Machine learning-based prediction models affecting the recovery of postoperative bowel function for patients undergoing colorectal surgeries.

PURPOSE: The debate surrounding factors influencing postoperative flatus and defecation in patients undergoing colorectal resection prompted this study. Our objective was to identify independent risk factors and develop prediction models for postoperative bowel function in patients undergoing colorectal surgeries. METHODS: A retrospective analysis of medical records was conducted for patients who undergoing colorectal surgeries at Peking University People's Hospital from January 2015 to October 2021. Machine learning algorithms were employed to identify risk factors and construct prediction models for the time of the first postoperative flatus and defecation. The prediction models were evaluated using sensitivity, specificity, the Youden index, and the area under the receiver operating characteristic curve (AUC) through logistic regression, random forest, Naïve Bayes, and extreme gradient boosting algorithms. RESULTS: The study included 1358 patients for postoperative flatus timing analysis and 1430 patients for postoperative defecation timing analysis between January 2015 and December 2020 as part of the training phase. Additionally, a validation set comprised 200 patients who undergoing colorectal surgeries from January to October 2021. The logistic regression prediction model exhibited the highest AUC (0.78) for predicting the timing of the first postoperative flatus. Identified independent risk factors influencing the time of first postoperative flatus were Age (p < 0.01), oral laxatives for bowel preparation (p = 0.01), probiotics (p = 0.02), oral antibiotics for bowel preparation (p = 0.02), duration of operation (p = 0.02), postoperative fortified antibiotics (p = 0.02), and time of first postoperative feeding (p < 0.01). Furthermore, logistic regression achieved an AUC of 0.72 for predicting the time of first postoperative defecation, with age (p < 0.01), oral antibiotics for bowel preparation (p = 0.01), probiotics (p = 0.01), and time of first postoperative feeding (p < 0.01) identified as independent risk factors. CONCLUSIONS: The study suggests that he use of probiotics and early recovery of diet may enhance the recovery of bowel function in patients undergoing colorectal surgeries. Among the various analytical methods used, logistic regression emerged as the most effective approach for predicting the timing of the first postoperative flatus and defecation in this patient population.

Anorectal function and symptoms 6 months after robot-assisted laparoscopic radical prostatectomy: a single-center study.

INTRODUCTION: Robot-assisted laparoscopic radical prostatectomy (RALP) is a common procedure for the treatment of localised prostate cancer. Anorectal symptoms such as fecal incontinence (FI), rectal urgency or disturbed defecation have been reported after the operation. Anorectal function is dependent on the integrity of anal and pelvic nerves and muscles, rectal sensory function as well as rectal reservoir function. The aim of this study was to investigate the potential influence of RALP on anorectal physiological function and bowel symptoms. MATERIALS AND METHODS: In this pilot study, 29 patients with localised prostate cancer scheduled for RALP were included. Anorectal physiology was used to measure rectal sensitivity and reservoir function as well as anal sphincter pressures. Bowel symptoms were measured by a bowel function questionnaire and a 2-week bowel function diary. Measurements were done before the operation and repeated at 6 months after the operation. RESULTS: The study observed a significant postoperative increase in rectal sensory threshold for rectal balloon distention, from 20 to 40 mmHg, P < 0.001. This change is indicative of a decrease in rectal sensation after RALP. There were no other statistical significant differences in any of the physiological tests performed. Importantly, there was no change in any of the bowel symptoms after surgery. CONCLUSION: This study showed that RALP may lead to impaired rectal sensory function. This finding did not, however, seem to have any influence on the patients´ postoperative clinical bowel function.

Functional Disorders of the Ileal-Anal Pouch: A Systematic Review.

BACKGROUND: The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard to define because pouch anatomy is not normal and pouch physiology is a distortion of normal defecation. Patients with pouches develop multiple symptoms: some are expected, some are disease related, and some are the result of surgical complications. It is important to understand the cause of pouch-related symptoms so that appropriate management is offered. OBJECTIVES: The study aimed to review pouch symptoms and discuss their likely cause, review the literature on pouch function and dysfunction, and provide clarity to clear the confusion. DATA SOURCES: PubMed and Cochrane databases were searched using the terms "ileoanal pouch function" and "ileoanal pouch dysfunction." STUDY SELECTION: From 1983 to 2023, 553 articles related to "ileoanal pouch function" and 178 related to "ileoanal pouch dysfunction" were reviewed. Nine studies appeared under both headings. Case studies, duplicate publications, and articles concerning pouch diseases were excluded. MAIN OUTCOME MEASURES: Definitions of pouch function and dysfunction, methods of describing and scoring symptoms, and understanding of expected changes in pouch function given the nature of the surgery. RESULTS: Twenty-seven studies were reviewed from the ileoanal pouch dysfunction search and 38 from ileoanal pouch function. Three studies tried to define normal pouch function, 10 attempted to measure pouch function, and 4 aimed to score pouch function. Only 3 studies addressed pouch physiology. LIMITATIONS: A full discussion of pouch dysfunction is limited by the lack of studies focussing on the anatomic and physiologic consequences of turning the terminal ileum into an organ of storage. CONCLUSIONS: Most studies of pouch function and dysfunction do not consider expected changes in the physiology of defecation that follow restorative proctocolectomy. Thus, most studies of pouch function produce conclusions that lack an important dimension. See video from symposium.

Obesity Is Associated with Altered Rectal Sensitivity in Chronic Constipation.

BACKGROUND: Defecation dysfunction may contribute to chronic constipation (CC), but the impact of obesity on anorectal physiology in CC remains unclear. We aimed to evaluate the relationship between obesity and anorectal function on physiologic testing in patients presenting with CC. METHODS: This was a retrospective cohort study of consecutive adults who underwent high resolution anorectal manometry (HRAM) at a tertiary center for CC. Patient demographics, clinical history, surgical/obstetric history, medications, and HRAM results were reviewed. Patients were classified into obese (BMI > 30 kg/m2) vs non-obese (BMI < 30 kg/m2) groups at the time of HRAM. Fisher-exact/student t-test for univariate analyses and general linear regression for multivariable analysis were performed. RESULTS: 383 adults (mean 50.3 years; 85.8% female) with CC were included. On HRAM, patients with obesity had lower anal sphincter resting tone (37.3 vs 48.5 mmHg, p = 0.005) and maximum squeeze pressure (104.8 mmHg vs 120.0 mmHg, p = 0.043). No significant differences in dyssynergia (61% vs 53%, p = 0.294) and failed balloon expulsion (18% vs 25%, p = 0.381) were found between obese and non-obese groups. On balloon distention testing, the maximum tolerated (163.5 vs 147.6 mL, p = 0.042) and urge sensation (113.9 vs 103.7 mL, p = 0.048) volumes were significantly increased among patients with obesity. After adjusting for potential confounders, obesity remained independently associated with increased maximum tolerated volume (ß-coefficient 13.7, p = 0.049). CONCLUSION: Obesity was independently associated with altered rectal sensitivity among patients with CC. Altered rectal sensation may play an important role in CC among patients with obesity. Anorectal physiology testing should be considered to understand the pathophysiology and guide management.

Patient-reported Bowel Function and Bowel-related Quality of Life After Pelvic Radiation for Rectal Adenocarcinoma: The Impact of Radiation Fractionation and Surgical Resection.

INTRODUCTION: Multimodality treatment for locally advanced rectal cancer (LARC) can include long-course radiotherapy (LCRT) or short course radiotherapy (SCRT). Nonoperative management is increasingly pursued for those achieving a complete clinical response. Data regarding long-term function and quality-of-life (QOL) are limited. METHODS: Patients with LARC treated with radiotherapy from 2016 to 2020 completed the Functional Assessment of Cancer Therapy- General (FACT-G7), the Low Anterior Resection Syndrome Score (LARS) and the Fecal Incontinence QOL Scale (FIQOL). Univariate and multivariable linear regression analyses identified associations between clinical variables including radiation fractionation and the use of surgery versus non-operative management. RESULTS: Of 204 patients surveyed, 124 (60.8%) responded. Median (interquartile range) time from radiation to survey completion was 30.1 (18.3-43) months. Seventy-nine (63.7%) respondents received LCRT, and 45 (36.3%) received SCRT; 101 (81.5%) respondents underwent surgery, and 23 (18.5%) pursued nonoperative management. There were no differences in LARS, FIQoL or FACT-G7 between patients receiving LCRT versus SCRT. On multivariable analysis, only nonoperative management was associated with lower LARS score signifying less bowel dysfunction. Nonoperative management and female sex were associated with a higher FIQoL score signifying less disruption and distress from fecal incontinence issues. Finally, lower BMI at the time of radiation, female sex, and higher FIQoL score were associated with higher FACT-G7 scores signifying better overall QOL. CONCLUSIONS: These results suggest long-term patient-reported bowel function and QOL may be similar for individuals receiving SCRT and LCRT for the treatment of LARC, but nonoperative management may lead to improved bowel function and QOL.

A modified myotomy of the puborectalis for anismus.

Anismus or non-relaxing puborectalis muscle (PRM) on straining may affect over 40% of patients with obstructed defecation (OD). Management is usually with biofeedback, or botulin toxin injection or partial puborectalis muscle myotomy. Such a procedure can be difficult technically. Bleeding and rectal injury may occur when detaching the PRM from the rectum. A partial modification of surgical technique may avoid these complications. The diagnosis should be confirmed with exclusion of sphincter compromise. Through two cutaneous incisions, an Ellis forceps is advanced through the ischio-rectal space, whilst finger pressure per rectum allows the puborectalis to be visualized and grasped by the forceps. Removal of some ischiorectal fat may be necessary to allow division of half the PRM under direct view. From October 2020 to October 2021, 5 patients underwent the modified technique in our department (4 males, median age 43 years [range 34-58 years], median follow-up 6 months [range 2-12 months]). No patients suffered from injury of the rectum or bleeding during or after surgery. Operative time was 30 min less than conventional PRM division, as the time-consuming "blind dissection" of PRM was avoided. Four patients regained appropriate relaxation of the PRM on straining. One male patient had temporary minor anal incontinence for 2 weeks. One male patient with severe mental distress continued to have with anismus and OD after surgery and refused psychiatric support. This modified procedure is feasible and safe and quicker than our conventional technique. More cases with longer follow-up are needed to confirm its efficacy.

Pathophysiological basis, clinical assessment, investigation and management of patients with obstruction defecation syndrome.

Obstructed defecation syndrome (ODS) is a clinical syndrome manifest as difficulty in faecal evacuation despite no mechanical obstruction. It is the final clinical pathway of a number of anatomical and physiological pathologies they can result in considerable misery to the lives of the patients it afflicts. Herein, the authors seek to breakdown the syndrome into its component parts, looking first at normal pelvic floor anatomy and physiology; followed by each pathological element; clinical features and investigation; individual management and management of the patient as a whole. It must be stated that correction of anatomy is not the sine qua non, as this does not always correlate to improvement of symptoms. There is a complex interplay of all elements, and a holistic approach appreciating the gestalt principle of "the whole is greater than the sum of its parts" is paramount. Causes of pelvic pain (levator ani syndrome, coccygodynia, proctalgia fugax and pudendal neuralgia) do not fall into ODS and are beyond the scope of this paper.

Development and Validation of a Symptom-based Scoring System for Bowel Dysfunction After Ileoanal Pouch Reconstruction.

OBJECTIVE: To utilize items identified as priorities by the Patient-Reported Outcomes after Pouch Surgery Delphi consensus study to create a validated tool for quantifying pouch function. BACKGROUND: The Patient-Reported Outcomes After Pouch Surgery Delphi consensus study identified 7 symptoms and 7 consequences as key domains for evaluating and analyzing ileoanal pouch function. METHODS: Pouch patients were recruited at inflammatory bowel disease centers and via patient advocacy websites. They were administered a questionnaire-based survey eliciting responses regarding the frequency of a variety of bowel symptoms. Associations between items and quality of life were computed in a score generation cohort of 298 patients by logistic regression modeling. Individual score values were designated to items to create an additive score titled the "Ileoanal Pouch Syndrome Severity Score." Validity was tested in a subsequent cohort of 386 patients using receiver operating characteristic area under the curve. In addition, test-rest validity, convergent validity, and clinical validity were evaluated. RESULTS: After the determination of item weights, the range of possible scores was 0 to 145. Score ranges were then determined as cutoff values for "ileoanal pouch syndrome." The score was then validated on the second patient cohort, with a receiver operating characteristic area under the curve of 0.83. Importantly, worsening severity of Ileoanal Pouch Syndrome score significantly correlated with higher rates of poor quality of life. Lastly, the questionnaire was rigorously validated to show test-retest validity, convergent validity compared with other bowel function scores, and clinical validity. CONCLUSIONS: This study developed a patient-centered, clinically useful scoring system that can quantify the range and severity of symptoms experienced by ileoanal pouch patients and their correlation with quality of life.

Anorectal volume-pressure relations, contraction work, and flow during defecation.

Fecobionics is an integrated device that has shown promise for assessment of anorectal function. We used a wireless Fecobionics prototype to visualize defecatory patterns and to compute volume-pressure, contraction work, and flow. Twelve normal subjects were studied. The probe was 10 cm-long and contained pressure sensors and electrodes for impedance planimetry. Pressures, diameters, and volume data during defecation were analyzed. The bag was distended inside rectum to the urge-to-defecate level where after the subjects were asked to evacuate. The contraction work and defecatory flow were computed from the volume changes during expulsion. The minimum anal diameter during the evacuation was 17.6 ± 1.5 mm. The middle diameter recording was 10-20% lower than the front diameter channels and 10-20% bigger than the rear channels. The bag volume at urge correlated with the minimum diameter (r = 0.63). The diameter-pressure and volume-pressure loops were counterclockwise with phases of bag filling, isometric contraction, ejection and anal passage. The defecatory contraction work was 3520 ± 480 mL × cmH2O. The maximum flow during defecation was 302 ± 33 mL/s. The flow was associated with the anal diameter (r = 0.84) but not with the rectoanal pressure gradient (r = 0.14). Volume-pressure loops have a tremendous impact on the understanding of cardiopulmonary pathophysiology. Future studies will shed light on potential clinical impact in defecatory pathophysiology.

Prevalence and predictors of functional evacuation disorder in patients with chronic constipation

Background: Functional evacuation disorder (FED) is the second most common cause of functional constipation (FC) after constipation-predominant irritable bowel syndrome. However, the data on FED is relatively scanty in our region. Hence, the present study was performed to evaluate the demographics of FED and to find out the predictors of FED in patients with chronic constipation. Methods: A total of 134 patients with chronic constipation diagnosed according to the Rome IV criteria who were referred for high-resolution anorectal manometry (HRAM) were retrospectively enrolled in the present study. All FC patients who underwent HRAM were asked to fill a questionnaire and underwent anorectal manometry and were submitted to the balloon expulsion test (BET). Results: The mean age of patients was 43.09 ± 9.32 years old, with a total of 76 (54%) males. The most common symptom was straining during defecation (87%) followed by incomplete evacuation (86%). The prevalence of FED, diagnosed by HRAM and by the BET was 39%. Patients with FED had a significantly higher percentage of straining and sensation of anorectal blockade compared with those without FED (96 versus 82%; p < 0.01; 81 versus 44%; p < 0.001, respectively). On the multivariate regression analysis, straining > 30 minutes (odds ratio [OR] = 3.63; p = 0.03), maximum squeeze pressure (OR = 1.05; p < 0.001), and balloon volume at maximal sensation (OR = 1.06; p < 0.001) were found to be significant independent predictors of FED. Conclusion: Prolonged straining and sensation of anorectal blockade were significant indicators of FED in patients with chronic constipation. (AU)

Intrathecally administered substance P activated the spinal defecation center and enhanced colorectal motility in anesthetized rats.

Noxious stimuli on the colorectum cause colorectal contractions through activation of descending monoaminergic pathways projecting from the supraspinal defecation center to the spinal defecation center. Since it is known that substance P is involved in the response to peripheral noxious stimuli in the spinal cord, we investigated the effects of intrathecally administered substance P at L6-S1 levels on colorectal motility in rats that were anesthetized with α-chloralose and ketamine. Intrathecally administered substance P enhanced colorectal motility, even after transection of the thoracic spinal cord at the T4 level. Severing the pelvic nerves, but not the colonic nerves, abolished substance P enhanced colorectal motility. In the spinal cord at L6-S1 levels, expression of mRNA coding neurokinin (NK) 1-3 receptors was detected by RT-PCR. Immunohistological experiments revealed that preganglionic neurons of the pelvic nerves express NK1 receptors, whereas expression of NK2 receptors was not found. In addition, substance P-containing fibers densely innervated around the preganglionic neurons expressing NK1 receptors. An intrathecally administered NK1 receptor antagonist (spantide) attenuated capsaicin-induced colorectal contractions. These results suggest that the colokinetic action of substance P is mediated by the NK1 receptor in the spinal defecation center. Our findings indicate that substance P may function as a neurotransmitter in the spinal defecation center.NEW & NOTEWORTHY We found that intrathecally administered substance P enhanced colorectal motility in anesthetized rats. Neurokinin (NK) 1 receptors, but not NK2 receptors, were detected in preganglionic neurons of the pelvic nerves. Blockade of NK1 receptors in the spinal cord attenuated the enhanced colorectal motility in response to intracolonic noxious stimuli. The findings indicate that substance P may function as a neurotransmitter in the spinal reflex pathway controlling defecation.

Contribution of sex hormones to the sexually dimorphic response of colorectal motility to noxious stimuli in rats.

Our recent studies have shown that noxious stimuli in the colorectum enhance colorectal motility via the brain and spinal defecation centers in male rats. In female rats, however, noxious stimuli have no effect on colorectal motility. The purpose of this study was to determine whether sex hormones are major contributing factors for sex-dependent differences in neural components of the spinal defecation center. Colorectal motility was measured using an in vivo method under ketamine and α-chloralose anesthesia in rats. Capsaicin was administered into the colorectal lumen as noxious stimuli. Orchiectomy in male rats had no effect on the capsaicin-induced response of colorectal motility. However, in ovariectomized female rats, capsaicin administration enhanced colorectal motility, though intact female animals did not show enhanced motility. When estradiol was administered by using a sustained-release preparation in ovariectomized female rats, capsaicin administration did not enhance colorectal motility unless a GABAA receptor antagonist was intrathecally administered to the lumbosacral spinal cord. These findings suggest that estradiol allowed the GABAergic neurons to operate in response to intracolonic administration of capsaicin. The operation of GABAergic inhibition by the action of estradiol could be manifested in male rats only when the effects of male sex hormones were removed by orchiectomy. Taken together, our results indicate that sex hormones contribute to the sexually dimorphic response in colorectal motility enhancement in response to noxious stimuli through modulating GABAergic pathways.NEW & NOTEWORTHY This study demonstrated that estradiol permits inhibitory regulation in the spinal defecation center not only in female rats but also in orchiectomized male rats. GABAergic pathways are likely involved in the effect of estradiol. This is the first report showing that sex hormones affect colorectal motility through the alteration of neural components of the regulatory pathways. Our findings provide a novel insight into pathophysiological mechanisms of defecation disorders related to changes in sex hormones.

Evaluation of Short Term Outcome of Stapled Transanal Rectal Resection (STARR) for ODS (Obstructed Defecation Syndrome) by Comparing Pre and Post-operative ODS Score.

Obstructed defecation syndrome (ODS) is a common anorectal problem and it can be corrected by various surgical approaches but most of these have high recurrence and complication rates. Antonio Longo introduced Stapled transanal rectal resection (STARR) in 2003 as a minimally invasive transanal operation for correction ODS associated with rectocele and or rectal intussusception. This study was designed to assess the short term outcome of Stapled Transanal Rectal Resection (STARR) as a surgical treatment of Obstructed Defecation Syndrome (ODS). This is a quasi experimental study which was carried out in the department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from May 2016 to June 2017. Seventeen (17) patients were included in the study. Patients with obstructed defecation syndrome and rectocele and or rectal intussusception admitted in the department of Colorectal Surgery were enrolled in the study as per inclusion and exclusion criteria. History, clinical examination, Proctoscopy, Colonoscopy and MR Defecography was done for evaluation of the patients. During evaluation preoperative Longo's ODS score of every patient also determined and compared with postoperative ODS score. The patient was followed up regularly at one, three and six months after each operation. The ODS score in 82.35% patients improved significantly. The postoperative score was high (13-15) only in 02(11.8%) patients probably due to presence of physiological factors. Post-operative defecatory urgency was developed in only 02(11.76%) patients. Major postoperative complication like hemorrhage or rectovaginal fistula did not develop in any patient. STARR is an effective, less invasive and simple procedure for the treatment of ODS with rectocele and/or rectal intussusception without major morbidity but other physiological causes of ODS should exclude preoperatively because its presence makes the surgical intervention fruitless.

The prediction of postoperative anorectal dysfunction after low anterior resection for lower rectal cancer by measuring the volume of defecation-related muscles.

PURPOSE: Approximately 90% of patients are thought to develop bowel dysfunction after low anterior resection (LAR). Although some prognostic factors have been reported, the volumes of defecation-related muscles have not been examined. This retrospective study investigated the association between the preoperative volume of defecation-related muscles and major LARS. METHODS: Forty-six patients who underwent LAR for rectal cancer between 2013 and 2020 in our institution were analyzed. They had no local residual tumor or local recurrence at the time of the study and no problems with their defecation function pre-operatively. Defecation-related muscle volume measurements were made before surgery, and the patients answered a low anterior resection syndrome (LARS) score questionnaire after surgery. The muscle volume was adjusted by the patient's height squared. RESULTS: Twenty-seven patients (58.7%) developed major LARS. In the univariate analysis, sex, lateral lymph node dissection, and diverting ileostomy as well as muscle volume of the external anal sphincter, pubococcygeal + iliococcygeus muscle, and puborectal muscle were associated with major LARS. In a multivariate analysis, pubococcygeal + iliococcygeus muscle (< 5.96 ml/m2) was the only factor (p = 0.02). CONCLUSIONS: Measuring the volume of the defecation-related muscles may aid in predicting major LARS.

The anorectal defaecation reflex: a prospective intervention study.

AIM: Our hypothesis is that there may be a neural pathway with sensory afferent neurons in the anal canal that leads to rectal contraction to assist defaecation. We aimed to compare rectal motility between healthy participants with or without anal anaesthesia. METHOD: This prospective intervention study consisted of two test sessions: a baseline session followed by an identical second session. During each session we performed the anal electrosensitivity test, the rectoanal inhibitory reflex test and rapid phasic barostat distensions. Prior to the second session, participants were randomly assigned to receive either a local anal anaesthetic or a placebo. RESULTS: We included 23 healthy participants aged 21.1 ± 0.5 years, 13 of whom received an anal anaesthetic and 10 a placebo. All participants showed a transient rectal contraction during the first test session, which decreased significantly after anal anaesthesia (18.6 ml vs. 4.9 ml, p = 0.019). The maximum rectal contraction was comparable to the baseline results in the placebo group. Furthermore, the electrosensitivity at the highest centimetre of the anal canal correlated with the maximum rectal contraction (r = -0.452, p = 0.045). CONCLUSION: All healthy study participants display an involuntary, reproducible rectal reflex contraction that appears to be innervated by afferent nerves in the proximal anal canal. The rectal reflex contraction appears to play a role in defaecation and we therefore refer to this phenomenon as the anorectal defaecation reflex. Knowledge of the anorectal defaecation reflex may have consequences for the diagnostics and treatment of constipation.

Disorders of anorectal motility: Functional defecation disorders and fecal incontinence.

Functional defecation disorders (FDDs) and fecal incontinence (FI) are common anorectal disorders often distressing and significantly add to the healthcare burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathophysiology and can pose significant management dilemmas. A detailed history, stool diaries and visual scales of stool form, a careful digital rectal examination are needed to guide anorectal physiology tests. With high-resolution (3-D) anorectal manometry, anal ultrasonography, (magnetic resonance) defecography and imaging, and neurophysiological tests, it is possible to define and characterize the underlying structural and functional abnormalities more accurately. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of FDDS, fecal incontinence and abnormalities of rectal capacity (i.e., megarectum, microrectum).

Opioid-Associated Anorectal Dysfunction in Chronic Constipation.

INTRODUCTION: The role of anorectal and defecatory dysfunction in opioid-related constipation is unclear. We aimed to evaluate the relationship between opioid use and rectal sensation, defecatory function, and balloon expulsion on anorectal physiology testing. METHODS: This was a retrospective cohort study of consecutive adults undergoing high-resolution anorectal manometry (HRAM) at a tertiary center for constipation. Clinical characteristics, medication use, and HRAM findings were obtained. Statistical analyses were performed using Fisher-exact/student t-test for univariate analyses and logistic/general linear regression for multivariable analyses to compare patients with no opioid use, recent (< 3 months) use, and distant (> 3 months) use. RESULTS: 424 patients (49.8 ± 17.2 years; 85.6% female) were included. Compared to those without opioid history, patients with recent use had increased volumes for first rectal sensation (70.4 mL vs 59.4, p = 0.043), urge (120.5 mL vs 101.5, p = 0.017), and maximal tolerance (170.2 mL vs 147.2, p = 0.0018), but not patients with distant use. Recent opioid use was associated with increased risk of dyssynergic defecation (DD) (61.8% vs 46.4%, p = 0.035), but not failed balloon expulsion. On multivariable models controlling for potential confounders, recent opioid use, but not distant use, remained independently correlated with increased volumes for first rectal sensation (ß-coefficient 9.78, p = 0.019), urge (ß-coefficient 16.7, p = 0.0060), and maximal tolerance (ß-coefficient 22.9, p = 0.0032), and higher risk for DD (aOR = 2.18, p = 0.026). CONCLUSION: Recent opioid use was an independent risk factor for rectal hyposensitivity and DD on HRAM in patients with constipation, but that effect may decrease with discontinuation of use. Anorectal physiology testing should be considered in patients with opioid-associated constipation.

The Role of Traditional Acupuncture in Low Anterior Resection Syndrome Treatment: A Pilot Study.

BACKGROUND: There is limited evidence on the efficacy of acupuncture in bowel dysfunction treatment. OBJECTIVE: The aim of this pilot study was to investigate the potential value of acupuncture in the treatment of low anterior resection syndrome. DESIGN: This was an open-design pilot study. SETTINGS: This was a single-center study. PATIENTS: Nine (5 female) patients with major low anterior resection syndrome were included. INTERVENTIONS: All patients underwent acupuncture by a trained specialist once a week for 10 weeks. MAIN OUTCOME MEASURES: Bowel function was assessed by using the low anterior resection syndrome score and the Memorial Sloan-Kettering Cancer Center bowel function instrument before the procedure, just after finishing the course of acupuncture, and 6 months after the treatment. RESULTS: The average age was 56.44 (50-65; SD ±5.4). Median age was 56 years. At the end of the procedure, all patients reported significant improvement in low anterior resection syndrome symptoms: the average low anterior resection syndrome score before acupuncture was 39 (±2.7), after acupuncture it was 30.3 (±10.6), and 6 months after acupuncture it was 7.22 (±10.244; p < 0.000). The average Memorial Sloan-Kettering Cancer Center bowel function instrument score before acupuncture was 55.33 (±11.55), after the procedure it was 60 (±14.97), and 6 months later it was 70.22 (±12.2; p < 0.000). LIMITATIONS: The small sample size and the fact that this is a single-center nonblinded study are limitations of this work. CONCLUSIONS: Acupuncture may be effective in low anterior resection syndrome treatment and needs further evaluation. The procedure is safe and feasible. See Video Abstract at http://links.lww.com/DCR/B700. REGISTRATION: ClinicalTrials.gov: NCT03916549. EL PAPEL DE LA ACUPUNTURA TRADICIONAL EN EL TRATAMIENTO DEL SNDROME DE RESECCIN ANTERIOR BAJA UN ESTUDIO PILOTO: ANTECEDENTES:Existe evidencia limitada sobre la eficacia de la acupuntura para el tratamiento de la disfunción intestinal.OBJETIVO:El objetivo de este estudio piloto fue investigar el valor potencial de la acupuntura en el tratamiento del síndrome de resección anterior baja.DISEÑO:Este fue un estudio piloto de diseño abiertoAJUSTES:Este fue un estudio en un solo centroPACIENTES:Fueron incluidos nueve pacientes con síndrome de resección anterior baja (muy sintomáticos), cinco de ellos eran mujeresINTERVENCIONES:Todos los pacientes fueron tratados con acupuntura, una vez a la semana durante diez semanas por un especialista capacitado.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal fue evaluada, antes del procedimiento, justo al finalizar el ciclo de acupuntura y a los seis meses, utilizando la puntuación (score) para el síndrome de resección anterior baja y el instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center.RESULTADOS:La edad media fue 56,44 (50 - 65) (DE ± 5,4). Edad mediana 56 años. Al final del procedimiento, todos los pacientes manifestaron una mejoría significativa de los síntomas del síndrome de resección anterior baja: La puntuación promedio del síndrome de resección anterior baja antes de la acupuntura fue 39 (± 2,7), después de - 30,3 (± 10,6) y 6 meses después de 7,22 (± 10,244) (p <0,000). El puntaje promedio del instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center antes de la acupuntura fue 55.33 (± 11.55), después del procedimiento 60 (± 14.97) y 6 meses después 70.22 (± 12.2) (p <0,000).LIMITACIONES:Tamaño de muestra pequeño, estudio no cegado en un solo centro.CONCLUSIONES:La acupuntura puede ser eficaz en el tratamiento del síndrome de resección anterior baja, pero es necesario continuar evaluando su utilidad. El procedimiento es seguro y factible. Consulte Video Resumen en http://links.lww.com/DCR/B700.

Evaluation of Bowel Function After Surgical Treatment for Intestinal Endometriosis: A Prospective Study.

BACKGROUND: Defecation symptoms related to intestinal deep infiltrative endometriosis are caused by anatomical and functional disorders and are probably linked to the course of the disease and surgical treatment. OBJECTIVE: The primary aim of this study was to assess bowel function before and after intestinal deep infiltrative endometriosis surgery. Secondarily, we sought to correlate defecatory symptoms with preoperative risk factors. DESIGN/SETTINGS: This is a single-center prospective cohort study, using the low anterior resection syndrome score to evaluate bowel function 4 weeks before, as well as at 6 months and 1 year after surgery. The Wilcoxon signed-rank test and logistic multiple regression analyses were performed to compare preoperative and postoperative scores. The level of significance was set at <0.05 for all comparisons. PATIENTS: Thirty-seven adult female patients who underwent intestinal resection for deep infiltrative endometriosis between 2015 and 2017 were included. MAIN OUTCOME MEASURES: The primary outcome was bowel function appraisement in deep infiltrative endometriosis intestinal surgery. RESULTS: During the preoperative evaluation, 48.6% of patients reported low anterior resection syndrome score ≥21. This group presented a mean score of 17.9 ± 13.7, with a median of 20 and a range of 5 to 30. After 1 year, the mean score was decreased to 9.6 ± 11.1, with a median of 4 and a range of 0 to 22. A significant difference was detected when comparing the post- and preoperative scores (p = 0.0006). Improvements in defecatory symptoms such as reduced fecal incontinence for flatus (p = 0.004) and liquid stools (p = 0.014) were also reported. The clustering of stools (p = 0.005) and fecal urgency (p = 0.001) also improved 1 year after surgery. The preoperative multiple logistic regression showed that dyschezia was the only independent variable associated with bowel symptoms. LIMITATIONS: This is a well-documented prospective study, but the data presented have a relatively small population. CONCLUSIONS: This study provides evidence that intestinal deep infiltrative endometriosis surgery improves bowel function and has a positive impact on evacuation symptoms. See Video Abstract at http://links.lww.com/DCR/B534. EVALUACIN DE LA FUNCIN INTESTINAL DESPUS DEL TRATAMIENTO QUIRRGICO PARA LA ENDOMETRIOSIS INTESTINAL UN ESTUDIO PROSPECTIVO: ANTECEDENTES:Se considera que los síntomas defecatorios relacionados con la endometriosis intestinal infiltrativa profunda, son causados por trastornos anatómicos y funcionales, y probablemente estén relacionados con el curso de la enfermedad y tratamiento quirúrgico.OBJETIVO:El objetivo principal fue evaluar la función intestinal antes y después de la cirugía por endometriosis intestinal infiltrativa profunda. En segundo lugar, correlacionar los síntomas defecatorios con los factores de riesgo preoperatorios.DISEÑO / AJUSTES:Es un estudio de cohorte prospectivo de un solo centro, utilizando la puntuación del síndrome de resección anterior baja (LARS Score) para evaluar la función intestinal 4 semanas antes, 6 meses y un año después de la cirugía. Se realizaron pruebas de rango firmado de Wilcoxon y análisis de regresión logística múltiple para comparar puntuaciones preoperatorias y postoperatorias. Para todas las comparaciones, el nivel de significancia se estableció en <0.05.ENTORNO CLINICO:Se incluyeron 37 mujeres adultas sometidas a resección intestinal por endometriosis infiltrativa profunda entre 2015 y 2017.PRINCIPALES MEDIDAS DE VALORACION:El resultado principal, fue la evaluación de la función intestinal en cirugía de endometriosis infiltrativa profunda intestinal.RESULTADOS:Durante la evaluación preoperatoria, el 48,6% de los pacientes reportaron Síndrome de Resección Anterior Baja ≥ 21. Este grupo presentó una puntuación media de 17,9 ± 13,7, con una mediana de 20 y un rango de 5 a 30. Después de un año, la puntuación media se redujo a 9,6 ± 11,1, con una mediana de 4 y un rango de 0 a 22 Se detectó una diferencia significativa al comparar las puntuaciones postoperatorias y preoperatorias (p = 0,0006). Se informó de mejoras en los síntomas defecatorios como la reducción de la incontinencia fecal por flatos (p = 0,004) y heces líquidas (p = 0,014). La agrupación de heces (p = 0,005) y la urgencia fecal (p = 0,001) presentaron mejoría a un año después de la cirugía. La regresión logística múltiple preoperatoria mostró que la disquecia fue la única variable independiente asociada con los síntomas intestinales.LIMITACIONES:A pesar de que es un estudio prospectivo bien documentado, los datos presentados son de una población relativamente pequeña.CONCLUSIONES:El estudio proporciona evidencia de que la cirugía intestinal por endometriosis infiltrativa profunda, mejora la función intestinal y tiene un impacto positivo en los síntomas de evacuación. Consulte Video Resumen en http://links.lww.com/DCR/B534.