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Issue 2:
The Integration Crystal Ball (September 2001)
  • In this issue the article chosen to be discussed illustrates how can a well designed study using traditional research methodology lead to a multitude of data which can best be explained only using the flow equation. The article will be discussed regarding the data studied and the previously published articles used as a database in their discussion.
    Title: Clinical Manometric and EMG characteristics of Patients with
    Fecal Incontinence.
    Authors: A. Ferrara, J.H. Lujan J. Cebrian, S.W. Larach,
    P.R. Williamson, M. Arroyo, J. Mills.
    Journal: Tech Coloproctol (2001) 5:13-18

This study was done on 53 incontinent adult males Vs 72 age matched incontinent adult females using clinical numerical scoring system which relies on two main variables namely consistency of the leakage material and the frequency of leakage modified by Pesctori et al , a simplified life style score and anorectal physiologic studies namely EMG and anorectal manometry.
They found that male patients had higher incontinence scores at presentation and a longer history before presentation while females tend to have a worse sphincter function than males where mean maximum resting and squeeze pressures were significantly lower in women and more women had sphincter asymmetry than men.
Both groups have the same EMG changes, PNTML delay and delayed rectal sensation despite the disparity between the causes of incontinence between both sexes.

In fact the results illustrates the failure of the used clinical scoring system to reflect the severity of the sphincter damage due to the inclusion of frequency of incontinence episodes in the system.
According to the flow equation the frequency does not show itself in the factors maintaining continence. In fact the frequency may Vary over time e.g. a patient with incontinence to watery stools will have the worst frequency score, if he develops watery diarrhea and will have the best score if this diarrhea is treated by simple medications which has no effect on the recto-anal physiology.
Since frequency and quality of life are important parameters of success of any sort of treatment of anal incontinence from the patients' point of view despite the lack of correlation with the anorectal physiology, both should be included as two separate adjunctive to the Clinico-functional scoring suggested by the flow equation
Resulting in a composite scoring system CQF for anal incontinence akin to the composite TNM staging for cancer.
Similarly the use of the un-integrated methodology ignores the role of the rectum, sensations, reflexes, and recto-anal interaction in inducing the worst types of incontinence in the presence of an otherwise normal anal sphincter e.g. Overflow incontinence due to fecal impaction.
(If you are interested in a detailed analysis of this article and its brainstorming discussion from the flow equation point of view we will be pleased to send the complete review on your e-mail).

Cairo, September 2001



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