World Journal of Surgery

, Volume 16, Issue 5, pp 811–819 | Cite as

Autonomic influences on colorectal motility and pelvic surgery

  • J. S. Varma
World Progress In Surgery

Abstract

The nervous control of the motility of the human distal bowel was investigated by two physiological studies of electrical stimulation of sacral parasympathetic outflow in patients with high spinal injuries and in patients with intractable constipation following pelvic surgery. Identical and reproducible motility responses of the left colon, rectum, and anal sphincters were obtained by sequential electrical stimulation of anterior sacral roots S2, S3, and S4 in patients with spinal injury. S2 stimulation provoked isolated low-pressure colorectal contractions. S3 stimulation initiated frequency-dependent high-pressure colorectal motor activity which appeared peristaltic and was enhanced with repetitive stimuli. S4 stimulation increased colonic and rectal tone. Quantitative responses were maximal at the splenic flexure and rectum. Pelvic floor activity was stimulated in increasing magnitude from S2 to S4. These results of distal bowel motility were achieved by an implanted Brindley stimulator. A newer generation of externally active stimulators are envisaged for the control of lower bowel in fecal incontinence.

Women with intractable constipation following hysterectomy had significantly increased rectal volume and compliance together with deficits of rectal sensory function. Following stimulation with Prostigmin (neostigmin) a colorectal motility gradient was paradoxically reversed in the patients following hysterectomy, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in 2 patients tested with carbachol provocation. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients following hysterectomy.

Résumé

Le contôle nerveux de la motricité de l'intestin terminal a été évalué par deux études physiologiques comprenant une stimulation électrique du nerf parasympathique sacré, d'une part chez le patient ayant une lésion rachidienne haute et d'autre part, chez le patient ayant une constipation rebelle au traitement après chirurgie pelvienne. Par stimulation électrique séquentielle des racines sacrées antérieurs S2, S3 et S4 chez le patient ayant une lésion rachidienne, les réponses obtenues pour le côlon gauche, le rectum, et le sphincter anal étaient identiques et reproducibles. La stimulation S2 provoquait des contractions colorectales de basse pression, isolées. La stimulation S3 provoquait une activité motrice colorectale de haute pression en rapport avec la fréquence de la stimulation. Cette activité apparaissait liée au péristaltisme et elle augmentait lors des stimulations répétées. La stimulation S4 haussait le tonus rectal et colique. Le réponse quantitatives étaient maximales au niveau de l'angle gauche et du rectum. L'activité du plancher pelvien était stimulée de façon croissante de S2 à S4. Ces résultats ont été obtenus en utilisant un stimulateur implantable du type Brindley. La nouvelle génération de stimulateurs, actifs par voie externe, sera appelée à contrôler la continence aux selles du rectum. Chez la femme ayant eu une hystérectomie suivie de constipation rebelle au traitement, le volume et la compliance du rectum sont augmentés, alors que la fonction sensitive du rectum s'avère défectueuse. Après stimulation par la prostigmine (neostigmine, USP), le gradient colorectal est inversé de façon paradoxale chez les femmes hystérectomisées, créant ainsi une obstruction fonctionnelle. L'hypersensibilité de dénnervation a été mise en évidence chez les patientes ayant eu le test de provocation au carachol. Ces données suggèrent une anomalie de fonctionnement du système autonome de l'intestin distal chez certaines patientes hystérectomisées.

Resumen

El control nervioso de la motilidad del tracto intestinal distal fue investigado en dos estudios fisiológicos sobre el estímulo eléctrico de los nervios parasimpáticos sacros en 5 hombres con lesiones altas de la medula espinal y en 14 mujeres con estreñimiento intratable resultante de cirugía pélvica. Se demostraron idénticas respuestas de la motilidad del colon izquierdo, del recto y de los esfínteres anales mediante la estimulación eléctrica secuencial de las raíces sacras anteriores S2, S3 y S4 en los pacientes con lesión de la medula espinal. La estimulación de S2 indujo contracciones colorectales de baja presión. La estimulación de S3 dió origen a una actividad motora de alta presión dependiente de la frecuencia, con apariencia peristáltica, la cual apareció incrementada con estímulos repetidos. La estimulación de S4 resultó en aumento del tono colónico y rectal. Las respuestas cuantitativas aparecieron máximas a nivel del ángulo esplénico y del recto. La actividad del piso pélvico apareció estimulada, con magnitud creciente, entre S2 y S4. Tales resultados sobre la motilidad del tracto intestinal distal fueron logrados por medio de la implantación del denominado estimulador de Brindley. Se presagia una nueva generación de estimuladores de acción externa para el control de la incontinencia fecal.

Las mujeres con estreñimiento intratable consecuente a histerectomía exhibieron significativo aumento de los volumenes y de la compliancia rectales, junto con déficits de la función sensorial rectal. La estimulación con prostigmina (neostigmina, USP) revirtió, paradójicamente, un gradiente de motilidad colorrectal en las pacientes histerectomizadas, lo equivale a una obstrucción funcional. Supersensibilidad de denervación fue demonstrada en dos pacientes estudiadas por medio de la provocación con carbacol. Estos hallazgos sugieren disfunción en la inervación autonómica del intestino distal en algunas pacientes sometidos a histerectomía.

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Copyright information

© Société Internationale de Chirurgie 1992

Authors and Affiliations

  • J. S. Varma
    • 1
  1. 1.Department of SurgeryWestern General HospitalEdinburghScotland

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