Introduction

Following sphincter-preserving surgery for rectal cancer, many patients develop low anterior resection syndrome (LARS). Symptoms of LARS include fecal incontinence, urgency, frequent bowel movements, and incomplete evacuation. Treatment of these symptoms through anorectal biofeedback that focuses solely on anal sphincter function has shown limited benefits (Koifman et al.). This may be due to a relatively preserved sphincter function in these patients but a disruption in the anorectal apparatus as a working unit. Therefore, we hypothesize that a comprehensive anorectal biofeedback (cBF) program, which addresses both anal sphincter weakness and issues of recto-anal incoordination and rectal sensory abnormalities, may provide greater benefits for patients with LARS.

Aims & Methods

We aimed to evaluate the effectiveness of cBF in LARS patients. Consecutive LARS patients referred a tertiary referral centre were prospectively enrolled. Surgical clearance and rectal examination were required to rule out local complications (e.g., strictures), and anorectal manometry was performed in all patients. A physiotherapist, guided by a gastroenterologist, performed 4-6 cBF session using instrumental anal EMG and a rectal balloon (guided by ARM results and limited to 100 ml). Symptom severity, LARS scores and quality-of-life questionnaires were collected pre- and post-therapy, and at 6-month follow-up. Primary endpoints were end of treatment Clinical Global Impression (CGI) and improvement in LARS scores.

Results

22 patients (median age 59, IQR 53-69; 68% male) were included. Median time from ileostomy closure was 12 months (IQR 6.0-33.0). Median baseline LARS score was 36 (IQR 34-41). Most patients completed 4 cBF sessions (73%), the remainder completed 6 (27%). Baseline ARM showed median maximum resting pressure of 91 mmHg (IQR 77-115) and squeeze pressure of 200 mmHg (IQR 139-255), indicating relatively preserved sphincter function. Post-cBF, the median LARS score improved to 29 (IQR 19-39), with a median within-patient change of -11 (IQR -19 to -6; p=0.002). CGI ratings indicated 73% of patients as "improved," 18% "minimally improved," and 9% reported "no change."

Conclusion

cBF appears effective for LARS, at least in the short term. Addressing recto-anal incoordination and sensory abnormalities may provide additional benefit, even in patients with preserved sphincter function. These findings suggest integrating physician supervised ARM-guided cBF into multidisciplinary care for post-LAR patients may be of importance.

References

1. Koifman E, et al. Long-term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer. BMC Gastroenterol. 2024;24(1):31.

Introduction

High-resolution colonic manometry (HRCM) is the gold standard for measuring colonic contractility and guiding decisions for subtotal colectomy in refractory slow-transit constipation (STC). However, it is only available in a handful of centers worldwide. Body surface colonic mapping (BSCM) is a recently validated technology that allows for easy-to-apply and non-invasive transcutaneous evaluation of pre- and post-prandial colonic motility, and has shown strong correlation with HRCM.

Aims & Methods

We sought to evaluate pre- and post-prandial colonic activity using BSCM in patients with refractory STC and correlate with real-time symptoms.
We applied BSCM to refractory chronic constipation patients while undergoing standard diagnostic HRCM. After bowel prep and an overnight fast a HRCM catheter (36 sensors, 3 cm spacing) was advanced and clipped to the caecum. Two BSCM electrode arrays (each 8x8 sensors, 2 cm spacing, Alimetry) were placed on the abdomen after skin prep. Simultaneous HRCM and BSCM recordings were obtained during a 1-hour fasting period, 1 hour after a standardized low-fat meal, and 1 hour after luminally applied 10 mg of bisacodyl. BSCM electrical recordings were band-pass filtered to isolate colonic cyclic motor patterns (CMPs) of 4-10 cycles per minute. The BSCM motility index (MI) was computed from the global continuous wavelet transform spectrum and compared to a real-time symptom score (1-10 scale). Meal response was quantified based on the fasted-fed ratio (FFR) and response time (RT), a marked rise in MI relative to mealtime. Symptoms were recorded for 15 min. during 3,5h.

Results

A total of 9 patients with refractory STC (mean age 45, range 27-60, 22% male) were enrolled. BSCM MI correlated with bloating in 6 subjects, whereof strongly in 2 subjects (R= 0.53 and 0.74). Abdominal discomfort was even correlated to the BSCM MI in 8 subjects, whereof strongly in 2 (R0.74 and 0.79). Flatulence was only reported by 6 subjects and correlated to the BCSM MI in 4 of them, of which 2 strongly (Rs=0.67). While the desire to defecate was correlated with BSCM MI in 6 subjects, the urge to defecate was in 5. However, in both symptoms, there was a strong correlation in 3 subjects (R between 0.69-0.85). These symptoms were mainly provoked by the administration of bisacodyl, followed by strong colonic contractions. Lastly, BSCM MI correlated well with stomach ache symptoms in 6 subjects, of which 2 strongly (R=0.74 and 0.84). Overall symptom burden was strongly correlated with BSCM MI in 3 subjects (R between 0.61-0.8). One subject had clear increases in symptoms, while the colonic activity was low, whereas another subject had an almost perfect correlation between the two. The other subjects had an overall average correlation between symptoms and colonic motility.

Conclusion

BSCM is an easy-to-apply, painless, non-invasive tool that has the potential to elucidate underlying mechanisms driving symptoms in patients with refractory STC. Relating colonic motility to symptoms could aid in developing a more personalized approach to manage these patients' clinical treatment pathway

Introduction

The treatment of esophageal motor disorders (EMD) has historically been focused on decreasing pressure at the gastro-esophageal junction (GEJ) by disrupting muscular fibers at this level. The classic management through dilatation, botulinum toxin injection, and Heller's myotomy (HM) underwent a revolution with the advent of third-space endoscopy, offering safe access to the submucosal space and enabling peroral endoscopic myotomy (POEM).
In this prospective national multicenter study, the results of the implementation period of this technique in Spain from 2016 to the present are analyzed, examining its short, medium, and long-term outcomes. Furthermore, outcomes based on EMD, previous treatments, and other multiple variables are also investigated.

Aims & Methods

The primary aim of this study was to ascertain the clinical efficacy of POEM.
Secondary objectives included the identification of predictors of clinical success and the measurement of the incidence of post-POEM GERD and significant complications, as well as the determination of the risk factors for complications
This is a prospective multicenter study conducted across 13 hospitals in Spain. Symptomatic patients undergoing POEM for any EMD were recruited between June 2016 and February 2023. Baseline characteristics, procedural details and outcomes related to efficacy and safety during short and long-term follow-up were analyzed.

Results

A total of 441 patients were enrolled, with type II achalasia representing the most common diagnosis (62.1%). POEM was the primary treatment in 277 patients (62.8%). Clinical success data were available for 396 patients, with a success rate of 94.4% at the last available follow-up (2 years in 117 patients, 1 year in 140, <1 year in 139). A higher baseline Eckardt score was an independent risk factor for clinical failure in the long-term follow-up (p = 0.024). Symptomatic reflux occurred in 4.7% of the patients, with a significant esophagitis rate of 10.1%. Complication incidence was 9.3% (41/441), including 14 (3.2%) severe events. Older age (p = 0.025) and total procedure duration (p=0.036) were independent risk factors for complications, while mucosal injury was found to be a predictor of severe complications (p = 0.027).

Conclusion

These findings confirm the clinical efficacy and safety during the implementation phase of POEM for all EMD in Spain.

Introduction

Anti-reflux surgery is a treatment option for patients with gastroesophageal reflux disease (GERD) in which medical therapy has failed, is not tolerated, or is not desired. Conventional surgical interventions have well-known sequelae non grata, such as postoperative dysphagia, possibly more severe in subjects with ineffective esophageal motility (IEM), and hiatal hernia (HH) recurrence, for which a large HH (>3 cm) at baseline is a risk factor.^1-3 These real-world disease features complicate optimal treatment. RefluxStop is an emerging technology that treats GERD without encircling the lower esophagus (avoiding dysphagia) and acts as a mechanical stop preventing re-herniation.⁴ This study aims to present 12-month outcomes of the first 100 patients at our center in Switzerland.

Aims & Methods

A retrospective analysis of the first 100 patients (June 2020-December 2023) that underwent RefluxStop surgery with 12-month follow-up. Clinical outcomes included GERD Health-Related Quality of Life (GERD-HRQL) scores, patient satisfaction, proton pump inhibitor (PPI) use, and postoperative adverse outcomes.

Results

Patient characteristics are shown in Table 1. Median (IQR) total GERD-HRQL score (0-75) decreased from 41 (28.75-50) at baseline to 1 (0-5) at 12 months (p<.001) with patient satisfaction fulfilled in 92% after surgery. Non-reliance on PPIs increased from 5% at baseline to 92% at follow-up. One case of early device penetration (1%) occurred likely from overly tight closure of the invagination pouch, without action required, an outcome attributed to the learning curve of a new procedure. The device is designed to disassociate into its five components and pass uneventfully through the digestive tract. One dislocation (1%) occurred from improper closure of the deployment tool channel (i.e., surgical error). Three cases of re-do hiatus repair (3%) occurred in patients with very large HH (>7 cm) at baseline, where even the large fundic package (~4 cm) with the invaginated device is not sufficient to prevent recurrence in the case of total hiatus repair collapse.

Table 1. Baseline clinical characteristics

Conclusion

RefluxStop showed excellent 12-month results in the treatment of GERD despite the inclusion of difficult-to-treat patients with esophageal dysmotility (66%) and large HH >3 cm in size (55%). Quality of life (i.e., GERD-HRQL) substantially improved by 97.6% from score 41 to 1, with minimal adverse effects. This data contributes to the growing body of evidence supporting the benefits of RefluxStop in the surgical treatment of GERD patients.

References

1. Baison GN, Jackson AS, Wilshire CL, et al. The Impact of Ineffective Esophageal Motility on Patients Undergoing Magnetic Sphincter Augmentation. Ann Surg. 2023;277(4):e793-e800.
2. Hasak S, Brunt LM, Wang D, Gyawali CP. Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia. Clin Gastroenterol Hepatol. 2019;17(10):1982-90.
3. Armijo PR, Pokala B, Misfeldt M, et al. Predictors of Hiatal Hernia Recurrence After Laparoscopic Anti-reflux Surgery with Hiatal Hernia Repair: a Prospective Database Analysis. J Gastrointest Surg. 2019;23(4):696-701.
4. Bonavina L. Individualizing surgical therapy for gastroesophageal reflux disease. Curr Opin Gastroenterol. 2025.

Disclosure

Ioannis Linas and Joerg Zehetner are consultants for Implantica (producer of the RefluxStop device).

Introduction

Lower gastrointestinal (GI) disorders of gut-brain interaction (DGBIs) - including irritable bowel syndrome (IBS), chronic constipation, and faecal incontinence - are highly prevalent conditions that significantly affect patients' quality of life. These disorders often present with complex and overlapping symptomatology, necessitating a nuanced understanding of each patient's unique symptom profile to provide the best chance of treatment success. Furthermore, a significant proportion have psychological comorbidities, and a history of psychological trauma is common. Consequently, eliciting a comprehensive clinical history from these patients can be challenging, and requires significant skill and sensitivity. Despite this, formal training in the clinical assessment of these patients is rare in training programs throughout the UK and Europe.

Aims & Methods

This study aimed to investigate the self-reported confidence of gastroenterologists and colorectal surgeons in obtaining comprehensive histories from patients with lower GI DGBIs, identify potential barriers to their confidence and understand their training needs. A cross-sectional survey comprising 12 questions was distributed online using the Qualtrics platform to UK gastroenterologists and colorectal surgeons between March-April 2025. The survey explored clinician demographics, confidence levels in aspects of history taking as well as perceived barriers to confidence and preferred training modalities. Confidence was rated on a 1-10 scale. Participant responses were collected anonymously.

Results

Out of 73 survey responses, 50 were included in the analysis after excluding 23 incomplete submissions. The cohort comprised 29 (58%) colorectal surgeons and 21 (42%) gastroenterologists, primarily consisting of resident doctors (93%) with a minority being post-CCT participants (7%).
Overall, reported confidence in history taking increased with training progression, demonstrating a median self-reported confidence level of 7 during specialty training and 10 at the post-CCT/attending level (T-test, p<0. 0001). Specific confidence ratings for ‘trauma/abuse history’ and ‘psychological co-morbidities’ were notably lower, with medians of 5 and 6, respectively, highlighting significant gaps (ANOVA, p<0. 0001) compared to other areas such as ‘toileting habits’ and ‘pain history’.
The major barriers to confidence included a lack of training (58%) and experience (50%), followed by concerns regarding the management of sensitive information (26%) and difficulties in discussing these topics with patients from different genders/social backgrounds (18%). Less than half (38%) reported receiving any form of training in history taking, and among those, only 47% received training from their institution. Notably, 83% of participants expressed a desire for additional training, with the majority (76%) preferring to receive this from their training providers.

Conclusion

As GI clinicians progress through their medical career, their confidence in conducting histories from patients with lower GI DGBIs increases. However, confidence is lacking when enquiring about psychological factors, in particular a history of trauma or abuse. Enhancing the competence of doctors in this area early is likely to foster confidence and improve patient outcomes in this field.

Introduction

Rectal sensitivity is most frequently assessed by elastic balloon distension to a maximum tolerated volume, as determined by the patient. In clinical practice, some of the more commonly used systems to assess rectal sensitivity include the Laborie water-perfused manometry system (LWP, balloon volume 400mL) and the Medtronic solid-state 3D manometry system (MSS, balloon volume 400mL). There are no studies that compare diagnostic yield, as defined by the London Classification^[1], from these two independent systems.

Aims & Methods

This retrospective service evaluation investigates whether the proportion of diagnostic yield for disorders of rectal sensation differed between two commonly utilised rectal sensitivity measurement methods.
Rectal sensitivity data was collected from 200 patients at the same hospital site, with 100 consecutive patients undergoing rectal sensitivity testing with the LWP system and 100 consecutive patients assessed with the MSS system. Standard investigative protocols were followed, and balloon inflation rate was 2mL/s for both systems^[1]. Reference ranges for each system were based on published studies^[2-3]. The elastic balloon volume (mL) at each sensory threshold (first sensation volume, desire to defecate volume, and sustained urgency volume), diagnosis of disorders of rectal sensation according to the London Classification, and patient reported predominant symptom was assessed (urgency +/-incontinence, passive incontinence, obstructive defecation syndrome (ODS)/constipation, or anal pain).

Results

In total, rectal sensitivity data from 200 patients was collected (LWP: 100 patients 90F, MSS: 100 patients 91F), and there were no significant differences between sex per cohort (p=1.00). There were no significant differences in the proportions of patient reported predominant symptom per cohort: urgency +/-incontinence (41 LWP, 42 MSS), passive incontinence (23 LWP, 23 MSS), ODS/constipation (33 LWP, 31 MSS), and anal pain (3 LWP, 4 MSS), (p=0.99).
There were significant differences in the proportions of London Classification diagnoses obtained between the two systems: rectal hypersensitivity (9 LWP, 64 MSS), rectal hyposensitivity (3 LWP, 26 MSS), borderline rectal hyposensitivity (5 LWP, 4 MSS), rectal hypersensitivity and rectal hyposensitivity (0 LWP, 4MSS), no disorder of rectal sensation (83 LWP, 2 MSS) (p<0.001).

Conclusion

Despite there being similar patient cohorts in relation to proportions of sex and predominant bowel symptom, there was a significant difference in diagnoses based on London Classifications obtained by the LWP and MSS systems. A large proportion of patients tested using the LWP system had no disorder of rectal sensation, conversely the MSS system reported a much larger proportion of patients with rectal hypersensitivity. As most patients reported urgency +/- incontinence as their predominant symptom, it is plausible that rectal hypersensitivity is a common finding in this patient cohort.
The diagnostic accuracy of the London Classification is likely dependant on the system used and the available published reference values. Accurate assessment of rectal sensitivity can be valuable in guiding effective management of patients with rectal sensitivity disorder. Thus, this data indicates comparative studies using different systems to reduce discrepancies of diagnoses are required to improve clinical management^[4].

References

[1] Carrington, E.V. et al. Expert consensus document: Advances in the evaluation of anorectal function. Nature Reviews Gastroenterology and Hepatology. 2018. 15(5): p309-323.
[2] Mion, F. et al. 3D High-definition anorectal manometry: Values obtained in asymptomatic volunteers, fecal incontinence and chronic constipation. Results of a prospective multicenter study (NOMAD). Neurogastroenterol Motil. 2017 Aug;29(8).
[3] Townsend, D.C. et al. Pathophysiology of fecal incontinence differs between men and women: a case-matched study in 200 patients. Neurogastroenterol Motil. 2016 Oct;28(10):1580-8.
[4] Chiarioni, G. et al. Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence. American Journal of Gastroenterology. 2002. 97(1): p109-117.

Introduction

Aging is associated with physiological changes in esophageal function, influencing motility and increasing susceptibility to dysphagia.

Aims & Methods

This study investigates esophageal peristaltic reserve across different age groups by employing multiple rapid swallow (MRS) during high-resolution manometry (HRM). A retrospective analysis was conducted on 331 patients presenting with dysphagia who underwent HRM between 2021 and 2023. Participants were stratified into four age groups: early adulthood (≤34 years, 12.1%), early middle-age (35–49 years, 12.7%), late middle-age (50–64 years, 45.3%), and late adulthood (≥65 years, 29.9%). Peristaltic reserve was assessed using MRS to evaluate esophageal contractile function.

Results

Among the 311 patients included, 195 (58.9%) were male, with a median age of 57 years (IQR 45–66). The prevalence of normal esophageal motility was highest in early adulthood (67.5%) and early middle-age (78.6%) but declined significantly in late middle-age (48.7%; p=0.014) and late adulthood (44.4%; p<0.001). Late adulthood was also characterized by lower median upper esophageal sphincter (UES) pressure (101 mmHg) and reduced UES length (3 cm; p<0.05). Additionally, esophagogastric junction (EGJ) type II and III morphology was more frequently observed in late adulthood (52.5%; p<0.05). In patients with normal motility (n=177), MRS motor wave transmission was lower in late adulthood (75%, p<0.05) compared to early adulthood (96.3%), early middle age (88.1%) and late middle age (93.2%), and the prevalence of incomplete MRS inhibition was higher in late adulthood (79.5%, p<0.05) compared to early adulthood (11.1%), early middle age (21.2%) and late middle age (46.6%). The DCI-MRS and DCI wet ratio were significantly lower in late adulthood (0.51, IQR 0.13 – 0.88; p<0.01).

Conclusion

Peristaltic reserve declines with advancing age, which may contribute to dysphagia. MRS proves to be a useful diagnostic tool for detecting subtle motility impairments related to aging.