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Gallo G, Pegoraro V, Trompetto M. Description and management of patients with anal fissure: insights on Italian primary care setting coming from real-world data. Updates Surg 2024:10.1007/s13304-024-01882-8. [PMID: 38796820 DOI: 10.1007/s13304-024-01882-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
To describe patients with anal fissure (AF) and their management in primary care. Retrospective study using the Italian Longitudinal Patient Database on 18 + years old subjects with AF records during 'July 2016-June 2021' (selection period). Index Date (ID) was the first AF record during selection period. Sub-cohorts were defined by presence/absence of prescriptions on ID of the combination of topical nifedipine 0.3% and lidocaine 1.5% (NIF/LID). Patients' information on the 12-month period before (baseline) and after (follow-up) ID was analyzed. Subjects with AF were 8632: 14.0% had NIF/LID on ID. Mean age was 52 (± 17.2) years, there were more women in ' < 50 years' group, and more men in '50-70' one. Prevalences of pregnancy and immunodepression were around 5%; most common comorbidities were hypertension (29.6%) and heart disease (13.1%), while constipation and diarrhea were < 5%. Healthcare resources utilization (HRUs) increased during follow-up, but still few patients were prescribed NIF/LID (2.8%), other treatments for AF (10.3%), or proctological visits (7.7%). NIF/LID patients were younger (< 40 years people: 30.7% versus 23.9%; p value < 0.0001), and more likely to have constipation (4.3% versus 2.5%; p value < 0.001); patients without NIF/LID showed slightly higher prevalences of hypertension (30.0% versus 27.1%; p value: 0.039) and depression (4.0% versus**2.5%; p value: 0.009), and a little higher overall HRUs. Results show that general practitioners are used to manage AF. However, there is still a gap between guidelines' recommendations and actual management. Educational campaigns on common anal problems in primary care might help further improving AF management and optimizing HRUs.
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Affiliation(s)
- Gaetano Gallo
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, RM, Italy.
| | | | - Mario Trompetto
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
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2
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Young S, Lee B, Smukalla S, Axelrad J, Chang S. Anorectal Manometry in Patients With Fecal Incontinence After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Cohort Study. CROHN'S & COLITIS 360 2023; 5:otad063. [PMID: 38077748 PMCID: PMC10708921 DOI: 10.1093/crocol/otad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Indexed: 02/12/2024] Open
Abstract
Background Fecal incontinence commonly occurs in patients with ulcerative colitis and ileal pouch-anal anastomosis. There is a paucity of manometric data in pouch patients. We aimed to better define manometric parameters in pouch patients with fecal incontinence. Methods We compared clinical and manometric variables in ulcerative colitis patients with pouch and fecal incontinence to ulcerative colitis patients with pouch without fecal incontinence and to non-ulcerative colitis patients with fecal incontinence. Manometric data for the 3 cohorts were compared to established normative data. An independent-samples t-test was performed for continuous variables, and chi-square test was used for categorical variables. Logistic regression was performed to identify predictors of incontinence in pouch patients (P < .05). Results Among 26 pouch patients with fecal incontinence (73% female), 26 pouch patients without fecal incontinence (35% female), and 84 patients with fecal incontinence without ulcerative colitis (68% female), there were no differences in anorectal pressures between patients with fecal incontinence. Lower pressures were observed in pouch patients with fecal incontinence compared to those without fecal incontinence. Resting pressure was similar between pouch patients with fecal incontinence and healthy controls (60.9 ± 36.1 mmHg vs. 66.9 ± 3.2 mmHg, P = .40). Female sex (P = .019) and defecatory disorders (P = .033) each independently predicted fecal incontinence in pouch patients. Conclusions Pouch patients with fecal incontinence have lower anorectal pressures compared to pouch patients without incontinence, though have similar pressures to non-ulcerative colitis patients with fecal incontinence. Pouch patients with fecal incontinence have similar resting pressures as healthy controls. Distinct manometric normative values for pouch patients are needed.
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Affiliation(s)
- Sigrid Young
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Briton Lee
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott Smukalla
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
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3
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Toshimori A, Tanabe M, Shimamura Y, Shiomi D, Ushikubo K, Kishi Y, Kato H, Fukuda M, Shibata Y, Kunita K, Fujiyoshi MRA, Fujiyoshi Y, Nishikawa Y, Sumi K, Ikeda H, Onimaru M, Uragami N, Yokoyama N, Inoue H. Endoscopic carbon dioxide insufflation tolerance test on the anal sphincter for anorectal hypofunction: a pilot and feasibility study. Ann Gastroenterol 2023; 36:437-441. [PMID: 37396011 PMCID: PMC10304521 DOI: 10.20524/aog.2023.0805] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/25/2023] [Indexed: 07/04/2023] Open
Abstract
Background Anorectal function deteriorates with age. The diagnostic performance of the endoscopic pressure study integrated system (EPSIS), an endoscopic carbon dioxide (CO2) insufflation stress test of the lower esophageal sphincter has been previously evaluated as a diagnostic tool for gastroesophageal reflux disease. We aimed to evaluate the applicability of EPSIS in improving anorectal function. We hypothesized that EPSIS can be applied to the diagnosis of lower gastrointestinal tract disorders. Methods This was a pilot, single-center, retrospective study using prospectively collected data between December 2021 and March 2022. It was designed to evaluate the differences in EPSIS rectal pressure measurements between older (≥80 years) and younger (<80 years) patients. At the end of the screening colonoscopy, the colonoscope was fixed in a retroflex position. When bowel movement was observed, CO2 was insufflated to the point where gas leakage occurred through the anus. The measured maximum pressure was defined as EPSIS-rectal pressure max (EPSIS-RP max) and compared between the groups. Results Overall, 30 patients were included and examined. The median ages of the <80 and ≥80 years' groups were 53 (range: 27-79) and 82 (range: 80-94) years, respectively, with corresponding median measured EPSIS-RP max of 18.7 (range: 8.5-30.2) and 9.8 (range: 5.4-22.3) mmHg (P<0.001). Conclusions Measurement of maximum rectal pressure illustrates the age-related decline in physiological anorectal function. Future studies should consider a loading test using EPSIS to quantify the decline in anorectal function and use it as a routine tool for screening and adjunctive diagnosis of anorectal hypofunction.
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Affiliation(s)
- Akiko Toshimori
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Daijiro Shiomi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kei Ushikubo
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yumi Kishi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hisaki Kato
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mai Fukuda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuki Shibata
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kosuke Kunita
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Yusuke Fujiyoshi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yohei Nishikawa
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Naoyuki Uragami
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Noboru Yokoyama
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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4
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Nazarko L. Bowel care at end of life. Br J Community Nurs 2023; 28:138-142. [PMID: 36853892 DOI: 10.12968/bjcn.2023.28.3.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Most people, given a choice prefer to die at home. As death approaches the dying person may say "please let me die at home, in my own bed". Many relatives promise their loved ones that they can remain at home until the end. One issue that can cause great distress and at times lead to unnecessary hospital admission is poorly managed bowel care. This article will examine how ageing, illness and medication can affect bowel function and quality of life.
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Kim HJ, Kim N, Choi Y, Lee J, Yoon H, Shin CM, Park YS, Lee DH, Kim HR, Kang SB. Effects of Aging and Gender on the Anorectal Function of Healthy Subjects Assessed with Conventional Anorectal Manometry. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 80:254-261. [PMID: 36567438 DOI: 10.4166/kjg.2022.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 12/27/2022]
Abstract
Background/Aims Anorectal functions are influenced by gender and age. This study sought to define the normal anorectal pressure values measured with conventional anorectal manometry (ARM) and to evaluate the effects of age and gender on anorectal function in asymptomatic subjects. Methods Conventional ARM was used to measure the anorectal pressures of 164 asymptomatic healthy subjects, including 86 males and 76 females. Results The resting anal pressures of males and females aged >60 years were significantly lower than those ≤60 years (males, 44.09±14.22 vs. 57.45±17.69, p<0.001; females, 44.09±14.22 vs. 57.45±17.69, p<0.001). The anal high-pressure zone was significantly lower in older males than in younger males (2.42±0.93 vs. 2.82±0.739, p=0.048). In both age groups (<60 and ≥60 years), the anal squeezing pressures of males were significantly higher than those of females (<60 years old, 168.40±75.94 vs. 119.15±57.53, p=0.001; ≥60 years, 149.61±64.68 vs. 101.3±54.92, p=0.006). Conclusions The normal anorectal pressure values measured with ARM in males and females were different. Older males and females had lower anal resting pressures than those of the younger subjects, but squeezing pressure was not affected by age.
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Affiliation(s)
- Hee Jin Kim
- Department of Internal Medicine, Gyeongsang National University College of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yonghoon Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jongchan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Rang Kim
- Department of Gastroenterology, Burjeel Marina Health Promotion Center, Abu Dhabi, UAE
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Shore BM, Kochar B, Herfarth HH, Barnes EL. Current Perspectives on Indications for Ileal Pouch-Anal Anastomosis in Older Patients. Clin Exp Gastroenterol 2022; 15:163-170. [PMID: 36176671 PMCID: PMC9514131 DOI: 10.2147/ceg.s340338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022] Open
Abstract
The population of older patients with inflammatory bowel disease (IBD) is expected to continue to increase in the coming decades, which necessitates and improved understanding of the critical issues faced by patients in this population. Although restorative proctocolectomy with IPAA remains the surgical procedure of choice for the majority of patients with medically refractory ulcerative colitis (UC) and UC-related dysplasia, the evidence surrounding surgery for older patients UC remains sparse. In particular, comparisons of outcomes among older and younger patients undergoing IPAA and comparisons between older patients undergoing IPAA and those undergoing proctocolectomy with end ileostomy remain an understudied and important issue, as evidence in this area will be used to guide patient-centered surgical choices among older patients who require colectomy for UC. In this narrative review, we review the available literature regarding IPAA for older patients, as well as the pre-, peri-, and postoperative factors that may influence outcomes in this population.
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Affiliation(s)
- Brandon M Shore
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,The Mongan Institute, Boston, MA, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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7
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Ketelaers SHJ, van Heinsbergen M, Orsini RG, Vogelaar FJ, Konsten JLM, Nieuwenhuijzen GAP, Rutten HJT, Burger JWA, Bloemen JG. Functional Bowel Complaints and the Impact on Quality of Life After Colorectal Cancer Surgery in the Elderly. Front Oncol 2022; 12:832377. [PMID: 35242714 PMCID: PMC8886503 DOI: 10.3389/fonc.2022.832377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/17/2022] [Indexed: 12/11/2022] Open
Abstract
Background The Low Anterior Resection Syndrome (LARS) is commonly reported after colorectal cancer surgery and significantly impairs quality of life. The prevalence and impact of LARS in the elderly after rectal cancer as well as colon cancer surgery is unclear. We aimed to describe the prevalence of LARS complaints and the impact on quality of life in the elderly after colorectal cancer surgery. Materials and Methods Patients were included from seven Dutch hospitals if they were at least one year after they underwent colorectal cancer surgery between 2008 and 2015. Functional bowel complaints were assessed by the LARS score. Quality of life was assessed by the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Outcomes in patients ≥70 years were compared to a reference group of patients <70 years. Results In total 440 rectal cancer and 1183 colon cancer patients were eligible for analyses, of whom 133 (30.2%) rectal and 536 (45.3%) colon cancer patients were ≥70 years. Major LARS was reported by 40.6% of rectal cancer and 22.2% of colon cancer patients ≥70 years. In comparison, patients <70 years reported major LARS in 57.3% after rectal cancer surgery (p=0.001) and in 20.4% after colon cancer surgery (p=0.41). Age ≥70 years was independently associated with reduced rates of major LARS after rectal cancer surgery (OR 0.63, p=0.04). Patients with major LARS reported significantly impaired quality of life on almost all domains. Conclusion Elderly should not be withheld a restorative colorectal cancer resection based on age alone. However, a substantial part of the elderly colorectal cancer patients develops major LARS after surgery, which often severely impairs quality of life. Since elderly frequently consider quality of life and functional outcomes as one of the most important outcomes after treatment, major LARS and its impact on quality of life should be incorporated in the decision-making process.
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Affiliation(s)
| | | | - Ricardo G Orsini
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | | | - Joop L M Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, Netherlands
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands.,GROW, School for Developmental Biology & Oncology, Maastricht University, Maastricht, Netherlands
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8
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Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am 2022; 51:71-91. [PMID: 35135666 DOI: 10.1016/j.gtc.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.
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Affiliation(s)
- Stacy Menees
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA
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9
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Korai T, Akizuki E, Okita K, Nishidate T, Okuya K, Sato Y, Hamabe A, Ishii M, Nobuoka T, Takemasa I. Defecation disorder and anal function after surgery for lower rectal cancer in elderly patients. Ann Gastroenterol Surg 2022; 6:101-108. [PMID: 35106420 PMCID: PMC8786691 DOI: 10.1002/ags3.12505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 11/23/2022] Open
Abstract
AIM This study aims to investigate the association of patient age with defecation disorders and anal function after lower rectal cancer surgery. METHODS We retrospectively reviewed the data of 141 consecutive patients with lower rectal cancer who underwent sphincter-preserving operation. The patients were classified into five categories by age thresholds at 65, 70, 75, 80, and 85 years, for disaggregate analysis. Anal manometry was used for measuring the maximum resting pressure, high-pressure zone, and maximum squeeze pressure. Anal manometry was performed preoperatively and at 3, 6, 9, and 12 months postoperatively. The Wexner and low anterior resection syndrome scores were assessed at 1, 3, 6, 9, and 12 months after rectal surgery or stoma closure for patients with ileostomy. RESULTS The data of 117 patients were reviewed. No significant differences were found between the younger and elderly groups in any characteristics across the six age groups. The preoperative intra-anal pressures of the elderly patients were slightly lower than those of the younger patients; however, there was no significant difference in the course of postoperative intra-anal pressures. Defecation disorder, as measured by the Wexner and low anterior resection syndrome scores, improved significantly in elderly patients compared to younger patients. CONCLUSION There was no significant difference in the course of postoperative intra-anal pressures between the elderly and younger patients. However, defecation disorders in elderly patients significantly improved compared with younger patients. Sphincter-preserving operation can be a viable treatment option for active elderly patients.
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Affiliation(s)
- Takahiro Korai
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Emi Akizuki
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Kenji Okita
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Toshihiko Nishidate
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Koichi Okuya
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Yu Sato
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Atsushi Hamabe
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Masayuki Ishii
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Takayuki Nobuoka
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Ichiro Takemasa
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
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10
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Jutras G, Wahba G, Ayuso E, Neshkova E, Bouin M. Do Age and Sex Influence Anorectal Manometry Parameters? J Can Assoc Gastroenterol 2021; 4:235-241. [PMID: 34617005 PMCID: PMC8489528 DOI: 10.1093/jcag/gwaa045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/05/2021] [Indexed: 12/17/2022] Open
Abstract
Background High-resolution anorectal manometry (HRM) is widely used in the evaluation of anal incontinence and constipation, which become increasingly prevalent with age. However, the impact of age and comorbidities on physiological digestive parameters remains poorly understood. In this study, we aimed to evaluate the effect of age on anorectal function. Methods We conducted a retrospective study on patients at our digestive motility clinic between January 2016 and May 2019. All patients with a normal HRM were included. Clinical data and HRM parameters were collected in a database. Multivariate regression analyses were performed to evaluate the effects of age, sex, medical comorbidities and obstetric history on anorectal HRM parameters. Key Results One hundred and forty-four patients were included (mean age: 53 ± 16 years, 72% females). The main indications for anorectal HRM were incontinence (44%), constipation (37%) and anorectal pain (9%). Age was significantly associated with higher maximum tolerable volume (β = +0.48 mL year-1, P = 0.04) and higher rectal compliance (β = +0.04 mL year-1, P = 0.01). Independently from age and medical comorbidities, female demonstrated significantly lower mean endurance squeeze pressure (β = −44.4 mmHg, P < 0.001), maximal squeeze pressure (β = −62.3 mmHg; P < 0.001), volume at first urge (β = −16.7 mL, P = 0.02) and maximum tolerable volume (β = −16.1 mL, P = 0.046). Vaginal birth was associated with lower tolerable maximum pressure (β = −39.4 mmHg, P = 0.046). Conclusion Age and sex are independent factors which influence anorectal HRM parameters. These findings should be taken into consideration when interpreting anorectal HRM.
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Affiliation(s)
- Gabrielle Jutras
- Centre Hospitalier Universitaire de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - George Wahba
- Centre Hospitalier Universitaire de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Eloise Ayuso
- Centre Hospitalier Universitaire de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Elissaveta Neshkova
- Centre Hospitalier Universitaire de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mickael Bouin
- Centre Hospitalier Universitaire de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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11
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Mei L, Patel K, Lehal N, Kern MK, Benjamin A, Sanvanson P, Shaker R. Fatigability of the external anal sphincter muscles using a novel strength training resistance exercise device. Am J Physiol Gastrointest Liver Physiol 2021; 320:G609-G616. [PMID: 33596155 PMCID: PMC8238165 DOI: 10.1152/ajpgi.00456.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Exercises involving pelvic floor muscles including repetitive voluntary contractions of external anal sphincter (EAS) musculature have been used to improve fecal incontinence. Muscle fatigue is a prerequisite for successful strength training. However, muscle fatigue induced by these exercises has not been systematically studied. We aimed to assess the fatigability of EAS muscles during various exercise methods. Twelve nulliparous (21 ± 2.7 yr) women were studied. We evaluated fatigue during 40 repetitive 3-s contractions and 30-s long squeeze contractions both with and without an intra-anal compressible resistant load. The sequence of exercises was randomized. This load was provided by the continence muscles Resistance Exerciser Device. Anal canal pressures were recorded by high-resolution manometry. Exercise against a resistive load showed significant decrease in anal contractile integral (CI) and maximum squeeze pressure during repetitive short squeeze contractions compared with exercise without a load. Linear regression analysis showed a significant negative correlation between anal CI and successive contraction against load, suggesting "fatigue." Similar findings were observed for maximum squeeze pressure (slope with load = -4.2, P = 0.0003, vs. without load = -0.9, P = 0.3). Long squeeze contraction against a load was also more susceptible to fatigue than without a load (P < 0.0001). In conclusion, repetitive contractions against a compressible load induce fatigue and thus have the potential to strengthen the anal sphincter contractile function than contractions without a load. Fatigue rate in long squeeze contraction exercises with a load is significantly faster than that without a load, also indicating greater effectiveness in inducing muscle fatigue.NEW & NOTEWORTHY Fecal incontinence is a distressing disorder with a mainstay of treatment being pelvic floor muscle exercises. However, none of these exercises has proven occurrence of fatigability, which is an important prerequisite for successful muscle strengthening in rehabilitative exercises. In this study, we proved that we can fatigue the external anal sphincter muscles more efficiently by providing a resistive load during anal repetitive short squeeze contractions and long squeeze contraction exercise.
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Affiliation(s)
- Ling Mei
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Krupa Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Navjit Lehal
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mark K. Kern
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Benjamin
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Patrick Sanvanson
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Lucak S, Lunsford TN, Harris LA. Evaluation and Treatment of Constipation in the Geriatric Population. Clin Geriatr Med 2020; 37:85-102. [PMID: 33213776 DOI: 10.1016/j.cger.2020.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chronic constipation affects one-third of the US population and occurs disproportionately in the elderly and female individuals, increasing in older individuals who are institutionalized. This condition has a significant impact on health care costs and quality of life. Clinicians need to consider primary as well as secondary causes of constipation in elderly individuals because the cause is often multifactorial. Diagnostic algorithms should eliminate red-flag symptoms that may indicate a malignancy but also consider pelvic floor dysfunction, which is more common in this age group. An appropriate treatment plan is tailored to the severity of the patient's symptoms.
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Affiliation(s)
- Susan Lucak
- Weill Cornell Medicine, Columbia University Medical Center
| | - Tisha N Lunsford
- Division of Gastroenterology & Hepatology, Alix School of Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Lucinda A Harris
- Division of Gastroenterology & Hepatology, Alix School of Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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13
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Giarratano G, Shalaby M, Toscana C, Sileri P. Video-assisted anal fistula treatment for complex anal fistula: a long-term follow-up study. Colorectal Dis 2020; 22:939-944. [PMID: 32030874 DOI: 10.1111/codi.15005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 01/07/2020] [Indexed: 12/14/2022]
Abstract
AIM This prospective study aimed to evaluate the safety and efficacy of video-assisted anal fistula treatment (VAAFT) in complex fistula-in-ano (FIA). METHOD Consecutive patients presenting with complex FIA were recruited between November 2012 and November 2018. The primary outcome was healing of the fistula. RESULTS Seventy-two patients were included, 39 (54%) of whom were men, with a mean age of 46 (±11) years. The mean follow-up was 32 (±18) months. Complete healing was achieved in 64 (89%) patients. When persistent and recurrent cases were considered together, the failure rate was 21% and the success rate 79%. When patients failed, they were offered VAAFT again, after which there was an in increase in the healing rate, which overall (primary and secondary) was 86%. There was no statistically significant deterioration in continence. Eight (11%) patients experienced postoperative complications which required no additional surgical intervention. CONCLUSION VAAFT represents a promising, sphincter-saving technique for the treatment of complex FIA. It has proved efficacious, with 79% of patients achieving complete healing after its primary application. After a second use, this reached 86%. The main advantage of VAAFT compared with other sphincter-saving techniques is working under direct vision. VAAFT has a good safety profile with 11% of patients experiencing minor complications, and there is no effect on continence.
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Affiliation(s)
- G Giarratano
- Department of General Surgery, Casa di Cura Nuova Itor, Rome, Italy.,Department of General Surgery, University of Rome Tor Vergata, Rome, Italy
| | - M Shalaby
- Department of General Surgery, Mansoura University, Mansoura, Egypt.,Department of General Surgery UOC C, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - C Toscana
- Department of General Surgery, Casa di Cura Nuova Itor, Rome, Italy
| | - P Sileri
- Department of General Surgery, University of Rome Tor Vergata, Rome, Italy.,Department of General Surgery UOC C, Policlinico Tor Vergata University Hospital, Rome, Italy
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14
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Mueller K, Karimuddin AA, Metcalf C, Woo A, Lefresne S. Management of Malignant Rectal Pain and Tenesmus: A Systematic Review. J Palliat Med 2019; 23:964-971. [PMID: 31682188 DOI: 10.1089/jpm.2019.0139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Malignant rectal pain (MRP) and tenesmus cause significant morbidity for cancer patients at all stages of disease. There is little evidence to guide management of these symptoms. Objective: The objective of this review was to summarize the existing evidence base for palliative management of MRP and tenesmus outside of standard oncologic or surgical management. Design: A systematic review of PubMed and Embase was conducted according to PRISMA guidelines using preselected search terms for publications between 1980 and January 2017. Setting/Subjects: Studies that described management for patients with tenesmoid pain from malignant tumors of the rectum, anus, or perineum were identified. Measurements: The primary outcome was response of pain to treatment. Results: The search produced 1412 titles. Twenty articles met criteria for inclusion in the review, including 11 case series and 9 case reports. A variety of treatments were found with most patients receiving interventional procedures, but overall evidence to support any particular intervention is limited and of poor quality. Conclusions: This review highlights the limited current evidence base for medical and interventional treatments for MRP and tenesmus. Further study is needed to clarify the best approach to managing these challenging symptoms.
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Affiliation(s)
- Katelyn Mueller
- 2D Palliative Care, Burnaby Hospital, Burnaby, British Columbia, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, Providence Health, Vancouver, British Columbia, Canada
| | - Corey Metcalf
- Department of Medical Oncology/Palliative Care, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Annie Woo
- Department of Pharmacy, and BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Shilo Lefresne
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
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15
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Mege D, Meurette G, Brochard C, Damon H, Lambrescak E, Faucheron JL, Wyart V, Lehur PA, Sielezneff I, Siproudhis L, Mion F, Etienney I, Houivet E, Bridoux V, Leroi AM. Sacral nerve modulation for faecal incontinence: influence of age on outcomes and complications. A multicentre study. Colorectal Dis 2019; 21:1058-1066. [PMID: 30985984 DOI: 10.1111/codi.14649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/02/2019] [Indexed: 02/08/2023]
Abstract
AIM Faecal incontinence is frequent in the elderly. Little is currently known about the efficacy of sacral nerve modulation (SNM) in the elderly. The present study aimed to assess the impact of age on the outcome of SNM and on the surgical revision and explantation rates by comparing the results of a large data set of patients. METHOD Prospectively collected data from patients who underwent an implant procedure between January 2010 and December 2015 in seven French centres were retrospectively evaluated. In total, 352 patients [321 women; median age (range): 63 (24-86) years] were included. Clinically favourable and unfavourable outcomes, and surgical revision and explantation rates, were compared according to the age of the patients. RESULTS A similar outcome was observed when comparing patients < 70 years and ≥ 70 years (a favourable outcome in 79.2% and 76.2%, respectively, P = 0.89). The probability of a successful treatment as a function of time was similar for the two age groups (< 70 years and ≥ 70 years, P = 0.54). The explantation and revision rates were not influenced by age (explantation rate: 17% in patients < 70 years vs 14% in patients ≥ 70 years, P = 0.89; and revision rate: 42% in patients < 70 years vs 40% in patients ≥ 70 years, P = 0.89). The probability of explantation as a function of time was similar for the two age groups (P = 0.82). The limitations of this study were its retrospective status, the rate of loss at follow-up and different durations of patient follow-up. CONCLUSIONS Our results suggest that patients ≥ 70 years suffering from faecal incontinence benefit from SNM with a similar risk as a younger population.
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Affiliation(s)
- D Mege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - G Meurette
- Digestive and Endocrine Surgery Clinic, Diseases of the Digestive Tract Institute, University Hospital of Nantes, Nantes, France
| | - C Brochard
- Diseases of the Digestive Tract Department, Functional Digestive Explorations Division, CHU Pontchaillou, CIC1414, INPHY, INSERM U1241, Université de Rennes 1, Rennes, France
| | - H Damon
- Digestive Physiology, University Hospital of Lyon, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - E Lambrescak
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - J-L Faucheron
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps, UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - V Wyart
- Digestive and Endocrine Surgery Clinic, Diseases of the Digestive Tract Institute, University Hospital of Nantes, Nantes, France
| | - P-A Lehur
- Digestive and Endocrine Surgery Clinic, Diseases of the Digestive Tract Institute, University Hospital of Nantes, Nantes, France.,Department of General Surgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - I Sielezneff
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - L Siproudhis
- Diseases of the Digestive Tract Department, Functional Digestive Explorations Division, CHU Pontchaillou, CIC1414, INPHY, INSERM U1241, Université de Rennes 1, Rennes, France
| | - F Mion
- Digestive Physiology, University Hospital of Lyon, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - I Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - E Houivet
- Biostatistics Unit, INSERM CIC 1404, Rouen, France
| | - V Bridoux
- Department of Digestive Surgery, Normandie Univ, UNIROUEN Inserm U1073, Rouen University Hospital, Rouen, France
| | - A-M Leroi
- Department of Digestive Physiology and CIC-CRB 1404, Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Rouen, France
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Abstract
PURPOSE OF REVIEW Chronic diarrhea is a common problem in all age groups but is a particularly challenging diagnostic problem in the elderly, since many different conditions need to be considered. The purpose of this review is to discuss the evaluation of chronic diarrhea in older individuals. It highlights those conditions that seem to occur with increased frequency in the elderly, discusses the diagnostic tests that are of greatest value in sorting out these problems, and presents an approach to evaluation that is both practical and affordable. RECENT FINDINGS There appears to be little value in distinguishing irritable bowel syndrome with diarrhea (IBS-D) from functional diarrhea in most patients, including older individuals. Both conditions need a thoughtful analysis of potential causes that may lead to more focused treatment. Older individuals may be more at risk of having certain structural disorders, and these need to be considered when constructing a differential diagnosis. In addition, elderly patients may have atypical presentations of specific disorders that require an increased index of suspicion. Diagnostic tests generally seem to perform well in older patients but have not been validated in this cohort of patients. Although the pretest probabilities of certain diseases are different in the elderly, the conventional algorithm for assessment of chronic diarrhea should lead to a diagnosis in most cases. Better studies are needed to adequately quantitate the likelihood of different diagnoses and the operating characteristics of diagnostic tests in older patients with chronic diarrhea. Lacking that information, physicians can still do a good job of making a diagnosis in these patients by adopting a stepwise approach.
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Abstract
BACKGROUND The differential impact of aging on fecal incontinence symptom severity and condition-specific quality of life remains unclear. OBJECTIVE The purpose of this study was to characterize differences in symptom distress, quality of life, and anorectal physiology assessments in older versus younger women with fecal incontinence. DESIGN This was a cross-sectional study. SETTINGS This study was conducted at a tertiary genitorectal disorder clinic. PATIENTS Women presenting for fecal incontinence evaluation between 2003 and 2016 were classified as older or younger based on age ≥65 or <65 years. MAIN OUTCOME MEASURES The main outcomes were symptom-specific quality of life and distress measured by validated questionnaires (the Modified Manchester Health Questionnaire containing the Fecal Incontinence Severity Index); anorectal physiology and anatomy were assessed by manometry and endoanal ultrasound. RESULTS Of 879 subjects, 286 and 593 were classified as older and younger (mean ages, 71.4 ± 5.3 y and 51.3 ± 10.5 y). Solid stool leakage was more frequent in older women (83.2% vs 76.7%; p = 0.03), whereas liquid stool leakage (83.2% vs 82.8%; p = 0.88) and fecal urgency (76.9% vs 78.8%; p = 0.54) did not differ between groups. Mean symptom severity scores were similar between groups (28.0 ± 11.9 and 27.6 ± 13.5; p = 0.69); however, there was greater negative impact on quality of life among younger women (46.3 ± 22.0 vs 51.8 ± 21.8; p < 0.01). Multivariable linear regression controlling for pertinent covariates revealed younger age as an independent predictor for worse condition-specific quality-of-life scores (p < 0.01). Squeeze pressures were similar between groups, whereas younger women had greater resting pressures and higher rates of sphincter defects (external, 7.7% vs 20.2%; internal, 12.2% vs 26.8%; both p < 0.01). LIMITATIONS This study was limited by its lack of patient obstetric history and the duration of their incontinence symptoms. CONCLUSIONS Characteristics differ between older and younger women seeking care for fecal incontinence. The differential impact and age-related phenotypes may provide useful information for patient counseling and developing management algorithms for women with fecal incontinence. See Video Abstract at http://links.lww.com/DCR/A910.
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18
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Pinto RA, Corrêa Neto IJF, Nahas SC, Froehner Junior I, Soares DFM, Cecconello I. IS THE PHYSICIAN EXPERTISE IN DIGITAL RECTAL EXAMINATION OF VALUE IN DETECTING ANAL TONE IN COMPARISON TO ANORECTAL MANOMETRY? ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:79-83. [PMID: 31141075 DOI: 10.1590/s0004-2803.201900000-04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/23/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient's complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient's management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient's history was blinded for the examiner's knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.
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Affiliation(s)
- Rodrigo Ambar Pinto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
| | | | - Sérgio Carlos Nahas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
| | - Ilario Froehner Junior
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
| | | | - Ivan Cecconello
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
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19
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Ng SY, Colborn KL, Cambridge L, Cercek A, Reidy-Lagunes DL, Segal N, Stadler Z, Saltz LB, Paty PB, Guillem J, Weiser MR, Nash G, Garcia-Aguilar J, Goodman KA. Induction Chemotherapy Reduces Patient-reported Toxicities During Neoadjuvant Chemoradiation with Intensity Modulated Radiotherapy for Rectal Cancer. Clin Colorectal Cancer 2019; 18:167-174. [PMID: 31104990 DOI: 10.1016/j.clcc.2019.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Initial treatment with either neoadjuvant chemoradiation (CRT) or induction FOLFOX (5-Fluorouracil, leucovorin, and oxaliplatin) chemotherapy followed by CRT is considered standard treatment for locally advanced rectal cancer. We compared patient-reported outcomes (PRO) during CRT in patients who had received induction chemotherapy versus those who did not. PATIENTS AND METHODS We reviewed records of patients with locally advanced rectal cancer who were treated with CRT between September 2009 and October 2014, and who had completed ≥ 4 PRO assessments during treatment. Clinician- and patient-reported toxicities were collected each week during treatment. We fit binomial generalized linear models to maximum toxicity scores across all patients' visits. RESULTS Of 123 patients with ≥ 4 PRO assessments, 87 (71%) patients reported a clinically meaningful PRO score of 3 or higher for diarrhea, and 91 (74%) patients reported a PRO score of ≥ 3 for urgency, during 1 or more weeks of treatment, corresponding to 'very frequent' or worse. Of 116 patients who had also completed ≥ 4 clinician-reported assessments for descriptive analysis, clinically significant diarrhea (Common Terminology Criteria for Adverse Events grade ≥ 2) was reported in 9% of patients, and grade 2 proctitis and cystitis were reported in 20% and 4%, respectively. Eighty-four (68%) patients had undergone induction chemotherapy prior to CRT. Patients who received induction chemotherapy had 68% lower odds of experiencing significant urgency (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.11-0.95; P = .04), 76% lower odds of bleeding (OR, 0.24; 95% CI, 0.1-0.62; P < .01), and 75% lower odds of tenesmus (OR, 0.25; 95% CI, 0.11-0.6; P < .01) versus those treated with upfront CRT. CONCLUSION Based on PROs, a high proportion of patients experienced clinically significant symptoms during pelvic CRT, with diarrhea and urgency being most commonly reported. This appears to be under-reported on clinician-reported assessments. Delivery of induction chemotherapy was associated with lower odds of experiencing urgency, bleeding, and tenesmus on PROs during subsequent CRT, with no significant impact on diarrhea and rectal pain.
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Affiliation(s)
- Shu Y Ng
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathryn L Colborn
- Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Denver, CO
| | - Lajhem Cambridge
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Neil Segal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zsofia Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Philip B Paty
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jose Guillem
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin R Weiser
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Garrett Nash
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julio Garcia-Aguilar
- Department of Colorectal Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Denver, CO.
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20
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Yue Y, Wang X, Yang H, Sun M, Chen S, Qian H, Xu T, Yan S. Clinical efficacy of the traditional Chinese herbal formula, (Tong Bian Decoction) on laxative dependence constipation in elderly persons: A randomized, multicenter, controlled trial. Eur J Integr Med 2018. [DOI: 10.1016/j.eujim.2018.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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21
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Khan MS, Roberts MS. Challenges and innovations of drug delivery in older age. Adv Drug Deliv Rev 2018; 135:3-38. [PMID: 30217519 DOI: 10.1016/j.addr.2018.09.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/31/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.
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22
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Frudinger A, Marksteiner R, Pfeifer J, Margreiter E, Paede J, Thurner M. Skeletal muscle-derived cell implantation for the treatment of sphincter-related faecal incontinence. Stem Cell Res Ther 2018; 9:233. [PMID: 30213273 PMCID: PMC6136163 DOI: 10.1186/s13287-018-0978-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 12/21/2022] Open
Abstract
Background In an earlier pilot study with 10 women, we investigated a new approach for therapy of faecal incontinence (FI) due to obstetric trauma, involving ultrasound-guided injection of autologous skeletal muscle-derived cells (SMDC) into the external anal sphincter (EAS), and observed significant improvement. In the current study, we tested this therapeutic approach in an extended patient group: male and female patients suffering from FI due to EAS damage and/or atrophy. Furthermore, feasibility of lower cell counts and cryo-preserved SMDC was assessed. Methods In this single-centre, explorative, baseline-controlled clinical trial, each patient (n = 39; mean age 60.6 ± 13.81 years) received 79.4 ± 22.5 × 106 cryo-preserved autologous SMDC. Changes in FI parameters, Fecal Incontinence Quality of Life (FIQL), anorectal manometry and safety from baseline to 1, 6 and 12 months post implantation were evaluated. Results SMDC used in this trial contained a high percentage of myogenic-expressing (CD56+) and muscle stem cell marker-expressing (Pax7+, Myf5+) cells. Intervention was well tolerated without any serious adverse events. After 12 months, the number of weekly incontinence episodes (WIE, primary variable), FIQL and patient condition had improved significantly. In 80.6% of males and 78.4% of females, the WIE frequency decreased by at least 50%; Wexner scores and severity of FI complaints decreased significantly, independent of gender and cause of FI. Conclusions Injection of SMDCs into the EAS effectively improved sphincter-related FI due to EAS damage and/or atrophy in males and females. When confirmed in a larger, placebo-controlled trial, this minimal invasive procedure has the potential to become first-line therapy for FI. Trial registration EU Clinical Trials Register, EudraCT 2010-023826-19 (Date of registration: 08.11.2010).
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Affiliation(s)
- Andrea Frudinger
- Department of Obstetrics and Gynaecology, Division of Gynaecology, Medical University of Graz, Auenbruggerplatz 14, 8036, Graz, Austria.
| | | | - Johann Pfeifer
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Eva Margreiter
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Johannes Paede
- B-K Ultrasound, Pascalkehre 13, 25451, Quickborn, Germany
| | - Marco Thurner
- Innovacell Biotechnologie AG, Science Park, Innsbruck, Austria
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23
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Gamage PPKM, Patel BA, Yeoman MS, Ranson RN, Saffrey MJ. Interstitial cell network volume is reduced in the terminal bowel of ageing mice. J Cell Mol Med 2018; 22:5160-5164. [PMID: 30047236 PMCID: PMC6156346 DOI: 10.1111/jcmm.13794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 12/15/2022] Open
Abstract
Ageing is associated with impaired neuromuscular function of the terminal gastrointestinal (GI) tract, which can result in chronic constipation, faecal impaction and incontinence. Interstitial cells of cajal (ICC) play an important role in regulation of intestinal smooth muscle contraction. However, changes in ICC volume with age in the terminal GI tract (the anal canal including the anal sphincter region and rectum) have not been studied. Here, the distribution, morphology and network volume of ICC in the terminal GI tract of 3‐ to 4‐month‐old and 26‐ to 28‐month‐old C57BL/6 mice were investigated. ICC were identified by immunofluorescence labelling of wholemount preparations with an antibody against c‐Kit. ICC network volume was measured by software‐based 3D volume rendering of confocal Z stacks. A significant reduction in ICC network volume per unit volume of muscle was measured in aged animals. No age‐associated change in ICC morphology was detected. The thickness of the circular muscle layer of the anal sphincter region and rectum increased with age, while that in the distal colon decreased. These results suggest that ageing is associated with a reduction in the network volume of ICC in the terminal GI tract, which may influence the normal function of these regions.
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Affiliation(s)
| | - Bhavik A Patel
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK.,Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK
| | - Mark S Yeoman
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK.,Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK
| | - Rachel N Ranson
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - M Jill Saffrey
- School of Life, Health and Chemical Sciences, Open University, Milton Keynes, UK.,Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
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24
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Kupsch J, Jackisch T, Matzel KE, Zimmer J, Schreiber A, Sims A, Witzigmann H, Stelzner S. Outcome of bowel function following anterior resection for rectal cancer-an analysis using the low anterior resection syndrome (LARS) score. Int J Colorectal Dis 2018. [PMID: 29541896 DOI: 10.1007/s00384-018-3006-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Severity of anorectal dysfunction after low anterior resection is associated with various patient- and treatment-related factors. We aimed to quantify anorectal dysfunction after treatment for rectal cancer using the low anterior resection syndrome (LARS) score. METHODS We retrieved from a prospective database 331 eligible patients on whom anterior resection for rectal cancer had been performed from 2000 to 2014. All patients were sent a LARS score accompanied by a supplementary questionnaire. Response rate was 78.8% (261 patients). The main outcome measure was the relation of the LARS score to potentially associated patient and treatment factors. Secondary endpoints were further measures that reflect anorectal dysfunction, e.g., Vaizey score. RESULTS Overall, 144 (55.2%) patients exhibited scores > 20 reflecting minor (n = 51 (19.5%)) or major (n = 93 (35.6%)) LARS. A significant difference for scores > 20 was found for intersphincteric resection (IR, 73.2% affected patients) compared to total mesorectal excision (TME, 58.4%) and partial mesorectal excision (PME, 38.0%, p = 0.001). Radio(chemo)therapy resulted in LARS scores > 20 in 64.6% of patients compared to 43.1% in patients without irradiation (p = 0.001). Type of procedure (TME and IR as compared to PME), radio(chemo)therapy, and younger age were independently associated with LARS in logistic regression analysis. However, younger age remained the only independent factor for higher scores after exclusion of PME. CONCLUSIONS The LARS score identified a substantial proportion of patients after surgery for rectal cancer with anorectal dysfunction. The extent of surgical procedure is independently associated with the severity of symptoms whereas the role of radiotherapy needs further assessment.
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Affiliation(s)
- Juliane Kupsch
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Thomas Jackisch
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Klaus E Matzel
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Joerg Zimmer
- Department of Radiation Therapy, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Andreas Schreiber
- Department of Radiation Therapy, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Anja Sims
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Helmut Witzigmann
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Sigmar Stelzner
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany.
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Al-Momani LA, Arikapudi S, Gaddam S, Treece J, Rashid S, Baumrucker S. Home-Based Treatment for Chronic Constipation. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2018. [DOI: 10.1177/1084822317746403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Saima Rashid
- East Tennessee State University, Johnson City, TN, USA
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Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, Christensen P, Laurberg S, Moran BJ. Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut 2018; 67:688-696. [PMID: 28115491 DOI: 10.1136/gutjnl-2016-312695] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/22/2016] [Accepted: 12/28/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Bowel dysfunction is common following a restorative rectal cancer resection, but symptom severity and the degree of quality of life impairment is highly variable. An internationally validated patient-reported outcome measure, Low Anterior Resection Syndrome (LARS) score, now enables these symptoms to be measured. The study purpose was: (1) to develop a model that predicts postoperative bowel function; (2) externally validate the model and (3) incorporate these findings into a nomogram and online tool in order to individualise patient counselling and aid preoperative consent. DESIGN Patients more than 1 year after curative restorative anterior resection (UK, median 54 months; Denmark (DK), 56 months since surgery) were invited to complete The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 version3 (EORTC QLQ-C30 v3), LARS and Wexner incontinence scores. Demographics, tumour characteristics, preoperative/postoperative treatment and surgical procedures were recorded. Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, risk factors for bowel dysfunction were independently assessed by advanced linear regression shrinkage techniques for each dataset (UK:DK). RESULTS Patients in the development (UK, n=463) and validation (DK, n=938) datasets reported mean (SD) LARS scores of 26 (11) and 24 (11), respectively. Key predictive factors for LARS were: age (at surgery); tumour height, total versus partial mesorectal excision, stoma and preoperative radiotherapy, with satisfactory model calibration and a Mallow's Cp of 7.5 and 5.5, respectively. CONCLUSIONS The Pre-Operative LARS score (POLARS) is the first nomogram and online tool to predict bowel dysfunction severity prior to anterior resection. Colorectal surgeons, gastroenterologist and nurse specialists may use POLARS to help patients understand their risk of bowel dysfunction and to preoperatively highlight patients who may require additional postoperative support.
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Affiliation(s)
- Nick J Battersby
- The Pelican Cancer Foundation, The Ark, Basingstoke, Hampshire, UK.,Department of Colorectal and Peritoneal Malignancy Surgery, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - George Bouliotis
- Department of Clinical Statistics, Imperial College London, London, UK
| | | | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Rob Glynne-Jones
- Radiotherapy Department, Mount-Vernon Cancer Centre, Mount-Vernon Hospital, Northwood, UK
| | - Graham Branagan
- Department of Colorectal Surgery, Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
| | | | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Brendan J Moran
- The Pelican Cancer Foundation, The Ark, Basingstoke, Hampshire, UK.,Department of Colorectal and Peritoneal Malignancy Surgery, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
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Brusa T, Abler D, Tutuian R, Gingert C, Heverhagen JT, Adamina M, Brügger LE, Büchler P. Anatomy and mechanical properties of the anal sphincter muscles in healthy senior volunteers. Neurogastroenterol Motil 2018; 30. [PMID: 29542838 DOI: 10.1111/nmo.13335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/13/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND A large proportion of age-related fecal incontinence is attributed to weakness or degeneration of the muscles composing the anal continence organ. However, the individual role of these muscles and their functional interplay remain poorly understood. METHODS This study employs a novel technique based on the combination of MR imaging and FLIP measurements (MR-FLIP) to obtain anatomical and mechanical information simultaneously. Unlike previous methods used to assess the mechanics of the continence organ, MR-FLIP allows inter-individual comparisons and statistical analysis of the sphincter morpho-mechanical parameters. The anatomy as well as voluntary and involuntary mechanical properties of the anal continence organ were characterized in 20 healthy senior volunteers. RESULTS Results showed that the external anal sphincter (EAS) forms a funnel-like shape with wall thickness increasing by a factor of 2.5 from distal (6 ± 0 mm) to proximal (15 ± 3 mm). Both voluntary and involuntary mechanical properties in this region correlate strongly with the thickness of the muscle. The positions of least compliance and maximal orifice closing were both located toward the proximal EAS end. In addition, maximal contraction during squeeze maneuvers was reached after 2 s, but high muscle fatigue was measured during a 7 s holding phase, corresponding to about 60% loss of the energy produced by the muscles during the contraction phase. CONCLUSIONS This work reports baseline parameters describing the morpho-mechanical condition of the sphincter muscle of healthy elderly volunteers. New parameters were also proposed to quantify the active properties of the muscles based on the mechanical energy associated with muscle contraction and fatigue. This information could be used to assess patients suffering from AI or for the design of novel implants.
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Affiliation(s)
- T Brusa
- Institute for Surgical Technology and Biomechanics (ISTB), University of Bern, Bern, Switzerland
| | - D Abler
- Institute for Surgical Technology and Biomechanics (ISTB), University of Bern, Bern, Switzerland
| | - R Tutuian
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - C Gingert
- Clinic for Visceral- and Thoracic Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Faculty of Health, Department of Human Medicine, University of Witten/Herdecke, Witten, Germany
| | - J T Heverhagen
- University Institute of Diagnostic, Interventional and Pediatric Radiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Adamina
- Clinic for Visceral- and Thoracic Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Basel, Basel, Switzerland
| | - L E Brügger
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - P Büchler
- Institute for Surgical Technology and Biomechanics (ISTB), University of Bern, Bern, Switzerland
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Baffy N, Foxx-Orenstein AE, Harris LA, Sterler S. Intractable Constipation in the Elderly. ACTA ACUST UNITED AC 2017; 15:363-381. [PMID: 28801825 DOI: 10.1007/s11938-017-0142-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.
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Affiliation(s)
- Noemi Baffy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
| | - Amy E Foxx-Orenstein
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA.
| | - Lucinda A Harris
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
| | - Susan Sterler
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
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Age and Dyssynergia Subtypes Associated With Normal Sphincter Pressures in Women With Fecal Incontinence. Female Pelvic Med Reconstr Surg 2017; 24:247-251. [PMID: 28657991 DOI: 10.1097/spv.0000000000000415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Fecal incontinence (FI) is frequently associated with low sphincter pressures, sensory abnormalities, and advanced age. Twenty-three percent of patients with FI and 22% of healthy patients demonstrate dyssynergic defecation (DD) on high-resolution anorectal manometry. Overflow incontinence occurs in some DD patients with normal resting and squeeze anal sphincter pressures. Our aim was to identify factors associated with normal sphincter pressures in women with FI. METHODS We reviewed medical records of 134 women with FI. Patients with normal resting and squeeze anal pressures were compared with those with abnormal pressures using Wilcoxon rank sum test and Fisher exact. Multivariable logistic regression was performed to identify factors associated with normal resting and squeeze anal pressures. RESULTS Among 134 women, abnormal resting and/or squeeze pressures were identified in 113 and normal pressures were identified in 21. Women with normal sphincter pressures were younger (mean age 52.7 ± 10.8 years vs 59.0 ± 14.0 years, P = 0.036), more often had abnormal defecation indices (100% vs 83.2%, P = 0.043) and higher rectal defecation pressures (30.8 ± 18.8 mm Hg vs 50.8 ± 22.6 mm Hg, P < 0.001). There was an overall association between DD subtype and normal and abnormal sphincter pressure groups (P = 0.021). Dyssynergia subtypes I or III (odds ratio, 7.2; 95% confidence interval, 1.8-28.8) and age younger than 67 years (odds ratio, 8.5; 95% confidence interval, 1.5-48.6) were associated with greater odds of having normal sphincter pressures. CONCLUSIONS Female FI patients with normal anal sphincter pressures are younger, have higher rectal defecation pressures, and more often have type I or type III DD.
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Epidemiology, Pathophysiology and Management of Fecal Incontinence in the Older Woman. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0201-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lin LH, Siu JJY, Liao PC, Chiang JH, Chou PC, Chen HY, Ho TJ, Tsai MY, Chen YH, Chen WC. Association of chronic obstructive pulmonary disease and hemorrhoids: A nationwide cohort study. Medicine (Baltimore) 2017; 96:e6281. [PMID: 28272246 PMCID: PMC5348194 DOI: 10.1097/md.0000000000006281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
According to traditional Chinese medicine (TCM) theory, a specific physiological and pathological relationship exists between the lungs and the large intestine. The aim of this study is to delineate the association of chronic obstructive pulmonary disease (COPD) and hemorrhoids in order to verify the "interior-exterior" relationship between the lungs and the large intestine. A retrospective cohort study is conceived from the National Health Insurance Research Database, Taiwan. The 2 samples (COPD cohort and non-COPD cohort) were selected from the 2000 to 2003 beneficiaries of the NHI, representing patients age 20 and older in Taiwan, with the follow-up ending on December 31, 2011. The COPD cohort (n = 51,506) includes every patient newly diagnosed as having Chronic Obstructive Pulmonary Disease (COPD, ICD-9-CM: 490-492, 494, 496), who have made at least 2 confirmed visits to the hospital/clinic. The non-COPD cohort (n = 103,012) includes patients without COPD and is selected via a 1:2 (COPD: non-COPD) matching by age group (per 5 years), gender, and index date (diagnosis date of COPD for the COPD cohort). Compared with non-COPD cohorts, patients with COPD have a higher likelihood of having hemorrhoids and the age-, gender- and comorbidies-adjusted hazard ratio (HR) for hemorrhoids is 1.56 (95% confidence intervals [CI]:1.50-1.62). The adjusted HR of hemorrhoids for females is 0.79 (95% CI: 0.77-0.83), which is significantly less than that for males. The elderly groups, 40 to 59 years and aged 60 or above, have higher adjusted HRs than younger age groups (20-39 years), 1.19 (95% CI: 1.14-1.26), and 1.18 (95% CI: 1.12-1.24), respectively. Patients with COPD may have a higher likelihood to have hemorrhoids in this retrospective cohort study. This study verifies the fundamental theorem of TCM that there is a definite pathogenic association between the lungs and large intestine.
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Affiliation(s)
- Lih-Hwa Lin
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Division of Chinese Medicine, An Nan Hospital, China Medical University, Tainan
| | - Justin Ji-Yuen Siu
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Departments of Urology, Chinese Medicine, Medical Research, and Obstetrics and Gynecology, Management Office for Health Data, China Medical University Hospital
| | - Po-Chi Liao
- Department of Urology, Taichung Veterans General Hospital
| | - Jen-Huai Chiang
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Departments of Urology, Chinese Medicine, Medical Research, and Obstetrics and Gynecology, Management Office for Health Data, China Medical University Hospital
| | - Pei-Chi Chou
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Departments of Urology, Chinese Medicine, Medical Research, and Obstetrics and Gynecology, Management Office for Health Data, China Medical University Hospital
| | - Huey-Yi Chen
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Departments of Urology, Chinese Medicine, Medical Research, and Obstetrics and Gynecology, Management Office for Health Data, China Medical University Hospital
| | - Tsung-Jung Ho
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Division of Chinese Medicine, An Nan Hospital, China Medical University, Tainan
- Division of Chinese Medicine, China Medical University Beigang Hospital, Yunlin
| | - Ming-Yen Tsai
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yung-Hsiang Chen
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Departments of Urology, Chinese Medicine, Medical Research, and Obstetrics and Gynecology, Management Office for Health Data, China Medical University Hospital
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung
| | - Wen-Chi Chen
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, Graduate Institute of Integrated Medicine, College of Chinese Medicine, College of Medicine, Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung
- Departments of Urology, Chinese Medicine, Medical Research, and Obstetrics and Gynecology, Management Office for Health Data, China Medical University Hospital
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Ng SY, Colborn KL, Cambridge L, Hajj C, Yang TJ, Wu AJ, Goodman KA. Acute toxicity with intensity modulated radiotherapy versus 3-dimensional conformal radiotherapy during preoperative chemoradiation for locally advanced rectal cancer. Radiother Oncol 2016; 121:252-257. [PMID: 27751605 DOI: 10.1016/j.radonc.2016.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE We examined acute toxicity profiles and outcomes among rectal cancer patients treated with pre-operative chemoradiation using intensity modulated radiotherapy (IMRT) or 3-dimensional conformal radiotherapy (3DCRT) to identify predictive clinical factors associated with increased acute toxicity. MATERIAL AND METHODS We retrospectively reviewed records of 301 consecutive rectal cancer patients treated with pre-operative chemotherapy and radiotherapy (median dose 5000cGy) at our institution between 2007 and 2014. RESULTS Of the 301 patients, 203 (67.4%) were treated with IMRT and 98 (32.6%) with 3DCRT. Significantly more patients experienced ⩾grade 2 diarrhea in the 3DCRT group compared to the IMRT group (22% vs 10%, p=0.004), and those who received 3DCRT had 2.7 times greater odds of a higher diarrhea score than those on IMRT, even after adjusting for patient characteristics and chemotherapy (OR 2.71, p=0.01) Fewer patients experienced grade 2 genitourinary toxicity in the IMRT group (6% vs 13% 3DCRT, p=0.04) and there was a trend toward decreased grade 2 proctitis in the IMRT group (22% vs 32% 3DCRT, p=0.07). Patients over the age of 55 had 45% lower odds of proctitis than patients younger than 55. CONCLUSION The use of IMRT significantly reduced grade ⩾2 diarrhea and GU toxicity during chemoradiation. Younger patients were more likely to report grade 2 or higher proctitis.
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Affiliation(s)
- Shu Y Ng
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Kathryn L Colborn
- Division of Health Care Policy and Research, Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Denver School of Medicine, USA
| | - Lajhem Cambridge
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, USA.
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Abstract
Fecal incontinence affects patients of all sexes, races, and ethnicities; however, those affected often are afraid or too embarrassed to ask for help. Attention to risk factors and directed physical examinations can help healthcare providers diagnose and formulate treatment plans. Numerous diagnostic tests are available. Diligent follow-up is needed to direct patients to second-line therapies such as sacral nerve stimulation or surgical procedures.
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Abstract
Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.
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Sokol ER. Management of fecal incontinence - focus on a vaginal insert for bowel control. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:85-91. [PMID: 27274318 PMCID: PMC4869843 DOI: 10.2147/mder.s86483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Fecal incontinence, also referred to as accidental bowel leakage, is a debilitating condition that impacts quality of life in a significant number of women. Current treatments for fecal incontinence include behavioral modification, biofeedback, drug therapy, and invasive surgical procedures. However, these treatments have suboptimal efficacy due to patient adherence, variability of presentation across patients, cost, and additional health risks. A vaginal bowel control system (Eclipse™ System) was developed to offer a low-risk, effective, and patient-managed approach to treating accidental bowel leakage. The vaginal bowel control system consists of a vaginal insert and user-controlled, pressure-regulated pump. Once inflated, the balloon of the vaginal insert is directed posteriorly to occlude the rectum, allowing the woman to immediately regain control of bowel function. This article will introduce the design evolution and feasibility studies of the Eclipse System. In addition, this review will discuss the results from a recent clinical trial that demonstrated the safety and efficacy of the vaginal bowel control system in managing fecal incontinence and other symptoms of bowel dysfunction.
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Affiliation(s)
- Eric R Sokol
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Kornmann VNN, Walma MS, de Roos MAJ, Boerma D, van Westreenen HL. Quality of Life After a Low Anterior Resection for Rectal Cancer in Elderly Patients. Ann Coloproctol 2016; 32:27-32. [PMID: 26962533 PMCID: PMC4783508 DOI: 10.3393/ac.2016.32.1.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/13/2015] [Indexed: 11/18/2022] Open
Abstract
Purpose Fecal incontinence is a major concern, and its incidence increases with age. Quality of life may decrease due to fecal incontinence after both sphincter-saving surgery and a rectal resection with a permanent stoma. This study investigated quality of life, with regard to fecal incontinency, in elderly patients after rectal-cancer surgery. Methods All patients who underwent elective rectal surgery with anastomosis for rectal cancer between December 2008 and June 2012 at two Dutch hospitals were eligible for inclusion. The Wexner and the fecal incontinence quality of life (FIQoL) scores were collected. Young (<70 years of age) and elderly (≥70 years of age) patients were compared. Results Seventy-nine patients were included, of whom 19 were elderly patients (24.1%). All diverting stomas that had been placed (n = 60, 75.9%) had been closed at the time of the study. There were no differences in Wexner or FIQoL scores between the young and the elderly patients. Also, there were no differences between patients without a diverting stoma and patients in whom bowel continuity had been restored. Elderly females had significantly worse scores on the FIQoL subscales of coping/behavior (P = 0.043) and depression/self-perception (P = 0.004) than young females. Elderly females scored worse on coping/behavior (P = 0.010) and depression/self-perception (P = 0.036) than elderly males. Young and elderly males had comparable scores. Conclusion Quality of life with regard to fecal incontinency is worse in elderly females after sphincter-preserving surgery for rectal cancer. Patients should be informed of this impact, and a definite stoma may be considered in this patient group.
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Affiliation(s)
| | - Marieke S Walma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Abstract
PURPOSE OF REVIEW This article reviews the impact of ageing on the gastrointestinal tract, including effects on the absorption of nutrients and drugs and the gastrointestinal tract defence system against ingested pathogens. RECENT FINDINGS Recent publications support earlier observations of an age-related selective decline in gut function including changes in taste, oesophageal sphincter motility, gastric emptying, and neurons of the myenteric plexus related to gut transit which may impact the nutritional status. Ageing is also associated with structural and functional mucosal defence defects, diminished abilities to generate protective immunity, and increased incidence of inflammation and oxidative stress. A number of gastrointestinal disorders occur more frequently in the elderly population. SUMMARY Alterations in gut function with ageing have particular implications for oesophageal, gastric, and colonic motility. Older individuals are particularly susceptible to malnutrition, postprandial hypotension, dysphagia, constipation, and faecal incontinence. Decrease in the number of nerve cells of the myenteric plexus that impact digestive absorption and the surface area of the small intestine because of degeneration of villi may lead to blunted absorption of nutrients. Impairment of the intestinal immune system as a result of ageing, including the mucosal layer of the gastrointestinal tract, appears to be a significant contributor to the age-related increase in the incidence and severity of infections.
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Affiliation(s)
- Stijn Soenen
- National Health and Medical Research Council of Australia (NHMRC), Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Royal Adelaide Hospital, South Australia, Australia
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Soh JS, Lee HJ, Jung KW, Yoon IJ, Koo HS, Seo SY, Lee S, Bae JH, Lee HS, Park SH, Yang DH, Kim KJ, Ye BD, Byeon JS, Yang SK, Kim JH, Myung SJ. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol 2015; 110:1197-204. [PMID: 26032152 DOI: 10.1038/ajg.2015.153] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 04/20/2015] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Jae Seung Soh
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Jeong Lee
- 1] Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea [2] Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In Ja Yoon
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyun Sook Koo
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So Young Seo
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seohyun Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Ho Bae
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho-Su Lee
- 1] Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea [2] Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Vazquez Roque M, Bouras EP. Epidemiology and management of chronic constipation in elderly patients. Clin Interv Aging 2015; 10:919-30. [PMID: 26082622 PMCID: PMC4459612 DOI: 10.2147/cia.s54304] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Constipation is a common functional gastrointestinal disorder, with prevalence in the general population of approximately 20%. In the elderly population the incidence of constipation is higher compared to the younger population, with elderly females suffering more often from severe constipation. Treatment options for chronic constipation (CC) include stool softeners, fiber supplements, osmotic and stimulant laxatives, and the secretagogues lubiprostone and linaclotide. Understanding the underlying etiology of CC is necessary to determine the most appropriate therapeutic option. Therefore, it is important to distinguish from pelvic floor dysfunction (PFD), slow and normal transit constipation. Evaluation of a patient with CC includes basic blood work, rectal examination, and appropriate testing to evaluate for PFD and slow transit constipation when indicated. Pelvic floor rehabilitation or biofeedback is the treatment of choice for PFD, and its efficacy has been proven in clinical trials. Surgery is rarely indicated in CC and can only be considered in cases of slow transit constipation when PFD has been properly excluded. Other treatment options such as sacral nerve stimulation seem to be helpful in patients with urinary dysfunction. Botulinum toxin injection for PFD cannot be recommended at this time with the available evidence. CC in the elderly is common, and it has a significant impact on quality of life and the use of health care resources. In the elderly, it is imperative to identify the etiology of CC, and treatment should be based on the patient’s overall clinical status and capabilities.
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Affiliation(s)
- Maria Vazquez Roque
- Gastroenterology and Hepatology Department, Mayo Clinic, Jacksonville, FL, USA
| | - Ernest P Bouras
- Gastroenterology and Hepatology Department, Mayo Clinic, Jacksonville, FL, USA
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Motilitätsstörungen des Dickdarms. Internist (Berl) 2015; 56:648-52. [DOI: 10.1007/s00108-014-3607-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brisinda G, Bianco G, Silvestrini N, Maria G. Cost considerations in the treatment of anal fissures. Expert Rev Pharmacoecon Outcomes Res 2014; 14:511-25. [PMID: 24867398 DOI: 10.1586/14737167.2014.924398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital "Agostino Gemelli", Largo Agostino Gemelli 8, 00168, Rome, Italy
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