usefulness, limitations, when and why anorectal … · anorectum: – preservation of continence...
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Digestive Phisiology and Motility LabUniversity of Veracruz, Mexico
José María Remes Troche.
HIGH RESOLUTION AND HIGH DEFINITION ANORECTAL MANOMETRY:
USEFULNESS, LIMITATIONS, WHEN AND WHY
DISCLOSURE: José María Remes-Troche
José-María Remes-Troche has served on the Advisory Board of Allergan, Carnot and Sanfer.
He has been a consultant for Alfa-Wasserman, Almirall, Commonwealth Laboratories Inc, Takeda Mexico, Asofarma Mexico and Sanfer.
He has also been a speaker for Alfa Wasserman, Takeda Mexico, Carnot, Sanfer and Almirall.
He has received grant supports from Alfa Wasserman and Sanfer.
AIMüTo review and analyze
ü Indications ü Limitationsü Clinical utility
HRAM
3-D HDAM
Pelvic Floor Structure Colonic Transit Time
Motor Function Neuro Sensory FUnction
•• Ultrasound (2-3D)Ultrasound (2-3D)•• MRIMRI•• DephecographyDephecography•• Barium proctogramBarium proctogram•• EndoscopyEndoscopy
•• Breath testBreath test•• Radiopaque markersRadiopaque markers•• Smart pillSmart pill•• GammagraphyGammagraphy•• RFITransitRFITransit
•• Anorectal ManometryAnorectal Manometry•• Conventional Conventional •• HRAM HRAM •• 3-D HDAM3-D HDAM
•• Colonic manometryColonic manometry•• EMGEMG
•• PNLPNL•• TL and TSMSTL and TSMS•• BarostatBarostat•• EndoFLIPEndoFLIP•• EMGEMG•• CEPCEP
Pelvic Floor Structure Colonic Transit Time
Motor Function Neuro Sensory FUnction
•• Ultrasound (2-3D)Ultrasound (2-3D)•• MRIMRI•• DephecographyDephecography•• Barium proctogramBarium proctogram•• EndoscopyEndoscopy
•• Breath testBreath test•• Radiopaque markersRadiopaque markers•• Smart pillSmart pill•• GammagraphyGammagraphy•• RFITransitRFITransit
•• Anorectal ManometryAnorectal Manometry•• Conventional Conventional •• HRAM HRAM •• 3-D HDAM3-D HDAM
•• Colonic manometryColonic manometry•• EMGEMG
•• PNLPNL•• TL and TSMSTL and TSMS•• BarostatBarostat•• EndoFLIPEndoFLIP•• EMGEMG•• CEPCEP
Why ARM is important ?• Physiological evaluation of the two main functions of the
anorectum: – Preservation of continence and regulation of defecation.
1. Fecal incontinence
2. Constipation/ evacuatory dysfunction.
2. Facilitate biofeedback training.
2. Assess patients before intervention (e.g., as a prognostic indicator of continence prior to surgical pouch construction);
2. Objectively assess therapeutic efficacy.
Dinning P, Carrington E, Scott MS. Neurogastro and Motil 2015
t1/2: 0.7 – 1.2 h
1950 1960 1970 1980 1990 2000 2010
What is HR-ARM and 3-D HD-ARM
* Raizada et al Pelvic Floor Anatomy and Applied Physiology. Gastroenterol Clin North Am. 2008 September; 37(3): 493–vii.
IS
ES
Puborectalis
*
1. A high degree of asymmetry both axially and circumferentially
1. A more inferior position of the sphincter in the anterior compared to the posterior midline
1. The greatest contribution during squeeze was from the distal anterior canal (PR)
1. During squeeze, the posterior peak pressure in the anal canal moves cranially in relation to the anterior peak pressure.
Limitations of ARM
ü Lack of uniformity regarding equipment
ü Lack of standarization in protocol
ü Lack of normal valuesü What is normal ?ü What is dissynergia?ü Metrics developed in conventional
are not for HR and 3-D HDü Costs , fragilityü Clinical utility?
Limitations of ARM
ü Lack of uniformity regarding equipment
ü Lack of standarization in protocolsü Minimal standards. Rao et al. 2002
ü Lack of normal valuesü What is normal ?ü What is dissynergia?
ü Metrics developed in conventional are not for HR and 3-D HD
ü Clinical utility?
125 surveys, 30 different countries
53%47%
October 2014, Ascona, Switzerlandü To develop and promote internationally
accepted standards for the clinical measurement of anorectal physiology, with a particular focus on HR-ARM.
Limitations of ARM
ü Lack of uniformity regarding equipmentü Lack of standarization in protocols
ü Minimal standards. Rao et al. 2002
ü Lack of normal values, reproducibility?ü What is normal ?ü What is dissynergia?
ü Metrics developed in conventional are not for HR and 3-D HD
ü Clinical utility?
61 children
(34 male; mean age, 8.28 years)
Limitations of ARM
ü Lack of uniformity regarding equipment
ü Lack of standarization in protocolsü Minimal standards. Rao et al. 2002
ü Lack of normal valuesü What is normal ?ü What is dissynergia?
ü Metrics developed in conventional are not for HR and 3-D HD
ü Clinical utility?
100 FC Rome II(80 Female)
Type I Type II Type IIIRectal
Anal Anal Anal
Rectal Rectal
0 mm Hg
50
Rao SSC, et al. Neurogastroenterol Motil.2004;16:1-8.
Gastroenterol Clin North Am. 2008 Sep; 37(3): 569–586.
Three traditional parammeters unlikely to have diagnostic utility because wide vartiations in health
•Rectal push pressure•Anal residual pressure •Endurance of squeeze
Recto anal gradientDefecation index
Seated Evaluation of Anorectal Function By High Resolution Manometry: A Randomized Comparison of Measurements in the Seated and Left Lateral Positions.
Heinrich H, Reiner C, Parker H, et al . Oral Presentation 834,2016
HR-ARM and BET is affected by position, especially in DD patients. Comparison of HR-ARM with MRD suggests more accurate assessment of simulated defecation in the physiologic SP.
A Characterization of Dyssynergia Phenotypes With High Resolution Anorectal Manometry (HRAM).
Rao SS, Leelasinjaroen P, Amieva-Balmori M, et al. 771,2016
174 DD patients
1.Dyssynergia in 2 positions
1.Interobserver agreement
Dyssynergia pattern 85%
Dyssynergia pattern 65%
Normalize 27%
Kappa 0.8
62 HVFemale
295Female with CC
Normaln = 60
Abnormaln = 2
Normaln = 224
Abnormaln = 71
Proposed Phenotypes
6% 11%
Anal blockage
5% 13%
Present in CCNormal BET
Excessive strainingagainst high ARP
Inappropriate Abdominal contraction
Rectal sensorimotordysfunction
Unclear ?Structural
A Characterization of Dyssynergia Phenotypes With High Resolution Anorectal Manometry (HRAM).
Rao SS, Leelasinjaroen P, Amieva-Balmori M, et al. 771
D = Difuse P=Puborectal A= Anal sphincter
10%
Pitfalls for ARM
• Lack of uniformity regarding equipment• Lack of standarization in protocols
Minimal standards. Rao et al. 2002
• Lack of normal values• What is normal ? What is dissynergia?• Metrics developed in conventional are not
for HRM-3D HRM • Clinical utility?
New parammeters, New analysis for HRAM ?Post-relaxation cough reflexCarrington E et al .2014
Integrated pressurized volume (IPV)Jung KE et al .2014
Positive gradient and High band pressureHeinrich H et al .2014
Phenotipic classificationRatuapli et al .2014
Remes-Troche JM et al, DDW 2013
Novel parammetersRemes-Troche et al .DDW 2013
IPV ratioMion et al 201.7
Pitfalls for ARM• Lack of uniformity regarding equipment• Lack of standarization in protocols
Minimal standards. Rao et al. 2002
• Lack of normal values• What is normal ? What is dissynergia?• Metrics developed in conventional are not
for HRM-3D HRM • Clinical utility?
Clinical Utility
1. Color contour/ topography plots provide a dynamic and continuous representation of anorectal pressure information, which is both more visually arresting and intuitive compared to traditional line plots.
1. Anal sphincter defects can be mapped and readily detected using 3-D technology
1. HRAM study is ~12 min quicker than performing a traditional anorectal manometry study
188 patients with obstructive defecation
87 structural pathology
Lower resting pressure (p<0.003)Lower squeze pressure (p<0.011)
Higher rectoanal pressure gradient (p<0.0001)
24 patients with Intra-Anal Intussusception exhibit a unique pattern
30 HV 118 patients 51 CC, 48 FI, 19 RP
A PC logistic model discriminated between patients with and without prolapse with 96% accuracy.
Present in 21/26 (80%)PPV 100%, NPV 100%, S 69.2%
Anal Sphincter Integrity
Normal
HDMAUS
Abnormal
Squeeze
rest
EAS
IAS
rest
defectdefect
Squeeze
defectdefect
Rezaie A, Iriana S, Pimentel M, Murrell Z, Fleshner P, Zaghiyan K. Colorectal Dis 2016. DOI: 10.1111/codi.13530.
39 patients = 14 (36%) defects with 3D-HDAM
Sensitivity = 75%Specificity =74%
PPV = 43%NPV 92%
Prevalence of defects with 3D-HDAM = 22%
Sensitivity = 37.5%Specificity =100%
PPV = 100%NPV 44%
CONCLUSIONSüThe greater yield of anatomical and
functional information may supersede the limitations of costs, fragility, and shorter life-span associated with these new techniques.
üThus, HDAM and HRAM are not just new gadgets but constitute a significant and novel diagnostic advance.
üHowever, more prospective studies are needed to better define anorectal disorders with these techniques and to confirm their superiority.