Background:The maintenance of fecal continence depends upon coordinated interactions between the pelvic floor, anorectum, and anal sphincter complex orchestrated by central and peripheral neural activities. The current techniques to objectively measure anorectal function rely on fixed diameter catheters placed inside the anal canal with a rectal balloon to obtain measurements of anal resting and squeeze function, and rectal compliance. Until recently it had not been possible to measure the distensibility of the anal canal, or in other words its ability to resist opening against an increasing pressure, which has been proposed as the main determinant of a biological sphincter's function. Anal acoustic reflectometry (AAR) and the functional lumen imaging probe (FLIP) are two novel, provocative techniques that dynamically assess the anal sphincter complex under volume-controlled distension. In doing so, both provide information on the viscoelastic properties of the anal canal and offer new insights into its function.Purpose: This review details the current and potential future applications of AAR and FLIP and highlights the unanswered questions relevant to these new technologies.
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Introduction
Sacral neuromodulation is an established intervention for faecal incontinence (FI). This investigation aimed to determine the relationship between patient satisfaction and (1) device status (active/inactive) and (2) long-term functional outcomes.
Methods
Patients treated with sacral neuromodulation for at least 5 years reported bowel habits, FI severity, and impact on quality of life via bowel diaries, St. Marks incontinence score, and the Manchester Health Questionnaire at baseline and follow-up. On all measures, lower scores represent favourable outcomes. Satisfaction since treatment initiation and over the preceding 2 weeks was assessed using visual analogue scales (0%-100%). Individuals with inactive devices were awaiting battery revision surgery due to service delays encountered during the COVID-19 pandemic.
Results
In total, 74/110 eligible individuals completed follow-up measures (median: 130 months). Median overall satisfaction was high at 80% (IQR:60%-95%, n=70). Median two-week satisfaction was 75% (IQR:40%-90%, n=50) for individuals with active devices, and 20% (IQR:0%-45%, n=17) for those with inactive devices. Between-group differences were significant for two-week satisfaction (p<0.001), but not overall satisfaction (p=0.114). Two-week satisfaction was negatively correlated with all outcome measures (FI episodes: -0.46, faecal urgency episodes: -0.52, St. Marks incontinence score: -0.68, Manchester Health Questionnaire: -0.62 [all p<0.001]). However, of 12 individuals with active devices who did not meet the conventional treatment success threshold (50% FI reduction), 4 still reported ≥80% two-week satisfaction.
Conclusion
Standardised outcome measures reflect subjective satisfaction but cannot be used alone to assess positive outcomes as perceived by patients. Timely device revision is imperative for continued success of treatment.
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