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Shen ZY, Zhang Y, Tao CH, Wang DJ, Zhang ZB, Zhang SC. A Predictive Model to Identify the Effects of Transcutaneous Sacral Nerve Stimulation With Pelvic Floor Exercises in Fecal Incontinence After Surgery for Anorectal Malformation. Am J Gastroenterol 2024; 119:191-199. [PMID: 37787428 DOI: 10.14309/ajg.0000000000002544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Although the combination of transcutaneous sacral nerve stimulation (tSNS) and pelvic floor exercises (PFEs) has shown significant effectiveness in treating fecal incontinence (FI) after surgery for congenital anorectal malformation (CARM), not all patients achieve satisfactory continence. Therefore, identifying which individuals will benefit from this method is crucial. METHODS A prospective cohort study enrolled 92 children with FI. All patients underwent tSNS with PFE treatment, and an improved outcome was defined as a Wexner score ≤4. A predictive model to identify the effects of tSNS with PFEs in FI was developed based on the analysis of magnetic resonance imaging and high-resolution anorectal manometry with area under the receiver-operating characteristic curve to evaluate the predictive value of external anal sphincter (EAS) thickness index and anal squeezing pressure (ASP). RESULTS tSNS with PFEs improved outcomes in 72 patients and led to poor outcomes in 20 (4 had their rectums deviate from the puborectalis muscle center or puborectal muscle ruptures while 16 lacked EAS with a lower ASP). The areas under the receiver-operating characteristic curve for EAS thickness index and ASP in predicting the effects of tSNS with PFEs were 0.915 (95% confidence interval 0.846-0.983, P = 0.000) and 0.886 (95% confidence interval 0.819-0.952, P = 0.000), respectively. By applying cutoff values of 0.076 for EAS thickness index and 21.95 mm Hg for ASP, tSNS with PFEs was found to be ineffective. DISCUSSION tSNS with PFEs is effective for most patients with FI after CARM surgery, except when the rectum deviates from the puborectal muscle center, puborectal muscle rupture occurs, or EAS is absent with a low ASP.
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Affiliation(s)
- Zhe-Ying Shen
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yao Zhang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chun-Hong Tao
- Department of Obstetrics and Gynecology, 962 Hospital of PLA Joint Logistic Support Force, Harbin, China
| | - Da-Jia Wang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhi-Bo Zhang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Cheng Zhang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
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Prichard DO, Fetzer J. Recto-anal Pressures in Constipated Men and Women Undergoing High-Resolution Anorectal Manometry. Dig Dis Sci 2023; 68:922-930. [PMID: 35727425 DOI: 10.1007/s10620-022-07590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/04/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND In constipated individuals, high-resolution anorectal manometry (HRM) may suggest the presence of a defecatory disorder. Despite known physiological differences between men and women, our understanding of functional anorectal pathophysiology is based upon predominantly female cohorts. Results are generalized to men. AIMS To evaluate whether recto-anal pressure patterns in constipated men are similar to those in constipated women. METHODS The electronic health records at Mayo Clinic, Rochester were used to identify constipated adult patients, without organic anorectal disease, who had undergone HRM and balloon expulsion testing (BET) in 2018, 2019, and 2020. Comparative analyses were performed. RESULTS Among 3,298 constipated adult patients (2,633 women, 665 men), anal and rectal pressures were higher in men. Women more likely to have HRM findings suggestive of a defecatory disorder (39% versus 20%, P < 0.001). Women were more likely to exhibit a type 4 pattern (27% versus 14%, P < 0.001), and less likely to exhibit a type 1 pattern (14% versus 38%, P < 0.001), of dyssynergia. Men were more likely to have an abnormal balloon expulsion test (BET, 34% versus 29%, P = 0.006). Nominal logistic regression demonstrates that male sex, age over 50 years, reduced recto-anal gradient during simulated evacuation, and types 2 and 4 dyssynergia are associated with an abnormal BET. CONCLUSIONS In this large retrospective study, constipated men and women exhibited different patterns of dyssynergia both in the presence and absence of an abnormal BET. These findings were independent of sex-specific baseline physiological differences.
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Affiliation(s)
- David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Jeffrey Fetzer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
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Bharucha AE, Basilisco G, Malcolm A, Lee TH, Hoy MB, Scott SM, Rao SSC. Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test. Neurogastroenterol Motil 2022; 34:e14335. [PMID: 35220645 PMCID: PMC9418387 DOI: 10.1111/nmo.14335] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. PURPOSE This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guido Basilisco
- UO Gastroenterologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Tae Hee Lee
- Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Matthew B Hoy
- Mayo Medical Library, Mayo Clinic, Rochester, Minnesota, USA
| | - S Mark Scott
- National Bowel Research Centre, Queen Mary University of London, London, UK
| | - Satish S C Rao
- Department of Gastroenterology, Augusta University, Augusta, Georgia, USA
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Prichard DO, Fetzer JR. Retrospective evaluation of operator bias in the performance of high-resolution anorectal manometry. Neurogastroenterol Motil 2022; 34:e14341. [PMID: 35238445 DOI: 10.1111/nmo.14341] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/21/2022] [Accepted: 02/12/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Measurements obtained during high-resolution anorectal manometry (HRM) are subject to operator-patient interactions. For example, standardized enhanced instruction delivered by a single operator in a test-retest fashion did not consistently increase pressures generated during dynamic maneuvers. It is probable that factors other than verbal instruction effect communication during the procedure. To investigate this hypothesis, we retrospectively examined inter-operator variance in HRM results. METHODS The electronic health records at Mayo Clinic, Rochester, were used to identify patients who had undergone HRM in 2019 and 2020. The analysis focused on constipated patients. The instructions given to the patients they had examined, and the pressure measurements obtained during HRM, by 6 different nurse operators were compared. KEY RESULTS When performing HRM on their individual patients (range 126-673), the 6 nurses used similar instructions for each of the maneuvers and sensory testing thresholds. The proportion of patients with prolonged balloon expulsion tests and the rectal sensory thresholds were similar among operators. Significant variance was seen in the mean rectoanal pressures at rest, during squeeze, and during dynamic maneuvers. The proportion of patients with manometry results suggestive of a defecatory disorder differed between operators by 18% and 28% in women <50 and >50 years old, respectively. CONCLUSIONS & INFERENCES Operators obtain significantly different results during HRM despite using similar instructions to patients. Substantial differences in the proportion of patients with manometry findings suggestive of a defecatory disorder among operators may have a significant impact on the diagnoses and therapies offered to constipated patients.
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Affiliation(s)
- David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey R Fetzer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Bharucha AE, Knowles CH, Mack I, Malcolm A, Oblizajek N, Rao S, Scott SM, Shin A, Enck P. Faecal incontinence in adults. Nat Rev Dis Primers 2022; 8:53. [PMID: 35948559 DOI: 10.1038/s41572-022-00381-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/09/2022]
Abstract
Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Charles H Knowles
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Isabelle Mack
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Satish Rao
- Department of Gastroenterology, University of Georgia, Augusta, GA, USA
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Enck
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany.
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Han D, Yan G, Hua F, Wang L. Preliminary study of a novel artificial anal sphincter with perception reconstruction. Artif Organs 2021; 46:794-803. [PMID: 34845737 DOI: 10.1111/aor.14129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/11/2021] [Accepted: 11/18/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Artificial anal sphincter (AAS), as an advanced device, has been widely investigated by researchers around world. But the reliability of the structure is still unsatisfactory according to clinical results. What's more, the previous AAS systems are lack the ability of rectal perception as native anal sphincter, which fails to guarantee the safety of the blood supply. In addition, without it, the patient cannot determine when to defecate. METHODS In order to improve the reliability and safety of current AAS systems, a novel structure AAS system with rectal perception function, based on pressure sensor module, is proposed in this article. The novel AAS system has a closed three-arm clamping mechanism, with transmission structure of cam-follower system. Then, the design, strength check, optimization and force analysis of the proposed mechanism are investigated. After that, to remodel rectal perception function, the novel sensor module system based on strain gauge is established. Finally, in vitro experiments are conducted. RESULTS In vitro test, the sensor system could monitor the rectal pressure accurately. And when H = 24.6 cm (feeling the urge to have a bowel movement), the clamping pressure is 7.39 kPa. which is also less than the safe pressure 9.33 kPa. CONCLUSIONS Good performance of the reliability and safety of both novel rectal perception function and new clamping mechanism have been showed.
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Affiliation(s)
- Ding Han
- School of electronic information and electrical engineering, Shanghai Jiao Tong University, Shanghai, China.,Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
| | - Guozheng Yan
- School of electronic information and electrical engineering, Shanghai Jiao Tong University, Shanghai, China.,Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
| | - Fangfang Hua
- School of electronic information and electrical engineering, Shanghai Jiao Tong University, Shanghai, China.,Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
| | - Lichao Wang
- School of electronic information and electrical engineering, Shanghai Jiao Tong University, Shanghai, China.,Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
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Abstract
Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.
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Sharma M, Muthyala A, Feuerhak K, Puthanmadhom Narayanan S, Bailey KR, Bharucha AE. Improving the utility of high-resolution manometry for the diagnosis of defecatory disorders in women with chronic constipation. Neurogastroenterol Motil 2020; 32:e13910. [PMID: 32613711 PMCID: PMC7529936 DOI: 10.1111/nmo.13910] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND We compared the utility of existing and modified versions of high-resolution manometry for diagnosing defecatory disorders (DD). METHODS In 64 healthy and 136 constipated women, we compared left lateral (LL) and seated manometry, and analyzed with existing (ManoView™) and new methods, for discriminating between constipated patients with normal and prolonged rectal balloon expulsion time (BET). In both positions, the rectoanal gradient (RAG) and, for the new analysis, the pressure topography pattern during evacuation were used to discriminate between constipated patients without and with DD. KEY RESULTS The BET was prolonged, suggestive of a DD, in 52 patients (38%). During evacuation, rectoanal pressures and the RAG were greater in the seated than the LL position (P≤.001). The new analysis identified 4 rectoanal pressure patterns. In the seated position, the BET was associated with the pattern (P=.0001), being prolonged in, respectively, 45%, 15%, 53%, and 0% of patients with minimal change, anal relaxation, paradoxical contraction, and transmission. Within each pattern, the RAG was greater (ie, less negative, P<.0001) in patients with a normal than a prolonged BET. Compared to the ManoView™ RAG in the LL position, the integrated analysis (ie, pattern and new RAG) in the LL position (P<.01) and the seated ManoView™ gradient (P=.02) were more effective for discriminating between constipated patients without and with DD. CONCLUSIONS & INFERENCES Anorectal HRM ideally should be performed in the more physiological seated position and analyzed by a two-tier approach, which incorporates the overall pattern followed by the rectoanal gradient. These findings reinforce the utility of manometry for diagnosing DD.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Anjani Muthyala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Kent R Bailey
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Lee TH, Lee JS, Kim J, Kim JO, Kim HG, Jeon SR, Hong SJ, Cho YS, Park S. Spontaneous Internal Anal Sphincter Relaxation During High-resolution Anorectal Manometry Is Associated With Peripheral Neuropathy and Higher Charlson Comorbidity Scores in Patients With Defecatory Disorders. J Neurogastroenterol Motil 2020; 26:362-369. [PMID: 32403904 PMCID: PMC7329158 DOI: 10.5056/jnm19129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/12/2019] [Accepted: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims We aimed to evaluate associations between comorbidities, peripheral neuropathy, and spontaneous internal anal sphincter relaxation (SAR) in patients with defecatory disorders. Methods A patient was considered to exhibit SAR during high-resolution anorectal manometry (HR-ARM) when the nadir pressure is < 15 mmHg and the time from onset to relaxation was ≥ 15 seconds in the resting pressure frame. A case-control study was performed using HR-ARM data collected from 880 patients from January 2010 to May 2015. We identified 23 cases with SAR (median age 75 years; 15 females; 12 fecal incontinence and 11 constipation). We compared HR-ARM values, Charlson index comorbidity scores, neuropathy, and the prevalence of diseases that potentially cause neuropathy between controls and SAR patients. Each SAR case was compared to 3 controls. Controls were selected to match the age, gender, and examination year of each SAR case. Results Compared to controls (26.1%), SAR patients (52.2%) exhibited a significantly higher frequency of fecal incontinence. SAR patients also had higher Charlson index scores (5 vs 4, P = 0.028). Nine of 23 SAR patients (39.1%) exhibited peripheral neuropathy— this frequency was higher than that for the control group (11.6%; P = 0.003). Diseases that potentially cause neuropathy were observed in 17 of 23 SAR cases and 32 of 69 controls (P = 0.022). Conclusions SAR develops in patients with constipation and fecal incontinence but is more common in patients with fecal incontinence. Our controlled observational study implies that SAR is associated with peripheral neuropathy and more severe comorbidities.
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Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Joon Seong Lee
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeeyeon Kim
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyun Gun Kim
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Su Jin Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi-do, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Chungcheongnam-do, Korea
| | - Suyeon Park
- Department of biostatistics, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam. Adv Ther 2020; 37:1136-1144. [PMID: 31997241 DOI: 10.1007/s12325-020-01238-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Doppler-guided transanal hemorrhoidal dearterialization (THD) was considered a less invasive and innovative method to treat hemorrhoidal disease, but it may impact the anal area during dearterialization and mucopexy. Thus, this study aimed to assess any changes in anorectal manometry of grade III and IV hemorrhoidal patients following THD treatment. METHODS This prospective observational study was conducted with patients who had grades III and IV hemorrhoidal disease. The patients were treated using THD at the Department of Surgery in the National Hospital of Traditional Medicine (Hanoi, Vietnam) between June 2012 and December 2013. Anorectal manometry was performed prior to THD and again between 6 and 12 months following the procedure. RESULTS A total of 40 patients were enrolled in the study, including 32 with grade III hemorrhoids and 8 with grade IV hemorrhoids. The proportion of male patients (65%) was higher than that of female patients (35%), and the majority of patients (82.5%) were > 40 years old. The mean duration of symptoms prior to treatment was 12.3 years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40 cm prior to treatment vs. 3.66 ± 0.48 cm following treatment; p = 0.57). Significant differences in treatment-related changes were detected for all anorectal manometric measurements except maximum squeezing pressure (p < 0.05). No patient showed anal stenosis or fecal incontinence. CONCLUSION The THD technique did not change the length of the anal sphincter 6 months after hemorrhoid treatment. The values of anal pressure and rectal sensation decreased almost significantly between treatment and the follow-up visit. We suggest that further studies, which include larger sample sizes, should be conducted to confirm THD effectiveness in terms of anorectal functions.
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Ciriza de Los Ríos C, Mínguez M, Remes-Troche JM, Lacima G. High-resolution and high-definition anorectal manometry: rediscovering anorectal function. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:794-805. [PMID: 30345781 DOI: 10.17235/reed.2018.5705/2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Anorectal motor and functional disorders are common among the general population. Anorectal manometry allows the study of anorectal motor activity both at rest and mimicking different physiological situations. High-resolution anorectal manometry (HR-ARM) and high-definition anorectal manometry (HD-ARM) are increasingly used in clinical practice. In comparison with the conventional technique, HR-ARM and HD-ARM catheters provide a higher number of recording points because of their many, closely packed circumferential sensors. This allows time-space visualization (topographic or 2-3-plane mode) as spatially continuous measurements are obtained by interpolation between near sensors. HR-ARM and HD-ARM allow a more standardized, reproducible technique, and a better assessment and understanding of the functional anatomy of the sphincter complex. Newer specific parameters are now being developed for use with these systems. They are being currently assessed by multiple research teams, and many of them remain unavailable for clinical practice as of today. However, they provide highly relevant information, which is now prompting a redefinition of anorectal anatomy and physiology. The goal of the present review was to describe the currently available HR-ARM and HD-ARM techniques, to discuss the normal values so far reported, and to analyze the newer parameters that may be assessed with these techniques, and which will likely be highly useful for clinical practice in the upcoming future.
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Affiliation(s)
| | - Miguel Mínguez
- Gastroenterología y Hepatología, Hospital Clínico Universitario Valencia, España
| | - Jose María Remes-Troche
- Fisiología digestiva y motilidad avanzada, Instituto de Investigaciones Médico-Biologicas, Universidad Veracruzana, Mexico
| | - Glòria Lacima
- Cirugía Gastrointestinal, Hospital Univeristario Clinic Barcelona
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12
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Carrington EV, Scott SM, Bharucha A, Mion F, Remes-Troche JM, Malcolm A, Heinrich H, Fox M, Rao SS. Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 2018; 15:309-323. [PMID: 29636555 PMCID: PMC6028941 DOI: 10.1038/nrgastro.2018.27] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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Affiliation(s)
- Emma V. Carrington
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - S. Mark Scott
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Adil Bharucha
- Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, MN, USA
| | - François Mion
- Exploration Fonctionnelle Digestive, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon I University and Inserm 1032 LabTAU, Lyon, France
| | - Jose M. Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México
| | - Allison Malcolm
- Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia
| | - Henriette Heinrich
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
- Clinic for Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Satish S. Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia
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Heinrich H, Misselwitz B. High-Resolution Anorectal Manometry - New Insights in the Diagnostic Assessment of Functional Anorectal Disorders. Visc Med 2018; 34:134-139. [PMID: 29888243 PMCID: PMC5981680 DOI: 10.1159/000488611] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional anorectal disorders such as faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD) are highly prevalent and represent a high socioeconomic burden. Several tests of anorectal function exist in this setting; however, high-resolution anorectal manometry (HR-ARM) is a new tool that depicts pressure all along the anal canal and can assess rectoanal coordination. HR-ARM is used in the diagnosis of FI and especially FDD although data in health is still sparse, and pressure phenomena seen during simulated defecation, such as dyssynergia, are highly prevalent in health.
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Affiliation(s)
- Henriette Heinrich
- Abdominal Center: Gastroenterology, St. Claraspital Basel, Basel, Switzerland
- Department of Gastroenterology and Hepatology, Universitätsspital Zürich, Zurich, Switzerland
| | - Benjamin Misselwitz
- Department of Gastroenterology and Hepatology, Universitätsspital Zürich, Zurich, Switzerland
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Arroyo A, Montes E, Calderón T, Blesa I, Elía M, Salgado G, García-Armengol J, de-la-Portilla F. Treatment algorithm for anal fissure. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons. Cir Esp 2018. [PMID: 29525120 DOI: 10.1016/j.ciresp.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Spanish Association of Coloproctology and the Coloproctology Division of the Spanish Association of Surgeons propose this consensus document with a treatment algorithm for anal fissure that could be used for decision making. Non-surgical therapy and surgical treatment of anal fissure are explained, and the recommended algorithm is provided. The methodology used was: creation of a group of experts; search in PubMed, MEDLINE and the Cochrane Library for publications from the last 10 years about anal fissure; presentation at the 21st National Meeting of the Spanish Association of Coloproctology Foundation 2017 with voting for/against each conclusion by the attendees and review by the scientific committee of the Spanish Association of Coloproctology.
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Affiliation(s)
- Antonio Arroyo
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario, Elche, Alicante, España.
| | - Elisa Montes
- Servicio de Cirugía General y Aparato Digestivo, Hospital de Jerez, Jerez de la Frontera, Cádiz, España
| | - Teresa Calderón
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, España
| | - Isabel Blesa
- Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Manuela Elía
- Servicio de Cirugía General y Digestiva, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Gervasio Salgado
- Sección de Cirugía Colorrectal, Hospital Santa Elena, Málaga, España
| | - Juan García-Armengol
- Servicio de Cirugía General y Aparato Digestivo, Hospital Nisa 9 de Octubre, Valencia, España
| | - Fernando de-la-Portilla
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, España
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Young CJ, Zahid A, Koh CE, Young JM. Hypothesized summative anal physiology score correlates but poorly predicts incontinence severity. World J Gastroenterol 2017; 23:5732-5738. [PMID: 28883698 PMCID: PMC5569287 DOI: 10.3748/wjg.v23.i31.5732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/14/2017] [Accepted: 07/12/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To explore the relationship between such a construct and an existing continence score.
METHODS A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed.
RESULTS Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP (P = 0.0002), ACL (P = 0.0006) and pudendal neuropathy (P < 0.0001). The association between APS and CCCS was significant (P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%.
CONCLUSION This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores.
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Affiliation(s)
- Christopher J Young
- Department of Colorectal Surgery, University of Sydney, Sydney, NSW 2042, Australia
- RPAH Medical Centre, Sydney, NSW 2042, Australia
- Discipline of Surgery, University of Sydney, Sydney, NSW 2042, Australia
| | - Assad Zahid
- Department of Colorectal Surgery, University of Sydney, Sydney, NSW 2042, Australia
- Discipline of Surgery, University of Sydney, Sydney, NSW 2042, Australia
| | - Cherry E Koh
- Department of Colorectal Surgery, University of Sydney, Sydney, NSW 2042, Australia
- Surgical Outcome Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW 2042, Australia
| | - Jane M Young
- Surgical Outcome Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW 2042, Australia
- School of Public health, University of Sydney, Sydney, NSW 2006, Australia
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Prichard DO, Lee T, Parthasarathy G, Fletcher JG, Zinsmeister AR, Bharucha AE. High-resolution Anorectal Manometry for Identifying Defecatory Disorders and Rectal Structural Abnormalities in Women. Clin Gastroenterol Hepatol 2017; 15:412-420. [PMID: 27720913 PMCID: PMC5316318 DOI: 10.1016/j.cgh.2016.09.154] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/19/2016] [Accepted: 09/30/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Contrary to conventional wisdom, the rectoanal gradient during evacuation is negative in many healthy people, undermining the utility of anorectal high-resolution manometry (HRM) for diagnosing defecatory disorders. We aimed to compare HRM and magnetic resonance imaging (MRI) for assessing rectal evacuation and structural abnormalities. METHODS We performed a retrospective analysis of 118 patients (all female; 51 with constipation, 48 with fecal incontinence, and 19 with rectal prolapse; age, 53 ± 1 years) assessed by HRM, the rectal balloon expulsion test (BET), and MRI at Mayo Clinic, Rochester, Minnesota, from February 2011 through March 2013. Thirty healthy asymptomatic women (age, 37 ± 2 years) served as controls. We used principal components analysis of HRM variables to identify rectoanal pressure patterns associated with rectal prolapse and phenotypes of patients with prolapse. RESULTS Compared with patients with normal findings from the rectal BET, patients with an abnormal BET had lower median rectal pressure (36 vs 22 mm Hg, P = .002), a more negative median rectoanal gradient (-6 vs -29 mm Hg, P = .006) during evacuation, and a lower proportion of evacuation on the basis of MRI analysis (median of 40% vs 80%, P < .0001). A score derived from rectal pressure and anorectal descent during evacuation and a patulous anal canal was associated (P = .005) with large rectoceles (3 cm or larger). A principal component (PC) logistic model discriminated between patients with and without prolapse with 96% accuracy. Among patients with prolapse, there were 2 phenotypes, which were characterized by high (PC1) or low (PC2) anal pressures at rest and squeeze along with higher rectal and anal pressures (PC1) or a higher rectoanal gradient during evacuation (PC2). CONCLUSIONS In a retrospective analysis of patients assessed by HRM, measurements of rectal evacuation by anorectal HRM, BET, and MRI were correlated. HRM alone and together with anorectal descent during evacuation may identify rectal prolapse and large rectoceles, respectively, and also identify unique phenotypes of rectal prolapse.
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Affiliation(s)
- David O Prichard
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota
| | - Taehee Lee
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota
| | - Gopanandan Parthasarathy
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota
| | | | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota.
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Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Functional Anorectal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00175-X. [PMID: 27144630 PMCID: PMC5035713 DOI: 10.1053/j.gastro.2016.02.009 10.1053/j.gastro.2016.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 01/11/2024]
Abstract
This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.
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Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Functional Anorectal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00175-X. [PMID: 27144630 PMCID: PMC5035713 DOI: 10.1053/j.gastro.2016.02.009] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.
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Abstract
PURPOSE OF REVIEW The past few years have seen an increase in the number of research and clinical groups around the world using high-resolution manometry (HRM) to record contractile activity in the anorectum and colon. Yet despite the uptake and growing number of publications, the clinical utility and potential advantages over traditional manometry remain undetermined. RECENT FINDINGS Nearly all of the publications in the field of anorectal and colonic HRM have been published within the last 3 years. These studies have included some data on normal ranges in healthy adults, and abnormalities in patient groups with constipation or fecal incontinence, anal fissure, perineal descent, rectal cancer, and Hirschsprung's disease. Most of the studies have been conducted on adults, with only three published studies in pediatric populations. Very few studies have attempted to show advantages of HRM over traditional manometry SUMMARY High-resolution anorectal and colonic manometry provide a more comprehensive characterization of motility patterns and coordinated activity; this may help to improve our understanding of the normal physiology and pathophysiology in these regions. To date, however, no published study has conclusively demonstrated a clinical, diagnostic, or interventional advantage over conventional manometry.
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Lee TH, Bharucha AE. How to Perform and Interpret a High-resolution Anorectal Manometry Test. J Neurogastroenterol Motil 2015; 22:46-59. [PMID: 26717931 PMCID: PMC4699721 DOI: 10.5056/jnm15168] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/20/2015] [Accepted: 12/11/2015] [Indexed: 12/13/2022] Open
Abstract
High-resolution anorectal manometry (HR-ARM) and high-definition anorectal manometry (HD-ARM) catheters have closely spaced water-perfused or solid state circumferentially-oriented pressure sensors that provide much better spatiotemporal pressurization than non-high resolution catheters. This is a comprehensive review of HR-ARM and HD-ARM anorectal manometry catheter systems, the methods for conducting, analyzing, and interpreting HR-ARM and HD-ARM, and a comparison of HR-ARM with non-high resolution anorectal manometry. Compared to non-high resolution techniques, HR-ARM and HD-ARM studies take less time and are easier to interpret. However, HR-ARM and HD-ARM catheters are more expensive and fragile and have a shorter lifespan. Further studies are needed to refine our understanding of normal values and to rigorously evaluate the incremental clinical utility of HR-ARM or HD-ARM compared to non-high resolution manometry.
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Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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