Background/Aims:It is a common belief that constipated patients have hard feces that contributes to the difficulties defecating. To the best of our knowledge, no studies had been published on controlled evacuation of simulated feces with different consistencies. Methods:Twelve normal subjects were recruited for studies with the simulated feces device "Fecobionics" of different consistency (silicone shore 0A-40A corresponding to Bristol stool form scale types 2-4). The subjects filled out questionnaires and had the balloon expulsion test and anorectal manometry done for reference. The Fecobionics probes were inserted in rectum in random order with +20 minutes between insertions. The bag was filled to urge-to-defecate and evacuations took place in privacy. Non-parametric statistics with median and quartiles are provided. Results:One subject was excluded due to technical issues, and another had abnormal anorectal manometry-balloon expulsion test. The 4 females/6 males subjects were aged 23 (range 20-48) years. Most differences were observed between the 0A and 10A probe (duration, maximum bag pressure, duration x maximum bag pressure, and relaxation of the front pressure and the bend angle during evacuation), eg, the duration was 9 (8-12) seconds at 0A and 18 (12-21) seconds at 10A (P < 0.05), and maximum bag pressure was 107 (96-116) cmH2O at 0A and 140 (117-162) cmH2O at 10A (P < 0.05). The bend angle before evacuation differed between the probes whereas only the 10A differed from 40A during defecation. The 10A was harder to evacuate than the 0A probe. Except for the bend angles, no further significant change was observed from 10A to 40A. Conclusion:Fecal consistency affects defecatory parameters.

Contractile patterns in rectum, puborectalis muscle and anal sphincter must be studied to understand defecation. Six subjects had contractile waveforms studied with Fecobionics. Symptom questionnaires, balloon expulsion test and anorectal manometry were done for reference. The Fecobionics bag was filled in rectum to urge-to-defecate volume and measurements were done for 4 h before the subjects attempted to evacuate the device. Pressures and bend angle (BA) variations were analyzed with Fast Fourier Transformation. Four normal subjects exhibited low frequency waves (< 0.06 Hz) for pressures and BA. The waves were uncoordinated between recordings, except for rear and bag pressures. Peak wave amplitudes occurred at 0.02–0.04 Hz. Pressures and the BA differed for peak 1 (p < 0.001) and peak 2 amplitudes (p < 0.005). The front pressure amplitude was bigger than the others (rear and BA, p < 0.05; bag, p < 0.005) for peak 1, and bigger than bag pressure (p < 0.005) and BA (p < 0.05) for peak 2. One subject was considered constipated with lower front pressure amplitudes compared to normal subjects and increased amplitudes for other parameters. The sixth subject was hyperreactive and differed from the other subjects. In conclusion, the rectum, anal sphincter and puborectalis muscle showed different contraction waves during prolonged measurements. The data call for larger studies to better understand normal defecation, feces-withholding patterns, and the implications on anorectal disorders.

Only limited data exist on repeatability of anorectal studies with the established physiological and clinical technologies for assessment of anorectal function. Fecobionics is a new multi-sensor simulated feces that provide data by integrating elements from current tests. To study repeatability of anorectal data obtained with the Fecobionics device. We assessed the database of Fecobionics studies to determine how many repeated studies were done. From a total of 260 Fecobionics studies, 19 subjects with repeated studies using approximately the same protocol and prototype were identified. Key pressure and bending parameters were assessed and the repeatability analyzed using Bland Altman plots. Furthermore, the inter- and intra-individual coefficient of variation (CV) were computed. Fifteen subjects (5F/10 M) with repeated studies were normal subjects, three were patients with fecal incontinence and one subject suffered from chronic constipation. The main analysis was conducted on the cohort of normal subjects. The bias for 11 parameters were within the confidence interval, whereas two were slightly outside. The interindividual CV was lowest for the bend angle (10.1–10.7) and between 16.3 and 51.6 for the pressure parameters. The intra-individual CVs were approximately half of the inter-individual CVs, spanning from 9.7 to 27.6. All data from normal subjects were within previously defined normality. The Fecobionics data showed acceptable repeatability with bias within the confidence limits for almost all parameters. The intra-individual CV was much lower than the inter-individual CV. Dedicated large-scale studies are warranted to evaluate the influence of age, sex, and disease on repeatability as well as comparing between technologies.

INTRODUCTION: Biofeedback therapy (BFT) is a well-known treatment for functional anorectal disorders. The effect of BFT was monitored in fecal incontinence (FI) patients with the Fecobionics test and with the conventional technologies, anorectal manometry (ARM) and balloon expulsion test (BET). METHODS: Studies were performed in 12 patients before and after 8 weeks of biofeedback training. The Fecal Incontinence Severity Index (FISI) score was obtained. Anal resting and squeeze pressures were measured before the bag was distended in the rectum until urge to defecate. Pressure recordings were made during Fecobionics evacuation. RESULTS: BFT resulted in 24% reduction in FISI scores (P < 0.01). Seven patients were characterized as responders. Anal pressures, the urge-to-defecate volume, and defecatory parameters did not change significantly during BFT. For ARM-BET, the maximum anal squeeze pressure, the urge-to-defecate volume, and the expulsion time were lower after BFT compared with those before BFT (P < 0.05). For Fecobionics, the change in urge volume (r = 0.74, P < 0.05) and the change in defecation index (r = 0.79, P < 0.01) were associated with the change in FISI score. None of the ARM-BET parameters were associated with the change in FISI score. It was studied whether any pre-BFT data could predict treatment success. The Fecobionics expulsion duration and the defecation index predicted the outcome (P < 0.05). The defecation index had a sensitivity of 100% and a specificity of 72%. None of the ARM-BET parameters predicted the outcome (all P > 0.2). DISCUSSION: Fecobionics was used as a tool to monitor the effect of BFT and proved better than conventional technologies for monitoring and predicting the outcome in the FISI score.

Defecatory disorders including fecal incontinence (FI) are diagnosed on the symptom pattern supplemented by anorectal manometry (ARM), the balloon expulsion test (BET), and endo-anal ultrasonography. In this study, we used a simulated stool named Fecobionics to study distinct defecation patterns in FI patients using preload-afterload diagrams and to provide comparative data on defecation indices (DIs) between passive and urge incontinent patients. All subjects had Fecobionics, endo-anal ultrasonography and ARM-BET done. The Fecobionics bag was distended in rectum until urge in 37 female patients (64.1 ± 1.5 yrs) and a group of normal subjects (NS, 12F, age 64.8 ± 2.8 yrs). Rear-front pressure (preload-afterload) diagrams and DIs were compared between groups. The FISI score in the patients was 8.6 ± 0.6. The NS did not report FI-related symptoms. All patients and NS defecated Fecobionics and ARM-BET within 2 min. The urge volume was 46.1 ± 3.6 and 35.3 ± 5.9 mL in the FI and normal groups (P > 0.1). The expulsion duration was 14.8 ± 2.4 and 19.8 ± 5.1 s for the two groups (P > 0.1). The preload-afterload diagrams demonstrated clockwise loops that clearly differed between the FI subtypes and NS. The DIs showed profound difference between patients and NS. Fecobionics data showed higher correlation with symptoms in FI patients than ARM-BET. Fecobionics obtained novel pressure signatures in subtypes of FI patients and NS. Fecobionics provides DI data that cannot be obtained with ARM-BET.

INTRODUCTION: Defecatory disorders including obstructed defecation (OD) are currently diagnosed using specialized investigations including anorectal manometry and the balloon expulsion test. Recently, we developed a simulated stool named Fecobionics that provides a novel type of pressure measurements and analysis. The aim was to study OD phenotypes compared with slow transit constipation (STC) patients and normal subjects (NS). METHODS: Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics device contained pressure sensors at the front, rear, and inside a bag. All constipation patients had colon transit study, defecography, anorectal manometry, and balloon expulsion test performed. The Fecobionics bag was distended in the rectum until desire-to-defecate in 26 OD compared with 8 STC patients and 10 NS. Rear-front pressures (preload-afterload parameters) and defecation indices (DIs) were compared between groups. RESULTS: The Wexner constipation scoring system score was 13.8 ± 0.9 and 14.6 ± 1.5 in the OD and STC patients (P > 0.5). The median desire-to-defecate volume was 80 (quartiles 56–80), 60 (54–80), and 45 (23–60) mL in OD, STC, and NS, respectively (P < 0.01). The median expulsion duration was 37 (quartiles 15–120), 6 (3–11), and 11 (8–11) seconds for the 3 groups (P < 0.03). Fecobionics rear-front pressure diagrams demonstrated clockwise loops with distinct phenotype differences between OD and the other groups. Most DIs differed between OD and the other groups, especially those based on the anal afterload reflecting the nature of OD constipation. Several OD subtypes were identified. DISCUSSION: Fecobionics obtained novel pressure phenotypes in OD patients. DIs showed pronounced differences between groups. Larger studies are needed on OD subtyping.

BACKGROUND:Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device.METHODS:Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores.KEY RESULTS:The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p < 0.01). The resting anal pressure and squeeze pressure were lowest in LARS patients (p < 0.05). The urge volume was 11.8 ± 4.2, 59.6 ± 6.4, and 41.6 ± 6.4 ml in the LARS, FI, and NS groups, respectively (p < 0.001). The expulsion duration did not differ between groups. Defecation indices were lowest in the LARS patients (p < 0.05). ARM-BET confirmed the low urge volume in LARS patients whereas anal pressures did not differ between groups.CONCLUSIONS AND INFERENCES:The LARS patients had low anal pressures and urge volume. Most Defecation Indices differed between the LARS group and the other groups.

Introduction: Defecation is a complex process that is difficult to study and analyze. Objectives: Here, we present new analytical tools to calculate frictional force and tension during expulsion of the Fecobionics simulated stool in human subjects. Methods: The 12-cm-long Fecobionics device contained pressure sensors, motion processor units for measurement of orientation and bending, and impedance rings for measurement of cross-sectional areas. Eight normal subjects defecated Fecobionics. The bending angle of the device, frictional force between the device and the surrounding tissue, and the stretch tensions were calculated. Results: The bending angle and pressures changed during expulsion with the maximum pressure recorded at the rear. The averaged circumferential tension, longitudinal tension and friction force in each subject were associated with the front-rear pressure difference (r > 0.7, p < 0.005). The peak circumferential tension, longitudinal tension, and friction force immediately before expulsion of the rear were significantly higher compared to when the front entered the anal canal (F = 164.7, p < 0.005; F = 152.1, p < 0.005; F = 71.4, p < 0.005; respectively.). Conclusion: This study shows that Fecobionics obtained reliable data under physiological conditions. Mechanical features such as frictional force and stretch tensions were assessable during Fecobionics expulsion.

Fecal continence is maintained by several mechanisms including anatomical factors, anorectal sensation, rectal compliance, stool consistency, anal muscle strength, mobility, and psychological factors. The homeostatic balance is easily disturbed, resulting in symptoms including fecal incontinence and constipation. Current technologies for assessment of anorectal function have limitations. Overlap exist between data obtained in different patient groups, and there is lack of correlation between measurements and symptoms. This review describes a novel technology named Fecobionics for assessment of anorectal physiology. Fecobionics is a simulated stool, capable of dynamic measurements of a variety of variables during defecation in a single examination. The data facilitate novel analysis of defecatory function as well as providing the foundation for modeling studies of anorectal behavior. The advanced analysis can enhance our physiological understanding of defecation and future interdisciplinary research for unraveling defecatory function, anorectal sensory-motor disorders, and symptoms. This is a step in the direction of improved diagnosis of anorectal diseases.

IntroductionDefecation is a complex process that may easily get disturbed. Defecatory disorders are commonly diagnosed with anorectal manometry and the balloon expulsion test. Recently we developed a simulated electronic stool named Fecobionics that integrates several tests and simultaneously assesses pressures, orientation, bending and geometry during expulsion of the device. The aim was to use new analytical tools to calculate frictional force and tension during expulsion of Fecobionics in normal subjects.MethodsThe 12‐cm‐long 12mm OD Fecobionics contained pressure sensors at the front, rear and inside a bag, two motion processor units for measurement of orientation and bending, and impedance rings for measurement of eight cross‐sectional areas/diameters. The geometry of the bag was computed from the cross‐sectional area measurements. Eight presumed normal subjects (4F/4M) defecated Fecobionics. High‐resolution anorectal manometry and the balloon expulsion test confirm that the subjects were normal. The bending angle of the device, the frictional force between the probe and the surrounding tissue, the membrane tension, and the probe expulsion velocity were calculated.ResultsData examples are shown in figure 1. The bending angle and pressures changed during expulsion of the device with the maximum pressure recorded at the rear. The change in bending angle during defecation was approximately 40 degrees. The averaged circumferential tension, longitudinal tension and friction force change were associated with the pressure difference between the rear and the front ends (R2=0.878±0.011, p<0.005; R2=0.885±0.01, p<0.005; R2=0.411±0.007, p<0.005; respectively). The peak tensions and friction force immediately before expulsion of the rear were significantly higher than that when the front entered into the anal canal (circumferential and longitudinal tension p<0.005, and friction force p<0.05).ConclusionsFecobionics obtained reliable data under physiological conditions. Mechanical features such as frictional force and membrane tension were assessable during Fecobionics expulsion using the developed analysis.Support or Funding InformationNIH SPARC FundingTop panels: The geometry and the membrane tension distributions of the Fecobionics during expulsion. Bottom panel: The recorded pressures and bending angles in the Fecobionics during expulsion.Figure 1Acknowledgements.Abbey Chen, Cherry Wong, Wingwah Leung, Kaori Futaba, Tony Mak and Simon Ng are thanked for providing data.

INTRODUCTION: Defecation is a complex process that can be easily disturbed. Defecatory disorders may be diagnosed using specialized investigation, including anorectal manometry (ARM) and the balloon expulsion test (BET). Recently, we developed a simulated stool named Fecobionics that integrates several tests and assesses pressures, orientation, and bending during evacuation. The aim was to evaluate the feasibility and performance of Fecobionics for assessing defecatory physiology in normal subjects. METHODS: Physiological expulsion parameters were assessed in an interventional study design. The 10-cm-long Fecobionics probe contained pressure sensors at the front and rear and inside a bag and 2 motion processor units. The bag was distended in the rectum of 20 presumed normal subjects (15 female/5 male) until urge to defecate. ARM-BET was also performed. Three subjects used +2 minutes to evacuate BET, and 1 subject had a high fecal incontinence score. Therefore, the normal group consisted of 16 subjects (13 female/3 male aged 25–78 years). RESULTS: All subjects reported that Fecobionics evacuation was similar to normal defecation. Fecobionics expulsion pressure signatures demonstrated 5 phases, reflecting rectal pressure, anal relaxation, and anal passage. Preload-afterload loop diagrams demonstrated clockwise contraction cycles. The expulsion duration for BET and Fecobionics was 16 ± 2 and 23 ± 5 seconds ( P > 0.2), respectively. The duration of the Fecobionics and BET expulsions was associated ( P < 0.001). The change in bending of Fecobionics during defecation was 40 ± 3°. DISCUSSION: Fecobionics obtained reliable data under physiological conditions. Agreement was found for comparable variables between ARM-BET and Fecobionics but not for other variables. The study suggests that Fecobionics is safe and effective in evaluation of key defecatory parameters.

Background The mechanism of defaecation and continence is a complex process involving several factors. Identifying the cause of faecal incontinence is often difficult. Assessment of patients currently involve functional assessment with high-resolution anorectal manometry (HR-ARM) and anatomical assessment using Endoanal ultrasound (EAUS) scan, providing limited information. EndoFLIP (Functional Lumen Imaging Probe) allows additional assessment of anal canal distensibility.1 2 Aim To compare anal canal function using EndoFLIP between faecally incontinent patients (FI) and asymptomatic subjects (AS). Methods All subjects were assessed using HR-ARM, EAUS and EndoFLIP. Using the EndoFLIP, continuous ramp distension was carried out up to 5=bag vol. In second ramp distension, the 5=volume was maintained while the subjects were asked to squeeze their anus. Anal competence of the narrowest area of the anal canal was evaluated using three distinct parameters derived from the EndoFLIP data. Mann-Whitney’s U test was used for statistical analysis. Results Sixteen FI patients (2M/14F, Mean age 61.38 years, SEM +3.34) and 9 AS (3M/6F, Mean age 57.9 years, SEM +3.69) were assessed. The median yield pressure (the pressure when the diameter increased from baseline) was significantly lower in the FI group at 22.99 cmH20 (17.67–45.49 cmH20) compared to 55.95 cmH20 (36.56–64.82 cmH20) in asymptomatic subjects. There was no significant difference in the distensibility between the FI group 0.18 (0.17–0.35) mm/cmH20 compared to AS group 0.23 (0.12–0.39) mm/cmH20 calculated as the change in diameter divided by the change in distension pressure. The squeeze strength was significantly higher in the AS group 167.3 (62.0–270.8) mm.cmH20 compared to FI group 23.6 (8.1–86.1) mm.cmH20. Conclusions EndoFLIP demonstrated that FI patient‘s anal sphincters yielded at a lower pressure and had lower squeeze strength than in asymptomatic subjects, which may be clinically more relevant than squeeze pressures alone.

Background Defecation is a complex process. Defecatory disorders may be assessed using rectal balloon expulsion test (BET), high-resolution anorectal manometry (HR-ARM) and defecography. We have developed a Fecobionics device that integrates several current tests1 to assess pressures, orientation and bending all at once by the patient bedside. The Fecobionics probe is 10 cm long, 12 mm in diameter with 8 cm long inflatable bag and pressure sensors at each end. It contains two gyroscopes to measure the orientation and bending during defaecation. Aim To characterise physiological expulsion parameters in asymptomatic subjects using Fecobionics. Methods Fecobionics was inserted into the rectum and subjects were asked to sit on a commode. The bag was filled with fluid until subjects had the sensation to defaecate. Patients were asked to expel the Fecobionics. Time to expulsion, pressures and bending angles were assessed during the expulsion. This was compared to conventional 5=BET and HR-ARM. Results Eight subjects (6F/2M, 50 years (25–77)) were assessed. Defaecation urge was felt at 32±=. Five subjects expelled Fecobionics in one attempt. The expulsion time for Fecobionics and BET were 32.2±6.3 and 15.7±3.3 s respectively (p<0.05). Linear association was found between the duration of Fecobionics and BET expulsions (R2=0.48). During Fecobionics expulsion all pressure sensors showed elevated pressures. The front end pressure reached 20–50 cm/H2O above baseline rectal pressure during anal canal passage. Rear end pressure was 28.9±4.6 cm/H2O before expulsion to a maximum pressure of 144.7±15.7 cm/H2O during the expulsion. Defecations could be subdivided into five distinct phases based on the front and rear pressures and their pressure difference1. The bending angle was 137.2±9.6o before defaecation, 145.3±5.0o at maximum contraction, and 178.7±0.9o during anal passage (p<0.05); indicative of changes in the anorectal angle. Conclusions It was possible to obtain reliable data under physiological conditions using Fecobionics. Five defecatory phases could be defined by the pressure signature. Orientation and bending could also be assessed.

Transcutaneous electric nerve stimulation on acupoints (Acu-TENS) is a non-invasive modality that has been used successfully to treat pain of various origins, but few studies have evaluated its role in treating pain/anxiety during colonoscopy.

Introduction: Financial implications on regionalization of healthcare and programmatic development are not often considered. We undertook this study to evaluate and compare hospital cost of care and income with a common operation (laparoscopic cholecystectomy) versus an operation often associated with HPB programmatic development and healthcare regionalization (pancreaticoduodenectomy). Methods and Procedures: The charges and reimbursements of all laparoscopic cholecystectomies (n=201) and pancreaticoduodenectomies (n=44) at one hospital undertaken from June 2012 to June 2013 were determined. Comparisons were undertaken using ANOVA with significance accepted at p ≤ 0.05. Data are reported as median data or as median (mean ± SD). Results: Pancreaticoduodenectomy, relative to laparoscopic cholecystectomy, had greater time in the operating room (283 min vs. 93 min), hospital charges ($108,040.87 vs. $25,055.85), and hospital costs ($15,482.15 vs. $3,453.78) (p<0.0001 for each), but generated similar income ($2,480.23 vs. $3,058.83, p=0.88). Conclusions: Pancreaticoduodenectomy requires more resource allocation and costs hospitals more but leads to no more income. Many hospitals invest great effort and resources to build programs and centers for regional healthcare. However, their accounting systems are not based on cost accounting, but rather on complex formulas of cost allocation. Consequently, these accounting systems have great, and possibly inappropriate, impact on perceived income associated with care. Considering these systems, it seems hospitals derive more return on investment from commonly undertaken operations than those often associated with regionalization of healthcare and programmatic development. Accounting systems need to reflect actual costs to allow determinations of actual income to better allocate healthcare resources and to seek appropriate compensation for hospital care.

Colonoscopy is often regarded as a painful and unpleasant procedure. Electroacupuncture (EA) has been used successfully to treat pain of various origins, but few good-quality studies have evaluated its role in treating pain and anxiety during colonoscopy.

1. Electroacupuncture at acupoints of Zusanli, Sanyinjiao, Hegu, and Zhigou is more effective than no acupuncture and sham acupuncture in stimulating early return of bowel function and reducing analgesic requirement after laparoscopic colorectal surgery. 2. Electroacupuncture is more effective than no acupuncture in reducing the duration of hospital stay. 3. Receipt of electroacupuncture is an independent predictor of shorter duration of ileus and hospital stay after laparoscopic colorectal surgery.