The digital rectal examination scoring system (DRESS)

Intersphincteric resection for very low rectal cancer: A review of the updated literature

Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.

Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult

In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.

Transanal total mesorectal excision for restorative coloproctectomy in an obese high-risk patient with colitis-associated carcinoma

Transanal total mesorectal excision (TaTME) offers great potential for the treatment of malign and benign diseases. However, laparoscopic-assisted TaTME in ulcerative colitis has not been described in more than a handful of patients. We present a 47-year-old highly comorbid female patient with an ulcerative colitis-associated carcinoma of the ascending colon and steroid- refractory pancolitis. A two-stage restorative coloproctectomy including right-sided complete mesocolic excision was conducted. The second step consisted of a successful nerve-sparing TaTME and a handsewn ileal pouch-anal anastomosis. TaTME may extend the possible treatment options in inflammatory bowel disease, especially for high-risk patients.

[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]

In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.

Functional Disorders of Constipation: Paradoxical Puborectalis Contraction and Increased Perineal Descent

Paradoxical puborectalis contraction (PPC) and increased perineal descent (IPD) are subclasses of obstructive defecation. Often these conditions coexist, which can make the evaluation, workup, and treatment difficult. After a thorough history and examination, workup begins with utilization of proven diagnostic modalities such as cinedefecography and anal manometry. Advancements in technology have increased the surgeon's diagnostic armamentarium. Biofeedback and pelvic floor therapy have proven efficacy for both conditions as first-line treatment. In circumstances where PPC is refractory to biofeedback therapy, botulinum toxin injection is recommended. Historically, pelvic floor repair has been met with suboptimal results. In IPD, surgical therapy now is directed toward the potentially attendant abnormalities such as rectoanal intussusception and rectal prolapse. When these associated abnormalities are not present, an ostomy should be considered in patients with IPD as well as medically refractory PPC.

[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]

In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.

Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests?

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and time-consuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests of DD. Methods. We performed a systematic search in PUBMED and MEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (I2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to perform better when a cut-off time of 2 minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.

Electrophysiology-based quality assurance of nerve-sparing in laparoscopic rectal cancer surgery: Is it worth the effort?

BACKGROUND

After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique.

METHODS

We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery.

RESULTS

One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %.

CONCLUSIONS

LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.

The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence

OBJECTIVES

Digital rectal examination (DRE) is a simple clinical method to diagnose anorectal disorders. High-resolution antorectal manometry (HRAM) based on a spatiotemporal plot is expected to promote improved diagnostic accuracy. However, there are no reports comparing the effectiveness of DRE and HRAM. The aim of our study was therefore to evaluate the diagnostic value of DRE compared with HRAM.

METHODS

A total of 309 consecutive patients with chronic constipation (n=268) or fecal incontinence (n=41) who underwent a standardized DRE, HRAM, and balloon expulsion test were enrolled in this study. The diagnostic yield of DRE compared with HRAM was determined, and agreement between DRE and HRAM data was evaluated.

RESULTS

Of the constipated patients, 207 (77.2%) were diagnosed with dyssynergia using HRAM. The sensitivity, specificity, and positive predictive value of DRE in the diagnosis of dyssynergia were 93.2%, 58.7%, and 91.0%, respectively, and moderate agreement was seen between the two modalities (κ-coefficient =0.542, P<0.001). In patients with fecal incontinence, there was moderate agreement in terms of anal squeeze pressure between the two modalities (κ-coefficient =0.418, P=0.006); however, there was poor agreement for anal resting tone (κ-coefficient =0.079, P=0.368).

CONCLUSIONS

DRE shows high sensitivity and positive predictive value in detecting dyssynergia compared with HRAM, and could therefore be used as a bedside screening test for the diagnosis of this disorder. Further studies are warranted to evaluate the correlation between DRE and HRAM in assessing anal sphincter pressure.

What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? a randomized, controlled study in men

BACKGROUND

Digital rectal examination is an essential tool in the evaluation of the rectum. The aim of this trial was to determine the best position for performing a digital rectal examination.

METHODS

A total of 321 patients were randomized into "dorsal" or "lateral" groups in this multicentre randomized controlled trial performed in an outpatient setting. The primary endpoint was the proportion of patients with a complete digital rectal examination, defined as the examination of the rectum (upper border of the prostate), the entire circumference, and the assessment of the sphincter tone.

RESULTS

The dorsal group included a total of 161 patients (mean age: 62.3 ± 13.04 years), while the lateral group included 160 patients (mean age: 62.7 ± 14.4 years). The proportion of patients with a complete digital rectal examination was 44% (n=71) in the dorsal group and 49% (n=79) in the lateral group (p=0.3). The entire circumference of the rectum could be examined in 66% of the patients (n=106) in the dorsal group and in 79.5% of the patients (n=128) in the lateral group (p=0.007).

CONCLUSION

The intergroup difference in terms of digital rectal examination completion rate was not significant. In the lateral position, however, the entire circumference of the rectum could be examined more thoroughly.

Medical student recognition of benign anorectal conditions: the effect of attending the outpatient colorectal clinic

Background

Benign anorectal conditions are fairly common. Physicians of various specialties usually see patients with these conditions before being referred to colorectal specialists, frequently with an incorrect diagnosis.

We sought to evaluate the effect of attending an outpatient colorectal clinic by medical students on the diagnostic accuracy of these conditions.

Methods

Over a 1-year period, medical students were randomized into a group that attended the clinic, and one that did not. Both groups were shown images of six common benign anorectal conditions. The overall diagnostic accuracy as well as the diagnostic accuracy for each one of these conditions was prospectively evaluated for both groups.

Results

Nineteen students attended clinic and 17 did not. Overall diagnostic accuracy was 80.6% for students attending clinic and 43.1% for non-attending students. (p < 0.05) In the attending group, diagnostic accuracy was significantly greater for prolapsed internal hemorrhoids (73.6% versus 35.2%, p < 0.05), thrombosed external hemorrhoid, (73.6% versus 17.6%, p < 0.05) fissure (100% versus 47%, p < 0.05), and anal tags (68.4% versus 11.7%, p < 0.05%).

Conclusion

Exposure to these conditions during surgical clerkships in medical school may help future specialists provide better care for patients with benign anorectal disorders.

An Evidence-Based Approach to the Evaluation, Diagnostic Assessment and Treatment of Fecal Incontinence in Women

Fecal incontinence (FI) is a debilitating disorder which negatively impacts quality of life. The etiology is often multifactorial and although most women with FI are able to be treated, many remain untreated because a significant proportion of women do not report their symptoms and seek care. The evaluation and treatment of FI can be also hindered by a lack of understanding of the mechanisms and current options. This article provides a review on the evidence-based evaluation and management for FI.

ACG clinical guideline: management of benign anorectal disorders

These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and/or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids. Each section reviews the definitions, epidemiology and/or pathophysiology, diagnostic assessment, and treatment recommendations of each entity. These recommendations reflect a comprehensive search of all relevant topics of pertinent English language articles in PubMed, Ovid Medline, and the National Library of Medicine from 1966 to 2013 using appropriate terms for each subject. Recommendations for anal fissure and hemorrhoids lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and supplemented with subsequent publications through 2013. We used systematic reviews and meta-analyses when available, and this was supplemented by review of published clinical trials.

Intraoperative monitoring of bladder and internal anal sphincter innervation: a predictor of erectile function following low anterior rectal resection for rectal cancer? Results of a prospective clinical study

BACKGROUND

The objective was to investigate whether two-dimensional intraoperative neuromonitoring (IONM) of pelvic autonomic nerves has the potential to predict erectile function (EF) following surgery for rectal cancer.

METHODS

A consecutive series of 17 sexually active male rectal cancer patients undergoing IONM-based nerve-sparing low anterior rectal resection were evaluated prospectively. IONM was performed by electric stimulation of the pelvic splanchnic nerves with concomitant electromyography of the internal anal sphincter and cystomanometry. Sexual function was assessed using a validated questionnaire.

RESULTS

The degree of agreement between electromyography-based and cystomanometry-based IONM with postoperative EF was moderate and good (κ = 0.43 and κ = 0.66). Combined assessment yielded the best agreement (κ = 0.76) with sensitivity of 90%, specificity of 86%, positive predictive value of 90%, negative predictive value of 86%, and overall accuracy of 88%, respectively, in terms of prediction of postoperative EF.

CONCLUSION

The method may be suitable to predict male EF following rectal resection.

An update on anorectal disorders for gastroenterologists

Gastroenterologists frequently encounter pelvic floor disorders, which affect 10% to 15% of the population. The anorectum is a complex organ that collaborates with the pelvic floor muscles to preserve fecal continence and enable defecation. A careful clinical assessment is critical for the diagnosis and management of defecatory disorders and fecal incontinence. Newer diagnostic tools (eg, high-resolution manometry and magnetic resonance defecography) provide a refined understanding of anorectal dysfunctions and identify phenotypes in defecatory disorders and fecal incontinence. Conservative approaches, including biofeedback therapy, are the mainstay for managing these disorders; new minimally invasive approaches may benefit a subset of patients with fecal incontinence, but more controlled studies are needed. This mini-review highlights advances, current concepts, and controversies in the area.

Chronic constipation: a critical review

Chronic constipation is a very common symptom that is rarely associated with life-threatening diseases, but has a substantial impact on patient quality of life and consumption of healthcare resources. Despite the large number of affected patients and the social relevance of the condition, no cost-effectiveness analysis has been made of any diagnostic or therapeutic algorithm, and there are few data comparing different diagnostic and therapeutic approaches in the long term. In this scenario, increasing emphasis has been placed on demonstrating that a number of older and new therapeutic options are effective in treating chronic constipation in well-performed randomised controlled trials, but there is still debate as to when these therapeutic options should be included in diagnostic and therapeutic algorithms. The aim of this review is to perform a critical evaluation of the current diagnostic and therapeutic options available for adult patients with chronic constipation in order to identify a rational patient approach; furthermore we attempt to clarify some of the more controversial points to aid clinicians in managing this symptom in a more efficacious and cost-effective manner.

Laparoscopic neuromapping in pelvic surgery: scopes of application

BACKGROUND

New developments in intraoperative electrophysiological neuromonitoring for conventional surgery are providing further insights into functional neuroanatomy and nerve-sparing in the minor pelvis. The aim of this study was to open up potential scopes of application in laparoscopy.

METHODS

Ten patients with different indications for surgery (presacral tumor excision, n = 2; resection rectopexy. n = 2; low anterior rectal resection, n = 2; proctocolectomy. n = 2; abdomino-perineal excision of the rectum, n = 2) were investigated prospectively. The pelvic autonomic nerves were bilaterally mapped by laparoscopic electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Stimulation results were compared to patients' anorectal and urogenital functional outcome.

RESULTS

In all the operations laparoscopic neuromapping (LNM) was technically feasible. Laparoscopy enabled excellent visibility of pelvic neural structures for simple and differentiated electric stimulation. In all cases LNM resulted in significantly evoked electromyographic potentials and intravesical pressure rises. The technique facilitated electrophysiological determination of functional neuroanatomical topography in the minor pelvis. The stimulation results were suitable to confirm laparoscopic nerve-sparing and compatible with patients' anorectal and urogenital functional outcome.

CONCLUSIONS

LNM is technically feasible and opens up a new dimension for verification of functional nerve integrity. Further developments and investigations are mandatory to evaluate its role for laparoscopic nerve-sparing procedures.

Is intraoperative neuromonitoring associated with better functional outcome in patients undergoing open TME? Results of a case-control study

AIMS

Intraoperative neuromonitoring (IONM) aims to control nerve-sparing total mesorectal excision (TME) for rectal cancer in order to improve patients' functional outcome. This study was designed to compare the urogenital and anorectal functional outcome of TME with and without IONM of innervation to the bladder and the internal anal sphincter.

METHODS

A consecutive series of 150 patients with primary rectal cancer were analysed. Fifteen match pairs with open TME and combined urogenital and anorectal functional assessment at follow up were established identical regarding gender, tumour site, tumour stage, neoadjuvant radiotherapy and type of surgery. Urogenital and anorectal function was evaluated prospectively on the basis of self-administered standardized questionnaires, measurement of residual urine volume and longterm-catheterization rate.

RESULTS

Newly developed urinary dysfunction after surgery was reported by 1 of 15 patients in the IONM group and by 6 of 15 in the control group (p = 0.031). Postoperative residual urine volume was significantly higher in the control group. At follow up impaired anorectal function was present in 1 of 15 patients undergoing TME with IONM and in 6 of 15 without IONM (p = 0.031). The IONM group showed a trend towards a lower rate of sexual dysfunction after surgery.

CONCLUSIONS

In this study TME with IONM was associated with significant lower rates of urinary and anorectal dysfunction. Prospective randomized trials are mandatory to evaluate the definite role of IONM in rectal cancer surgery.

Topical glyceryl trinitrate ointment for pain related to anal hypertonia after stapled hemorrhoidopexy: a randomized controlled trial

BACKGROUND

Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles.

OBJECTIVE

We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy.

DESIGN

This was a single-blind, parallel-group, randomized controlled trial.

SETTING

The study was conducted at a university teaching hospital in Rome, Italy.

PATIENTS

Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded.

INTERVENTIONS

Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days.

MAIN OUTCOME MEASURES

Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy.

RESULTS

Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5 ± 1.0 vs 4.0 ± 1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4 ± 7.4 mmHg vs 85.6 ± 7.9 mmHg, p < 0.0001).

LIMITATIONS

GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded.

CONCLUSION

Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

Evaluation of two-dimensional intraoperative neuromonitoring for predicting urinary and anorectal function after rectal cancer surgery

PURPOSE

The aim of this study was to compare the results of two-dimensional intraoperative neuromonitoring (IONM) with the postoperative urinary and anorectal function of rectal cancer patients.

METHODS

A consecutive series of 35 patients undergoing low anterior resection were investigated prospectively. IONM was performed with electric stimulations of the pelvic splanchnic nerves under simultaneous manometry of the bladder and electromyography (EMG) of the internal anal sphincter (IAS). Urinary and anorectal function were evaluated preoperatively and at follow-up by standardized questionnaires, digital rectal examination scoring system, and long-term catheterization rate.

RESULTS

The rate of postoperative newly developed bladder dysfunction was 17 %. IONM with bladder manometry had a sensitivity of 100 %, specificity of 96 %, positive predictive value of 83 %, negative predictive value of 100 %, and overall accuracy of 97 %, respectively. The proportion of patients with severely impaired anorectal function at follow-up was 8 %. The sensitivity, specificity, and positive and negative predictive values for IONM with EMG of the IAS were, respectively, 100, 96, 67, and 100 % with an accuracy of 96 %. The degree of agreement for IONM with EMG of the IAS was good for anorectal function (к = 0.780) and poor for urinary function (к = 0.119). IONM with bladder manometry yielded a very good degree of agreement for urinary function (к = 0.891) and a fair agreement for anorectal function (к = 0.336).

CONCLUSIONS

The two-dimensional IONM method is suitable for verification of bladder and IAS innervation. Accurate prediction of urinary and anorectal function necessitates both bladder manometry and EMG of the IAS.

Oncologic outcomes of intersphincteric resection without preoperative chemoradiotherapy for very low rectal cancer

BACKGROUND

When a rectal cancer is located at less than 4cm from the anal verge, abdominoperineal resection (APR) is generally performed. If an ideal surgery that could replace APR were to be developed, it could contribute to anal preservation in patients with very low rectal cancer. The aim of this study was to investigate oncologically whether intersphincteric resection (ISR) could replace APR for a very low rectal cancer.

METHODS

Between 2001 and 2011, ISR was curatively performed in 124 patients with a very low rectal cancer who might otherwise have been treated with APR. No patient received preoperative chemoradiotherapy. The median duration of follow-up was 65 months (range 14-122 months). Local recurrence was defined as only intra-pelvic recurrences including lateral lymph node metastasis. The survival rate was calculated using the Kaplan-Meier method.

RESULTS

Postoperative morbidity including anastomotic leakage (5.6%) was 12%. There was no in-hospital mortality. In those patients with Stages I, II, and III disease, the local recurrence rate was 4.7%, 4.9%, and 5.0%, respectively. The recurrence-free 5-year survival rates were 92.2% (95% CI: 84-100%), 81.9% (95% CI: 70-94%) and 69.6% (95% CI: 53-87%) at each stage, respectively. The cancer-specific 5-year survival rates were 90.5% (95% CI: 81-100%), 91.0% (95% CI: 82-100%), and 83.6% (95% CI: 70-97%) at each stage, respectively. The overall recurrence-free survival and local recurrence rates after ISR were similar to those after APR.

CONCLUSIONS

The ISR procedure appears to be oncologically acceptable, replacing APR in selected patients. Accumulated experience supports this practice worldwide in future.

Resection rectopexy--laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results

PURPOSE

Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping.

METHODS

Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up.

RESULTS

Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1-18) to 1 (range 0-3) at follow-up (p = 0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5-17) to 3 (range 1-7; p = 0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed.

CONCLUSIONS

Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.

Normative values in anorectal manometry using microtip technology: a cohort study in 172 subjects

PURPOSE

The aims of this study were to obtain normative values in resting/squeeze pressure and surface electromyography (s-EMG) in anorectal manometry using microtip technology and to determine the relationship between objective measurable values, gender and age in a cohort with no anorectal disorders.

METHODS

One hundred seventy-two white central European subjects (106 males/66 females) were recruited prior to left colonic or upper rectal surgery and studied by anorectal rapid pull-through manometry with a microtip transducer system and endoanal s-EMG using a bipolar plug electrode. s-EMG patterns were determined as plateau, peak and decrease by a blinded co-investigator. Objective measurable sphincter pressures and s-EMG values were correlated with gender, age and s-EMG patterns.

RESULTS

Squeeze pressure, voluntary pressure as well as s-EMG amplitude and its area under the curve were significantly lower in women compared to men (p < 0.001 each), whereas resting pressure showed no gender differences. s-EMG patterns were strongly influenced by gender. Male patients showed significantly more plateau pattern whereas peak pattern was significantly more often in women. In both genders, the peak pattern was associated with significant higher squeeze pressures. In all measurements, we found considerable inter-individual variations being higher in elder patients. There was no manometric parameter correlating with age.

CONCLUSIONS

Gender is the strongest factor influencing objective measurable manometric data for healthy men and women. There are significant gender differences concerning squeeze patterns. All manometric values should be interpreted in the context of gender and of methodology used. Large prospective cohort studies matched for gender are necessary to clarify the effect of ageing on anal sphincter strength.

Utility of the digital rectal examination in the emergency department: a review

BACKGROUND

The digital rectal examination (DRE) has been reflexively performed to evaluate common chief complaints in the Emergency Department without knowing its true utility in diagnosis.

OBJECTIVE

Medical literature databases were searched for the most relevant articles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive rate of fecal occult blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the correlation between DRE and anal manometry in determining anal tone.

DISCUSSION

Sixteen articles met our inclusion criteria; there were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was shown to add no additional diagnostic information and confounded the diagnosis in acute, undifferentiated abdominal pain. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children and adults. No statistical differences in the number of colonic pathologies were found between stool collection methods in those with positive FOBT. The DRE correlation with anal manometry in determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, respectively.

CONCLUSION

We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis. Stool obtained by DRE doesn't seem to increase the false-positive rate of FOBTs, and the DRE correlated moderately well with anal manometric measurements in determining anal sphincter tone.

The digital rectal examination: a multicenter survey of physicians' and students' perceptions and practice patterns

OBJECTIVES

The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs among a variety of providers and explored factors affecting its performance and utilization.

METHODS

A total of 652 faculty, fellows, medical residents, and final-year medical students completed a questionnaire about their use of DREs.

RESULTS

On average, 41 DREs per year were performed. The yearly number of examinations was associated with years of experience and specialty type. Patient refusal rates were lowest among gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were negatively correlated with comfort level of the physician in performing a DRE. More gastroenterologists used sophisticated methods to detect anorectal conditions, and gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis with a DRE was strongly associated with the number of DREs performed annually.

CONCLUSIONS

The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic confidence, and training adequacy were directly related to level of experience with the examination. Training in DRE technique has diminished and may be lost. The DRE's role in medical school and advanced training curricula needs to be re-established.

Total mesorectal excision with intraoperative assessment of internal anal sphincter innervation provides new insights into neurogenic incontinence

BACKGROUND

The aim of this prospective study was to assess internal anal sphincter (IAS) innervation in patients undergoing total mesorectal excision (TME) by intraoperative neuromonitoring (IONM).

STUDY DESIGN

Fourteen patients underwent TME. IONM was carried out through pelvic splanchnic nerve stimulation under continuous electromyography of the IAS. Anorectal function was assessed with the digital rectal examination scoring system and a standardized questionnaire.

RESULTS

Nine of 11 patients who underwent low anterior resection had positive IONM results, with stimulation-induced increased IAS electromyographic amplitudes (median 0.23 μV (interquartile range [IQR] 0.05, 0.56) vs median 0.89 μV (IQR 0.64, 1.88), p < 0.001) after TME. The patients with the positive IONM results were continent after stoma closure. Of 2 patients with negative IONM results, 1 had fecal incontinence after closure of the defunctioning stoma and received a permanent sigmoidostomy. In the other patient the defunctioning stoma was deemed permanent due to decreased anal sphincter function. In 3 patients who underwent abdominoperineal excision, IONM assessed denervation of the IAS after performance of the abdominal part.

CONCLUSIONS

This study demonstrated that IONM of IAS innervation in rectal cancer patients is feasible and may predict neurogenic fecal incontinence.

Difficult defecation: difficult problem assessment and management; what really helps?

Difficult defecation is a common and perhaps underrecognized cause of chronic constipation. While the history and a careful digital rectal examination are very useful for diagnosing defecatory disorders, the diagnosis needs to be confirmed by anorectal tests. Anorectal manometry and a rectal balloon expulsion test generally suffice to diagnose defecatory disorders; barium or MR defecography may necessary in selected cases. Colonic transit is normal or slow in patients with defecatory disorders. Pelvic floor retraining by biofeedback therapy is superior to laxatives for managing defecatory disorders.

Recent advances in functional anorectal disorders

Defecatory disorders are a common cause of chronic constipation and should be managed by biofeedback-guided pelvic floor retraining. While anorectal tests are necessary to diagnose defecatory disorders, recent studies highlight the utility of a careful digital rectal examination. While obstetric anal injury can cause fecal incontinence (FI), diarrhea is a more important risk factor for FI among women in the community, who typically develop FI after age 40. Initial management of fecal incontinence should focus on bowel disturbances. Pelvic floor retraining with biofeedback therapy is beneficial for patients who do not respond to bowel management. Sacral nerve stimulation should be considered in patients who do not respond to conservative therapy.