic anastomosis, during the occurrence of 10% acetic acid induced colitis, in Wistar rats. METHODS: There were used 48 Wistar rats, distributed in two groups. All animals were subjected to induction of colitis by aqueous solution of 10% acetic acid. Twenty-four hours later, the animals were subjected to laparotomy, transverse total colotomy and end-to-end anastomosis with 5-0 polypropylene. Group A (vehicle), animals treated with carboxymethylcellulose based vehicle. Group B (aroeira), animals treated with 10% aroeira aqueous extract. Both treatments were by means of enema. Groups A and B were distributed in subgroups A3, A7, A14 and A21; B3, B7, B 14 and B21, according to the foreseen euthanasia date (days 3, 7, 14 and 21). On these dates, the animals were relaparotomized, the colonic segment containing the anastomosis was ressected subjected to the pressure test and then to the, histological analysis. For the momphologic study, the slides were dyed with hematoxilin-eosine and the healing status was evaluated based on a score chart that ranked from 0 to 16. The higher the score, the better the healing. RESULTS: On the evaluation of the morphologic study, which quantifies the evolution and degree of healing, as a final result of the healing process, the group aroeira was superior to the group vehicle (p<0.05) on the twenty-first day, showing higher velocity on tissue repair that occurs by regeneration and not by fibrosis. With respect to the tension test, there was a statistically significant difference on day 3, with predominance of the group aroeira over the group vehicle (p<0.05). CONCLUSION: The 10% aroeira-do-sertão aqueous extract, has healing activity on the colonic anstomosis during the occurrence of 10% acetic acid induced colitis. It improves the resistance to tension on the colonic anastomosis zone on the 3rd day.

[Experimental model of laparoscopic handsewn suture in colon of dogs]. / Modelo experimental de sutura manual em colon de cão por vídeo-laparoscopia.

PURPOSE: Develop an experimental model of laparoscopic hand-sewn suture in colon of dogs to be specially used for surgeons' training. METHODS: Forty male dogs were operated on, weight between 15 and 20 kg, from the laboratory of the Veterinary School of the State University of Ceara. They were distributed within two groups with 20 animals each: GI--The colonic wall incision was done with an electrical scalpel followed by haemosthasia and GII--The colonic wall incision was performed with a scissors. Each group was shared in two other groups with 10 animals each, according to the abdominal approach used. A-Laparotomic approach and B-Laparoscopic approach. Under intra-venous general anesthesia, a transverse incision was performed envolving 50% of the sigmoid wall, 15 cm far from the pelvic peritoneal pouch, followed by an extra-mucosa, one layer and interrupted suture with 000 polydioxanona (PDSâ). The animals were evaluated concerning to the clinical recovery, macroscopic appearance, suture-tension test and histologic study. The animals were sacrificed on the 7th postoperative day. Fisher and Qui-square tests were used for statistical analysis. RESULTS: All the animals submitted to colotomy performed by scissor (GIIA, GIIB) and nine animals operated on with an electrical scalpel (GI), five (50.0%) by laparotomic approach (GIA) and four (40.0%) laparoscopically (GIB) had a satisfactory clinical recovery, walking and accepting oral diet on the first post-operative day. The first bowel movement occurred between 48 and 72 hours. It didn't occur diarrhea or vomits. Eleven animals from group I, five (50%) from group IA and six (60.0%) from group IB didn't accept oral diet and complained of diarrhea (3 to 5 evacuations each day), 1 to 3 episodes of vomits each day and they die between the fourth and seventh postoperative day. Comparing groups GI with GII, a statistical significant difference was observed (p<0.005). There was no difference between GIA and GIB. Colonic sutures were intact in all the animals from group II and in five from group I with statistical significant difference (p<0.005). Three (30.0%) were from group IA and two (20.0%) from group IB. The colonic suture was envolved by epiploon in four animals, two (20%) from GIA and 2 (20%) from GIB. Suture dehiscence with peritonitis occurred in eleven (55%) animals from GI (p<0.005), five (50%) from GIA and six (60%) from GIB (p>0.005). All the animals died between the fourth and seventh postoperative day. The tension suture test was performed with an average pressure of 222,1 mmHg and there was no colonic suture disruption in any animal from the group II and in five (40.0%) from the group I (p<0.005). Three (30%) animals were from GIA and two (20.0%) from GIB (P>0.005). Colonic suture rupture occurred in four (20%) dogs from group I, two from GIA and two (20%) from GIB with an average pressure of 94.0 mmHg. The histological analysis of the surgical specimens removed on the 7th postoperative day demonstrated the same level of the inflammatory process in both approach used. CONCLUSION: The handsewn laparoscopic colonic suture in dogs can be safely performed, showing the same results of the laparotomic approach. The surgical results depend specially on the adequate surgeon's training in laparoscopic surgical technique.

Do changes in anal sphincter anatomy correlate with anal function in women with a history of vaginal delivery?

OBJECTIVES: To evaluate anal sphincter anatomy using three-dimensional ultrasonography (3-DAUS) in incontinent women with vaginal delivery, correlate anatomical findings with symptoms of fecal incontinence and determine the effect of vaginal delivery on anal canal anatomy and function. METHODS: Female with fecal incontinence and vaginal delivery were assessed with Wexner's score, manometry, and 3DAUS. A control group comprising asymptomatic nulliparous was included. Anal pressure, the angle of the defect and length of the external anal sphincter (EAS), the anterior and posterior internal anal sphincter (IAS), the EAS + puborectal and the gap were measured and correlated with score. RESULTS: Of the 62, 49 had fecal incontinence and 13 were asymptomatic. Twenty five had EAS defects, 8 had combined EAS+IAS defects, 16 had intact sphincters and continence scores were similar. Subjects with sphincter defects had a shorter anterior EAS, IAS and longer gap than women without defects. Those with a vaginal delivery and intact sphincters had a shorter anterior EAS and longer gap than nulliparous. We found correlations between resting pressure and anterior EAS and IAS length in patients with defects. CONCLUSIONS: Fecal incontinence symptoms did not correlate with anal pressures and anal sphincter anatomy changes, but women with sphincter defects have shorter anterior EAS and IAS and a longer gap.

Electroacupuncture ameliorates experimental colitis induced by TNBS through activation of interleukin-10 and inhibition of iNOS in mice.

PURPOSE: To study the anti-inflammatory actions of electroacupuncture (EAc) on an experimental colitis model in mice. METHODS: Thirty-eight male Swiss mice, divided in five groups, were subjected to induction of colitis by TNBS in 50% ethanol. Saline (SAL) and ethanol (ETNL) groups served as controls. TNBS+EAc and TNBS+ dexamethasone subgroups were treated with EAc 100Hz and dexamethasone (DEXA) 1 mg/Kg/day, respectively. After three days, a colon segment was obtained for quantification of myeloperoxidase (MPO) activity, immunohistochemistry for iNOS, malondialdehyde (MDA) and cytokines (IL-1ß and IL-10). RESULTS: Neutrophilic activity, assayed as MPO activity, was significantly higher in the TNBS colitis group than that in the saline control group. TNBS+EAc group showed suppression of IL-10 in the colon. EAc treatment significantly reduced the concentration of MDA and the expression of iNOS, as compared to the other groups. CONCLUSION: Electroacupuncture 100Hz applied to acupoint ST-36 promotes an anti-inflammatory action on the TNBS-induced colitis, mediated by increase of IL-10 and decrease of iNOS expression.

Hepatic repercussions of azoxymethane-induced colorectal carcinogenesis.

OBJECTIVE: To evaluate the hepatic effects of colonic carcinogenesis induced by azoxymethane at different doses and times of exposure in rats. METHODS: Forty-four Wistar rats were divided into four groups. The animals were eight weeks at the beginning of the experiment. group 1 received 1.0 ml of saline intraperitoneally once a week for two weeks. Group 2 received 15 mg/kg of azoxymethane intraperitoneally once a week for two weeks. These animals were killed at the 15th week of the experiment. The animals of group 3 received saline intraperitoneally once a week for two weeks. Group 4 animals received 20mg/kg of azoxymethane intraperitoneally once a week for two weeks. These animals were killed at the 26th week of the experiment. The fragments of liver tissue were stained with hematoxylin and eosin and evaluated microscopically. RESULTS: Groups 1 and 2 differed significantly in relation to steatosis, no difference having been found between group 3 and group 4. However, in group 4 we observed pre-neoplastic lesions (foci of altered, clear, vacuolated, basophilic, amphophilic tigroid, oncocytic, small or acidophilus cells, spongiosis and peliosis) and neoplastic lesions (adenomas and colangiomas) containing atypical hepatocytes in between, not identified in group 3. CONCLUSION: In the model of colorectal carcinogenesis, preneoplastic and neoplastic hepatic lesions appear and evolve in proportion to the time of exposure and dose of azoxymethane.

Ponderal behavior of rats fed an omegas 3, 6 and 9 enriched diet submitted to colon carcinogenesis induced by azoxymethane.

PURPOSE: To assess weight changes in rats fed diets with different ratios of omegas 3, 6 and 9 submitted to colonic carcinogenesis induced by Azoxymethane (AOM). METHODS: Sixty rats with three weeks of life were distributed into five groups of specific diets containing 12 animals each: GI- Standard diet without administration of AOM, GII- Standard diet with administration of AOM; GIII- Hyperlipidic diet with administration of AOM; GIV-Normolipidic diet with administration of AOM; GV- Hypolipidic diet with administration of AOM. The weight and food intake of each group were assessed four times in each week throughout the experiment until euthanasia at 36th week. RESULTS: GI and GII had no significant difference in weight. GI showed a significant increase when compared to GIII, GIV and GV. GII also showed a significant increase when compared to GIII, GIV and GV. When comparing intake of GI as compared to GII no significant difference was found, however such groups had higher intake than groups III, IV and V. There were found no difference in weight when comparing among rats with and without cancer within each groups: GII, GIII, GIV and GV. CONCLUSIONS: Diets rich in omega 3, 6 and 9 reduced food intake and weight. Rats with colorectal cancer had no decrease in weight as compared to those without this condition in the same group.

Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome.

CONTEXT: Management of patients with obstructed defecation syndrome is still controversial. OBJECTIVE: To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. METHODS: The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. RESULTS: Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. CONCLUSIONS: Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts.

Immunohistochemical evaluation of p53 and Ki-67 proteins in colorectal adenomas.

CONTEXT: The appearance of adenomas and their progression to adenocarcinomas is the result of an accumulation of genetic changes in cells of the intestinal mucosa inherited or acquired during life. Several proteins have been studied in relation to the development and progression of colorectal cancer, including tumor protein p53 (p53) and antigen identified by monoclonal antibody Ki-67 (Ki-67). OBJECTIVE: To evaluate the expression of p53 and Ki-67 in colorectal adenomas and correlate the observed levels with clinical and pathologic findings. METHOD: The sample consisted of 50 adenomatous polyps from patients undergoing colonoscopy. After performing polypectomy, polyps were preserved in a formalin solution with 10% (vol./vol.) phosphate buffer, submitted for routine preparation of sections and slides and stained with hematoxylin and eosin. For each adenoma we then performed immunohistochemistry to detect specific p53 and Ki-67 proteins using a streptavidin-biotin-peroxidase enzyme immunoassay. RESULTS: p53 was detected in 18% of the adenomas. The average Ki-67 protein index (i.Ki-67) was 0.49. A statistically significant difference was observed in p53 (P = 0.0003) and Ki-67 (P = 0.02) expression between adenomas with low- and high-grade dysplasia, particularly for p53. The expression of Ki-67 was greater in rectal adenomas than in colic adenomas (P = 0.02). No relationship was found between the expression of the two proteins in the sample. CONCLUSION: The p53 protein is expressed in a proportion of adenomas, while the Ki-67 protein was expressed in all adenomas. The expression of p53 was higher in adenomas with high-grade dysplasia. The expression of Ki-67 was higher in rectal adenomas and in adenomas with high-grade dysplasia.

Effect of a hyperlipidic diet rich in omegas 3, 6 and 9 on aberrant crypt formation in rat colonic mucosa.

PURPOSE: To determine whether a hypercaloric and hyperlipidic diet enriched with polyunsaturated fatty acids influences the formation of aberrant crypt foci (ACF) in colonic mucosa of Wistar rats treated with azoxymethane (AOM). METHODS: At eight weeks of life, the rats were assigned to four groups: Group I-standard diet (STD) not treated with AOM; Group II-hypercaloric and hyperlipidic diet (FED), not treated with AOM; Group III-STD, treated with AOM; Group IV-FED, treated with AOM. At 16 weeks, the animals were injected intraperitoneal with 0.9% saline solution (Group I and II) or AOM at 15 mg/Kg (Groups III and IV) once a week for two weeks. Fifteen weeks later, the animals were euthanized. RESULTS: FED promoted weight gain in Groups II and IV compared to Groups I and III, respectively. The groups did not differ with regard to the total number of ACF. The Chi-square test revealed no predominance of the presence of foci with <4 crypts. However, foci with ≥5 crypts were proportionally more prevalent in Group III than in Group IV (p=0.043). CONCLUSION: The administration of polyunsaturated fatty acids did not interfere with the formation of aberrant crypt foci, but reduced ACF multiplicity, exercising an attenuating effect on carcinogenesis.

Giant appendiceal mucinous cystadenoma treated by laparoscopy: a case report and review of the literature / Cistadenoma mucinoso apendicular gigante tratado por laparoscopia: relato de caso e revisão de literatura

ABSTRACT Appendiceal mucinous cystadenoma is a rare entity, which causes appendicular mucocele. It is more frequent in women over 50 years old. In half of the cases it is asymptomatic. Tomography of the abdomen is the gold standard in its preoperative diagnosis. The treatment is surgical, with good prognosis, the complete resection evolves without appendicular rupture and extravasation. We report a case of a 64-year-old man with appendiceal mucinous cystadenoma. A laparoscopic right hemicolectomy was performed. This therapy that can be safely used to treat appendiceal mucocele, as long as it is cautious.

RESUMO O cistadenoma mucinoso apendicular é entidade rara que causa mucocele apendicular, sendo mais frequente em mulheres acima dos 50 anos. Em metade dos casos, o cistadenoma mucinoso apendicular é assintomático. A tomografia do abdome é o padrão-ouro para um diagnóstico pré-operatório. O tratamento é cirúrgico e tem bom prognóstico; a ressecção completa evolui sem ruptura apendicular e sem extravasamento. Relatamos um caso de paciente homem de 64 anos com cistadenoma mucinoso apendicular. Foi realizada hemicolectomia laparoscópica direita. Esse é um procedimento que pode ser usado com segurança no tratamento de mucocele apendicular, desde que seja executado com cautela.

Hepatic and biochemical repercussions of a polyunsaturated fat-rich hypercaloric and hyperlipidic diet in Wistar rats.

CONTEXT: Non-alcoholic fatty liver disease is characterized by lipid deposits in the hepatocytes and has been associated with obesity, dyslipidemia and type-2 diabetes. It is considered a hepatic manifestation of the metabolic syndrome, of which the main component is insulin resistance leading to hyperinsulinemia and increased production of inflammatory cytokines. Saturated fat promotes hypertriglyceridemia and hyperinsulinemia, reduces levels of high-density cholesterol and increases levels of low-density cholesterol, while polyunsaturated fat is associated with hypolipidemic, antiinflammatory and imunoregulating action. OBJECTIVE: To evaluate the hepatic and biochemical repercussions of a polyunsaturated fat-rich diet in Wistar rats. METHODS: Twenty-two rats were distributed equally in two groups: GI - standard diet (Biobase Bio-tec Ratos e Camundongos®) providing 3.000 kcal/kg and GII - hypercaloric and hyperlipidic diet providing 4.250 kcal/kg (ω-6:ω-3 = 3:1). The animals were euthanized after 23 weeks of experiment. The weight, biochemical parameters and hepatohistological changes were registered. RESULTS: Findings were submitted to variance analysis with the level of statistical significance at 5%. The average weight did not differ significantly between the groups at baseline (P = 0.711), but was greater in Group II by the end of the experiment (P = 0.000). The levels of triglycerides (P = 0.039), total cholesterol (P = 0.015) and HDL (P = 0.005) were higher in Group I than in Group II. Macrovesicular steatosis was significantly more common in Group II than in Group I (P = 0.03). CONCLUSION: Hypercaloric and hyperlipidic diet rich in polyunsaturated fat promotes weight gain and favors the development of hepatic steatosis while reducing serum levels of triglycerides, total cholesterol and HDL.