The M.F.A.: a new device for an early

selection of patients.Piercarlo Meinero M.D.

pp

Proctological visit for minor pathologies

Positive anamnesis

Other exames

Negative anamnesis

Routine exames

Surgical treatment

Critical point

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

MFA functions

1) Rectal Sensation Test (RST)2) Balloon Expulsion Test (BET)3) Extent of Prolapse Assessment (EPA)4) Length Measurement of the Anal

Canal (LMAC)

pp

FS First Sensation

DDV Defecatory Desire

Volume

MTV Maximum Tolerable

Volume

The same procedure like the manometry

1) Rectal Sensation Test

(RST)

RST with the MFA: the method

1

3 4

2

Rectal sensitivity thresholds

Rectal sensitivity alterations

HYPOSENSITIVITY

FS > 60

DDV > 160

MTV > 270

FS < 30

DDV < 60

MTV < 160 HYPERSENSITIVITY

FS 30 - 60

DDV 60 - 160

MTV 160 - 270

NORMAL VALUES

The RST is important because…

First visit

Hypersensitivity

Hyposensitivity

External sphincter disfuncions

IBD

Faecal incontinence (FI e UFI)

Pudendal neuropathyODS

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.

Normal

RST: the references

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.

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.

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.

Gloria Lacima, M.D., Miguel Pera, M.D., Josep Valls-Solé, M.D., Xavier Gonzales-Argenté, M.D., Montserrat Puig-Clota, 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.

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.

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.

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

Hypo

27

16

4

Positive (57.4%)

Normal (34%)

Normal (8.5%)

> 60

44+/-11

5

> 60

< 56

< 6

• Without the anoscope

• 150-160 cc of air

• Traction during the squeeze

• Perineal information

• Vaginal exploration

3) Extent of Prolapse Assessment (EPA)

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.

4) Length Measurement of the Anal Canal (LMAC)

My own study: 218 patients Jan. 2006 / Sept. 2008

• 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 post-operatory complications.

To demostrate that:189 patients: 128 PMRE; 61 ODS

R=0.99, p<0.001 R=0.96, p<0.001

R=0.98, p<0.001

FS DDV

MTV

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.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

TotalMFA MANOMETRIA0

20406080

100120140

128 patients tested with MFA and manometry suffering from

PMRE

N° pazientiIpersensibiliIposensibili

128 128

27 2619 22

MFA MANOMETRIA

0

10

20

30

40

50

60

70

61 patients tested with the MFA and manometry suffering

from ODS

61 61

3 226 25

020406080

100120140160180200

189

30 47

RST

Diagnostic Assessment(US, EMG, PNTML, Defecography, Coloscopy, Manovolumetry)

30 patients with hypersensitivity

6 females and 1 male with EAS disfunctions (23.3%)

1 male with RCU (3.3%)*

3 males and 7 fimales with MII (33.3%)

1 fimale with celiac disease (3.3%)*

47 patients with hyposensitivity

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 %)

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)

Permanent (PU)

Severe (SU)UD

that resolves itself within three weeks without consequences

that continues up to three months but also resolves itself without consequences

that lasts more than three months and shows itself in an increase of the daily evacuations but the urgency decreases or disappears completely.

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)

OR: Odds Ratio CI: Confidential Interval

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

(0.9-26.2)

10.1

(1.4-71.3)

20.6

(1.8-226.2)

64.5

(6.9-603.2)

p value 0.07 0.02 0.01 <0.001

MFA TestRST BET (60 cc)

cc air v.n. Result MET ET n.v.

FS 30-60 Hyper < 60 sec

DDV 60-160 Normal BET result

MTV 160-270 Hypo

EPA LMAC

Examination Operating Theatre cm Risult

S NS Consensus MTV

Suspect:

Other exams:

Diagnosis:

+ -

MFA test plan

Conclusions

• 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.

The use of the MFA at the first proctological visit allows:

MFA COURSESIf you are interested in attending such courses please get in touch with

the Sapi-Med stand.

My Family

Thank you all for your attention.