Search Results (97)

Background/Objectives: Chronic anal fissure, an anorectal condition, is characterized by internal anal sphincter fibers at the base of the fissure. The lifetime prevalence is 7–8%. Medical management and lifestyle modifications are the first-line treatments, whereas chemical or surgical internal anal sphincterectomy is an option for refractory cases. The aim of this study was to evaluate the impact of surgical anal canal length and sphincter pressure on postoperative symptom relief and continence outcomes. Methods: A total of 26 patients diagnosed with chronic anal fissures were selected for surgical treatment. Five patients voluntarily withdrew, leaving 21 cases for analysis. In patients undergoing open lateral internal sphincterotomy, anal canal length and sphincter pressure were assessed preoperatively and three months postoperatively using endoanal ultrasonography and high-resolution anal manometry. Results: Postoperatively, all patients experienced complete resolution of pain and bleeding. The expected decrease in resting pressure was not significantly associated with sex. A significant weight gain was observed postoperatively (p = 0.001). Although a significant decrease was observed in preoperative sphincter resting pressure and VAS scores, Wexner scores remained unchanged. Preoperatively and postoperatively, mean sphincter pressure was significantly lower in the spontaneous vaginal delivery group than that in the non-spontaneous vaginal delivery group (p < 0.05). Patients with short anal canal lengths had greater pressures reductions, though not statistically significant. Conclusions: Lateral internal sphincterotomy is an effective and safe treatment for chronic anal fistula when performed by experienced surgeons. Anal canal length may influence postoperative complications and surgical decisions. Larger studies are needed to confirm these findings. Full article

Gastroesophageal reflux disease (GERD) is a prevalent disorder caused by lower esophageal sphincter (LES) dysfunction, often requiring long-term treatment. This study assessed the feasibility of endoscopic balloon-assisted laser treatment (EBLT) using a porcine GERD model. One week after GERD induction, EBLT was performed on three animals, while one served as a control. A 980 nm continuous-wave laser was delivered at 30 W for 90 s (energy = 2700 J and power density = 2.17 W/cm²) in a circumferential, non-contact manner using a balloon-assisted catheter. Real-time mucosal temperature monitoring was achieved using a fiber Bragg grating (FBG) sensor integrated with the balloon, maintaining temperatures below 40 °C. Endoscopic ultrasound and manometry were used to evaluate LES thickness and pressure before and after treatment. After a 12-week observation period, esophageal tissues were harvested for histological and gene expression analysis. Compared to the control, the treated group showed an increase in LES thickness (3.6 ± 0.2 mm vs. 1.5 mm) and relative LES pressure changes (2.9 ± 1.6 vs. 0.6). Upregulation of fibrosis- and hypertrophy-related genes suggested structural remodeling of the LES. No adverse effects or mucosal injury were observed. These findings support EBLT as a promising and minimally invasive strategy for GERD treatment. Full article

Background: Distinguishing between the anatomical variant of an anterior anus and mild forms of imperforate anus with rectoperineal fistula often requires inspection, calibration, and, in uncertain cases, electrical stimulation (ES) under general anesthesia. Anorectal manometry (AM), despite its ability to assess sphincter configuration and function, is rarely reported as a diagnostic tool. This study evaluated the utility of AM in such cases. Methods: A retrospective analysis of AM and clinical data from 38 patients (35 female, 3 male) with suspected anterior anus was conducted from October 2009 to September 2021. Water-perfused catheter probes with eight radial channels were used to perform pull-through maneuvers. Sphincter locations were identified through vector reconstruction, and pressure ratios of the anterior part to the circumference were recorded. Results were compared to clinical data, including ES findings. Statistical significance was assessed using Mann–Whitney U and Chi-Square tests. Results: Following AM, ES was unnecessary in 25 patients. Of the remaining patients, 83% showed abnormal sphincter configurations on ES, and seven underwent anoplasty. Patients with abnormal sphincter complexes demonstrated significantly lower mean anterior pressures (61.2 mmHg vs. 136.4 mmHg, U = 336.5, p = 0.001) and a trend toward lower anterior-to-circumferential pressure ratios (mean 0.42 vs. 0.85, U = 613, p = 0.270). Constipation was also more frequent in this group (X²(1,N = 38) = 4.1, p = 0.044). Average anterior pressures < 75 mmHg and ratios < 0.7 indicated an anus outside the sphincter complex (sensitivity 80%, specificity 90%). Conclusions: AM proves valuable for evaluating ambiguous anterior anus cases, potentially reducing reliance on ES under general anesthesia. 3D high-resolution AM may further increase diagnostic accuracy. Full article

Background: Anorectal Manometry (ARM) plays a crucial role in diagnosing potential motility disorders of anorectum in pediatric gastroenterology. Despite its prevalence, the predictive utility of ARM in guiding therapeutic response remains poorly characterized. Objectives: This study aims to evaluate the effectiveness of ARM in predicting therapeutic responses among children with functional constipation. Methods: A retrospective chart review was conducted at two tertiary centers examining pediatric patients who underwent ARM between January 2018 and July 2022. Key ARM parameters were analyzed, including anal resting pressure, recto-anal inhibitory reflex (RAIR), first rectal sensation, and bear-down maneuver (BDM). Therapeutic responses were assessed post-ARM, with success defined as an increase in bowel movement frequency and/or a decrease in fecal incontinence. In addition, we also intended to evaluate the eventual need for surgical intervention as another outcome. Results: The study included 327 patients, with a median age of 8.2 years. The overall therapeutic response rate was 40.7%, with stimulant laxatives showing a 48% response. Notably, lower anal resting pressures and delayed rectal sensations were associated with better therapeutic outcomes. Abnormal BDM correlated with a lack of response to therapies, while the presence of abnormal RAIR was linked to a higher eventual need for surgical intervention. Conclusions: ARM is instrumental in predicting therapeutic responses in pediatric patients with functional constipation. In addition to diagnosing HD, ARM could be an instrumental tool in identifying patients with dyssynergic defecation for early intervention with targeted therapy in age-appropriate patients. Full article

Non-expandable lung (NEL) occurs when the lung fails to fully re-expand after pleural fluid drainage, complicating management and limiting therapeutic options. Diagnosis, based on clinical symptoms, pleural manometry, and traditional imaging, is often delayed to the peri- or post-procedural stages, leading to improper management, complications, and higher healthcare costs. Therefore, early, pre-procedural diagnostic methods are needed. Thoracic ultrasound (TUS) has emerged as a non-invasive tool with the potential to enhance diagnostic accuracy and guide clinical decisions, yet, it remains inadequately studied within the context of NEL. We conducted a non-systematic narrative review using a structured methodology, including a comprehensive database search, predefined inclusion criteria, and QUADAS-2 quality assessment. This approach ensured a rigorous synthesis of evidence on TUS in NEL, with the aim of identifying knowledge gaps and guiding future studies. Non-invasive, real-time, bedside M-mode TUS has demonstrated efficacy in predicting NEL prior to thoracentesis by detecting an absent sinusoidal sign and reduced atelectatic lung movement. Emerging experimental techniques, including 2D shear wave elastography (SWE), speckle tracking imaging (STI) strain analysis, the lung/liver echogenicity (LLE) ratio, TUS assessment of dynamic air bronchograms, and pleural thickening evaluation, show additional potential to enhance pre-procedural NEL detection. However, all these methods have significant limitations that require further comprehensive investigation. Despite their significant promise, TUS modalities for early NEL detection still require rigorous validation and standardization before broad clinical use. A multimodal diagnostic approach, combining clinical manifestations, pleural manometry, radiologic and ultrasonographic findings, along with emerging techniques (once fully validated), may provide the most extensive framework for NEL. Regardless of advancements, patient-centered care and shared decision-making remain essential. Further research is needed to improve outcomes, reduce healthcare costs, and enhance long-term treatment strategies. Full article

Background/Objectives: Patients with spina bifida (SB) commonly experience neurogenic bowel dysfunction, characterized by defecation-related symptoms. While anorectal dysfunction and slow transit constipation (STC) have been implicated, the role of colonic motility in SB remains unclear. This study aimed to evaluate colonic motility in SB patients with refractory bowel dysfunction. Methods: This retrospective cohort study included SB patients who failed the repeated optimization of a bowel regimen including stimulant laxatives and subsequently underwent anorectal manometry (ARM), colonic transit time (CTT) studies, or colonic manometry (CM). Diagnostic findings were analyzed alongside treatment outcomes. Results: A total of 13 patients with myelomeningocele were included; one declined further treatment, and 12 underwent treatment optimization, with four achieving bowel continence. Of the five patients who proceeded with advanced motility testing, two had abnormal ARM findings, one of three had abnormal CTT results, and all five had normal CM findings. Conclusions: These findings suggest that anorectal dysfunction or STC may play a larger role in refractory bowel symptoms, while colonic motility appears to be preserved, and this highlights the importance of maximizing conservative therapies, particularly with stimulant laxatives, before pursuing invasive tests or surgical interventions for bowel dysfunction in this population. Full article

Background/Objectives: Anal incontinence is linked to pelvic floor dysfunction. Diagnosis involves assessing both the function and structure of the anorectal unit. Although transperineal ultrasound has gained attention as a less invasive option, its effectiveness as a diagnostic tool for evaluating the relationship between structure and function is still debated. This study aimed to explore the relationship between quantitative measurements of anal sphincter and pelvic floor structures as well as the subjective symptoms and objective assessments of sphincter function regarding anal incontinence. Methods: 50 women with pelvic floor dysfunction were recruited for the study. The severity of anal incontinence was assessed using the CACP score. Ultrasound imaging was employed to measure anal sphincter area, while sphincter pressures were evaluated through manometry. The relationships between variables were analyzed using Pearson’s and Spearman’s correlation tests. Results: The mean anal sphincter area was 5.51 cm² at rest and 4.06 cm² during maximal contraction. Resting anal sphincter pressure had an average of 46.29 mmHg, and contraction pressure averaged 103.25 mmHg. No significant correlation was found between the anal sphincter area and pressure at rest (r = 0.018) or during contraction (r = −0.210). However, a moderate correlation was observed between the change in sphincter pressure and area during contraction (r = 0.312). The CACP score showed no significant correlation with the sphincter area at rest (r = −0.084) but was weakly correlated during contraction (r = −0.270). Conclusions: Conventional diagnostic tools for evaluating anal incontinence can be uncomfortable and are not always readily available. Perineal sonography presents a promising, less invasive alternative for dynamic assessment of the anal sphincter. Full article

Background: The increased popularity and ubiquitous use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for the treatment of diabetes, heart failure, and obesity has led to significant concern for increased risk for perioperative aspiration, given their effects on delayed gastric emptying. This concern is highlighted by many major societies that have published varying guidance on the perioperative management of these medications, given limited data. We conducted a scoping review of the available literature regarding the aspiration risk and aspiration/regurgitant events related to GLP-1 RAs. Methods: A librarian-assisted search was performed using five electronic medical databases (PubMed, Embase, and Web of Science Platform Databases, including Web of Science Core Collection, KCI Korean Journal Database, MEDLINE, and Preprint Citation Index) from inception through March 2024 for articles that reported endoscopic, ultrasound, and nasogastric evaluation for increased residual gastric volume retained food contents, as well as incidences of regurgitation and aspiration events. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. Results: Of the 3712 citations identified, 24 studies met eligibility criteria. Studies included four prospective, six retrospective, five case series, and nine case reports. The GLP-1 RAs reported in the studies included semaglutide, liraglutide, lixisenatide, dulaglutide, tirzepatide, and exenatide. All studies, except one case report, reported patients with confounding factors for retained gastric contents and aspiration, such as a history of diabetes, cirrhosis, hypothyroidism, psychiatric disorders, gastric reflux, Barrett’s esophagus, Parkinson’s disease, dysphagia, obstructive sleep apnea, gastric polyps, prior abdominal surgeries, autoimmune diseases, pain, ASA physical status classification, procedural factors (i.e., thyroid surgery associated with risk for nausea, ketamine associated with nausea and secretions), and/or medications associated with delayed gastric emptying (opioids, anticholinergics, antidepressants, beta-blockers, calcium channel blockers, DPP-IV inhibitors, and antacids). Of the eight studies (three prospective and five retrospective) that evaluated residual contents in both GLP-1 users and non-users, seven studies (n = 7/8) reported a significant increase in residual gastric contents in GLP-1 users compared to non-users (19–56% vs. 5–20%). In the three retrospective studies that evaluated for aspiration events, there was no significant difference in aspiration events, with one study reporting aspiration rates of 4.8 cases per 10,000 in GLP-1 RA users compared to 4.6 cases per 10,000 in nonusers and the remaining two studies reporting one aspiration event in the GLP-1 RA user group and none in the non-user group. In one study that evaluated for regurgitation or reflux by esophageal manometry and pH, there was no significant difference in reflux episodes but a reduction in gastric acidity in the GLP-1 RA user group compared to the non-user group. Conclusions: There is significant variability in the findings reported in the studies, and most of these studies include confounding factors that may influence the association between GLP-1 RAs and an increased risk of aspiration and related events. While GLP-1 RAs do increase residual gastric contents in line with their mechanism of action, the currently available data do not suggest a significant increase in aspiration and regurgitation events associated with their use and the withholding of GLP-1 RAs to reduce aspiration and regurgitation events, as is currently recommended by many major societal guidelines. Large randomized controlled trials (RCTs) may be helpful in further elucidating the impact of GLP-1 RAs on perioperative aspiration risk. Full article

Introduction: Although several treatments for faecal incontinence are available, gas incontinence (GI) and soiling are difficult to manage. The aim of this study is to evaluate Gatekeeper™ for this subtype of faecal incontinence. Methods: Prospective single-centre case series. Patients with mainly soiling and/or GI were treated with polyacrylonitrile prostheses. An evaluation was performed with a 3-week continence diary. St. Mark’s score and a Visual Analogue Scale (VAS) were used to study the patient’s continence perception and surgical satisfaction, at baseline and 1, 3, 6, 12, and 24 months postoperatively. 3D-Endoanal Ultrasound and Anorectal Manometry were performed at baseline and postoperatively. Results: A total of 13 patients were enrolled (11 women), aged (median (IQR)) 62 (13) years, and all implants were uneventful. A significant reduction in soiling and GI episodes was documented at 1 year, 7 (18) baseline days of soiling/3 weeks vs. 2 (4) (p = 0.002); 13 (13) baseline episodes of GI/3 weeks vs. 4 (10) (p = 0.01). This improvement was correlated with a significant increase in VAS (0–10), 3 (2, 5) baseline vs. 7 (1, 5) (p = 0.03), and maintained throughout the follow-up. There was complete remission or significant improvement defined as >70% reduction in gas and soiling days in 6 patients at 2 years follow-up. Soiling episodes were reduced ≥70% in 8/11 patients (72.7%). Nine (70%) patients would repeat the treatment. Conclusions: Gatekeeper™ is a safe, minimally invasive treatment for soiling and GI. A significant reduction in soiling and GI was observed in our series, with a better response to soiling. Most of the patients would repeat the treatment. Other studies are needed to confirm these findings in this subgroup of FI patients. Full article

Background: Chronic constipation (CC) is one of the most common disorders of gut–brain interaction (DGBI). The management of CC requires specific skills due to its complex and multifactorial pathophysiology and its multistep treatment. The aims of this study were to evaluate the availability and the use of diagnostic tools for CC in Italy and the therapeutic management of CC by Italian gastroenterologists (GEs). Methods: A survey was conducted during the 28th meeting of the Italian Federation of Digestive Disease Societies (FISMAD; Rome, Italy, 11–14 May 2022). The survey explored the presence of a clinic dedicated to DGBIs, the availability and the use of specific diagnostic tools, the routine use of digital rectal examination (DRE), and the therapeutic approach to CC by Italian GEs. Results: The survey was taken by 236 GEs. The most significant results were that 42% of respondents had a clinic dedicated to DGBI in their institute; DRE was regularly performed by 56.8% of GEs when evaluating a CC patient; young GEs (≤40 years) performed DRE less frequently than older ones (p < 0.001); anorectal manometry was available to 44.3% of GEs; balloon expulsion test (BET) was available to 19.1% of GEs; GEs with a clinic dedicated to DGBI had more frequent access to anorectal physiology testing (p < 0.001); diet and lifestyle advice were the most frequently prescribed treatments; and fiber and macrogol were the second and third most prescribed treatments, respectively. Conclusions: The survey provides an interesting picture of CC management by Italian GEs. The results are in line with previous data collected about 10 years ago among Italian GEs (“CHRO.CO.DI.T.E study”); DRE is still rarely performed by Italian GEs (particularly by young GEs). The availability of anorectal physiology testing is still limited, and BET, which could be easily performed in everyday clinical settings, is rarely performed. Lifestyle suggestions, macrogol and fiber are the preferred treatment, as recommended by all guidelines. These results will be useful to identify as yet unmet educational needs and critical issues to improve CC management. Full article

Objectives: Esophageal high-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, but it may be poorly tolerated and unsuccessful. We sought to evaluate a protocol for sedation and endoscopy-assisted (SEA) HRM in patients who previously failed standard HRM and assess patient perspectives towards it. Methods: Adult patients who previously failed HRM were prospectively enrolled. Under propofol sedation, an upper endoscopy was performed during which the HRM catheter was advanced under endoscopic visualization. If the catheter did not reach the stomach on its own, the endoscope itself or a snare was used to help it traverse the esophagogastric junction (EGJ). Results: Thirty patients participated (mean age 67.8, 70% female). The technical success of SEA-HRM was 100%. Twenty-two (73.3%) were diagnosed with a motility disorder including thirteen (43.3%) with achalasia. Eighteen (60%) had previously failed HRM due to discomfort/intolerance, while twelve (40%) failed due to catheter coiling in the esophagus. Subjects in the coiling group were more likely to need endoscopic assistance to traverse the EGJ (91.7% vs. 27.7%, p = 0.001) and have a motility disorder (100.0% vs. 55.6%, p = 0.010), including achalasia (75.0% vs. 22.2%, p = 0.004), compared to the discomfort/intolerance group. All patients preferred SEA-HRM and rated it higher than standard HRM (9.5 ± 1.3 vs. 1.9 ± 2.1, p = <0.001, on a scale of 1–10). Conclusions: SEA-HRM is a highly successful and well-tolerated option in patients who previously failed standard HRM. This should be the recommended approach in cases of failed HRM rather than secondary tests of esophageal motility. Full article

Artificial intelligence (AI) has emerged as a transformative tool across several specialties, namely gastroenterology, where it has the potential to optimize both diagnosis and treatment as well as enhance patient care. Coloproctology, due to its highly prevalent pathologies and tremendous potential to cause significant mortality and morbidity, has drawn a lot of attention regarding AI applications. In fact, its application has yielded impressive outcomes in various domains, colonoscopy being one prominent example, where it aids in the detection of polyps and early signs of colorectal cancer with high accuracy and efficiency. With a less explored path but equivalent promise, AI-powered capsule endoscopy ensures accurate and time-efficient video readings, already detecting a wide spectrum of anomalies. High-resolution anoscopy is an area that has been growing in interest in recent years, with efforts being made to integrate AI. There are other areas, such as functional studies, that are currently in the early stages, but evidence is expected to emerge soon. According to the current state of research, AI is anticipated to empower gastroenterologists in the decision-making process, paving the way for a more precise approach to diagnosing and treating patients. This review aims to provide the state-of-the-art use of AI in coloproctology while also reflecting on future directions and perspectives. Full article

Background/Objectives: To develop a deep learning model for esophageal motility disorder diagnosis using high-resolution manometry images with the aid of Gemini. Methods: Gemini assisted in developing this model by aiding in code writing, preprocessing, model optimization, and troubleshooting. Results: The model demonstrated an overall precision of 0.89 on the testing set, with an accuracy of 0.88, a recall of 0.88, and an F1-score of 0.885. It presented better results for multiple categories, particularly in the panesophageal pressurization category, with precision = 0.99 and recall = 0.99, yielding a balanced F1-score of 0.99. Conclusions: This study demonstrates the potential of artificial intelligence, particularly Gemini, in aiding the creation of robust deep learning models for medical image analysis, solving not just simple binary classification problems but more complex, multi-class image classification tasks. Full article

Background and Objectives: The threshold for ineffective esophageal motility (IEM) diagnosis was changed in Chicago v4.0. Our aim was to determine IEM prevalence using the new criteria and the differences between patients with definite IEM versus “inconclusive diagnosis”. Materials and Methods: We retrospectively selected IEM and fragmented peristalsis (FP) patients from the high-resolution esophageal manometries (HREMs) database. Clinical, demographic data and manometric parameters were recorded. Results: Of 348 HREMs analyzed using Chicago v3.0, 12.3% of patients had IEM and 0.86% had FP. Using Chicago v4.0, 8.9% of patients had IEM (IEM-4 group). We compared them with the remaining 16 with an inconclusive diagnosis of IEM (borderline group). Dysphagia (77% vs. 44%, Z-test = 2.3, p = 0.02) and weight loss were more commonly observed in IEM-4 compared to the borderline group. The reflux symptoms were more prevalent in the borderline group (87.5% vs. 70.9%, p = 0.2). Type 2 or 3 esophagogastric junction morphology was more prevalent in the borderline group (81.2%) vs. 64.5% in IEM-4 (p = 0.23). Distal contractile integral (DCI) was lower in IEM-4 vs. the borderline group, and resting lower esophageal sphincter (LES) pressure and mean integrated relaxation pressure (IRP) were similar. The number of ineffective swallows and failed swallows was higher in IEM-4 compared to the borderline group. Conclusions: Using Chicago v4.0, less than 10% of patients had a definite diagnosis of IEM. The dominant symptom was dysphagia. Only DCI and the number of failed and inefficient swallows were different between definite IEM patients and borderline cases. Full article

Background/Objective: Multiple system atrophy (MSA) is often associated with dysphagia and esophageal dysmotility (ED). However, ED in patients with MSA is poorly understood. To assess the relationship between ED, dysphagia, and other clinical findings in such patients and investigate the details of ED in MSA using high-resolution manometry (HRM). Methods: Patients from The University of Tokyo Hospital with MSA who underwent swallowing examinations, esophagography, and HRM between 2017 and 2022 were enrolled. A retrospective chart review of patients’ backgrounds, swallowing function, and esophageal motility was performed. ED was evaluated using the Chicago Classification version 4.0. Results: Seventy-four patients with MSA were identified. The median age was 64 years, 48 patients (65%) were male, and the cerebellar variant type was predominant (69%). Abnormal upper esophageal sphincter (UES) resting pressure was observed in 34 patients (46%) and intraesophageal stasis in 65 (88%). High-severity MSA was a risk factor for developing dysphagia, vocal fold movement impairment, and abnormal UES function (p < 0.05). However, no overt clinical risk factors for ED were identified. Various types of ED were detected using HRM, and ineffective esophageal motility was the most frequent disorder. Conclusions: ED is a common occurrence in patients with MSA. Although a high-severity MSA may be a risk factor for developing dysphagia and vocal fold motion impairment, ED can occur regardless of clinical severity. Since ED is rarely detected based on subjective symptoms, careful evaluation of esophageal motility by esophagography or HRM is warranted in patients with MSA. Full article