Cristian Gallardo interviews Emma Carrington, colorectal surgeon at St Vincent’s University Hospital, Dublin, Ireland, who will be presenting 'Anal Pathophysiology: beyond the sphincter' at Virtually Vilnius.

Emma graduated from Imperial College School of Medicine in 2004 and was supported by a Royal College of Surgeons fellowship during her PhD in Neurogastroenterology. She completed her training in general and colorectal surgery in 2019 as an NIHR clinical lecturer and is currently working as a Consultant Colorectal Surgeon with a specialist interest in pelvic floor disorders and minimally invasive colorectal surgery in St Vincent’s University Hospital, Dublin.

Her research focuses on optimisation of functional outcomes following colorectal resectional surgery, improving physiological phenotyping of functional gastrointestinal disorders and development of novel investigations of lower gastrointestinal function. She was a founder member of the International Anorectal Physiology Working Group and co-author of the recently published London Classification consensus guidelines for tests of anorectal function.

Cristian Gallardo: Dear Emma, thanks for agreeing to speak at the ESCP 15th Annual & Scientific Conference about the pathophysiology of faecal incontinence.

Emma Carrington: Thanks Christian, although I’m sad not to be visiting Vilnius, I’m really looking forward to being part of the first ever virtual ESCP conference. Thanks for helping to organise it!

CG: Could you give us some information about your topic?

EC: Faecal incontinence is a much bigger problem than most people realise. It’s highly prevalent and affects about 12% of the population. This is even when accounting for an estimated 30% under-reporting rate. Symptoms have a significant impact on social functioning and quality of life, particularly as they are chronic in nature. What’s even worse, is that treatment options are on the whole, poorly effective as we fail to tailor treatment plans to the underlying physiological problem.

As incontinence is multifactorial, physiological testing often demonstrates abnormalities in the function of multiple facets of the anorectal unit. Despite this, many of us place undue emphasis on rehabilitation/repair of anal sphincter abnormalities and fail to appreciate the contribution of the other aspects of continence.

CG: In which cases do you think anorectal function testing should be indicated?

EC: In our institution the decision to refer will somewhat depend on the clinical history. In those patients who describe a gradual decline in continence we will often try a period of conservative management with bowel retraining before referring them for testing. In those patients with an obvious precipitant (obstetric anal sphincter injury, rectal surgery, radiotherapy) we use function testing a little earlier in the treatment pathway as we can then better tailor our treatment to the underlying pathophysiological cause.

CG: What do you think The London Classification of anorectal dysfunction, in which you are the main author, adds to the diagnosis and treatment of functional anorectal disorders?

EC: Unfortunately, there has been enormous historical variability in the nomenclature used to describe physiological findings during anorectal function testing as well as the methods used to gather and report results. This has resulted in significant difficulty in communicating between institutions and limited the usefulness of comparing studies in the literature. Prior to the guideline development we surveyed over 100 centres around the world and found that every single institution performed or interpreted physiology studies in a different manner. We hope that the London Classification guidelines will simplify this process and be a first step to more standard methods of reporting.

CG: How will your talk differ from a normal textbook description of pathophysiology of incontinence?

EC: To those who are new to the topic, learning about the physiology of continence can be daunting as there are many interacting components and lots of detail involved in the descriptions. I certainly struggled when I began in the field! In my talk I will take the learner step by step through some of the more important mechanisms of incontinence.

For those that are experts already I will present the evidence that backs up our knowledge and talk through areas which require further ongoing study.

CG: Are there any future developments in the field?

EC: Its hard to know where to start with this question! My hope is that we can find ways in which to better tailor treatments to patients’ underlying physiological problems. To do this we need to first develop more meaningful metrics to describe function and also embrace standard reporting so that we can all collaborate together in a more collegiate way.

Hear more from Emma on the ‘Anal Pathophysiology: beyond the sphincter´ at ESCP Virtually Vilnius 2020 at 17:25-18:05 on Tuesday 22 September 2020.

Twitter handle: @emmaVcarrington

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