3D High-resolution Anorectal Manometry Research Articles

Study on 3D High-Resolution Anorectal Manometry Interrater Agreement in the Evaluation of Dyssynergic Defecation Disorders.

Anorectal manometry measurements exhibit significant interrater variability. Newer techniques like 3D high-resolution anorectal manometry (3D-HRAM) have the potential to enhance diagnostic accuracy and our understanding of defecation disorders. However, the extent of interrater variability in 3D-HRAM is still unknown. Between January 2020 to April 2022, patients referred for pelvic floor physical therapy (PFPT) due to functional defecation complaints underwent 3D-HRAM testing. In a retrospective analysis, three expert raters independently evaluated the 3D-HRAM results in a blinded matter to assess interrater agreement. The evaluation also determined the level of agreement concerning dyssynergic patterns during simulated defecation. The 3D-HRAM results of 50 patients (37 females) were included. Twenty-nine patients had complaints of fecal incontinence, eleven patients had chronic constipation, and ten patients had several other complaints. There was a substantial agreement (kappa 0.612) between the raters concerning the 3D images on dyssynergic patterns during simulated defecation. Our study emphasizes the need for standardized guidelines in evaluating 3D-HRAM test results to reduce subjectivity and further improve agreement among raters. Implementing these guidelines could improve diagnostic consistency and enhance personalized treatment strategies, increasing the reliability and usefulness of 3D-HRAM testing in clinical practice.

To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound

BackgroundAnorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests.MethodsBetween January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG).ResultsA total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively.ConclusionDRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution.What does this paper add to the literature?Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.

Role of 3D high resolution anorectal manometry compared to conventional technique in management of constipation and fecal incontinence in children

BackgroundAnorectal manometry is a valuable tool for objective assessment of motility motor and sensory function of the anorectum. The aim of this study was to investigate role of water-perfused (WP) three dimensional high-resolution anorectal manometry (3D-HRARM) compared to WP conventional manometry (CM) in the management of chronic idiopathic constipation (CIC) and faecal incontinence (FI) in children. MethodsThis was a retrospective review of 122 consecutive children, who had WP 8-channel CM or 24 channel 3D-HRARM and endosonography under ketamine anaesthesia from September 2012 to February 2019. All patients had a validated symptom severity score questionnaire ranging from 0 (best) to 65 (worst). Mann-Whitney-U test and Spearman rank test were used and p<0.05 was considered significant. ResultsSubjects were divided according to investigation: CM group (n = 75) and 3D-HRAM (n = 47), who were otherwise comparable. Median anal resting pressure was 50 mmHg and rectoanal inhibitory reflex (RAIR) threshold volume was 10mls across the entire cohort. There were no significant differences in resting pressure or RAIR threshold when using conventional or 3D-HRARM. Rectal capacity was significantly higher in the CM group (p = 0.002). Rectal capacity and internal anal sphincter (IAS) thickness positively correlated with symptom severity, duration and patient age. 3D-HRARM provided a more detailed depiction of the anorectal pressure profile. Botulinum toxin was injected into the external anal sphincter (EAS) muscle (n = 75, 61%) and an anterograde colonic enema (ACE) stoma was needed subsequently in 19 (16%) to treat recurrent constipation and soiling symptoms. Rectal biopsy was done in 43(35%) patients, if RAIR was absent or inconclusive. ConclusionCM and 3D-HRARM are comparable in terms of resting pressure and RAIR threshold. 3D-HRAM is safe and provides detailed functional morphology of anal sphincters and it is useful to understand underlying pathophysiology of constipation and faecal incontinence in children and plan further treatment. Level of EvidenceLevel I

Three-dimensional high-resolution anorectal manometry in functional anorectal disorders: results from a large observational cohort study.

The aim of the study was to describe the results of 3D high-resolution anorectal manometry (3DHRAM) in a large cohort of patients with functional anorectal disorders. In this single-center retrospective study, all consecutive patients referred for investigation of fecal incontinence (FI) or dyssynergic defecation (DD) underwent 3DHRAM. The parameters analyzed were usual manometric data, repartition of dyssynergic patterns, and the prevalence of a new "muscular subtype classification" underlying dyssynergia, anal sphincter defects, and pelvic floor disorders. Final analyses were performed in 1477 patients with a mean age 54 ± 16years; 825 patients suffered from DD, and 652 patients suffered from FI. Among these patients, 86% met the diagnostic criteria for dyssynergia. Type II dyssynergia was the most frequently observed (56%) in women and men suffering from FI and in women with DD. Type I was the most frequently observed in men with DD (49%). Regarding the muscle type subgroups, combined puborectalis muscle involvement with an external anal sphincter profile was the most frequently observed. The global prevalence of rectal intussusception and excessive perineal descent were 12% and 21%, respectively. Type III dyssynergia was more frequently associated with pelvic floor disorders than were other types of dyssynergia (p < 0.001). This large cohort study provides reference values for 3DHRAM in patients with functional anorectal disorders. Further studies are necessary to assess the prevalence of pelvic floor disorders in healthy volunteers and to develop new scores and classifications including all of these new parameters.

Su1617 - 3D High-Resolution Anorectal Manometry Correlates with Magnetic Resonance Defecography in Detection of Clinically Relevant Rectoceles

Su1617 - 3D High-Resolution Anorectal Manometry Correlates with Magnetic Resonance Defecography in Detection of Clinically Relevant Rectoceles

3D high-resolution anorectal manometry in patients with perianal fistulas: comparison with 3D-anal ultrasound

BackgroundPerianal fistula surgery can damage the anal sphincters which may cause faecal incontinence. By measuring regional pressures, 3D-HRAM potentially provides better guidance for surgical strategy in patients with perianal fistulas. The aim was to measure regional anal pressures with 3D-HRAM and to compare these with 3D-EUS findings in patients with perianal fistulas.MethodsConsecutive patients with active perianal fistulas who underwent both 3D-EUS and 3D-HRAM at a clinic specialised in proctology were included. A group of 30 patients without fistulas served as controls. Data regarding demographics, complaints, previous perianal surgical procedures and obstetric history were collected. The mean and regional anal pressures were measured with 3D-HRAM. Fistula tract areas detected with 3D-EUS were analysed with 3D-HRAM by visual coding and the regional pressures of the corresponding and surrounding area of the fistula tract areas were measured. The study was granted by the VUmc Medical Ethical Committee.ResultsForty patients (21 males, mean age 47) were included. Four patients had a primary fistula, 19 were previously treated with a seton/abscess drainage and 17 had a recurrence after previously performed fistula surgery. On 3D-HRAM, 24 (60%) fistula tract areas were good and 8 (20%) moderately visible. All but 7 (18%) patients had normal mean resting pressures. The mean resting pressure of the fistula tract area was significantly lower compared to the surrounding area (47 vs. 76 mmHg; p < 0.0001). Only 2 (5%) patients had a regional mean resting pressure < 10 mmHg of the fistula tract area. Using a Δ mean resting pressure ≥ 30 mmHg difference between fistula tract area and non-fistula tract area as alternative cut-off, 21 (53%) patients were identified. In 6 patients 3D-HRAM was repeated after surgery: a local pressure drop was detected in one patient after fistulotomy with increased complaints of faecal incontinence.ConclusionsProfound local anal pressure drops are found in the fistula tract areas in patients normal mean resting pressures. Fistulotomy may affect local sphincter pressure. This might influence surgical decision making in future.

Role of Menopausal Status in Dyssynergic Defecation Diagnosed by 3D High-Resolution Anorectal Manometry

Introduction: Dyssynergic Defecation (DD) is the most common cause of constipation in tertiary referral centers and is predominantly found in women. Previous studies have established a positive association between age and DD. While lack of estrogen has been implicated in pelvic floor weakness, it has rarely been studied in relation to DD. In addition, no study has used 3D High Resolution Anorectal Manometry (3D-HRARM) to decipher if a relationship exists between women with a confirmed diagnosis of PFD and menopausal status. Methods: A retrospective review of all (3D-HRARM) was performed at the Drexel University College of Medicine Gastroenterology Motility Center between January 2015 and August 2016. Background data on female patients was collected as well as risk factors for DD including: surgical history, obstetric history, menopausal status, hormone replacement, birth control, history of episiotomies, and history of abuse. Results: Of the 3D-HRARMs completed, 88%(157/179) were female and 91%(143/157) of the females had an abnormal 3D-HRAM. The subset of abnormal 3D-HRAMs with pelvic floor dysfunction (PFD) was 62% (97/157). These women were further subdivided into Type -1(35%;34/97), -2(9%;9/97), -3(31%;30/97), and -4(25%;24/97). Fifty percent (55/109) were postmenopausal. Systemic or local hormone use in postmenopausal women was clearly documented in 20%(11/55) and 7%(4/55) respectively. When comparing women with PFD and without PFD, there was a significant difference noted in age (49 vs 44, p Conclusion: This is the first study to specifically evaluate the relationship between women with a diagnosis of PFD by 3D-HRARM and menopausal status. We raise the possibility that menopausal status in addition to traditionally taught risk factors, is integrally involved in the development of PFD. The lack of correlation between PFD and hormonal replacement in postmenopausal women may be secondary to our small numbers; however, we strongly suggest that post-menopausal women with symptoms of DD be referred for anorectal physiologic studies.

Three-Dimensional Anorectal Manometry Enhances Diagnostic Gain by Detecting Sphincter Defects and Puborectalis Pressure.

Constipation and fecal incontinence (FI) are common and are often evaluated with anorectal manometry. Three-dimensional high-resolution anorectal manometry (HRAM) is a promising technology; however, implementation has been limited by lack of metrics and unclear clinical utility. To investigate the diagnostic utility of 3D HRAM compared to 2D HRAM. Three-dimensional HRAM studies performed from April 2012 to October 2013 were identified and re-interpreted by two blinded investigators examining 3D function. Disagreements were resolved by a third investigator. Puborectalis (PR) visualization, focal defects, and dyssynergy were reported. Differences between groups were analyzed with Fisher's exact test. Discordance was analyzed with McNemar Chi-square test. Two hundred and twenty-one 3D HRAM studies were identified. Mean age and BMI were 52.2±17.4 and 27.1±7.5years (81% female, 74% white). Most common indications for 3D HRAM were constipation (65%) and FI (28%). PR function was visualized in 81% (rest), 97% (squeeze), and 73% (strain). PR was visualized less often at rest in FI than constipation (68 vs. 85%, p=0.007). Defects were identified twice as often in FI than constipation (19 vs. 10%, p=0.113). Twenty-nine defects (86% anterior) were visualized on 3D HRAM. Inter-reader agreement was moderate for PR function (κ=0.471), but fair for focal defects (κ=0.304). PR function and focal defects can be visualized on 3D-HRAM with added diagnostic benefit compared to 2D. Fair inter-reader agreement for focal defects highlights the need for quantitative metrics.

Gender differences in chronic constipation on anorectal motility.

The epidemiology of chronic constipation (CC) skews toward female predominance, yet men make up an important component of those suffering from CC. We sought to determine whether there are sex-specific differences in symptoms and physiologic parameters on anorectal manometry (ARM). We performed a case-control analysis of sequential men and age-matched women (2:1 ratio) presenting for ARM as part of the evaluation of CC. We collected physiologic parameters derived from 3D high-resolution ARM in addition to the ROME III constipation module and the Pelvic Floor Distress Inventory 20 (PFDI-20) questionnaires. We analyzed univariate, sex-specific differences in ARM physiologic parameters and PFDI-20 parameters and adjusted for putative confounders using multivariate logistic regression. Our study enrolled 80 men and 165 age-matched women. Men had a higher median sphincter resting pressure (81.2 vs 75.2mm Hg, P=.01) and mean squeeze pressure (257.0 vs 170.5mm Hg, P<.0001) than women. Although men reported significantly less severe straining and incomplete evacuation, they had greater mean rectoanal pressure differential (-106.7 vs -71.1mm Hg, P<.0001), smaller mean defecation index (0.17 vs 0.27, P=.03) and higher volume threshold for urgency (115.2 v. 103.4mL, P=.03). However, women were more likely to have abnormal balloon expulsion time (BET) than men (52.7% vs 35.0%, P=.01). After multivariate analysis, male gender was the only independent predictor of a normal BET (OR: 0.48, 95% CI: 0.27-0.86, P=.01). Men and women with CC differ with regard to symptom severity and physiologic parameters derived from ARM suggesting differences in their pathophysiology.

Sa1372 Can 3D High Resolution Anorectal Manometry Detect Anal Sphincter Defects in Patients With Fecal Incontinence?

Sa1372 Can 3D High Resolution Anorectal Manometry Detect Anal Sphincter Defects in Patients With Fecal Incontinence?