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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 43 | A Prospective Evaluation of the Value of Anorectal Physiology in the Management of Fecal Incontinence [2001년 11월 DCR] | 2011-11-17 | 3404 |
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Harry Liberman, M.D., Julio Faria, M.D., Charles A. Ternent, M.D., Garnet J. Blatchford, M.D.
From the Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska
PURPOSE: This study was designed to determine whether anorectal physiology testing significantly altered patient management in the setting of fecal incontinence.
METHODS: Patients referred to the anorectal physiology laboratory for evaluation of fecal incontinence were prospectively interviewed and examined by a colon and rectal surgeon. A decision to treat either medically or surgically was reached. The patients underwent physiologic testing with transanal
ultrasound, pudendal nerve terminal motor latency, and anorectal manometry. A panel of board-certified colon and rectal surgeons then reviewed the history and physical examination, as well as the anorectal physiology tests, of each patient and reached a consensus on management. Management plans before and after physiologic evaluation were compared. RESULTS: Ninety patients (6 males) were entered into the study. The patients were divided in two
groups: those with pretest medical management plans (n = 45) and those with pretest surgical management plans (n = 45). A change in management was noted in nine patients (10 percent). In the medical management group, the management changed from medical to surgical therapy in five patients. Transanal ultrasound detected anal sphincter defects in all patients who changed from medical to surgical management but in only 10 percent of those who remained under medical management (P = 0.0001). In the surgical management group, three patients (7 percent) changed from surgical to medical therapy and one patient (2 percent) changed from sphincteroplasty to neosphincter. Transanal ultrasound detected a limited anal sphincter defect in one patient (33 percent) who changed from surgical to medical management and a significant defect in all 41 patients (100 percent) who remained under surgical management (P = 0.003). CONCLUSIONS: Anorectal physiology testing is usefi.d in the evaluation of patients with fecal
incontinence. Without the information obtained from physiologic testing, 11 percent of patients who may have benefited from surgery would not have been given this option, and 7 percent of patients could have potentially undergone unnecessary surgery. Transanal ultrasound is the study most likely to change a patient's management plan. Many anorectal physiology techniques are available and have contributed to understanding the
pathophysiology of fecal incontinence. There remains, however, disagreement on the value of routine anorectal physiology testing in the clinical management of patients with fecal incontinence. At this institution, anorectal manometry (ARM), pudendal nerve terminal motor latency (PNTML), and transanal ultrasound (TAUS) are used routinely as an adjunct to the clinical assessment of patients with fecal incontinence. Retrospective review has shown that this combination of anorectal physiology tests altered the treatment plan in 20 percent of patients with fecal incontinence. The primary aim of the present study was to prospectively determine whether anorectal physiology testing altered the management of patients with fecal incontinence. Secondary goals were to determine which anorectal tests exerted the greatest influence on patient management decisions and to identify patients most likely to benefit from anorectal physiology testing. DISCUSSION
The routine use of anorectal physiology testing to supplement a complete history and physical examination in the evaluation of fecal incontinence remains debatable. Opponents to routine anorectal physiologic testing have argued that this specialized form of testing fails to meet the criteria of a useful clinical test and will likely remain of interest only to specialists and researchers. Arguments supporting such a viewpoint contend that anorectal physiology testing lacks clinical usefulness because it is not widely available, it does not have a reproducible normal range between different laboratories, and, when abnormal, values do not correlate with disease entities or explain symptoms. It is also argued that anorectal physiology testing adds little additional diagnostic information to an otherwise complete clinical patient assessment. Testing is thought to be unlikely to result in a significant alteration in a patient's management plan. In addition, clinical outcome after intervention does not correlate with the obtained physiologic measurements.
Despite the limitations of anorectal physiology studies, there are various reports that do support the
clinical use of anorectal physiology testing in the assessment of patients with fecal incontinence. Anorectal physiology testing has also been reported to predict outcome after medical and surgical management of fecal incontinence. Anorectal physiology testing permits clinicians to provide patients with sound, specific treatment recommendations and allows patients to have realistic expectations. In a retrospective study of 32 patients with fecal incontinence, Speakman and Henry reported that
anorectal physiology testing provided new information in 53 percent of patients, influenced patient management in 75 percent of cases, and changed the treatment plan in 16 percent of patients. Wexner and Jorge found that anorectal physiologic studies increased the diagnostic yield of thorough clinical history and physical examination from 11 to 66 percent in a prospective series of 80 patients with fecal incontinence. Rao and Patel reported a series of 56 patients in whom anorectal physiology testing provided new information regarding the pathophysiology of fecal incontinence in 55 patients (98 percent). As a result of the new findings, a change in clinical management was realized in 47 patients (84 percent). In a prospective evaluation of 50 patients, Keating et al. found that anorectal physiology testing "altered the diagnosis of the cause of fecal incontinence in 19 percent of patients and the management p]an in 16 percent of patients. In a retrospective review of 84 consecutive patients with fecal incontinence, Tement et al. noted a change in management in 17 patients (20 percent) after anorectal physiology testing was added to full clinical assessment. Sixteen patients (19 percent) were found to have occult anal sphincter injuries and underwent a change in management from medical to surgical therapy. In the present prospective study of 90 consecutive patients with fecal incontinence who were tested with
ARM, PNTML, and TAUS, anorectal physiology test results directly affected the management of 9 patients (10 percent). Within the medical group, 5 (11 percent) of 45 patients changed from medical to surgical management. Within the surgical group, 3 (7 percen0 of 45 patients changed from surgical to medical therapy, and 1 patient (2 percent) changed from one type of surgical intervention to another. The clinical impression before testing remained unchanged in 40 (93 percent) of 43 patients who ultimately received medical management. Thus, without anorectal physiology testing, three patients (7 percent) may have received unnecessary surgical intervention. Of the patients who ultimately received surgical treatment, the clinical impression before anorectal physiology testing remained unchanged in 41 (87 percent) of 47 patients. The implication of this finding is that five patients (11 percent) who may have benefited from surgery would not have been offered surgery, and 1 patient (2 percent) may have undergone an inappropriate procedure. Each of the five patients who underwent a management plan change from medical to surgical treatment
had a large anterior anal sphincter injury encompassing both internal and external sphincters detected with TAUS. This finding was consistent with previous obstetric trauma in each case. Reasons for initially selecting medical management in this group included the following: two patients had fecal incontinence that appeared to be secondary to diarrhea, two had fecal incontinence associated with symptoms of irritable bowel syndrome with urgency, and one was suspected of having diabetic neuropathy. Four of these patients had normal PNTML bilaterally, and one had a slight unilateral PNTML prolongation (2.48 ms). The three patients who underwent treatment change from surgical to medical management were
clinically suspected of having anal sphincter injury and were expected to undergo overlapping anal sphincteroplasty. Their treatment plan was changed when TAUS revealed normal-appearing anal sphincters in two patients and a very limited external anal sphincter defect in one patient. It was the consensus of the consulting surgeons that the limited sphincter injury identified by TAUS in the latter patient was inadequate to explain her symptoms. Additionally, her ARM and PNTML results were within tile normal ranges. The sole patient who experienced a change from one type of surgical treatment to another was suspected of having a significant anal sphincter defect related to a previous posterior midline fissurectomy. The planned sphincteroptasty was abandoned when TAUS demonstrated minimal thinning of the internal anal sphincter and a normal external anal sphincter, and the patient was offered a neosphincter procedure instead.
In the majority of cases in which patient management plans were changed, TAUS appeared to be the
test on which the decision to change treatment plans was most heavily based. All of the patients who changed from medical to surgical management had a significant injury detected with TAUS. Two of three patients who changed from surgical to medical management had normal anal sphincters, and the third patient had minimal sphincter injury. The single patient who changed from one type of surgical procedure to another did so because the suspected anal sphincter injury was not confirmed by TAUS. Finally, in three of the four patients who had abnormal TAUS findings but did not change from medical management, the anal sphincter abnormality was considered to be clinically insignificant. The only patient with a significant anterior anal sphincter injury who did not change from medical management presented with atypical symptoms, as described previously, and has responded well to medical management thus far. TAUS has been shown to be accurate and reliable in the assessment of anal sphincter injury, and its use has been recommended in the assessment of all patients with fecal incontinence to detect occult sphincter defects. Additionally, TAUS can be used to assess the adequacy of sphincteroplasty in the evaluation of patients with continuing or recurrent fecal incontinence after surgery. ARM serves to objectively quantify clinical findings in the assessment of a symptomatic patient. AtOM
assists the "educated index finger" by actually measuring the mean rest and squeeze pressures generated by the anal sphincters. In the present study, ARM was found to be abnormal in approximately one third of patients, irrespective of patient group. An association between ARM results and anagement plan change was not observed. There also did not appear to be an association between manometry results and TAUS or PNTML findings. It has been concluded by some that ARM assessment of anal sphincters is no better than a digital rectal examination by an experienced examiner. The American Gastroenterological Association has recommended the use of ARM in the assessment of fecal incontinence to define functional weakness of one or both sphincter muscles and to perform and predict response to biofeedback training. Since its inception, PNTML measurement proposed to assist clinical decision making by distinguishing
between fecal incontinence caused by pudendal nel-ve injury and that caused by anal sphincter disruption. However, PNTML measurement has been shown to correlate poorly with patient symptoms, findings on clinical examination, and results of other anorectal physiology tests. The American Gastroenterological Association does not recommend PNTML for evaluation of patients with fecal incontinence. In the present study, no patient had their treatment plan changed because of PNTML findings, although PNTML results were used when patients were counseled about sphincteroplasty outcomes. Various studies have reported that prolonged PNTMLs, whether unilateral or bilateral, are predictive of poor patient outcome after sphincter repair, although this remains debatable. The different specific patient characteristics in the present study do not identify a subgroup of patients
who have increased diagnostic yield from anorectal physiology testing.' The majority of patients who had an anal sphincter defect and who underwent surgical therapy had obstetric trauma to the anal sphincters. The patient characteristics identified to be significantly different between the medical and surgical management groups are in keeping with this finding. In contrast to patients who do not have a sphincter defect, patients likely to have anal sphincter defects and undergo surgery were younger and had a shorter time interval from last delivery to presentation. They were also more likely to have type C buttocks and to have had a history of episiotomy or tear during vaginal delivery. |
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