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Manometry, Rectoanal Inhibition and Compliance Assessment in Proctologic Practice: Approaches in the Reoperative Case

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Reconstructive Surgery of the Rectum, Anus and Perineum

Abstract

The use of anorectal physiological assessment in the management of patients undergoing reoperative surgery has diminished over the years because it has become clear that functional outcome does not directly correlate with preoperative manometry. This chapter discusses conventional manometry, vector volume manometry, and assessment of the rectoanal inhibitory reflex along with their interpretation and the limitations of their determination and assessment. Newer techniques of compliance assessment after the construction of a neorectal reservoir are defined, including impedance planimetry, anal acoustic reflectometry, and barostat assessment. A better understanding of the use of these modalities is required in cases where poor functional outcome may accompany irradiation or anastomotic sepsis after pouch anal reconstruction. Although conventional electromyography has disappeared in the assessment of patients with anal incontinence, operative neurophysiological assessment has shown a resurgence with the introduction of sacral neuromodulation technology and in the determination of which patients are likely to benefit from permanent stimulator implantation after temporary periods of nerve stimulation. This chapter and the next describes the clinical role of manometry and neurophysiology in patients who are potential candidates for reconstructive surgery and the complex physiological limitations inherent in these new modalities.

This chapter combines an assessment of conventional anorectal manometry, rectoanal inhibition, rectal sensation, and compliance testing, along with vector volume manometry and neurophysiologic assessment specifically as they apply to the reoperative and reconstructive case. It includes editorial comments by Andrew P. Zbar about the value of the various techniques in clinical proctologic practice for those interested in the fine details of manometric interpretation and its pitfalls (see Chap. 7).

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References

  1. Sangwan YP, Coller JA, Schoetz Jr DJ, Murray JJ, Roberts PL, Rao SS, et al. How useful are manometric tests of anorectal function in the management of defecation disorders? Am J Gastroenterol. 1997;92:469–75.

    Google Scholar 

  2. Zbar AP, Kmiot WA. Anorectal investigation. In: Phillips RKS, editor. A companion to specialist surgical practice; colorectal surgery. 1st ed. London: WB Saunders; 1997. p. 1–33.

    Google Scholar 

  3. Schuster MM. Colon motility and anosphincteric manometric recordings by air-filled balloon technique. In: Smith LE, editor. Practical guide to anorectal testing. 2nd ed. New York: Igaku-Shoin; 1995. p. 37–50.

    Google Scholar 

  4. Smith LE. Practical guide to anorectal testing. 2nd ed. New York: Igaku-Shoin; 1995.

    Google Scholar 

  5. Harris LD, Winans CS, Pope CE. Determination of yield pressure: a method for measuring anal sphincter competence. Gastroenterology. 1996;50:754–60.

    Google Scholar 

  6. Brusciano L, Limongelli P, del Genio G, Rossetti G, Sansone S, Healey A, et al. Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders. Int J Colorectal Dis. 2009;24:961–7.

    Article  PubMed  CAS  Google Scholar 

  7. Gruppo Lombardo per lo Studio della Motilita` Intestinale. Anorectal manometry with water-perfused catheter in healthy adults with no functional bowel disorders. Colorectal Dis. 2009;12:220–5.

    Article  Google Scholar 

  8. Jorge JMN, Wexner SD. Anorectal manometry: techniques and clinical applications. South Med J. 1993;86:924–31.

    Article  PubMed  CAS  Google Scholar 

  9. Marcello PW, Barrett RC, Coller JA, Schoetz Jr DJ, Roberts PL, Murray JJ, et al. Fatigue rate as a new measurement of external sphincter function. Dis Colon Rectum. 1998;41:336–43.

    Article  PubMed  CAS  Google Scholar 

  10. Brusciano L, Limongelli P, del Genio G, Sansone S, Rossetti G, Maffettone V, et al. Useful parameters helping proctologists to identify patients with defaecatory disorders that may be treated with pelvic floor rehabilitation. Tech Coloproctol. 2007;11: 45–50.

    Article  PubMed  CAS  Google Scholar 

  11. Garavoglia M, Borghi F, Levi AC. Arrangement of the anal striated musculature. Dis Colon Rectum. 1993;36:10–5.

    Article  PubMed  CAS  Google Scholar 

  12. Farouk R, Duthie GS, Bartolo DCG. Functional anorectal disorders and physiological evaluation. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery. New York: McGraw-Hill; 1992. p. 173–83.

    Google Scholar 

  13. Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, American Society of Colon and Rectal Surgeons; Association of Coloproctology of Great Britain and Ireland; Coloproctology Surgical Society of Australia, et al. Consensus statement of definitions for anorectal physiology and rectal cancer. Colorectal Dis. 2001;3:272–5.

    Article  PubMed  CAS  Google Scholar 

  14. Miller R, Bartolo DCC, Cervero F. Anorectal sampling: a comparison of normal and incontinent patients. Br J Surg. 1998;75:44–7.

    Article  Google Scholar 

  15. Lane RH, Parks AG. Function of the anal sphincters following colo-anal anastomosis. Br J Surg. 1977;64:596–9.

    Article  PubMed  CAS  Google Scholar 

  16. O’Riordain MG, Molloy RG, Gillen P, Horgan A, Kirwan WO. Rectoanal inhibitory reflex following low stapled anterior resection of the rectum. Dis Colon Rectum. 1992;35:874–8.

    Article  PubMed  Google Scholar 

  17. Sangwan YP, Coller JA, Barrett RC, Murray JJ, Roberts PL, Schoetz Jr DJ. Distal rectoanal excitatory reflex: a reliable index of pudendal neuropathy. Dis Colon Rectum. 1995;38:916–22.

    Article  PubMed  CAS  Google Scholar 

  18. Sangwan YP, Coller JA, Schoetz Jr DJ, Murray JJ, Roberts PL. Latency measurement of rectoanal reflexes. Dis Colon Rectum. 1995;38:1281–5.

    Article  PubMed  CAS  Google Scholar 

  19. Kaur G, Gardiner A, Lee PW et al.; Increased sensitivity to the rectoanal reflex is seen in incontinent patients. Colorectal Dis. 1999; Suppl 1:39A–40A

    Google Scholar 

  20. Kaur G, Gardiner A, Duthie GS. Rectoanal reflex parameters in incontinence and constipation. Dis Colon Rectum. 2002;45:928–33.

    Article  PubMed  Google Scholar 

  21. Zbar AP, Aslam M, Gold DM, Gatzen C, Gosling A, et al. Parametrs of the rectoanal inhibitory reflex in patients with idiopatic fecal incontinence and chronic constipation. Dis Colon Rectum. 1998;41:200–8.

    Article  PubMed  CAS  Google Scholar 

  22. Sagar PM, Holdsworth PJ, Johnston D. Correlation between laboratory findings and clinical outcome after restorative proctocolectomy: serial studies in 20 patients with end-to-end pouch anal anastomosis. Br J Surg. 1991;78:67–70.

    Article  PubMed  CAS  Google Scholar 

  23. Horgan AF, Molloy RG, Coulter J, Sheehan M, Kirwan WO. Nerve regeneration across colorectal anastomosis after low anterior resection in a canine model. Int J Colorectal Dis. 1993;8:167–9.

    Article  PubMed  CAS  Google Scholar 

  24. Satish SC, Rao SS. Constipation: evaluation and treatment of colonic and anorectal motility disorders. Gastrointest Endosc Clin N Am. 2009;19:117–39.

    Article  Google Scholar 

  25. Rao SS, Hatfield R, Soffer E, Rao S, Beaty J, Conklin JL. Manometric tests of anorectal function in healthy adults. Am J Gastroenterol. 1999;94:773–83.

    Article  PubMed  CAS  Google Scholar 

  26. Haynes WG, Read NW. Ano-rectal activity in man during rectal infusion of saline: a dynamic assessment of the anal continence mechanism. J Physiol. 1982;330:45–56.

    PubMed  CAS  Google Scholar 

  27. Read NW, Haynes WG, Bartolo DC, Hall J, Read MG, Donnelly TC, et al. Use of anorectal manometry during rectal infusion of saline to investigate sphincter function in incontinent patients. Gastroenterology. 1983;85:105–13.

    PubMed  CAS  Google Scholar 

  28. Rao SS, Read NW, Stobart JA, Haynes WG, Benjamin S, Holdsworth CD. Anorectal contractility under basal conditions and during rectal infusion of saline in ulcerative colitis. Gut. 1988;29:769–77.

    Article  PubMed  CAS  Google Scholar 

  29. Bordeianou L, Savitt L, Dursun A. Measurements of pelvic floor dyssynergia: which test result matters? Dis Colon Rectum. 2011;54:60–5.

    Article  PubMed  Google Scholar 

  30. Fleshman JW, Dreznik Z, Cohen E, Fry RD, Kodner IJ. Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle. Dis Colon Rectum. 1992;35:1019–25.

    Article  PubMed  CAS  Google Scholar 

  31. Dedeli O, Turan I, Oztürk R, Bor S. Normative values of the balloon expulsion test in healthy adults. Turk J Gastroenterol. 2007;18:177–81.

    PubMed  Google Scholar 

  32. Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Preoperative anal manometry predicts continence after perineal proctectomy for rectal prolapse. Dis Colon Rectum. 2006;49:1052–8.

    Article  PubMed  Google Scholar 

  33. Poen AC, De Brauw M, Felt-Bersma RJF, de Jong D, Cuesta MA. Laparoscopic rectopexy for complete rectal prolapse. Clinical outcome and anorectal function tests. Surg Endosc. 1996;10:904–8.

    Article  PubMed  CAS  Google Scholar 

  34. Delemarre JB, Gooszen HG, Kruyt RH, Soebhag R, Geesteranus AM. The effect of posterior rectopexy on fecal continence. A prospective study. Dis Colon Rectum. 1991;34:311–6.

    Article  PubMed  CAS  Google Scholar 

  35. Brodon G, Dolk A, Holmström B. Recovery of the internal anal sphincter following rectopexy: a possible explanation for continence improvement. Int J Colorectal Dis. 1988;3:23–8.

    Article  Google Scholar 

  36. Felt-Bersma RJF, Klinkenberg-Knol EC, Meuwissen SGM, Felt-Bersma RJF, Klinkenberg-Knol EC, Meuwissen SGM, Felt-Bersma RJF, Klinkenberg-Knol EC, Meuwissen SGM. Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum. 1990;33:479–86.

    Article  PubMed  CAS  Google Scholar 

  37. Zbar AP, Takashima S, Hasegawa T, Kitabayashi K. Perineal rectosigmoidectomy (Altemeier’s procedure): a review of physiology, technique and outcome. Tech Coloproctol. 2002;6:109–16.

    Article  PubMed  CAS  Google Scholar 

  38. Madden MV, Kamm MA, Nicholls RJ, Santhanam AN, Cabot R, Speakman CT. Abdominal rectopexy for complete prolapse: prospective study evaluating changes in symptoms and anorectal function. Dis Colon Rectum. 1992;35:48–55.

    Article  PubMed  CAS  Google Scholar 

  39. Reboa G, Gipponi M, Ligorio M, Marino P, Lantieri F. The impact of stapled transanal rectal resection on anorectal function in patients with obstructed defecation syndrome. Dis Colon Rectum. 2009;52:1598–604.

    Article  PubMed  Google Scholar 

  40. Behboo R, Zanella S, Ruffolo C, Vafai M, Marino F, Scarpa M. Stapled haemorroidopexy: extent of tissue excision and clinical implications in the early postoperative period. Colorectal Dis. 2011;13(6):697–702. doi:10.1111/j.1463-1318.2010.02247.x. Epub 2010 Feb 24.

    Article  PubMed  CAS  Google Scholar 

  41. Boccasanta P, Venturi M, Salamina G, Cesana BM, Bernasconi F, Roviaro G. New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial. Int J Colorectal Dis 2004;19:359–369.

    Article  PubMed  Google Scholar 

  42. Renzi A, Talento P, Giardiello C, Angelone G, Izzo D, Di Sarno G. Stapled trans-anal rectal resection (STARR) by a new dedicated device for the surgical treatment of obstructed defaecation syndrome caused by rectal intussusception and rectocele: early results of a multicenter prospective study. Int J Colorectal Dis. 2008;23:999–1005.

    Article  PubMed  Google Scholar 

  43. Frascio M, Stabilini C, Ricci B, Marino P, Fornaro R, De Salvo L, et al. Stapled transanal rectal resection for outlet obstruction syndrome: results and follow-up. World J Surg. 2008;32:1110–5.

    Article  PubMed  Google Scholar 

  44. Wong RK, Palsson OS, Turner MJ, Levy RL, Feld AD, von Korff M, et al. Inability of the Rome III criteria to distinguish functional constipation from constipation-subtype irritable bowel syndrome. Am J Gastroenterol. 2010;105:2228–34.

    Article  PubMed  Google Scholar 

  45. Suttor VP, Prott GM, Hansen RD, Kellow JE, Malcolm A. Evidence for pelvic floor dyssynergia in patients with irritable bowel syndrome. Dis Colon Rectum. 2010;53:156–60.

    Article  PubMed  CAS  Google Scholar 

  46. Faried M, El Nakeeb A, Youssef M, Omar W, El Monem HA. Comparative study between surgical and non-surgical treatment of anismus in patients with symptoms of obstructed defecation: a prospective randomized study. J Gastrointest Surg. 2010;14:1235–43.

    Article  PubMed  Google Scholar 

  47. Keating JP, Stewart PJ, Eyers AA, Warner D, Bokey EL. Are special investigations of value in the management of patients with fecal incontinence? Dis Colon Rectum. 1997;40:896–901.

    Article  PubMed  CAS  Google Scholar 

  48. Solomon MJ, Pager CK, Rex J, Roberts R, Manning J. Randomized, controlled trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance alone in the treatment of mild to moderate fecal incontinence. Dis Colon Rectum. 2003;46:703–10.

    Article  PubMed  Google Scholar 

  49. Boselli AS, Pinta F, Cecchini S, Costi R, Marchesi F, Violi V, et al. Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology. World J Surg. 2010;34:815–21.

    Article  PubMed  Google Scholar 

  50. Kenefick NJ, Christiansen J. A review of sacral nerve stimulation for the treatment of faecal incontinence. Colorectal Dis. 2004;6:75–80.

    Article  PubMed  CAS  Google Scholar 

  51. Amend B, Matzel KE, Abrams P, de Groat WC, Sievert KD. How does neuromodulation work. Neurourol Urodyn. 2011;30:762–5. doi:10.1002/nau.21096.

    Article  PubMed  Google Scholar 

  52. Otto SD, Burmeister S, Buhr HJ, Kroesen A. Sacral nerve stimulation induces changes in the pelvic floor and rectum that improve continence and quality of life. J Gastrointest Surg. 2010;14:636–44.

    Article  PubMed  Google Scholar 

  53. Michelsen H-B, Worsoe J, Krogh K, Lundby L, Christensen P, Buntzen S, et al. Rectal motility after sacral nerve stimulation for faecal Incontinence. Neurogastroenterol Motil. 2009;22:36–46.

    PubMed  Google Scholar 

  54. de Leeuw JW, Vierhout ME, Struijk PC, Auwerda HJ, Bac DJ, Wallenburg HC. Anal sphincter damage after vaginal delivery relationship of anal endosonography and manometry to anorectal complaints. Dis Colon Rectum. 2002;8:1004–10.

    Article  Google Scholar 

  55. Gearhart S, Hull T, Floruta C, Schroeder T, Hammel J. Anal manometric parameters: predictors of outcome following anal sphincter repair? J Gastrointest Surg. 2005;9:115–20.

    Article  PubMed  Google Scholar 

  56. Zutshi M, Salcedo L, Hammel J, Hull T. Anal physiology testing in fecal incontinence: is it of any value? Int J Colorectal Dis. 2010;25:277–82.

    Article  PubMed  Google Scholar 

  57. Nordenstam JF, Altman DH, Mellgren AF, Rothenberger DA, Zetterström JP. Impaired rectal sensation at anal manometry is associated with anal incontinence one year after primary sphincter repair in primiparous women. Dis Colon Rectum. 2010;53:1409–14.

    Article  PubMed  Google Scholar 

  58. Ha HT, Fleshman JW, Smith M, Read TE, Kodner IJ, Birnbaum EH. Manometric squeeze pressure difference parallels functional outcome after overlapping sphincter reconstruction. Dis Colon Rectum. 2001;44:655–60.

    Article  PubMed  CAS  Google Scholar 

  59. Elton C, Stoodley BJ. Anterior anal sphincter repair: results in a district general hospital. Ann R Coll Surg Engl. 2002;84:321–4.

    Article  PubMed  Google Scholar 

  60. Sitzler PJ, Thompson JP. Overlap repair of damaged anal sphincter. A single surgeon’s series. Dis Colon Rectum. 1996;39:1356–60.

    Article  PubMed  CAS  Google Scholar 

  61. Oliveira L, Pfeifer J, Wexner SD. Physiological and clinical outcome of anterior sphincteroplasty. Br J Surg. 1996;83:502–5.

    Article  PubMed  CAS  Google Scholar 

  62. Fleshman JW, Peters WR, Shemesh EL, Fry RD, Kodner IJ. Anal sphincter reconstruction: anterior overlapping muscle repair. Dis Colon Rectum. 1991;34:739–43.

    Article  PubMed  CAS  Google Scholar 

  63. Van Tets WF, Kuijpers JHC. Pelvic floor procedures produce no consistent changes in anatomy or physiology. Dis Colon Rectum. 1998;41:365–9.

    Article  PubMed  Google Scholar 

  64. Ooi BS, Tjandra JJ, Tang CL, et al. Anorectal physiology testing before and after a successful sphincter repair: a prospective study. Colorectal Dis. 2000;2:220–8.

    Article  Google Scholar 

  65. Evans C, Davis K, Kumar D. Overlapping anal sphincter repair and anterior levatorplasty: effect of patient’s age and duration of follow-up. Int J Colorectal Dis. 2006;21:795–801.

    Article  PubMed  Google Scholar 

  66. Roig JV, Jorda J, García-Armengol J, Esclapez P, Solana A. Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery. Dis Colon Rectum. 2009;52:1462–9.

    Article  PubMed  Google Scholar 

  67. Nicholls RJ, Belliveau P, Neill M, Wilks M, Tabaqchali S. Restorative proctocolectomy with ileal reservoir: a pathophysiological assessment. Gut. 1981;22:462–8.

    Article  PubMed  CAS  Google Scholar 

  68. Nasmyth DG, Johnston D, Godwin PG, Dixon MF, Smith A, Williams NS. Factors influencing bowel function after ileal pouch–anal anastomosis. Br J Surg. 1986;73:469–73.

    Article  PubMed  CAS  Google Scholar 

  69. Scott NA, Pemberton JH, Barkel DC, Wolff BG. Anal and ileal pouch manometric measurements before ileostomy closure are related to functional outcome after ileal pouch–anal anastomosis. Br J Surg. 1989;76:613–6.

    Article  PubMed  CAS  Google Scholar 

  70. Church JM, Saad R, Schroeder T, Fazio VW, Lavery IC, Oakley JR, et al. Predicting the functional result of anastomoses to the anus: the paradox of preoperative anal resting pressure. Dis Colon Rectum. 1993;36:895–900.

    Article  PubMed  CAS  Google Scholar 

  71. Efthimiadis C, Basdanis G, Zatagias A, Tzeveleki I, Kosmidis C, Karamanlis E, et al. Manometric and clinical evaluation of patients after low anterior resection for rectal cancer. Tech Coloproctol. 2004;8 Suppl 1:205–7.

    Article  Google Scholar 

  72. Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome. Colorectal Dis. 2006;8:650–6.

    Article  PubMed  CAS  Google Scholar 

  73. Koda K, Yasuda H, Hirano A, Kosugi C, Suzuki M, Yamazaki M, et al. Evaluation of postoperative damage to anal sphincter/levator ani muscles with three-dimensional vector manometry after sphincter-preserving operation for rectal cancer. J Am Coll Surg. 2009;208:362–7.

    Article  PubMed  Google Scholar 

  74. Pucciani F, Ringressi MN, Redditi S, Masi A, Giani I. Rehabilitation of fecal incontinence after sphincter-saving surgery for rectal cancer: encouraging results. Dis Colon Rectum. 2008;51:1552–8.

    Article  PubMed  Google Scholar 

  75. Kumar D, Hallan RI, Womack NR, O’Connell PR, Miller R. Measurement of anorectal function, ch 3. In: Kumar D, Waldron DJ, Williams NS, editors. Clinical measurement in coloproctology. London: Springer; 1991. p 40.

    Chapter  Google Scholar 

  76. Roberts PL. Rectoanal inhibition, ch 2.2. In: Wexner SD, Zbar AP, Pescatori M, editors. Complex anorectal disorders: investigation and management. London: Springer; 2005.

    Google Scholar 

  77. Duthie GS, Gardiner AB. Impedance planimetry: clinical impedance planimetry, Ch 2.5 (ii). In: Wexner SD, Zbar AP, Pescatori M, editors. Complex anorectal disorders: investigation and management. London: Springer; 2005.

    Google Scholar 

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Authors and Affiliations

  1. XI Division of General and Obesity Surgery, Second University of Naples, Aversa, Italy

    Luigi Brusciano M.D., Ph.D., C. Di Stazio M.D., F. Lucido M.D. & A. Del Genio M.D.

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  1. Luigi Brusciano M.D., Ph.D.
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  2. C. Di Stazio M.D.
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  3. F. Lucido M.D.
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  4. A. Del Genio M.D.
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Correspondence to Luigi Brusciano M.D., Ph.D. .

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Editors and Affiliations

  1. Tamworth Rural Referral Hospital, Dean Street, Tamworth, 2340, New South Wales, Australia

    Andrew P. Zbar

  2. Delware Street 420, Minneapolis, 55455, Minnesota, USA

    Robert D. Madoff

  3. , Dept. Colorectal Surgery, Cleveland Clinic, Florida, Cleveland Clinic Blvd. 2950, Weston, 33331, Florida, USA

    Steven Wexner

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Brusciano, L., Di Stazio, C., Lucido, F., Del Genio, A. (2013). Manometry, Rectoanal Inhibition and Compliance Assessment in Proctologic Practice: Approaches in the Reoperative Case. In: Zbar, A., Madoff, R., Wexner, S. (eds) Reconstructive Surgery of the Rectum, Anus and Perineum. Springer, London. https://doi.org/10.1007/978-1-84882-413-3_6

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