Rectal Capacity Research Articles

Comparative analysis of the characteristics of high-resolution anorectal manometry in children with outlet obstructive constipation of different age groups

Objective: To compare the characteristics of high-resolution anorectal manometry (HR-ARM) in children with outlet obstructive constipation (OOC) in different age groups. Methods: Retrospective inclusion of clinical data of functional constipation (FC) patients who underwent HR-ARM examination in the Department of Gastroenterology of Children's Hospital Affiliated of Zhengzhou University from January 2019 to September 2023 was conducted. The patients were divided into low age group (4 years old≤age<6 years) and high age group (6 years old≤age≤15 years old) according to age. They were divided into OOC group (the pediatric patients with uncoordinated pelvic floor muscle contractions, insufficient rectal thrust during defecation, or insufficient relaxation of anal sphincter muscles during contraction) and non-OOC group based on HR-ARM results. The rectal motility [rectal resting pressure, maximum squeeze pressure (MSP), rectal pressure during force delivery, residual anal pressure, rectal anal pressure gradient], rectal sensory function (initial rectal sensory capacity threshold, initial fecal sensory capacity threshold, defecation distress capacity threshold, and maximum tolerance capacity threshold) and other indicators were compared between OOC group and non-OOC group in 2 age groups, respectively. Results: A total of 228 children with FC were included, including 146 males and 82 females, with an age [M (Q1, Q3)] of 7.5 (6.0, 9.7) years, including 54 in the low age group and 174 in the high age group. There were 131 cases in the OOC group and 97 cases in the non-OOC group. Compared with non OOC children (24 cases), there were no statistically significant differences in rectal resting pressure, anal sphincter resting pressure, MSP, rectal pressure during force delivery, initial rectal sensory capacity threshold, initial fecal sensory capacity threshold, defecation distress capacity threshold, and maximum tolerance capacity threshold among OOC children (30 cases) in the low age group (all P>0.05). In the high age group, the residual anal pressure of the OOC children (101 cases) was higher than that of the non-OOC children (73 cases) [102 (70, 113) vs 41 (24, 58) mmHg (1 mmHg=0.133 kPa), P<0.001], and the rectal anal pressure gradient was lower than that of the non-OOC children [-43 (-55, -23) vs 16 (9, 29) mmHg, P<0.001];The initial fecal sensory capacity threshold of the OOC children was higher than that of the non-OOC children [90 (54, 110) vs 60 (50, 91) ml, P=0.024]. Conclusions: Compared with non-OOC children in the same age group, OOC children aged 6 years and above have higher residual anal pressure and initial fecal sensory capacity threshold, and lower rectal anal pressure gradient. There is no statistically significant differences in the rectal sensory function in children under 6 years old with OOC.

Constipated patients with functional defecatory disorder have secondary rectal hyposensitivity due to altered rectal biomechanics.

Rectal hyposensitivity (RH) is common in constipation and often coexists with functional defecatory disorder (FDD). Rectal sensory thresholds are routinely evaluated with the anorectal manometry probe; however, the gold standard for the assessment of rectal sensitivity is with a barostat, use of which is limited by time constraints and availability. A novel rapid barostat bag (RBB) may facilitate measurements of rectal sensitivity. The aim is to evaluate the relationship between RH (measured by the RBB) and FDD (defined as any minor disorder of rectoanal coordination by the London classification) in constipated patients. Consecutive constipated patients referred for anorectal function testing underwent anorectal manometry with the 3D-HDAM probe as well as rectal sensation testing with the RBB pump. RH was defined by volume to first sensation >30%, urge to defecate >80%, or discomfort >100% (normalized to rectal capacity). Fifty-three percent of constipated patients had RH. Patients with FDD had a significantly increased volume to first sensation (134.5mL vs 102.0, P=0.02), urge to defecate (187.0mL vs 149.0, P=0.04), and rectal capacity (253.5mL vs 209.0, P=0.04) compared to constipated patients without FDD. There was no difference in normalized sensory thresholds (percent of rectal capacity) nor the prevalence of hyposensitivity to each sensory threshold nor overall hyposensitivity. Patients with FDD, when measured with the RBB, have increased sensory thresholds on volumetric distension, but RH was not observed when sensory threshold volume were normalized to rectal capacity. This may reflect "secondary" RH due to altered rectal biomechanics.

Anorectal Function and Clinical Characteristics Associated with Faecal Incontinence in Patients with Crohn's Disease.

Faecal incontinence is an important complaint reported by patients with Crohn's disease [CD] and it is associated with several disease-related mechanisms, including anorectal functional disorders. This study aimed to assess the anorectal function and clinical characteristics to identify parameters associated with faecal incontinence in CD patients. This is a cross-sectional study of 104 patients with CD, aged 18 years or older, from a referral centre between August 2019 and May 2021. Patients responded to a specific questionnaire, and underwent medical record review, proctological examination and anorectal functional assessment with anorectal manometry. Of the 104 patients, 49% were incontinent. Patients with incontinence had a lower mean resting pressure [43.5 vs 53.1 mmHg; p = 0.038], lower mean squeeze pressure [62.1 vs 94.1 mmHg; p = 0.036] and lower maximum rectal capacity [140 vs 180 mL; p < 0.001]. Faecal incontinence was also associated with disease activity [p < 0.001], loose stools [p = 0.02], perianal disease [p = 0.006], previous anoperineal surgery [p = 0.048] and number of anorectal surgeries [p = 0.036]. This is the largest reported study describing manometric findings of Crohn's disease patients with and without faecal incontinence. Our results identified an association between faecal incontinence and functional disorders, in addition to clinical features in these patients. Functional assessment with anorectal manometry may help choose the best treatment for faecal incontinence in patients with CD.

Effects of PAR2 Gene Knockout on Visceral Sensitivity, Stress Behaviors, and Colonic Electrical Activities in Irritable Bowel Syndrome.

Irritable bowel syndrome (IBS) could seriously affect the patient's health quality by its recurrence. There is a great medical and social need to explore the mechanisms and new treatment strategies of IBS. To explore the influence of protease-activated receptor 2 (PAR2) gene knockout on IBS visceral sensitivity, stress behaviors, and colonic electrical activities. The PAR2 gene knockout and IBS model rats were generated and divided into PAR2+/+ wild control (WC) group, PAR2+/+ wild IBS model (WM) group, PAR2-/- knockout control (KC) group and PAR2-/- knockout IBS model (KM) group. The stress behaviors scores, minimum rectal fluid injection capacity threshold value of abdominal withdrawal reflex (AWR) = 3, and the colonic electrical activities indexes were recorded and the experimental results were analyzed statistically. (1) PAR2 gene deletion and IBS models were successfully generated. (2) The scores of aggressive and exploratory behaviors in WM and KM groups were higher than WC and KC groups (p < 0.05). The grooming behavior scores in WC and KC groups were higher than the WM and KM groups (p < 0.05). WM group had the highest aggressive and exploratory behavior scores; WC group had the highest grooming behavior scores. (3) The minimum rectal fluid injection capacity threshold value of AWR = 3 in WM and KM groups were lower than WC and KC groups (p < 0.05); WM group had the lowest value. (4) The maximum amplitude and wave frequency of colonic fast and slow waves in WM and WC groups were greater than in the KM and KC groups, respectively (p < 0.05). The amplitude index and number of colonic contraction waves in WM and KM groups were greater than the WC and KC groups (p < 0.05). Colonic electrical activity indexes were highest in the WM group. The PAR2 gene deletion could have a beneficial effect on visceral sensitivity, stress behaviors and colonic electrical activities in rats with IBS.

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

S2466 Pelvic Floor Dysfunction as a Cause of Chronic Intestinal Pseudo Obstruction

Introduction: Chronic intestinal pseudo-obstruction (CIPO) is a rare motility disorder with a variety of secondary causes, including genetics, metabolic disease, paraneoplastic syndromes, inflammatory disorders, and neurologic disorders. We present a case of CIPO secondary to pelvic floor dyssynergia. Case Description/Methods: A 64 year-old male with a past medical history of hypertension, atrial tachycardia, and heavy alcohol use was referred for further GI workup by his primary care physician following a 5 month history of worsening constipation after a viral infection. Prior to the infection, he had a bowel movement 2-3 times per week. However, he now describes one Bristol 4 or 7 bowel movement with straining per month. Symptoms were refractory to Dulcolax and Colace. Initial workup included a normal extended electrolyte panel, normal TSH, and negative Celiac disease serologies. A CT abdomen and pelvis revealed extensive dilation of proximal colon, compression of descending and sigmoid colon, and small bowel fecalization. A representative coronal image is shown in Figure 1. Subsequent colonoscopy did not reveal any evidence of obstruction. Anorectal manometry (ARM) findings included elevated resting pressure (74.94 mmHg), decreased sensation, paradoxical contraction with Valsalva, and inability to pass the balloon catheter after 2.5 minutes. Normal rectal capacity (280 mL) and excellent squeeze pressure but paradoxical contraction with Valsalva is consistent with pelvic floor dyssynergia. Biofeedback therapy was recommended. Discussion: Evaluating for secondary causes of CIPO (i.e., obstruction, metabolic disturbances, autoimmune disorders, neurologic disorders, and musculoskeletal disorders) is an important diagnostic step. Key tests include imaging, colonoscopy, electrolytes and autoimmune panels, and anorectal manometry. This case highlights long-standing pelvic floor dyssynergia as an underlying cause of CIPO.Figure 1.: CT abdomen and pelvis with extensive dilation of proximal colon and small bowel fecalization.

Disorders of anorectal motility: Functional defecation disorders and fecal incontinence.

Functional defecation disorders (FDDs) and fecal incontinence (FI) are common anorectal disorders often distressing and significantly add to the healthcare burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathophysiology and can pose significant management dilemmas. A detailed history, stool diaries and visual scales of stool form, a careful digital rectal examination are needed to guide anorectal physiology tests. With high-resolution (3-D) anorectal manometry, anal ultrasonography, (magnetic resonance) defecography and imaging, and neurophysiological tests, it is possible to define and characterize the underlying structural and functional abnormalities more accurately. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of FDDS, fecal incontinence and abnormalities of rectal capacity (i.e., megarectum, microrectum).

Assessment of defecation function after sphincter-saving resection for mid to low rectal cancer: A cross-sectional study.

Patients with mid-to low-rectal cancer can have various dysfunctions of defecation after sphincter-saving resection. Defecation dysfunction can manifest as incontinence, urgency, or frequent bowel movements, and is called low anterior resection syndrome (LARS). This study aimed to examine LARS score and objective anorectal function indices in Chinese patients receiving sphincter-saving surgery for mid-to low-rectal cancer. This was a single-center cross-sectional study of patients undergoing sphincter-saving resection for low- or mid-rectal cancer and had restoration of trans-anal defecation for at least 1 month seen between January 2019 and June 2020. Patients completed a questionnaire regarding clinical characteristics, and Low Anterior Resection Syndrome (LARS) score and high-resolution anorectal manometry (HR-ARM) were used to assess defecation function. Multivariable analysis was used to identify variables significantly associated with defecation dysfunction. 146 patients completed and returned the questionnaires. 25 healthy adults also participated as control group for the anorectal manometry. Approximately 76% of patients developed LARS after surgery, of which 35.6% had major LARS. In these patients, anorectal manometry indices including initial rectal sensory capacity and rectal fecal sensory capacity, were significantly lower than normal. Logistic regression analysis showed that preoperative chemo-radiotherapy and the tumor inferior margins being close to the dentate line, especially 2-5cm, were independent risk factors for defecation dysfunction after surgery. Defecation dysfunction is a frequent occurrence after sphincter-saving resection for mid- and low-rectal cancer. Preoperative chemo-radiotherapy and a shorter tumor inferior margins distance to the dentate line are independent factors for defecation dysfunction.

Long-term anorectal function in rectal cancer patients treated with chemoradiotherapy and endorectal brachytherapy.

The aim was to study anorectal function in long-term survivors after combined, curatively intended, chemoradiotherapy and endorectal brachytherapy for low rectal cancer. This was a case-control design. We compared anorectal function by anal manometry, anal functional lumen imaging probe (EndoFLIP) and rectal bag distension in rectal cancer patients (RCPs) and healthy, normal subjects (NSs). Symptoms were assessed by the low anterior resection syndrome (LARS) and Wexner faecal incontinence scores. Thirteen RCPs (12 men, median age 68years, range 52-92) after 60Gy radiotherapy, 5Gy endorectal brachytherapy and oral tegafur-uracil with complete clinical response (median time since treatment 2.8years, range 2.2-5.6) were compared to 15 NSs (14 men, median age 64years, range 47-75). RCPs had lower than normal anal resting pressure, 38.6 mmHg (range 8.8-67.7) versus 58.8mmHg (25.7-105.2) (P<0.003), and squeeze pressure, 117 mmHg (55.2-203) versus 188mmHg (103-248) (P<0.01). Squeeze-induced pressure increase recorded by EndoFLIP was also lower in RCPs (q>7.56, P<0.001) as was the anal canal resistance to increasing distension (q=3.13, P<0.05). No differences in median rectal volume at first sensation (72 [22-158] vs. 82 [36-190] ml, P=0.4) or at urge to defaecate (107 [42-227] vs. 132 [59-334] ml, P=0.2) were found. However, maximum tolerable rectal volume was lower in RCPs (145 [59-319] vs. 222 [106-447] ml, P<0.02). The median (range) low anterior resection syndrome score was 27 (0-39) for RCPs and 7 (0-23) for NSs (P<0.001), while the Wexner score was 0 (0-5) versus 0 (0-4) (P=0.56). Radiotherapy combined with endorectal brachytherapy for rectal cancer causes long-term anorectal symptoms, impaired anal sphincter function and reduced rectal capacity.

Symptoms affecting quality of life after sphincter-saving rectal cancer surgery: A systematic review.

Rectal cancer is common and is frequently treated with surgery which removes the rectum but retains anal sphincters. After sphincter-saving rectal cancer surgery, which can result in a reduced rectal storage capacity and nerve damage, symptoms frequently occur. A systematic review was undertaken to determine which symptoms occur and their effect on quality of life. Data from questionnaires and interviews were analysed thematically. Fourteen heterogeneous studies were identified reporting both qualitative and quantitative data on over 1700 individuals. The most commonly reported symptoms related to bowel changes. The most problematic changes were bowel and sexual dysfunction. Quality of life was most affected by an inability to function as individuals desired, specifically in their chosen role and socially. Quality of life improved as time progressed or symptoms resolved; but symptoms could persist for many years. After sphincter-saving rectal cancer surgery quality of life is affected by symptoms such as bowel dysfunction. Healthcare professionals need to gain a better understanding of which symptoms most bother individuals to enable patient-focussed interventions to be planned and improve quality of life.

P063 Manometric Study and the Role of the Perianal Disease and the Clinical Activity in Anorectal Dysfunction in Crohn's Disease.

BACKGROUND: Although Crohn's disease frequently affects the perianal region and its function, studies evaluating anorectal function in these patients are rare and with controversial results. The impact of perianal disease on anorectal function complaints is not clear, other factors such as disease activity, stool consistency and decreased rectal capacity may have a more important role in its pathogenesis. Athanasios et al. found no association between the values of resting and squeeze pressure and fecal incontinence in Crohn's disease (CD) patients. According to the authors, this result could be explained by the difference in the pathophysiology of fecal incontinence among patients with inflammatory bowel disease (IBD). The aim of this study is to determine associated manometric factors, the role of perianal disease, disease activity and fecal consistency in anorectal dysfunction in CD patients. METHODS: This is an observational, cross-sectional study. Fifty-six Crohn's disease patient under outpatient follow-up, completed a questionnaire and were submitted to a medical record review, and anorectal manometry. Manometric variables studied: resting and squeeze pressure, anismus, rectoanal inhibitory reflex (RAIR), rectal sensitivity and capacity and proof of balloon expulsion. Functional disorders studied: fecal incontinence and urgency, incomplete/obstructed evacuation and tenesmus. Software R for Windows, version 4.0.2 was used for the statistical analyses. Pearson's χ2 test, Fisher's exact test and T-Student Test for independence was used to study the association between manometric and clinical variables and functional disorders, with P < 0,05. RESULTS: Of the 56 patients evaluated, 53.6% are male, with a mean age of 41.4 years (SD: 12.4). According to the Montreal Classification, most patients have non-penetrating/non-stenosing disease (61.5%). Perianal disease, was present in 44.2% of the patients. Most patients were in remission, according to the Harvey-Bradshaw Index. Among the functional complaints, the most common is fecal incontinence (38%), followed by a sensation of obstructed/incomplete evacuation (36%) and fecal urgency (29%). When patients with anorectal functional complaints (fecal incontinence, incomplete/obstructed evacuation, fecal urgency and tenesmus) were compared with patients without anorectal functional complaints, no statistically significant difference was found in relation to perianal disease. On the other hand, a statistically significant difference was found when we compared the patients with any anorectal functional complaint (fecal incontinence, incomplete/obstructed evacuation, fecal urgency and tenesmus) with the patient without any complaints in relation to activity index of the disease and fecal consistency. CONCLUSION: Our results suggest that functional complaints in patients with Crohn's disease are more related to disease activity and fecal consistency, among other factors, than structural and functional ano-rectal-perineal abnormality, including those caused by perianal involvement of the disease. Therefore, the control of the disease activity probably is critical for the management of this function symptoms.

Cold acclimation preserves hindgut reabsorption capacity at low temperature in a chill-susceptible insect, Locusta migratoria

Cold acclimation increases cold tolerance of chill-susceptible insects and the acclimation response often involves improved organismal ion balance and osmoregulatory function at low temperature. However, the physiological mechanisms underlying plasticity of ion regulatory capacity are largely unresolved. Here we used Ussing chambers to explore the effects of cold exposure on hindgut KCl reabsorption in cold- (11 °C) and warm-acclimated (30 °C) Locusta migratoria. Cooling (from 30 to 10 °C) reduced active reabsorption across recta from warm-acclimated locusts, while recta from cold-acclimated locusts maintained reabsorption at 10 °C. The differences in transport capacity were not linked to major rearrangements of membrane phospholipid profiles. Yet, the stimulatory effect of two signal transduction pathways were altered by temperature and/or acclimation. cAMP-stimulation increased reabsorption in both acclimation groups, with a strong stimulatory effect at 30 °C and a moderate stimulatory effect at 10 °C. cGMP-stimulation also increased reabsorption in both acclimation groups at 30 °C, but their response to cGMP differed at 10 °C. Recta from warm-acclimated locusts, characterised by reduced reabsorption at 10 °C, recovered reabsorption capacity following cGMP-stimulation at 10 °C. In contrast, recta from cold-acclimated locusts, characterised by sustained reabsorption at 10 °C, were unaffected by cGMP-stimulation. Furthermore, cold-exposed recta from warm-acclimated locusts were insensitive to bafilomycin-α1, a V-type H+-ATPase inhibitor, whereas this blocker reduced reabsorption across cold-exposed recta from cold-acclimated animals. In conclusion, bafilomycin-sensitive and cGMP-dependent transport mechanism(s) are likely blocked during cold exposure in warm-acclimated animals while preserved in cold-acclimated animals. These may in part explain the large differences in rectal ion transport capacity between acclimation groups at low temperature.

Early Effects of High-intensity Focused Ultrasound (HIFU) Treatment for Prostate Cancer on Fecal Continence and Anorectal Physiology

To evaluate high-intensity focused ultrasound (HIFU) effects on anorectal physiology and fecal continence or constipation, and on quality of life (QoL). 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. 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). HIFU did not cause significant changes in anorectal physiology. Fecal incontinence or constipation after HIFU was not observed via validated questionnaires.

MAIN MANOMETRIC FINDINGS AND POTENTIAL FOR ANORECTAL PHYSICAL THERAPY IN THE TREATMENT OF PATIENTS WITH EVACUATION DISORDERS.

Evacuation disorders are prevalent in the adult population, and a significant portion of cases may originate from pelvic floor muscle dysfunctions. Anorectal manometry (ARM) is an important diagnostic tool and can guide conservative treatment. To evaluate the prevalence of pelvic dysfunction in patients with evacuation disorders through clinical and manometric findings and to evaluate, using the same findings, whether there are published protocols that could be guided by anorectal manometry. A retrospective analysis of a prospective database of 278 anorectal manometries performed for the investigation of evacuation disorders in patients seen at the anorectal physiology outpatient clinic of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto between January 2015 to June 2019 was conducted. The following parameters were calculated: resting pressure (RP), squeeze pressure (SP), high-pressure zone (HPZ), rectal sensitivity (RS) and rectal capacity (RC). The pressure measurements and manometric plots were reviewed to determine the diagnosis and to propose potential pelvic physical therapy procedures. Analysis of variance (ANOVA) and Fisher's exact test were used to compare the continuous variables and to evaluate the equality of variances between groups of patients with fecal incontinence (FI) and chronic constipation (CC). Results with a significance level lower than 0.05 (P-value <0.05) were considered statistically significant. Statistical analysis was performed using IBM® SPSS® Statistics version 20. The mean age of the sample was 45±22 years, with a predominance of females (64.4%) and economically inactive (72.7%) patients. The indications for exam performance were FI (65.8%) and CC (34.2%). Patients with FI had lower RP (41.9 mmHg x 67.6 mmHg; P<0.001), SP (85.4 mmHg x 116.0 mmHg; P<0.001), HPZ (1.49 cm x 2.42 cm; P<0.001), RS (57.9 mL x 71.5 mL; P=0.044) and RC (146.2 mL x 195.5 mL; P<0.001) compared to those of patients with CC. For patients with FI, the main diagnosis was the absence of a functional anal canal (49.7%). For patients with CC, the main diagnosis was outflow tract obstruction (54.7%). For patients with FI, the main protocol involved a combination of anorectal biofeedback (aBF) with tibial nerve stimulation (TNS) (57.9%). For patients with CC, the most indicated protocol was aBF combined with TNS and rectal balloon training (RBT) (54.7%). There was a high prevalence of pelvic floor changes in patients with evacuation disorders. There was a high potential for performing pelvic floor physical therapy based on the clinical and manometric findings.

Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial.

Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy. Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes. Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted. TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).

Intervention effect of biofeedback combined with pelvic floor muscle exercise on low anterior resection syndrome in patients with low anus-preserving rectal cancer

Objective: To explore the effect of biofeedback training combined with pelvic floor muscle exercise on the recovery of anorectal function in patients with middle and low rectal cancer undergoing sphincter-preserving surgery, and to find the best way to prevent low anterior resection syndrome. Methods: A single-center prospective randomized controlled study was conducted. One hundred and nine patients with mid-low rectal cancer in Sun Yat-sen University Cancer Centre from June 2015 to December 2016 were enrolled in the study, who were going to undergo sphincter-preserving surgery or preventive ostomy after preoperative chemoradiotherapy. They were divided into three groups: blank control group, pelvic floor muscle exercise group and biofeedback training combined with pelvic floor muscle exercise group. Intervention and follow-up were conducted for 16 months. High-resolution anorectal manometry was used to measure the objective anorectal pressure and sensory index of patients, and the Chinese version of MSKCC Intestinal Function Questionnaire was used to evaluate the intestinal function of patients. The differences of objective anorectal manometry index and subjective intestinal function between the three groups were compared, and the occurrence of low anterior rectal resection syndrome was evaluated. Results: At the end of the intervention, the total scores of anal resting pressure, rectal resting pressure, anal maximum systolic pressure, anal maximum systolic time, initial rectal volume, rectal fecal sensory capacity, rectal maximum tolerance capacity, rectal compliance, anorectal hypertensive zone and total score of intestinal function in the biofeedback training combined with pelvic floor muscle exercise group were (44.83±9.01) mmHg, (4.31±1.75) mmHg, (130.46±10.00) mmHg, (19.94±4.30) s, (32.71±5.00) ml, (74.26±8.30) ml, (188.4±12.68) ml, (5.69±1.18) ml/kPa, (3.31±0.96) cm and (68.09±6.38) points respectively. The main effects of the changes of five indices, including anal resting pressure, rectal resting pressure, anal maximum systolic pressure, anal maximum systolic time and anal high pressure zone, were time. Significant differences were found in initial rectal capacity, sensory capacity of rectal defecation, maximum tolerance capacity of rectum, rectal compliance and total score of intestinal function in every time point of measurement in the biofeedback training group combined with pelvic floor muscle exercise group. They were significantly higher than those in the blank control group (P<0.05); the score of the biofeedback training group combined with pelvic floor muscle exercise group at one month after operation, perioperative period and 3 months after operation were significantly higher than those in pelvic floor muscle exercise group (P<0.05). Biofeedback training combined with pelvic floor muscle exercise reduced the incidence of low anterior resection syndrome of rectum (P<0.05). Conclusion: Biofeedback training combined with pelvic floor muscle exercise can significantly improve the sensory indicators of patients with mid-low rectal cancer, promote the recovery of intestinal function, and alleviate low anterior resection syndrome of rectal cancer patients, which is worthy of popularization and application.

Clinical and manometric investigation in constipated Chagasic patients with and without megacolon

BackgroundChagasic colopathy is the second most common digestive manifestation, and constipation is the main symptom. The absence of the Rectoanal Inhibitory Reflex plays an important role in constipation and anal manometry is crucial for appropriate evaluation. PurposeEvaluate anal manometry findings (mainly Rectoanal Inhibitory Reflex) in Chagasic patients with chronic constipation, with and without megacolon and correlate these findings with clinical and demographic data. MethodsCross-sectional study of patients with chronic constipation who underwent Chagasic serologic test, barium enema, and anal manometry. The absence of Rectoanal Inhibitory Reflex was evaluated using the mid-P Exact Test. Results64 Patients were included: 23 Chagasic patients with megacolon/megarectum (G1), 21 Chagasic patients without megacolon/megarectum (G2) and 20 non-Chagasic patients without megacolon/megarectum (G3). Chagasic patients with megacolon had a higher incidence of fecaloma (39%) compared to the other two groups (9.5% and 10% for G2 and G3, respectively, p=0.03). Rectal capacity on manometry was statically higher for G1 patients. Rectoanal Inhibitory Reflex was absent in 91.3% of patients in G1, 47.29% in G2 and present in all patients in G3. There was a significant difference in the absence of the Rectoanal Inhibitory Reflex when comparing the groups (G1 vs. G2: p=0.002, G1 vs. G3: p<0.001, G2 vs. G3: p<0.001). ConclusionThe absence of RAIR confirms the diagnosis of Chagasic colopathy and endorses surgical treatment whenever clinical treatment fails. The presence of the RAIR in patients with positive serology for Chagas disease without megacolon/megarectum might not be due chagasic colopathy and other causes should be considered.

Efficacy of biofeedback therapy for objective improvement of pelvic function in low anterior resection syndrome

PurposeThere is no established treatment of choice for low anterior resection syndrome (LARS). To evaluate the efficacy of biofeedback therapy for objective improvement of pelvic function in LARS, we performed the present study.MethodsThe primary endpoint was the change of Wexner score. Consenting patients between 20 and 80 years old with major LARS at least 2 months after sphincter preserving proctectomy for rectal cancer were enrolled. After recommendation of biofeedback therapy, patients who accept it were enrolled in the biofeedback group and patients who refuse were enrolled in the control group. Initial and follow-up evaluations were performed and analyzed.ResultsFifteen and sixteen patients were evaluated in the control group and the biofeedback group, respectively. There was no statistically significant difference of LARS score between both groups. Decrease in Wexner score and increase in rectal capacity were significantly higher in the biofeedback group (odds ratio [OR], 5.386; 95% confidence interval [CI], 1.194–24.287; P = 0.028 and OR, 1.061; 95% CI, 1.002–1.123; P = 0.042).ConclusionBiofeedback therapy was superior for objective improvement of pelvic function to observation in LARS. It can be considered to induce more rapid improvement of major LARS.

Anorectal dynamics of Bu-Zhong-Yi-Qi decoction with biofeedback therapy for fecal incontinence after anus-preserving surgery in patients with low rectal cancer

Objective To evaluate the effect and mechanism of Bu-Zhong-Yi-Qi decoction with biofeedback therapy on defecation dysfunction after anus-preserving surgery in patients with low rectal cancer through anal defecation function and anorectal dynamic indexes. Methods 120 patients with low rectal cancer preparing for anterior resection were randomized for three groups (45 cases of groups A and B, and 30 cases of group C). Group A was treated with Bu-Zhong-Yi-Qi decoction with biofeedback therapy for 3 months after the operation, group B was only treated with biofeedback, and group C was not given special treatment. Before operation, 2 weeks after operation and 2, 6, 10 and 14 months after intervention, the indexes about the change of defecation function and anorectal dynamics were continuously observed. Results There was no significant difference between group A and group B at 14th month after intervention in anal canal resting pressure (t=1.467, P=0.146), maximum anal canal systolic pressure (t=0.774, P=0.441), rectal threshold sensory capacity (t=1.856, P=0.067), rectal sense of sensory capacity (t=1.498, P=0.138) and rectal maximum tolerance (t=0.893, P=0.374), and those were (47.8±8.3), (188.8±19.2) mmHg (1 mmHg=0.133 kPa), (22.4±4.5), (48.1±9.9), (187.4±25.8) ml in group A. As compared with group C, the resting pressure of anal canal (t=10.018, P=0.000), the maximum systolic pressure of the anal canal (t=15.460, P=0.000) and the maximum rectal tolerance (t=12.835, P=0.000) at 14th month after treatment were significantly increased in group A , while the rectal threshold sensory capacity (t=1.546, P=0.127) and the rectal defecation capacity (t=1.754, P=0.084) showed no statistically significant difference between group A and group C. As compared with group C, the resting pressure of the anal canal (t=9.239, P=0.000), the maximum systolic pressure of the anal canal (t=16.543, P=0.000) and the maximum rectal tolerance (t=11.995, P=0.000) were significantly increased in group B [(45.2±7.6), (185.8±15.8) and (182.4±26.5) mmHg], and the rectal threshold sensory capacity (t=-0.009, P=0.993) and the rectal defecation capacity (t=0.476, P=0.636) showed no statistically significant difference [(20.6±4.4) and (44.9±9.9) ml]. In groups A and B, the number of patients with defecation function in general (6-5 points) and poor (less than 4 points) at 14th month after treatment was significantly increased as compared with that before treatment (χ2=13.105, P=0.000; and χ2=14.419, P=0.000, respectively) and in group C (χ2=15.238, P=0.000; χ2=14.364, P=0.000, respectively). There was no significant difference between group A and group B (χ2=0.025, P=0.874). Conclusion Bu-Zhong-Yi-Qi decoction with biofeedback therapy can effectively treat the defecation dysfunction after anus preserving operation in patients with low rectal cancer, mainly by tonifying Qi, invigorating splenic yang, and accelerating the recovery of anal sphincter function. Key words: Bu-Zhong-Yi-Qi decoction; Biofeedback therapy; Low rectal caicinoma; Fecal incontinence

Continence changes following transanal endoscopic microsurgery result from the impact on rectal capacity: clinical and functional evaluation before and after surgical treatment

IntroductionDescribed in 1983 and with a stable clinical application, the impact of Transanal Endoscopic Microsurgery on anorectal function remains unknown. The objectives of the present study were to evaluate the impact of Transanal Endoscopic Microsurgery on anorectal function according to clinical (Wexner score) and functional (anorectal manometry) evaluations before and after surgery. MethodProspectively, 23 consecutive patients with rectal lesions were operated using TEO® equipment (Karl Storz, Tuttlingen, Germany). For all patients, the value of Wexner score was obtained before and after surgery (7, 30 and 90 days) and anorectal electromanometry was performed before surgery, and also postoperatively (30 and 90 days). ResultsFourteen patients were men. The mean age was 53.7 (24–81) years. The mean distance from the lesion to the pectineal line was 7 (2–15)cm. The histopathologic analysis revealed adenoma in 14 (61%); neuroendocrine tumor in 5 (21.7%); invasive carcinoma in 3 (13%); and hyperplastic polyp in 1 (4.3%) case. The mean duration of postoperative follow-up was 5 (3–7) months. Wexner score was significantly lower at 30 days compared to 7 days (Wilcoxon; p=0.03). Rectal capacity was significantly lower 30 days after surgery and recovered at 90 days of surgery (ANOVA; p=0.04). ConclusionsAfter Transanal Endoscopic Microsurgery, a modest impact on anorectal function can be observed. The transient impairment results from loss of rectal capacity and not from impairment of the anal sphincters, being completely resolved 90 days after surgery.