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Church J. Functional Disorders of the Ileal-Anal Pouch: A Systematic Review. Dis Colon Rectum 2024; 67:S36-S45. [PMID: 38459724 DOI: 10.1097/dcr.0000000000003332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
BACKGROUND The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard to define because pouch anatomy is not normal and pouch physiology is a distortion of normal defecation. Patients with pouches develop multiple symptoms: some are expected, some are disease related, and some are the result of surgical complications. It is important to understand the cause of pouch-related symptoms so that appropriate management is offered. OBJECTIVES The study aimed to review pouch symptoms and discuss their likely cause, review the literature on pouch function and dysfunction, and provide clarity to clear the confusion. DATA SOURCES PubMed and Cochrane databases were searched using the terms "ileoanal pouch function" and "ileoanal pouch dysfunction." STUDY SELECTION From 1983 to 2023, 553 articles related to "ileoanal pouch function" and 178 related to "ileoanal pouch dysfunction" were reviewed. Nine studies appeared under both headings. Case studies, duplicate publications, and articles concerning pouch diseases were excluded. MAIN OUTCOME MEASURES Definitions of pouch function and dysfunction, methods of describing and scoring symptoms, and understanding of expected changes in pouch function given the nature of the surgery. RESULTS Twenty-seven studies were reviewed from the ileoanal pouch dysfunction search and 38 from ileoanal pouch function. Three studies tried to define normal pouch function, 10 attempted to measure pouch function, and 4 aimed to score pouch function. Only 3 studies addressed pouch physiology. LIMITATIONS A full discussion of pouch dysfunction is limited by the lack of studies focussing on the anatomic and physiologic consequences of turning the terminal ileum into an organ of storage. CONCLUSIONS Most studies of pouch function and dysfunction do not consider expected changes in the physiology of defecation that follow restorative proctocolectomy. Thus, most studies of pouch function produce conclusions that lack an important dimension. See video from symposium.
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Affiliation(s)
- James Church
- Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Medical Center, New York, New York
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Psarias T, Walter S, Holmbom M, Khayoun Issa I, Abdul-Sattar Aljabery F, Hallböök O. Anorectal function and symptoms 6 months after robot-assisted laparoscopic radical prostatectomy: a single-center study. Scand J Urol 2024; 59:104-108. [PMID: 38738961 DOI: 10.2340/sju.v59.35396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/22/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Robot-assisted laparoscopic radical prostatectomy (RALP) is a common procedure for the treatment of localised prostate cancer. Anorectal symptoms such as fecal incontinence (FI), rectal urgency or disturbed defecation have been reported after the operation. Anorectal function is dependent on the integrity of anal and pelvic nerves and muscles, rectal sensory function as well as rectal reservoir function. The aim of this study was to investigate the potential influence of RALP on anorectal physiological function and bowel symptoms. MATERIALS AND METHODS In this pilot study, 29 patients with localised prostate cancer scheduled for RALP were included. Anorectal physiology was used to measure rectal sensitivity and reservoir function as well as anal sphincter pressures. Bowel symptoms were measured by a bowel function questionnaire and a 2-week bowel function diary. Measurements were done before the operation and repeated at 6 months after the operation. RESULTS The study observed a significant postoperative increase in rectal sensory threshold for rectal balloon distention, from 20 to 40 mmHg, P < 0.001. This change is indicative of a decrease in rectal sensation after RALP. There were no other statistical significant differences in any of the physiological tests performed. Importantly, there was no change in any of the bowel symptoms after surgery. CONCLUSION This study showed that RALP may lead to impaired rectal sensory function. This finding did not, however, seem to have any influence on the patients´ postoperative clinical bowel function.
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Affiliation(s)
- Theodoros Psarias
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden.
| | - Susanna Walter
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Martin Holmbom
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Issa Khayoun Issa
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Firas Abdul-Sattar Aljabery
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Olof Hallböök
- Department of Biomedical and Clinical Sciences, Division of Surgery, Linköping University, Linköping, Sweden
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Ramu SK, Oblizajek NR, Savica R, Chunawala ZS, Deb B, Bharucha AE. Defecatory disorders are a common cause of chronic constipation in Parkinson disease. Neurogastroenterol Motil 2024; 36:e14767. [PMID: 38376243 PMCID: PMC11061800 DOI: 10.1111/nmo.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND AIMS Up to 50% of patients with Parkinson disease have constipation (PD-C), but the prevalence of defecatory disorders caused by rectoanal dyscoordination in PD-C is unknown. We aimed to compare anorectal function of patients with PD-C versus idiopathic chronic constipation (CC). METHODS Anorectal pressures, rectal sensation, and rectal balloon expulsion time (BET) were measured with high-resolution anorectal manometry (HR-ARM) in patients with PD-C and control patients with CC, matched for age and sex. RESULTS We identified 97 patients with PD-C and 173 control patients. Eighty-six patients with PD-C (89%) had early PD, and 39 (40%) had a defecatory disorder, manifest by a prolonged rectal balloon expulsion time (37 patients) or a lower rectoanal pressure difference during evacuation (2 patients). PD-C patients with a prolonged BET had a greater anal resting pressure (p = 0.02), a lower rectal pressure increment (p = 0.005), greater anal pressure (p = 0.047), and a lower rectoanal pressure difference during evacuation (p < 0.001). Rectal sensory thresholds were greater in patients with abnormal BET. In the multivariate model comparing CC and PD-C (AUROC = 0.76), PD-C was associated with a lower anal squeeze increment (odds ratio [OR] for PD-C, 0.93 [95% CI, 0.91-0.95]), longer squeeze duration (OR, 1.05 [95% CI, 1.03-1.08]), lower rectal pressure increment (OR per 10 mm Hg, 0.72 [95% CI, 0.66-0.79]), and negative rectoanal gradient during evacuation (OR per 10 mm Hg, 1.16 [95% CI, 1.08-1.26]). CONCLUSIONS Compared with CC, PD-C was characterized by impaired squeeze pressure, longer squeeze duration, lower increase in rectal pressure, and a more negative rectoanal gradient during evacuation.
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Affiliation(s)
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rodolfo Savica
- Division of Movement Disorders, Mayo Clinic, Rochester, Minnesota, USA
| | - Zainali S Chunawala
- Research Fellow in the Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Brototo Deb
- Research Fellow in the Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Neshatian L, Triadafilopoulos G, Wallace S, Jawahar A, Sheth V, Shen S, Gurland B. Increased Grades of Rectal Intussusception: Role of Decline in Pelvic Floor Integrity and Association With Dyssynergic Defecation. Am J Gastroenterol 2024; 119:946-956. [PMID: 37975595 DOI: 10.14309/ajg.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades. METHODS Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression. RESULTS Analysis included a total of 238 women: 90 had no RI, 43 Oxford 1-2, 49 Oxford 3, and 56 Oxford 4-5. Age ( P = 0.017), vaginal delivery ( P = 0.008), and prior pelvic surgery ( P = 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion ( P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining, was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades. DISCUSSION Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation.
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Affiliation(s)
- Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shannon Wallace
- Women's Health Institute, Division of Urogynecology and Pelvic Floor Disorders, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Anugayathri Jawahar
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Vipul Sheth
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Sa Shen
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, USA
| | - Brooke Gurland
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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Bolia R, Goel A, Thapar N. Transanal irrigation in children with functional constipation: A systematic review and meta-analysis. J Pediatr Gastroenterol Nutr 2024; 78:1108-1115. [PMID: 38558090 DOI: 10.1002/jpn3.12200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/19/2023] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Refractory functional constipation is a challenging condition to manage in children. The use of transanal irrigation (TAI) is well reported in children with neurological disorders as well as anorectal malformations but less so in children with functional disorders of defecation. The objective of our study was to evaluate the effectiveness, safety and outcomes of TAI in children with functional constipation. METHODS PubMed, Scopus and Google Scholar were searched for publications related to the use of TAI in functional constipation. Data regarding the study design, sample size, patient characteristics, investigator-reported response to TAI and adverse effects were extracted from studies that met the selection criteria. The inverse variance heterogeneity model was used for ascertaining the summary effect in this meta-analysis. RESULTS The search strategy yielded 279 articles of which five studies were included in the final review. The studies were from the United Kingdom (n = 2), Netherlands (n = 2) and Denmark (n = 1). These studies included 192 children with a median age ranging from 7 to 12.2 years old. The TAI systems used in these studies were: Peristeen (n = 2), Peristeen or Qufora (n = 1), Alterna (n = 1) and Navina (n = 1). The follow-up duration ranged from 5.5 months to 3 years. Eleven (5.7%) children did not tolerate TAI and withdrew from treatment soon after initiation. The pooled investigator-reported success of TAI was 62% (95% CI: 52%-71%). The most common adverse event was pain which was experienced by 21.7% of children. A total of 27 (14%) were successfully weaned off TAI at the last follow-up. CONCLUSIONS TAI is reported to be successful in 62% of children with refractory functional constipation. There is a need for well-designed prospective trials to evaluate this treatment option in children with refractory functional constipation.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, South Brisbane, Australia
| | - Akhil Goel
- Departement of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, South Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
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Bazzocchi G, Corazziari ES, Staiano A, Bassotti G, Bellini M, Chiarioni G, D'Alba L, Scarpato E. Position paper on transanal irrigation in chronic non-organic constipation. Dig Liver Dis 2024; 56:770-777. [PMID: 38461046 DOI: 10.1016/j.dld.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 03/11/2024]
Abstract
The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases. However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.
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Affiliation(s)
- G Bazzocchi
- Montecatone Rehabilitation Institute, Imola - University of Bologna, Italy
| | - E S Corazziari
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy.
| | - A Staiano
- Department of Translational Medical Science - Section Of Pediatrics, University Federico II, Naples, Italy
| | - G Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine & Surgery, University of Perugia, Perugia, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Chiarioni
- Il Centro Med Healthcare, Verona Center, Verona, Italy & UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - L D'Alba
- Gastroenterology and Endoscopy Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - E Scarpato
- Department of Translational Medical Science - Section Of Pediatrics, University Federico II, Naples, Italy
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Sakamoto A, Sasaki K, Nozawa H, Murono K, Emoto S, Yokoyama Y, Matsuzaki H, Nagai Y, Abe S, Shinagawa T, Sonoda H, Ishihara S. Evaluation of anorectal function using real-time tissue elastography before and after preoperative chemoradiotherapy. Int J Colorectal Dis 2024; 39:56. [PMID: 38662090 PMCID: PMC11045657 DOI: 10.1007/s00384-024-04633-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE This study aimed to clarify the relationship between changes in elasticity and anorectal function before and after chemoradiotherapy. METHODS This is a single-center prospective cohort study (Department of Surgical Oncology, The University of Tokyo). We established a technique to quantify internal anal sphincter hardness as elasticity using transanal ultrasonography with real-time tissue elastography. Twenty-seven patients with post-chemoradiotherapy rectal cancer during 2019-2022 were included. Real-time tissue elastography with transanal ultrasonography was performed before and after chemoradiotherapy to measure internal anal sphincter hardness as "elasticity" (hardest (0) to softest (255); decreased elasticity indicated sclerotic changes). The relationship between the increase or decrease in elasticity pre- and post-chemoradiotherapy and the maximum resting pressure, maximum squeeze pressure, and Wexner score were the outcome measures. RESULTS A decrease in elasticity was observed in 16/27 (59.3%) patients after chemoradiotherapy. Patients with and without elasticity decrease after chemoradiotherapy comprised the internal anal sphincter sclerosis and non-sclerosis groups, respectively. The maximum resting pressure post-chemoradiotherapy was significantly high in the internal anal sphincter sclerosis group (63.0 mmHg vs. 47.0 mmHg), and a majority had a worsening Wexner score (60.0% vs. 18.2%) compared with that of the non-sclerosis group. Decreasing elasticity (internal anal sphincter sclerosis) correlated with a higher maximum resting pressure (r = 0.36); no correlation was observed between the degree of elasticity change and maximum squeeze pressure. CONCLUSION Internal anal sphincter sclerosis due to chemoradiotherapy may correlate to anorectal dysfunction.
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Affiliation(s)
- Akira Sakamoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Matsuzaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yuzo Nagai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Shinya Abe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Takahide Shinagawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
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Xue Y, Zhou H, Zeng Y, Wang C, Yang Y, Wang X, He Z, Yao Y, Wang X, Fan Z. Efficacy of electroacupuncture therapy in patients with functional anorectal pain: study protocol for a multicenter randomized controlled trial. Int J Colorectal Dis 2024; 39:55. [PMID: 38647724 PMCID: PMC11035392 DOI: 10.1007/s00384-024-04628-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Some Chinese scholars have initially explored the efficacy of electroacupuncture at Baliao acupoint in patients with functional anorectal pain (FAP). However, their studies are performed in a single center, or the sample size is small. Therefore, we aim to further explore the efficacy of electroacupuncture at Baliao acupoint on the treatment of FAP. METHODS In this multicenter randomized controlled trial, 136 eligible FAP patients will be randomly allocated into an electroacupuncture group or sham electroacupuncture group at a 1:1 ratio. This trial will last for 34 weeks, with 2 weeks of baseline, 4 weeks and 8 weeks of treatment, and 1, 3, and 6 months of follow-up. Outcome assessors and statisticians will be blind. The primary outcome will be clinical treatment efficacy, and secondary outcomes will be pain days per month, quality of life, psychological state assessment, anorectal manometry, pelvic floor electromyography, and patient satisfaction. DISCUSSION Results of this trial will be contributed to further clarify the value of electroacupuncture at Baliao acupoint as a treatment for FAP in the clinic. TRIAL REGISTRATION This trial has been registered in Chinese Clinical Trial Registry https://www.chictr.org.cn/ (ChiCTR2300069757) on March 24, 2023.
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Affiliation(s)
- Yahong Xue
- Department of Anorectal, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No.157 Daming Road, Qinhuai District, Nanjing, 210022, People's Republic of China.
| | - Huifen Zhou
- Department of Anorectal, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No.157 Daming Road, Qinhuai District, Nanjing, 210022, People's Republic of China
| | - Yusha Zeng
- Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210023, People's Republic of China
| | - Chen Wang
- Department of Anorectal, Longhua Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, People's Republic of China
| | - Yun Yang
- Anorectal Department, Yinchuan Traditional Chinese Medicine Hospital, Yinchuan, 750010, People's Republic of China
| | - Xiaopeng Wang
- Department of Anorectal, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China
| | - Zongqi He
- Department of Anorectal, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, People's Republic of China
| | - Yibo Yao
- Department of Anorectal, Longhua Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, People's Republic of China
| | - Xiaofeng Wang
- Department of Anorectal, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No.157 Daming Road, Qinhuai District, Nanjing, 210022, People's Republic of China
| | - Zhimin Fan
- Department of Anorectal, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No.157 Daming Road, Qinhuai District, Nanjing, 210022, People's Republic of China
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Zhang Y, Xiang C, Liang J. Correlation between Pain and Anal Defecation Function in Postoperative Patients with Colorectal Cancer and Related Factors Affecting Patients' Prognosis. Ann Ital Chir 2024; 95:136-143. [PMID: 38684502 DOI: 10.62713/aic.3173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND The degree of postoperative pain and defecation function in colorectal cancer will affect patients' prognosis. Therefore, exploring the correlation between postoperative pain and defecation function, and analyzing the related factors, will help to improve the quality of patients' prognosis. METHODS A total of 94 patients with colorectal cancer admitted to our hospital from March 2022 to June 2023 were retrospectively selected for study. The visual analog scale (VAS) was used to evaluate the pain level of the patients. The low anterior resection syndrome (LARS) scale was used to evaluate bowel function of the patients, and the incidence of LARS was recorded. The patients were grouped according to whether or not they had the complications of LARS, and they were divided into the groups of concurrent LARS and non-concurrent LARS. The patients' anorectal pressure was measured, and the measurements included maximum tolerated volume (MTV), anorectal resting pressure (ARP), and maximum squeeze pressure (MSP). Pearson's correlation coefficient was used to test associations between anal defecation function and postoperative pain and anorectal manometry. Logistic regression was used to test predictors of concurrent LARS, and the value of each of the indices for prediction of LARS was examined using the receiver operating characteristic (ROC). RESULTS Patients' VAS scores were positively correlated with LARS scores (p < 0.05). A total of 22 patients with VAS score ≥20 points were found to have a LARS incidence of 23.40% based on the LARS score. The VAS score was higher in the concurrent LARS group than in the non-concurrent LARS group (p < 0.05). The concurrent LARS group had a higher percentage of patients with age ≥60 years, body mass index ≥24 kg/m2, anastomotic position <5 cm from the anal verge, preoperative radiotherapy, and anastomotic fistula than the non-current LARS group (p < 0.05). The levels of MTV, ARP, and MSP were lower in patients in the concurrent LARS group than in the non-current LARS group (p < 0.05). Patients' LARS scores were negatively correlated with MTV (r = -0.420), ARP (r = -0.300) and MSP (r = -0.220) levels (p < 0.05). Logistic regression analysis showed that anastomotic position <5 cm from the anal verge, preoperative radiotherapy, anastomotic fistula, high VAS level, and low MTV level were all significant predictors of concurrent LARS. Anastomotic position, whether or not radiotherapy was administered preoperatively, anastomotic fistula, VAS score, and MSP level all had high sensitivity and specificity for prediction of concurrent LARS, and the combined area under the curve (AUC) of each index was 0.921, sensitivity was 0.818, and specificity was 0.944. CONCLUSION LARS is strongly associated with the patient's pain level, and factors such as anastomotic position <5 cm from the anal verge, preoperative radiotherapy, anastomotic fistula, high VAS level, and low MTV level will increase the risk of concurrent LARS in patients.
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Affiliation(s)
- Yuanwei Zhang
- Department of General Surgery Ward 3, Shengzhou People's Hospital (Shengzhou Branch of the First Affiliated Hospital of Zhejiang University School of Medicine, the Shengzhou Hospital of Shaoxing University), 312400 Shengzhou, Zhejiang, China
| | - Chengjiang Xiang
- Department of General Surgery Ward 3, Shengzhou People's Hospital (Shengzhou Branch of the First Affiliated Hospital of Zhejiang University School of Medicine, the Shengzhou Hospital of Shaoxing University), 312400 Shengzhou, Zhejiang, China
| | - Jinhao Liang
- Department of General Surgery Ward 3, Shengzhou People's Hospital (Shengzhou Branch of the First Affiliated Hospital of Zhejiang University School of Medicine, the Shengzhou Hospital of Shaoxing University), 312400 Shengzhou, Zhejiang, China
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Bellini M, Chiarioni G. Staying in HRAM's Way: Tweaking the London Classification for Disorders of Anorectal Function. Dig Dis Sci 2022; 67:748-749. [PMID: 33939155 DOI: 10.1007/s10620-021-06995-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Massimo Bellini
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona, AOUI Verona, Verona, Italy.
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Divisione di Gastroenterologia B, Ospedale Policlinico GB Rossi, Piazzale LA Scuro, 10, 37134, Verona, Italy.
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Han SH, Choi K, Shim GY, Kim J. Pudendal Nerve Terminal Motor Latency Compared by Anorectal Manometry Diagnosing Fecal Incontinence: A Retrospective Study. Am J Phys Med Rehabil 2022; 101:124-128. [PMID: 33789323 DOI: 10.1097/phm.0000000000001744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare the clinical value of pudendal nerve terminal motor latency in fecal incontinence patients with that of another diagnostic test-anorectal manometry. DESIGN This study used a cross-sectional design. Medical records of fecal incontinence patients who underwent pudendal nerve terminal motor latency and anorectal manometry testing were reviewed. Greater than 2.4 ms of pudendal nerve terminal motor latency was determined to be abnormal. Anorectal manometry was performed using a station pull-through technique. Mean resting anal pressure, maximal resting anal pressure, mean squeezing anal pressure, and maximal squeezing anal pressure were investigated. For normal and abnormal pudendal nerve terminal motor latency groups, comparative analyses were performed on anorectal manometry results. RESULTS A total of 31 patients were included. Thirteen patients showed normal pudendal nerve terminal motor latency. For anorectal manometry results, there was no significant difference between normal and abnormal pudendal nerve terminal motor latency groups. Fourteen patients had diabetes mellitus. Subgroup analysis of the 14 diabetic patients showed no significant difference between normal and abnormal pudendal nerve terminal motor latency groups. For 17 nondiabetic patients, there was a significant difference between the groups with positive correlations with mean/maximal resting anal pressures. CONCLUSIONS Pudendal nerve terminal motor latency significantly correlates with anorectal manometry in fecal incontinence only in nondiabetic patients.
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Affiliation(s)
- Seung Hee Han
- From the Department of Physical Medicine and Rehabilitation, Seoul Medical Center, Seoul, Republic of Korea (SHH, KC, GYS, JK); and Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea (GYS)
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12
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Abstract
BACKGROUND Neuropathy may cause fecal incontinence and mixed fecal incontinence/constipation, but its prevalence is unclear, partly due to the lack of comprehensive testing of spino-anorectal innervation. OBJECTIVE This study aimed to develop and determine the clinical usefulness of a novel test, translumbosacral anorectal magnetic stimulation for fecal incontinence. DESIGN This observational cohort study was conducted from 2012 to 2018. SETTINGS This study was performed at a tertiary referral center. PATIENTS Patients with fecal incontinence, patients with mixed fecal incontinence/constipation, and healthy controls were included. INTERVENTIONS A translumbosacral anorectal magnetic stimulation test was performed by using an anorectal probe with 4 ring electrodes and magnetic coil, and by stimulating bilateral lumbar and sacral plexuses, uses and recording 8 motor-evoked potentials at anal and rectal sites. MAIN OUTCOME MEASURES The prevalence of lumbar and/or sacral neuropathy was examined. Secondary outcomes were correlation of neuropathy with anorectal sensorimotor function(s) and morphological changes. RESULTS We evaluated 220 patients: 144 with fecal incontinence, 76 with mixed fecal incontinence/constipation, and 31 healthy controls. All 8 lumbar and sacral motor-evoked potential latencies were significantly prolonged (p < 0.01) in fecal incontinence and mixed fecal incontinence/constipation groups compared with controls. Neuropathy was patchy and involved 4.0 (3.0) (median (interquartile range)) sites. Lumbar neuropathy was seen in 29% to 65% of the patients in the fecal incontinence group and 22% to 61% of the patients in the mixed fecal incontinence/constipation group, and sacral neuropathy was seen in 24% to 64% and 29% to 61% of these patients. Anal neuropathy was significantly more (p < 0.001) prevalent than rectal neuropathy in both groups. There was no correlation between motor-evoked potential latencies and anal sphincter pressures, rectal sensation, or anal sphincter defects. LIMITATIONS No comparative analysis with electromyography was performed. CONCLUSION Lumbar or sacral plexus neuropathy was detected in 40% to 75% of patients with fecal incontinence with a 2-fold greater prevalence at the anal region than the rectum. Lumbosacral neuropathy appears to be an independent mechanism in the pathogenesis of fecal incontinence, unassociated with other sensorimotor dysfunctions. Translumbosacral anorectal magnetic stimulation has a high yield and is a safe and clinically useful neurophysiological test. See Video Abstract at http://links.lww.com/DCR/B728. PRUEBA DE ESTIMULACIN MAGNTICA TRANSLUMBOSACRAL ANORECTAL PARA LA INCONTINENCIA FECAL ANTECEDENTES:La neuropatía puede causar incontinencia fecal y una combinación de incontinencia fe-cal/estreñimiento, pero su prevalencia no está clara, en parte debido a la falta de pruebas comple-tas de inervación espino-anorrectal.OBJETIVO:Desarrollar y determinar la utilidad clínica de una nueva prueba, estimulación magnética trans-lumbosacral anorrectal para la incontinencia fecal.DISEÑO:Estudio de cohorte observacional del 2012 al 2018.ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes con incontinencia fecal, combinación de incontinencia fecal/estreñimiento y controles sanos.INTERVENCIONES:Se realizó una prueba de estimulación magnética translumbosacral anorrectal utilizando una sonda anorrectal con 4 electrodos anulares y bobina magnética, y estimulando los plexos lumbares y sacros bilaterales y registrando ocho potenciales evocados motores las regiones anal y rectal.PRINCIPALES MEDIDAS DE RESULTADO:Se examinó la prevalencia de neuropatía lumbar y/o sacra. Los resultados secundarios fueron la correlación de la neuropatía con las funciones sensitivomotoras anorrectales y cambios morfológi-cos.RESULTADOS:Evaluamos 220 pacientes, 144 con incontinencia fecal, 76 con combinación de incontinencia fe-cal/estreñimiento y 31 sujetos sanos. Las ocho latencias de los potenciales evocadas motoras lum-bares y sacras se prolongaron significativamente (p <0,01) en la incontinencia fecal y el grupo mixto en comparación con los controles. La neuropatía fue irregular y afectaba 4,0 (3,0) (mediana (rango intercuartílico) sitios. Se observó neuropatía lumbar en 29-65% en la incontinencia fecal y 22-61% en el grupo mixto, y neuropatía sacra en 24-64% y 29-61 % de pacientes respectivamen-te. La neuropatía anal fue significativamente más prevalente (p <0,001) que la rectal en ambos grupos. No hubo correlación entre las latencias de los potenciales evocadas motoras y las presio-nes del esfínter anal, la sensación rectal o los defectos del esfínter anal.LIMITACIONES:Sin análisis comparativo con electromiografía.CONCLUSIÓNES:Se detectó neuropatía del plexo lumbar o sacro en el 40-75% de los pacientes con incontinencia fecal con una prevalencia dos veces mayor en la región anal que en el recto. La neuropatía lumbo-sacra parece ser un mecanismo independiente en la patogenia de la incontinencia fecal, no asocia-do con otras disfunciones sensitivomotoras. La estimulación magnética translumbosacral anorrec-tal tiene un alto rendimiento, es una prueba neurofisiológica segura y clínicamente útil. Consulte Video Resumen en http://links.lww.com/DCR/B728.
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Affiliation(s)
- Yun Yan
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, Georgia
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13
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Patel K, Mei L, Yu E, Kern M, Lehal N, Edeani F, Sanvanson P, Davidson ERW, Shaker R. Differences in fatigability of muscles involved in fecal continence: Potential clinical ramifications. Physiol Rep 2021; 9:e15144. [PMID: 34927399 PMCID: PMC8685596 DOI: 10.14814/phy2.15144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Fatigue of the anal sphincter complex has been demonstrated using high-resolution anorectal manometry (HRAM). However, the fatigability of individual muscles such as the external anal sphincter (EAS) and puborectalis muscles (PRM) has not been described. Vaginal manometry has been used to study contractile activity of the PRM. By applying both modalities, we attempted to differentiate the fatigability between the PRM and the EAS under different exercise conditions. METHODS We studied two groups: group 1, 12 healthy women (21 ± 2.7 years) with HRAM and group 2, 10 healthy (20 ± 3 years) women with vaginal manometry. All subjects performed 40 repetitive contractions with and without an intra-anal resistive load. In group 1, areas under the curve (AUC) of the anal canal high-pressure zone (HPZ) including the caudal and rostral halves were compared. In group 2, the maximum and mean pressures of the vaginal HPZ were compared. RESULTS The AUC decreased significantly only after repetitive contractions against a resistive load (462 ± 129 vs. 390 ± 131 mmHg-cm, p = 0.02), indicating fatigue. The caudal half (EAS) decreased significantly after contractions against a load (288 ± 75 vs. 239 ± 82 mmHg-cm, p = 0.02), while the rostral half (PRM) did not. The vaginal pressures (PRM) also decreased only after repetitive contractions against a load (maximum pressures, 358 ± 171 vs. 239 ± 109 mmHg, p = 0.02). CONCLUSIONS The EAS and PRM both exhibit fatigue with contractions only against a resistive load. These findings may guide the development of appropriate exercise regimens to target specific muscles involved in fecal continence.
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Affiliation(s)
- Krupa Patel
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Ling Mei
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Elliot Yu
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mark Kern
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Navjit Lehal
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Francis Edeani
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Patrick Sanvanson
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Emily R. W. Davidson
- Department of Obstetrics and GynecologyDivision of UrogynecologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Reza Shaker
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
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Brand DH, Brüningk SC, Wilkins A, Fernandez K, Naismith O, Gao A, Syndikus I, Dearnaley DP, Tree AC, van As N, Hall E, Gulliford S. Estimates of Alpha/Beta (α/β) Ratios for Individual Late Rectal Toxicity Endpoints: An Analysis of the CHHiP Trial. Int J Radiat Oncol Biol Phys 2021; 110:596-608. [PMID: 33412260 PMCID: PMC8129972 DOI: 10.1016/j.ijrobp.2020.12.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 12/04/2022]
Abstract
PURPOSE Changes in fraction size of external beam radiation therapy exert nonlinear effects on subsequent toxicity. Commonly described by the linear-quadratic model, fraction size sensitivity of normal tissues is expressed by the α/β ratio. We sought to study individual α/β ratios for different late rectal effects after prostate external beam radiation therapy. METHODS AND MATERIALS The CHHiP trial (ISRCTN97182923) randomized men with nonmetastatic prostate cancer 1:1:1 to 74 Gy/37 fractions (Fr), 60 Gy/20 Fr, or 57 Gy/19 Fr. Patients in the study had full dosimetric data and zero baseline toxicity. Toxicity scales were amalgamated to 6 bowel endpoints: bleeding, diarrhea, pain, proctitis, sphincter control, and stricture. Lyman-Kutcher-Burman models with or without equivalent dose in 2 Gy/Fr correction were log-likelihood fitted by endpoint, estimating α/β ratios. The α/β ratio estimate sensitivity was assessed using sequential inclusion of dose modifying factors (DMFs): age, diabetes, hypertension, inflammatory bowel or diverticular disease (IBD/diverticular), and hemorrhoids. 95% confidence intervals (CIs) were bootstrapped. Likelihood ratio testing of 632 estimator log-likelihoods compared the models. RESULTS Late rectal α/β ratio estimates (without DMF) ranged from bleeding (G1 + α/β = 1.6 Gy; 95% CI, 0.9-2.5 Gy) to sphincter control (G1 + α/β = 3.1 Gy; 95% CI, 1.4-9.1 Gy). Bowel pain modelled poorly (α/β, 3.6 Gy; 95% CI, 0.0-840 Gy). Inclusion of IBD/diverticular disease as a DMF significantly improved fits for stool frequency G2+ (P = .00041) and proctitis G1+ (P = .00046). However, the α/β ratios were similar in these no-DMF versus DMF models for both stool frequency G2+ (α/β 2.7 Gy vs 2.5 Gy) and proctitis G1+ (α/β 2.7 Gy vs 2.6 Gy). Frequency-weighted averaging of endpoint α/β ratios produced: G1 + α/β ratio = 2.4 Gy; G2 + α/β ratio = 2.3 Gy. CONCLUSIONS We estimated α/β ratios for several common late adverse effects of rectal radiation therapy. When comparing dose-fractionation schedules, we suggest using late a rectal α/β ratio ≤ 3 Gy.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Tumour Cell Biology Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Fernandez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials QA Group, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Litta F, Marra AA, Ortega Torrecilla N, Orefice R, Parello A, De Simone V, Campennì P, Goglia M, Ratto C. Implant of Self-Expandable Artificial Anal Sphincter in Patients With Fecal Incontinence Improves External Anal Sphincter Contractility. Dis Colon Rectum 2021; 64:706-713. [PMID: 33496487 DOI: 10.1097/dcr.0000000000001857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND External anal sphincter contractility significantly contributes to control the passage of stool. An artificial anal sphincter placed into the intersphincteric space is a safe and effective procedure to treat fecal incontinence, even if its mechanism of action has not been fully elucidated. OBJECTIVE The aim of this study was to evaluate external anal sphincter contractility changes after a self-expandable hyexpan prostheses was implanted into the intersphincteric space of the anal canal and clinical outcomes compared. DESIGN This was a prospective clinical study. SETTINGS The study was conducted at a university teaching hospital. PATIENTS Consecutive patients affected by fecal incontinence for at least 6 months after failure of conservative treatment were included. INTERVENTIONS All of the patients underwent 10-prostheses implantation and were examined preoperatively and postoperatively by endoanal ultrasound and anorectal manometry. MAIN OUTCOME MEASURES Fecal incontinence symptoms were assessed by severity scores. The external anal sphincter muscle tension was calculated using a specific equation. RESULTS Thirty-nine patients (34 women; median age = 68 y) were included in the study; no morbidity was registered. After a median follow-up period of 14 months, both the median maximum voluntary squeeze pressure and the median inner radius of the external anal sphincter significantly increased. A statistically significant increase of external anal sphincter muscle tension was detected. A decrease of any fecal incontinence symptom and an improvement in severity scores were observed at the last follow-up examination. The external anal sphincter contractility was significantly higher in patients reducing incontinence episodes to solid stool by >50% and improving their ability to defer defecation for >15 minutes. LIMITATIONS This was a single-center experience with a relatively small and heterogeneous sample size, patients with a potentially more severe disease because our institution is a referral center, and an absence of quality-of-life evaluation. CONCLUSIONS Artificial anal sphincter implantation improved the external anal sphincter muscle tension; there was a positive correlation between its increase and the clinical outcome. See Video Abstract at http://links.lww.com/DCR/B468. IMPLANTE DE ESFNTER ANAL ARTIFICIAL AUTOEXPANDIBLE EN PACIENTES CON INCONTINENCIA FECAL MEJORA LA CONTRACTILIDAD DEL ESFNTER ANAL EXTERNO ANTECEDENTES:La contractilidad del esfínter anal externo contribuye significativamente al control del paso de las heces. Un esfínter anal artificial colocado en el espacio interesfinteriano es un procedimiento seguro y eficaz para tratar la incontinencia fecal, incluso si su mecanismo de acción no se ha definido por completo.OBJETIVO:El objetivo de este estudio fue evaluar los cambios en la contractilidad del esfínter anal externo después de la implantación de una prótesis de hyexpan autoexpandible en el espacio interesfinteriano del canal anal y comparar los resultados clínicos.DISEÑO:Estudio clínico prospectivo.ENTORNO CLINICO:El estudio se realizó en un hospital universitario.PACIENTES:Pacientes consecutivos afectados por incontinencia fecal durante al menos 6 meses, tras fracaso de tratamiento conservador.INTERVENCIONES:Todos los pacientes fueron sometidos a la implantación de 10 prótesis, y fueron examinados pre y postoperatoriamente mediante ecografía endoanal y manometría anorrectal.PRINCIPALES MEDIDAS DE VALORACION:Los síntomas de incontinencia fecal se evaluaron mediante puntuaciones de gravedad. La tensión del músculo del esfínter anal externo se calculó mediante una formula específica.RESULTADOS:Treinta y nueve pacientes (34 mujeres; mediana de edad 68 años) fueron incluidos en el estudio; no se registró morbilidad. Después de un período de seguimiento medio de 14 meses, tanto la presión de compresión voluntaria máxima media como el radio interior medio del esfínter anal externo aumentaron significativamente. Se detectó un aumento estadísticamente significativo de la tensión del músculo del esfínter anal externo. En el último examen de seguimiento se observó una disminución de cualquier síntoma de incontinencia fecal y una mejora en las puntuaciones de gravedad. La contractilidad del esfínter anal externo fue significativamente mayor en los pacientes que redujeron los episodios de incontinencia a heces sólidas en más del 50% y mejoraron la capacidad para diferir la defecación durante más de 15 minutos.LIMITACIONES:Experiencia de un solo centro; tamaño de muestra relativamente pequeño y heterogéneo; pacientes con una enfermedad potencialmente más grave porque nuestra institución es un centro de referencia; ausencia de evaluación de la calidad de vida.CONCLUSIONES:La implantación del esfínter anal artificial mejoró la tensión muscular del esfínter anal externo; hubo una correlación positiva entre su aumento y el resultado clínico. Consulte Video Resumen en http://links.lww.com/DCR/B468.
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Affiliation(s)
- Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Angelo A Marra
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | | | - Raffaele Orefice
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Angelo Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Veronica De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Paola Campennì
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Marta Goglia
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Gregersen H, Chen SC, Leung WW, Wong C, Mak T, Ng S, Daming S, Futaba K. Characterization of Patients With Obstructed Defecation and Slow Transit Constipation With a Simulated Stool. Clin Transl Gastroenterol 2021; 12:e00354. [PMID: 33949343 PMCID: PMC8099406 DOI: 10.14309/ctg.0000000000000354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Defecatory disorders including obstructed defecation (OD) are currently diagnosed using specialized investigations including anorectal manometry and the balloon expulsion test. Recently, we developed a simulated stool named Fecobionics that provides a novel type of pressure measurements and analysis. The aim was to study OD phenotypes compared with slow transit constipation (STC) patients and normal subjects (NS). METHODS Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics device contained pressure sensors at the front, rear, and inside a bag. All constipation patients had colon transit study, defecography, anorectal manometry, and balloon expulsion test performed. The Fecobionics bag was distended in the rectum until desire-to-defecate in 26 OD compared with 8 STC patients and 10 NS. Rear-front pressures (preload-afterload parameters) and defecation indices (DIs) were compared between groups. RESULTS The Wexner constipation scoring system score was 13.8 ± 0.9 and 14.6 ± 1.5 in the OD and STC patients (P > 0.5). The median desire-to-defecate volume was 80 (quartiles 56-80), 60 (54-80), and 45 (23-60) mL in OD, STC, and NS, respectively (P < 0.01). The median expulsion duration was 37 (quartiles 15-120), 6 (3-11), and 11 (8-11) seconds for the 3 groups (P < 0.03). Fecobionics rear-front pressure diagrams demonstrated clockwise loops with distinct phenotype differences between OD and the other groups. Most DIs differed between OD and the other groups, especially those based on the anal afterload reflecting the nature of OD constipation. Several OD subtypes were identified. DISCUSSION Fecobionics obtained novel pressure phenotypes in OD patients. DIs showed pronounced differences between groups. Larger studies are needed on OD subtyping.
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Affiliation(s)
- Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sun Daming
- School of Microelectronics and Communication Engineering, Chongqing University, Shapingba, China
| | - Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
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Zhuang Z, Hung H, Chen S, Futaba K, Gregersen H. Translating Fecobionics Into a Technique That Addresses Clinical Needs for Objective Perineal Descent Measurements. Clin Transl Gastroenterol 2021; 12:e00342. [PMID: 33956418 PMCID: PMC8049154 DOI: 10.14309/ctg.0000000000000342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/05/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Perineal descent is a phenomenon associated with anorectal dysfunction. It is diagnosed by defecography but subjected to manual measurements on the images/videos and interobserver bias. Fecobionics is a simulated feces for assessing important physiological parameters during defecation. Here, we translate Fecobionics into a new method for estimation of perineal descent based on electronic signals from the embedded inertial measurement units (IMUs). METHODS A displacement measurement method by a combined zero-velocity update and gravity compensation algorithm from IMUs was developed. The method was verified in a robot model, which mimicked perineal descent motion. RESULTS The method correlated well with the reference (R = 0.9789) and had a deviation from the peak displacement (range 0.25-2.5 cm) of -0.04 ± 0.498 cm. The method was further validated in 5 human experiments with comparison to the benchmark defecography technology (R = 0.79). DISCUSSION The proposed technology is objective, i.e., electronic measurements rather than by fluoroscopy or MRI. The development may impact clinical practice by providing a resource-saving and objective technology for diagnosing perineal descent in the many patients suffering from anorectal disorders. The technology may also be used in colon experiments with Fecobionics and for other gastrointestinal devices containing IMUs such as ingestible capsules like the Smartpill.
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Affiliation(s)
- Z. Zhuang
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - H.Y. Hung
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Shatin, Hong Kong.
| | - S.C. Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - K. Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - H. Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
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Baaleman DF, Malamisura M, Benninga MA, Bali N, Vaz KH, Yacob D, Di Lorenzo C, Lu PL. The not-so-rare absent RAIR: Internal anal sphincter achalasia in a review of 1072 children with constipation undergoing high-resolution anorectal manometry. Neurogastroenterol Motil 2021; 33:e14028. [PMID: 33301220 PMCID: PMC8047870 DOI: 10.1111/nmo.14028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/21/2020] [Accepted: 10/16/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Our objective is to describe the prevalence of patients with internal anal sphincter achalasia (IASA) without Hirschsprung disease (HD) among children undergoing anorectal manometry (ARM) and their clinical characteristics. METHODS We performed a retrospective review of high-resolution ARM studies performed at our institution and identified patients with an absent rectoanal inhibitory reflex (RAIR). Clinical presentation, medical history, treatment outcomes, and results of ARM and other diagnostic tests were collected. We compared data between IASA patients, HD patients, and a matched control group of patients with functional constipation (FC). KEY RESULTS We reviewed 1,072 ARMs and identified 109 patients with an absent RAIR, of whom 28 were diagnosed with IASA. Compared to patients with FC, patients with IASA had an earlier onset of symptoms and were more likely to have abnormal contrast enema studies. Compared to patients with HD, patients with IASA were more likely to have had a normal timing of meconium passage, a later onset of symptoms, and were diagnosed at an older age. At the latest follow-up, the majority of patients diagnosed with IASA (54%) were only using oral laxatives. Over half of patients with IASA had been treated with anal sphincter botulinum toxin injection, and 55% reported a positive response. CONCLUSIONS AND INFERENCES Patients diagnosed with IASA may represent a more severe patient population compared to patients with FC, but have a later onset of symptoms compared to patients with HD. They may require different treatments for their constipation and deserve further study.
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Affiliation(s)
- Desiree F. Baaleman
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
- Department of Pediatric Gastroenterology and NutritionEmma Children’s Hospital, Amsterdam UMCUniversity of Amsterdam & VU UniversityAmsterdamthe Netherlands
- Amsterdam UMCUniversity of Amsterdam, Gastroenterology and HepatologyAmsterdam Gastroenterology Endocrinology MetabolismAmsterdamthe Netherlands
| | - Monica Malamisura
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
- Digestive endoscopy and surgery UnitBambino Gesù Children’s Hospital IRCCSRomeItaly
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and NutritionEmma Children’s Hospital, Amsterdam UMCUniversity of Amsterdam & VU UniversityAmsterdamthe Netherlands
| | - Neetu Bali
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Karla H. Vaz
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Desale Yacob
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Peter L. Lu
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
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Hoey RF, Medina-Aguiñaga D, Khalifa F, Ugiliweneza B, Zdunowski S, Fell J, Naglah A, El-Baz AS, Herrity AN, Harkema SJ, Hubscher CH. Bladder and bowel responses to lumbosacral epidural stimulation in uninjured and transected anesthetized rats. Sci Rep 2021; 11:3268. [PMID: 33558526 PMCID: PMC7870824 DOI: 10.1038/s41598-021-81822-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/12/2021] [Indexed: 01/09/2023] Open
Abstract
Spinal cord epidural stimulation (scES) mapping at L5-S1 was performed to identify parameters for bladder and bowel inhibition and/or contraction. Using spinally intact and chronic transected rats of both sexes in acute urethane-anesthetized terminal preparations, scES was systematically applied using a modified Specify 5-6-5 (Medtronic) electrode during bladder filling/emptying cycles while recording bladder and colorectal pressures and external urethral and anal sphincter electromyography activity. The results indicate frequency-dependent effects on void volume, micturition, bowel peristalsis, and sphincter activity just above visualized movement threshold intensities that differed depending upon neurological intactness, with some sex-dependent differences. Thereafter, a custom-designed miniature 15-electrode array designed for greater selectivity was tested and exhibited the same frequency-dependent urinary effects over a much smaller surface area without any concurrent movements. Thus, select activation of autonomic nervous system circuitries with scES is a promising neuromodulation approach for expedient translation to individuals with SCI and potentially other neurologic disorders.
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Affiliation(s)
- Robert F Hoey
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, MDR, 511 S. Floyd St., Room 111, Louisville, KY, 40202, USA
| | - Daniel Medina-Aguiñaga
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, MDR, 511 S. Floyd St., Room 111, Louisville, KY, 40202, USA
| | - Fahmi Khalifa
- Bioengineering Department, University of Louisville J. B. Speed School of Engineering, Louisville, KY, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Sharon Zdunowski
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Jason Fell
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, MDR, 511 S. Floyd St., Room 111, Louisville, KY, 40202, USA
| | - Ahmed Naglah
- Bioengineering Department, University of Louisville J. B. Speed School of Engineering, Louisville, KY, USA
| | - Ayman S El-Baz
- Bioengineering Department, University of Louisville J. B. Speed School of Engineering, Louisville, KY, USA
| | - April N Herrity
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, USA
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Susan J Harkema
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, USA
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Charles H Hubscher
- Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, MDR, 511 S. Floyd St., Room 111, Louisville, KY, 40202, USA.
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.
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Sindou M, Joud A, Georgoulis G. Usefulness of external anal sphincter EMG recording for intraoperative neuromonitoring of the sacral roots-a prospective study in dorsal rhizotomy. Acta Neurochir (Wien) 2021; 163:479-487. [PMID: 33064201 DOI: 10.1007/s00701-020-04610-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In conus medullaris and cauda equina surgery, identification of the sacral nerve roots may be uncertain in spite of their anatomical/radiological landmarks. Mapping the sacral roots by recording the muscular responses to their stimulation may benefit from EMG recording of the External Anal sphincter (EAS) in addition to the main muscular groups of the lower limbs. METHOD In a consecutive series of 27 lumbosacral dorsal rhizotomy (DRh), authors carried out a prospective study on the reliability of the EMG recording of the EAS for identification of the S1 and S2 sacral roots. RESULTS An EAS-response was recorded in all the 27 (bilaterally) explored individuals, testifying good sensitivity and selectivity of the method. EAS-responses were obtained in 96.3% of the 54 stimulated sides of the S2 root versus in only 16.66% for the S1 root, so that an absence of response would indicate S1 rather than S2 level. Furthermore, comparison between myotomal distribution of the S1 and S2 roots showed a significant difference (p < 0.00001), so that myotomal profile may help to identify root level. CONCLUSIONS EMG recording of the EAS can be recommended for current intraoperative neuromonitoring. This simple method also provides-indirectly by extrapolation-information on the sacral motor pathways of the external urethral sphincter (EUS), as the later has the same somatic innervation via the pudendal nerve and related S2, S3, and S4 roots. Method can be helpful not only for DRh, of all varieties, but also for spine surgery, correction of dysraphisms, lipomas and/or tethered cord, and tumor resection.
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Affiliation(s)
- Marc Sindou
- University of Lyon, Lyon, France
- IRR Flavigny, UGECAM Nord-Est, Nancy, France
- Pediatric Neurosurgery Department, CHRU Nancy, Nancy, France
| | - Anthony Joud
- IRR Flavigny, UGECAM Nord-Est, Nancy, France
- Pediatric Neurosurgery Department, CHRU Nancy, Nancy, France
| | - George Georgoulis
- Department of Neurosurgery, General Hospital of Athens "G.Gennimatas", Mesogeion Avenue 154, 11527, Athens, Greece.
- Medical School, University of Athens, Athens, Greece.
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22
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Gallese N. Identification of a new syndrome: ASS-SSA or anal sphincter syndrome. Ann Ital Chir 2021; 92:180-182. [PMID: 34031287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM The author proposes a new, original Syndrome, observing the relationship between some of the most frequent anal pathologies, apparently different from each other in terms of morphological aspect and symptomatologic expression, but united by the same pathogenic cause, represented by the hypertonicity of the anal sphincter apparatus. There are already descriptions of other "syndromes" of the pelvic floor, inaccurate and subject to different interpretations. The proposed syndrome, instead, called Anal Sphincter Syndrome - ASS (in Italian SSA - Sindrome dello Sfintere Anale) presents clarity on the determining cause (sphincter hypertonicity) and descriptive simplicity, including only two welldefined pathological conditions: anal fissure and anal thrombosis; other ancillary conditions or symptoms are inconstantly possible, but not decisive. The author will present, as soon as possible, in subsequent works, a retrospective study (still to be completed) on a wide personal case history, dating back to the 1990s. KEY WORDS Anal sphincter hypertonia, Anal thrombosis, Anal fissure, Syndrome, Proctology, Somatization.
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Rangan V, Nee J, Singh P, Ballou S, Iturrino J, Hirsch W, Lembo A. Fecal Urgency: Clinical and Manometric Characteristics in Patients With and Without Diarrhea. Dig Dis Sci 2020; 65:3679-3687. [PMID: 32468228 DOI: 10.1007/s10620-020-06349-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 05/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fecal urgency is classically associated with diarrhea, but is also common in individuals with normal bowel habits or constipation. Its etiology, particularly in non-diarrhea individuals, is unclear. METHODS We examined data from 368 individuals with and without diarrhea who underwent three-dimensional high-resolution anorectal manometry and balloon expulsion test. All patients completed the Rome III constipation module and the pelvic floor distress inventory (PDFI-20) survey. Patients were considered to have fecal urgency if they reported being bothered "moderately" or "quite a bit" by it in the past 3 months. RESULTS A total of 103 patients (28.0%) met our definition of fecal urgency. These patients were significantly more likely to meet criteria for irritable bowel syndrome and to report fecal incontinence, urinary incontinence, and diarrhea. Fecal urgency was associated with rectal hypersensitivity in those with diarrhea, but not in those without diarrhea. Fecal urgency was associated with urinary urge incontinence in those without diarrhea, but not those with diarrhea. CONCLUSIONS In patients with diarrhea, fecal urgency is associated with rectal hypersensitivity, whereas in patients without diarrhea, fecal urgency is associated with urinary urge incontinence. This suggests that fecal urgency has different pathophysiological mechanisms in patients with different underlying bowel habits.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - William Hirsch
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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de Almeida RVS, Silvino JRC, Kalil JR, Dos Santos VL, de Souza VMG, Pontes J, Guglielmetti GB, Sanchez-Salas RE, Claro JFDA, Murta CB. Early Effects of High-intensity Focused Ultrasound (HIFU) Treatment for Prostate Cancer on Fecal Continence and Anorectal Physiology. Urology 2020; 148:211-216. [PMID: 33080255 DOI: 10.1016/j.urology.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/29/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate high-intensity focused ultrasound (HIFU) effects on anorectal physiology and fecal continence or constipation, and on quality of life (QoL). METHODS We prospectively evaluated 26 patients with localized prostate cancer who underwent HIFU. The Rome III criteria for functional constipation, the Cleveland Clinic Florida Fecal Incontinence Score, and the Fecal Incontinence QoL Score questionnaires were answered before and after treatment. Anorectal manometry was used to evaluate resting and squeezing pressures, sustained contraction, paradoxical puborectalis contraction, rectal sensation, and rectal capacity. RESULTS Thirteen patients underwent hemiablation and 13 underwent whole-gland ablation. There was no difference between groups regarding the Rome III criteria for functional constipation results. The Cleveland Clinic Florida Fecal Incontinence Score results showed that 3 (11.5%) of patients had mild fecal incontinence before HIFU and 5 (19.2%) had it afterward (P = .625). No patients reported poor QoL due to fecal incontinence in the Fecal Incontinence QoL Score. Anorectal manometry demonstrated no decrease in resting pressure after treatment (P = .299), while squeezing pressure significantly increased from 151.87 to 167.91 mm Hg (P = .034). The number of patients with normal sustained contraction remained the same (20 [77%]). Paradoxical puborectalis contraction was seen in 12 (46%) of the patients before the procedure and in 13 (50%) after (P = .713). Improvement in sensory parameters was not significant: first sense changed from 73.46 to 49.71 mL (P = .542) and first urge from 98.27 to 82.88 mL (P = .106). Rectal capacity had a nonsignificant decrease from 166.15 to 141.15mL (P = .073). CONCLUSION HIFU did not cause significant changes in anorectal physiology. Fecal incontinence or constipation after HIFU was not observed via validated questionnaires.
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Affiliation(s)
| | | | - Jamile Rosario Kalil
- Department of Gastrointestinal motility, University of São Paulo, São Paulo, SP, Brazil
| | | | | | - Jose Pontes
- Department of Urology, Men's Health Centre, Hospital Brigadeiro, São Paulo, SP, Brazil
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Attari A, Chey WD, Baker JR, Ashton-Miller JA. Comparison of anorectal function measured using wearable digital manometry and a high resolution manometry system. PLoS One 2020; 15:e0228761. [PMID: 32991595 PMCID: PMC7523952 DOI: 10.1371/journal.pone.0228761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022] Open
Abstract
There is a need for a lower cost manometry system for assessing anorectal function in primary and secondary care settings. We developed an index finger-based system (termed "digital manometry") and tested it in healthy volunteers, patients with chronic constipation, and fecal incontinence. Anorectal pressures were measured in 16 participants with the digital manometry system and a 23-channel high-resolution anorectal manometry system. The results were compared using a Bland-Altman analysis at rest as well as during maximum squeeze and simulated defecation maneuvers. Myoelectric activity of the puborectalis muscle was also quantified simultaneously using the digital manometry system. The limits of agreement between the two methods were -7.1 ± 25.7 mmHg for anal sphincter resting pressure, 0.4 ± 23.0 mmHg for the anal sphincter pressure change during simulated defecation, -37.6 ± 50.9 mmHg for rectal pressure changes during simulated defecation, and -20.6 ± 172.6 mmHg for anal sphincter pressure during the maximum squeeze maneuver. The change in the puborectalis myoelectric activity was proportional to the anal sphincter pressure increment during a maximum squeeze maneuver (slope = 0.6, R2 = 0.4). Digital manometry provided a similar evaluation of anorectal pressures and puborectalis myoelectric activity at an order of magnitude less cost than high-resolution manometry, and with a similar level of patient comfort. Digital Manometry provides a simple, inexpensive, point of service means of assessing anorectal function in patients with chronic constipation and fecal incontinence.
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Affiliation(s)
- Ali Attari
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | - William D. Chey
- Division of Gastroenterology and Hepatology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, United States of America
| | - Jason R. Baker
- Division of Gastroenterology and Hepatology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, United States of America
| | - James A. Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States of America
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Abstract
Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.
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Affiliation(s)
- Alice C Jiang
- Division of Gastroenterology, Department of Internal Medicine, Rush University Medical Center, 600 S Paulina St, Chicago, IL 60612, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard M. Miller School of Medicine, 1601 NW 12th Ave, Miami, FL, USA
| | - Yun Yan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Augusta University Medical Center, 1120 15th Street, AD 2226, Augusta, GA 30912, USA.
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Fernández-Cuadros ME, Martín-Martín LM, Albaladejo-Florín MJ, Álava-Rabasa S, Pérez-Moro OS. [Tarlov cyst and faecal incontinence: A case report and literature review]. Rehabilitacion (Madr) 2020; 54:215-220. [PMID: 32441263 DOI: 10.1016/j.rh.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/30/2019] [Indexed: 06/11/2023]
Abstract
Tarlov, or perineural cysts, are lesions of the nerve root usually located at the sacral level of the spine. Their cause is unclear. These cysts are generally identified as an incidental finding and are usually asymptomatic. Symptomatic cysts are infrequent, with symptoms usually consisting of pain, radiculopathy and, less frequently, bladder, bowel and sexual dysfunction. We report the case of a 70-year-old woman with Tarlov cyst, provoking faecal incontinence, and review the aetiology, pathophysiology and management of this particular case.
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Affiliation(s)
- M E Fernández-Cuadros
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España.
| | - L M Martín-Martín
- Servicio de Neurofisiología, Hospital Universitario Santa Cristina, Madrid, España
| | - M J Albaladejo-Florín
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - S Álava-Rabasa
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - O S Pérez-Moro
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
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Talebi A, Alimadadi E, Akbari A, Bahardoust M, Towliat M, Eslami M, Agah S, Kashani AF. Improvement of Patient Satisfaction and Anorectal Manometry Parameters After Biofeedback Therapy in Patients with Different Types of Dyssynergic Defecation. Appl Psychophysiol Biofeedback 2020; 45:267-274. [PMID: 32556708 DOI: 10.1007/s10484-020-09476-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biofeedback is a well-known and effective treatment for patients with fecal evacuation disorder (FED). The main purpose of this study was to investigate the outcome and the effects of biofeedback therapy on physiological parameters as assessed by manometry in patients with FED. Data from 114 consecutive patients with FED who underwent biofeedback therapy in Sara Gastrointestinal clinic in Tehran, Iran during 2015-2018 were retrospectively reviewed and analyzed. All participants underwent a comprehensive evaluation of anorectal function that included anorectal manometry and a balloon expulsion test at the baseline and after biofeedback therapy. Maximum anal squeeze pressure and sustained anal squeeze pressure were improved up to 100% and 94.7% of normal values in the patients after biofeedback, respectively (P < 0.001). First rectal sensation, was significantly decreased (25 ± 18.5 vs. 15.5 ± 5.2) while the maximum tolerable volume was significantly increased (233.6 ± 89.7 vs. 182.4 ± 23.1) after biofeedback therapy (P < 0.001). Type I dyssynergia was the most common type, effecting 82 cases (71.9%) of our patients. Dyssynergia parameters were improved 50-80% in 34 (41.5%) and 10 (31.3%) type I and non-type I patients, respectively. Over 80% improvement of dyssynergia parameters occurred in 48 (58.5%) and 22 (68.8%) type I and non-type I patients, respectively. These differences were not statistically significant between the two groups (P = 0.3). In addition, the ability to reject the balloon was significantly better in post intervention measurements (P < 0.001). Biofeedback not only improves the symptoms in patients of FED but also reverses more than 80% the dyssynergic parameters of defecation. However, due to the general effectiveness of biofeedback treatment in different types of DD, there were no significant differences between their improvement scores.
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Affiliation(s)
- Atefeh Talebi
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Elaheh Alimadadi
- Colorectal and Ostomy Nurse, Special Education of OWI (Ostomy Wound Incontinence) from Shahid Beheshti University, Tehran, Iran
| | - Abolfazl Akbari
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mansour Bahardoust
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Shahram Agah
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Subramaniam N, Dietz HP. Does exclusion of subcutaneous external anal sphincter on exoanal imaging matter? Ultrasound Obstet Gynecol 2020; 55:830-834. [PMID: 31605510 DOI: 10.1002/uog.21886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/26/2019] [Accepted: 09/20/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE There is some speculation that an intact distal anal sphincter complex is of decisive importance for continence, although the external anal sphincter (EAS) is considered to be a single functional and anatomical entity. On tomographic translabial ultrasound (TLUS), the caudal slice at the level of the subcutaneous EAS is currently omitted from the diagnostic algorithm due to the prevalence of artifact at that level. The aim of this study was to determine the predictive value of assessment of the subcutaneous EAS on tomographic TLUS for anal incontinence (AI). METHODS This was a retrospective study of 463 women seen at our urogynecological service in 2015. All underwent a standardized questionnaire, including determination of St Mark's incontinence score (SMIS), clinical examination and three-/four-dimensional TLUS. On tomographic TLUS, EAS defect angles in slices one to seven were measured on maximum pelvic floor muscle contraction. A slice was defined as positive for a defect if the defect angle was ≥ 30°. The association between significant subcutaneous EAS trauma (i.e. defect angle of ≥ 30° in slice seven) and symptoms of AI, symptom bother score and SMIS was assessed. The performances of the standard six-slice model and the seven-slice model, including the subcutaneous EAS, in the prediction of AI were compared. RESULTS While there was a highly significant association between all measures of AI and significant EAS trauma in slice seven, addition of the seventh slice to the existing six-slice model did not improve the predictive value for AI. CONCLUSION As inclusion of the subcutaneous slice of the EAS on tomographic TLUS does not seem to improve the predictive value for AI, the current methodology for assessment of EAS trauma on tomographic TLUS can remain unchanged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Subramaniam
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
| | - H P Dietz
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
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Sato D, Takami H, Teranishi Y, Ishikawa O, Saito N. Pseudofailure of Ventriculoperitoneal Shunt due to Drug-Resistant Constipation, Dramatically Responsive to Rectal Tube Placement: Pitfall Case Series of Avoidable Shunt Revision. World Neurosurg 2020; 141:131-136. [PMID: 32461182 DOI: 10.1016/j.wneu.2020.05.169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/16/2020] [Accepted: 05/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ventriculoperitoneal shunt placement is a common standard treatment for hydrocephalus, and these shunts function appropriately in the presence of a pressure gradient between the ventricular and abdominal cavities. CASE DESCRIPTION We encountered 2 cases of shunt malfunction that was due to an increase in intra-abdominal pressure, mainly caused by constipation and excessive accumulation of enteric gas. Although aggressive bowel regimens were implemented, this management failed in both patients. Careful physical examination revealed unusually elevated tonus of the anus sphincter muscle, and a fecal incontinence catheter was inserted into the rectum. Following this procedure, constipation rapidly improved together with a marked reduction in enteric gas, leading to a normalization of ventricular size on imaging and neurologic improvements. Both patients were able to avoid unnecessary surgical exploration or shunt revision. CONCLUSIONS Constipation is one of the differential diagnoses of ventriculoperitoneal shunt malfunction, and bowel regimens are the first-line treatment. However, some cases can prove resistant to medical therapy, and mechanical tube placement can provide an alternative or additional solution. Before proceeding to surgical exploration, the intra-abdominal environment should be properly assessed and every option should be explored to address underlying causes of shunt failure to avoid unnecessary intervention.
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Affiliation(s)
- Daisuke Sato
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Hirokazu Takami
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yu Teranishi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Schwandner F, Klimars U, Gock M, Schiffmann L, Witte M, Schiergens T, Rentsch M, Klar E, Kühn F. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg 2020; 24:411-417. [PMID: 30825120 DOI: 10.1007/s11605-019-04171-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND A defunctioning stoma can become necessary in a relevant number of patients undergoing gastrointestinal surgery. As a matter of course, patients seek an early closure of the stoma. However, preoperative management of these patients varies and the prediction of continence after stoma removal can become challenging. Patients might be fully continent despite low manometric pressures and vice versa. An easy and reliable way to predict continence after stoma reversal would improve patients' management and outcome. Although frequently performed in various surgical centers in Germany, there is no published data on the water-holding test. Hence, this is the first study evaluating the role of the test in clinical practice. METHOD We performed a prospective pilot study to evaluate the role of anorectal manometry and the water-holding procedure as a predictor of postoperative continence prior to stoma reversal. Inclusion criteria were a successfully passed water-holding test, any type of fecal diversion and the possibility of restoring intestinal continuity. Preoperative low manometric pressure levels were not an exclusion criteria for stoma reversal. Fifty-two patients with ostomy were consecutively enrolled in this study between October 2013 and February 2016. Anorectal manometry was performed in all patients prior to stoma reversal. After stoma removal, patients were followed-up for 6 months. Postoperative incontinence was determined using the Wexner incontinence score. RESULTS A total of 52 patients (38 males, 14 females) were included at an average age of 59 (range 33-83) years. Most frequent indications for intestinal diversion were rectal cancer surgery, IBD-related surgery, or surgery for diverticular disease. Low anterior rectal resection was performed in 17 patients (32.7%), followed by a proctocolectomy in 9 (17.3%), colectomy in 9 (17.3%), and recto-sigmoid resection in 7 patients (13.5%). Median time from stoma creation to reversal was 206 days (range 48-871 days). All patients had successfully passed the standardized water-holding test. At the same time, the majority of patients had low preoperative manometric pressure values and would normally not have been reversed at that point. The median postoperative Wexner incontinence score was at 1.5 (range 0-20), 0.5 (range 0-14), and 0 (range 0-11) at 14, 60, and 180 days after stoma reversal. Low preoperative manometric squeeze and/or resting pressure levels were not associated with a higher postoperative incontinence score at 14, 60, or 180 days after stoma reversal. CONCLUSION A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.
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Affiliation(s)
- Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ulrich Klimars
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Leif Schiffmann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Tobias Schiergens
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Gaj F, Bianchi FP, Passannanti D, Telesco D. Relief of hemorrhoid symptoms: pilot study of a new topical ally. G Chir 2020; 41:118-125. [PMID: 32038023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
AIM The pathogenesis of hemorrhoids involves vascular congestion, fragmentation of supporting tissues and, in many cases, increased resting anal pressure. A new ointment (Hemolen®) has been devised to control hemorrhoids symptoms acting on all the pathophysiologic mechanisms involved. METHODS Pilot study on patients with grade I-III hemorrhoids. The ointment was applied twice daily for 30 days and follow-up visits were scheduled 7 days (T1), 14 days (T2) and 30 days (T3) after recruitment (T0). Signs and symptoms (bleeding, discomfort, itching, edema, thrombosis, congestion, inflammation, pain) were evaluated at each visit using dedicated scores and VAS scale. Resting anal pressure was measured at time T0, 1 hour after the first application and at T1. Use of painkiller was recorded. RESULTS 48 patients (25 females; mean age 47±15.8 years) were enrolled; 52.1% of them had II degree hemorrhoids and 27.1% had III degree hemorrhoids. The severity scores significantly dropped from T0 to each scheduled visit and a significant reduction of resting anal pressure was observed from T0 to 1 hour after application (z=13.5; p<0.001) and from T0 to T1 (z=6; p<0.001). The comparison of the resting pressure among whole time series showed a significant reduction (Fr=124.4; p=<0.001). Use of pain-killers decreased significantly from T0 to T1 (p<0.001) and from T1 to T2 (p=0.001). CONCLUSION The new ointment tested in the present study is safe and effective for the management of hemorrhoid symptoms in the early stages hemorrhoids, during the acute phases and in patients with more severe hemorrhoids awaiting surgery. Prospective, randomized controlled trials are needed to confirm these encouraging results.
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Carrington EV, Heinrich H, Knowles CH, Fox M, Rao S, Altomare DF, Bharucha AE, Burgell R, Chey WD, Chiarioni G, Dinning P, Emmanuel A, Farouk R, Felt‐Bersma RJF, Jung KW, Lembo A, Malcolm A, Mittal RK, Mion F, Myung S, O’Connell PR, Pehl C, Remes‐Troche JM, Reveille RM, Vaizey CJ, Vitton V, Whitehead WE, Wong RK, Scott SM. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil 2020; 32:e13679. [PMID: 31407463 PMCID: PMC6923590 DOI: 10.1111/nmo.13679] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. METHODS Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018. KEY RECOMMENDATIONS The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia. CONCLUSIONS AND INFERENCES This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.
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Affiliation(s)
| | | | | | - Mark Fox
- University of ZürichZürichSwitzerland
| | - Satish Rao
- Medical College of GeorgiaAugustaGeorgiaUSA
| | | | | | - Rebecca Burgell
- Monash University and Alfred HealthMelbourneVictoriaAustralia
| | | | | | | | | | - Ridzuan Farouk
- National University Hospital SingaporeSingapore CitySingapore
| | | | | | | | - Allison Malcolm
- University of Sydney and Royal North Shore HospitalSydneyNew South WalesAustralia
| | | | - Franҫois Mion
- Université de Lyon et Hospices Civils de LyonLyonFrance
| | | | | | - Christian Pehl
- Krankenhaus Vilsbiburg and Technical University MunichMunichGermany
| | | | | | | | | | | | - Reuben K. Wong
- National University Hospital SingaporeSingapore CitySingapore
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Roorda D, Abeln ZAM, Oosterlaan J, van Heurn LWE, Derikx JPM. Botulinum toxin injections after surgery for Hirschsprung disease: Systematic review and meta-analysis. World J Gastroenterol 2019; 25:3268-3280. [PMID: 31333317 PMCID: PMC6626723 DOI: 10.3748/wjg.v25.i25.3268] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/05/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A large proportion of patients with Hirschsprung disease experience persistent obstructive symptoms after corrective surgery. Persistent obstructive symptoms may result in faecal stasis that can develop into Hirschsprung-associated enterocolitis, a potential life-threatening condition. Important treatment to improve faecal passage is internal anal sphincter relaxation using botulinum toxin injections.
AIM To give an overview of all empirical evidence on the effectiveness of botulinum toxin injections in patients with Hirschsprung disease.
METHODS A systematic review and meta-analysis was done by searching PubMed, EMBASE and the Cochrane Library, using entry terms related to: (1) Hirschsprung disease; and (2) Botulinum toxin injections. 14 studies representing 278 patients met eligibility criteria. Data that were extracted were proportion of patients with improvement of obstructive symptoms or less enterocolitis after injection, proportion of patients with adverse effects and data on type botulinum toxin, mean dose, average age at first injection and patients with associated syndromes. Random-effects meta-analysis was used to aggregate effects and random-effects meta-regression was used to test for possible confounding factors.
RESULTS Botulinum toxin injections are effective in treating obstructive symptoms in on average 66% of patients [event rate (ER) = 0.66, P = 0.004, I2 = 49.5, n = 278 patients]. Type of botulinum toxin, average dose, average age at first injections and proportion of patients with associated syndromes were not predictive for this effect. Mean 7 duration of improvement after one botulinum toxin injections was 6.4 mo and patients needed on average 2.6 procedures. There was a significant higher response rate within one month after botulinum toxin injections compared to more than one month after Botulinum toxin injections (ER = 0.79, vs ER = 0.46, Q = 19.37, P < 0.001). Botulinum toxin injections were not effective in treating enterocolitis (ER 0.58, P = 0.65, I2 = 71.0, n = 52 patients). There were adverse effects in on average 17% of patients (ER = 0.17, P < 0.001, I2 = 52.1, n = 187 patients), varying from temporary incontinence to mild anal pain.
CONCLUSION Findings from this systematic review and meta-analysis indicate that botulinum toxin injections are effective in treating obstructive symptoms and that adverse effects were present, but mild and temporary.
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Affiliation(s)
- Daniëlle Roorda
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development, Amsterdam 1105 AZ, Netherlands
| | - Zarah AM Abeln
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development, Amsterdam 1105 AZ, Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Emma Neuroscience Group, Amsterdam Reproduction and Development, Amsterdam 1105 AZ, Netherlands
| | - Lodewijk WE van Heurn
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development, Amsterdam 1105 AZ, Netherlands
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam 1105 AZ, Netherlands
| | - Joep PM Derikx
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development, Amsterdam 1105 AZ, Netherlands
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam 1105 AZ, Netherlands
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Toro-Monjaraz EM, Peña-Vélez R, Ignorosa-Arellano KR, Zaráte-Mondragón F, Cervantes-Bustamante R, Ramírez-Mayans JA. Anorectal manometry in children with retentive fecal incontinence: What parameters should we evaluate? Rev Gastroenterol Mex (Engl Ed) 2019; 84:419-422. [PMID: 31151864 DOI: 10.1016/j.rgmx.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/21/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Children with functional constipation frequently present with alterations in rectal compliance and the urge-to-defecate sensation that can be evaluated through anorectal manometry (ARM). In the present study, we evaluated the usefulness of the parameters obtained through ARM in children with retentive fecal incontinence (RFI). MATERIALS AND METHODS Children with functional constipation, aged 4 to 17years, that underwent ARM were included in the study. RESULTS Of the 35 children evaluated, 21 presented with functional constipation and 14 had functional constipation and RFI. The children with both constipation and RFI tolerated greater volumes of air insufflation for triggering the urge to defecate and reaching maximum tolerance of pain, compared with the children that did not have RFI. We identified the cutoff point of 135ml of air as the maximum tolerance sensation for distinguishing children with RFI. CONCLUSIONS Maximum tolerance of pain was the most useful parameter for evaluating RFI in children with functional constipation.
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Affiliation(s)
- E M Toro-Monjaraz
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Coyoacán, Ciudad de México, México
| | - R Peña-Vélez
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Coyoacán, Ciudad de México, México.
| | - K R Ignorosa-Arellano
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Coyoacán, Ciudad de México, México
| | - F Zaráte-Mondragón
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Coyoacán, Ciudad de México, México
| | - R Cervantes-Bustamante
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Coyoacán, Ciudad de México, México
| | - J A Ramírez-Mayans
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Coyoacán, Ciudad de México, México
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Park JY, Oh S, Han YM, Lee J, Kim JS, Jung HC, Hong KS. There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives: A retrospective, longitudinal symptom analysis. Medicine (Baltimore) 2019; 98:e15884. [PMID: 31261496 PMCID: PMC6617427 DOI: 10.1097/md.0000000000015884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively, P = .042). Back pain (16.2% vs 2.0%, P < .001) and sharp abdominal pain (13.5% vs 0.9%, P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%, P = .036) and squeezing pressure (62.2% vs 50.7%, P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%, P = .004), and maximal volume (25.7% vs 15.0%, P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.
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Affiliation(s)
- Jae Yong Park
- Department of Internal Medicine, Chung-Ang University Hospital
| | - Sooyeon Oh
- Chaum Life Center, CHA Medical University
| | - Yoo Min Han
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center
| | - Jooyoung Lee
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Kyoung Sup Hong
- Department of Gastroenterology, Mediplex Sejong Hospital, Incheon, South Korea
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Chakraborty S, Feuerhak K, Muthyala A, Harmsen WS, Bailey KR, Bharucha AE. Effects of Alfuzosin, an α 1-Adrenergic Antagonist, on Anal Pressures and Bowel Habits in Women With and Without Defecatory Disorders. Clin Gastroenterol Hepatol 2019; 17:1138-1147.e3. [PMID: 30130627 PMCID: PMC6379158 DOI: 10.1016/j.cgh.2018.08.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some patients with defecatory disorders (DD) have high anal pressures that may impede rectal evacuation. Alpha-1 adrenoreceptors mediate as much as 50% of anal resting pressure in humans. We performed a randomized, placebo-controlled study of the effects of alfuzosin, an alpha1-adrenergic receptor antagonist, on anal pressures alone in healthy women and also on bowel symptoms in women with DD. METHODS In a double-blind study performed from March 2013 through March 2017, anal pressures were evaluated before and after 36 women with DD (constipation for at least 1 year) and 36 healthy women (controls) were randomly assigned (1:1) to groups given oral alfuzosin (2.5 mg immediate release) or placebo. Thereafter, patients were randomly assigned (1:1) to groups given oral alfuzosin (10 mg extended release) or placebo each day for 2 weeks. Participants kept daily diaries of bowel symptoms for 2 weeks before (baseline) and during administration of the test articles (treatment). Weekly questionnaires recorded the overall severity of constipation symptoms, bloating, abdominal pain, nausea, and vomiting; overall satisfaction with treatment of constipation was evaluated at weeks 2 and 4. The primary endpoint was the change in the number of spontaneous (SBMs) and complete SBMs (CSBMs) between the treatment and baseline periods. We evaluated relationships between stool form, passage, and complete evacuation. RESULTS Alfuzosin reduced anal resting pressure by 32 ± 3 mm Hg versus 16 ± 3 mm Hg for placebo (P = .0001) and anal pressure during evacuation by 26 ± 3 mm Hg versus 16 ± 3 mm Hg for placebo, (P = .03). However, alfuzosin did not significantly increase the rectoanal gradient, SBMs or CSBMs compared with placebo. Both formulations of alfuzosin were well tolerated. Hard stools and the ease of passage during defecation accounted for 72% and 76% of the variance in the satisfaction after defecation, respectively, during baseline and treatment periods. CONCLUSIONS In a randomized trial, alfuzosin reduced anal pressure at rest and during simulated evacuation in healthy and constipated women, compared with placebo, but did not improve bowel symptoms in constipated women. This could be because the drug does not improve stool form or dyssynergia, which also contribute to DD. ClinicalTrials.gov number, NCT 01834729.
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Affiliation(s)
- Subhankar Chakraborty
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anjani Muthyala
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kent R Bailey
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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García-Valencia OA, Sánchez-Ávila MT, Martínez-Ordaz L, Hernández-Flores I, Moreno Medrano E, Morales-Garza LA, Chávez-Caraza KL. [Manometric characteristics in children with chronic constipation and acquired anorectal pathology]. Rev Gastroenterol Peru 2019; 39:136-140. [PMID: 31333230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To describe the anorectal manometry results in the pediatric population with chronic constipation and acquired anorectal disease. MATERIALS AND METHODS We reviewed the records of children who were referred to the Motility and Pelvic Floor Laboratory of the Hospital San Jose Tecnologico de Monterrey between 2004-2016 for further evaluation with anorectal manometry and who presented acquired anorectal disease. RESULTS We reviewed 170 records. The mean age was 7.18 ± 4.51 years old. The prevalence of anorectal disease was 73%. The symptoms more frequently presented were difficult evacuation (78%), painful defecation (67%), large and hard stool (50%) and fecal soiling (49%). 44% of patients with hypotonic external anal sphincter (EAS) presented with soiling and 74% of those had diminished critical volume. Significant manometric values (p<0.05) were EAS resting pressure, maximal squeeze pressure, and critical volume. 97.7% of those who underwent abdomino pelvic coordination evaluation had pelvic floor dyssynergia (anismus). CONCLUSIONS Contrary to adult population, the manometric values in children with acquire anorectal pathology were within normal values except for the EAS resting pressure and critical volume that were diminished. This could suggest a different mechanism in the pediatric population. Pelvic floor dyssynergia could explain chronic constipation in these patients.
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Affiliation(s)
| | | | - Lourdes Martínez-Ordaz
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud. Monterrey, Nuevo León, México
| | - Irene Hernández-Flores
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud. Monterrey, Nuevo León, México
| | - Edgar Moreno Medrano
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud. Monterrey, Nuevo León, México
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Duran P, Ward S, Christman KL, Alperin M. Mechanical impact of parturition-related strains on rat pelvic striated sphincters. Neurourol Urodyn 2019; 38:912-919. [PMID: 30779377 PMCID: PMC6431564 DOI: 10.1002/nau.23946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 11/08/2022]
Abstract
AIMS To define the operational resting sarcomere length (Ls ) of the female rat external urethral sphincter (EUS) and external anal sphincter (EAS) and to determine the mechanism of parturition-related injury of EUS and EAS using a simulated birth injury (SBI) vaginal distention model. METHODS EUS and EAS of 3-month-old Sprague-Dawley control and injured rats were fixed in situ, harvested, and microdissected for Ls measurements and assessment of ultrastructure. EUS and EAS function was determined at baseline, and immediately and 4 weeks after SBI, using leak point pressure (LPP) and anorectal manometry (ARM), respectively. Operational L s was compared to species-specific optimal L s using one sample Student's t test. Data (mean ± SD) were compared between groups and time points using repeated measures one-way analysis of variance, followed by Tukey's post hoc pairwise comparisons, with significance set to 0.05. RESULTS The operational resting Ls of both sphincters (EUS: 2.09 ± 0.07 µm, EAS: 2.02 ± 0.03 µm) was significantly shorter than optimal rat Ls of 2.4 µm. Strains imposed on EUS and EAS during SBI resulted in significant sarcomere elongation and disruption, compared with the controls (EUS: 3.09 ± 0.11 µm, EAS: 3.37 ± 0.09 µm). Paralleling structural changes, LPP and ARM measures were significantly lower immediately (LPP: 21.5 ± 1.0 cmH2 O, ARM: 5.1 ± 2.31 cmH2 O) and 4 weeks (LPP: 27.7 ± 1.3cmH2 O, ARM: 2.5 ± 1.0 cmH2 O) after SBI relative to the baseline (LPP: 43.4 ± 8.5 cmH2 O, ARM: 8.2 ± 2.0 cmH2 O); P < 0.05. CONCLUSIONS Analogous to humans, the short resting Ls of rat EUS and EAS favors their sphincteric function. The insult experienced by these muscles during parturition leads to sarcomere hyperelongation, myofibrillar disruption, and dysfunction of the sphincters long-term.
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Affiliation(s)
- Pamela Duran
- Department of Bioengineering, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Samuel Ward
- Department of Orthopaedic Surgery, University of California San Diego, La Jolla, CA
- Department of Radiology, University of California San Diego, La Jolla, CA
| | - Karen L. Christman
- Department of Bioengineering, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Marianna Alperin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California San Diego, La Jolla, CA
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Abstract
BACKGROUND VACTERL association is a sporadic, nonrandom series of congenital malformations diagnosed by the presence of three or more of the following: vertebral malformations, anal atresia, cardiac defects, tracheoesophageal fistula, renal malformations, and limb malformations. Situs inversus totalis (SIT) and esophageal malformations are rarely associated. This is the first reported case in North America of VACTERL association with SIT. IMPLICATIONS FOR PRACTICE Respiratory distress in the term infant requires full exploration of all possible causes because the etiology may be far more complex than routinely diagnosed respiratory distress syndrome. This particular case demonstrates physical exam findings and supportive imaging that would be observed in infants with VACTERL association and with SIT, highlighting considerations when, rarely, both occur simultaneously.
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MESH Headings
- Aftercare/methods
- Anal Canal/abnormalities
- Anal Canal/physiopathology
- Diagnosis, Differential
- Esophagus/abnormalities
- Esophagus/physiopathology
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/therapy
- Humans
- Infant, Newborn
- Kidney/abnormalities
- Kidney/physiopathology
- Limb Deformities, Congenital/complications
- Limb Deformities, Congenital/diagnosis
- Limb Deformities, Congenital/physiopathology
- Limb Deformities, Congenital/therapy
- Neonatal Screening/methods
- Patient Care Management/methods
- Physical Examination/methods
- Radiography, Abdominal/methods
- Radiography, Thoracic/methods
- Respiratory Distress Syndrome, Newborn/diagnosis
- Situs Inversus/complications
- Situs Inversus/diagnosis
- Situs Inversus/physiopathology
- Situs Inversus/therapy
- Spine/abnormalities
- Spine/physiopathology
- Trachea/abnormalities
- Trachea/physiopathology
- Vestibulocochlear Nerve Diseases/congenital
- Vestibulocochlear Nerve Diseases/diagnosis
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Guttadauro A, Maternini M, Ripamonti L, Pecora N, Aliprandi A, Chiarelli M, Gabrielli FM. Value of colpo-cysto-entero defecography to predict the post operative results in patients with obstructed defecation. Ann Ital Chir 2019; 90:447-450. [PMID: 31814598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION The conventional video colpo-cysto entero defecography describing the morpho- functional imaging features, physiological and pathological of the recto-anal region and pelvic floor . It represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions. MATERIALS AND METHODS Between January 2010 to January 2013 88 patients underwent STARR procedure for obstructed defecation syndrome (ODS) caused by single rectocele or internal rectal intussusception. We retrospectively analyzed the collected data,in particular we reviewed the defecography results before surgery. RESULTS At defecography imaging , 30 patients (34 %) had an anal canal opening between 0 and 5 seconds, 44 (50 %) between 6 and 10 seconds and 14 patients (16 %) over 10 seconds at defecography imaging. The defecography showed an enterocele in 30 patients (34 %) The enterocele was functional in 25 (28,4 %) and stable in 5 (5,6 %) patients. 53 patients have a II° rectocele (60,2 %) and 35 patients a III° rectocele (39,7 %). The average preoperative ODS score was 14 . The average ODS score revaluated at 1 year was 3.1, 4.3 at 3 years an 6,4 after 5 years. The improvement of the ODS score was lower in the subgroup of patients presenting a slow opening of the anal canal (> 10 sec): 7.5 at one year, 9.1 at 3 years and 11 after 5 years follow-up. Also in the subgroup of patients with stable enterocele (5,6 %) the improvement was less evident: 6.7 at 1 year, 8 at 3 years and 9.7 after 5 years follow-up. DISCUSSION AND CONCLUSION We have observed that a coexistence of a long opening time of the anal canal and / or the presence of a stable enterocele are factors that significantly reduce the effectiveness of the surgery leading over time to ODS score values close to those present before surgery. In the fisrt case we suggest a pre and post-operative perineal physiotherapy, in the second case a Dougla's platsy KEY WORDS: Defecography, Obstructed defecation syndrome, Rectocele, Recto-anal prolapse.
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Chang HH, Lee U, Vu T, Pikov V, Nieto JH, Christe KL, Havton LA. EMG characteristics of the external anal sphincter guarding reflex and effects of a unilateral ventral root avulsion injury in rhesus macaques ( Macaca mulatta). J Neurophysiol 2018; 120:2710-2718. [PMID: 30089020 PMCID: PMC6337026 DOI: 10.1152/jn.00435.2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022] Open
Abstract
The external anal sphincter (EAS) is important for the maintenance of bowel continence and may be compromised by a variety of neuropathic conditions. However, large animal models for the study of EAS functions have been sparse. The EAS guarding reflex was examined by electromyography (EMG) in neurologically intact rhesus macaques ( n = 6) and at 4-6 wk after a unilateral EAS denervation from an L6-S3 ventral root avulsion (VRA) injury ( n = 6). Baseline EAS EMG recordings were quiescent in all subjects, and evoked responses showed an initial large-amplitude EMG activity, which gradually returned to baseline within 1-2 min. At 4-6 wk postoperatively, the EAS guarding reflex showed a significantly reduced EMG response duration of 47 ± 15 s and area under the curve (AUC) of 0.198 ± 0.097 mV·s compared with the corresponding evoked EAS EMG duration of 102 ± 19 s and AUC of 0.803 ± 0.225 mV·s ( P < 0.05) in the control group. Detailed time- and frequency-domain analysis of the evoked EAS EMG responses for the first 40 s showed no difference between groups for the maximum amplitude but a significant decrease for the mean amplitude across the study period and an early AUC reduction for the first 10 s in the VRA injury group. Time-frequency analysis and power spectrum plots indicated decreased intensity and a narrower midrange of frequencies in the VRA injury group. We conclude that the EAS guarding reflex in rhesus macaques shows characteristic EMG features in control subjects and signs of partial target denervation after a unilateral L6-S3 VRA injury. NEW & NOTEWORTHY The external anal sphincter guarding reflex showed initial large-amplitude peaks and a gradual return to a quiescent baseline after a rectal probe stimulus in rhesus macaques. At 4-6 wk after a unilateral ventral root avulsion (VRA) injury, the electromyography duration, mean amplitude, and area under the curve measurements were decreased. Time-frequency analysis and power spectrum plots indicated decreased intensity and a narrowed midrange of frequencies in the VRA injury cohort.
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Affiliation(s)
- Huiyi H Chang
- Department of Urology and Reeve-Irvine Research Center, University of California , Irvine, California
| | - Una Lee
- Section of Urology, Virginia Mason Medical Center , Seattle, Washington
| | - Timothy Vu
- Department of Biochemistry and Molecular Biology, University of Chicago , Chicago, Illinois
| | | | - Jaime H Nieto
- Department of Neurology, David Geffen School of Medicine, University of California , Los Angeles, California
| | - Kari L Christe
- California National Primate Research Center, University of California , Davis, California
| | - Leif A Havton
- Department of Neurology, David Geffen School of Medicine, University of California , Los Angeles, California
- Department of Neurobiology, David Geffen School of Medicine, University of Los Angeles, California
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Fukui Y, Kuroyanagi H, Toda S, Tomizawa K, Hanaoka Y, Matoba S. Laparoscopic intersphincteric resection of rectal cancer with posterior vaginal wall excision without hysterectomy. Tech Coloproctol 2018; 22:719-724. [PMID: 30324408 DOI: 10.1007/s10151-018-1865-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/05/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Y Fukui
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - H Kuroyanagi
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - S Toda
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - K Tomizawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Y Hanaoka
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - S Matoba
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
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Birsen O, Ozban AS, Ozban M, Kuzu MA. Effects of abdominal and vaginal hysterectomy on anorectal functions along with quality of life of the patient. Afr Health Sci 2018; 18:612-622. [PMID: 30602994 PMCID: PMC6307020 DOI: 10.4314/ahs.v18i3.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives and background Hysterectomy is the most commonly performed major gynecological operation for both benign and malign gynecologic conditions. After hysterectomy, although some investigators have declared an increased incidence of urinary and anorectal dysfunction, some others could not show any connection. Methods The voluntary patients were divided in two groups: abdominal hysterectomy (Group 1) and vaginal hysterectomy (Group 2). Anal manometry and all the other examinations of the patients were performed at the Department of General Surgery Endoscopy Unit of Ankara University, Faculty of Medicine. Results When the quality of life of the patients was assessed before the operation and on the 12th post-operative month via the SF-36 form; it can be seen that body pain parameters of the patients in Group 1 had significantly improved and there is no statistical difference in other parameters. When the effect of hysterectomy on the quality of life of the patients was evaluated by the “Cleveland Clinic Global Quality of Life” form, the statistically significant improvement in the quality of life of the patients in Group 2 was observed. Conclusion If the type of operation (vaginal or abdominal) is performed due to benign causes, it does not affect the urinary and anorectal functions of the patients. Depending on the decrease of complaints of the patients, it has a positive effect on the quality of life.
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Affiliation(s)
- Onur Birsen
- Pamukkale University School of Medicine, Department of Surgery
| | - Ayse Secil Ozban
- The Private Health Hospital, Department of Obstetrics and Gynecology
| | - Murat Ozban
- Pamukkale University School of Medicine, Department of Surgery
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Abstract
Anorectal disorders are common and present with overlapping symptoms. They include several disorders with both structural and functional dysfunction(s). Because symptoms alone are poor predictors of the underlying pathophysiology, a diagnosis should only be made after evaluating symptoms and physiologic and structural abnormalities. A detailed history, a thorough physical and digital rectal examination and a systematic evaluation with high resolution and/or high definition three-dimensional (3D) anorectal manometry, 3D anal ultrasonography, magnetic resonance defecography and neurophysiology tests are essential to correctly identify these conditions. These physiological and imaging tests play a key role in facilitating a precise diagnosis and in providing a better understanding of the pathophysiology and functional anatomy. In turn, this leads to better and more comprehensive management using medical, behavioral and surgical approaches. For example, patients presenting with difficult defecation may demonstrate dyssynergic defecation and will benefit from biofeedback therapy before considering surgical treatment of coexisting anomalies such as rectoceles or intussusception. Similarly, patients with significant rectal prolapse and pelvic floor dysfunction or patients with complex enteroceles and pelvic organ prolapse may benefit from combined behavioral and surgical approaches, including an open, laparoscopic, transabdominal or transanal, and/or robotic-assisted surgery. Here, we provide an update on the pathophysiology, diagnosis, and management of selected common anorectal disorders.
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Affiliation(s)
- Tanisa Patcharatrakul
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA,
USA
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok,
Thailand
| | - Satish S.C. Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA,
USA
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Rottoli M, Vallicelli C, Gionchetti P, Rizzello F, Boschi L, Poggioli G. Transabdominal salvage surgery after pouch failure in a tertiary center: A case-matched study. Dig Liver Dis 2018; 50:446-451. [PMID: 29208550 DOI: 10.1016/j.dld.2017.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/15/2017] [Accepted: 11/19/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Salvage surgery after failure of ileal pouch-anal anastomosis (IPAA) could be offered to selected patients. However, the results vary widely in different centers. AIMS To assess the outcomes of salvage surgery by comparison with a control group matched for confounding variables. METHODS From a prospective database of 1286 IPAA, patients undergoing transabdominal salvage surgery were compared for perioperative and functional outcomes and quality of life (QOL) to a 1:3 control group of primary IPAA cases. RESULTS Salvage surgery patients (30) had a higher rate of hand-sewn anastomoses (80 vs 20%, p <0.0001) and reoperations (10 vs 2.2%, p 0.02) than control group (90). A higher number of daytime and nighttime bowel movements (7.4 vs 4.1, p <0.0001, and 2.6 vs 1.8, p=0.002), a lower median CGQL score (0.7 vs 0.8, p=0.0001) and a higher rate of pouch fistulae (13.3 vs 1.1%, p=0.003) were reported after salvage surgery. Pouch failure rate after salvage surgery was 10.1%, 18.7% and 26.8% at 1, 5 and 10 years (vs 0%, 3.5% and 8.4% in control group, p=0.0085). CONCLUSIONS Although worse functional outcomes and decreased QOL have to be expected, salvage surgery after pouch failure is associated with acceptable outcomes when performed in a referral center.
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Affiliation(s)
- Matteo Rottoli
- Surgery of the Alimentary Tract - Digestive Disease Department, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Carlo Vallicelli
- Surgery of the Alimentary Tract - Digestive Disease Department, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Paolo Gionchetti
- Intestinal Chronic Bowel Disease Unit - Digestive Disease Department, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Fernando Rizzello
- Intestinal Chronic Bowel Disease Unit - Digestive Disease Department, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Luca Boschi
- Surgery of the Alimentary Tract - Digestive Disease Department, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract - Digestive Disease Department, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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de Araujo CC, Coelho SA, Stahlschmidt P, Juliato CRT. Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review. Int Urogynecol J 2018; 29:639-645. [PMID: 29564512 DOI: 10.1007/s00192-018-3609-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/16/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound. METHODS This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders. RESULTS The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle. CONCLUSIONS Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.
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Affiliation(s)
- Camila Carvalho de Araujo
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil.
| | - Suelene A Coelho
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil
| | - Paulo Stahlschmidt
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil
| | - Cassia R T Juliato
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil
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Joshi A. Anorectal Gastrointestinal Stromal Tumour: A Case Treated with Radical Surgery. J Nepal Health Res Counc 2018; 16:99-101. [PMID: 29717299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 06/08/2023]
Abstract
Gastrointestinal Stromal Tumour involving rectum and anal canal is an extremely rare entity. This is a case report of a 47 years lady presented with fresh rectal bleed associated with rectal pain and foul smelling rectal mucus discharge. On rectal examination, she had a firm mass palpable about 1.5 cm from anal verge. Considering the size of the tumour and its close proximity with cervix and involvement of levator muscles, extralevator abdominal perineal excision of rectum was undertaken with good recovery after surgery. It was followed by imatinib therapy.
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Affiliation(s)
- Arbin Joshi
- Phect Nepal, Kirtipur Hospital, Kirtipur, Kathmandu, Nepal
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50
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Abstract
The effect of unprocessed bran in a dose of 5 g three times daily and a dose of 2.5 g three times daily for one year on the recurrence rate of anal fissures was studied in a double-blind, placebo-controlled trial in 90 patients with recently healed acute posterior anal fissures. Fifteen patients (16.6%) were withdrawn before the code was broken due to failure to follow the trial protocol for various reasons. Significantly fewer recurrences occurred in patients receiving bran 5 g throe times daily (recurrence rate 16%, 95% confidence limits, 4.54 to 36.08) when compared with patients receiving bran 2.5 g three times daily (60%; 38.67 to 78.87) ( P<0.01) and with patients receiving placebo three times daily (68%; 46.50 to 85.05) ( P<0.01). No significant difference in recurrences was found between patients on bran 2.5 g and those on placebo.
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