Implantable Agents for Fecal Incontinence: An Age-Matched Retrospective Cohort Analysis of GateKeeper versus SphinKeeper

Background. We aim to evaluate morphofunctional changes of the sphincter complex after GateKeeper (GK) and SphinKeeper (SK) procedures and correlate these with symptom improvement. Methods. Ten consecutive females undergoing SK implant were age-matched with a cohort of 10 females who previously underwent the GK procedure. Patients in the SK and GK groups underwent implantation of 10 and 6 prostheses, respectively. Muscle tension (Tm), expressed in millinewtons per centimetre squared, mN (cm²)^-1, was calculated using the equation Tm = P(r_i)(tm)^-1, where P is the average maximum squeeze pressure and r_i and tm the inner radius and thickness of the external anal sphincter, respectively. The pre- and postimplant changes in Tm and Cleveland Clinic Fecal Incontinence Score (CCFIS) were tested by linear and Poisson regression models, respectively. Results. The CCFIS significantly improved in both groups at 12-month postimplantation. Although not reaching statistical significance, symptom improvement after SK was 33% above that observed after GK (P = .088). Compared to the baseline, a significant increase in Tm was observed in both groups at 12 months (GK, 508.1 [478.8-568.0] vs 864.4 [827.0-885.8] mN (cm²)^-1; SK, 528.0 [472.7-564.0] vs 858.6 [828.0-919.6] mN (cm²)^-1, P = .005). Compared to the GK group, Tm was significantly higher in patients after SK implant (158.3 mN (cm²)^-1 [95% confidence interval, 109.6-207.0]; P < .001), after controlling for baseline values, at 12-month postimplantation. Conclusions. GK and SK are safe and effective treatments for FI with good short-term clinical outcomes. Comparative analysis showed superiority of SK over GK in terms of gain in Tm, with borderline significantly better improvement in symptoms. Larger studies are needed to confirm these findings.

Radial-scanning flexible EUS of the anorectum and pelvis

Standard upper gastrointestinal flexible radial EUS probes are well suited for imaging of anorectum and pelvic pathologies. They offer multiple advantages over conventional rigid rectal probes. The current transducers allow imaging at variable frequencies and are Doppler capable. The flexible shaft of the endoscope and optics allow easy probe insertion to upper sigmoid. Flexible radial EUS probes allow evaluation of anal sphincter complex, rectosigmoid mural pathologies, and paraluminal pelvic disorders. A thorough understanding of pelvic anatomy and image orientation is the key to appropriate image interpretation. In this review, we describe the principles and methodology for anorectal EUS imaging using a flexible radial EUS probe.

Three-dimensional high-resolution anorectal manometry and diagnosis of excessive perineal descent: a comparative pilot study with defaecography

AIM

Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can simultaneously provide physiological and topographical data on the terminal part of the digestive tract. Our object was to assess whether 3DHRAM is able to reliably diagnose excessive perineal descent already diagnosed with conventional defaecography, which is considered to be the gold standard.

METHOD

All patients referred to our centre for anorectal manometry and conventional defaecography were evaluated with a maximum of 6 months between the two examinations. Anorectal manometry was performed using the 3D High-Resolution Given Imaging® probe. Excessive perineal descent was defined as the downward movement of the anal high-pressure zone during straining. At the end of the straining effort, the high-pressure zone regained its initial position, thereby indicating that the probe had not moved.

RESULTS

Nineteen female patients of median age 53 (21-70) years were included in the study. All cases with excessive perineal descent diagnosed using defaecography were visualized with 3DHRAM. The degree of perineal descent determined by 3D and conventional defaecography was compared (Spearman correlation 0.726, P = 0.01). In contrast, the averages measured were significantly different; the average was 11.68 ± 3.3 mm for 3DHRAM but 34.21 ± 13.3 mm for conventional defaecography (P = 0.002).

CONCLUSION

The results of the study demonstrate that 3DHRAM can diagnose excessive perineal descent with the same degree of reliability as defaecography. Quantitative measures were not correlated, however, possibly because of methodological differences. The study confirms the value of the morphological data provided by 3DHRAM.

Distensibility of the anal canal in patients with idiopathic fecal incontinence: a study with the Functional Lumen Imaging Probe

BACKGROUND

Anatomical structures and their distensibility vary along the length of the anal canal. The anal sphincter muscles have dynamic properties that are not well-reflected by standard manometry. Abnormal distensibility of the anal canal may be of importance in idiopathic fecal incontinence (IFI). The functional lumen imaging probe (FLIP) allows detailed studies of the distensibility and axial variation of sphincters. We aimed at comparing segmental distensibility of the anal canal in patients with IFI and healthy subjects.

METHODS

The FLIP was used for distension of the anal canal in 22 patients with IFI (17 female, age 27-82 years) and 21 healthy volunteers (18 female, age 32-73 years). The distensibility was determined from changes in luminal diameter. Closure of the anal canal during voluntary squeeze was computed as the combined length of closed anal canal and time. Pressure-strain elastic modulus was computed at rest.

KEY RESULTS

In all subjects, the proximal anal canal was the most distensible segment. During distension at rest and during squeeze the middle and distal anal canal became significantly larger in IFI than in healthy (F < 22.4, p < 0.05). The closure of the anal canal during voluntary squeeze did not differ between healthy (75.9 ± 92.9 mm s) and IFI patients (90.4 ± 105 mm s; p = 0.6). Compared with healthy, IFI patients had lower pressure-strain elastic modulus of the middle and distal (q > 4.5, p < 0.05) but not the proximal anal canal (q < 0.7, p > 0.05).

CONCLUSIONS & INFERENCES

Patients with IFI have increased distensibility of the middle and distal parts of the anal canal.