2. The M.F.A.: a new device for an early selection of patients. Piercarlo Meinero M.D. pp

3. Proctological visit for minor pathologies Positive anamnesis Other exames Negative anamnesis Routine exames Surgical treatment Critical point

4. What are the critical points of the proctological examination today? We can only detect the morphological aspects of the anus and the rectum but not their functionality. We can only detect the morphological aspects of the anus and the rectum but not their functionality. At present, a device does not exist that, already at the first visit, allows us to supect the presence of attendant diseases and also to predict postoperatory complications. At present, a device does not exist that, already at the first visit, allows us to supect the presence of attendant diseases and also to predict postoperatory complications. Guidelines do not exist that provide for the anorectal manometry in patients with minor diseases (mucosal rectal prolaps and/or haemorrhoids). Guidelines do not exist that provide for the anorectal manometry in patients with minor diseases (mucosal rectal prolaps and/or haemorrhoids).

5. The Meinero Multi-Functional Anoscope (MFA ) pp It doesnt replace manometryIt doesnt replace manometry Between nothing and manometryBetween nothing and manometry It tests anorectal functionalityIt tests anorectal functionality Early patients selectionEarly patients selection Its easy and fast to useIts easy and fast to use

6. MFA functions 1)Rectal Sensation Test (RST) 2)Balloon Expulsion Test (BET) 3)Extent of Prolapse Assessment (EPA) 4)Length Measurement of the Anal Canal (LMAC) pp

7. FS First Sensation DDV Defecatory Desire Volume MTV Maximum Tolerable Volume FS First Sensation DDV Defecatory Desire Volume MTV Maximum Tolerable Volume The same procedure like the manometry 1) Rectal Sensation Test (RST)

8. RST with the MFA: the method 1 3 4 2

9. Rectal sensitivity thresholds Rectal sensitivity alterations HYPOSENSITIVITY FS > 60 DDV > 160 MTV > 270 FS < 30 DDV < 60 MTV < 160 HYPERSENSITIVITY FS 30 - 60 DDV 60 - 160 MTV 160 - 270 NORMAL VALUES

10. The RST is important because… First visit Hypersensitivity Hyposensitivity External sphincter disfuncions IBD Faecal incontinence (FI e UFI) Pudendal neuropathy ODS Idiopatic Faecal Incontinence (IFI) Puborectalis Syndrome, Dissynergy Solitary Ulcer- Megarectum. Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S., F.R.C.S., Peter J. Lunniss, M.S., F.R.C.S.: Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable Constipation and Fecal Incontinence D.C.R. 2003 Vol.46, N° 2:238-246. Christopher L.H. Chan, F.R.C.S., S. Mark Scott, Ph.D., Norman S. Williams, F.R.C.S., Peter J. Lunnis, F.R.C.S. Rectal Hypersensitivity Worsens Stool Frequency, Urgency and Lifestyle in Patients With Urge Fecal Incontinence. D.C.R. 2005 Vol. 48, N°1: 134-140. Normal

11. RST: the references M.D. Crowell, Ph.D., B.E.Lacy, M.D., Ph.D., V.A. Schettler, B.S.N., T.N. Dineen, M.D., K.W.Olden, M.D., N.J. Talley, M.D., Ph.D.: Subtypes of Anal Incontinence Associated With Bowel Dysfunction: Clinical, Physiologic, and Psychosocial Characterization. D.C.R. 2004 Vol. 47 N° 10 : 1627-1635. M.J. Gosselink, M.D., Ph.D., W.R. Schouten, M.D., Ph.D.: Rectal Sensory Perception in Females with Obstructed Defecation. D.C.R.2001 Vol. 44 N° 9: 1337-1344. Paul Broens, M.D., Dirk Vanbeckevoort, M.D., Erwin Bellon, M.Sc., freddy Penninckx, M.D., Ph.D.: Combined Radiologic and Manometric Study of Rectal Filling Sensation. D.C.R. 2002 Vol. 45 N° 8: 1016-1022. Gloria Lacima, M.D., Miguel Pera, M.D., Josep Valls-Solé, M.D., Xavier Gonzales-Argenté, M.D., Montserrat Puig- Clota, M.D.: Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A prospective Study. D.C.R. 2006 Vol. 49 N° 3: 353-359. Tetsuo Yamana, M.D., Masatoshi Oya, M.D., Junji Komatsu, M.D., Yasuo Takase, M.D., Noboru Mikuni, M.D., Hiroshi Ishikawa, M.D.: Preoperative Anal Sphincter High Pressure Zone, Maximum Tolerable Volume and Anal Mucosal Electrosensitivity Predict Early Postoperative Defecatory Function After Low Anterior Resection for Rectal Cancer. D.C.R. 1999 Vol.42 N° 9: 1145-1151. Emanuel Chrysos, M.D., Ph.D., Elias Athanasakis, M.D., John Tsiaoussis, M.D., Ph.D., Odysseas Zoras, M.D., Ph.D., Antonios Nickolopoulos, M.D., Joho Sophocles Vassilakis, M.D., Ph.D., Evaghelos Xynos, M.D., Ph.D., F.A.C.S.:Rectoanal Motility in Crohns Disease Patients. D.C.R. 2001 Vol.44, N° 10: 1509-1513.

12. 2) Balloon Expulsion Test by MFA (BET) 60 cc of air – Sitting position – Maximum Expulsion Time 60 sec.

13. Without the anoscope Without the anoscope 150-160 cc of air 150-160 cc of air Traction during the squeeze Traction during the squeeze Perineal information Perineal information Vaginal exploration Vaginal exploration 3) Extent of Prolapse Assessment (EPA)

14. It is possible thanks to graduated scale in centimeters. Useful in case of operation for faecal incontinence. It can predict the biofeedback failure in the cases of anismus. Poong-Lyul Rhee, M.D., Moon Seok Choi, M.D., Young Ho Kim, M.D., Hee Jung Son, M.D., Jae Jun Kim, M.D., Kwang Cheol Koh, M.D., Seung Woon Paik, M.D., Jong Chul Rhee, M.D., Kyoo Wan Choi, M.D.: An Increased Rectal Maximum Tolerable Volume and Long Anal Canal Are Associated with Poor Short-Term Response to Biofeedback Therapy for patients with Anismus with Decreased Bowel Frequency and Normal Colonic Transit Time. D.C.R. 2000 Vol. 43 N° 10: 1405-1411. 4) Length Measurement of the Anal Canal (LMAC)

15. My own study: 218 patients Jan. 2006 / Sept. 2008 The rectal sensitivity thresholds are the same with MFA and anorectal manometry.The rectal sensitivity thresholds are the same with MFA and anorectal manometry. The RST alterated values, detected with the MFA during the first visit, could be an expression of attendant diseases and they could predict post- operatory complications.The RST alterated values, detected with the MFA during the first visit, could be an expression of attendant diseases and they could predict post- operatory complications. To demostrate that: 189 patients: 128 PMRE; 61 ODS

16. FSDDV MTV First aim. The correlation on the three parameters related to the measures detected with MFA and manometry, is very high (R= Pearsons correlation coefficient). By Biostatistic Unit of tha Genova University – Doctor Mariapia Sormani. Rectal sensitivity thresholds are the same if detected with MFA or anorectal manometry (R = 0,99 p<0,001).

17. Identification of patients with hyper or hyposensitivity Total RST

18. Diagnostic Assessment (US, EMG, PNTML, Defecography, Coloscopy, Manovolumetry) 30 patients with hypersensitivity 6 females and 1 male with EAS disfunctions (23.3%) 1 male with RCU (3.3%)* 3 males and 7 fimales with MII (33.3%) 1 fimale with celiac disease (3.3%)* 47 patients with hyposensitivity 9 females with IRA+RA+ slow transit costipation (19.1%) 1 male with slow transit costipation (2.1%) 17 females with IRA+RA (36.1 %) 5 males and 3 females with puborectalis syndrome (17%) 1 female with faecal incontinences (gas and liquid stools) (2.1%) 1 female with both constipation and faecal incontinence (2.1%) 1 female only with rectocele (2.1%) 2 females only with IRA (4.25%)

19. Surgical treatment selection of the 189 patients of the first group Operated patients DiseaseN°OperationNormalsHyper.Hypo PMRE 123 Prolassectomy82 2615 ODS 43 S.T.A.R.R.22 318

20. Complication: the urgency (DU) Temporary (TU) Permanent (PU) Severe (SU) UD that resolves itself within three weeks without consequences that continues up to three months but also resolves itself without consequences that lasts more than three months and shows itself in an increase of the daily evacuations but the urgency decreases or disappears completely.

21. There is an important correlation between hypersensitivity and Permanent Urgency (p=0.02), between hypersensitivity and Severe Urgency (p=0.01) and not so important between hypersensitivity and Temporary Urgency (p=0.07). As a whole the correlation between Hypersensitivity and Urgency is asbolutely significant (p> 0,001) OR: Odds Ratio CI: Confidential Interval OR correlation between rectal hypersensitivity and Urgency Pre-op. RSTPatientsTUPUSUDU OR (95% CI) Not hyper971 (ref) Hyper26 4.8 (0.9-26.2) 10.1 (1.4-71.3) 20.6 (1.8-226.2) 64.5 (6.9-603.2) p value0.070.020.01<0.001

22. MFA Test RSTBET (60 cc) cc airv.n.ResultMETETn.v. FS30-60Hyper< 60 sec DDV60-160NormalBET result MTV160-270Hypo EPALMAC ExaminationOperating TheatrecmRisult SNSConsensusMTV Suspect: Other exams: Diagnosis: +- MFA test plan

23. Conclusions To perform Rectal Sensation Test in case of minor pathologies, too;To perform Rectal Sensation Test in case of minor pathologies, too; To suspect attendant diseases;To suspect attendant diseases; To foresee postoperatory complications;To foresee postoperatory complications; To avoid hurried surgical decisions;To avoid hurried surgical decisions; To assess the correct prolapse extent;To assess the correct prolapse extent; To foresee biofeedback results.To foresee biofeedback results. The use of the MFA at the first proctological visit allows:

24. MFA COURSES If you are interested in attending such courses please get in touch with the Sapi-Med stand.

25. My Family

26. Thank you all for your attention.