Iatrogenic colorectal perforation induced by anorectal manometry:Report of two cases after restorative proctectomy for distal rectal cancer

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed alter restorative proctectomy for distal rectal cancer.

Effect of Modified Sinisan (四逆散) on Anorectal Manometry of the Constipation Predominant Type of Irritable Bowel Syndrome

Objective: To explore the mechanism in patients with irritable bowel syndrome (IBS) of the constipation predominant type and observe the therapeutic effects of Sinisan (四逆散, SNS). Methods: Forty -seven IBS patients with the constipation predominant type were randomly divided into the treated group ( n =24) and the control group ( n =23). Another group of 22 healthy subjects was set up for healthy control. The treated group was treated with modified SNS, and the control group was treated with Cisapride, the therapeutic course for both groups was 8 weeks. The changes of symptom scoring and anorectal manometry (the anorectal resting pressure, anal tract systolic pressure, anal tract diastolic pressure, rectal threshold feeling, maximal tolerance volume of rectum, and rectum compliance) of these two groups were recorded respectively and compared with each other. Results: Compared with the healthy control group, the rectal threshold feeling, maximal tolerance volume of rectum and rectal compliance of the treated groups got reduced significantly before treatment ( P <0.05). After treatment, the symptom scoring, rectal threshold feeling and maximal tolerance volume of rectum were improved in both groups ( P <0.05), and the improvement of the treated group was more significant than that of the control group( P <0.01). The total effective rate and recurrence rate of the treated group were superior to those of the control group significantly ( P <0.05, P <0.01).Conclusion: SNS has good effect on IBS of the constipation predominant type.

A Study of Anorectal Manometry in Patients with Chronic Idiopathic Constipation

To study the changes of anorectal motility in patients with chronic idiopathic constipation, anorectal motility was investigated by water-perfused manometric system in 30 patients with chronic idiopathic constipation and 18 healthy subjects. Our results showed that there was no significant dif- ference between the constipation group and the control group in anal sphincteric resting pressure and anal maximal squeezing pressure. The minimum relaxation volume, the rectal defecatory threshold, the rectal maximal tolerable volume and the rectal compliance in the patients were significantly higher than those in the controls (P< 0. 01 or P< 0. 05). It is concluded that patients with chronic idio- pathic constipation have anorectal motility disturbances.

Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM： TO evaluate the status of anorectal function after repeated transanal endoscopic microsurgery （TEN）. METHODS： Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large （〉 1 cm） polyps in the remaining rectum （range： 6-20 cm from the anal edge）. All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a question- naire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maxi- mum squeeze pressure, maximum tolerable volume （MTV） and rectoanal inhibitory reflexes （RAIR） were recorded. The integrity and thickness of the internal anal sphincter （IAS） and external anal sphincter （EAS） were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life （QoL）. RESULTS： All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38±5 mmHg to 19±3 mmHg （38±5 mmHg vs 19±3 mmHg, P = 0.000） and MTV from 165± 19mLto60± 11mL（165± 19mLvs60± 11 mL, P = 0.000） at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg （38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057） and 159 ± 19 mL （165 ± 19 mL vs 159 ± 19 mL, P = 0.071）, respectively, at month 6 after TEM. Maximal squeeze pressure de- creased from 171 ± 19 mmHg to 62 ± 12 mmHg （171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000） at week 2 after operation, and returned to normal values by postoperative month 3 （171 ± 19 vs 166 ± 18, P = 0.051）. RAIR were absent in 4 patients preoperatively and in 12 （χ2 = 4.947, P = 0.026） patients at month 3 after surgery. PAIR was absent only in 5 patients at postoperative month 6 （χ2 = 0.141, P = 0.707）. Endo- sonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary inconti- nence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm （1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000） at postoperative month 3 and increased to 1.8 ± 0.5 mm （1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239） at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm （3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510） at month 3 and then increased to 3.6 ± 0.4 mm （3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123） at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 pa- tients. With regard to the QoL, the physical and mental health status scores （SF-36） were 56.1 and 46.2 （50 in the general population）, respectively.CONCLUSION： The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.

Colorectal motility patterns and psychiatric traits in functional constipation and constipation-predominant irritable bowel syndrome:A study from China

BACKGROUND Functional constipation(FC)and constipation-predominant irritable bowel syndrome(IBS-C)represent a spectrum of constipation disorders.However,the majority of previous clinical investigations have focused on Western populations,with limited data originating from China.AIM To determine and compare the colorectal motility and psychiatric features of FC and IBS-C in an Eastern Chinese population.METHODS Consecutive chronic constipation patients referred to our motility clinic from December 2019 to February 2023 were enrolled.FC and IBS-C diagnoses were established using ROME IV criteria,and patients underwent high-resolution anorectal manometry(ARM)and a colonic transmit test using the Sitz marker study.Constipation-related symptoms were obtained through questionnaires.Anxiety and depression were assessed by the Hamilton anxiety rating scale and the Hamilton Depression Rating Scale-21.The clinical characteristics and colorectal motility patterns of FC and IBS-C patients were compared.RESULTS No significant differences in sex,age or abdominal discomfort symptoms were observed between IBS-C and FC patients(all P>0.05).The proportion of IBS-C patients with delayed colonic transit was higher than that of patients with FC(36.63%vs 15.91%,P<0.05),while rectosigmoid accumulation of radiopaque markers was more common in the FC group than in the IBS-C group(50%vs 26.73%,P<0.05).Diverse proportions of these dyssynergic patterns were noted within both the FC and IBS-C groups by ARM.IBS-C patients were found to have a higher prevalence of depression than FC patients(66.30%vs 42.42%,P<0.05).The scores for feelings of guilt,suicide,psychomotor agitation,diurnal variation,obsessive/compulsive disorder,hopelessness,self-abasedment and gastrointestinal symptoms were significantly higher in IBS-C patients than that in FC patients(P<0.05).For IBS-C(χ^(2)=5.438,P<0.05)but not FC,patients with normal colon transit time were significantly more likely to have anxiety than those with slow colon transit time.For IBS-C patients but not FC patients,the threshold of first constant sensation,desire to defecate and sustained urgency were all weakly correlated with the degree of anxiety(r=0.414,r=0.404,and r=0.418,respectively,P<0.05).The proportion of patients with a low threshold of desire to defecate among IBS-C patients with depression was lower than that in those without depression(69.6%vs 41.9%,χ2=4.054,P<0.05).CONCLUSION Our findings highlight both overlapping and distinctive patterns of colon transit,dyssynergic patterns,anorectal sensation,psychological distress,and associations of psychiatric and colorectal motility characteristics in FC and IBS-C patients in an Eastern Chinese population,providing valuable insights into the pathophysiological underpinnings of these disorders.

Consensus statement AIGO/SICCR:Diagnosis and treatment of chronic constipation and obstructed defecation(partⅠ:Diagnosis)

Chronic constipation is a common and extremely troublesome disorder that significantly reduces the quality of life,and this fact is consistent with the high rate at which health care is sought for this condition.The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation.The commission presents its results in a "Question-Answer" format,including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine.This section represents the consensus for the diagnosis.The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation.The presence of alarm symptoms and risk factors requires investigation.The physical examination should assess the presence of lesions in the anal and perianal region.The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation.Various scoring systems are available to quantify the severity of constipation;the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable.The Constipation-Related Quality of Life is an excellent tool for evaluating the patient's quality of life.No single test provides a pathophysiological basis for constipation.Colonic transit and anorectal manometry define the pathophysiologic subtypes.Balloon expulsion is a simple screening test for defecatory disorders,but it does not define the mechanisms.Defecography detects structural abnormalities and assesses functional parameters.Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports.All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

Study on the characteristics of intestinal motility of constipation in patients with Parkinson's disease

BACKGROUND Constipation is one of the most important nonmotor symptoms in Parkinson's disease(PD)patients,and constipation of different severities is closely related to the pathogenesis of PD.PD with constipation(PDC)is considered a unique type of constipation,but its mechanism of formation and factors affecting its severity have been less reported.Understanding the gastrointestinal motility characteristics and constipation classification of PDC patients is essential to guide the treatment of PDC.In this study,the colonic transit test and high-resolution anorectal manometry were used to identify the intestinal motility of PDC to provide a basis for the treatment of PDC.AIM To investigate the clinical classification of PDC,to clarify its characteristics of colonic motility and rectal anal canal pressure,and to provide a basis for further research on the pathogenesis of PDC.METHODS Twenty PDC patients and 20 patients with functional constipation(FC)who were treated at Xuanwu Hospital of Capital Medical University from August 6,2018 to December 2,2019 were included.A colonic transit test and high-resolution anorectal manometry were performed to compare the differences in colonic transit time,rectal anal canal pressure,and constipation classification between the two groups.RESULTS There were no statistically significant differences in sex,age,body mass index,or duration of constipation between the two groups.It was found that more patients in the PDC group exhibited difficulty in defecating than in the FC group,and the difference was statistically significant.The rectal resting pressure,anal sphincter resting pressure,intrarectal pressure,and anal relaxation rate in the PDC group were significantly lower than those in the FC group.The proportion of paradoxical contractions in the PDC group was significantly higher than that in the FC group.There was a statistically significant difference in the type composition ratio of defecatory disorders between the two groups(P<0.05).The left colonic transit time,rectosigmoid colonic transit time(RSCTT),and total colonic transit time were prolonged in PDC and FC patients compared to normal values.The patients with FC had a significantly longer right colonic transit time and a significantly shorter RSCTT than patients with PDC(P<0.05).Mixed constipation predominated in PDC patients and FC patients,and no significant difference was observed.CONCLUSION Patients with PDC and FC have severe functional dysmotility of the colon and rectum,but there are certain differences in segmental colonic transit time and rectal anal canal pressure between the two groups.

Effect of Reinforcing Qi and Moistening Intestine Oral Liquid on Anorectal Manometry of Asthenia Type Constipation Patients

Objective: To study the change of anorectal manometry in asthenia type constipation patients and effect of reinforcing Qi and moistening intestine oral liquid (RQMI) on it. Methods: The total of 135 cases were divided into healthy group, RQMI treated group, Maren pill (MRP) treated group and prepulsid (PPS) treated group, their anal maximal voluntary squeez pressure, rectoanal contraction reflex, rectoanal inhibitory reflex, defecation reflex, rectal volume sensory threshold and rectal maximal tolerable volume were observed. Results: The rectal sensory function of patients weakened obviously and anal sphincter reactivity reduced as compared with those of healthy person (P＜0.01), and both were improved by RQMI treatment (P＜0.05). Conclusion: RQMI is superior to MRP and prepulside in improving anorectal dynamic abnormality in constipation patient of asthenia type.

Manometric Comparison of Anorectal Function after Posterior Vaginal Compartment Repair with and without Mesh

Background：Although repair augmented with mesh has been proved its priority in anatomical and functional recovery after anterior compartment reconstruction,the data about posterior compartment are scarce.The aim of this study was to compare bowel functional outcome of posterior vaginal compartment repair with and without mesh in patients with pelvic organ prolapse （POP）.Methods：This was a prospective,double-blind,clinical pilot study of 22 postmenopausal women with symptomatic POP （overall POP-quantification [POP-Q] Stage Ⅲ-ⅣV） who underwent total pelvic floor reconstruction.Patients were grouped according to the use of mesh for posterior vaginal compartment repair：A mesh group and a nonmesh group.POP-Q stage,the pelvic floor impact questionnaire short form-7 （PFIQ-7） and anorectal manometry were evaluated before and 3 months after surgery.Anatomical success was defined as POP-Q Stage Ⅱ or less.A t-test was used to compare preoperative with postoperative data in the two groups.Results：Totally,17 （71％） were available for the follow-up.POP-Q measurements improved significantly compared to baseline （P ＜ 0.05） in both groups.No recurrence was observed.Subjects in both groups reported improvement in pelvic floor symptoms,and there was no significant difference in the PFIQ-7 score between groups at follow-up （P ＞ 0.05）.Compared with baseline,the nonmesh group exhibited a statistically significant decrease in anal residual pressure,a significant increase in the anorectal pressure difference during bowel movement,and a reduced rate ofdyssynergia defecation pattern （P ＜ 0.05）.Conclusions：Provided there is sufficient support for the anterior wall and apex of vagina with mesh,posterior compartment repair without mesh may be as effective as repair with mesh for anatomical recovery while providing better anorectal motor function.

Anorectal functions in patients with lumbosacral spinal cord injury

To investigate the anorectal status in patients with lumbosacral spinal cord injury （SCI）. Methods： Twenty six patients （23 males, 3 females） with lumbosacral SCI and 13 normal volunteers were enrolled into this study as controls. The median age was 43.7 years （ranging 17-68 years） and the median time of patients since injury was 59.1 months （ ranging 8 months-15 years）. They were diagnosed as complete lumbosacral SCI （n=2, American Spinal Injury Association （ASIA） score A）, or incomplete lumbosacral SCI （n =24, ASIA score B- D） with mixed symptoms of constipation and/or fecal incontinence, and were studied by anorectal manometry. None of the patients had any medical treatments for neurogenic bowel prior to this study. Results： The maximum anal resting pressure in lumbosacral SCI patients group was slightly lower than that in control group （ One-way ANOVA： P = 0. 939 ）. During defecatory maneuvers, 23 of 26 （ 88. 5 %） patients with lumbosacral SCI and I of 13 （ 7. 7 % ） in the control group showed pelvic floor dysfunction （PFD） （Fisher＇ s exact test： P〈0.0001）. Rectoanal inhibitory reflex （RAIR） was identified in both patients with lumbosacral SCI and the controls. The rectal volume for sustained relaxation of the anal sphincter tone in lumbosacral SCI patients group was significantly higher than that in the control group （Independent-Samples t test： P〈0.0001）. The mean rectal volume to generate the first sensation was 92.7 ml ± 57.1 mi in SCI patients, 41. S ml ± 13.4 ml in the control group （ Independent-Samples t test： P 〈0.0001 ）. Conclusions： Most of the patients with lumbosacral SCI show PFD during defecatory maneuvers and their rectal sensation functions are severely damaged. Some patients exhibit abnormal cough reflex. Anorectai manometry may be helpful to find the unidentified supraconal lesions. RAIR may be modulated by central nervous system （CNS）.