Recent basic science investigations have suggested that the upper esophageal sphincter (UES), in cross section, is not round, but that it more closely approximates a kidney shape. Dilation with simultaneous use of two cylindrical dilators provides a novel, physiology-based approach to UES distention. We evaluated the initial safety and efficacy of UES dilation with simultaneous use of two controlled radial expansion balloon dilators.Using a computerized database, we reviewed the charts of all persons who underwent UES dilation with simultaneous use of two radial expansion balloon dilators between December 1, 2011, and March 15, 2012. Information regarding patient demographics, indications, technique, and complications was abstracted. Self-reported swallowing impairment was assessed with the validated 10-item Eating Assessment Tool (EAT-10).Ten individuals underwent simultaneous dilation with two dilators. Their mean age was 65 years (SD, 14 years), and 7 (70%) of them were male. The indications for dilation were radiation-induced UES stenosis (50%), cricopharyngeus muscle dysfunction (30%), upper esophageal web (10%), and anastomotic stricture (10%). After the double-balloon dilation, no complications were reported. The mean EAT-10 score improved significantly, from 34.3 (SD, 13.5) to 16.7 (SD, 8.4), after the simultaneous dilation (p = 0.003).Pilot data suggest that simultaneous dilation of the UES with two controlled radial expansion balloon dilators is feasible, safe, and effective. Future investigation is necessary to confirm the safety of this technique in a larger cohort and to use objective measures of efficacy to compare the technique to conventional dilation with a single dilator.

To study the development of pelvic floor muscle, morphology and location of rectum and anal canal as well as morphology of spinal cord and sacrum based on pelvic magnetic resonance imaging(MRI) of children with fecal incontinence after anoplasty for anorectal malformation and to provide information on management of fecal incontinence.Clinical and MRI data of 34 children with fecal incontinence after anoplasty for anorectal malformation in the Second Hospital of Shangdong University from September 2009 to December 2011 were analyzed retrospectively. There were 21 males and 13 females with the age of 3 to 14 years old. All the children underwent MRI detection. The morphology of external anal sphincter, puborectalis, ani levator, rectum and anal canal as well as the development of spinal cord and sacrum were observed using 1.5T MR scanner, including routine axial view, coronal view and sagittal view.MRI revealed that dysplasia of external anal sphincter, puborectalis and anilavatory were found in 18, 23 and 27 children, respectively. MRI also showed ectopia of rectum(n=6), dilation of rectum(n=12), increased anorectal angle(n=11), fat tissue around the anal canal(n=5), tethered cord syndrome(n=2), Currarino syndrome(n=2), sacrum dysplasia(n=11); and rectourethral fistula(n=2). The above MRI findings were confirmed by operation and clinical practice.MRI can provide clear morphology of external anal sphincter, puborectalis and ani lavatory, and location of rectum and anal canal as well as the development of spinal cord and sacrum. MRI is a valuable method to evaluate the children with fecal incontinence after anoplasty.

Background and Introduction Constipation following posterior sagittal anorectoplasty (PSARP) is common. We correlated the dimensions of rectal pouch before PSARP with the postoperative bowel habit. Classical PSARP was modified with tapering of rectal pouch by plication of its walls thus preserving the internal sphincter because we believe that this preserves continence and lead to better results. It was observed that a distinct relationship exists between the preoperative size of the rectal pouch and constipation.Aim The aim of this study is to correlate the dimensions of preoperative rectal pouch with postoperative constipation.Materials and Methods PSARP was performed (n: 45) in anorectal malformations using an indigenous muscle stimulator. Before PSARP, a distal cologram via high sigmoid colostomy was performed. All the distal cologram were performed by a single senior radiologist and the pressure was kept constant between 15 and 20 cm of water while filling to rule out the confounding factor related to incomplete filling. Rectum index was calculated as follows: The maximum radiological diameter of the rectum within the pelvis in the sagittal plane was multiplied by the maximum diameter of the rectum in the frontal plane. The result of this calculation was divided by the product of multiplying the distance between the ischial spines and the distance between the posterior surface of the pubic symphysis and the anterior surface of the last sacral vertebrae.Results Symptomatic constipation requiring treatment developed in 25 patients (48%). None of these patients had anal stenosis or stricture. Constipation was managed by dietary measures and laxatives. Fifteen patients (60%) had grade 1 constipation and responded favorably. Eight and two patients had grades 2 and 3 constipation, respectively. Those patients who had a rectal pouch index of less than 0.8 had mild constipation grades 0 and 1, whereas those in whom the rectal pouch index was more than 0.8 had severe degrees of constipation (grades 2 and 3).Conclusion Measuring the rectal pouch index can help in identifying the group which is likely to develop constipation after PSARP. These patients can be put on bowel training early on, after the colostomy closure, instead of waiting.

BACKGROUND:

The present study demonstrates our experience with a novel use of the Platysma in facial reanimation, as a balancing procedure by counteracting an overactive free muscle transfer, and improving oral continence by re-establishing the oral sphincter mechanism.

MATERIAL AND METHODS:

Twelve patients, nine female (75%) and three male (25%), with a mean age of thirty-eight years (range: 2-66) are presented. Of these, in seven patients (58%) who had excessive excursion of the free muscle, the contralateral pedicled platysma was transferred to counteract the excessive pull. Four patients (33%) underwent bilateral platysma transfer for oral sphincter restoration, while one (8%) had ipsilateral platysma transfer. Evaluation of aesthetic and functional results was performed by a panel of three independent observers, and the long term efficacy of the procedure was assessed through a patient questionnaire.

RESULTS:

All patients demonstrated significant upgrading of their oral competence associated with eating, drinking and smiling, as it was confirmed by the behavioural analysis (p < 0.01). Six of the ten patients that were available, responded to the Quality of Life Questionnaire. Five out of six were satisfied with their mouth appearance when they smile and five patients have a regular diet and without drooling.

CONCLUSION:

A novel use of Platysma transposition is described that can substitute for a paralysed orbicularis oris muscle in restoring oral sphincter function or to counter balance an excessively active free muscle that was previously transferred for smile restoration. This novel Platysma transfer technique is intended to be used as an adjunct to other reanimation procedures.

Muscularis propria of the esophagus is organized into circular and longitudinal muscle layers. Goal of this review is to summarize the role of longitudinal muscle in physiology and pathophysiology of esophageal sensory and motor function. Simultaneous manometry and ultrasound imaging that measure circular and longitudinal muscle contraction respectively reveal that during peristalsis 2 layers of the esophagus contract in perfect synchrony. On the other hand, during transient relaxation of the lower esophageal sphincter (LES), longitudinal muscle contracts independently of circular muscle. Recent studies provide novel insights, i.e., longitudinal muscle contraction of the esophagus induces LES relaxation and possibly descending relaxation of the esophagus. In achalasia esophagus and other motility disorders there is discoordination between the 2 muscle layers. Longitudinal muscle contraction patterns are different in the recently described three types of achalasia identified by high-resolution manometry. Robust contraction of the longitudinal muscle in type II achalasia causes pan-esophageal pressurization and is the mechanism of whatever little esophageal emptying that take place in the absence of peristalsis and impaired LES relaxation. It may be that preserved longitudinal muscle contraction is also the reason for superior outcome to medical/surgical therapy in type II achalasia esophagus. Prolonged contractions of longitudinal muscles of the esophagus is a possible mechanism of heartburn and "angina like" pain seen in esophageal motility disorders and possibly achalasia esophagus. Novel techniques to record longitudinal muscle contraction are on the horizon. Neuro-pharmacologic control of circular and longitudinal muscles is different, which provides an important opportunity for the development of novel pharmacological therapies to treat sensory and motor disorders of the esophagus.

Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ∼2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.

: Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles.: We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy.: This was a single-blind, parallel-group, randomized controlled trial.: The study was conducted at a university teaching hospital in Rome, Italy.: Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded.: Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days.: Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy.: Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5±1.0 vs 4.0±1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4±7.4 mmHg vs 85.6±7.9 mmHg, p < 0.0001).: GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded.: Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

The smooth muscle cell is the principal component responsible for involuntary control of visceral organs, including vascular tonicity, secretion, and sphincter regulation. It is known that the neurotransmitters released from nerve endings increase the intracellular Ca(2+) level in smooth muscle cells followed by muscle contraction. We herein report that femtosecond laser pulses focused on the diffraction-limited volume can induce intracellular Ca(2+) increases in the irradiated smooth muscle cell without neurotransmitters, and locally increased intracellular Ca(2+) levels are amplified by calcium-induced calcium-releasing mechanisms through the ryanodine receptor, a Ca(2+) channel of the endoplasmic reticulum. The laser-induced Ca(2+) increases propagate to adjacent cells through gap junctions. Thus, ultrashort-pulsed lasers can induce smooth muscle contraction by controlling Ca(2+) , even with optical stimulation of the diffraction-limited volume. This optical method, which leads to reversible and reproducible muscle contraction, can be used in research into muscle dynamics, neuromuscular disease treatment, and nanorobot control. (© 2013 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim).

: We report a case of congenital mydriasis in a neonate with megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS). Pilocarpine testing and gastrointestinal pathology in our patient suggest that the mydriasis is due to an underlying smooth muscle myopathy of the iris sphincter muscle. These findings may have important implications regarding the pathogenesis of MMIHS.

BACKGROUND:

The innervation of the mouse internal anal sphincter (IAS) has been little studied, and how it changes during aging has not previously been investigated. The aim of this study was therefore to characterize the distribution and density of subtypes of nerve fibers in the IAS and underlying mucosa in 3-, 12- to 13-, 18- and 24- to 25-month-old male C57BL/6 mice.

METHODS:

Nerve fibers were immunolabeled with antibodies against protein gene product 9.5 (PGP9.5), neuronal nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP), substance P (SP), calcitonin gene-related peptide (CGRP), and calretinin (CR). Immunoreactivity in nerve fibers in the circular muscle and mucosa was quantified using Image J software. KEY

RESULTS:

In young adult (3 month) mice, nNOS-immunoreactive (IR) nerve fibers were densely distributed in the circular muscle, but relatively few in the mucosa; VIP-IR nerve fibers were abundant in the circular muscle and common in the mucosa; SP-IR nerve fibers were common in circular muscle and mucosa; CGRP- and CR-IR nerve fibers were dense in mucosa and sparse in circular muscle. The density of PGP9.5 immunoreactivity (IRY) was not significantly reduced with age, but a significant reduction in nNOS-IRY and SP-IRY with age was found in the IAS circular muscle. Neuronal nitric oxide synthase-, VIP-, and SP-IRY in the anal mucosa were significantly reduced with age. CGRP-IRY in both circular muscle and mucosa was increased in 18-month-old animals.

CONCLUSIONS

& INFERENCES: The density of immunoreactivity of markers for some types of IAS nerve fibers decreases during aging, which may contribute to age-related ano-rectal dysfunction.