E0363 - Anorectal Manometry Protocols and Biofeedback Outcomes Vary for Patients With Ileal Pouch-Anal Anastomosis

Tuesday, October 25, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Natalia Schmidt, MD

Icahn School of Medicine at Mount Sinai
New York, NY

Natalia Schmidt, MD, Yuying Luo, MD, Barry Jaffin, MD, Maia Kayal, MD, MS
Icahn School of Medicine at Mount Sinai, New York, NY

Introduction: Ileal pouch-anal anastomosis (IPAA) is commonly performed for patients with inflammatory bowel disease (IBD) requiring a total proctocolectomy (TPC). Emerging data suggests functional and evacuation disorders post-IPAA are common. The utility and role of anorectal manometry and biofeedback for patients with IPAA remain unclear. We aim to evaluate the role of ARM in diagnosing pouch evacuation disorders and efficacy of biofeedback.

Methods: We conducted a retrospective qualitative review of UC or IBD unspecified adult patients who underwent TPC with IPAA for refractory disease or dysplasia between 2008 and 2018 followed at one tertiary academic center. Demographics, clinical parameters and outcomes were collected in a REDCap database. Of the 794 patients with IPAA, 19 patients completed anorectal manometry at five centers.

Results: Our study included 19 patients (52.6% males) with an average age of 38.5 ± 14.5 years (standard deviation, SD) at time of ARM, an average of 3.6 ± 2.1 years after the final stage of IPAA. Seven patients had a history of pouch complications requiring pouch revision (36.8%). Five patients carried a diagnosis of pouchitis at the time of ARM (26.3%). The indications for completing ARM were incomplete defecation (47.4%), dyschezia (26.3%), diarrhea (15.8%), fecal incontinence (10.5%).

ARM continuous parameters were not pooled given different manometry systems and protocols. 47.3% patients completed balloon expulsion tests (BET) at time of ARM (66.7% of which were abnormal). 52.6% patients were ultimately found to have pouchitis or mucosal changes on subsequent pouchoscopy (n=5) or structural etiologies on MRI defecography (n=5) which were thought to account for their defecatory symptoms. The recto-anal inhibitory reflex (RAIR) was absent in four patients (21.1%). Ten patients were recommended for biofeedback; of the eight patients who started biofeedback, only three completed biofeedback with significant subjective patient-reported improvement in symptoms (none with IPAA revisions) including one patient without a RAIR. Three of the eight patients stopped biofeedback because of no improvement.

Discussion: Consensus guidelines are needed for positioning of ARM and MRI defecography for evaluation of defecatory symptoms post-IPAA as well as standardization of ARM protocol. The role of biofeedback in IPAA evacuatory disorders requires further investigation as well as validated criteria to assess improvement.

Patient #	Sex	Age at ARM	IPAA Revision?	Indication	BET	Defecography	Opioid Use within 30 days of ARM	RAIR present?	ARM Findings	Biofeedback Response
1	M	64	Yes	Incomplete evacuation	-	-	Yes	Yes	Hyposensitive pouch, inability to completely relax.	2 sessions, no improvement
2	M	43	No	Dyschezia	-	-	Yes	Yes	High resting tone. No paradoxical contraction during evacuation	Not explicitly recommended
3	F	58	No	Fecal Incontinence	-	-	Yes	Absent	Hyposensitive pouch. Slight paradoxical contraction on evacuation	Completed, no improvement
4	F	56	No	Fecal Incontinence	-	-	-	-	Low resting tone, squeeze and push. No paradoxical contraction	Not explicitly recommended
5	M	21	No	Incomplete evacuation	Abnormal	Abnormal	-	Yes	Hypertonic sphincter. No paradoxical contraction during evacuation	Completed, significant improvement
6	F	36	Yes	Incomplete evacuation	-	-	Yes	Yes	Abnormal sensation. No paradoxical contraction during evacuation	Not explicitly recommended
7	M	32	No	Dyschezia	-	-	Yes	Absent	Spontaneous spasms of puborectalis. Paradoxical contraction during evacuation	Not explicitly recommended
8	M	22	No	Incomplete evacuation	Normal	Normal	-	Yes	No paradoxical contraction during evacuation	Not explicitly recommended
9	F	39	Yes	Dyschezia	Abnormal	-	Yes	Yes	No paradoxical contraction during evacuation	Completed, incomplete relief
10	F	63	No	Diarrhea	Normal	-	Yes	Yes	No paradoxical contraction during evacuation	Not explicitly recommended
11	M	32	Yes	Diarrhea	Abnormal	Normal	-	Yes	Paradoxical contraction during evacuation	Not explicitly recommended
12	M	20	Yes	Incomplete evacuation	-	-	-	Yes	Hyposensitive rectum. No paradoxical contraction during evacuation	Not explicitly recommended
13	F	35	No	Dyschezia	Normal	Normal	-	Yes	No paradoxical contraction during evacuation	Completed, incomplete relief
14	M	41	Yes	Diarrhea	Abnormal	-	-	Yes	Paradoxical contraction during evacuation	Not explicitly recommended
15	F	43	No	Incomplete evacuation	-	Abnormal	-	Yes	Mild paradoxical contraction evacuation	"Limited trial" with no improvement
16	F	23	Yes	Incomplete evacuation	-	Normal	Yes	Yes	Inadequate relaxation during evacuation	Recommended, not performed
17	M	34	No	Incomplete evacuation	Abnormal	-	-	Absent	Paradoxical contraction during evacuation	Completed, significant improvement
18	M	19	No	Dyschezia	-	Abnormal	-	Yes	Hyposensitive rectum. Paradoxical contraction during evacuation	Recommended, not performed
19	F	50	Yes	Incomplete evacuation	Abnormal	Normal	Yes	Absent	Paradoxical contraction during evacuation	5 sessions, with minimal improvement

Table: Table 1. Patient Characteristics and Anorectal Manometry Findings

(Key: M, Male. F, Female. ARM, Anorectal Manometry. RAIR, IPAA, Ileal Pouch-Anal Anastomosis. BET, balloon expulsion test.)

Disclosures:

Natalia Schmidt indicated no relevant financial relationships.

Yuying Luo indicated no relevant financial relationships.

Barry Jaffin indicated no relevant financial relationships.

Maia Kayal indicated no relevant financial relationships.

Natalia Schmidt, MD, Yuying Luo, MD, Barry Jaffin, MD, Maia Kayal, MD, MS. E0363 - Anorectal Manometry Protocols and Biofeedback Outcomes Vary for Patients With Ileal Pouch-Anal Anastomosis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.