Advertisement

Role of 3D high resolution anorectal manometry compared to conventional technique in management of constipation and faecal incontinence in children

  • Alireza S. Keshtgar
    Correspondence
    Corresponding author at: Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom.
    Affiliations
    Evelina London Children's Hospital, Guy's and St. Thomas’ NHS Foundation Trust, London, United Kingdom

    Kings College London, Guy's and St. Thomas’ NHS Foundation Trust, London, United Kingdom
    Search for articles by this author
  • Iman M. Selim
    Affiliations
    Kings College London, Guy's and St. Thomas’ NHS Foundation Trust, London, United Kingdom
    Search for articles by this author

      Highlights

      • 3D High resolution anorectal manometry (3D-HRAM) provides useful measurements that help guide treatment of chronic constipation and faecal incontinence in children.
      • 3D-HRAM is safe and provides detailed functional morphology of anal sphincters and it is useful to understand underlying pathophysiology of constipation and fecal incontinence in children.
      • This articles demonstrartes that water perfused 3D-HRAM and conventional manometry (CM) profiles are comparable.

      Abstract

      Background

      Anorectal manometry is a valuable tool for objective assessment of motility motor and sensory function of the anorectum. The aim of this study was to investigate role of water-perfused (WP) three dimensional high-resolution anorectal manometry (3D-HRARM) compared to WP conventional manometry (CM) in the management of chronic idiopathic constipation (CIC) and faecal incontinence (FI) in children.

      Methods

      This was a retrospective review of 122 consecutive children, who had WP 8-channel CM or 24 channel 3D-HRARM and endosonography under ketamine anaesthesia from September 2012 to February 2019. All patients had a validated symptom severity score questionnaire ranging from 0 (best) to 65 (worst). Mann-Whitney-U test and Spearman rank test were used and p<0.05 was considered significant.

      Results

      Subjects were divided according to investigation: CM group (n = 75) and 3D-HRAM (n = 47), who were otherwise comparable. Median anal resting pressure was 50 mmHg and rectoanal inhibitory reflex (RAIR) threshold volume was 10mls across the entire cohort. There were no significant differences in resting pressure or RAIR threshold when using conventional or 3D-HRARM. Rectal capacity was significantly higher in the CM group (p = 0.002). Rectal capacity and internal anal sphincter (IAS) thickness positively correlated with symptom severity, duration and patient age. 3D-HRARM provided a more detailed depiction of the anorectal pressure profile. Botulinum toxin was injected into the external anal sphincter (EAS) muscle (n = 75, 61%) and an anterograde colonic enema (ACE) stoma was needed subsequently in 19 (16%) to treat recurrent constipation and soiling symptoms. Rectal biopsy was done in 43(35%) patients, if RAIR was absent or inconclusive.

      Conclusion

      CM and 3D-HRARM are comparable in terms of resting pressure and RAIR threshold. 3D-HRAM is safe and provides detailed functional morphology of anal sphincters and it is useful to understand underlying pathophysiology of constipation and faecal incontinence in children and plan further treatment.

      Level of Evidence

      Level I

      Keywords

      Abbreviations:

      EPR (Electronic Patient Record), CM (Conventional Manometry), 3D-HRARM (3D-High Resolution Anorectal Manometry), IAS (Internal Anal Sphincter), RAIR (Rectoanal Inhibitory Reflex), SS (Solid-state), WP (Water-perfused)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Keshtgar A.S.
        • Ward H.C.
        • Clayden G.S.
        Pathophysiology of chronic childhood constipation:  Functional and morphological evaluation by anorectal manometry and endosonography and colonic transit study.
        J Pediatr Surg. 2013 Apr; 48; (RAM): 806-812
        • Lawson J.O.N.
        • Nixon H.H.
        Anal canal pressures in the diagnosis of Hirschsprung's disease.
        J Pediatr Surg. 1967; 2: 544-552
        • Alessandrella A.
        • Turco R.
        • Russo M.
        • et al.
        High-resolution anorectal manometry in children with functional constipation with or without fecal incontinence.
        Neurogastroenterol Motil. 2020 Sep 1; 32
        • Meunier P.
        • Marechal J.M.
        • de Beaujeu M.J.
        Rectoanal pressures and rectal sensitivity studies in chronic childhood constipation.
        Gastroenterology. 1979; 77: 330-336
        • Loening-Baucke V.A
        Abnormal rectoanal function in children recovered from chronic constipation and encopresis.
        Gastroenterology. 1984; 87: 1299-1304
        • Hosie G.P.
        • Spitz L.
        Idiopathic constipation in childhood is associated with thickening of the internal anal sphincter.
        J Pediatr Surg. 1997; 32: 1041-1044
        • Loening-Baucke V.
        Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis.
        J Pediatr. 1990; 116: 214-222
        • Banasiuk M.
        • Banaszkiewicz A.
        • Dziekiewicz M.
        • et al.
        Values from three-dimensional high-resolution anorectal manometry analysis of children without lower gastrointestinal symptoms.
        Clin Gastroenterol Hepatol. 2016 Jul 1; 14 (993-1000.e3)
        • Carrington E v.
        • Heinrich H.
        • Knowles C.H.
        • et al.
        Methods of anorectal manometry vary widely in clinical practice: results from an international survey.
        Neurogastroenterol Motil. 2017 Aug 1; 29
        • Aziz I.
        • Whitehead W.E.
        • Palsson O.S.
        • et al.
        An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation.
        Expert Rev Gastroenterol Hepatol. 2020; 14: 39-46
        • Clayden G.S.
        • Keshtgar A.S.
        • Carcani-Rathwell I.
        • et al.
        The management of chronic constipation and related faecal incontinence in childhood.
        Arch Dis Child Educ Pract Ed. 2005; 90
        • Keshtgar A.S.
        • Ward H.C.
        • Sanei A.
        • et al.
        Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial.
        J Pediatr Surg. 2007; 42: 672-680
        • Keshtgar A.S.
        • Ward H.C.
        • Clayden G.S.
        Pathophysiology of chronic childhood constipation: functional and morphological evaluation by anorectal manometry and endosonography and colonic transit study.
        J Pediatr Surg. 2013; 42: 672-680
        • Raizada V.
        • Bhargava V.
        • Karsten A.
        • et al.
        Functional morphology of anal sphincter complex unveiled by high definition anal manometery and three dimensional ultrasound imaging.
        Neurogastroenterol Motil. 2011; 23: 1013-e460
        • Lee Y.Y.
        • Erdogan A.
        • Rao S.S.C.
        High resolution and high definition anorectal manometry and pressure topography: diagnostic advance or a new kid on the block?.
        Curr Gastroenterol Rep. 2013; 15 (360–360)
        • Benezech A.
        • Behr M.
        • Bouvier M.
        • et al.
        Three-dimensional high-resolution anorectal manometry: does it allow automated analysis of sphincter defects?.
        Colorectal disease. 2015; 17: O202-O207
        • Ratuapli S.K.
        • Bharucha A.E.
        • Noelting J.
        • et al.
        Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry.
        Gastroenterology. 2013; 144 (.e2.): 314-322
        • Ambartsumyan L.
        • Rodriguez L.
        • Morera C.
        • et al.
        Longitudinal and radial characteristics of intra-anal pressures in children using 3D high-definition anorectal manometry: new observations.
        Am J Gastroenterol. 2013; 108: 1918-1928
        • Ambartsumyan L.
        • Shaffer M.
        • Carlin K.
        • et al.
        Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation.
        Neurogastroenterol Motil. 2021; 33 (-n/a): e13971
        • Molnar D.
        • Taitz L.S.
        • Urwin O.M.
        • et al.
        Anorectal manometry results in defecation disorders.
        Arch Dis Child. 1983; 58: 257-261
        • Kumar S.
        • Ramadan S.
        • Gupta V.
        • et al.
        Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait.
        J Pediatr Surg. 2009; 44 (Sep): 1786-1790
        • Benninga M.A.
        • Wijers O.B.
        • van der Hoeven C.W.P.
        • et al.
        Manometry, profilometry, and endosonography: normal physiology and anatomy of the anal canal in healthy children.
        J Pediatr Gastroenterol Nutr. 1994; 18: 68-77
        • Banasiuk M.
        • Dobrowolska M.E.
        • Skowrońska B.
        • et al.
        Comparison of anorectal function as measured with high-resolution and high-definition anorectal manometry.
        Dig Dis. 2022; 40: 448-457
        • Raghunath N.
        • Glassman M.S.
        • Halata M.S.
        • et al.
        Anorectal motility abnormalities in children with encopresis and chronic constipation.
        J Pediatr. 2011; 158: 293-296
        • Bigélli R.H.M.
        • Fernandes M.I.M.
        • Vicente Y.A.
        • de MV de A.
        • et al.
        Anorectal manometry in children with chronic functional constipation.
        Arq Gastroenterol. 2005; 42: 178-181
        • Keshtgar A.S.
        • Ward H.C.
        • Clayden G.S.
        Thickening of the internal anal sphincter in idiopathic constipation in children.
        Pediatr Surg Int. 2004; 20 (23): 817-823
        • Corazziari E.
        • Cucchiara S.
        • Staiano A.
        • et al.
        Gastrointestinal transit time, frequency of defecation, and anorectal manometry in healthy and constipated children.
        J Pediatr. 1985; 106: 379-382
        • Wald A
        Colonic transit and anorectal manometry in chronic idiopathic constipation.
        Arch Intern Med. 1986; 146: 1713-1716
        • Rasijeff A.M.P.
        • Withers M.
        • Burke J.M.
        • et al.
        High-resolution anorectal manometry: a comparison of solid-state and water-perfused catheters.
        Neurogastroenterol Motil. 2017; 29 (-n/a): e13124