Kumar, Lalit; (2020) Investigating the utility of EndoFLIP, a novel diagnostic modality for assessing anal canal function. Doctoral thesis (M.D(Res)), UCL (University College London).

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Abstract

Evaluation of anal sphincter function is of critical importance in the investigation and management of faecal incontinence, a problem which affects 2% of the general population. Structural assessment by ultrasound is of proven value in defining aetiology and treatment of faecal incontinence, but the currently available physiological assessments are of little value. This is in part because existing physiological techniques assess static properties, whilst faecal incontinence is a dynamic event. Additionally, the heterogeneous structures of the muscle complex surrounding the anal canal require evaluation of the biomechanical properties at multiple locations along the anal canal, not the single measurement of pressure currently available to us with existing techniques. The EndoFLIP technique is a novel methodology that has been used to assess physiology of the upper gut. It allows determination of serial cross-sectional areas (CSAs) during distension thereby providing a detailed segmental geometric and mechanical properties. Custom made probes better suited for anorectum were made as a part of this study to evaluate the biomechanical properties of the anal canal in healthy volunteers. This was followed by study of patients with anorectal dysfunction, specifically dysfunction of the internal anal sphincter and those suffering from scleroderma. The hypothesis for the study was that the dynamic mechanical properties vary at different locations in the anal canal, in response to the anal distension. The study proved a good in-vitro repeatability of the custom-made anorectal probes. This was followed by validation of EndoFLIP in the healthy subjects by confirmation of the pre-existing knowledge of the anorectum besides demonstration of the sampling reflex in real life. A comparison of healthy cohort with morphologically intact faecal incontinence patients and scleroderma patients highlighted a number of significant differences amongst these groups during resting, squeeze and RAIR phase. The clinical utility of EndoFLIP was proven by the new knowledge that was gained during this study.

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