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sphincter muscle [keywords]
- Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons' view. [JOURNAL ARTICLE]
- Int J Colorectal Dis 2014 Oct 15.
Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision.This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p = 0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.
- Zenker's diverticulum: a case report and literature review. [Journal Article]
- Pan Afr Med J 2014.:267.
The pharyngeal pouch (Zenker's diverticulum) is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the oesophagus). It occurs commonly in elderly patients (over 70 year) and the typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss. We are reporting a case of an oropharyngeal dysphagia due to a Zenker's diverticulum in 75 years old Sudanese man with a chronic history of dysphagia for solids. The pathophysiology of Zenker's diverticulum, clinical presentation, and management are reviewed.
- Nitrergic neuromuscular transmission in the mouse internal anal sphincter is accomplished by multiple pathways and post-junctional effector cells. [JOURNAL ARTICLE]
- Am J Physiol Gastrointest Liver Physiol 2014 Oct 9.
The effector cells and second messengers participating in nitrergic neuromuscular transmission (NMT) were investigated in the mouse internal anal sphincter (IAS). Protein expression of guanylate cyclase (GCα, GCβ) and cyclic GMP dependent protein kinase I (cGKI) were examined in cryostat sections with dual labeling immunohistochemical techniques in PDGFRα(+) cells, interstitial cells of Cajal (ICC) and smooth muscle cells (SMC). Gene expression levels were determined with qPCR of dispersed cells from Pdgfrα(egfp/+), Kit(copGFP/+) and smMHC(Cre-egfp) mice sorted with FACS. The relative gene and protein expression levels of GCα and GCβ were: PDGFRα(+) cells>ICC>SMC. In contrast, cGKI gene expression sequence was SMC=ICC>PDGFRα(+) cells while cGKI protein expression sequence was neurons>SMC>ICC=PDGFRα(+) cells. The functional role of cGKI was investigated in cGKI(-/-) mice. Relaxation with 8-Br-cGMP was greatly reduced in cGKI(-/-) mice while responses to sodium nitroprusside (SNP) were partially reduced and forskolin responses were unchanged. A nitrergic relaxation occurred with nerve stimulation (NS, 5Hz, 60s) in cGKI(+/+) and cGKI(-/-) mice although there was a small reduction in the cGKI(-/-) mouse. L-NNA abolished responses during the first 20-30s of NS in both animals. The GC inhibitor ODQ greatly reduced or abolished SNP and nitrergic NS responses in both animals. These data confirm an essential role for GC in NO-induced relaxation in the IAS. However, the expression of GC and cGKI by all three cell types suggests that each may participate in coordinating muscular responses to NO. The persistence of nitrergic NMT in the cGKI(-/-) mouse suggests the presence of a significant GC-dependent, cGKI-independent pathway.
- Length tension function of puborectalis muscle: implications for the treatment of fecal incontinence and pelvic floor disorders. [Journal Article]
- J Neurogastroenterol Motil 2014 Oct 30; 20(4):539-46.
External anal sphincter (EAS) and puborectalis muscle (PRM) play important role in anal continence function. Based on length-tension measurement, we recently reported that the human EAS muscle operates at short sarcomere length under phys-iological conditions. Goal of our study was to determine if PRM also operates at the short sarcomere length.Length-tension relationship of the PRM muscle was studied in vivo in 10 healthy nullipara women. Length was altered by vagi-nal distension using custom-designed probes of 5, 10, 15, 20, 25 and 30 mm diameters as well as by distending a poly-ethylene bag with different volumes of water. Probes were equipped with a reverse perfuse sleeve sensor to measure vaginal pressure (surrogate of PRM tension). PRM electromyogram (EMG) was recorded using wire electrodes. Three-dimensional ultra-sound images were obtained to determine effect of vaginal distension on PRM length.Ultrasound images demonstrate distension volume dependent increase in PRM length. Rest and squeeze pressures of vaginal bag increased with the increase in bag volume. Similarly, the change in vaginal pressure, which represents the PRM contraction increased with the increase in the probe size. Increase in probe size was not associated with an increase in EMG activity (a marker of neural drive) of the PRM.Probe size dependent increase in PRM contraction pressure, in the presence of constant EMG (neural input) proves that the hu-man PRM operates at short sarcomere length. Surgically adjusting the PRM length may represent a novel strategy to improve treat anal continence and possibly other pelvic floor disorders.(J Neurogastroenterol Motil 2014;20:539-546).
- Urethroplasty for high-risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap. [JOURNAL ARTICLE]
- J Urol 2014 Sep 24.
Long-segment urethral strictures with a compromised graft bed and poor vascular supply are unfit for standard repair, and are at high-risk for stricture recurrence. Our objective was to assess the success of urethral reconstruction in these patients with a ventral buccal mucosa graft (BMG) and gracilis muscle flap (GMF).A retrospective review of 1039 patients who underwent urethroplasty at Lahey Hospital and Medical Center between 1999 and 2014 was performed. We identified 20 patients who underwent urethroplasty with a ventral BMG and GMF graft bed. Stricture recurrence was defined as the inability to pass a 16 Fr cystoscope.Mean stricture length was 8.2 cm (3.5-15). Strictures were located in the posterior urethra with or without involvement of the bulbar urethra in 50%, bulbomembranous urethra (35%), bulbar urethra (10%), and proximal pendulous urethra (5%). Stricture etiology was radiation therapy in 45% followed by idiopathic (20%), trauma (15%), prostatectomy (10%), hypospadias failure (5%), and transurethral surgery (5%). 9 patients (45%) had previous urethroplasty and 3 (15%) had previous UroLume® stents. Urethral reconstruction was successful in 16 patients (80%), with a mean follow-up of 40 months. Of the failures, one patient had an ileal loop, two a suprapubic tube, and one urethral dilation. Mean time to recurrence was 10 months (2-17). 5 patients (25%) had postoperative incontinence requiring an artificial urinary sphincter.Urethroplasty for high-risk, long segment urethral strictures can be successfully performed with a ventral BMG and GMF avoiding urinary diversion in the majority of patients.
- Botulinum toxin type-A injection to treat patients with intractable anismus unresponsive to simple biofeedback training. [Journal Article]
- World J Gastroenterol 2014 Sep 21; 20(35):12602-7.
To evaluate the efficacy of botulinum toxin type A injection to the puborectalis and external sphincter muscle in the treatment of patients with anismus unresponsive to simple biofeedback training.This retrospective study included 31 patients suffering from anismus who were unresponsive to simple biofeedback training. Diagnosis was made by anorectal manometry, balloon expulsion test, surface electromyography of the pelvic floor muscle, and defecography. Patients were given botulinum toxin type A (BTX-A) injection and pelvic floor biofeedback training. Follow-up was conducted before the paper was written. Improvement was evaluated using the chronic constipation scoring system.BTX-A injection combined with pelvic floor biofeedback training achieved success in 24 patients, with 23 maintaining persistent satisfaction during a mean period of 8.4 mo.BTX-A injection combined with pelvic floor biofeedback training seems to be successful for intractable anismus.
- Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence. [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Sep 25.
The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI).Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included.Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21 %, p < 0.001), cross-sectional area (20 %, p = 0.003), and volume (12 %, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly.This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.
- Effect of myogenic stem cells on the integrity and histomorphology of repaired transected external anal sphincter. [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Sep 25.
The objective was to evaluate the effect of myogenic stem cells on histological properties and the volume of striated muscle of the external anal sphincter after transection and repair.Histological analysis was performed on the external anal sphincters of 40 young female rats euthanized at 7 or 90 days after transection and repair and randomization to injection of either phosphate buffered solution (PBS) or myogenic stem cells (SC) at the transection site. Sphincter complexes, previously evaluated for neurophysiological function, were processed for histology and analyzed for possible disruption, amount of inflammation, and volume of striated muscle. The relationship between the muscular disruption and contractile force of sphincters was evaluated.Disruption was seen in 100 % of sphincters 7 days after repair for both SC and control animals. Eighty-nine percent of controls and 78 % of SC-administered animals had intact sphincters at 90 days. Significant inflammatory infiltrate was seen in repaired anal sphincters for both the PBS and the SC groups at 7 days, and persisted at 90 days, with no difference between treatment groups. Striated muscle volume increased from 7 to 90 days for both control and SC-administered animals. Although there was no difference in volume between treatments, there was substantial temporal improvement in contractile force generation of the sphincters receiving SC compared with those receiving PBS.In this animal model, administration of myogenic stem cells to transected/repaired anal sphincters did not alter the amount of inflammation nor the volume of striated muscle, suggesting that stem cells might improve contractile function through other cellular processes.
- Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study. [JOURNAL ARTICLE]
- Dis Esophagus 2014 Sep 12.
Peroral endoscopic myotomy (POEM) has been developed as a minimally invasive endoscopic treatment for achalasia for years. However, the optimal length of submucosal tunnel and myotomy of muscle bundles during procedure of POEM has not yet been determined, so we aim to assess safety and efficacy of modified POEM with shorter myotomy of muscle bundles in achalasia patients. Consecutive achalasia patients had been performed modified POEM with shorter myotomy, and assessed by symptoms, high-resolution manometry, and barium swallow examinations before and 3 months after POEM for safety and efficacy evaluation. Modified POEM with shorter submucosal tunnel (mean length 6.8 cm) and endoscopic myotomy of muscle bundles (total mean length 5.4 cm) were completed in 46 consecutive achalasia patients. During the 3-month follow up in all cases, significant improvement of symptoms (a significant drop in the Eckardt score 8.4 ± 3.2 vs. 2.7 ± 1.9; P < 0.001), decreased lower esophageal sphincter pressure (39.4 ± 10.1 vs. 24.4 ± 9.1 mmHg; P < 0.001) and integrated relaxation pressure (38.6 ± 10.4 vs. 25.7 ± 9.6 mmHg; P < 0.01), and a drop in height of esophagus barium-contrast column (5.4 ± 3.1 vs. 2.6 ± 1.8 cm; P < 0.001) were observed. The frequencies of adverse events were lower in those under endotracheal anesthesia and CO2 insufflations compared with intravenous anesthesia and air insufflations. Only three patients were found to have gastroesophageal reflux disease on follow up. Modified POEM with shorter myotomy under endotracheal anesthesia and CO2 insufflations shows its good safety and excellent short-term efficacy in the treatment of achalasia. But further studies are warranted to assess the long-term efficacy.
- [Catheter-related bladder discomfort after urological surgery: Importance of the type of surgery and efficiency of treatment by clonazepam]. [English Abstract, Journal Article]
- Prog Urol 2014 Sep; 24(10):628-33.
Bladder catheter can induce a Catheter-Related Bladder Discomfort (CRBD). Antagonist of muscarinic receptor is the gold standard treatment. Clonazepam is an antimuscarinic, muscle relaxing oral drug. The aim of this study is to look for a correlation between the type of surgical procedure and the existence of CRBD and to evaluate the efficiency of clonazepam.One hundred patients needing bladder catheter were evaluated. Sexe, age, BMI, presence of diabetes, surgical procedure and existence of CRBD were noted. Pain was evaluated with analogic visual scale. Timing of pain, need for specific treatment by clonazepam and its efficiency were noted. Correlation between preoperative data, type of surgical procedure, existence of CRBD and efficiency of treatment were evaluated.There were 79 men and 21 women (age: 65.9 years, BMI: 25.4). Twelve patients presented diabetes. Surgical procedure concerned prostate in 39 cases, bladder in 19 cases (tumor resections), endo-urology in 20 cases, upper urinary tract in 12 cases (nephrectomy…) and lower urinary tract in 10 cases (sphincter, sub-uretral tape). Forty patients presented CRBD, (pain 4.5 using VAS). This pain occurred 0.6 days after surgery. No correlation was found between preoperative data and CRBD. Bladder resection and endo-urological procedures were surgical procedures which procured CRBD. Clonazepam was efficient in 30 (75 %) out of 40 patients with CRBD. However, it was less efficient in case of bladder tumor resection.CRBD is frequent and occurred immediately after surgery. Bladder resection and endo-urology were the main surgical procedures which induced CRBD. Clonazepam is efficient in 75 %. Bladder resection is the surgical procedure which is the most refractory to treatment.5.