605
In several parts of the developing world malting has been used for partial digestion of the starch. Cereal grains are germinated by soaking in the dark for 48-72 hours; they are then dried, toasted, and, after removal of the potentially toxic sprouting vegetative parts, ground or milled into flour. The process releases alpha-amylase, which digests amylose and amylopectins of starch to dextrins and maltose. These carbohydrates have less water-binding capacity and may be more easily digested and absorbed.During germination of cereals there are other nutritional changes: (a) some insoluble proteins are solubilised; (b) the concentration of certain aminoacids (lysine and tryptophan) and vitamins (ascorbic acid, riboflavin, and niacin) is increased; and (c) trypsin inhibitors and phytic acid concentrations are reduced.8 Small quantities of amylase-rich flour, when added to freshly prepared thick gruels, liquify them, reducing their viscosity while preserving their energy content. The energy density of cereal gruels may be doubled, from around 40-50 kcal/dl to 80-100 kcal/dl, thereby doubling the energy and nutrient intake per unit volume ingested (or halving the amount of gruel consumed to achieve the same energy and nutrient intake). Such treatment may raise the calorie intake to within the requirements for normal growth.9 Another source of the enzyme is bacterial amylase of food grade, which is commercially available and widely used in the food industry. Its use eliminates the risk of contamination during germination, and the amount required to reduce the viscosity is so small that its cost is very low. Fermentation (souring) of cereal gruels can also be used to enhance their protein and energy digestibilities, and may reduce contamination with
gram-negative enteropathogenic bacilli, permitting longer storage time between preparation and consumption of feeds.ll Rowland2 noted in 1980 that "there has been little attempt to improve traditional weaning foods in terms of consistency, shelf-life and bioavailability of nutrients". The use of amylase-rich "power-flour" for weanlings is an attractive way of improving traditional weaning foods. Nevertheless, several outstanding issues must be settled before this method is advocated for widespread use in the developing world. We need controlled studies to assess the intake and digestibility of such reduced-bulk, energy-dense foods, and to determine their ease of preparation and cultural acceptability in traditional communities. We also need to know more about the chemical composition of gruels treated with amylase-rich flour or amylase, and about the bioavailability of the nutrients within them.7,8 The proof of the pudding will be in showing improved growth and nutritional status in children taking such feeds compared with those consuming unmodified watery gruels. The next step will be to introduce these food technologies to mothers in parts of the world where weanling growth failure and undernutrition remain endemic.
1.
Snyder JO, Merson MH. The magnitude of the global problem of acute
diarrhoea. Bull WHO 1982; 60: 605-13. 2. Rowland MGM. The weanling’s dilemma—are we making progress? Acta Pediatr Scand 1980; 232: 33-42. 3. Gordon JE, Chitkara IE, Wyon SL. Weanling diarrhoea. Am J Med Sci
1963; 245: 345-77. 4. Werlin SL. Exocrine pancreas: structure and function. In: Walker WA, Durie PR, Hamilton JR, Walker-Smith JA, Watkins JB, eds. Pediatric gastrointestinal disease. Toronto: Decker, 1991: 335-50. 5. Dewit O, Dibba B, Prentice A. Breast-milk amylase activity in English and Gambian mothers: effects of prolonged lactation, maternal parity and individual variations. Pediatr Res 1990; 28: 502-06. 6. Lebenthal E, Lee PC. Alternate pathways of digestion and absorption in early infancy. J Pediatr Gastroenterol Nutr 1984; 3: 1-3. 7. Hellstrom A, Hermansson A-M, Karlsson A, Lungqvist B, Mellander O, Svanberg U. Dietary bulk as a limiting factor in nutrient intake—with special reference to the feeding of pre-school children. II Consistency as related to dietary bulk—a model study. J Trop Pediatr 1981; 27: 127-35. 8. Brandtzaeg B, Malleshi NG, Svanberg U, Desikachar HSB, Mellander O. Dietary bulk as a limiting factor for nutrient intake—with special reference to the feeding of pre-school children. III Studies of malted flour from raji, sorghum and green gram. J Trop Pediatr 1981; 27: 184-89. 9. Prentice AM, Lucas A, Vasquez-Velasquez L, Davies PSW, Whitehead RG. Are current dietary guidelines for young children a prescription for overfeeding? Lancet 1988; ii: 1066-68. 10. Graham GG, MacLean WC, Morales E, et al. Digestibility and utilisation of protein and energy from nasha, a traditional Sudanese fermented sorghum weaning food. J Nutr 1986; 116: 978-84. 11. Mensah PPA, Tomkins AM, Draser BS, Harrison TJ. Fermentation of cereals for reduction of bacterial contamination of weaning foods in Ghana. Lancet 1990; 336: 140-43.
Rectal
prolapse
Patients with rectal prolapse seek medical advice because they are distressed by the presence of the prolapsed bowel, which bleeds or secretes large volumes of mucus and which unpredictably falls out not only during defaecation but also during social occasions. Patients feel even more isolated from society if they are incontinent, a symptom that complicates rectal prolapse in 70-80% of cases. The disorder can occur at any age but is most common in elderly women. In children it may complicate constipation and cystic fibrosis, and in young women it is nearly always secondary to chronic straining at defaecation and may therefore be associated with a rectocele, a solitary rectal ulcer, and perineal descent. Colonic inertia sometimes leads to prolapse. In elderly people, colonic and rectal function is often normal but there may be urinary as well as faecal incontinence as a result of uterine prolapse in combination with complete rectal procidentia. Ten years ago surgeons were largely convinced that
abdominal rectopexy was the operation of choicer Despite the age of the population, Keighley and colleagues reported no deaths and complete control of the prolapse in 173 of 176 patients. These elderly individuals seemed to tolerate the procedure, which included a major laparotomy with a full pelvic dissection, very well; 21 of the operations were carried out under spinal anaesthesia with the patient fully awake. Most surgeons now recognise that the functional results after rectopexy are far from acceptable. Although incontinence is relieved in 60% of the patients who are incontinent preoperatively,
606
there are many who continue to wear some protection despite succssful control of the prolapse. The second consideration is that constipation and failure of rectal evacuation is a source of morbidity in at least 60% of patients after rectopexy; although some of these patients had needed to strain or were constipated beforehand, most had had no difficulty. If colonic transit is defective preoperatively partial colonic resection is now advised at the time of rectopexy, the extent of the resection depending on the degree and site of the stasis. Abdominal rectopexy commonly impairs rectal motility, either because
rectal dissection causes denervation, or because there is a redundant sigmoid colon above the fixed rectum which causes a functional obstruction. Thus many surgeons now confine rectal mobilisation to the posterior plane, and resect the redundant sigmoid to form an anastomosis between the descending colon and the upper rectum after sutured rectopexy.This procedure is potentially more hazardous than rectopexy and requires longer anaesthesia. Moreover, the addition of a total pelvic floor repair for incontinence necessitates an extensive operation with an abdominal and a perineal dissection that may be inappropriate in frail elderly people. What are the alternatives? Most of them-eg, an encircling perianal suture of ’Teflon’, wire, or silastic,3-S the Delorme operation,6--8 perineal rectopexy, and rectosigmoidectomy alones-give very poor results with a high frequency of recurrent prolapse. Nevertheless, the perianal approach causes little or no morbidity: patients are mobilised the day after operation and can be discharged within 4-5 days. A perineal operation that successfully controlled the prolapse and corrected the physiological abnormality, would be worth exploring.9 In this respect perineal rectosigmoidectomy combined with perineal rectopexy and total pelvic floor repair with coloanal anastomosis has some appeal. There is no wound because the operation merely amputates the prolapse while the remaining additions are done through the exposure. The procedure takes less than an hour, general anaesthesia is not necessary and, although there is an anastomosis, it is so low that it can easily be protected by a rectal catheter placed above it. Stapling techniques should increase the safety of this approachIt remains to be seen whether this perineal operation both controls the prolapse and overcomes the functional complications that have been so troublesome to patients undergoing abdominal rectopexy. So what will be the options in 10 years’ time? Perineal procedures are probably here to stay, especially when the technique of laparoscopic colectomy and mobilisation of the rectum to the pelvic floor has been fully developed. When these methods have been mastered and instrumentation has improved, it will be possible to design operative procedures for benign disease that allow partial and complete colectomy through the everted rectum.
These resections could even be combined with stapled construction of complex reservoirs with rectal or anal anastomoses.
Keighley MRB, Fielding JWL, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consective patients. Br J Surg 1983; 70: 229-32. 2. Prykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969; 2: 1225-30. 3. Gabriel WB. Thiersch’s operation for anal incontinence. Proc R Soc Med 1.
1948; 42: 467-68. TM, Fraser IA, Maybury NK. Treatment of rectal prolapse by sphincteric support using silastic rods. Br J Surg 1985; 72: 491-92. 5. Vongsangnak V, Varma JS, Smith AN. Reappraisal of Thiersch’s operation for complete rectal prolapse. J R Coll Surg Edin 1985; 30:
4. Hunt
185-87. 6. Christiansen
J, Kirkegaard P. Delorme’s operation for complete rectal prolapse. Br J Surg 1987; 68: 537-38. 7. Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme’s operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986; 68: 143-46. 8. Uhlig B, Sullivan E. The modified Delorme operation. Dis Colon Rectum
1979; 22: 513-21. Finlay IG, Aitchison M. Perineal excision of the rectum for prolapse in the elderly. Br J Surg 1991; 78: 687-89. 10. Vormeulen FB, Nivatvongs S, Franze DT, Balcos EG, Goldberg SM. A technique for perineal rectosigmoidectomy using autosuture devices. Surg Gynecol Obstet 1983; 156: 84-86. 9.
Monitoring TURP Transurethral resection of the prostate (TURP) remains under close scrutiny after the publication of a study 2 years ago1 which suggested that long-term mortality from this procedure is higher than with open prostatectomy or other forms of surgery. An earlier editorial2 likened the effects of this article to a boulder rolling into the urological millpond. So far, the study has withstood critical analysis, and waves continue to spread in the mare urologica. Absorption of irrigating solution during the procedure is an important difference between TURP and open prostatectomy and the consequences remain understood. incompletely Despite modem techniques, nearly 1 litre of irrigating solution is absorbed on average during a routine TURP procedure.3,4 In addition to volume effects (hypervolaemia and dilutional hyponatraemia), metabolic complications such as hyperammonaemia may develop and patients may become hypothermic if unheated irrigant is used.Irrigating solution is forced into the retroperitoneum when the prostatic capsule is perforated. When the large valveless veins within the prostate are opened, irrigant is injected directly into the circulation because of the pressure difference between the venous circulation and the height of the irrigant above the patient. These routes of absorption-one slow and the other much more rapid-give rise to different clinical manifestations. There is little doubt that absorption of large amounts of irrigant (3 litres or more) can result in acute distress, sometimes leading to death. The proposition that there is a continuum of effects and that smaller degrees of absorption may be stressful has lately been revived.6
In several parts of the developing world malting has been used for partial digestion of the starch. Cereal grains are germinated by soaking in the dark for 48-72 hours; they are then dried, toasted, and, after removal of the potentially toxic sprouting vegetative parts, ground or milled into flour. The process releases alpha-amylase, which digests amylose and amylopectins of starch to dextrins and maltose. These carbohydrates have less water-binding capacity and may be more easily digested and absorbed.During germination of cereals there are other nutritional changes: (a) some insoluble proteins are solubilised; (b) the concentration of certain aminoacids (lysine and tryptophan) and vitamins (ascorbic acid, riboflavin, and niacin) is increased; and (c) trypsin inhibitors and phytic acid concentrations are reduced.8 Small quantities of amylase-rich flour, when added to freshly prepared thick gruels, liquify them, reducing their viscosity while preserving their energy content. The energy density of cereal gruels may be doubled, from around 40-50 kcal/dl to 80-100 kcal/dl, thereby doubling the energy and nutrient intake per unit volume ingested (or halving the amount of gruel consumed to achieve the same energy and nutrient intake). Such treatment may raise the calorie intake to within the requirements for normal growth.9 Another source of the enzyme is bacterial amylase of food grade, which is commercially available and widely used in the food industry. Its use eliminates the risk of contamination during germination, and the amount required to reduce the viscosity is so small that its cost is very low. Fermentation (souring) of cereal gruels can also be used to enhance their protein and energy digestibilities, and may reduce contamination with
gram-negative enteropathogenic bacilli, permitting longer storage time between preparation and consumption of feeds.ll Rowland2 noted in 1980 that "there has been little attempt to improve traditional weaning foods in terms of consistency, shelf-life and bioavailability of nutrients". The use of amylase-rich "power-flour" for weanlings is an attractive way of improving traditional weaning foods. Nevertheless, several outstanding issues must be settled before this method is advocated for widespread use in the developing world. We need controlled studies to assess the intake and digestibility of such reduced-bulk, energy-dense foods, and to determine their ease of preparation and cultural acceptability in traditional communities. We also need to know more about the chemical composition of gruels treated with amylase-rich flour or amylase, and about the bioavailability of the nutrients within them.7,8 The proof of the pudding will be in showing improved growth and nutritional status in children taking such feeds compared with those consuming unmodified watery gruels. The next step will be to introduce these food technologies to mothers in parts of the world where weanling growth failure and undernutrition remain endemic.
1.
Snyder JO, Merson MH. The magnitude of the global problem of acute
diarrhoea. Bull WHO 1982; 60: 605-13. 2. Rowland MGM. The weanling’s dilemma—are we making progress? Acta Pediatr Scand 1980; 232: 33-42. 3. Gordon JE, Chitkara IE, Wyon SL. Weanling diarrhoea. Am J Med Sci
1963; 245: 345-77. 4. Werlin SL. Exocrine pancreas: structure and function. In: Walker WA, Durie PR, Hamilton JR, Walker-Smith JA, Watkins JB, eds. Pediatric gastrointestinal disease. Toronto: Decker, 1991: 335-50. 5. Dewit O, Dibba B, Prentice A. Breast-milk amylase activity in English and Gambian mothers: effects of prolonged lactation, maternal parity and individual variations. Pediatr Res 1990; 28: 502-06. 6. Lebenthal E, Lee PC. Alternate pathways of digestion and absorption in early infancy. J Pediatr Gastroenterol Nutr 1984; 3: 1-3. 7. Hellstrom A, Hermansson A-M, Karlsson A, Lungqvist B, Mellander O, Svanberg U. Dietary bulk as a limiting factor in nutrient intake—with special reference to the feeding of pre-school children. II Consistency as related to dietary bulk—a model study. J Trop Pediatr 1981; 27: 127-35. 8. Brandtzaeg B, Malleshi NG, Svanberg U, Desikachar HSB, Mellander O. Dietary bulk as a limiting factor for nutrient intake—with special reference to the feeding of pre-school children. III Studies of malted flour from raji, sorghum and green gram. J Trop Pediatr 1981; 27: 184-89. 9. Prentice AM, Lucas A, Vasquez-Velasquez L, Davies PSW, Whitehead RG. Are current dietary guidelines for young children a prescription for overfeeding? Lancet 1988; ii: 1066-68. 10. Graham GG, MacLean WC, Morales E, et al. Digestibility and utilisation of protein and energy from nasha, a traditional Sudanese fermented sorghum weaning food. J Nutr 1986; 116: 978-84. 11. Mensah PPA, Tomkins AM, Draser BS, Harrison TJ. Fermentation of cereals for reduction of bacterial contamination of weaning foods in Ghana. Lancet 1990; 336: 140-43.
Rectal
prolapse
Patients with rectal prolapse seek medical advice because they are distressed by the presence of the prolapsed bowel, which bleeds or secretes large volumes of mucus and which unpredictably falls out not only during defaecation but also during social occasions. Patients feel even more isolated from society if they are incontinent, a symptom that complicates rectal prolapse in 70-80% of cases. The disorder can occur at any age but is most common in elderly women. In children it may complicate constipation and cystic fibrosis, and in young women it is nearly always secondary to chronic straining at defaecation and may therefore be associated with a rectocele, a solitary rectal ulcer, and perineal descent. Colonic inertia sometimes leads to prolapse. In elderly people, colonic and rectal function is often normal but there may be urinary as well as faecal incontinence as a result of uterine prolapse in combination with complete rectal procidentia. Ten years ago surgeons were largely convinced that
abdominal rectopexy was the operation of choicer Despite the age of the population, Keighley and colleagues reported no deaths and complete control of the prolapse in 173 of 176 patients. These elderly individuals seemed to tolerate the procedure, which included a major laparotomy with a full pelvic dissection, very well; 21 of the operations were carried out under spinal anaesthesia with the patient fully awake. Most surgeons now recognise that the functional results after rectopexy are far from acceptable. Although incontinence is relieved in 60% of the patients who are incontinent preoperatively,
606
there are many who continue to wear some protection despite succssful control of the prolapse. The second consideration is that constipation and failure of rectal evacuation is a source of morbidity in at least 60% of patients after rectopexy; although some of these patients had needed to strain or were constipated beforehand, most had had no difficulty. If colonic transit is defective preoperatively partial colonic resection is now advised at the time of rectopexy, the extent of the resection depending on the degree and site of the stasis. Abdominal rectopexy commonly impairs rectal motility, either because
rectal dissection causes denervation, or because there is a redundant sigmoid colon above the fixed rectum which causes a functional obstruction. Thus many surgeons now confine rectal mobilisation to the posterior plane, and resect the redundant sigmoid to form an anastomosis between the descending colon and the upper rectum after sutured rectopexy.This procedure is potentially more hazardous than rectopexy and requires longer anaesthesia. Moreover, the addition of a total pelvic floor repair for incontinence necessitates an extensive operation with an abdominal and a perineal dissection that may be inappropriate in frail elderly people. What are the alternatives? Most of them-eg, an encircling perianal suture of ’Teflon’, wire, or silastic,3-S the Delorme operation,6--8 perineal rectopexy, and rectosigmoidectomy alones-give very poor results with a high frequency of recurrent prolapse. Nevertheless, the perianal approach causes little or no morbidity: patients are mobilised the day after operation and can be discharged within 4-5 days. A perineal operation that successfully controlled the prolapse and corrected the physiological abnormality, would be worth exploring.9 In this respect perineal rectosigmoidectomy combined with perineal rectopexy and total pelvic floor repair with coloanal anastomosis has some appeal. There is no wound because the operation merely amputates the prolapse while the remaining additions are done through the exposure. The procedure takes less than an hour, general anaesthesia is not necessary and, although there is an anastomosis, it is so low that it can easily be protected by a rectal catheter placed above it. Stapling techniques should increase the safety of this approachIt remains to be seen whether this perineal operation both controls the prolapse and overcomes the functional complications that have been so troublesome to patients undergoing abdominal rectopexy. So what will be the options in 10 years’ time? Perineal procedures are probably here to stay, especially when the technique of laparoscopic colectomy and mobilisation of the rectum to the pelvic floor has been fully developed. When these methods have been mastered and instrumentation has improved, it will be possible to design operative procedures for benign disease that allow partial and complete colectomy through the everted rectum.
These resections could even be combined with stapled construction of complex reservoirs with rectal or anal anastomoses.
Keighley MRB, Fielding JWL, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consective patients. Br J Surg 1983; 70: 229-32. 2. Prykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969; 2: 1225-30. 3. Gabriel WB. Thiersch’s operation for anal incontinence. Proc R Soc Med 1.
1948; 42: 467-68. TM, Fraser IA, Maybury NK. Treatment of rectal prolapse by sphincteric support using silastic rods. Br J Surg 1985; 72: 491-92. 5. Vongsangnak V, Varma JS, Smith AN. Reappraisal of Thiersch’s operation for complete rectal prolapse. J R Coll Surg Edin 1985; 30:
4. Hunt
185-87. 6. Christiansen
J, Kirkegaard P. Delorme’s operation for complete rectal prolapse. Br J Surg 1987; 68: 537-38. 7. Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme’s operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986; 68: 143-46. 8. Uhlig B, Sullivan E. The modified Delorme operation. Dis Colon Rectum
1979; 22: 513-21. Finlay IG, Aitchison M. Perineal excision of the rectum for prolapse in the elderly. Br J Surg 1991; 78: 687-89. 10. Vormeulen FB, Nivatvongs S, Franze DT, Balcos EG, Goldberg SM. A technique for perineal rectosigmoidectomy using autosuture devices. Surg Gynecol Obstet 1983; 156: 84-86. 9.
Monitoring TURP Transurethral resection of the prostate (TURP) remains under close scrutiny after the publication of a study 2 years ago1 which suggested that long-term mortality from this procedure is higher than with open prostatectomy or other forms of surgery. An earlier editorial2 likened the effects of this article to a boulder rolling into the urological millpond. So far, the study has withstood critical analysis, and waves continue to spread in the mare urologica. Absorption of irrigating solution during the procedure is an important difference between TURP and open prostatectomy and the consequences remain understood. incompletely Despite modem techniques, nearly 1 litre of irrigating solution is absorbed on average during a routine TURP procedure.3,4 In addition to volume effects (hypervolaemia and dilutional hyponatraemia), metabolic complications such as hyperammonaemia may develop and patients may become hypothermic if unheated irrigant is used.Irrigating solution is forced into the retroperitoneum when the prostatic capsule is perforated. When the large valveless veins within the prostate are opened, irrigant is injected directly into the circulation because of the pressure difference between the venous circulation and the height of the irrigant above the patient. These routes of absorption-one slow and the other much more rapid-give rise to different clinical manifestations. There is little doubt that absorption of large amounts of irrigant (3 litres or more) can result in acute distress, sometimes leading to death. The proposition that there is a continuum of effects and that smaller degrees of absorption may be stressful has lately been revived.6
![[Rectal prolapse].](/assets/img/hold.png)
