Is the technique important? A review of 499 patients undergoing biofeedback for fecal incontinence
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April 2000 4376 EFFECTS OF ANGIOTENSIN II (ANG II) IN THE INTERNAL ANAL SPHINCTER (lAS) VERSUS THE LOWER ESOPHAGEAL SPHINCTER (LES) SMOOTH MUSCLE. Yaping Fan, Raj Puri, Andrew S. Greene, Satish Rattan, Jefferson Med Coil, Thomas Jefferson Univ, Philadelphia, PA; Med Coil of Wisconsin, Milwaukee, WI. Background & Aims: Angiotensin II (Ang II) has been suggested to be a potent smooth muscle contractile neurohumoral agonist. A majority of actions of Ang II are known to be mediated by the activation of specific receptor (AT l ), primarily via PKC or tyrosine kinase pathways. The mechanism of action of Ang II and the nature of Ang II receptors in the GI smooth muscle especially the sphincteric smooth muscle are poorly under- stood. This knowledge may lead to advances in the therapeutic manage- ment of GI motility disorders characterized by hypertensive GI smooth muscles. Methods: The studies were performed to compare the actions of Ang II in the lAS vs. LES smooth muscle in vitro, in the opossum, rabbit and rat. Changes in isometric tension were recorded before and after different neurohumoral antagonists. To determine the presence of Ang II receptors (AT! and AT 2 ), we carried out Western blot analyses. Studies were also carried out in the isolated smooth muscle cells. Results: In the opossum, Ang II produced no discernible effects in the lAS, but it pro- duced a dose-dependent' contraction of the LES smooth muscle. Interest- ingly, in the rat and rabbit, Ang II caused contraction of not only the LES but also of the lAS smooth muscle. Ang II produced only modest responses in the rabbit IAS. The contractile responses of Ang II were relatively resistant to different neurohumoral antagonists but were antagonized by AT! antagonist losartan in a concentration-dependent manner. AT2 antag- onist rather than inhibiting, prolonged the contractile action of AT. The contractile actions of Aug II in the opossum LES were not modified by any of the tyrosine kinase inhibitors (genistein and tyrphostin I fLM) but were partially attenuated by the PKC inhibitor H-7 (lfLM), Ca 2 + channel blocker nicardipine (lOfLM) or Rho kinase inhibitor HA-I077 (I fLM). The combi- nation of HA-I077 and H-7 caused a complete obliteration of Ang II responses. Western blot analyses showed the presence of both AT! and AT 2 receptors. The tissues that responded poorly to Ang II, showed relatively higher expression of AT2 receptors. Conclusion: The sphincteric contraction caused by Ang II occurs primarily by the activation of AT! receptors at the smooth muscle cells and involves both PKC and Rho kinase. Rat is an appropriate animal model for the investigation of Ang II actions in the lAS. 4377 RECTAL COMPLIANCE AS A ROUTINE MEASUREMENT: EX- TREME VOLUMES HAVE CLINICAL IMPORTANCE. Richelle 1. Felt-Bersma, Cornelius E. Sloots, Alexander C. Poen, Miguel A. Cuesta, Stephan G. Meuwissen, Acad Hosp Vrije Univ, Amsterdam, Netherlands. Introduction: The clinical impact of rectal compliance (RC) measurement is not clear. The aim of this study was to establish the RC in different patient groups compared to controls and to establish whether small or large volumes have discriminatory value. Patients and methods: In 974 consec- utive patients (284 men), anorectal function tests were performed. Their results were compared with 24 controls. RC was performed with a rectal latex balloon slowly being filled with water at a speed of 60 ml per minute. Volume and pressure were measured simultaneously. At three moments volume and pressure were noted for analysis: first sensation (FS), urge(U) and maximal toleration (MT). At MT, the rectal compliance (dV/dP) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity and anal endosonography were also performed. Results: No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had an increased volume at FS and an increased pressure at MT (p=O.03). The presence of a sphincter defect, low or normal anal pressures made no difference. Patients with a rectocele had an increased volume at FS (p=O.OO4). Patients with rectal prolapse did not differ from controls, a rectopexy decreased RC. Patients with IBD had a decreased RC, most pronounced in active proctitis (p=0.OO3). Patients with ileo-anal pouches also had a decreased RC (p<O.OOOI). Patients with constipation had a larger volume at FS and U (p<O.OOI). In 17patients a MTV<60 ml was found, 11 were fecal incontinent and 6 had a stoma for that reason. In 31 patients a MTV between 60-1OD ml was found, 12 were fecal incontinent and 6 had a stoma. Proctitis or pouchitis was the main cause for a small RC. In 29 patients a MTV>5OD ml was found, all were constipated. No correlation between rectal and anal mucosal sensitivity existed. Conclu- sion:Some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Patients with proctitis and pouchitis had the smallest RC. A MTV< 60 ml always led to fecal incontinence, a MTV> 50D ml was only seen in constipated patients. Therefore, extreme values in RC have an impact on therapeutic strategy. AGAA831 4378 IS THE TECHNIQUE IMPORTANT? A REVIEW OF 499 PA· TIENTS UNDERGOING BIOFEEDBACK FOR FECAL INCONTI- NENCE. Linda L. Jensen, Melissa A. Lelvloine, Lisabeth A. Overton, Ann C. Lowry, Univ of Minnesota, St. Paul, MN. Multiple small series have been published reporting good success with biofeedback for fecal incontinence. Purpose: To determine whether early success could be demonstrated in a large number of patients and whether technical factors altered the success rate. Method: Retrospective chart review of patients undergoing biofeedback for fecal incontinence. Results: 499 patients (445 female, 54 males), average age 55 years (range 9-94 years), were seen for biofeedback over a 10 year period. Biofeedback was performed using an intra-anal EMG sensor in all patients. In 129 patients, a second modality, surface electrodes were used to monitor the gluteal muscle activity. A computer monitor was used for the feedback. Patients were seen an average of 3 sessions (range 2-7) in an office setting. All patients were instructed to do home exercises. Success was measured by the incontinence score and patient reported improvement. 82% of the patients improved. Mean incontinence score decreased from 20 pre-treat- ment to 5 post-treatment. Age, gender, diagnosis, pre-treatment resting pressure, squeeze pressure, rectal sensation, PNTML, the number of ses- sions and the number of modalities used were analyzed with a multi-variant regression. The odds of improvement were increased with age and male gender. More patients improved when surface electrodes were added. In addition, a higher rate of success was seen the more training sessions the patients had. None of the other variables were significantly related to success. Conclusion: In this large series, biofeedback for fecal incontinence was successful in 82% of patients. With EMG biofeedback, the use of surface electrodes in addition to intra-anal sensor and increased number of sessions contributes to the success rate. 4379 RESTORATION OF CONTINENCE IS ASSOCIATED WITH IM- PROVED QUALITY OF LIFE (QOL)FOLLOWING DYNAMIC GRACILOPLASTY (DG). Robert D. Madoff, Cor G. Baeten, W. Donald Buie, Klaus E. Matzel, Anthony M. Vernava, Dynamic Graciloplasty Study Group, Univ of Min- nesota, Minneapolis, MN; Acad Hosp Maastricht, Maastricht, Netherlands; Univ of Calgary, Calgary.Alberta, Canada; Chirurgische Clin der Univ Erlangen, Erlangen, Germany; Cleveland Clin Fdn, Naples, FL. DG has been shown to alleviate refractory fecal incontinence(FI) but its effect on QoL is uncertain. METHODS: 129 patients underwent DG in a prospective clinical trial; 98 completed a continence diary and QoL ques- tionnaire at 12 months. Patient functional outcome was classified based on 12 month diary data recording all continent and incontinent bowel move- ments. Univariate indices were developed based upon pre- and post- operative SF-36 and TyPE questionnaires. SF-36 success was defined as a 25% or greater improvement in score for at least 4 of the 8 parameters. TyPE success was defined as "a little" or "no" leakage or fear of leakage during at least 75% of the activities of daily living. RESULTS: 17 patients (17%) were fully continent, 47 (48%) improved 14(14%)improved <50%, and 20 patients (20%) failed. QoL success rates where related to functional improvement (see table). QoL success rates were highest in the continent and 50% improved functional outcome groups and lowest in the <50% improved and failed functional groups. CONCLUSIONS: Func- tional success following DG is correlated with improved QoL. Author note: In addition to the authors, members of the Dynamic Graciloplasty Study Group include Randolph H. Bailey, Arne Bakka, Paul Belliveau, E. Berg, Marcus J. Burnstein, John Christiansen, John A. Coller, Susan Galandiuk, J. Lange, Lars Pahlman, Roland Pare, John C. Reilly, Massimo Seccia, Alan Thorson, and Steven Wexner. Percentage of Successful QoL Patients byFunctional Outcome Group Continent >50% imp. <50% imp. FaJled P·value SF·36 76% 55% 29% 30% 0.001 TyPE.leak 100% 65% 21% 38% <0.0001 TyPE·fear 94% 67% 36% 53% 0003 P-values were determined using logistic regression.
Transcript of Is the technique important? A review of 499 patients undergoing biofeedback for fecal incontinence
April 2000
4376
EFFECTS OF ANGIOTENSIN II (ANG II) IN THE INTERNALANAL SPHINCTER (lAS) VERSUS THE LOWER ESOPHAGEALSPHINCTER (LES) SMOOTH MUSCLE.Yaping Fan, Raj Puri, Andrew S. Greene, Satish Rattan, Jefferson MedCoil, Thomas Jefferson Univ, Philadelphia, PA; Med Coil of Wisconsin,Milwaukee, WI.
Background & Aims: Angiotensin II (Ang II) has been suggested to be apotent smooth muscle contractile neurohumoral agonist. A majority ofactions of Ang II are known to be mediated by the activation of specificreceptor (AT l ) , primarily via PKC or tyrosine kinase pathways. Themechanism of action of Ang II and the nature of Ang II receptors in the GIsmooth muscle especially the sphincteric smooth muscle are poorly understood. This knowledge may lead to advances in the therapeutic management of GI motility disorders characterized by hypertensive GI smoothmuscles. Methods: The studies were performed to compare the actions ofAng II in the lAS vs. LES smooth muscle in vitro, in the opossum, rabbitand rat. Changes in isometric tension were recorded before and afterdifferent neurohumoral antagonists. To determine the presence of Ang IIreceptors (AT! and AT2) , we carried out Western blot analyses. Studieswere also carried out in the isolated smooth muscle cells. Results: In theopossum, Ang II produced no discernible effects in the lAS, but it produced a dose-dependent' contraction of the LES smooth muscle. Interestingly, in the rat and rabbit, Ang II caused contraction of not only the LESbut also of the lAS smooth muscle. Ang II produced only modest responsesin the rabbit IAS. The contractile responses of Ang II were relativelyresistant to different neurohumoral antagonists but were antagonized byAT! antagonist losartan in a concentration-dependent manner. AT2 antagonist rather than inhibiting, prolonged the contractile action of AT. Thecontractile actions of Aug II in the opossum LES were not modified by anyof the tyrosine kinase inhibitors (genistein and tyrphostin I fLM) but werepartially attenuated by the PKC inhibitor H-7 (lfLM), Ca2+ channel blockernicardipine (lOfLM) or Rho kinase inhibitor HA-I077 (I fLM). The combination of HA-I077 and H-7 caused a complete obliteration of Ang IIresponses. Western blot analyses showed the presence of both AT! andAT2 receptors. The tissues that responded poorly to Ang II, showedrelatively higher expression of AT2 receptors. Conclusion: The sphinctericcontraction caused by Ang II occurs primarily by the activation of AT!receptors at the smooth muscle cells and involves both PKC and Rhokinase. Rat is an appropriate animal model for the investigation of Ang IIactions in the lAS.
4377RECTAL COMPLIANCE AS A ROUTINE MEASUREMENT: EXTREME VOLUMES HAVE CLINICAL IMPORTANCE.Richelle 1. Felt-Bersma, Cornelius E. Sloots, Alexander C. Poen, MiguelA. Cuesta, Stephan G. Meuwissen, Acad Hosp Vrije Univ, Amsterdam,Netherlands.
Introduction: The clinical impact of rectal compliance (RC) measurementis not clear. The aim of this study was to establish the RC in differentpatient groups compared to controls and to establish whether small or largevolumes have discriminatory value. Patients and methods: In 974 consecutive patients (284 men), anorectal function tests were performed. Theirresults were compared with 24 controls. RC was performed with a rectallatex balloon slowly being filled with water at a speed of 60 ml per minute.Volume and pressure were measured simultaneously. At three momentsvolume and pressure were noted for analysis: first sensation (FS), urge(U)and maximal toleration (MT). At MT, the rectal compliance (dV/dP) wascalculated. Proctoscopy, anal manometry, anal mucosal sensitivity and analendosonography were also performed. Results: No effect of age or genderwas observed in either controls or patients. Patients with fecal incontinencehad an increased volume at FS and an increased pressure at MT (p=O.03).The presence of a sphincter defect, low or normal anal pressures made nodifference. Patients with a rectocele had an increased volume at FS(p=O.OO4). Patients with rectal prolapse did not differ from controls, arectopexy decreased RC. Patients with IBD had a decreased RC, mostpronounced in active proctitis (p=0.OO3). Patients with ileo-anal pouchesalso had a decreased RC (p<O.OOOI). Patients with constipation had alarger volume at FS and U (p<O.OOI). In 17 patients a MTV<60 ml wasfound, 11 were fecal incontinent and 6 had a stoma for that reason. In 31patients a MTV between 60-1OD ml was found, 12 were fecal incontinentand 6 had a stoma. Proctitis or pouchitis was the main cause for a small RC.In 29 patients a MTV>5OD ml was found, all were constipated. Nocorrelation between rectal and anal mucosal sensitivity existed. Conclusion:Some patient groups showed an abnormal rectal visceral sensitivityand compliance, but there was an overlap with controls. Patients withproctitis and pouchitis had the smallest RC. A MTV< 60 ml always led tofecal incontinence, a MTV> 50D ml was only seen in constipated patients.Therefore, extreme values in RC have an impact on therapeutic strategy.
AGAA831
4378IS THE TECHNIQUE IMPORTANT? A REVIEW OF 499 PA·TIENTS UNDERGOING BIOFEEDBACK FOR FECAL INCONTINENCE.Linda L. Jensen, Melissa A. Lelvloine, Lisabeth A. Overton, Ann C.Lowry, Univ of Minnesota, St. Paul, MN.
Multiple small series have been published reporting good success withbiofeedback for fecal incontinence. Purpose: To determine whether earlysuccess could be demonstrated in a large number of patients and whethertechnical factors altered the success rate. Method: Retrospective chartreview of patients undergoing biofeedback for fecal incontinence. Results:499 patients (445 female, 54 males), average age 55 years (range 9-94years), were seen for biofeedback over a 10 year period. Biofeedback wasperformed using an intra-anal EMG sensor in all patients. In 129 patients,a second modality, surface electrodes were used to monitor the glutealmuscle activity. A computer monitor was used for the feedback. Patientswere seen an average of 3 sessions (range 2-7) in an office setting. Allpatients were instructed to do home exercises. Success was measured bythe incontinence score and patient reported improvement. 82% of thepatients improved. Mean incontinence score decreased from 20 pre-treatment to 5 post-treatment. Age, gender, diagnosis, pre-treatment restingpressure, squeeze pressure, rectal sensation, PNTML, the number of sessions and the number of modalities used were analyzed with a multi-variantregression. The odds of improvement were increased with age and malegender. More patients improved when surface electrodes were added. Inaddition, a higher rate of success was seen the more training sessions thepatients had. None of the other variables were significantly related tosuccess. Conclusion: In this large series, biofeedback for fecal incontinencewas successful in 82% of patients. With EMG biofeedback, the use ofsurface electrodes in addition to intra-anal sensor and increased number ofsessions contributes to the success rate.
4379RESTORATION OF CONTINENCE IS ASSOCIATED WITH IMPROVED QUALITY OF LIFE (QOL)FOLLOWING DYNAMICGRACILOPLASTY (DG).Robert D. Madoff, Cor G. Baeten, W. Donald Buie, Klaus E. Matzel,Anthony M. Vernava, Dynamic Graciloplasty Study Group, Univ of Minnesota, Minneapolis, MN; Acad Hosp Maastricht, Maastricht, Netherlands;Univ of Calgary, Calgary.Alberta, Canada; Chirurgische Clin der UnivErlangen, Erlangen, Germany; Cleveland Clin Fdn, Naples, FL.
DG has been shown to alleviate refractory fecal incontinence(FI) but itseffect on QoL is uncertain. METHODS:129 patients underwent DG in aprospective clinical trial; 98 completed a continence diary and QoL questionnaire at 12 months. Patient functional outcome was classified based on12 month diary data recording all continent and incontinent bowel movements. Univariate indices were developed based upon pre- and postoperative SF-36 and TyPE questionnaires. SF-36 success was defined as a25% or greater improvement in score for at least 4 of the 8 parameters.TyPE success was defined as "a little" or "no" leakage or fear of leakageduring at least 75% of the activities of daily living. RESULTS: 17 patients(17%) were fully continent, 47 (48%) improved ~50%, 14(14%)improved<50%, and 20 patients (20%) failed. QoL success rates where related tofunctional improvement (see table). QoL success rates were highest in thecontinent and ~ 50% improved functional outcome groups and lowest inthe <50% improved and failed functional groups. CONCLUSIONS: Functional success following DG is correlated with improved QoL. Author note:In addition to the authors, members of the Dynamic Graciloplasty StudyGroup include Randolph H. Bailey, Arne Bakka, Paul Belliveau, E. Berg,Marcus J. Burnstein, John Christiansen, John A. Coller, Susan Galandiuk,J. Lange, Lars Pahlman, Roland Pare, John C. Reilly, Massimo Seccia,Alan Thorson, and Steven Wexner.
Percentage ofSuccessful QoL Patients byFunctional Outcome Group
Continent >50% imp. <50% imp. FaJled P·value
SF·36 76% 55% 29% 30% 0.001TyPE.leak 100% 65% 21% 38% <0.0001TyPE·fear 94% 67% 36% 53% 0003
P-values were determined using logistic regression.
