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S1230

Characterization and Pathophysiologic Mechanisms of Anorectal Dysfunctionin Patients with Diabetes MellitusThomas Hester, Noemi A. Montes, Freya T. Hickey, Marc A. Gladman

Purpose: Gastrointestinal symptoms are frequently experienced by patients with diabetesmellitus (DM). A proportion of such patients report anorectal dysfunction, which is assumedto reflect neuropathy. As the prevalence of DM is increasing in Western populations, improvedunderstanding of the etiology of such symptoms is required. The aim of the present studywas to characterize clinical symptoms and pathophysiologic mechanisms in patients withDM referred for assessment of anorectal dysfunction. Methods: The study population com-prised 158 patients with DM (132 NIDDM,; 122 female; median age 62 years [range 23-87]), identified from a population of 3627 patients referred consecutively to a tertiary centrefor anorectal physiological investigation from 1997-2007. The control group consisted of159 non-diabetic, age and sex matched patients (123 female; median age 55 [range 22-83])who were investigated during the same period. All subjects underwent detailed symptomassessment and comprehensive physiologic investigation, including colonic transit studies /defecography, as indicated. Results: Patients with DM presented most commonly with fecalincontinence (46%), constipation (25%), and combined constipation and incontinence(17%). The corresponding percentages were similar in non-diabetic patients (35%, 34%and 18%, respectively; p=0.124). Anorectal manometry revealed that a significantly greaterproportion of patients with DM (47/158, 30%) had reduced anal squeeze pressures comparedto controls (25/159, 16%) (p=0.007), but anal resting pressures, rectal sensitivity, pudendalterminal motor latencies and the proportion of patients with anal sphincter defects onultrasound were similar between the groups. Colonic transit studies revealed delayed transitin a significantly smaller proportion of patients with DM (11/34, 32%) compared to controls(34/55, 62%) (p=0.009). Defecography was abnormal in a significantly greater proportion ofpatients with DM (86/93, 92%) compared to controls (100/123, 81%) (p=0.03). Conclusion:Diabetic patients experience similar symptoms of anorectal dysfunction to non-diabeticcontrols. Anorectal physiologic investigation did not reveal direct evidence of a sensorimotorneuropathy in such patients. However, reduced anal squeeze pressures and impaired rectalevacuation, but not delayed colonic transit, appear to be important mechanisms for thedevelopment of symptoms in diabetic patients. Directed therapies to address the underlyingpathophysiology may improve outcomes in the management of anorectal dysfunction inthese patients.

S1231

Levator Ani: What Is Left of Idiopathic Anal Incontinence?Christian Thomas, Isabelle Etienney

Anal incontinence (AI) is most often due to rupture of the internal and/or external sphincterand /or pudendal neuropathy. When these are not present, anal incontinence is said to beidiopathic. This classification however ignores a possible role of the the puborectal fasciculus(PR) of the levator ani, which is not always innervated by the pudendal nerve. The aim ofour study was to evaluate how far the puborectal fasciculus has an influence in patientssuffering from AI, either isolated or associated with urinary incontinence. 78 female patients,mean age 61.3 years [29.5-84.3], were investigated for isolated or mixed AI, between January2007 and June 2008, by the same two people working consecutively and using anorectalmanometry (ARM), three-dimensional endoanal ultrasound examination (3D echography),and concentric needle electromyography (EMG) of the PR muscles and the external analsphincter (EAS). The pudendal nerve motor terminal latencies (PNMTL) were determined.Defect and volume of the PR were evaluated by 3D echography. A Wexner index wascalculated for each patient. Damage to the PR was defined as the presence of an ultrasounddefect and/or an abnormal EMG of the PR. EMG of the PR was only performed in 73 femalepatients, including 71 bilaterally. The EMG revealed damage of the PR in 39 cases, whichwas isolated in 4 cases and associated with damage to the EAS in 35 patients. The frequencyof neurogenic damage increased with the number of EMG tests undertaken:unilateral orbilateral increase of PNMTL was found in 61% (44/77) of the cases. The frequency ofneurogenic AI increased to 86% (67/78) of the cases if one took into account the damageassociated with the EAS, and to 90% (70/78) of the cases if damage to the PR was considered.An echography fault was discovered in 23% (18/78) of the cases. It concerned the IAS, theEAS and the PR in 10, 9 and 3 cases respectively. The mean Wexner index score was notincreased by the existence of a damage of the PR nor by abnormal PR EMG. It was notincreased as a function of the number of childbirths nor by the existence of both anal andurinary incontinence. On the other hand, voluntary contraction evaluated by ARM wassignificantly reduced when the PR was damaged (26 vs 38 cm H2O p<0.05) and/or the ES(28 vs 39 cm H2O p<0.05) and the volume of the PR was also significantly reduced inthese circumstances (6.2 vs 7.2 cm3 p<0.05). Conclusion Exploration of the PR is basedon 3D echography and EMG examination; it allows the number of so-called idiopathic AIcases to be reduced. If it is not possible to undertake an EMG examination,the PR volumemay help predict damage to it.

A-218AGA Abstracts

S1232

Electrically Stimulated Gracilis Neosphincter Construction for End StageFaecal Incontinence: Evaluation of Long-Term Functional OutcomeChetan Bhan, Jamie Murphy, Derek J. Boyle, S Mark Scott, Norman S. Williams

Introduction: Electrically stimulated gracilis neosphincter (ESGN) construction is an estab-lished treatment for patients with end stage faecal incontinence who wish to avoid a permanentstoma. However, few data are available describing the long-term efficacy of this procedure.The aim of this study was to assess the functional outcome of patients who have undergoneESGN construction at the 2 and 10-year time points. Methods: 119 patients (median age42 [range 13-75]; 81F), with Williams' continence score ≥5 underwent ESGN constructionbetween 1988 and 1999. ESGN was performed for: traumatic childbirth (n=52), surgicaltrauma (n=23), atresia (n=20), anorectal excision (n=11), idiopathic incontinence (n=9), andileo-anal pouch incontinence (n=4). Symptomatic assessment by standardised questionnairespreoperatively was repeated following surgery, and at 2 and 10 years. Anorectal physiologicalinvestigation was also performed preoperatively and at 2 years. Results:119 patients consentedto immediate postoperative follow up; 117 consented at 2-years, while 57 patients consentedat 10-years. Continence improved for all patients postoperatively (median score - 2 [1-6];P < 0.0001) and at 2-years (score - 2 [1-6]; P < 0.0001). When assessing all patients, nosignificant difference was found between continence scores preoperatively and at 10-years(score - 4 [1-6]). However, a sustained improvement at 10-year follow up (score - 3 [1-6];P = 0.0013) was noted for patients in the surgical trauma group. 25/119 patients requiredfurther interventions (colonic conduit - 23; ACE - 2) for postoperative rectal evacuatorydisorder (RED). Postoperative RED was more common in patients undergoing ESGN con-struction for obstetric injury (P = 0.0079), with previous hysterectomy conferring additionalrisk (P = 0.013). Discussion: These data suggest that ESGN results in significant and sustainedsymptomatic improvement in both the short and medium term. However, long-term func-tional outcome is influenced by both the indication for surgery and preoperative state ofthe patient. Currently the effect of improvements in ESGN technique introduced after 1999are unknown. Nevertheless, the reported data support the continued use of this procedurein highly selected patients.

S1233

Anorectal Toxicity After High Dose 3D Conformal Radiotherapy for ProstateCancerAdeel A. Bajwa, Kumaran Thiruppathy, Paul Boulos, Anton V. Emmanuel

Introduction: Studies indicate that maximising radiotherapy dose improves outcomes inprostate cancer. Three-dimensional conformal radiotherapy (3DCRT) is a technique in whichthe profile of each radiation beam is shaped to fit the profile of the prostatic target theoreticallyreducing toxicity to the surrounding normal tissues and allowing a higher dose of radiationto be delivered to the tumour. We aimed to assess the anorectal toxicity after high dose3DCRT . Methods: 18 consecutive prostate cancer patients with no anorectal symptoms(Mean age 68.4, mean Wexner score 0) receiving 74 grays of 3DCRT for localised prostatecancer were recruited. Faecal incontinence scores, anal manometery, rectal distension thresh-olds, mucosal electrosensitivity, rectal mucosal blood flow and rectal elastance (barostat)were measured before and 4 months (mean follow up=18.5 weeks) after radiation. Data arepresented as mean (SD) pre- and post-treatment. Results: Mean post treatment Wexner scoreincreased to 2.6 (SD 2.1) with 13/18 (72%) patients developing new symptoms. There wasa significant reduction in anal canal resting pressure (72.2(22.7) v 64.7(22.7) cmH20,p=0.043) but not squeeze pressure (189.7(53.9) v 185.9(58.1) cmH20, p=0.36). Rectalelectrosensitivity, a measure of mucosal innervation, was attenuated (27.4(11.8) v 33.3(7.8)mA, p=0.028), with an increase seen in 8/13 (62%) of symptomatic patients. . Finally, meanrectal elastance increased significantly (0.046(0.026) v 0.067(0.023) mmHG/mL, p=0.003),with an increase seen in 10/13 (77%) of symptomatic patients. Conclusions: At 4 months,three-quarters of patients treated with high dose 3D conformal RT for prostate cancerdeveloped symptoms. This was associated with modest alterations in anal pressure and rectalsensation and elasticity, comparing favourably with traditional radiotherapy modalities.Longer term and larger studies are underway to compare this.

S1234

The Anal Band for Severe Faecal IncontinenceDave R. Chatoor, Anton V. Emmanuel, Richard Cohen, Mostafa Abdel-Halim, Stuart A.Taylor, Ulrich Baumgartner

Introduction For patients with severe faecal incontinence who fail conservative and minimallyinvasive treatments there is a need for salvage procedures. The previously available artificialbowel sphincter was plagued with infection, erosion, device malfunction and evacuationdifficulty. Our multicentre experience of a new device which has become available is reportedin this study. Methods 14 patients (10 female) with severe faecal incontinence were treatedin two specialised units; all failed optimum conservative treatment with biofeedback, 9 ofthese were deemed suitable for sacral nerve stimulation but failed this. As an alternative tostoma formation, these patients underwent implantation of a subcutaneous soft anal bandsystem. It is composed of a soft silicone band that encircles the anal sphincter, attached toa valve that controls bidirectional flow of fluid from the balloon implanted under the skinof the anterior abdominal wall, and a calibration port used for adjusting the fluid in thesystem. Results Mean patient age was 59 (39 -71), mean duration of follow up 13 months(3- 40). The aetiology of incontinence was post colorectal resection in 6 patients, obstetricin 4, scleroderma-related in 2, post-radiotherapy in 1 and spinal injury associated in 1. Selfreported quality of life improvement of 70-100% was reported in 7/14 patients, 30-70%improvement in 4/14 (no data was available in 3/14). Wexner incontinence scores improvedfrom a median of 16 (12-18) pre treatment to 2 (0-6) post operatively (P = 0.001). Complica-tions occurred in 7/14 patients: 5 had device-related problems requiring revisional procedures(repositioning in 2 and device failure in 3); 1 had chronic pain requiring explantation and1 had minor evacuation difficulty requiring regular suppositories. Of note there were noinfections or erosions. Conclusion This largest reported series of the new anal band device