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Clemente N, Yagnik VD, James KCW. A new scoring system on the horizon to assess fecal incontinence: Garg Incontinence Scores (GIS). Updates Surg 2024; 76:723-724. [PMID: 38150156 DOI: 10.1007/s13304-023-01742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Nicola Clemente
- U.O. ChirugiaOspedale di Montebelluna (TV), AULSS 2 Marca Tevigiana, Treviso, Italy
| | - Vipul D Yagnik
- Department of Surgery, Banas Medical College and Research Institute, Palanpur, Gujarat, 385001, India
| | - Khaw C W James
- Department of Colorectal Surgery, Penang General Hospital, Penang, Malaysia.
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Besendörfer M, Kirchgatter A, Carbon R, Weiss C, Müller H, Matzel KE, Diez S. Sacral neuromodulation for constipation and fecal incontinence in children and adolescents - study protocol of a prospective, randomized trial on the application of invasive vs. non-invasive technique. Trials 2024; 25:210. [PMID: 38515199 PMCID: PMC10958925 DOI: 10.1186/s13063-024-08052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND A therapeutic effect of sacral neuromodulation (SNM) on fecal incontinence (FI) and quality of life has been proven in adults. SNM is, however, rarely used in pediatric cases. The aim of the study is to investigate effects of SNM in pediatric constipation in a prospective parallel-group trial. METHODS A monocentric, randomized, unblinded, parallel-group trial is conducted. SNM is conducted in the invasive variant and in an innovative, external approach with adhesive electrodes (enteral neuromodulation, ENM). We include patients with constipation according to the ROME IV criteria and refractory to conventional options. Patients with functional constipation and Hirschsprung's disease are able to participate. Participants are allocated in a 1:1 ratio to either SNM or ENM group. Clinical data and quality of life is evaluated in regular check-ups. Neuromodulation is applied continuously for 3 months (end point of the study) with follow-up-points at 6 and 12 months. Findings are analyzed statistically considering a 5% significance level (p ≤ 0.05). Outcome variables are defined as change in (1) episodes of abdominal pain, (2) episodes of FI, (3) defecation frequency, (4) stool consistency. Improvement of proprioception, influence on urinary incontinence, quality of life and safety of treatment are assessed as secondary outcome variables. We expect a relevant improvement in both study groups. DISCUSSION This is the first trial, evaluating effects of neuromodulation for constipation in children and adolescents and comparing effects of the invasive and non-invasive application (SNM vs. ENM). TRIAL REGISTRATION The study is registered with clinicaltrials.gov, Identifier NCT04713085 (date of registration 01/14/2021).
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Affiliation(s)
- Manuel Besendörfer
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Annemarie Kirchgatter
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Roman Carbon
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics, and Information Processing, Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, Haus 3, Ebene 4, Mannheim, 68167, Germany
| | - Hanna Müller
- Neonatology and Pediatric Intensive Care, Hospital for Children and Adolescents, University of Marburg, Baldingerstaße, Marburg, 35043, Germany
| | - Klaus E Matzel
- Department of Surgery, Section of Coloproctology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Maximiliansplatz 2, 91054, Erlangen, Germany
| | - Sonja Diez
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany.
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Weimer A, Hallock JL, Chen CCG. Primary care providers practice patterns regarding female pelvic floor disorders. Fam Med Community Health 2024; 12:e002448. [PMID: 38485284 PMCID: PMC10941109 DOI: 10.1136/fmch-2023-002448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
INTRODUCTION Pelvic floor disorders (PFDs) pose substantial physical and psychological burdens for a growing number of women. Given the ubiquity of these conditions and known patient reluctance to seek care, primary care providers (PCPs) have a unique opportunity to increase treatment and provide appropriate referrals for these patients. METHODS An online survey was administered to PCPs to assess provider practices, knowledge, comfort managing and ease of referral for PFDs. Logistic regression was used to assess the association between demographic/practice characteristics of PCPs and two primary outcomes of interest: discomfort with management and difficulty with referral of PFDs. RESULTS Of the 153 respondents to the survey, more felt comfortable managing stress urinary incontinence (SUI) and overactive bladder (OAB), compared with pelvic organ prolapse (POP) and faecal incontinence (FI) and were less likely to refer patients with urinary symptoms. Few providers elicited symptoms for POP and FI as compared with SUI and OAB. Provider variables that were significantly associated with discomfort with management varied by PFD, but tended to correlate with less exposure to PFDs (eg, those with fewer years of practice, and internal medicine and family physicians as compared with geriatricians); whereas the factors that were significantly associated with difficulty in referral, again varied by PFD, but were related to practice characteristics (eg, specialist network, type of practice, practice setting and quantity of patients). CONCLUSION These findings highlight the need to increase PCPs awareness of PFDs and develop effective standardised screening protocols, as well as collaboration with pelvic floor specialists to improve screening, treatment and referral for patients with PFDs.
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Affiliation(s)
- Anna Weimer
- Magee-Women's Hospital of UPMC, Pittsburgh, Pennsylvania, USA
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Cerdán Miguel J, Arroyo Sebastián A, Codina Cazador A, de la Portilla de Juan F, de Miguel Velasco M, de San Ildefonso Pereira A, Jiménez Escovar F, Marinello F, Millán Scheiding M, Muñoz Duyos A, Ortega López M, Roig Vila JV, Salgado Mijaiel G. Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology. Cir Esp 2024; 102:158-173. [PMID: 38242231 DOI: 10.1016/j.cireng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 01/21/2024]
Abstract
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
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Affiliation(s)
| | - Antonio Arroyo Sebastián
- Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - Antonio Codina Cazador
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain
| | | | | | | | | | - Franco Marinello
- Unidad de Cirugía Colorrectal, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mónica Millán Scheiding
- Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Arantxa Muñoz Duyos
- Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Mario Ortega López
- Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Liptak P, Duricek M, Banovcin P. Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step. World J Gastroenterol 2024; 30:516-522. [PMID: 38463021 PMCID: PMC10921147 DOI: 10.3748/wjg.v30.i6.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 01/15/2024] [Indexed: 02/05/2024] Open
Abstract
The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.
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Affiliation(s)
- Peter Liptak
- Clinic of Internal Medicine- Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, Martin 03601, Slovakia
| | - Martin Duricek
- Clinic of Internal Medicine- Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, Martin 03601, Slovakia
| | - Peter Banovcin
- Clinic of Internal Medicine- Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, Martin 03601, Slovakia
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Julienne A, Gourcerol G, Amarenco G, Turmel N, Leroi AM, Desprez C. Fecal Incontinence Subtype Assessment (FI-SA): Validation of a new tool to distinguish among subtypes of fecal incontinence. Clin Res Hepatol Gastroenterol 2024; 48:102275. [PMID: 38158155 DOI: 10.1016/j.clinre.2023.102275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/13/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Three subtypes of fecal incontinence (FI) are described in the literature: urge, mixed and passive FI, but the relevance of this classification remains unknown. To our knowledge, no questionnaire has been validated in a general population of patients with FI to classify patients between the different subtypes of FI. The aim of the present study was to validate the Fecal Incontinence Subtype Assessment (FI-SA) questionnaire in a general population of patients with FI. METHODS All consecutive patients referred to our unit for physiological investigations of anorectal function in case of FI were included. A feasibility study was done to assess the acceptability, understanding, and the reproducibility of the FI-SA questionnaire. Its performance to correctly classify patients between subtypes of FI was evaluated in both a feasibility study and in a validation study, using clinical interview as gold standard. RESULTS The FI-SA questionnaire was found to be well accepted and easily understood by patients. Moreover, it was filled rapidly by patients, with a good reproducibility with an intra-class correlation coefficient of 0.97 and 0.87 for questions 1 and 2. Lastly, the accuracy of the FI-SA questionnaire to predict subtypes of FI was 93.3 % in the feasibility study (n = 30) and 81.1 % in the validation study (n = 100), in comparison with clinical interview as gold standard. CONCLUSION The FI-SA questionnaire could be used in the future to help standardize the methodology used among studies to evaluate the classification of patients in different subtypes of FI and ultimately to guide therapeutics.
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Affiliation(s)
- Audrey Julienne
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France
| | - Guillaume Gourcerol
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France; Normandie Univ, UNIROUEN, Nutrition, Brain and Gut Laboratory, INSERM 1073, F-76000 Rouen, France
| | - Gérard Amarenco
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, 75020 Paris, France
| | | | - Anne-Marie Leroi
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France; Normandie Univ, UNIROUEN, Nutrition, Brain and Gut Laboratory, INSERM 1073, F-76000 Rouen, France; CHU Rouen, INSERM CIC-CRB 1404, F-76000 Rouen, France
| | - Charlotte Desprez
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France; Normandie Univ, UNIROUEN, Nutrition, Brain and Gut Laboratory, INSERM 1073, F-76000 Rouen, France.
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Hudgi A, Yan Y, Ayyala D, Rao SSC. Accuracy of patient-reported bowel symptoms for fecal incontinence: Historical recall versus prospective evaluation. Neurogastroenterol Motil 2024; 36:e14714. [PMID: 37994807 PMCID: PMC10842103 DOI: 10.1111/nmo.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Fecal incontinence (FI) is characterized by both irregular and unpredictable bowel symptoms. An accurate history of symptoms is important for diagnosis and guiding management. Whether a patient's history of bowel symptoms is reliable or if there is recall bias is unknown. AIM To evaluate the accuracy of FI symptoms based on patient's recall compared with a prospective stool diary. METHODS FI (Rome IV) patients completed a bowel questionnaire that included leakage episodes and stool consistency. Subsequently they completed a one-week FI stool diary. Agreement and correlation between historical recall and stool diary were compared. RESULTS One hundred patients participated. On average they reported 12 bowel movements (BMs) and five FI episodes per week. Fifty-two percent had completed under-graduation, 33% high school and 15% postgraduation. Using recall, 23% of patients accurately reported the number of FI episodes, whereas 41% underestimated and 36% overestimated its prevalence compared to the FI diary. Similarly, the concordance for the number of BMs was 30%, urgency was 54%, amount of stool leakage was 16%, and stool consistency was 12.5%. The concordance for nocturnal FI events, use of pads and lack of stool awareness were 63%, 75%, and 66.6% respectively. CONCLUSION There is poor concordance for key bowel symptoms including the number of FI episodes as reported by FI patients, suggesting significant recall bias. Thus, historical recall of chronic FI symptoms may be less accurate. A prospective stool diary could provide more accurate information for the evaluation of FI patients.
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Affiliation(s)
- Amit Hudgi
- Division of Neurogastroenterology/Motility, Augusta University, Augusta, Georgia, USA
| | - Yun Yan
- Division of Neurogastroenterology/Motility, Augusta University, Augusta, Georgia, USA
| | | | - Satish S C Rao
- Division of Neurogastroenterology/Motility, Augusta University, Augusta, Georgia, USA
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Tsarkov P, Tulina I, Sheikh P, Shlyk DD, Garg P. Garg incontinence scores: New scoring system on the horizon to evaluate fecal incontinence. Will it make a difference? World J Gastroenterol 2024; 30:204-210. [PMID: 38314129 PMCID: PMC10835531 DOI: 10.3748/wjg.v30.i3.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024] Open
Abstract
The main aim of this opinion review is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. The authors in the published article developed a new scoring system, Garg incontinence scores (GIS), for fecal incontinence (FI). FI is a chronic debilitating disease that has a severe negative impact on the quality of life of the patients. Rome IV criteria define FI as multiple episodes of solid or liquid stool passed into the clothes at least twice a month. The associated social stigmatization often leads to significant under-reporting of the condition, which further impairs management. An important point is that the complexity and vagueness of the disease make it difficult for the patients to properly define and report the magnitude of the problem to their physicians. Due to this, the management becomes even more difficult. This issue is resolved up to a considerable extent by a scoring questionnaire. There were several scoring systems in use for the last three decades. The prominent of them were the Cleveland Clinic scoring system or the Wexner scoring system, St. Marks Hospital or Vaizey's scores, and the FI severity index. However, there were several shortcomings in these scoring systems. In the opinion review, we tried to analyze the strength of GIS and compare it to the existing scoring systems. The main pitfalls in the existing scoring systems were that most of them gave equal weightage to different types of FI (solid, liquid, flatus, etc.), were not comprehensive, and took only the surgeon's perception of FI into view. In GIS, almost all shortcomings of previous scoring systems had been addressed: different weights were assigned to different types of FI by a robust statistical methodology; the scoring system was made comprehensive by including all types of FI that were previously omitted (urge, stress and mucus FI) and gave priority to patients' rather than the physicians' perceptions while developing the scoring system. Due to this, GIS indeed looked like a paradigm shift in the evaluation of FI. However, it is too early to conclude this, as GIS needs to be validated for accuracy and simplicity in future studies.
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Affiliation(s)
- Petr Tsarkov
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Inna Tulina
- Department of Oncologic Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Parvez Sheikh
- Department of Colorectal Surgery, Saifee Hospital, Mumbai 400004, Maharashtra, India
| | - Darya D Shlyk
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
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Aydın ÖG, Baykara HB, Akın K, Kahveci S, Şeker G, Güler Y, Öztürk Y. Evaluation of functional gastrointestinal disorders in children aged 4-10 years with autism spectrum disorder. Turk J Pediatr 2024; 66:57-64. [PMID: 38523379 DOI: 10.24953/turkjped.2023.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND Gastrointestinal system disorders are known to be prevalent among children with autism spectrum disorder (ASD). Some ASD-associated comorbidities are abdominal pain, constipation, diarrhea, gastroesophageal reflux, sleep disturbances, epilepsy, and psychiatric problems. Nonetheless, there is still limited information about the presence of functional GI disorders (FGIDs) among children with ASD, especially in Türkiye. Using the Rome criteria, we aimed to investigate FGIDs in children with ASD. METHODS The sample of the study consisted of 68 children aged 4-10 years, diagnosed with ASD according to the DSM-5 diagnostic criteria and had scores greater than 30 on the Childhood Autism Rating Scale (CARS-2) and an age-sex matched control group (n=78). The Rome III criteria were used to evaluate FGIDs. RESULTS The frequency of FGIDs in the ASD group was higher (76.5%) compared to the control group (p < 0.001). Compared to the control group, abdominal migraine frequency increased 10 times (p=0.012), functional constipation 7 times (p < 0.001), and fecal incontinence 6 times (p < 0.001) in the ASD group. Stool retention was not present in most children in the ASD group who were found to have fecal incontinence. CONCLUSION In this study, the most common FGIDs in the ASD group were abdominal migraine, functional constipation, and non-retentive fecal incontinence. The finding that most children with ASD who had fecal incontinence did not show stool retention implicated social, psychological, and behavioral factors as the causes of incontinence. Raising awareness of healthcare professionals about the frequency of FGIDs in children with ASD will improve many areas in the daily lives of these children.
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Affiliation(s)
- Özlem Gülpınar Aydın
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, School of Medicine, Dokuz Eylul University, İzmir
| | - Hüseyin Burak Baykara
- Department of Child and Adolescent Psychiatry School of Medicine, Dokuz Eylul University, İzmir
| | - Kardelen Akın
- Department of Pediatrics School of Medicine, Dokuz Eylul University, İzmir, Türkiye
| | - Sinem Kahveci
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, School of Medicine, Dokuz Eylul University, İzmir
| | - Gül Şeker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, School of Medicine, Dokuz Eylul University, İzmir
| | - Yunus Güler
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, School of Medicine, Dokuz Eylul University, İzmir
| | - Yeşim Öztürk
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, School of Medicine, Dokuz Eylul University, İzmir
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Lu L. [Progress in pathophysiology research and update on diagnosis and treatment strategies for fecal incontinence]. Zhonghua Wei Chang Wai Ke Za Zhi 2023; 26:1126-1131. [PMID: 38110273 DOI: 10.3760/cma.j.cn441530-20231008-00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
The traditional barrier theory believes that fecal incontinence is related to an imbalance of the recto-anal barrier and the characteristics of stool. However, in clinical practice this theory proves unable to explain all types of fecal incontinence. In recent years, research on the mechanisms related to fecal incontinence has shifted to a new integrative concept with the rectum and anus as functional units, and the central-peripheral nervous system and internal and external anal sphincters as a control loop. The diagnosis and treatment strategy of fecal incontinence, which is replaced by sacral neuromodulation, is undergoing a quiet change. With the progressively aging population in China, the need to improve the diagnosis and treatment of fecal incontinence has become increasingly urgent. This article explores the trends in diagnosis and treatment and mechanism research from the perspective of recent advances in pathophysiological research and updated diagnosis and treatment methods for fecal incontinence.
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Affiliation(s)
- L Lu
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
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Dimitriu A, Saizu R, Oancea D, Gheorghe C. Normal Values of High Resolution Anorectal Manometry in 132 Romanian Healthy People. J Gastrointestin Liver Dis 2023; 32:473-478. [PMID: 38147617 DOI: 10.15403/jgld-4879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/14/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIMS The primary method for assessing anorectal function is high resolution anorectal manometry (HRAM). It is a useful tool in the diagnosis of different anorectal functional disorders such as fecal incontinence or dyssynergia. The aim of the present study was to propose a new set of normal values to be used in practice for East-European individuals, as it was proven that the results are highly influenced by race and sociocultural status. METHODS We conducted a study based on anorectal manometric values of healthy volunteers analyzed at Clinic Fundeni Institute, Bucharest, Romania, between 2017 and 2022. The anorectal manometry was performed using a solid-state catheter (Diversatek, 23 pressure sensors). All anorectal measurement values were analyzed using the Bioview Software Analysys, respecting the timing and the order from the standardized IAPWG protocol. Manometric measurements were summarized using mean, median, standard deviation, minimum and maximum values. The impact of age and gender on 8 different manometric parameters was further analyzed. Normal ranges for all numeric variables were estimated using the 5th and 95th percentiles of the measurements. RESULTS A total of 132 subjects (97 females, 35 males) were enrolled in the study. Median age was similar between groups (54 vs. 55 years). The values for rectal propulsion, anal gradient and anal relaxation proved to be higher in females under 54 years as opposed to older women. The values for resting pressure, maximum squeeze pressure, incremental squeeze pressure were significantly higher in males younger than 54. Regardless of age, values for maximum squeeze pressure, incremental squeeze pressure, duration of squeeze and rectal propulsion were found to be significantly higher in males than in females. Normal values of HRAM in healthy volunteers are presented in a table at the end of the study. CONCLUSIONS The data presented in the current study are of high value and have a great impact on clinical practice, being the first study offering a spectrum of the normal values for HRAM in an Eastern Europe population.
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Affiliation(s)
- Anca Dimitriu
- Carol Davila University of Medicine and Pharmacy, Bucharest; Department of Gastroenterology,Fundeni Clinical Institute, Bucharest, Romania.
| | - Roxana Saizu
- Department of Gastroenterology,Fundeni Clinical Institute, Bucharest, Romania.
| | - Dragos Oancea
- Department of Gastroenterology,Fundeni Clinical Institute, Bucharest, Romania.
| | - Cristian Gheorghe
- Carol Davila University of Medicine and Pharmacy, Bucharest; Department of Gastroenterology,Fundeni Clinical Institute, Bucharest, Romania.
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Tucker JM, Juszczyk KM, Murphy EMA. Development and Validation of a Tool to Identify Anal Incontinence in Pregnant and Postnatal Women. Dis Colon Rectum 2023; 66:1562-1569. [PMID: 37486896 DOI: 10.1097/dcr.0000000000002966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Neuromuscular and mechanical damage to the pelvic floor because of pregnancy and birth can result in anal incontinence. Pregnant and postnatal women are rarely screened for anal incontinence by clinicians who specialize in the care of these women, and no screening tool has been developed for routine use in these women. OBJECTIVE To develop and validate a tool for use in everyday clinical practice in the care of pregnant and postnatal women. DATA SOURCES The study includes 2 test phases with separate data sources. Phase I included test and retest phases of the Bowel-Screening Questionnaire in health professionals and women who were pregnant or had recently birthed (n = 45). Phase II included a pilot of the tool compared to 2 current scoring systems (n = 358). SETTING Large tertiary hospital in South Australia. PATIENTS Phase II: prospective recruitment of 358 prenatal parous women attending a first antenatal appointment. MAIN OUTCOMES MEASURES To evaluate the reliability and validity of the developed tool. RESULTS Test-retest agreement in phase I was excellent for each of the 6 items, with each κ statistic being between 0.83 and 1.0. In phase II, agreement between new and existing tools was fair to good for the detection of anal incontinence symptoms addressed as a composite question (κ between 0.41 and 0.71). Anal incontinence was detected in 191 women (53%) using the new tool, and there was a lower prevalence reported using the Vaizey score (n = 118) and Wexner score (n = 129). Completion rates of the new tool were 99%, higher than both the Vaizey score (33%) and Wexner score (36%). LIMITATIONS Sample size limits the generalization of findings. CONCLUSION The questionnaire is reliable and valid, reporting a high incidence of bowel incontinence, with predominant symptoms of rectal urgency and flatus as precursors for worsening function. DESARROLLO Y VALIDACIN DE UNA HERRAMIENTA PARA IDENTIFICAR LA INCONTINENCIA ANAL EN MUJERES EMBARAZADAS Y PURPERAS ANTECEDENTES:El daño neuromuscular y mecánico del piso pélvico debido al embarazo y al parto puede resultar en incontinencia anal. Las mujeres embarazadas y puérperas rara vez son examinadas para la incontinencia anal por médicos que se especializan en el cuidado de estas mujeres, y no se ha desarrollado ninguna herramienta de detección para uso rutinario en estas mujeres.OBJETIVO:Desarrollar y validar una herramienta para uso en la práctica clínica diaria en el cuidado de las mujeres embarazadas y puérperas.FUENTES DE DATOS:El estudio incluye 2 fases de prueba con fuentes de datos separadas. Fase 1, fase test y retest del Bowel Screening Questionnaire en profesionales sanitarios y mujeres embarazadas o recién paridas (n = 45). La Fase 2 incluyó una prueba piloto de la herramienta en comparación con dos sistemas de puntuación actuales (n = 358).ENTORNO CLINICO:Gran hospital terciario en el sur de Australia.PACIENTES:Fase 2: reclutamiento prospectivo de 358 mujeres con parto prenatal que asisten a una primera cita prenatal.PRINCIPALES MEDIDAS DE VALORACIÓN:Evaluar la confiabilidad y validez de la herramienta desarrollada.RESULTADOS:La concordancia test-retest en la fase 1 fue excelente para cada uno de los 6 ítems con cada estadística kappa entre 0,83 y 1,0. En la fase 2, el acuerdo entre las herramientas nuevas y las existentes fue regular a bueno para la detección de síntomas de incontinencia anal abordados como una pregunta compuesta (kappa entre 0,41 y 0,71). Se detectó incontinencia anal en 191 (53%) de las mujeres que utilizaban la nueva herramienta, y se notificó una prevalencia más baja utilizando la puntuación de Vaizey (n = 118) y la puntuación de Wexner (n = 129). Las tasas de finalización de la nueva herramienta fueron del 99%, más altas que la puntuación de Vaizey (33%) y las puntuaciones de Wexner (36%).LIMITACIONES:El tamaño de la muestra limita la generalización de los hallazgos.CONCLUSIONES:El cuestionario es confiable y válido reportando una alta incidencia de incontinencia intestinal, con síntomas predominantes de urgencia rectal y flatos como precursores del empeoramiento de la función. (Traducción-Dr. Ingrid Melo ).
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Affiliation(s)
- Julie M Tucker
- Northern Adelaide Local Health Network Women and Children's Division, Elizabeth Vale, South Australia, Australia
| | - Karolina M Juszczyk
- Division of Surgery Specialties and Anesthetics, Northern Adelaide Local Health Network, Elizabeth Vale, South Australia, Australia
| | - Elizabeth Mary Anne Murphy
- Division of Surgery Specialties and Anesthetics, Northern Adelaide Local Health Network, Elizabeth Vale, South Australia, Australia
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Moureau MK, Jones LM, Schmuhl NB, Brown HW. Men and women experience different barriers to care seeking for fecal incontinence. Neurourol Urodyn 2023; 42:1769-1776. [PMID: 37614056 PMCID: PMC10810259 DOI: 10.1002/nau.25266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Despite effective treatments for fecal incontinence (FI), FI remains underdiagnosed and undertreated. This study sought to characterize and compare rates of, delays in, experiences with, and barriers to care seeking for FI among men and women. METHODS This study was a secondary analysis of electronic survey data collected from adults with FI. The survey included the use of a validated instrument to assess FI severity and questions that now comprise a validated instrument for assessing barriers to care seeking for FI in women. Descriptive analyses characterized differences between men and women. χ2 testing for categorical variables and t-testing for normally distributed continuous variables compared statistical differences. RESULTS The sample (N = 548) was predominately female (84%), non-Hispanic White (90%), and insured (96%), with a mean Vaizey score (13.4 ± 5.3) consistent with moderate or severe FI. Care seeking rates (p = 0.81) and symptom duration before care seeking (p = 0.23) did not differ between women and men, but women were more likely than men to be told that effective treatments exist; most male and female respondents who sought care were offered treatment. Very few respondents had been asked about FI by a healthcare provider. Whereas normative thinking, limited life impact, and believing that a healthcare provider could not help were more common barriers to care seeking among men, avoidance, fear, and discouragement were more common in women. CONCLUSIONS Men and women with FI seek care at similar rates and after experiencing symptoms for a similar duration of time. Very few patients with FI have been screened for it by a healthcare provider. Barriers to FI care seeking are different for women and men, and men are less likely than women to be informed about effective treatments by a healthcare provider.
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Affiliation(s)
- Madeline K. Moureau
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health
| | - Lisa M. Jones
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health
| | | | - Heidi W. Brown
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health
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Saraiva MM, Pouca MV, Ribeiro T, Afonso J, Cardoso H, Sousa P, Ferreira J, Macedo G, Junior IF. Artificial Intelligence and Anorectal Manometry: Automatic Detection and Differentiation of Anorectal Motility Patterns-A Proof-of-Concept Study. Clin Transl Gastroenterol 2023; 14:e00555. [PMID: 36520781 PMCID: PMC10584284 DOI: 10.14309/ctg.0000000000000555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/18/2022] [Indexed: 10/20/2023] Open
Abstract
INTRODUCTION Anorectal manometry (ARM) is the gold standard for the evaluation of anorectal functional disorders, prevalent in the population. Nevertheless, the accessibility to this examination is limited, and the complexity of data analysis and report is a significant drawback. This pilot study aimed to develop and validate an artificial intelligence model to automatically differentiate motility patterns of fecal incontinence (FI) from obstructed defecation (OD) using ARM data. METHODS We developed and tested multiple machine learning algorithms for the automatic interpretation of ARM data. Four models were tested: k-nearest neighbors, support vector machines, random forests, and gradient boosting (xGB). These models were trained using a stratified 5-fold strategy. Their performance was assessed after fine-tuning of each model's hyperparameters, using 90% of data for training and 10% of data for testing. RESULTS A total of 827 ARM examinations were used in this study. After fine-tuning, the xGB model presented an overall accuracy (84.6% ± 2.9%), similar to that of random forests (82.7% ± 4.8%) and support vector machines (81.0% ± 8.0%) and higher that of k-nearest neighbors (74.4% ± 3.8%). The xGB models showed the highest discriminating performance between OD and FI, with an area under the curve of 0.939. DISCUSSION The tested machine learning algorithms, particularly the xGB model, accurately differentiated between FI and OD manometric patterns. Subsequent development of these tools may optimize the access to ARM studies, which may have a significant impact on the management of patients with anorectal functional diseases.
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Affiliation(s)
- Miguel Mascarenhas Saraiva
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
- WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Maria Vila Pouca
- Department of Mechanical Engineering, Faculty of Engineering of the University of Porto, Porto, Portugal
- INEGI—Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Tiago Ribeiro
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
- WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
| | - João Afonso
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
- WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
| | - Hélder Cardoso
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
- WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Pedro Sousa
- Department of Mechanical Engineering, Faculty of Engineering of the University of Porto, Porto, Portugal
- INEGI—Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - João Ferreira
- Department of Mechanical Engineering, Faculty of Engineering of the University of Porto, Porto, Portugal
- INEGI—Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
- WGO Gastroenterology and Hepatology Training Center, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ilario Froehner Junior
- Department of Gastrointestinal Motility, Nossa Senhora das Graças Hospital, Curitiba, Paraná, Brazil
- Department of Coloproctology, Pelvia—Gastrointestinal Motility and Continence, Curitiba, Paraná, Brazil
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Remes-Troche JM, Coss-Adame E, García-Zermeño KR, Gómez-Escudero O, Amieva-Balmori M, Gómez-Castaños PC, Charúa-Guindic L, Icaza-Chávez ME, López-Colombo A, Morel-Cerda EC, Pérez Y López N, Rodríguez-Leal MC, Salgado-Nesme N, Sánchez-Avila MT, Valdovinos-García LR, Vergara-Fernández O, Villar-Chávez AS. The Mexican consensus on fecal incontinence. Rev Gastroenterol Mex (Engl Ed) 2023; 88:404-428. [PMID: 38097437 DOI: 10.1016/j.rgmxen.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 01/01/2024]
Abstract
Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City, Mexico
| | - K R García-Zermeño
- Gastroenterología y Motilidad Digestiva, CIGMA, Boca del Río, Veracruz, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopía Digestiva y Motilidad Gastrointestinal, Hospital Ángeles de Puebla, Puebla, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - P C Gómez-Castaños
- Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - L Charúa-Guindic
- Práctica privada, Coloproctología del Hospital Ángeles Lomas, Mexico City, Mexico
| | - M E Icaza-Chávez
- Hospital Christus Muguerza Faro del Mayab, Mérida, Yucatán, Mexico
| | - A López-Colombo
- UMAE Hospital de Especialidades, Centro Médico Nacional Manuel Ávila Camacho, IMSS Puebla, Puebla, Mexico
| | - E C Morel-Cerda
- Laboratorio de Motilidad Gastrointestinal, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - M C Rodríguez-Leal
- Hospital Ángeles Valle Oriente, IMSS UMAE 25, Monterrey, Nuevo León, Mexico
| | - N Salgado-Nesme
- Departamento de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City,Mexico
| | - M T Sánchez-Avila
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
| | - L R Valdovinos-García
- Laboratorio de Motilidad Gastrointestinal Fundación Clínica Médica Sur, Mexico City, Mexico
| | - O Vergara-Fernández
- Departamento de Cirugía Colorrectal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, Mexico
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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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Karasu AFG, Cetin C, Pasin Ö, Karacabay M, Tanoglu FB, Ilhan G. Prevalence of urinary incontinence and anal incontinence: an internet-based cross-sectional study of female Turkish University students. Int Urogynecol J 2023; 34:2309-2315. [PMID: 37266726 DOI: 10.1007/s00192-023-05573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this cross-sectional, epidemiological study was to characterize urinary tract and bowel symptom prevalence and the extent of discomfort/bother associated with them. Additionally, the authors aimed to explore factors associated with both conditions among Turkish female university students. Also, an insight into women's "communication regarding urinary incontinence and anal incontinence" with their family members was sought. METHODS This is an internet-based national cross-sectional study. A study-specific 30-item questionnaire containing validated measures of symptom prevalence and bother (Urogenital Distress Inventory questionnaire short form and Colorectal-Anal Distress Inventory) were incorporated into the survey. Out of a total of 2,125 e-mail invitations that were sent, 1,226 responded with data included in this analysis. RESULTS The age and BMI of all respondents were 26.53 ± 10.082, 23.45 ± 6.609 respectively. Nine hundred and eighty-five (80.5%) respondents claimed that they did not suffer a UI episode in the last year, whereas 10 people (0.08%) claimed that they had a urinary incontinence episode every day. Three hundred and fifty-seven responders (29.1%) stated that they suffered from "gas incontinence," 6 (0.5%) stool incontinence, and 20 (1.6%) declared that they had episodes of both stool and gas incontinence. Five hundred and forty-four participants (44%) reported that they had family relatives with a problem of "urinary incontinence" and 576 (47%) stated they had a conversation on "urinary incontinence." Seventy-five of the responders (6.1%) stated that they had a family member with "anal incontinence" and 246 (20.1%) responded that they had a conversation regarding "anal incontinence" with them. CONCLUSION We have demonstrated that the prevalence of UI was 19.5%. Twenty-nine percent stated they suffered "gas incontinence," 0.5% stool incontinence, and 1.6% declared that they had episodes of both stool and gas incontinence.
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Affiliation(s)
- Ayse Filiz Gokmen Karasu
- Department of Obstetrics and Gynecology, Urogynecology and Pelvic Reconstructive Medicine Unit, Bezmialem Vakif University, Fatih, Turkey.
| | - Caglar Cetin
- Department of Obstetrics and Gynecology, Urogynecology and Pelvic Reconstructive Medicine Unit, Bezmialem Vakif University, Fatih, Turkey
| | - Özge Pasin
- Department of Biostatistics, Bezmialem Vakif University, Fatih, Turkey
| | | | - Fatma Basak Tanoglu
- Department of Obstetrics and Gynecology, Bezmialem Vakif University, Fatih, Turkey
| | - Gulsah Ilhan
- Department of Obstetrics and Gynecology, Suleymaniye Research and Training Hospital, Istanbul, Turkey
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Ortenzi M, Guerrieri M, Saraceno F, Reggiani A, Lepiane P, Sileri P, Balla A. Prospective Italian validation of the Vaizey and Wexner and fecal incontinence severity index (FISI) questionnaires. Updates Surg 2023; 75:1617-1623. [PMID: 37368229 DOI: 10.1007/s13304-023-01567-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Several objective severity measurement questionnaires of the fecal incontinence (FI), are available to describe type, frequency and degree of FI, and their impact on quality of life, aiming to establish baseline scores measure response to treatment over time and allow comparison among patients treated using different strategies. Presently, despite their widespread use in clinical practice, none of these questionnaire have been validated in the Italian language. The aim is to test the translated Italian version of the Vaizey and Wexner and Fecal Incontinence Severity Index (FISI) questionnaires assessing their reliability and validity among Italian-speaking patients. Two researchers proficient in spoken English and Italian translated both questionnaires in the Italian language. They independently translated the two questionnaires from English and then they met to produce a single version of the two questionnaires, to solve any possible discrepancy. A forward-backward translation was then obtained by a professional bilingual translator, so as to define the final version of the questionnaires. The questionnaires were independently administered twice to 100 Italian-speaking patients by two different and independent raters. Cronbach's α of the first and second Vaizey and Wexner questionnaire was 0.755 and 0.727, respectively. While Cronbach's α of the first and second FISI questionnaire was 0.810 and 0.806, respectively. Spearman correlation and inter-rater reliability were 0.937 and 0.913 for Vaizey and Wexner questionnaire, respectively, and 0.915 and 0.871 for FISI questionnaire, respectively. Italian version of the Vaizey and Wexner and FISI questionnaires proved good consistency, reliability, reproducibility, showing good psychometric properties.
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Affiliation(s)
- Monica Ortenzi
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Federica Saraceno
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy
| | - Angelica Reggiani
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Pasquale Lepiane
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy
| | - Pierpaolo Sileri
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Andrea Balla
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy.
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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Campbell J, Hubbard R, Ostaszkiewicz J, Green T, Coyer F, Mudge A. Incontinence during and following hospitalisation: a prospective study of prevalence, incidence and association with clinical outcomes. Age Ageing 2023; 52:afad181. [PMID: 37738169 PMCID: PMC10516354 DOI: 10.1093/ageing/afad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Incontinence is common in hospitalised older adults but few studies report new incidence during or following hospitalisation. OBJECTIVE To describe prevalence and incidence of incontinence in older inpatients and associations with clinical outcomes. DESIGN Secondary analysis of prospectively collected data from consecutive consenting inpatients age 65 years and older on medical and surgical wards in four Australian public hospitals. METHODS Participants self-reported urinary and faecal incontinence 2 weeks prior to admission, at hospital discharge and 30 days after discharge as part of comprehensive assessment by a trained research assistant. Outcomes were length of stay, facility discharge, 30-day readmission and 6-month mortality. RESULTS Analysis included 970 participants (mean age 76.7 years, 48.9% female). Urinary and/or faecal incontinence was self-reported in 310/970 (32.0%, [95% confidence interval (CI) 29.0-35.0]) participants 2 weeks before admission, 201/834 (24.1% [95% CI 21.2-27.2]) at discharge and 193/776 (24.9% [95% CI 21.9-28.1]) 30 days after discharge. Continence patterns were dynamic within the peri-hospital period. Of participants without pre-hospital incontinence, 74/567 (13.1% [95% CI 10.4-16.1) reported incontinence at discharge and 85/537 (15.8% [95% CI 12.8-19.2]) reported incontinence at 30 days follow-up. Median hospital stay was longer in participants with pre-hospital incontinence (7 vs. 6 days, P = 0.02) even in adjusted analyses and pre-hospital incontinence was significantly associated with mortality in unadjusted but not adjusted analyses. CONCLUSION Pre-hospital, hospital-acquired and new post-hospital incontinence are common in older inpatients. Better understanding of incontinence patterns may help target interventions to reduce this complication.
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Affiliation(s)
- Jill Campbell
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Southport, Australia
| | - Ruth Hubbard
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Geriatric Medicine Service, Princess Alexandra Hospital, Brisbane, Australia
| | - Joan Ostaszkiewicz
- Aged Care Division, National Ageing Research Institute, Melbourne, Australia
- Health and Innovation Transformation Centre, Federation University, Ballarat, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Theresa Green
- School of Nursing, Midwifery & Social Work, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Australia
| | - Fiona Coyer
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia
- School of Nursing, Queensland University of Technology, Brisbane, Australia
- Institute for Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
| | - Alison Mudge
- Internal Medicine and Aged Care Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Greater Brisbane Clinical School, Faculty of Medicine, University of Queensland, Brisbane, Australia
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20
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de Codes LMG, de Jesus ACC, de Codes JJG, Ferreira RF, da Silva Beda Sacramento C, da Cruz IDM, de Castro Ribeiro Fidelis F, de Carvalho AL, Motta MP, de Oliveira Alves C, Netto EM, Santana GO. Anorectal Function and Clinical Characteristics Associated with Faecal Incontinence in Patients with Crohn's Disease. J Crohns Colitis 2023; 17:1252-1261. [PMID: 36951290 DOI: 10.1093/ecco-jcc/jjad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Indexed: 03/24/2023]
Abstract
BACKGROUND AND AIMS Faecal incontinence is an important complaint reported by patients with Crohn's disease [CD] and it is associated with several disease-related mechanisms, including anorectal functional disorders. This study aimed to assess the anorectal function and clinical characteristics to identify parameters associated with faecal incontinence in CD patients. METHODS This is a cross-sectional study of 104 patients with CD, aged 18 years or older, from a referral centre between August 2019 and May 2021. Patients responded to a specific questionnaire, and underwent medical record review, proctological examination and anorectal functional assessment with anorectal manometry. RESULTS Of the 104 patients, 49% were incontinent. Patients with incontinence had a lower mean resting pressure [43.5 vs 53.1 mmHg; p = 0.038], lower mean squeeze pressure [62.1 vs 94.1 mmHg; p = 0.036] and lower maximum rectal capacity [140 vs 180 mL; p < 0.001]. Faecal incontinence was also associated with disease activity [p < 0.001], loose stools [p = 0.02], perianal disease [p = 0.006], previous anoperineal surgery [p = 0.048] and number of anorectal surgeries [p = 0.036]. CONCLUSIONS This is the largest reported study describing manometric findings of Crohn's disease patients with and without faecal incontinence. Our results identified an association between faecal incontinence and functional disorders, in addition to clinical features in these patients. Functional assessment with anorectal manometry may help choose the best treatment for faecal incontinence in patients with CD.
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Affiliation(s)
- Lina Maria Góes de Codes
- Medicine and Health Science Postgraduate Program, Universidade Federal da Bahia, Salvador, Brazil; Department of Surgery, Hospital Universitário Professor Edgard Santos, Salvador, Brazil
| | | | | | | | | | | | | | | | - Marina Pamponet Motta
- Department of Gastroenterology, Hospital Universitário Professor Edgard Santos, Salvador, Brazil
| | | | - Eduardo Martins Netto
- Medicine and Health Science Postgraduate Program, Universidade Federal da Bahia, Salvador, Brazil
| | - Genoile Oliveira Santana
- Medicine and Health Science Postgraduate Program, Universidade Federal da Bahia, Salvador, Brazil; Department of Life Sciences, Universidade do Estado da Bahia, Salvador, Brazil
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21
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Garg P, Sudol-Szopinska I, Kolodziejczak M, Bhattacharya K, Kaur G. New objective scoring system to clinically assess fecal incontinence. World J Gastroenterol 2023; 29:4593-4603. [PMID: 37621752 PMCID: PMC10445003 DOI: 10.3748/wjg.v29.i29.4593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/09/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Several scoring systems are used to assess fecal incontinence (FI), among which, the most commonly used are Wexner and Vaizey's scoring systems. However, there are significant lacunae in these scoring systems, due to which they are neither accurate nor comprehensive. AIM To develop a new scoring system for FI that is accurate, comprehensive, and easy to use. METHODS A pro forma was made in which six types of FI were included: solid, liquid, flatus, mucous, stress, and urge. The weight for each FI was determined by asking a group of patients and laypersons to give a disability score to each type of FI from 0 to 100 (0- least, 100- maximum disability). The disability was assessed on a modified EQ-5D+ (EuroQol) description system, 4D3L (4 dimensions and 3 levels) for each FI. The average score of each FI was calculated, divided by 10, and rounded off to determine the weight of each FI type. The scores for the three levels of frequency of each FI were assigned as never = 0 (No episode of FI ever), occasional = 1 (≤ 1 episode of FI/ wk), and common = 2 (> 1 episode of FI/ wk), and was termed as frequency score. The score for each FI would be derived by multiplying the frequency score and the weight for that FI type. In the second phase of the study, a group of colorectal surgeons was asked to rank the six FI types in order of severity, and their ranking was compared with the patient and laypersons' rankings. RESULTS Fifty patients and 50 laypersons participated in the study. The weight was assigned to each FI (solid-8, liquid-8, urge-7, flatus-6, mucus-6, and stress-5), and an new scoring system was formulated. The maximum possible score was 80 (total incontinence), and the least 0 (no incontinence). The surgeons' ranking of FI severity did not correlate well with patients' and laypersons' rankings of FI, highlighting that surgeons and patients may perceive the severity of FI differently. CONCLUSION A new scoring system for FI was formulated, which was simple, logical, comprehensive, and easy to use, and eliminated previous shortcomings. Patients' and surgeons' perceptions of FI severity of FI did not correlate well.
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Affiliation(s)
- Pankaj Garg
- Colorectal Surgery, Garg Fistula Research Institute (GFRI), Panchkula 134113, Haryana, India
- Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India
| | - Iwona Sudol-Szopinska
- Department ofRadiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw 02-637, Poland
| | | | - Kaushik Bhattacharya
- Department of Surgery, MGM Medical College and LSK Hospital, Kishanganj 855107, Bihar, India
| | - Gurleen Kaur
- Department of Pharmacology, Adesh Medical College and Hospital, Shahbad 136143, Haryana, India
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22
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Dulskas A. The 2022 European Society of Coloproctology (ESCP) global snapshot audit of faecal incontinence: Study protocol. Colorectal Dis 2023; 25:1694-1697. [PMID: 37277932 DOI: 10.1111/codi.16633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/07/2023] [Indexed: 06/07/2023]
Abstract
AIM Faecal incontinence (FI) is a common problem, affecting about 9% of Western populations. However, only a few patients seek consultation and the number of such patients reaching hospital care is unknown. Current treatment pathways are poorly evidence based and are thought to vary greatly between different countries. This audit will study the incidence of patients presenting to coloproctologists with FI, current practice including diagnostics, conservative and surgical techniques across different units in Europe and worldwide. The aim is to explore the incidence of FI in patients attending colorectal surgical clinics, treatment choices and accessibility to diagnostic tools/advanced treatments across the international cohort. Outcomes to be measured include the volume of FI patients consulting clinical practice per surgeon, patient demographics, and diagnostics and intervention details. METHOD An international multicentre snapshot audit will be performed. During the study period all consecutive eligible patients will be included over an 8-week period between 9 January and 28 February. Data will be entered and saved in a Research Electronic Data Capture secured database. Moreover, two short physician and centre-level surveys will be filled for current practice evaluation. The results will be published in international journals and will be prepared in accordance with guidelines set by the STROBE (strengthening the reporting of observational studies in epidemiology) statement for observational studies. DISCUSSION This multicentre, global prospective audit will be delivered by consultant colorectal and general surgeons as well as trainees. The data obtained will lead to a better understanding of the incidence of FI and treatment and diagnostic possibilities. This snapshot audit will be hypothesis generating and inform areas that need future prospective study.
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Affiliation(s)
- Audrius Dulskas
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
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23
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Kazi M, Jajoo B, Rohila J, Dohale S, Nashikkar C, Sainani R, Bhuta P, Desouza A, Saklani A. Should anorectal manometry be routine before stoma reversal in patients after an intersphincteric resection? Colorectal Dis 2023; 25:1638-1645. [PMID: 37391870 DOI: 10.1111/codi.16646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/07/2022] [Accepted: 05/30/2023] [Indexed: 07/02/2023]
Abstract
INTRODUCTION Anorectal manometry (ARM) is sometimes performed before ostomy reversal in patients with an intersphincteric resection (ISR) to predict bowel function. However, no clinical predictive data exist regarding its utility. METHODS The single-centre, retrospective data of ISR patients who had an ARM prior to ostomy reversal, and bowel functional assessment with the low anterior resection syndrome (LARS) and Wexner incontinence scores at least 6 months after reversal, were considered. Correlation statistics were performed with each of the manometric parameters and functional outcome categories. RESULTS Eighty-nine patients were included. The median basal and squeeze pressures were 41 and 100 mmHg, respectively. Any LARS (score ≥20) and major incontinence (score ≥11) was observed in 51.7% and 16.9%, respectively. None of the manometric parameters (median basal or maximum squeeze pressure, anal canal length, volume at urge and the ability to expel) correlated with LARS or incontinence. CONCLUSIONS Anorectal manometry (ARM) before ostomy reversal to predict bowel function at 6 months or beyond was not helpful in patients with an ISR and diverting stoma. No manometric parameter correlated with the LARS or Wexner incontinence scores.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Bhushan Jajoo
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Jitender Rohila
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Sayali Dohale
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Chaitali Nashikkar
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Rajesh Sainani
- Department of Medical Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India
| | - Prajesh Bhuta
- Department of Colorectal Surgery, Jaslok Hospital and Research Center, Mumbai, India
| | - Ashwin Desouza
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
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24
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Garoufalia Z, Gefen R, Emile SH, Silva-Alvarenga E, Freund MR, Horesh N, Wexner SD. Outcomes of graciloplasty in the treatment of fecal incontinence: a systematic review and meta-analysis of the literature. Tech Coloproctol 2023; 27:429-441. [PMID: 36479654 DOI: 10.1007/s10151-022-02734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with refractory fecal incontinence symptoms can be treated with several surgical procedures including graciloplasty. Reported outcomes and morbidity rates of this procedure are highly variable. The aim of this study was to assess continence rate and safety of dynamic and adynamic graciloplasty. METHODS PubMed and Google Scholar databases were systematically searched from inception until January 2022 according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Reviews, animal studies, studies with patients < 18 years or < 10 patients, with no success rate reported or non-English text, were excluded. Main outcome measures were overall continence and morbidity rates of each technique. RESULTS Fourteen studies were identified, incorporating a total of 450 patients (337 females), published between 1980 and 2021. Most common etiology of incontinence (35.5%-n = 160) was obstetric trauma followed by anorectal trauma (20%-n = 90). The weighted mean rate of continence after dynamic graciloplasty was 69.1% (95% CI 0.53-0.84%, I2 = 90%) compared to 71% (95% CI 0.54-0.87, I2 = 82.5%) after adynamic. Although the weighted mean short-term complication rate was lower in the dynamic group (26% versus 40%), when focusing on complications requiring intervention under general anesthesia, there was a much higher incidence (43.4% versus 10.5%) in the dynamic group. The weighted mean rate of long-term complications was 59.4% (95% CI 0.13-1.04%, I2 = 97.7%) in the dynamic group, almost twice higher than in the adynamic group [30% (95% CI - 0.03 to 0.63), I2 = 95.8%]. Median follow-up ranged from 1 to 13 years. CONCLUSIONS Our data suggest that graciloplasty may be considered for incontinent patients. Dynamic graciloplasty may harbor higher risk for reoperation and complications compared to adynamic. The fact that the functional results between adynamic and dynamic graciloplasty are equivalent and the morbidity rate of adynamic graciloplasty is significantly lower reinforce the graciloplasty as an option to treat appropriately selected patients with fecal incontinence.
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Affiliation(s)
- Z Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - R Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - S H Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - E Silva-Alvarenga
- Martin Health at Tradition HealthPark Two, Cleveland Clinic Florida, Weston, FL, USA
| | - M R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - N Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel
| | - S D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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25
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Qvist N, Hansen UD, Christensen P, Rijkhoff NMJ, Klarskov N, Duelund-Jakobsen J. Electrical stimulation of the dorsal clitoral nerve in the treatment of idiopathic defecatory urgency. A pilot study. Tech Coloproctol 2023; 27:459-463. [PMID: 36648602 PMCID: PMC10169878 DOI: 10.1007/s10151-023-02752-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023]
Abstract
PURPOSE To investigate the effect of dorsal clitoral nerve stimulation (DCNS) on bothersome urgency to defecate with or without fecal incontinence and the patient-reported discomfort or adverse effect with the method. METHODS For dorsal clitoral nerve stimulation, a battery powered, handheld stimulator was used, set to a pulse width of 200 µs and a frequency of 20 Hz. One electrode was placed at the preputium of the clitoris and acted as cathode while an anode electrode was placed on the belly. Prior to stimulation the patients were asked to complete a bowel habit diary throughout 14 consecutive days before and during stimulation. RESULTS Fourteen out of the 16 patients included completed the study. A decrease in the number of episodes (per day) with strong urgency declined in eight patients but increased in four cases during the stimulation period. An increase in episodes with moderate or mild urgency was observed in 11 and 6 cases, respectively, and a decrease in defecation without the feeling of urgency or passive incontinence decreased in two thirds of the patients. Two patients discontinued the study prematurely, on due to worsening in symptoms and one due to pelvic pain. CONCLUSION Although the results may be promising, much still must be learned about the method including mode and duration of stimulation, better electrodes and more patient friendly equipment together with the development of better questionnaires to assess the patient burden of urgency.
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Affiliation(s)
- N Qvist
- Research Unit for Surgery, Odense University Hospital Odense, Odense, Denmark.
- University of Southern Denmark, Odense, Denmark.
| | - U D Hansen
- University of Southern Denmark, Odense, Denmark
- Research Unit for Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - P Christensen
- Department of Surgery, Pelvic Floor Clinic, Aarhus University Hospital, Aarhus, Denmark
| | - N M J Rijkhoff
- Research Unit for Surgery, Odense University Hospital Odense, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - N Klarskov
- Department of Gynecology and Obstetrics, Herlev Hospital, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - J Duelund-Jakobsen
- Department of Surgery, Pelvic Floor Clinic, Aarhus University Hospital, Aarhus, Denmark
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Ambartsumyan L, Patel D, Kapavarapu P, Medina-Centeno RA, El-Chammas K, Khlevner J, Levitt M, Darbari A. Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr 2023; 76:533-546. [PMID: 36720091 DOI: 10.1097/mpg.0000000000003717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Children with Hirschsprung disease have postoperative long-term sequelae in defecation that contribute to morbidity and mortality and significantly impact their quality of life. Pediatric patients experience ongoing long-term defecation concerns, which can include fecal incontinence (FI) and postoperative obstructive symptoms, such as constipation and Hirschsprung-associated enterocolitis. The American Pediatric Surgical Association has developed guidelines for management of these postoperative obstructive symptoms and FI. However, the evaluation and management of patients with postoperative defecation problems varies among different pediatric gastroenterology centers. This position paper from the Neurogastroenterology & Motility Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviews the current evidence and provides suggestions for the evaluation and management of postoperative patients with Hirschsprung disease who present with persistent defecation problems.
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Affiliation(s)
- Lusine Ambartsumyan
- From the Division of Gastroenterology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Dhiren Patel
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St Louis, MO
| | - Prasanna Kapavarapu
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ricardo A Medina-Centeno
- the Division of Gastroenterology, Hepatology and Nutrition, Phoenix Children's, College of Medicine, University of Arizona, Tucson, AZ
| | - Khalil El-Chammas
- the Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julie Khlevner
- the Division of Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Marc Levitt
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
| | - Anil Darbari
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
- the Division of Gastroenterology and Nutrition, Children's National Hospital, Washington, DC
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27
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Pinta T, Ruohonen J, Kallio-Packalen M, Zhabin I, Kirss J. 3T external phased-array magnetic resonance imaging in detection of obstetric anal sphincter lesions: a pilot study. Acta Radiol 2023; 64:1238-1244. [PMID: 35787708 DOI: 10.1177/02841851221109139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Three-dimensional endoanal ultrasound (3D EAUS) has been the gold standard for detecting anal sphincter lesions in patients with a history of obstetric anal sphincter injury (OASI). Advances in imaging technologies have facilitated the detection of these lesions with external phased-array magnetic resonance imaging (MRI), which could offer an alternative imaging modality for the diagnosis of residual OASI (ROASI) in centers where 3D EAUS imaging is not available. PURPOSE To compare two diagnostic modalities: the 3D EAUS and 3T external phased-array MRI in the detection of residual anal sphincter lesions. MATERIAL AND METHODS A total of 24 women with a history of OASI were imaged with both 3D EAUS and 3T external phased-array MRI after primary repair of the injury. Intraclass correlation (ICC) and interrater reliability (IRR) values were calculated for the grade and circumference of the sphincter lesion. Sphincter lesions were graded according to the Sultan classification. RESULTS There was an almost perfect agreement between 3D EAUS and 3T external phased-array MRI in determining the extent of the sphincter lesions according to the Sultan classification (κ = 0.881; P < 0.001) and the circumference of the external anal sphincter defects, measured in degrees (κ = 0.896; P < 0.001). CONCLUSION The results of this study indicate that 3T external phased-array MRI and 3D EAUS yield comparable results in the diagnosis of ROASI. These findings suggest that 3T external phased-array MRI could serve as an alternative diagnostic modality to 3D EAUS in the diagnosis of ROASI.
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Affiliation(s)
- Tarja Pinta
- 176490Seinäjoki Central Hospital, Seinäjoki, Finland
- 8058University of Turku, Turku, Finland
| | | | | | - Ivan Zhabin
- 176490Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Jaan Kirss
- 8058University of Turku, Turku, Finland
- West Tallinn Central Hospital, Tallinn, Estonia
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Dekker L, van Reijn-Baggen DA, Han-Geurts IJM, Felt-Bersma RJF. To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound. Int J Colorectal Dis 2023; 38:12. [PMID: 36645523 PMCID: PMC9842578 DOI: 10.1007/s00384-022-04304-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests. METHODS Between January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG). RESULTS A total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively. CONCLUSION DRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.
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Affiliation(s)
- L Dekker
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands.
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
| | - D A van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Urology, Leiden University Center, Leiden, The Netherlands
| | - I J M Han-Geurts
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - R J F Felt-Bersma
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Location VU, Amsterdam, The Netherlands
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ElWazir M, Gautam M, Mishra R, Oblizajek NR, Blackett JW(W, Bharucha AE. Automated extraction of anorectal pressures from high-resolution manometry reports. Neurogastroenterol Motil 2022; 34:e14411. [PMID: 35593217 PMCID: PMC9588692 DOI: 10.1111/nmo.14411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND During high-resolution anorectal manometry (HR_ARM), the raw data are converted into software-derived summary variables (e.g., rectoanal gradient during evacuation) that capture only a snapshot of the data collected during HR_ARM and are less useful than newer indices, which are also derived from the raw data, for diagnosing defecatory disorders (DD). However, it is cumbersome and time-consuming to extract raw data from the program and calculate such indices. This study aimed to devise a user-friendly approach to extract anorectal pressures measured with HR_ARM. METHODS Anorectal pressures at rest, during anal squeeze, and evacuation were measured with HR_ARM in 180 women, among whom 60 each were healthy, had DD, or fecal incontinence. A reverse engineering approach extracted pressure values from color images in HR_ARM reports. The summary variables generated by the software and a reverse engineering approach were compared with Lin's concordance correlation coefficient (CCC), paired t-tests, and Bland-Altman's tests. RESULTS Anorectal pressures summarized by the software and a reverse engineering method were highly concordant for anal resting (CCC [95% CI], 0.98 [0.97, 0.99]) and squeeze pressures (0.99 [0.99, 0.99) and the rectoanal gradient during evacuation with an empty (0.98 [0.97, 0.98]) and a filled balloon (0.99 [0.99, 0.99]). For most variables, the paired t and Bland-Altman comparisons were not significant. CONCLUSIONS Anorectal pressures can be accurately determined from pressure topography images in HR_ARM reports. In future, this reverse engineering approach can be harnessed to compile large HR_ARM datasets across centers and to uncover newer, potentially more useful summary rectoanal pressure variables.
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Affiliation(s)
- Mohamed ElWazir
- Department of Cardiovascular Medicine, Suez Canal University, Ismailia, Egypt
| | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Oblizajek NR, Deb B, Ramu S(SK, Chunawala Z, Feuerhak K, Bailey KR, Bharucha AE. Optimizing techniques for measuring anal resting and squeeze pressures with high-resolution manometry. Neurogastroenterol Motil 2022; 34:e14383. [PMID: 35468247 PMCID: PMC9529769 DOI: 10.1111/nmo.14383] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/17/2022] [Accepted: 03/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal methods for measuring and analyzing anal resting and squeeze pressure with high-resolution manometry (HRM) are unclear. METHODS Anal resting and squeeze pressures were measured with HRM in 90 healthy women, 35 women with defecatory disorders (DD), and 85 with fecal incontinence (FI). Pressures were analyzed with Manoview™ software and a customized approach. Resting pressures measured for 20, 60, and 300 s were compared. During the squeeze period, (3 maneuvers, 20 s each), the squeeze increment, which was averaged over 5, 10, 15, and 20 s, and squeeze duration were evaluated. RESULTS Compared to healthy women, the anal resting pressure, squeeze pressure increment, and squeeze duration were lower in FI (p ≤ 0.04) but not in DD. The 20, 60, and 300 s resting pressures were strongly correlated (concordance correlation coefficients = 0.96-0.99) in healthy and DD women. The 5 s squeeze increment was the greatest; 10, 15, and 20 s values were progressively lower (p < 0.001). The squeeze pressure increment and duration differed (p < 0.01) among the three maneuvers in healthy and DD women but not in FI women. The upper 95th percentile limit for squeeze duration was 19.5 s in controls, 19.9 s in DD, and 19.3 s in FI. Adjusted for age, resting pressure, and squeeze duration, a greater squeeze increment was associated with a lower risk of FI versus health (OR, 0.96; 95% CI, 0.94-0.97). CONCLUSIONS These findings suggest that anal resting and squeeze pressures can be accurately measured over 20 s. In most patients, one squeeze maneuver is probably sufficient.
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Affiliation(s)
| | - Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | | | - Zainali Chunawala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kent R. Bailey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
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Assmann SL, Keszthelyi D, Breukink SO. Health aspects of faecal incontinence are complex and multi-layered. United European Gastroenterol J 2022; 10:603-604. [PMID: 35666023 DOI: 10.1002/ueg2.12261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Sadé L Assmann
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Stéphanie O Breukink
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
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Futaba K, Chen SC, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Fecobionics Evaluation of Biofeedback Therapy in Patients With Fecal Incontinence. Clin Transl Gastroenterol 2022; 13:e00491. [PMID: 35363631 PMCID: PMC9132520 DOI: 10.14309/ctg.0000000000000491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Biofeedback therapy (BFT) is a well-known treatment for functional anorectal disorders. The effect of BFT was monitored in fecal incontinence (FI) patients with the Fecobionics test and with the conventional technologies, anorectal manometry (ARM) and balloon expulsion test (BET). METHODS Studies were performed in 12 patients before and after 8 weeks of biofeedback training. The Fecal Incontinence Severity Index (FISI) score was obtained. Anal resting and squeeze pressures were measured before the bag was distended in the rectum until urge to defecate. Pressure recordings were made during Fecobionics evacuation. RESULTS BFT resulted in 24% reduction in FISI scores (P < 0.01). Seven patients were characterized as responders. Anal pressures, the urge-to-defecate volume, and defecatory parameters did not change significantly during BFT. For ARM-BET, the maximum anal squeeze pressure, the urge-to-defecate volume, and the expulsion time were lower after BFT compared with those before BFT (P < 0.05). For Fecobionics, the change in urge volume (r = 0.74, P < 0.05) and the change in defecation index (r = 0.79, P < 0.01) were associated with the change in FISI score. None of the ARM-BET parameters were associated with the change in FISI score. It was studied whether any pre-BFT data could predict treatment success. The Fecobionics expulsion duration and the defecation index predicted the outcome (P < 0.05). The defecation index had a sensitivity of 100% and a specificity of 72%. None of the ARM-BET parameters predicted the outcome (all P > 0.2). DISCUSSION Fecobionics was used as a tool to monitor the effect of BFT and proved better than conventional technologies for monitoring and predicting the outcome in the FISI score.
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Affiliation(s)
- Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
- California Medical Innovations Institute, San Diego, California, USA
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Assmann SL, Keszthelyi D, Kleijnen J, Anastasiou F, Bradshaw E, Brannigan AE, Carrington EV, Chiarioni G, Ebben LDA, Gladman MA, Maeda Y, Melenhorst J, Milito G, Muris JWM, Orhalmi J, Pohl D, Tillotson Y, Rydningen M, Svagzdys S, Vaizey CJ, Breukink SO. Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J 2022; 10:251-286. [PMID: 35303758 PMCID: PMC9004250 DOI: 10.1002/ueg2.12213] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI. METHODS These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus. RESULTS These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients. CONCLUSION These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.
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Affiliation(s)
- Sadé L. Assmann
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology‐HepatologyDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Jos Kleijnen
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | - Foteini Anastasiou
- 4rth TOMY – Academic Primary Care Unit Clinic of Social and Family MedicineUniversity of CreteHeraklionGreece
| | - Elissa Bradshaw
- Community Gastroenterology Specialist NurseRoyal Free HospitalLondonEnglandUK
| | | | - Emma V. Carrington
- Surgical Professorial UnitDepartment of Colorectal SurgerySt Vincent's University HospitalDublinIreland
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of VeronaAOUI VeronaVeronaItaly
- Center for Functional GI and Motility DisordersUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Marc A. Gladman
- The University of AdelaideAdelaide Medical SchoolFaculty of Health & Medical SciencesAdelaideAustralia
| | - Yasuko Maeda
- Department of Surgery and Colorectal SurgeryWestern General HospitalEdinburghUK
| | - Jarno Melenhorst
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
| | | | - Jean W. M. Muris
- Department of General PracticeCare and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | | | - Daniel Pohl
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
- Department of Gastrointestinal SurgeryUniversity Hospital of North NorwayTromsøNorway
| | | | - Mona Rydningen
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor HealthTromsøNorway
| | - Saulius Svagzdys
- Medical AcademyLithuanian University of Health SciencesClinic of Surgery Hospital of Lithuanian University of Health Sciences Kauno KlinikosKaunasLithuania
| | | | - Stephanie O. Breukink
- Department of Surgery and Colorectal SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
- School for Oncology and Developmental Biology (GROW)Maastricht UniversityMaastrichtThe Netherlands
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Han SH, Choi K, Shim GY, Kim J. Pudendal Nerve Terminal Motor Latency Compared by Anorectal Manometry Diagnosing Fecal Incontinence: A Retrospective Study. Am J Phys Med Rehabil 2022; 101:124-128. [PMID: 33789323 DOI: 10.1097/phm.0000000000001744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare the clinical value of pudendal nerve terminal motor latency in fecal incontinence patients with that of another diagnostic test-anorectal manometry. DESIGN This study used a cross-sectional design. Medical records of fecal incontinence patients who underwent pudendal nerve terminal motor latency and anorectal manometry testing were reviewed. Greater than 2.4 ms of pudendal nerve terminal motor latency was determined to be abnormal. Anorectal manometry was performed using a station pull-through technique. Mean resting anal pressure, maximal resting anal pressure, mean squeezing anal pressure, and maximal squeezing anal pressure were investigated. For normal and abnormal pudendal nerve terminal motor latency groups, comparative analyses were performed on anorectal manometry results. RESULTS A total of 31 patients were included. Thirteen patients showed normal pudendal nerve terminal motor latency. For anorectal manometry results, there was no significant difference between normal and abnormal pudendal nerve terminal motor latency groups. Fourteen patients had diabetes mellitus. Subgroup analysis of the 14 diabetic patients showed no significant difference between normal and abnormal pudendal nerve terminal motor latency groups. For 17 nondiabetic patients, there was a significant difference between the groups with positive correlations with mean/maximal resting anal pressures. CONCLUSIONS Pudendal nerve terminal motor latency significantly correlates with anorectal manometry in fecal incontinence only in nondiabetic patients.
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Affiliation(s)
- Seung Hee Han
- From the Department of Physical Medicine and Rehabilitation, Seoul Medical Center, Seoul, Republic of Korea (SHH, KC, GYS, JK); and Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea (GYS)
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Košťálová K, Zavoral M, Suchánek Š. High resolution anorectal manometry in patients with anorectal dysfunctions and the therapeutic consequences. Rozhl Chir 2022; 101:28-36. [PMID: 35148614 DOI: 10.33699/pis.2022.101.1.28-36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION High resolution anorectal manometry (HRAM) is a diagnostic method indicated in patients with anorectal dysfunction. The aim of the study was to evaluate the prevalence of anorectal dysfunctions and to assess therapeutic consequences. METHODS Retrospective data of consecutive patients referred to HRAM in the period from March 2019 to February 2021 were evaluated. Basic manometric parameters were assessed: resting pressure (RP), maximal squeeze pressure (SP), rectal sensitivity (RS), and dyssynergic defecation (DD). RESULTS 113 patients with combined fecal incontinence and obstructive defecation syndrome (FI + ODS: 44.2%), fecal incontinence (FI: 26.5%), obstructive defecation syndrome (ODS: 16.8 %), stoma before restoration of intestinal continuity (6.2%), functional pelvic pain (FP: 3.5 %) and controversial cases (2.7%) were analyzed. The average age was 54 years; female patients predominated (72 %). Patients with FI and FI+ODS had lower mean RP (57 mmHg and 53 mmHg) and/or lower SP (160 mmHg and 140 mmHg) compared to baseline. Patients with ODS had normal values of mean RP (75 mmHg) and SP (225 mmHg). DD was noted in most patients (FI: 76.6%, FI + ODS: 88%, ODS: 89.5%, FP: 100%). Conservative therapy with pelvic floor physiotherapy was provided in most cases (FI+ODS: 40%, ODS: 36.8%, FI: 13.3%, FP: 75%). CONCLUSION In patients with defecation disorders there is a high prevalence of pathological manometric findings that combine with each other. Based on manometric findings, conservative treatment with individual pelvic floor physiotherapy can be initiated.
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Patel K, Mei L, Yu E, Kern M, Lehal N, Edeani F, Sanvanson P, Davidson ERW, Shaker R. Differences in fatigability of muscles involved in fecal continence: Potential clinical ramifications. Physiol Rep 2021; 9:e15144. [PMID: 34927399 PMCID: PMC8685596 DOI: 10.14814/phy2.15144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Fatigue of the anal sphincter complex has been demonstrated using high-resolution anorectal manometry (HRAM). However, the fatigability of individual muscles such as the external anal sphincter (EAS) and puborectalis muscles (PRM) has not been described. Vaginal manometry has been used to study contractile activity of the PRM. By applying both modalities, we attempted to differentiate the fatigability between the PRM and the EAS under different exercise conditions. METHODS We studied two groups: group 1, 12 healthy women (21 ± 2.7 years) with HRAM and group 2, 10 healthy (20 ± 3 years) women with vaginal manometry. All subjects performed 40 repetitive contractions with and without an intra-anal resistive load. In group 1, areas under the curve (AUC) of the anal canal high-pressure zone (HPZ) including the caudal and rostral halves were compared. In group 2, the maximum and mean pressures of the vaginal HPZ were compared. RESULTS The AUC decreased significantly only after repetitive contractions against a resistive load (462 ± 129 vs. 390 ± 131 mmHg-cm, p = 0.02), indicating fatigue. The caudal half (EAS) decreased significantly after contractions against a load (288 ± 75 vs. 239 ± 82 mmHg-cm, p = 0.02), while the rostral half (PRM) did not. The vaginal pressures (PRM) also decreased only after repetitive contractions against a load (maximum pressures, 358 ± 171 vs. 239 ± 109 mmHg, p = 0.02). CONCLUSIONS The EAS and PRM both exhibit fatigue with contractions only against a resistive load. These findings may guide the development of appropriate exercise regimens to target specific muscles involved in fecal continence.
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Affiliation(s)
- Krupa Patel
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Ling Mei
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Elliot Yu
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mark Kern
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Navjit Lehal
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Francis Edeani
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Patrick Sanvanson
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Emily R. W. Davidson
- Department of Obstetrics and GynecologyDivision of UrogynecologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Reza Shaker
- Division of Gastroenterology and HepatologyMedical College of WisconsinMilwaukeeWisconsinUSA
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He S, Liu Z, Li L, Zhang J, Shi L, Song Y, Lin H, Sun W, Wang J, Deng Y, Wang H, Kang L, Dou R. Improvement of low anterior resection syndrome beyond 2 years after total mesorectal excision. J Surg Oncol 2021; 125:448-456. [PMID: 34689328 DOI: 10.1002/jso.26729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/15/2021] [Indexed: 11/07/2022]
Abstract
AIM Bowel dysfunction after sphincter-preserving proctectomy, also known as low anterior resection syndrome (LARS), has significant impact on survivors of rectal cancer. This study aimed to assess the temporal change of LARS beyond 2 years after proctectomy, which has not been fully studied. METHODS We longitudinally enrolled consecutive patients who had received total mesorectal excision in a tertiary academic medical center, with preoperative neoadjuvant therapy if indicated. LARS score was longitudinally assessed by two serial follow-ups, with a fixed interval of 18 months. RESULTS Overall, 107 patients responded for the first follow-up after a median of q20 months, 96 of whom responded for the second follow-up after a median of 38 months. At the first follow-up, 48 patients (44.9%) reported major LARS, compared with 23 (24.0%) at the second follow-up (p < 0.001). Mean LARS score improved from 27.3 to 18.6, mostly from "urgency" (12.2 vs. 6.2, p < 0.001) and "clustering of stools" (9.7 vs. 7.7, p = 0.001). Anastomosis less than 3 cm from the anal verge was independently associated with LARS improvement. CONCLUSION Bowel dysfunction continues to improve 2 years after total mesorectal excision, with most symptom relief in urgency and stool clustering, especially in patients with lower anastomosis.
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Affiliation(s)
- Siqi He
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Zhanzhen Liu
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Li Li
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Pelvic Floor Center, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Jinquan Zhang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Lishuo Shi
- Clinical Research Center, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Yuntao Song
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Hongcheng Lin
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Department of Anorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Weipeng Sun
- Department of Colorectal Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jianping Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Yanhong Deng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Department of Medical Oncology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Hui Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Liang Kang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Ruoxu Dou
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
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Wang JT, Miao YD, Guan QL. Comment on “Diagnostic approach to faecal incontinence: What test and when to perform?”. World J Gastroenterol 2021; 27:5622-5624. [PMID: 34588756 PMCID: PMC8433609 DOI: 10.3748/wjg.v27.i33.5622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/21/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
We recently read with interest the article "Diagnostic approach to faecal incontinence: What test and when to perform?". This is a comprehensive and practical review, which has particular significance for guiding clinicians to improve the examination strategy. Although we appreciate their work very much, based on the in-depth analysis of this research, we found some detailed problems in the article and will give our comments in this letter. If the author can further improve the relevant research, it will be valuable.
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Affiliation(s)
- Jiang-Tao Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Yan-Dong Miao
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Quan-Lin Guan
- Department of Oncology, The First Hospital of Lanzhou University, Lanzhou University, Lanzhou 730000, Gansu Province, China
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Rajindrajith S, Devanarayana NM, Thapar N, Benninga MA. Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management. J Pediatr Gastroenterol Nutr 2021; 72:794-801. [PMID: 33534361 DOI: 10.1097/mpg.0000000000003056] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT Functional fecal incontinence (FI) is a worldwide problem in children and comprises constipation-associated FI and nonretentive FI. Irrespective of pathophysiology, both disorders impact negatively on the psychological well-being and quality of life of affected children. A thorough clinical history and physical examination using the Rome IV criteria are usually sufficient to diagnose these conditions in most children. Evolving investigations such as high-resolution anorectal and colonic manometry have shed new light on the pathophysiology of functional FI. Although conventional interventions such as toilet training and laxatives successfully treat most children with constipation-associated FI, children with nonretentive FI need more psychologically based therapeutic options. Intrasphincteric injection of botulinum toxin, transanal irrigation and, in select cases, surgical interventions have been used in more resistant children with constipation-associated FI.
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Affiliation(s)
- Shaman Rajindrajith
- Department of Pediatrics, Faculty of Medicine, University of Colombo, Colombo 8
| | | | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Marc Alexander Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Sbeit W, Khoury T, Mari A. Diagnostic approach to faecal incontinence: What test and when to perform? World J Gastroenterol 2021; 27:1553-1562. [PMID: 33958842 PMCID: PMC8058654 DOI: 10.3748/wjg.v27.i15.1553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/01/2021] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Naharia 2210001, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Naharia 2210001, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Amir Mari
- Gastroenterology and Endoscopy Unit, The Nazareth Hospital, EMMS, Nazareth 464000, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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Zhuang Z, Hung H, Chen S, Futaba K, Gregersen H. Translating Fecobionics Into a Technique That Addresses Clinical Needs for Objective Perineal Descent Measurements. Clin Transl Gastroenterol 2021; 12:e00342. [PMID: 33956418 PMCID: PMC8049154 DOI: 10.14309/ctg.0000000000000342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/05/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Perineal descent is a phenomenon associated with anorectal dysfunction. It is diagnosed by defecography but subjected to manual measurements on the images/videos and interobserver bias. Fecobionics is a simulated feces for assessing important physiological parameters during defecation. Here, we translate Fecobionics into a new method for estimation of perineal descent based on electronic signals from the embedded inertial measurement units (IMUs). METHODS A displacement measurement method by a combined zero-velocity update and gravity compensation algorithm from IMUs was developed. The method was verified in a robot model, which mimicked perineal descent motion. RESULTS The method correlated well with the reference (R = 0.9789) and had a deviation from the peak displacement (range 0.25-2.5 cm) of -0.04 ± 0.498 cm. The method was further validated in 5 human experiments with comparison to the benchmark defecography technology (R = 0.79). DISCUSSION The proposed technology is objective, i.e., electronic measurements rather than by fluoroscopy or MRI. The development may impact clinical practice by providing a resource-saving and objective technology for diagnosing perineal descent in the many patients suffering from anorectal disorders. The technology may also be used in colon experiments with Fecobionics and for other gastrointestinal devices containing IMUs such as ingestible capsules like the Smartpill.
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Affiliation(s)
- Z. Zhuang
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - H.Y. Hung
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Shatin, Hong Kong.
| | - S.C. Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - K. Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - H. Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
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Nilsson IEK, Åkervall S, Molin M, Milsom I, Gyhagen M. Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries. Am J Obstet Gynecol 2021; 224:276.e1-276.e23. [PMID: 32835724 DOI: 10.1016/j.ajog.2020.08.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/06/2020] [Accepted: 08/19/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory. OBJECTIVE This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries. STUDY DESIGN Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components. RESULTS The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204). CONCLUSION The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.
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Affiliation(s)
- Ida E K Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden.
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Abstract
Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.
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Affiliation(s)
- Trisha Pasricha
- Division of Gastroenterology, Massachusetts General Hospital, Wang 5, Boston, MA 02114, USA; Department of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, CRP 9, Boston, MA 02114, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Wang 5, Boston, MA 02114, USA; Department of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, CRP 9, Boston, MA 02114, USA.
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Abstract
PURPOSE OF REVIEW This article provides an overview of the clinical presentation, investigations, and treatment options for lower urinary tract and bowel dysfunction in patients with neurologic diseases. RECENT FINDINGS The site of the neurologic lesion influences the pattern of lower urinary tract dysfunction. Antimuscarinic agents are first-line management for urinary incontinence; however, the side effect profile should be considered when prescribing them. β3-Receptor agonists are a promising alternative oral medication. Botulinum toxin injections into the detrusor have revolutionized the management of neurogenic detrusor overactivity.Bowel dysfunction commonly presents as constipation and fecal incontinence. Gastrointestinal emergencies may arise, including intestinal pseudoobstruction, intussusception, volvulus, and stercoral ulcer (ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation). Bowel function tests in neurologic patients often show a combination of slow transit and anorectal dysfunction. Management for slow transit constipation includes bulking agents, softening agents, yogurt/probiotics, and prokinetic agents. Suppositories, botulinum toxin injections, and transanal irrigation are options for managing anorectal constipation. SUMMARY Functions of the lower urinary tract and bowel are commonly affected in neurologic disease. Neurologists play an important role in assessing lower urinary tract and bowel symptoms in their patients and planning treatment strategies, often in collaboration with specialist teams.
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Rangan V, Nee J, Singh P, Ballou S, Iturrino J, Hirsch W, Lembo A. Fecal Urgency: Clinical and Manometric Characteristics in Patients With and Without Diarrhea. Dig Dis Sci 2020; 65:3679-3687. [PMID: 32468228 DOI: 10.1007/s10620-020-06349-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 05/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fecal urgency is classically associated with diarrhea, but is also common in individuals with normal bowel habits or constipation. Its etiology, particularly in non-diarrhea individuals, is unclear. METHODS We examined data from 368 individuals with and without diarrhea who underwent three-dimensional high-resolution anorectal manometry and balloon expulsion test. All patients completed the Rome III constipation module and the pelvic floor distress inventory (PDFI-20) survey. Patients were considered to have fecal urgency if they reported being bothered "moderately" or "quite a bit" by it in the past 3 months. RESULTS A total of 103 patients (28.0%) met our definition of fecal urgency. These patients were significantly more likely to meet criteria for irritable bowel syndrome and to report fecal incontinence, urinary incontinence, and diarrhea. Fecal urgency was associated with rectal hypersensitivity in those with diarrhea, but not in those without diarrhea. Fecal urgency was associated with urinary urge incontinence in those without diarrhea, but not those with diarrhea. CONCLUSIONS In patients with diarrhea, fecal urgency is associated with rectal hypersensitivity, whereas in patients without diarrhea, fecal urgency is associated with urinary urge incontinence. This suggests that fecal urgency has different pathophysiological mechanisms in patients with different underlying bowel habits.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - William Hirsch
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Gillor M, Shek KL, Dietz HP. How comparable is clinical grading of obstetric anal sphincter injury with that determined by four-dimensional translabial ultrasound? Ultrasound Obstet Gynecol 2020; 56:618-623. [PMID: 32149422 DOI: 10.1002/uog.22011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the agreement between grading of obstetric anal sphincter injuries (OASI) on translabial ultrasound (TLUS), using a newly developed algorithm, and grading on postpartum examination. A secondary aim was to assess the correlation between tear severity, as defined on ultrasound, and symptoms of anal incontinence and/or fecal urgency. METHODS This was a retrospective study of patients seen at a perineal clinic between 2012 and 2018, after recent primary repair of OASI. All patients underwent a standardized interview including the St Mark's anal incontinence test and four-dimensional TLUS. Post-processing of ultrasound volume data was performed blinded to all other data. Using tomographic ultrasound imaging, a set of eight slices was obtained, and the central six slices were evaluated for sphincter abnormalities. Slices with distortion, thinning or defects were rated as abnormal. The following algorithm was used to grade OASI: a Grade-3a tear was diagnosed if the external anal sphincter (EAS) was abnormal in < 4/6 slices; a Grade-3b tear was diagnosed if the EAS was abnormal in ≥ 4/6 slices; and a Grade-3c/4 tear was diagnosed if both the EAS and internal anal sphincter were abnormal in ≥ 4/6 slices. Clinical grading of OASI was determined according to the Royal College of Obstetricians and Gynaecologists guidelines. Agreement between clinical and TLUS diagnosis of OASI was evaluated using weighted κ. RESULTS Of the 260 women seen during the study period, 45 (17%) were excluded owing to missing data or a repeat OASI, leaving 215 complete datasets for analysis. The average follow-up interval was 2.4 months (range, 1-11 months) after OASI and the mean age of the women was 29 years (range, 17-42 years). One hundred and seventy-five (81%) women were vaginally primiparous. OASI was graded clinically as Grade 3a in 87 women, Grade 3b in 80, Grade 3c in 29 and Grade 4 in 19. On imaging, full agreement between clinical and TLUS grading was noted in 107 (50%) women, with a weighted κ of 0.398. In 96 (45%) women, there was disagreement by one category, with a weighted κ of 0.74 and in 12 (6%) there was disagreement by two categories. Twenty-four (11%) women were found to have a normal anal sphincter on imaging. Overall, potential clinical over-diagnosis was noted in 72 (33%) women and potential under-diagnosis in 36 (17%). The seniority of the diagnosing obstetrician did not significantly alter agreement between clinical and sonographic OASI grading (κ 0.44, 0.43, and 0.34, for specialists and senior and junior residents, respectively). The association between symptoms of anal incontinence and/or fecal urgency and TLUS grading did not reach significance (P = 0.052). CONCLUSIONS Clinical and TLUS-based grading of OASI showed fair agreement. Clinical over-diagnosis may be increasingly common in our population, although under-diagnosis may still occur in a significant minority. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Gillor
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Kaplan Medical Centre, Rehovot, Affiliated to the Hebrew University and Hadassah School of Medicine, Jerusalem, Israel
| | - K L Shek
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Liverpool Clinical School, Western Sydney University, Sydney, Australia
| | - H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
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Attari A, Chey WD, Baker JR, Ashton-Miller JA. Comparison of anorectal function measured using wearable digital manometry and a high resolution manometry system. PLoS One 2020; 15:e0228761. [PMID: 32991595 PMCID: PMC7523952 DOI: 10.1371/journal.pone.0228761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022] Open
Abstract
There is a need for a lower cost manometry system for assessing anorectal function in primary and secondary care settings. We developed an index finger-based system (termed "digital manometry") and tested it in healthy volunteers, patients with chronic constipation, and fecal incontinence. Anorectal pressures were measured in 16 participants with the digital manometry system and a 23-channel high-resolution anorectal manometry system. The results were compared using a Bland-Altman analysis at rest as well as during maximum squeeze and simulated defecation maneuvers. Myoelectric activity of the puborectalis muscle was also quantified simultaneously using the digital manometry system. The limits of agreement between the two methods were -7.1 ± 25.7 mmHg for anal sphincter resting pressure, 0.4 ± 23.0 mmHg for the anal sphincter pressure change during simulated defecation, -37.6 ± 50.9 mmHg for rectal pressure changes during simulated defecation, and -20.6 ± 172.6 mmHg for anal sphincter pressure during the maximum squeeze maneuver. The change in the puborectalis myoelectric activity was proportional to the anal sphincter pressure increment during a maximum squeeze maneuver (slope = 0.6, R2 = 0.4). Digital manometry provided a similar evaluation of anorectal pressures and puborectalis myoelectric activity at an order of magnitude less cost than high-resolution manometry, and with a similar level of patient comfort. Digital Manometry provides a simple, inexpensive, point of service means of assessing anorectal function in patients with chronic constipation and fecal incontinence.
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Affiliation(s)
- Ali Attari
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | - William D. Chey
- Division of Gastroenterology and Hepatology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, United States of America
| | - Jason R. Baker
- Division of Gastroenterology and Hepatology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, United States of America
| | - James A. Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States of America
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Abstract
Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.
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Affiliation(s)
- Alice C Jiang
- Division of Gastroenterology, Department of Internal Medicine, Rush University Medical Center, 600 S Paulina St, Chicago, IL 60612, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard M. Miller School of Medicine, 1601 NW 12th Ave, Miami, FL, USA
| | - Yun Yan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Augusta University Medical Center, 1120 15th Street, AD 2226, Augusta, GA 30912, USA.
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Košťálová K, Suchánek Š, Zavoral M. Update and review of diagnosing functional anorectal disorders - standardized protocol for high-resolution anorectal manometry and the London classification. ACTA ACUST UNITED AC 2020; 99:249-257. [PMID: 32736479 DOI: 10.33699/pis.2020.99.6.249-257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Complex anorectal examination including a detailed medical history, physical proctological examination and evaluation of the sensorimotor and structural function of the anorectum is essential for the diagnosis and therapeutic management of functional anorectal dysfunction. The aim of the work is to provide an overview of diagnosing functional anorectal disorders according to the new update and consensus statement of the International Anorectal Physiology Working Group (IAPWG) with a focus on indications, a standardized examination protocol and introduction of the new London classification of anorectal dysfunction. The indications are: fecal incontinence, defecation disorders, functional pelvic (anorectal) pain, evaluation before an anorectal intervention and before planned delivery to assess the function of a previously traumatized anal sphincter. Standardization of the diagnosis and the evaluated data are the basis for multidisciplinary cooperation and determination of a treatment plan for each patient individually.
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Affiliation(s)
- Roberto Peltrini
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Paola Antonella Greco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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