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Letters |
Thomas Jefferson University
Philadelphia, PA
I read with interest the article by Dobben et al. [1] in the November 2005 issue of the AJR in which they evaluated interobserver agreement of defecography in diagnosing various abnormalities in fecal-incontinent patients.
The authors state that patients with grade 3 intussusception and enterocele were not entered in their study. The reason was because the study group was part of a larger cohort study concerning the diagnostic workup in patients with fecal incontinence in relation to the two most commonly used treatment techniques: biofeedback and anterior anal repair. To my knowledge, the major indication for performing defecography in patients with fecal incontinence is to diagnose rectal intussusception, which the authors fail to state and also fail to explain that rectal intussusception ironically can lead to both obstructed defecation and incontinence at the same time. Why exclude those patients who had incontinence caused by rectal prolapse even though it required a different surgical treatment? The authors should explain the relationship, if any, of rectoceles and enteroceles with incontinence. Also lacking is the correlation between radiographic criteria to diagnose anismus and the biofeedback data. I do not see this information nor do I see any mention of anal manometry being performed in the study group.
Dobben et al. [1] state that incomplete evacuation after 30 seconds is more reproducible than puborectalis impression for the diagnosis of anismus. In my sole experience with more than 1,400 defecography studies over 15 years, innumerable patients were unable to evacuate completely after 30 seconds and it is hard for me to fathom that they all suffer from anismus. The radiographic criteria to diagnose anismus are, in my opinion, tenuous at best. There are many patients who suffer from "poor expulsive forces" that may or may not be in part related to a dyskinetic puborectalis (i.e., spastic pelvic floor syndrome, anismus).
In Figure 3 [1], the authors show the grading system for intussusception; however, they do not mention that minimal infolding of either the anterior or posterior rectal wall by itself can be a normal finding. It would be better to use the term "full-thickness intussusception" as the ultimate criterion to diagnose intussusception rather than minimal infolding.
I have difficulty with the primary aim of this study in that there should be no interobserver disagreement with regard to diagnosing enterocele, rectocele, and intussusception on defecography. These are clearly defined anatomic changes on defecography, much like a fracture or hernia. Why would this interobserver variance in a small group of fecal-incontinent patients be of interest to the general radiologist?
I would liked to have rendered these criticisms before the publication of this manuscript.
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