Use of biofeedback ( BFB ) in the treatment of fecal incontinence after surgi cal correction of anorectal malformations by posterior sagital anorectoplasty

Objective: To evaluate biofeedback(BFB)responses to rehabilitation techniques and physical exercises in incontinent or partially continent anorectal malformations patients after posterior sagital anorectoplasty (PSARP). Design: Prospective study. Setting: Pediatric Surgery Department of Surgery UNIFESP-EPM. Patients:The authors report on 14 patients with anorectal malformations (4 with partial fecal incontinence after primary PSARP; 6 with fecal incontinence after primary PSARP; 3 with partia' fecal incontinence after secondary PSARP; and 1 with fecal incontinence after secondary PSARP). Ali patients were rehabilitated via a BFB program of exercises in order to improve the function of the anal sphincteric muscular complex for a period of 1-3 years. Main outcome measure: Clinicai and manometric controlo Results: After BFB, of 4 partially continent patients after primary PSARR 3 became continent; of 6 incontinent patients after primary PSARR 4 became continent; of 3 partially continent patients after secondary PSARR 1 became continent, 1 showed no improvement and 1 became incontinent (infection + abscess + fibrosis + important anorectal stenosis). The incontinent patient after secondary PSARP showed no improvement. Conclusion: The authors concluded that BFB, used at the appropriate time with patient collaboration, is an important complement to the anatomical reconstruction of anorectal malformations in order to achieve good development and contractile functioning of the sphincteric muscular complex.


S
ince Pena and De Vries'l study in 1982, PSARP has been the preferred surgical technique of the majority of pediatric surgeons worldwide to correct anorectal malformations(AM).However, even with the good surgical results obtained with this technique, some patients, especially those with coexisting sacral malformations, remain partially or totally fecal incontinente

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For these patients, especially those without the possibility of another PSARP-type surgery for secondary incontinence, the use of biofeedback-type rehabilitation may result in clinicaI improvement.Biofeedback (BFB) is a functional rehabilitation program realized with the aid of monitors or devices, whose readings are made known to patients in hopes of sparking their interest in improving these readings, and thus inducing better clinicaI results and manometric scores.
BFB was used in the treatment of postoperative fecal incontinence by Olness et aI. 3 in patients operated for AM, using balloon devices connected to pressure transducters and an osciloscopy.Constantinides and Cywes 4 also used the balloon devices in the postoperative training of incontinent patients after AM surgical correction.Others 5 ,6,11 have used different BFB schedules to improve surgical results.

MATERIALS AND METHODS
Primary PSARP: 10 Secondary PSARP: 4 lable 2 Associated sacral malformations (n = 14) superior andoinferior part of the muscular sphincteric anorectal complexo PartialIy continent were those who had 3-5 bowel movements/day, with pasty feces, frequent escapes ~f feces and soiling, and whose anus was regular and dirty, with areas of mucous prolapse.Under digital exam they had regular contraction at the superior or inferior part of the muscular sphincteric anorectal' complexo Incontinent patients were classified as those with 5 or more bowel movements/day, with continuous and total lose ofliquid feces.The anus was abnormal, totally opened or with a great degree of mucous prolapse, with visible fecal loss.Under digital exam, they presented weak or absent contraction of the superior and inferior part of the muscular sphincteric anorectal complex. 5e submitted patients older than 4-years who possessed the necessary personal maturity and family collaboration to BFB.A defecogram and anorectal manometric evaluation were undertaken, the manometric evaluation by measuring the following: rest sphincteric anal pressure (RP); recto-sphincteric reflex (RSR); pressure response to cough (C), voluntary contraction (VC) and perianal stimulation (PAS); duration of voluntary contraction (TVC); and simple (SPC) and potentialized pressure curves (PPC) of the anorectal canal. 6atient and family were informed of the radiological findings and manometric scores.Patients then received instructions for physical exercises to strengthen the muscles of the anorectal sphincteric complexo These exercises were coughing, doing voluntary contractions, sustaining voluntary contractions, and other general exercises designed to improve the force of the gluteus and antero-lateral abdominal wall.
The most important thing was to inform the patient and family a~out his scores in order to promote the collaboration required to improve results each time readings were taken.Parents could assist in the prescribed exercises by instructing their child not to contract the gluteus muscle but preferentialIy the anorectal muscular sphincteric complex, which requires attention throughout the physiotherapy se~sion.Parents had previously received the necessary orientation on the anatomy and function of the anorectal region.
To undertake the BFB, we used a special ~alloon device developed by the Pediatric Surgery Manometry .Laboratory of UNIFESP-EPM.7After daily training at home, patients were evaluated every 3 months in this Iaboratory in order to control functionaI and clinicaI deveIopment.The first and Iast manometric controI readings are shown in Table 3. Table 1 shows 14 incontinent patients, 10 after primary PSARP surgical correction, and 4 after secondary surgical correction of AM.AlI patients had high AM.
We considered continent patients those who had 1-2 bowel movements/day, with feces normal in aspect and consistency, and without episodic escapes or soiling, whose anus was normal and clean upon clinicaI inspection.Under digital exam, they presented good contraction at the     We observed that the simple and potentialized pressure curves of the anal canal in Group 1 normalized after BFB, and the number of contractions in 3 of 4 patients increased.In Groups 2, 3 and 4, however, no changes in the aspect or leveI of the curves were observed, but the number of contractions in these groups also increased.
Fibrosis results in a curve with high pressure values and short duration caused by the tissue fibrosis, sometimes with local stenosis and few contractions in the potentialized curve.
. In our patients with high AM (absent externaI sphincter), we did not observed the r~cto-sphincteric reflex pre-or post-BFB. 8e used BFB in 14 patients after PSARP for anorectal malformations, divided into the foIlowing 4 groups: 1.
Four partiaIly continent patients after PSARP used as primary surgery for treatment of AM.

2.
Six incontinent patients after PSARP used as primary surgery for treatment of AM.

3.
Three partiaIly continent patients after PSARP used as a secondary surgery for treatment of fecal incontinence.

4.
One incontinent patient after PSARP used as secondary surgery for fecal incontinence treatment.In Group 1, of 4 partially-continent patients, 3 became continent after BFB, and one remained partially continente Of the 6 incontinent patients in Group 2, 4 became partially continent after BFB, and two showed no improvement.
Of the three partially-continent patients in Group 3, whose PSARP was a secondary surgery, 1 achieved fecal continence, one showed no improvement, and the last evolved fecal incontinence.This last case developed one important abscess in the anorectal region, with fibrosis and stenosis that contributed to the fecal incontinence, with weak manometric responses showing weak activity of the muscular sphincteric complexo In addition, the patient had a behavioral disturbance which could have impaired treatment.
We observed that contractions increased in number in the potentialized pressure curve, with clinicaI improvement in patients of alI groups, even in the Group 4 incontinent patient, who had undergone two prior operative procedures in another hospital.
We can see the continence status after BFB in Table 5.

DISCUSSION
Many complications may arise after the treatment of AM.These depend on the surgical technique employed, the experience of the surgeon, and especially on the presence of associated sacral malformations.Therefore, a meticulous follow-up in every case is crucial. 8he worst complication is fecal incontinence.Olness et aI. 3 used BFB in 50 children with fecal incontinence (10 operated for AM), who had all received conventional treatment without clinicaI improvement.The BFB was undertaken with baIloon devices connected to pressure transductors and to an osciloscopy, with the rectal baIloon positioned in the rectal ampulla and two others in the sphincteric region, to research the recto-sphincteric reflex and voluntary sphincteric muscular responses.
In patients without recto-sphincteric reflex, they attempted to improve responses ofthe child's anal, gluteus and thighs muscles.Of 10 patients, 8 developed the possibility of voluntary defecation; 6 had normal bowel movements within a few weeks.Constantinides and Cywes 4 used a simple two-baIloon (rectal and sphincteric) device in the postoperative training of patients submitted to surgical correction of AM in order to achieve fecal continence, with the sphincteric baIloon connected in Y to apressure manometer.
They hoped to improve puborectal contraction and anorectal continence with changes in Hg mano meter.
Gil-Vernet Hughet et a1. 9,IO used BFB in 35 patients operated with PSARP for AM, and in 31 cases they observed a real improvement in voluntary sphincteric contraction.Gonzales Vasquez ll used a sphincteric training device, the Erotithan sphincter trainer, with a system of balloons, in order to measure the maximal sphincteric contraction pressure of the externaI sphincter, contraction duration, and the anorectal sensibility to distention of the rectal balloon in incontinent patients following AM surgical correction.They improved results with BFB, but with the presence of encopresis.
The following conditions are necessary to achieve good results with BFB: 1.

3.
Intelligence, normal psychological profile, and adequate control of the central nervous system.4.
Age greater than 4 years.Long-term treatment.ClinicaI and manometric improvement are slow, and thus it is important to remember the following six commandments of chronic treatment: 1. Provide correct, personal and professional treatment.

2.
Establish mutual confidence through good communication.
Discuss the patient's condition with the family, and help them to understand different treatment options 5.
Provide continuous treatment and care in order to give stability and hope to the patient and family.Treatment results should be personalized, as it is impossible to make collective and statistical conclusions, given that every patient is uni que and we had a small sample size.
In conclusion, the use of BFB at an appropriate age, with patient cooperation, can be an excellent aid to the ànatomical reconstruction of AM to achieve the desired fecal continence.
coccyx, S5 and fusion of upper sacral vertebrae Others We decided to use BFB in patients operated by PSARP for AM who became totalIy or partialIy fecal incontinent in order to improve their quality of life.São Paulo Medicai Journal/RPM 115(3): 1427-1432, 1997 MARTINS, J.L.; PINUS, J. -Use of biofeedback (BFB) in the treatment of fecal incontinence after surgical correction of anorectal malformations by posterior sagital anorectoplasty (PSARP)

Table 3
Anorectal manometry evaluation pre-and post-BFB