Utilizzo del nuovo device MFA nella selezione preoperatoria deiN

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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 )
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•It doesn’t replace manometry
•Between nothing and manometry
•It tests anorectal functionality
•Early patients selection
•It’s easy and fast to use
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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.