[Show abstract][Hide abstract] ABSTRACT: Neurologic dysfunction causes fecal incontinence, but current techniques for its assessment are limited and controversial.
The purpose of this work was to investigate spino-rectal and spino-anal motor-evoked potentials simultaneously using lumbar and sacral magnetic stimulation in subjects with fecal incontinence and healthy subjects and to compare motor-evoked potentials and pudendal nerve terminal motor latency in subjects with fecal incontinence.
This was a prospective, observational study.
The study took place in 2 tertiary care centers.
Subjects included adults with fecal incontinence and healthy subjects.
Translumbar and transsacral magnetic stimulations were performed bilaterally by applying a magnetic coil to the lumbar and sacral regions in 50 subjects with fecal incontinence (1 or more episodes per week) and 20 healthy subjects. Both motor-evoked potentials and pudendal nerve terminal motor latency were assessed in 30 subjects with fecal incontinence. Stimulation-induced, motor-evoked potentials were recorded simultaneously from the rectum and anus with 2 pairs of bipolar ring electrodes.
Latency and amplitude of motor-evoked potentials after lumbosacral magnetic stimulation and agreement with pudendal nerve terminal motor latency were measured.
When compared with control subjects, 1 or more lumbo-anal, lumbo-rectal, sacro-anal, or sacro-rectal motor-evoked potentials were significantly prolonged (p < 0.01) and were abnormal in 44 (88%) of 50 subjects with fecal incontinence. Positive agreement between abnormal motor-evoked potentials and pudendal nerve terminal motor latency was 63%, whereas negative agreement was 13%. Motor-evoked potentials were abnormal in more (p < 0.05) subjects with fecal incontinence than pudendal nerve terminal motor latency, in 26 (87%) of 30 versus 19 (63%) of 30, and in 24% of subjects with normal pudendal nerve terminal motor latency. There were no adverse events.
Anal EMG was not performed.
Translumbar and transsacral magnetic stimulation-induced, motor-evoked potentials provide objective evidence for rectal or anal neuropathy in subjects with fecal incontinence and could be useful. The test was superior to pudendal nerve terminal motor latency and appears to be safe and well tolerated.
Full-text · Article · May 2014 · Diseases of the Colon & Rectum
[Show abstract][Hide abstract] ABSTRACT: Background: Understanding anal sphincter anatomy is crucial in management of anorectal disorders, including anorectal sepsis and fecal incontinence. Three-dimensional endoanal ultrasound (EAUS) provides better resolution of the tissue layers. Previous normative studies were obtained in Western populations. Objective: We demonstrated the anal sphincter. anatomy in normal East Asian subjects. Methods: Forty-six healthy subjects without anorectal symptoms (M:F = 15:31, mean age +/- SD = 47 +/- 13 years) were enrolled. High-frequency (16 MHz) EAUS was performed with a mechanically rotated probe. Thickness and length of anal sphincter components were measured. Differences between sexes were assessed using a Student t test. Results: We demonstrated 4 differentiable components: the anal sphincter; internal anal sphincter (IAS), subcutaneous external anal sphincter (Sc EAS), superficial external anal sphincter (Sp EAS), and puborectalis muscle (PRm). The mean length of anal sphincter components were obtained in nun (men vs. women), IAS (28.5 vs. 25.3, p = 0.03), Sc EAS (13.2 vs. 11.2, p = 0.005), Sp EAS (24.1 vs. 19.6, p = 0.0001), and PRm (12.4 vs. 12.2, p = 0.84). The anal canal was significantly longer in men (38.6 vs. 34.0, p = 0.007). The mean thickness for IAS (1.7 vs. 1.8, p = 0.095), Sc EAS (7.5 vs. 7.6, p = 0.587), Sp EAS (8.1 vs. 6.9, p = 0.001), and PRm (8.7 vs. 9.0, p = 0.605) were measured. The PRm was the thickest and the Sp EAS was the longest voluntary sphincter. Conclusion: Normative details of anal sphincter components in an East Asian population are described. This data can be used for future consideration of diseased states.
No preview · Article · Dec 2013 · Asian biomedicine
[Show abstract][Hide abstract] ABSTRACT: Marsupialization of anal fistulotomy results in less raw-surface wound and may improve postoperative outcomes. The present study was designed to test the benefit of marsupialization for simple fistula in ano.
This was a randomized controlled study conducted at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Fifty patients with simple uncomplicated fistula in ano were allocated into either fistulotomy group or fistulotomy with marsupialization group. Patients with complex fistula in ano, prior incontinence, immuno-compromised status and bleeding tendency were excluded from the present study. The postoperative pain score, the pain score after the first defecation, total amount of the analgesic usage and complications were evaluated. Recurrence was also assessed
There was no difference in the postoperative pain score between the treatment groups. However, there was a significant difference (p = 0.017) in the number of patients who needed pethidine injection (4 patients of the fistulotomy with marsupialization group versus 13 patients of the fistulotomy group). There was no statistical significant difference in the pain score after the first defecation and the amount of paracetamol usage in seven days. Five complications were found only in the fistulotomy group but the significant level was marginal (p = 0.0501). There was no recurrence of thefistula and none of the patients developed anal incontinence after the surgery.
Marsupialization for anal fistulotomy is safe. This technique helps to improve the postoperative outcomes.
Full-text · Article · Jun 2011 · Journal of the Medical Association of Thailand = Chotmaihet thangphaet
[Show abstract][Hide abstract] ABSTRACT: Spinal cord injury (SCI) causes anorectal problems, whose pathophysiology remains poorly characterized. A comprehensive method of evaluating spino-anorectal function is lacking. The aim of this study was to investigate the neuropathophysiology of bowel dysfunction in SCI by evaluating motor-evoked potentials (MEP) of anus and rectum following transspinal magnetic stimulation and anorectal physiology.
Translumbar and transsacral magnetic stimulations, anorectal manometry, and pudendal nerve terminal motor latency (PNTML) were performed in 39 subjects with SCI and anorectal problems and in 14 healthy controls, and data were compared. MEPs were recorded with an anorectal probe containing bipolar ring electrodes.
The MEPs were significantly prolonged (P<0.05) bilaterally, and at lumbar and sacral levels, as well as at rectal and anal sites in SCI subjects compared with controls. A total of 95% of SCI subjects had abnormal MEPs and 53% had abnormal PNTML. All subjects with abnormal PNTML also demonstrated abnormal MEP, but 16/17 subjects with normal PNTML had abnormal MEP. Overall, SCI patients had weaker anal sphincters (P<0.05), higher prevalence of dyssynergia (85%), and altered rectal sensation (82%).
Translumbar and transsacral MEPs revealed significant and hitherto undetected lumbosacral neuropathy in 90% of SCI subjects. Test was safe and provided neuropathophysiological information that could explain bowel dysfunction in SCI subjects.
No preview · Article · Jan 2011 · The American Journal of Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: Dyssynergic defecation is a common cause of chronic constipation; its diagnosis requires anorectal physiological tests that are not widely available. It is not known whether digital rectal examination (DRE) can be used to identify dyssynergia. We examined the diagnostic yield of DRE in patients with dyssynergic defecation.
Consecutive patients with chronic constipation (Rome III criteria, n = 209) underwent DREs, anorectal manometry analyses, balloon expulsion tests, and colonic transit studies. In the DRE, dyssynergia was identified by 2 or more of the following features: impaired perineal descent, paradoxic anal contraction, or impaired push effort; diagnostic yields were compared with physiological test results.
Of the patients included in the study, 187 (87%) had dyssynergic defecation, based on standard criteria; 134 (73%) of these were identified to have features of dyssynergia, based on DREs. The sensitivity and specificity of DRE for identifying dyssynergia in patients with chronic constipation were 75% and 87%, respectively; the positive predictive value was 97%. DRE was able to identify normal resting and normal squeeze pressure in 86% and 82% of dyssynergic patients, respectively.
DRE appears to be a reliable tool for identifying dyssynergia in patients with chronic constipation and detecting normal, but not abnormal, sphincter tone. DREs could facilitate the selection of appropriate patients for further physiologic testing and treatment.
No preview · Article · Nov 2010 · Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association
[Show abstract][Hide abstract] ABSTRACT: Brain-gut dysfunction has been implicated in gastrointestinal disorders but a comprehensive test of brain-gut axis is lacking. We developed and tested a novel method for assessing both afferent anorectal-brain function using cortical evoked potentials (CEP), and efferent brain-anorectal function using motor evoked potentials (MEP).
Cortical evoked potentials was assessed following electrical stimulations of anus and rectum with bipolar electrodes in 26 healthy subjects. Anorectal MEPs were recorded following transcranial magnetic stimulation (TMS) over paramedian motor cortices bilaterally. Anal and rectal latencies/amplitudes for CEP and MEP responses and thresholds for first sensation and pain (mA) were analyzed and compared. Reproducibility and interobserver agreement of responses were examined.
Reproducible polyphasic rectal and anal CEPs were recorded in all subjects, without gender differences, and with negative correlation between BMI and CEP amplitude (r -0.66, P=0.001). Transcranial magnetic stimulation evoked triphasic rectal and anal MEPs, without gender differences. Reproducibility for CEP and MEP was excellent (CV <10%). The inter-rater CV for anal and rectal MEPs was excellent (ICC 97-99), although there was inter-subject variation.
Combined CEP and MEP studies offer a simple, inexpensive and valid method of examining bidirectional brain-anorectal axes. This comprehensive method could provide mechanistic insights into lower gut disorders.
Full-text · Article · Oct 2010 · Neurogastroenterology and Motility
[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to compare the efficacy of 200 mg versus 400 mg daily of pyridoxine in preventing or delaying the onset of palmar-plantar erythrodysesthesia (PPE) in capecitabine-treated patients.
Patients with histologically confirmed breast cancer or colorectal cancer receiving single agent capecitabine started at 2000 to 2500 mg/m(2) daily from day 1 to 14 every 3 weeks were randomly assigned to receive 200 mg or 400 mg daily of pyridoxine for PPE prophylaxis. The primary endpoint was the reduction of incidence of grade 2 or greater PPE. Secondary endpoints were reduction of severe PPE and prolongation of time to development of grade 2 or greater PPE.
There were 56 patients in this study. The baseline characteristics were generally similar in both groups. The high dose arm had less PPE than the low dose arm (11 of 28 or 39% vs 20 of 28 or 71%, relative risk = 0.26 [0.08, 0.79], P = 0.031). Grade III PPE developed in 3 of 28 (10.7%) versus none in patients receiving 200 mg versus 400 mg pyridoxine, respectively (relative risk 2.12 [1.594, 2.819], P = 0.24). High dose pyridoxine had a longer time to development of grade 2 or greater PPE compared to the low dose arm, 87 days versus 62 days. The 400 mg pyridoxine group had, however, a worsened tumor response and tended to have greater tumor treatment failure and shorter time to treatment failure.
With the limitation of sample size in this study, there was a trend to improve PPE incidence and time to event with a higher dose of pyridoxine. Further validation of these results in a larger population is warranted.
No preview · Article · Sep 2010 · Asia-Pacific Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Introduction: Anorectal manometry (ARM) and anal ultrasound (AUS) are routinely performed
in patients with constipation or fecal incontinence. Whether a single test can simultaneously
evaluate both structure and function, provide more information, and minimize costs
has not been examined. Hypothesis: HDM simultaneously evaluates anal sphincter morphology
and function. Aim: To examine anorectal structure and function with HDM and compare
with ARM and AUS. Methods: During HDM (Sierra Scientific, CA) and ARM, anal sphincter
and rectal pressures were recorded during rest, squeeze, valsalva, and bear down. Rectal
sensations and rectoanal inhibitory reflexes (RAIR) were also assessed. Anal sphincter defects
were evaluated with HDM and AUS. Anal sphincter lengths were assessed using all three
techniques. 10 healthy (F:M 4:6, mean age 35 ± 4 yrs), 10 constipated (F:M 9:1, mean age
48 ± 4 yrs), and 10 fecal incontinent (F:M 8:2, mean age 58 ± 4 yrs) subjects were enrolled.
Statistical Analysis: Intraclass correlation (ICC) and Kappa coefficients were used. Results:
Mean procedure level of discomfort rated on visual analog scales were 2.9, 2.8, and 3.4
(10=worse discomfort) for ARM, AUS, and HDM, respectively. Intraclass correlations comparing
HDM and ARM variables are shown in Table. Sphincter pressures were comparable, but
more subjects showed features of dyssynergia with HDM. There was good agreement in 26/
30 (87%) subjects for sphincter defects; 16 (53%) were negative and 10 (33%) were positive
with both AUS andHDM(Kappa coefficient=0.72). Anal canal length showed good correlation
between AUS and HDM (ICC=0.64). Conclusions: HDM is feasible, safe, well-tolerated and
provides comparable information regarding sphincter defects when compared to AUS and
regarding manometric functions when compared to ARM. The circumferential array gives
superior definition of anal sphincter length, contraction, relaxation, and paradoxical contraction.
[Show abstract][Hide abstract] ABSTRACT: To compare the perioperative complications, analgesics requirement, and length of hospital stay between patients undergoing urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoid and elective closed hemorrhoidectomy.
Retrospective, comparative study.
All records of the patients who underwent urgent and elective hemorrhoidectomy between January 2000 and December 2005 were reviewed. Perioperative complications (bleeding, urinary retention, post-operative thrombosis, and wound dehiscence), analgesic requirement, and length of hospital stay were analyzed.
Chi-Square Test and Mann-Whitney U Test.
From 1440 patients, 1184 patients met the inclusion criteria. All were done with closed technique. The indication for urgent hemorrhoidectomy was prolapsed thrombosed hemorrhoid in 416 patients (group 1). The indication for elective hemorrhoidectomy were grade 3 and 4 internal hemorrhoid, external hemorrhoid or combined hemorrhoid in 768 patients (group 2). There was no statistically significant difference in urinary retention and bleeding complication between two groups; 31 patients (7.5%) in group 1 and 69 patients (8.9%) in group 2 experienced urinary retention p = 0.426, five patients (1.2%) in group 1 and 10 patients (1.3%) in group 2 had postoperative bleeding, p = 1.000). On the second postoperative week, wound dehiscence was found in nine patients (2.2%) from group 1 and 15 patients (2%) from group 2. On the fourth week, all the wounds were completely healed without granulation or stricture formation. Post-operative meperidine requirement was significantly lower in the urgent hemorrhoidectomy group (0.84 +/- 0.71 vs. 0.99 + 0.81 mg/kg, p < 0.001). Post-operative length of hospital stay were not statistically different (1.017 +/- 0.129 vs. 1.016 +/- 0.124, p = 0.107).
Urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids may be a preferable option for patients suffering from this condition.
Preview · Article · Dec 2009 · Journal of the Medical Association of Thailand = Chotmaihet thangphaet
[Show abstract][Hide abstract] ABSTRACT: To describe the use of biofeedback therapy in management of bowel symptoms after definitive surgery for Hirschsprung's disease.
This study describes two cases that exemplify the complex nature of these problems. These patients presented with constipation and faecal seepage several years after receiving treatment for Hirschsprung's disease. The approach to management of these patients including the use of biofeedback therapy is described.
After biofeedback therapy, there was improvement in bowel symptoms in both subjects. In case 1 (constipation), stool frequency increased from 0.5-1 time/week to 5-6 times/week together with improved stool consistency. In case 2 (faecal seepage), the number of incontinence episode decreased from >1/day to complete continence, together with decreased stool frequency. They were still satisfied with their bowel movement at 1-year follow-up.
Recognition of the underlying problems and therapy directed towards correcting these abnormalities may lead to significant symptomatic improvement in these patients.
No preview · Article · Jan 2009 · Developmental neurorehabilitation
[Show abstract][Hide abstract] ABSTRACT: Restorative proctocolectomy is a standard treatment for colorectal diseases over decades. At present, this technique is frequently performed via minimal invasive approach. Most reported techniques of laparoscopic restorative proctocolectomy involved a Pfannenstiel incision for the major part of the operation to be performed openly; a double-stapled pouch anal anastomosis technique and protective ileostomy. This study was designed to demonstrate the modification of this technique.
This was a retrospective study of seven patients (4 had ulcerative colitis and 3 had familial adenomatous polyposis) who underwent laparoscopic restorative proctocolectomy at King Chulalongkorn Memorial Hospital between September 2004 and February 2007. The details of the procedure are shown in the video. The techniques involve the following: full mobilization of entire colon and rectum using medial to lateral approach, division of submesenteric arcades for ileal pouch elongation with preservation of three to four inner most arcades of distal ileum segment and preservation of both superior mesenteric and ileocolic trunk, ileal pouch construction via a small (3-4 cm) McBurney incision, transanal mucosectomy with removal of the entire rectum and colon transanally, and handsewn ileal pouch-anal anastomosis. None of the patients underwent protective ileostomy.
Mean surgical time was 360 (270-510) minutes, and median blood loss was 230 (100-400) ml. There were neither conversions nor intraoperative surgical complications. However, one patient developed small-bowel obstruction, which was successfully treated by laparoscopic approach. Anastomotic leakage was not found in this series. All patients have good control of their bowel movement as well as a very good cosmetic result during the follow-up period.
Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction, without protective ileostomy, is technically feasible and safe.
No preview · Article · Aug 2008 · Diseases of the Colon & Rectum
[Show abstract][Hide abstract] ABSTRACT: To describe a new technique for fistula-in-ano surgery aimed at total sphincter preservation, and evaluate the preliminary results concerning non-healing and intact anal function.
A prospective observational study in eighteen fistula-in-ano patients treated by ligation of intersphincteric fistula tract (LIFT) technique, from January to June 2006.
Fistula-in-ano in seventeen patients healed primarily (94.4%). There was one non-healing case (5.6%). The mean healing time was four weeks. None had disturbances in clinical anal continence.
The early outcome of the LIFT technique is quite impressive. Results warrant a larger study with long-term evaluation. This technique has the potential to become a viable option for fistula-in-ano surgery.
Preview · Article · Apr 2007 · Journal of the Medical Association of Thailand = Chotmaihet thangphaet
[Show abstract][Hide abstract] ABSTRACT: The major problem in the treatment of rectal cancer is local recurrence. After the introduction of total mesorectal excision (TME), the recurrent rate decreased from 100% to around 10%.
The purpose of the present study was to evaluate the quality of organ and tissue plane preservation in soft cadaver and to assess the feasibility to perform the procedure (mobilization of colon and rectum, total mesorectal excision and stapler anastomosis) in soft cadaver.
Colorectal Division, Department of Surgery and Surgical Training Center Department of Anatomy, Faculty of Medicine, Chulalongkorn University.
Prospective descriptive study.
Seven soft cadavers were used for total mesorectal excision (TME) training. These procedures were performed by 21 participants (1 soft cadaver for 3 participants). The procedures were done under the supervision of experienced colorectal surgeons. The successfulness, satisfaction in performing the procedure and the quality of organ preservation were evaluated using standardized questionnaires.
Participants were satisfied about TME training in soft cadaver (mean 8.24-8.71) and rated that soft cadavers were good in terms of internal organs and tissue plane preservation (mean 7.19-8.19) (0 = extremely unsatisfied, 10 = extremely satisfied).
Training of TME in soft cadaver is feasible. The similarity in tissue quality (texture, consistency, color) of the preserved organs to that of the living and the good feel of performing the procedure make the trainee better understand the techniques and improve their skills.
No preview · Article · Oct 2006 · Journal of the Medical Association of Thailand = Chotmaihet thangphaet
[Show abstract][Hide abstract] ABSTRACT: Familial adenomatous polyposis (FAP) is characterized by the presence of numerous colorectal adenomatous polyps that progress to colorectal cancer if left untreated. Following colorectal cancer, periampullary cancer and aggressive desmoid tumor are also the common causes of death. The purpose of the present study was to describe the clinical course of FAP patients.
The authors conducted a retrospective study of 31 FAP patients who were treated at King Chulalongkorn Memorial Hospital (KCMH) between March 2000 and March 2006. Demographic data, family history, symptoms, extracolonic manifestations, operative procedures, pathologic findings, and postoperative results were collected.
Two patients were excludedfrom the present study. The average age of the 29 patients was 33.48 years with the sex ratio (male/female) of 0.93. Seventeen of the 29 patients (58.6%) had a family history of FAP Sixteen of 29 patients were discovered with colorectal cancer with a mean age of34.56 years. Mucous bloody stool was the most common presenting symptom and most of the patients with this symptom (11/13) already had colorectal cancer Gastroduodenal polyps and desmoid tumor were common extracolonic manifestations. The most common operative procedure was restorative proctocolectomy with ileal J pouch (RPC). Wound infection and gut obstruction were the frequent complications. Functional outcomes of patients with RPC were good. The mean age ofpatients with colon cancer was older than the mean age ofpatients without colon cancer However, there was no significant difference between the two groups. The sex ratio and family history of FAP were not statistically different. No significant differences were found in surgical procedures and postoperative complications. On the follow up period, two patients in the later group died of desmoid tumor and pancreatic cancer while seven patients in the former group died of metastatic colon cancer and one with desmoid tumor
The proportion ofpatients who were discovered with colorectal cancer in the present study was high with young age onset of cancer Moreover, patients in this group had poorer outcome compared to the group of patients without colorectal cancer; of which, metastatic colorectal cancer was the major cause of death. This result may be due to aggressiveness and advanced stage of disease at the first diagnosis.
No preview · Article · Oct 2006 · Journal of the Medical Association of Thailand = Chotmaihet thangphaet
[Show abstract][Hide abstract] ABSTRACT: To compare the operative time, postoperative complications, and analgesic requirement between closed hemorrhoidectomy and Ligasure hemorrhoidectomy.
The study was conducted in a prospectively randomized controlled fashion. Forty-seven patients with grade 3 or 4 hemorrhoids plus external component or skin tag were operated on by either hemorrhoidectomy with Ligasure (24 patients) or closed hemorrhoidectomy (23 patients). One patient in each group was lost to follow up. The operative time, postoperative verbal numeric pain score, analgesic requirement, bleeding, and wound dehiscence between the two groups were compared Unpaired t-tests, Mann-Whitney U tests, or Fisher's Exact tests were used where appropriate.
Demographic and clinical data between two groups were comparable. Operative time for the Ligasure hemorrhoidectomy was significantly shorter than the closed hemorrhoidectomy group (21.70 +/- 11.76 vs 35.68 +/- 14.25 min, p < 0. 001), while the number of resected hemorrhoids in the study group were 2.91 versus 2.18 in the control group. However, there were no differences in post-operative pain score, analgesic requirement, bleeding, or wound dehiscence between the two groups.
Ligasure hemorrhoidectomy is superior to closed hemorrhoidectomy in terms of reducing the operative time without affecting postoperative complications.
Preview · Article · May 2006 · Journal of the Medical Association of Thailand = Chotmaihet thangphaet