pp The M.F.A.: a new device for an early selection of patients. Piercarlo Meinero M.D. Proctological visit for minor pathologies Critical point Negative anamnesis Routine exames Positive anamnesis Other exames Surgical treatment What are the critical points of the proctological examination today? • We can only detect the morphological aspects of the anus and the rectum but not their functionality. • At present, a device does not exist that, already at the first visit, allows us to supect the presence of attendant diseases and also to predict postoperatory complications. • Guidelines do not exist that provide for the anorectal manometry in patients with minor diseases (mucosal rectal prolaps and/or haemorrhoids). The Meinero Multi-Functional Anoscope (MFA ) pp •It doesn’t replace manometry •Between nothing and manometry •It tests anorectal functionality •Early patients selection •It’s easy and fast to use pp MFA functions 1) 2) 3) 4) Rectal Sensation Test (RST) Balloon Expulsion Test (BET) Extent of Prolapse Assessment (EPA) Length Measurement of the Anal Canal (LMAC) 1) Rectal Sensation Test (RST) FS First Sensation DDV Defecatory Desire Volume MTV Maximum Tolerable Volume The same procedure like the manometry RST with the MFA: the method 1 2 3 4 Rectal sensitivity NORMAL VALUES thresholds FS 30 - 60 DDV 60 - 160 MTV 160 - 270 FS < 30 HYPERSENSITIVITY DDV < 60 MTV < 160 sensitivity Rectal alterations HYPOSENSITIVITY FS > 60 DDV > 160 MTV > 270 The RST is important because… External sphincter disfuncions Hypersensitivity IBD Faecal incontinence (FI e UFI) First visit Normal Pudendal neuropathy ODS Hyposensitivity Idiopatic Faecal Incontinence (IFI) Puborectalis Syndrome, Dissynergy Solitary Ulcer- Megarectum. Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S., F.R.C.S., Peter J. Lunniss, M.S., F.R.C.S.: “Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable Constipation and Fecal Incontinence” D.C.R. 2003 Vol.46, N° 2:238-246. Christopher L.H. Chan, F.R.C.S., S. Mark Scott, Ph.D., Norman S. Williams, F.R.C.S., Peter J. Lunnis, F.R.C.S. “Rectal Hypersensitivity Worsens Stool Frequency, Urgency and Lifestyle in Patients With Urge Fecal Incontinence”. D.C.R. 2005 Vol. 48, N°1: 134-140. RST: the references Emanuel Chrysos, M.D., Ph.D., Elias Athanasakis, M.D., John Tsiaoussis, M.D., Ph.D., Odysseas Zoras, M.D., Ph.D., Antonios Nickolopoulos, M.D., Joho Sophocles Vassilakis, M.D., Ph.D., Evaghelos Xynos, M.D., Ph.D., F.A.C.S.: “Rectoanal Motility in Crohn’s Disease Patients”. D.C.R. 2001 Vol.44, N° 10: 1509-1513. Tetsuo Yamana, M.D., Masatoshi Oya, M.D., Junji Komatsu, M.D., Yasuo Takase, M.D., Noboru Mikuni, M.D., Hiroshi Ishikawa, M.D.: “Preoperative Anal Sphincter High Pressure Zone, Maximum Tolerable Volume and Anal Mucosal Electrosensitivity Predict Early Postoperative Defecatory Function After Low Anterior Resection for Rectal Cancer”. D.C.R. 1999 Vol.42 N° 9: 1145-1151. Gloria Lacima, M.D., Miguel Pera, M.D., Josep Valls-Solé, M.D., Xavier Gonzales-Argenté, M.D., Montserrat PuigClota, M.D.: “Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A prospective Study”. D.C.R. 2006 Vol. 49 N° 3: 353-359. Paul Broens, M.D., Dirk Vanbeckevoort, M.D., Erwin Bellon, M.Sc., freddy Penninckx, M.D., Ph.D.: “Combined Radiologic and Manometric Study of Rectal Filling Sensation”. D.C.R. 2002 Vol. 45 N° 8: 1016-1022. M.J. Gosselink, M.D., Ph.D., W.R. Schouten, M.D., Ph.D.: “Rectal Sensory Perception in Females with Obstructed Defecation”. D.C.R.2001 Vol. 44 N° 9: 1337-1344. M.D. Crowell, Ph.D., B.E.Lacy, M.D., Ph.D., V.A. Schettler, B.S.N., T.N. Dineen, M.D., K.W.Olden, M.D., N.J. Talley, M.D., Ph.D.: “Subtypes of Anal Incontinence Associated With Bowel Dysfunction: Clinical, Physiologic, and Psychosocial Characterization”. D.C.R. 2004 Vol. 47 N° 10 : 1627-1635. 2) Balloon Expulsion Test by MFA (BET) 60 cc of air – Sitting position – Maximum Expulsion Time 60 sec. BET with MFA in 218 patients RST Patients BET ET (seconds) MET (seconds) Hyper 30 Normal 16+/-11 < 27 Normal 112 Normal 30+/-10 < 41 27 Positive (57.4%) > 60 > 60 16 Normal (34%) 44+/-11 < 56 4 Normal (8.5%) 5 <6 Hypo 3) Extent of Prolapse Assessment (EPA) • Without the anoscope • 150-160 cc of air • Traction during the squeeze • Perineal information • Vaginal exploration 4) Length Measurement of the Anal Canal (LMAC) It is possible thanks to graduated scale in centimeters. Useful in case of operation for faecal incontinence. It can predict the biofeedback failure in the cases of anismus. Poong-Lyul Rhee, M.D., Moon Seok Choi, M.D., Young Ho Kim, M.D., Hee Jung Son, M.D., Jae Jun Kim, M.D., Kwang Cheol Koh, M.D., Seung Woon Paik, M.D., Jong Chul Rhee, M.D., Kyoo Wan Choi, M.D.: “An Increased Rectal Maximum Tolerable Volume and Long Anal Canal Are Associated with Poor Short-Term Response to Biofeedback Therapy for patients with Anismus with Decreased Bowel Frequency and Normal Colonic Transit Time”. D.C.R. 2000 Vol. 43 N° 10: 1405-1411. My own study: 218 patients Jan. 2006 / Sept. 2008 189 patients: 128 PMRE; 61 ODS To demostrate that: • The rectal sensitivity thresholds are the same with MFA and anorectal manometry. • The RST alterated values, detected with the MFA during the first visit, could be an expression of attendant diseases and they could predict postoperatory complications. R=0.99, p<0.001 R=0.96, p<0.001 FS DDV First aim. The correlation on the three parameters related to the measures detected with MFA and manometry, is very high (R= Pearson’s correlation coefficient). By Biostatistic Unit of tha Genova University – Doctor Mariapia Sormani. R=0.98, p<0.001 MTV Rectal sensitivity thresholds are the same if detected with MFA or anorectal manometry (R = 0,99 p<0,001). Identification of patients with hyper or hyposensitivity 128 patients tested with MFA and manometry 61 patients tested with the MFA and suffering from PMRE manometry suffering from ODS 128 128 27 19 61 61 N° pazienti Ipersensibili Iposensibili 26 22 26 3 Total RST 189 30 47 2 25 Diagnostic Assessment (US, EMG, PNTML, Defecography, Coloscopy, Manovolumetry) 6 females and 1 male with EAS disfunctions (23.3%) 1 male with RCU (3.3%)* 30 patients with hypersensitivity 3 males and 7 fimales with MII (33.3%) 1 fimale with celiac disease (3.3%)* 9 females with IRA+RA+ slow transit costipation (19.1%) 1 male with slow transit costipation (2.1%) 17 females with IRA+RA (36.1 %) 47 patients with hyposensitivity 5 males and 3 females with puborectalis syndrome (17%) 1 female with faecal incontinences (gas and liquid stools) (2.1%) 1 female with both constipation and faecal incontinence (2.1%) 1 female only with rectocele (2.1%) 2 females only with IRA (4.25%) Surgical treatment selection of the 189 patients of the first group Operated patients Disease N° Operation Normals Hyper. Hypo PMRE 123 Prolassectomy 82 26 15 ODS 43 S.T.A.R.R. 22 3 18 Complication: the urgency (DU) Temporary (TU) that resolves itself within three weeks without consequences Permanent (PU) that continues up to three months but also resolves itself without consequences UD Severe (SU) that lasts more than three months and shows itself in an increase of the daily evacuations but the urgency decreases or disappears completely. OR correlation between rectal hypersensitivity and Urgency Pre-op. RST Patients TU PU SU DU OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Not hyper 97 1 (ref) 1 (ref) 1 (ref) 1 (ref) Hyper 26 4.8 10.1 20.6 64.5 (0.9-26.2) (1.4-71.3) (1.8-226.2) (6.9-603.2) 0.07 0.02 0.01 <0.001 p value OR: Odds Ratio CI: Confidential Interval There is an important correlation between hypersensitivity and Permanent Urgency (p=0.02), between hypersensitivity and Severe Urgency (p=0.01) and not so important between hypersensitivity and Temporary Urgency (p=0.07). As a whole the correlation between Hypersensitivity and Urgency is asbolutely significant (p> 0,001) MFA test plan MFA Test RST cc air BET (60 cc) v.n. Result FS 30-60 Hyper DDV 60-160 Normal MTV 160-270 Hypo EPA Examination S NS Suspect: Other exams: Diagnosis: Consensus Operating Theatre MET ET n.v. < 60 sec BET result + cm MTV LMAC Risult Conclusions The use of the MFA at the first proctological visit allows: • To perform Rectal Sensation Test in case of minor pathologies, too; • To suspect attendant diseases; • To foresee postoperatory complications; • To avoid hurried surgical decisions; • To assess the correct prolapse extent; • To foresee biofeedback results. MFA COURSES If you are interested in attending such courses please get in touch with the Sapi-Med stand. My Family Thank you all for your attention.