THE INTEGRATION CRYSTAL BALL

Issue 1:
Issue 2
Issue 3

• In this first issue the following interesting article had been chosen for discussion from the flow equation point of View :

  Rectal Augmentation and Stimulated Gracilis Anal Neosphincter. A New Approach in the Management of fecal Urgency and incontinence. N. S. Williams, O. A. Ogunbiyi, S. M. Scott, O. Fajobi,P. J. Lunniss. Diseases of The Colon & Rectum. February 2001,44(2). 192 - 8. From London, UK. http://www.discolrect.com/

• Despite the fact that this is a preliminary report on only 3 cases yet it acquired its importance from its authors and the novality of this comprehensive approach to the problem of anal incontinence including its 2 major components namely the rectum and anal canal.
  According to the flow equation:
  Flow (incontinence) = Intrarectal Pressure / Anal canal resistance
  In the above mentioned study the authors had used the intrarectal pressure as a study end-point for success of rectal augmentation as well as clinical urgency A. I. As a clinical end-point.
  From the flow equation point of flow this is quite justified since incontinence (flow) is dependent on 4 primary factors namely:
  
  1. Intrarectal pressure (IRP).
  2. Anal canal length (ACL).
  3. Anal canal diameter (ACD).
  4. Dynamic Viscosity of the stools (DV).
  
  
• The IRP represents the final common pathway of rectal factors maintaining normal continence including rectal capacity, rectal sensitivity and rectal compliance. Being also affected by intestinal factors such as the rate of rectal filling being higher in hurried intestinal motility.
• The 3 studied patients had high amplitude rectal contractions on ambulatory anorectal manometry. 2 of them were coincident with clinical urgency incontinence on ambulatory monitoring.
• All the three patients experienced clinical abolition of their urgency incontinence postoperatively in addition high amplitude rectal waves and other parameters of rectal motility were also improved in the 3 studied patients. This confirms the relation between clinically significant A.I. and intrarectal pressure as final primary rectal factor in A.I. as is suggested in the flow equation.
  
• The patient who had simultaneous rectal augmentation and Dynamic Graciloplasty had developed obstructed defecation. This in the flow equation point of view could be prevented or at least anticipated by staging the procedure and calculation of A. canal resistance during defecation after the dynamic Graciloplasty which can detect any possible iatrogenic anismus in the neosphincter thus avoiding the addition of the rectal augmentation if possible or at least anticipating the obstructed defecation if it seemed to be necessary for abolishion of urgency A.I.
  

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