Digestive Phisiology and Motility LabUniversity of Veracruz, Mexico

José María Remes Troche.

HIGH RESOLUTION AND HIGH DEFINITION ANORECTAL MANOMETRY:

USEFULNESS, LIMITATIONS, WHEN AND WHY

DISCLOSURE: José María Remes-Troche

José-María Remes-Troche has served on the Advisory Board of Allergan, Carnot and Sanfer.

He has been a consultant for Alfa-Wasserman, Almirall, Commonwealth Laboratories Inc, Takeda Mexico, Asofarma Mexico and Sanfer.

He has also been a speaker for Alfa Wasserman, Takeda Mexico, Carnot, Sanfer and Almirall.

He has received grant supports from Alfa Wasserman and Sanfer.

AIMüTo review and analyze

ü Indications ü Limitationsü Clinical utility

HRAM

3-D HDAM

Pelvic Floor Structure Colonic Transit Time

Motor Function Neuro Sensory FUnction

•• Ultrasound (2-3D)Ultrasound (2-3D)•• MRIMRI•• DephecographyDephecography•• Barium proctogramBarium proctogram•• EndoscopyEndoscopy

•• Breath testBreath test•• Radiopaque markersRadiopaque markers•• Smart pillSmart pill•• GammagraphyGammagraphy•• RFITransitRFITransit

•• Anorectal ManometryAnorectal Manometry•• Conventional Conventional •• HRAM HRAM •• 3-D HDAM3-D HDAM

•• Colonic manometryColonic manometry•• EMGEMG

•• PNLPNL•• TL and TSMSTL and TSMS•• BarostatBarostat•• EndoFLIPEndoFLIP•• EMGEMG•• CEPCEP

Pelvic Floor Structure Colonic Transit Time

Motor Function Neuro Sensory FUnction

•• Ultrasound (2-3D)Ultrasound (2-3D)•• MRIMRI•• DephecographyDephecography•• Barium proctogramBarium proctogram•• EndoscopyEndoscopy

•• Breath testBreath test•• Radiopaque markersRadiopaque markers•• Smart pillSmart pill•• GammagraphyGammagraphy•• RFITransitRFITransit

•• Anorectal ManometryAnorectal Manometry•• Conventional Conventional •• HRAM HRAM •• 3-D HDAM3-D HDAM

•• Colonic manometryColonic manometry•• EMGEMG

•• PNLPNL•• TL and TSMSTL and TSMS•• BarostatBarostat•• EndoFLIPEndoFLIP•• EMGEMG•• CEPCEP

Why ARM is important ?• Physiological evaluation of the two main functions of the

anorectum: – Preservation of continence and regulation of defecation.

1. Fecal incontinence

2. Constipation/ evacuatory dysfunction.

2. Facilitate biofeedback training.

2. Assess patients before intervention (e.g., as a prognostic indicator of continence prior to surgical pouch construction);

2. Objectively assess therapeutic efficacy.

Dinning P, Carrington E, Scott MS. Neurogastro and Motil 2015

t1/2: 0.7 – 1.2 h

1950 1960 1970 1980 1990 2000 2010

What is HR-ARM and 3-D HD-ARM

* Raizada et al Pelvic Floor Anatomy and Applied Physiology. Gastroenterol Clin North Am. 2008 September; 37(3): 493–vii.

IS

ES

Puborectalis

*

1. A high degree of asymmetry both axially and circumferentially

1. A more inferior position of the sphincter in the anterior compared to the posterior midline

1. The greatest contribution during squeeze was from the distal anterior canal (PR)

1. During squeeze, the posterior peak pressure in the anal canal moves cranially in relation to the anterior peak pressure.

Limitations of ARM

ü Lack of uniformity regarding equipment

ü Lack of standarization in protocol

ü Lack of normal valuesü What is normal ?ü What is dissynergia?ü Metrics developed in conventional

are not for HR and 3-D HDü Costs , fragilityü Clinical utility?

Limitations of ARM

ü Lack of uniformity regarding equipment

ü Lack of standarization in protocolsü Minimal standards. Rao et al. 2002

ü Lack of normal valuesü What is normal ?ü What is dissynergia?

ü Metrics developed in conventional are not for HR and 3-D HD

ü Clinical utility?

125 surveys, 30 different countries

53%47%

October 2014, Ascona, Switzerlandü To develop and promote internationally

accepted standards for the clinical measurement of anorectal physiology, with a particular focus on HR-ARM.

Limitations of ARM

ü Lack of uniformity regarding equipmentü Lack of standarization in protocols

ü Minimal standards. Rao et al. 2002

ü Lack of normal values, reproducibility?ü What is normal ?ü What is dissynergia?

ü Metrics developed in conventional are not for HR and 3-D HD

ü Clinical utility?

61 children  

(34 male; mean age, 8.28 years) 

Limitations of ARM

ü Lack of uniformity regarding equipment

ü Lack of standarization in protocolsü Minimal standards. Rao et al. 2002

ü Lack of normal valuesü What is normal ?ü What is dissynergia?

ü Metrics developed in conventional are not for HR and 3-D HD

ü Clinical utility?

100 FC Rome II(80 Female)

Type I Type II Type IIIRectal

Anal Anal Anal

Rectal Rectal

0 mm Hg

50

Rao SSC, et al. Neurogastroenterol Motil.2004;16:1-8.

Gastroenterol Clin North Am. 2008 Sep; 37(3): 569–586.

Three traditional parammeters unlikely to have diagnostic utility because wide vartiations in health

•Rectal push pressure•Anal residual pressure •Endurance of squeeze

Recto anal gradientDefecation index

Seated Evaluation of Anorectal Function By High Resolution Manometry: A Randomized Comparison of Measurements in the Seated and Left Lateral Positions.

Heinrich H, Reiner C, Parker H, et al . Oral Presentation 834,2016

HR-ARM and BET is affected by position, especially in DD patients. Comparison of HR-ARM with MRD suggests more accurate assessment of simulated defecation in the physiologic SP.

A Characterization of Dyssynergia Phenotypes With High Resolution Anorectal Manometry (HRAM).

Rao SS, Leelasinjaroen P, Amieva-Balmori M, et al. 771,2016

174 DD patients

1.Dyssynergia in 2 positions

1.Interobserver agreement

Dyssynergia pattern 85%

Dyssynergia pattern 65%

Normalize 27%

Kappa 0.8

62 HVFemale

295Female with CC

Normaln = 60

Abnormaln = 2

Normaln = 224

Abnormaln = 71

Proposed Phenotypes

6% 11%

Anal blockage

5% 13%

Present in CCNormal BET

Excessive strainingagainst high ARP

Inappropriate Abdominal contraction

Rectal sensorimotordysfunction

Unclear ?Structural

A Characterization of Dyssynergia Phenotypes With High Resolution Anorectal Manometry (HRAM).

Rao SS, Leelasinjaroen P, Amieva-Balmori M, et al. 771

D = Difuse P=Puborectal A= Anal sphincter

10%

Pitfalls for ARM

• Lack of uniformity regarding equipment• Lack of standarization in protocols

Minimal standards. Rao et al. 2002

• Lack of normal values• What is normal ? What is dissynergia?• Metrics developed in conventional are not

for HRM-3D HRM • Clinical utility?

New parammeters, New analysis for HRAM ?Post-relaxation cough reflexCarrington E et al .2014

Integrated pressurized volume (IPV)Jung KE et al .2014

Positive gradient and High band pressureHeinrich H et al .2014

Phenotipic classificationRatuapli et al .2014

Remes-Troche JM et al, DDW 2013

Novel parammetersRemes-Troche et al .DDW 2013

IPV ratioMion et al 201.7

Pitfalls for ARM• Lack of uniformity regarding equipment• Lack of standarization in protocols

Minimal standards. Rao et al. 2002

• Lack of normal values• What is normal ? What is dissynergia?• Metrics developed in conventional are not

for HRM-3D HRM • Clinical utility?

Clinical Utility

1. Color contour/ topography plots provide a dynamic and continuous representation of anorectal pressure information, which is both more visually arresting and intuitive compared to traditional line plots.

1. Anal sphincter defects can be mapped and readily detected using 3-D technology

1. HRAM study is ~12 min quicker than performing a traditional anorectal manometry study

188 patients with obstructive defecation

87 structural pathology

Lower resting pressure (p<0.003)Lower squeze pressure (p<0.011)

Higher rectoanal pressure gradient (p<0.0001)

24 patients with Intra-Anal Intussusception exhibit a unique pattern

30 HV 118 patients 51 CC, 48 FI, 19 RP

A PC logistic model discriminated between patients with and without prolapse with 96% accuracy.

Present in 21/26 (80%)PPV 100%, NPV 100%, S 69.2%

Anal Sphincter Integrity

Normal

HDMAUS

Abnormal

Squeeze

rest

EAS

IAS

rest

defectdefect

Squeeze

defectdefect

Rezaie A, Iriana S, Pimentel M, Murrell Z, Fleshner P, Zaghiyan K. Colorectal Dis 2016. DOI: 10.1111/codi.13530.

39 patients = 14 (36%) defects with 3D-HDAM

Sensitivity = 75%Specificity =74%

PPV = 43%NPV 92%

Prevalence of defects with 3D-HDAM = 22%

Sensitivity = 37.5%Specificity =100%

PPV = 100%NPV 44%

CONCLUSIONSüThe greater yield of anatomical and

functional information may supersede the limitations of costs, fragility, and shorter life-span associated with these new techniques.

üThus, HDAM and HRAM are not just new gadgets but constitute a significant and novel diagnostic advance.

üHowever, more prospective studies are needed to better define anorectal disorders with these techniques and to confirm their superiority.