Physiological and clinical outcome of anterior sphincteroplasty

Quo vadis STARR? A prospective long-term follow-up of stapled transanal rectal resection for obstructed defecation syndrome

INTRODUCTION

Functional and clinical long-term outcome after stapled transanal rectal resection (STARR) in patients with an isolated symptomatic rectocele are investigated. Short-term results after 1 year are comparable with the functional outcome even after 5 years. Eighty per cent of the patients were still satisfied. STARR is an alternative procedure to the conventional surgical approaches for patients with an obstructed defecation syndrome and rectocele. Several studies have reported short-term outcome after STARR, but long-term results are still missing. The objective of this study was to evaluate long-term clinical outcome after STARR with a follow-up of 5 years.

MATERIALS AND METHODS

Twenty patients with only an isolated symptomatic rectocele due to obstructed defecation syndrome were subjected to STARR. Functional and clinical outcome was assessed by Outlet Obstruction Syndrome score (OOS score), Wexner score (WS), and Symptom Severity score (SSS score). Data were prospectively collected over 7 years.

RESULTS

The perioperative morbidity after STARR accounted for 20% (n = 4). One patient was subjected to reoperation due to perforation, two postoperative bleedings occurred, and one patient developed an increasing local granulomatous reaction at the stapler line. The median follow-up accounted for 66 months (range 60-84). Sixteen patients (80%) were satisfied with the functional outcome. The median OOS, SSS and WS score improved significantly already after 1 year in these patients and remained stable at 5-year follow-up. In contrast, four patients were classified as treatment failures since the OOS score and the SSS score showed no improvement. At 5-year follow-up, these patients remained symptomatic without improvement in OOS and SSS scores.

CONCLUSIONS

The STARR procedure is an effective operation in isolated symptomatic rectoceles with regard to relief of the obstructed defecation syndrome. The short-term improvement after STARR predicts long-term outcome in obstructed defecation syndrome caused by a rectocele.

Overlapping sphincteroplasty: is it the standard of care?

Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition.

Assessing the safety, effectiveness, and quality of life after the STARR procedure for obstructed defecation: results of the German STARR registry

BACKGROUND

Internal rectal prolapse and rectocele are frequent clinical findings in patients with obstructed defecation syndrome (ODS). However, there is still no evidence whether stapled transanal rectal resection (STARR) provides a safe and effective surgical option. Therefore, the German STARR registry was initiated to assess safety, effectiveness, and quality of life.

METHODS

The German STARR registry was designed as an interventional, prospective, multicenter audit. Primary outcomes include safety (morbidity and adverse events), effectiveness (ODS, symptom severity, and incontinence scores), and quality of life (PAC-QoL and EQ-5D) documented at baseline and at 6 and 12 months. Statistical evaluation was performed by an independent research organization of clinical epidemiology.

RESULTS

Complete data of 379 patients (78% females, mean age 57.8 years) were entered into the registry database. Mean operative time was 40 min, mean hospitalization was 5.5 days. A total of 103 complications and adverse events were reported in 80 patients (21.1%) including staple line complications (minor bleeding, infection, or partial dehiscence; 7.1%), major bleeding (2.9%), and postsurgical stenosis (2.1%). Comparisons of ODS and symptom severity scores (SSS) demonstrated a significant reduction in ODS score between baseline (mean 11.14) and 6 months (mean 6.43), which was maintained at 12 months (mean 6.45), and SSS at preoperative and at 6- and 12-month follow-up (13.02 vs. 7.34 vs. 6.59; paired t test, p < 0.001). Significant reduction in ODS symptoms was matched by an improvement in quality of life as judged by symptom-specific PAC-QoL and generic ED-5Q (utility and visual analog scale) scores and was not associated with an impairment of incontinence score following STARR (p > 0.05). However, 11 patients (2.9%) showed de novo incontinence, and new-onset symptoms of fecal urgency were observed in 25.3% of patients.

CONCLUSION

These data indicate that STARR is a safe and effective procedure. However, conclusions are limited due to the selection and reporting bias of a registry. The problem of fecal urgency needs cautious reassessment.

Surgical approaches to postobstetrical perineal body defects (rectovaginal fistula and chronic third and fourth-degree lacerations)

Rectovaginal fistulas and chronic anal sphincter lacerations are uncommon complications that are most often secondary to vaginal delivery, gynecologic surgery, and inflammatory bowel disease. In this chapter, we will review the pertinent anatomy, focusing on the 6 structures that should be considered during the repair and surgical techniques to promote restoration on normal anatomy and function. Key concepts include a tension-free repair, meticulous hemostasis, and postoperative bowel management.

[Current indications, surgical technique and results of anterior sphincter repair as a treatment of faecal incontinence]

Faecal incontinence is a high prevalence disease in the general population. This pathology is commonly under-estimated and causes a great impact on clinical status and on the quality of life of affected patients. The prevalence of faecal incontinence in several studies has been estimated between 2% and 15% of the general population. The prevalence increases if we study selected populations, such as elderly people. The main cause of faecal incontinence is obstetric anal sphincter damage. In the past years, the presence of incontinence due to sphincter lesions, especially the obstetric ones, was an absolute indication of anterior anal sphincter repair. Actually, after knowing the long term follow up results of this technique, as well as the evolving knowledge on faecal incontinence and the development of new diagnostic and therapeutic techniques, this technique might be selected for cases with large sphincter defects. However there is limited information in the current literature on indications, surgical technique and results of anterior sphincter repair. The aim of this review is to analyse scientific evidence on current indications, surgical technique features and results of anterior sphincter repair as a therapy for faecal incontinence, also giving our point of view on controversial issues. A bibliography search was undertaken using Medline database including articles published from January 1985 to January 2009.

Anal physiology testing in fecal incontinence: is it of any value?

INTRODUCTION

The prognostic value of postoperative manometry in fecal incontinence is still controversial. The aims of this study were to establish if Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL) scores correlate with anal manometry and endoanal ultrasound findings and to define if there is any prognostic value in performing anal manometry after patients are surgically treated for fecal incontinence.

METHODS

Fifty-three patients, all women, were identified. All patients underwent a surgical procedure and were analyzed pre- and postoperatively. Fecal incontinence was assessed using the FISI and FIQL. Patients who did not have these score were excluded. Manometry and ultrasound findings before treatment and manometry findings after treatment were compared with surgical patient's incontinence scores. Anal canal length was noted, and its association with the pre- and postoperative manometry finding and incontinence scores were compared.

RESULTS

No correlation of pre- and postoperative resting and squeeze pressures with incontinence scores was found. Ultrasound findings had no correlation with manometry results and incontinence scores. Anal canal length correlated with both pre- and postoperative manometry findings but not with incontinence scores.

CONCLUSION

Preoperative anal manometry and endoanal ultrasound help in guiding treatment options in patients with fecal incontinence. A decrease in FISI and increase in FIQL scores after a sphincter repair quantifies improvement after incontinence surgery, while changes in anal manometry pressures readings do not.

Surgical reconstitution of a unilaterally avulsed symptomatic puborectalis muscle using autologous fascia lata

BACKGROUND

The puborectalis muscle is an important muscle for the maintenance of fecal continence. We present a novel surgical technique for repair of symptomatic avulsed puborectalis muscle.

CASE

This woman presented with dyspareunia and fecal incontinence since the vaginal birth of her child 2 years before. The diagnosis of an avulsed right puborectalis was made by physical examination and confirmed by magnetic resonance imaging and three-dimensional ultrasonography. Fascia lata was harvested from the patient's thigh and used to reconstitute the missing portion of the puborectalis muscle. At 12 months postoperatively, the patient was continent of stool and relieved of dyspareunia.

CONCLUSION

The patient's dyspareunia and fecal incontinence were alleviated by restoring normal anatomy.

Ten-year outcome after anal sphincter repair for fecal incontinence

PURPOSE

This study aimed to report at ten years on the results of the same cohort that had been studied at five years who had undergone an anal sphincter repair for fecal incontinence.

METHODS

Patients studied at five years were contacted after ten years and asked to fill out the Fecal Incontinence Quality of Life Scale, the Fecal Incontinence Severity Index, and the Bristol Stool Form Scale.

RESULTS

Thirty-one of 44 (71 percent) patients were contacted. Median follow-up time was 129 (range, 113 to 208) months. Median age at surgery was 44 (range, 22 to 80) years. No patients were fully continent at 129 months. Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores were correlated with the age at surgery. Older patients had lower Fecal Incontinence Quality of Life scores (P = 0.001), reflecting a lower quality of life, and a higher patient-rated Fecal Incontinence Severity Index score (P = 0.01) and a higher surgeon-rated Fecal Incontinence Severity Index score (P = 0.005), denoting more severe fecal incontinence. The Bristol Stool Form Scale, not utilized at 77 months, showed a correlation to patient-rated Fecal Incontinence Severity Index (P = 0.04) and surgeon-rated Fecal Incontinence Severity Index (P = 0.02). Fecal Incontinence Severity Index scores were significantly higher in women who had more than two vaginal births.

CONCLUSION

Continence after overlapping sphincter repair deteriorates in the long term. Long-term outcome was worse for patients who were older at the time of surgery or those with two or more vaginal births. The Bristol Stool Form Scale score correlates with the severity of incontinence, and may be used to guide the management of the patient's symptoms.

Prospective clinical and functional results of combined rectal and urogynecologic surgery in complex pelvic floor disorders

BACKGROUND

The aim of this prospective study was to evaluate the results of combined rectal and urogynecologic surgery in women with associated obstructed defecation, urinary incontinence, or genital prolapse.

METHODS

One hundred forty-two selected patients with obstructed defecation in isolation or associated with urinary incontinence, enterocele, or genital prolapse were consecutively operated on by stapled transanal rectal resection alone or associated with transobturator tape, vaginal repair of the enterocele, or vaginal hysterectomy, respectively, and followed up by clinical controls and defecography.

RESULTS

At 2 years, all symptom, quality-of-life, and defecographic parameters had significantly improved in all groups (P < .001). The association with hysterectomy showed higher risk for severe complications, longer operative time, hospital stay, and time of inability (P < .001). Recurrence of urinary incontinence was observed in 3 of 24 patients, while 2 of 21 showed residual vaginal prolapse.

CONCLUSION

The combination of rectal and urogynecologic surgery is effective, with higher morbidity in the association with vaginal hysterectomy. Randomized trials comparing surgery in 1 and more stages and longer follow-up are necessary for a definitive conclusion.

Measure of the voluntary contraction of the puborectal sling as a predictor of successful sphincter repair in the treatment of anal incontinence

PURPOSE

Overlapping sphincteroplasty is the surgery of choice for incontinent patients with an anterior defect after childbirth. Numerous predictive factors have been proposed, but no preoperative variables have been successfully shown to be reproducible. The purpose of this study was to assess the prognostic value of voluntary contraction of the puborectal sling before sphincter repair for anal incontinence.

METHODS

This prospective study evaluated 109 consecutive women who underwent surgery for postobstetric anal incontinence. Voluntary contraction of the puborectal sling was measured by perineal ultrasound before the surgery. Severity of anal incontinence was evaluated preoperatively and postoperatively with the Miller Incontinence Score (total incontinence = 18, complete continence = 0).

RESULTS

The proportion of patients with scores <or=3 was 16.7 percent when the preoperative voluntary contraction of the puborectal sling was <or=4 mm, 48.1 percent when it was 4.1 to 8 mm, and 98.7 percent when it was >8 mm (P < 0.001). Using <or=8 mm to define abnormal shortening, the sensitivity of the test was 0.95 (95 percent confidence interval, 0.75-1.00) and specificity was 0.84 (95 percent confidence interval, 0.75-0.91).

CONCLUSION

A preoperative voluntary contraction of the puborectal sling >8 mm convincingly discriminates between patients with a good functional outcome and those with an unsatisfactory outcome after sphincter repair for postobstetric anal incontinence.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized, controlled trial

PURPOSE

This study was designed to assess the safety and outcomes achieved with stapled transanal rectal resection vs. biofeedback training in obstructed defecation patients.

METHODS

A total of 119 women patients who suffered from obstructed defecation with associated rectocele and rectal intussusception were randomized to stapled transanal rectal resection or biofeedback training. Stapled transanal rectal resection was performed by using two circular staplers to produce transanal full-thickness rectal resection. Primary outcome was symptoms of obstructed defecation resolution at 12 months; secondary outcomes included safety, change in quality of life score, and anatomic correction of rectocele and rectal intussusception.

RESULTS

Fourteen percent (8/59) stapled transanal rectal resection and 50 percent (30/60) biofeedback training patients withdrew early. Eight (15 percent) patients treated with stapled transanal rectal resection and 1 (2 percent) biofeedback patient experienced adverse events. One serious adverse event (bleeding) occurred after stapled transanal rectal resection. Scores of obstructed defecation improved significantly in both groups as did quality of life (both P < 0.0001). Successful treatment was observed in 44 (81.5 percent) stapled transanal rectal resection vs. 13 (33.3 percent) evaluable biofeedback training patients (P < 0.0001). Functional benefit was observed early and remained stable during the study.

CONCLUSIONS

In this controlled trial, stapled transanal rectal resection was well tolerated, was more effective than biofeedback training for the resolution of obstructed defecation symptoms, and improved quality of life, with minimal risk of impaired continence. Thus, stapled transanal rectal resection offers a new treatment alternative for obstructed defecation after failure of conservative measures including biofeedback training, a noninvasive approach.

Surgical treatment of patients with constipation and fecal incontinence

Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.

Surgical strategies for faecal incontinence--a decision analysis between dynamic graciloplasty, artificial bowel sphincter and end stoma

BACKGROUND

Artificial bowel sphincter (ABS) and dynamic graciloplasty (DG) are surgical treatments for faecal incontinence (FI). FI may affect quality of life (QOL) so severely that patients are often willing to consider a permanent end stoma (ES). It is unclear which is the more cost-effective strategy.

METHOD

Probability estimates for patients with FI were obtained from published data (ABS, n = 319; DG, n = 301), supplemented by expert opinion. The primary outcome was quality-adjusted life years (QALYs) gained from each strategy. Factors considered were the risk of failure of the primary and redo operation and the consequent risk of permanent stoma. Results were assessed as incremental cost-effectiveness ratio (ICER).

RESULTS

Over the 5-year time horizon, ES gave a QALY gain of 3.45 for 16,280 pounds sterling, giving an ICER of 4719 pounds sterling/QALY. ABS produced a gain of 4.38 QALYs for 23,569 pounds sterling, giving an ICER of 5387 pounds sterling/QALY. DG produced a gain of 4.00 QALYs for 25,035 pounds sterling, giving an ICER of 6257 pounds sterling/QALY. With the willingness-to-pay threshold set at 30,000 pounds sterling/QALY, ES was the most cost-effective intervention. The ABS was most cost-effective after 10 years.

CONCLUSION

All three procedures were found to be cost-effective. The ES was most cost-effective over 5 years, while the ABS was most cost-effective in excess of 10. DG maybe considered as an alternative in specialist centres.

Diagnosis and management of obstetric anal sphincter injury

PURPOSE OF REVIEW

The purpose of this review is to outline optimum practice in diagnosis and management of obstetric anal sphincter injury. The review focuses briefly on prevention of the problem before outlining diagnosis of sphincter injury as well as immediate and long-term management of patients who have sustained such injuries.

RECENT FINDINGS

Increasing vigilance is vital in order that sphincter injury is not overlooked; immediate radiological assessment may play a role in diagnosis. Optimum anal sphincter repair should be followed by oral laxative administration to maintain sphincter integrity. Biofeedback physiotherapy and sacral nerve stimulation show great promise in treatment of persistent symptoms. Optimum mode of delivery in future pregnancies is not clearly defined, and decisions should be individualized.

SUMMARY

Because obstetric injury to the anal sphincter mechanism cannot always be prevented, efforts must focus on limiting its occurrence, documenting its severity and providing optimum therapy to women who have sustained it. Management includes routine postnatal review of at-risk women and antenatal assessment in future pregnancies to limit deterioration in continence after future deliveries.

Stapled transanal rectal resection for outlet obstruction syndrome: results and follow-up

BACKGROUND

The objective of the present study was to assess safety, effectiveness, and long-term outcomes of stapled transanal rectal resection (STARR) for the cure of outlet obstruction syndrome (OOS).

METHODS

Data were collected over a 3-year period (2004-2007), at the Department of Surgery of the University of Genoa, from 25 consecutive subjects (19 of them females) undergoing STARR because of OOS that had not responded to medical treatment,.

RESULTS

Preoperatively, patients were submitted to clinical examination, defecography, colonoscopy, manometry, and recto-anal reflexes determination. All patients had mucosal prolapse, 15 rectal intussusception, 15 rectocele. Postoperatively no deaths were observed; one patient had a hemorrhage requiring reintervention. Mean time to resumption of normal activity was 8.5 +/- 4.5 days. Patients were followed for a mean of 24.7 +/- 10.9 months (range: 6-42 months). Late specific complications included 3 cases of urge to defecate, 8 of incontinence to flatus. Functional outcome was positive for 22 patients (excellent in 4 cases, good in 15, fairly good in 3). Six months postoperatively (25 s), patients had improvement of the mean Constipation Score (p = 0.0002), less pain during evacuation (p = 0.0003), and reduced use of digital assistance to defecate (p < 0.0001). Continence Grading Scale and enema use remained stable after intervention. Patients had increase in basal sphincter pressure (p = 0.0078) and maximal squeeze pressure (p = 0.0051). Recto-anal reflex study showed increase in abdominal pain threshold (p < 0.0001); anal sphincter relaxation threshold and desire to defecate threshold did not change.

CONCLUSIONS

According to the present study, STARR seemed to be a safe and effective treatment for OOS associated with symptomatic rectocele and intussusception.

Obstetric anal sphincter injury: incidence, risk factors, and management

BACKGROUND AND AIMS

Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management.

METHOD

This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists.

RESULTS

A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality.

CONCLUSIONS

Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

Stapled transanal rectal resection in solitary rectal ulcer associated with prolapse of the rectum: a prospective study

PURPOSE

At present, none of the conventional surgical treatments of solitary rectal ulcer associated with internal rectal prolapse seems to be satisfactory because of the high incidence of recurrence. The stapled transanal rectal resection has been demonstrated to successfully cure patients with internal rectal prolapse associated with rectocele, or prolapsed hemorrhoids. This prospective study was designed to evaluate the short-term and long-term results of stapled transanal rectal resection in patients affected by solitary rectal ulcer associated with internal rectal prolapse and nonresponders to biofeedback therapy.

METHODS

Fourteen patients were selected on the basis of validated constipation and continence scorings, clinical examination, anorectal manometry, defecography, and colonoscopy and were submitted to biofeedback therapy. Ten nonresponders were operated on and followed up with incidence of failure, defined as no improvement of symptoms and/or recurrence of rectal ulceration, as the primary outcome measure. Operative time, hospital stay, postoperative pain, time to return to normal activity, overall patient satisfaction index, and presence of residual rectal prolapse also were evaluated.

RESULTS

At a mean follow-up of 27.2 (range, 24-34) months, symptoms significantly improved, with 80 percent of excellent/good results and none of the ten operated patients showed a recurrence of rectal ulcer. Operative time, hospital stay, and time to return to normal activity were similar to those reported after stapled transanal rectal resection for obstructed defecation, whereas postoperative pain was slightly higher. One patient complained of perineal abscess, requiring surgery.

DISCUSSION

The stapled transanal rectal resection is safe and effective in the cure of solitary rectal ulcer associated with internal rectal prolapse, with minimal complications and no recurrences after two years. Randomized trials with sufficient number of patients are necessary to compare the efficacy of stapled transanal rectal resection with the traditional surgical treatments of this rare condition.

Initial experience on efficacy in closure of cryptoglandular and Crohn's transsphincteric fistulas by the use of the anal fistula plug

BACKGROUND AND AIMS

It was the aim of this prospective study to analyze the efficacy of the Cook Surgisis AFP anal fistula plug (AFP) for the closure of cryptoglandular and Crohn's disease-associated transsphincteric anorectal fistulas.

MATERIALS AND METHODS

All patients with transsphincteric anorectal fistulas who underwent a surgical procedure using the AFP were prospectively enrolled in this study. Inclusion criteria included transsphincteric, single-tract fistulas. Patients' demographics, fistula etiology, surgical variables, continence (Cleveland Clinic Florida incontinence score), quality of life (fecal incontinence quality of life), and success rates were prospectively recorded. Surgery was performed in a standardized technique including irrigation of the fistula tract, placement, and internal fixation of the Cook Surgisis AFP anal fistula plug. No flap or excision of the fistula tract was performed. Success was defined as closure of both internal and external openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6, 9, and 12 months postoperatively.

RESULTS

Within 6 months (August 2006 to January 2007), a total of 19 AFPs were inserted in 19 patients (8 females, 11 males; mean age, 38 years). Out of 19 patients, 12 had cryptoglandular and 7 had Crohn's associated transsphincteric fistulas. Three patients were smokers, one patient had methicillin-resistant Staphylococcus aureus infection. Mean operative time was 15 min (range, 8-22); no morbidity occurred. After a mean follow-up of 279 days (SD = 68.0) and one patient lost to follow-up, the overall success rate was 61% (12 of 18) at 9 months postoperatively. Focusing solely on cryptoglandular fistulas, the success rate was 45.5% (5 of 11), whereas it was 85.7% (6 of 7) in transsphincteric fistulas associated with Crohn's disease. Five patients with failure of AFP (plug dislodgement, n = 2; persistent secretion, n = 3) had reoperation (27.8%). The reasons for failure were infection requiring drainage (n = 2) and persistent drainage (n = 3). No deterioration of continence was documented.

CONCLUSION

The success rate for the Cook Surgisis AFP anal fistula plug for the closure of complex anorectal fistulas both in cryptoglandular and Crohn's associated fistulas was 45.5 and 85.7%, respectively. Further analysis is needed to explain the definite role of this innovative technique in comparison to traditional surgical techniques.

Overlapping repair in patients with anal sphincter injury

OBJECTIVE

The aim of this study was to demonstrate the improvement of anal canal function after overlap sphincter repair and confirm that this treatment option is superior in patients with nonobstetric sphincter damage.

SUBJECTS AND METHODS

From 1998 to 2003, 44 women who underwent overlapping sphincter repair were enrolled in this study. The women were allocated to one of two groups, obstetric trauma (n = 31) and nonobstetric (perineal) trauma (n = 13). Both groups were compared in terms of age, operation time, number of deliveries, hospital stay, need for analgesics, complication rate, pre- and postoperative outcomes of anal manometry and quality of life, using the fecal incontinence severity index and a questionnaire for fecal disorders.

RESULTS

Anal canal length was significantly extended postoperatively in both groups compared to preoperative length. Eight-week postoperative resting and squeeze pressures were significantly higher than preoperative pressures in both patients with nonobstetric and obstetric sphincter injury. Although significant increase was seen in both groups, the mean postoperative resting and squeeze pressures at 1 year were rather high in patients with nonobstetric sphincter injury. At the end of a year of follow-up, overall satisfaction of the repair was about 82%.

CONCLUSION

Overlap sphincter repair was feasible, although patient satisfaction was slightly less in the obstetric than in the nonobstetric trauma group. The improvement of anal function at 20- to 24-month follow-up is attributed to both high squeeze pressure and broad anal canal.

Evolving therapy for fecal incontinence

BACKGROUND

Fecal incontinence is common and can be socially debilitating. Nonoperative management of fecal incontinence includes dietary modification, antidiarrheal medication, and biofeedback. The traditional surgical approach is sphincteroplasty if there is a defect of the external sphincter. Innovative treatment modalities have included sacral nerve stimulation, injectable implants, dynamic graciloplasty, and artificial bowel sphincter.

DISCUSSION

This review was designed to assess the various surgical options available for fecal incontinence and critically evaluate the evidence behind these procedures. The algorithm in the surgical treatment of fecal incontinence is shifting. Injectable therapy and sacral nerve stimulation are likely to be the mainstay in future treatment of moderate and severe fecal incontinence, respectively. Sphincteroplasty is limited to a small group of patients with isolated defect of the external sphincter. A stoma, although effective, can be avoided in most cases.

The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence

OBJECTIVE

Anterior sphincter repair has become the operation of choice in patients with fecal incontinence who have defects of the external anal sphincter (EAS), but not all patients benefit from surgery. The aim of this study was to investigate whether endoluminal imaging can identify determinants that play a role in the outcome of sphincter repair.

SUBJECTS AND METHODS

Thirty fecal incontinent patients with an EAS defect were included. The severity of incontinence was evaluated pre- and postoperatively using the Vaizey incontinence score. Patients underwent endoanal MRI and endoanal sonography before and after sphincter repair. We evaluated the association between preoperatively assessed EAS measurements with outcome and postoperatively depicted residual defects, atrophy, tissue at overlap, and sphincter overlap with clinical outcome.

RESULTS

After surgery, the mean Vaizey score in 30 patients (97% females; mean age, 50 years) had improved from 18 to 13 (p < 0.001). MRI showed that baseline measurement of preserved EAS thickness correlated with a better outcome (r = 0.42; p = 0.03). Clinical outcome did not differ between patients with and those without a persistent EAS defect (p = 0.54) or EAS atrophy (p = 0.26) depicted on MRI. Patients with a visible overlap and less than 20% fat tissue had a better outcome than patients with nonvisible, fatty overlap (decrease in Vaizey score, 7 vs 2 points, respectively; p = 0.04). Sonography showed that patients with a persistent EAS defect had a worse outcome than those without an EAS defect (17 vs 10 points, respectively; p = 0.003).

CONCLUSION

Endoanal MRI was useful in determining EAS thickness and structure, and endoanal sonography was effective in depicting residual EAS defects.

Epiploic appendagitis--clinical characteristics of an uncommon surgical diagnosis

Background

Early surgical results of anterior sphincter repair for faecal incontinence can be good, but in the longer term are often disappointing. This study aimed to determine the short and long term outcomes from anterior sphincter repair and identify factors predictive of long term success.

Methods

Patients who underwent anterior sphincter repair between 1989 and 2001 in one institution were identified. Postal questionnaires were sent to patients, which included validated scoring systems for symptom severity and quality of life assessments for faecal incontinence. Patient demographics and risk factors were recorded as were the results of anorectal physiology studies and endoanal ultrasound.

Results

Eighty-five patients underwent repair by one consultant. The length of follow up ranged from 1 to 12 years. Most patients (96%) had early symptom improvement postoperatively. Of the 47 patients assessed long term (≥ 5 years), 28 (60%) maintained this success. Significant improvements in quality of life were observed (P < 0.001). Neither patient, surgical nor anorectal physiology study parameters were predictive of outcome.

Conclusion

There were no predictive factors of outcome success and no changes in anal manometry identified, however anterior sphincter repair remains worthwhile. Changes in compliance of the anorectum may be responsible for symptom improvement.

Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial

PURPOSE

A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse.

METHODS

Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography.

RESULTS

At a mean follow-up of 8.1+/-2.0 and 7.9+/-1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p=0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p=0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p=0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p=0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse.

CONCLUSIONS

STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.

Overlapping anal sphincter repair and anterior levatorplasty: effect of patient's age and duration of follow-up

BACKGROUND AND AIMS

Anal sphincter repair can improve function in patients with faecal incontinence but it is unclear which benefit and its long-term efficacy has been questioned. This study aims to assess the functional outcome of a single surgeon series of overlapping anal sphincter repairs with anterior levatorplasty.

METHOD

A retrospective study of 66 patients' case notes and anorectal physiology combined with an interview to assess their current continence and associated quality of life after surgery.

RESULTS

Sixty-six female patients, mean age 62.8 years, mean follow-up 45.2 months, were assessed. Functional improvement in continence was seen in 77.1% of patients, which mirrored their subjective rating of surgery (62.7%--good/excellent). Continence grading scores improved from a mean (SD) 9.71 (4.82) pre-surgery to 5.55 (4.11) post-surgery. There was no statistical difference in functional results when stratified by age (<63 years or > or =63 years) or by follow-up [long-term (43-78 months) vs short-term (14-42 months)]. Post-surgical physiology data were not statistically improved compared to pre-surgery.

CONCLUSIONS

Overlapping anal sphincter repair with anterior levatorplasty is an effective treatment for faecal incontinence. Patient age does not correlate with outcome, and symptoms do not deteriorate over time. Anorectal physiology results don't predict for symptomatic improvement in patients with faecal incontinence.

Third-party prospective evaluation of patient outcomes after dynamic graciloplasty

Background

Dynamic graciloplasty (DGP) is a complex procedure designed to improve bowel function in patients with end-stage faecal incontinence. Outcomes of DGP were examined in comparison with stoma formation or continued medical management.

Methods

This third-party evaluation comprised a prospective case–comparison study of patient-based and clinical outcomes at a London hospital. Forty-nine patients who underwent DGP during 5 years from 1997 were compared with 87 patients with similar bowel disorders who did not undergo DGP. Outcome measures were quality of life (QoL), symptoms, anxiety and depression.

Results

At 2 years after surgery, bowel-related QoL and continence had improved by more than 20 per cent compared with the preoperative status for two-thirds of patients who had DGP (P &lt; 0·001). Two-thirds were continent all or most of the time, although one-third experienced disordered bowel evacuation. Large deteriorations on the Nottingham Health Profile pain score occurred in 11 of 34 patients who had DGP, compared with seven of 57 patients in comparison groups (P = 0·027). Patients in comparison groups experienced no significant changes in measured outcomes over the 2 years of follow-up.

Conclusion

Although DGP is associated with a high level of morbidity, it deserves consideration as an alternative to life with severe and refractory faecal incontinence or stoma formation in people in whom conventional treatments have failed.

Botulinum Toxin Type A for Chronic Pain and Pelvic Floor Spasm in Women

OBJECTIVE

To estimate whether botulinum toxin type A is more effective than placebo at reducing pain and pelvic floor pressure in women with chronic pelvic pain and pelvic floor muscle spasm.

METHODS

This study was a double-blinded, randomized, placebo-controlled trial. All participants presented with chronic pelvic pain of more than 2 years duration and evidence of pelvic floor muscle spasm. Thirty women had 80 units of botulinum toxin type A injected into the pelvic floor muscles, and 30 women received saline. Dysmenorrhea, dyspareunia, dyschezia, and nonmenstrual pelvic pain were assessed by visual analog scale (VAS) at baseline and then monthly for 6 months. Pelvic floor pressures were measured by vaginal manometry.

RESULTS

There was significant change from baseline in the botulinum toxin type A group for dyspareunia (VAS score 66 versus 12; chi2 = 25.78, P < .001) and nonmenstrual pelvic pain (VAS score 51 versus 22; chi2 = 16.98, P = .009). In the placebo group only dyspareunia was significantly reduced from baseline (64 versus 27; chi2 = 2.98, P = .043). There was a significant reduction in pelvic floor pressure (centimeters of H2O) in the botulinum toxin type A group from baseline (49 versus 32; chi2 = 39.53, P < .001), with the placebo group also having lower pelvic floor muscle pressures (44 versus 39; chi2 = 19.85, P = .003).

CONCLUSION

Objective reduction of pelvic floor spasm reduces some types of pelvic pain. Botulinum toxin type A reduces pressure in the pelvic floor muscles more than placebo. Botulinum toxin type A may be a useful agent in women with pelvic floor muscle spasm and chronic pelvic pain who do not respond to conservative physical therapy.

CLINICAL TRIAL REGISTRATION

Australian Clinical Trials Registry, http://www.actr.org.au/, ACTRN012605000515695 LEVEL OF EVIDENCE: I.

Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence?

BACKGROUND AND AIMS

More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects.

PATIENTS AND METHODS

We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of <or=5, whereas postoperative quality of life was assessed by a standardized questionnaire.

RESULTS

Twenty-eight patients (mean age 52.3 years) underwent overlapping anal sphincteroplasty. The mean follow-up was 33.8 months. Cleveland Clinic Florida scores postoperatively showed a significant improvement from preoperative values (14.2 vs 5.1, p<0.001). Seventeen patients (61%) underwent concomitant PFR with sphincteroplasty. Three patients (27%) without PFR and one patient (6%) with PFR underwent repeat sphincter repair due to worsening symptoms (p=0.15). Two patients with PFR and one patient without PFR ultimately had an ostomy due to a failed repair (p=0.66). Comparing patients with and without PFR, there was a trend toward higher success rates (71 vs. 45%) when pelvic prolapse issues were addressed during sphincter repair.

CONCLUSION

Concomitant evaluation and repair of pelvic floor prolapse may be a clinically significant component of a successful anal sphincteroplasty for fecal incontinence but warrant further prospective evaluation.

Treatment strategies in obstructed defecation and fecal incontinence

Obstructed defecation (OD) and fecal incontinence (FI) are challenging clinical problems, which are commonly encountered in the practice of colorectal surgeons and gastroenterologists. These disorders socially and psychologically distress patients and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, often incompletely understood and cannot always be determined. As a consequence, many medical, surgical, and behavioral approaches have been described, with no panacea. Over the past decade, advances in an understanding of these disorders together with rational and similar methods of evaluation in anorectal physiology laboratories (ARP), radiology studies, and new surgical techniques have led to promising results. In this brief review, we discuss treatment strategies and recent updates on clinical and therapeutic aspects of obstructed defecation and fecal incontinence.

Short-term and long-term effects of obstetric anal sphincter injury and their management

PURPOSE OF REVIEW

During the past decade increasing attention has focused on the problem of obstetric anal sphincter damage. Although risk factors are now well known, the effects of such damage have received less study. This review focuses on the early and long-term problems that may arise subsequent to anal sphincter injury following childbirth and assesses therapeutic options.

RECENT FINDINGS

Up to 25% of women experience altered faecal continence after vaginal delivery, with 4% having persistent symptoms. In those women who have sustained a recognized tear to the sphincter, the quality of primary repair is crucial. Nevertheless, evidence clearly supporting the superiority of overlap over approximation repair is still lacking. The importance of pudendal nerve damage in the aetiology of postpartum faecal incontinence is gaining increasing attention. Augmented biofeedback physiotherapy is the gold standard for treatment of women with such injury, whereas sacral nerve stimulation represents a newer treatment option.

SUMMARY

The short-term and long-term effects of obstetric anal sphincter injury warrant increased attention, because with increasing longevity more women are surviving into their 80s and the prevalence of faecal incontinence in this population will increase if measures are not taken to address the problem. Prevention of such injury is not always possible and management options must be further explored. Adequate primary treatment of third-degree tears is of paramount importance.

Restoration of fecal continence after functional gluteoplasty: long-term results, technical refinements, and donor-site morbidity

PURPOSE

For patients with severe fecal incontinence, reconstruction of the anal sphincter, via gluteoplasty, may improve quality of life, but little is known about long-term functional results. We present our comprehensive experience with gluteoplasty, highlighting technical refinements, donor-site morbidity, and functional outcomes.

METHODS

We performed a retrospective analysis of 25 consecutive patients (22 female, 3 male; mean age 42 years, range 23-65) undergoing gluteoplasty for fecal incontinence at a university teaching hospital from 1996-2004. Etiology of incontinence was as follows: obstetrical injury (n = 13), irritable bowel syndrome (n = 3), previous rectal surgery (n = 3), Crohn disease (n = 3), impalement (n = 1), rectocele (n = 1), and idiopathic (n = 1).

RESULTS

Gluteoplasty was successful in restoring fecal continence in 18 patients (72%) and was partially successful in 4 patients (16%). Two patients required permanent ostomy because of refractory incontinence. Donor-site morbidity and perirectal complications were observed in 16 patients (64%) and included dysthesias (n = 7), cellulitis (n = 5), irregular contour (n = 3), abscess (n = 2), seroma (n = 2), fistula (n = 1), but no hip dysfunction or altered gait. Mean length of follow-up was 20.6 months (range: 3-68 months).

CONCLUSIONS

Despite a high incidence of donor-site and perirectal complications, unilateral functional gluteoplasty was successful in restoring long-term fecal continence in most patients.

Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months

BACKGROUND

The aim of this study was to determine the functional results of anal sphincter repair after a long follow-up (mean 80.1 months).

METHODS

In the period 1990-2002, 65 sphincter repairs were performed. Obstetric trauma was the cause of incontinence in 72.3% cases, fistulotomy in 13.8%, nonspecific trauma in 9.2%, and war injury in 4.6%. At the time of surgery, 12 patients had undergone an urgent stoma procedure. In all cases, anal manometry, electromyography, and defecography were performed. The severity of incontinence was evaluated preoperatively using the Wexner score system. Anterior sphincteroplasty was performed in 52 cases, lateral in 9 cases, and posterior in 4 cases.

RESULTS

The results were determined according to the Wexner score system and the Browning-Parks scale. The Wexner score was calculated 3 months after operation and during every follow-up visit. Preoperative scores and those at the first and last follow-up visits were analyzed. Three months after operation excellent results were achieved in 55.5%, good in 18.5%, fair in 16.9%, and poor in 9.2% patients. After follow-up (mean 80.1 months), 26.8% had excellent results, 21.4% had good results, 12.5% had fair results, and 39.3% of patients had a poor outcome. Results determined by the Wexner score system improved from 17.8 preoperatively to 3.6 three months after operation, but deteriorated over time to 6.3 after longer follow-up (p<0.001).

CONCLUSION

Overlapping sphincter repair provides satisfactory results in more than two-thirds of patients initially, but the results tend to worsen over time and are satisfactory in half of patients after longer follow-up.

Outcome of anterior sphincter repair for obstetric injury: comparison of early and late results

INTRODUCTION

Fecal incontinence is commonly caused by structural sphincter damage secondary to obstetric trauma. Anterior sphincter repair achieves reasonable early improvement rates of between 69 and 97 percent. Few series have reported long-term results. This study was designed to evaluate the long-term outcome and examine whether there are any predictive factors that could refine patient selection and predict long-term outcome.

METHODS

The case records of all patients who underwent anterior sphincter repair between January 1991 and December 1999 were studied. The patients were sent a questionnaire that asked about preoperative and postoperative and current bowel function, with questions about quality of life and overall satisfaction with the outcome of the procedure. The late outcome after a mean period of 70 months from the operation was compared with the early clinical results. All the preoperative and operative variables were studied to ascertain their significance in predicting success.

RESULTS

Ninety-three patients were admitted to the study. Anterior sphincter repair was successful in improving continence in 73 percent of patients. Long-term results were obtained for 62 patients. Seventy percent had objective clinical improvement based on the questionnaire, but only 55 percent considered their bowel control had improved and only 45 percent were satisfied by the operation. Urgency was the most important symptom in determining patient satisfaction; 24 of 26 patients in whom urgency had improved were happy with their outcome. None of the preoperative and operative variables predicted the outcome.

CONCLUSIONS

Patients should be warned that complete continence is difficult to achieve and that symptoms tend to deteriorate with time.

[Fecal incontinence]

Diagnosis and management of fecal incontinence requires exact understanding of the anatomic and pathophysiologic principles involved and demands a methodical, stepwise approach. Despite the potential appeal of surgical intervention, a considerable number of patients can be helped by comparatively simple, noninvasive measures. Initial treatment should be medical, including biofeedback in combination with a bowel management program. In the presence of a severely denervated pelvic floor, physiotherapeutic techniques rarely give rise to a satisfactory and long-lasting response. Obvious external sphincter defects and patients who failed medical management are treated surgically. Many injuries of the external sphincter can be treated by direct sphincter repair. If patients with intact external sphincters are unresponsive to medical measures, descending perineum and resultant idiopathic fecal incontinence will improve by radio-frequency delivery, sacral nerve stimulation, or postanal plication. Patients with complex neurologic disorders or extensive sphincter defects or who have undergone previous unsuccessful attempts at repair of the puborectalis itself should be considered for dynamic gracilis plastic or an artificial sphincter.

Anal manometric parameters: predictors of outcome following anal sphincter repair?

Controversy exists over the utility of manometry in the management of fecal incontinence. In light of newer methods for the management of fecal incontinence demonstrating favorable results, this study was designed to evaluate manometric parameters relative to functional outcome following overlapping sphincteroplasty. Twenty women, 29 to 84 years of age (mean age 50 years), with severe fecal incontinence and large (>or=50%) sphincter defects on ultrasound were studied. All participants underwent anal manometry (mean resting pressure, mean squeeze pressure, anal canal length, compliance), pudendal nerve terminal motor latency (PNTML) testing, and completed the American Society of Colon and Rectal Surgeons fecal incontinence severity index (FISI) survey before and 6 weeks after sphincter repair. Statistical analysis for all data included the Wilcoxon rank-sum test, Mann-Whitney test, and Spearman's correlation. Significant perioperative improvement was seen in the absolute resting and squeeze pressures and anal canal length. Overlapping sphincteroplasty was also associated with significant improvement in fecal incontinence scores (FISI 36 vs. 16.4; P=0.0001). Although no single preoperative manometric parameter was able to predict outcome following sphincteroplasty, preoperative mean resting and squeeze pressures as well as anal canal length inversely correlated with the relative changes in these parameters achieved postoperatively. These findings suggest that either the physiologic parameters studied are not predictive of functional outcome or the scoring system used is ineffective in determining function. The perioperative paradoxical changes in resting pressure, squeeze pressure, and anal canal length would support the use of overlapping sphincteroplasty in patients with significant sphincter defects and poor anal tone.

Perineal puborectalis sling operation for fecal incontinence: preliminary report

PURPOSE

This study was designed to evaluate the safety efficacy, and impact on quality of life of the perineal puborectalis sling operation for fecal incontinence.

METHODS

Since August 2001, we performed the perineal puborectalis sling operation on eight patients with idiopathic fecal incontinence. A specially designed polyester mesh sling was introduced along the puborectalis muscle, from a posterior perianal incision, running to a small suprapubic incision. The ends were tied together with moderate tension. Patients were evaluated with the Fecal Incontinence Severity Index, the Cleveland Clinic Score of Incontinence, and the Fecal Incontinence Quality of Life Scale. Manometry and defecography were performed before and six months after the operation.

RESULTS

Eight patients (7 females; mean age, 63 (range, 44-77) years) were evaluated. A wound infection developed in one patient, which subsided with antibiotics. A rectal ulcer developed in one patient, necessitating sling removal. In the remaining seven patients, the Fecal Incontinence Severity Index improved from 27 to 9, and the Cleveland Clinic Score of Incontinence improved from 13 to 5 (P < 0.05). All parameters in the Fecal Incontinence Quality of Life Scale improved: lifestyle from 2.1 to 3.6; coping/behavior from 1.5 to 3.4; depression/self perception from 2.3 to 3.7; and embarrassment from 2 to 3.6 (P < 0.05). No significant difference was found between preoperative and postoperative maximum resting pressure and maximum squeeze pressure. However, the median anorectal angle on defecography after the operation was significantly reduced (P < 0.05).

CONCLUSIONS

We believe that the perineal puborectalis sling operation is technically feasible, with low morbidity, and can be an effective procedure for idiopathic fecal incontinence.

Adjuvant biofeedback following anal sphincter repair: a randomized study

AIMS

To evaluate the impact of adjuvant biofeedback following sphincter surgery.

METHODS

Thirty-eight patients were randomized into sphincter repair or sphincter repair plus biofeedback groups. Outcome measures included a symptom questionnaire, patient's rating of satisfaction with continence function and improvement, change in continence score, quality of life and anorectal physiology. Endoanal ultrasonography was also performed pre- and post-operatively.

RESULTS

Immediately following surgery, there was no statistically significant difference in any of the functional or physiological variables between the groups. Continence and patient satisfaction scores improved with a mean difference of -0.48 (95% CI: -3.30-2.33, P = 0.73) and 1.03 (95% CI: -1.40-3.46, P = 0.39), respectively. Only the difference in embarrassment scores reached statistical significance (mean) 0.56 (95% CI: 0.12-0.99, P = 0.014). Resting and squeeze pressures also improved. Thirteen of 14 in the biofeedback and 11 of 17 (control) reported symptomatic improvement. In the biofeedback group, although not statistically significant continence and satisfaction scores improved and were sustained over time. In the control group, continence and satisfaction scores changed little between 3 and 12 months (P = NS). Quality of life measures improved within the biofeedback group but there was no statistical difference between the groups.

CONCLUSION

Following surgery continence function improves in all patients but adjuvant biofeedback therapy improves quality of life and maintains symptomatic improvement over time.

New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial

BACKGROUND AND AIMS

A randomised trial was undertaken to compare the clinical and functional results of two novel transanal stapled techniques in patients with outlet obstruction syndrome.

MATERIALS AND METHODS

Ninety-six females with outlet obstruction were treated with medical therapy and biofeedback for 2 months; 67 non-responders were evaluated by the Constipation Scoring and Continence Grading Systems, clinical examination, endoscopy, dynamic defecography, anorectal manometry, transanal ultrasound and anal EMG, and 50 of them, all affected with descending perineum, intussusception and rectocele, were randomly assigned to two groups and operated on: 25 patients (mean age 53.2+/-15.3 years) underwent a single Stapled Trans-Anal Prolapsectomy, associated with Perineal Levatorplasty (STAPL Group), and the other 25 (mean 54.6+/-14.2 years) underwent a double Stapled Trans-Anal Rectal Resection (STARR Group). Patients were followed-up for a mean period of 23.4+/-5.1 months in STAPL Group and 22.3+/-4.8 in STARR Group.

RESULTS

STARR Group showed a significantly (p<0.0001) lower pattern of postoperative pain and a greater decrease (P=0.0117) of the rectal sensitivity threshold volume; otherwise, no differences were found in operative time, hospital stay, or time of inability to work. Complications included delayed healing of the perineal wound (ten), dyspareunia (five), urinary retention (two) and stenosis (one) in STAPL Group, and urge to defecate (four), transitory incontinence to flatus (two), urinary retention (two), bleeding (one) and stenosis (one) in STARR Group. All constipation symptoms significantly improved without worsening of anal continence and with excellent/good outcome at 20 months in 76 and 88% of patients of STAPL Group and STARR Group, respectively. Seven patients of STAPL Group had a little residual rectocele, while both intussusception and rectocele were corrected in all patients of STARR Group. Neither operation modified anal pressures or caused lesions of anal sphincters.

CONCLUSIONS

Both techniques are safe and effective in the treatment of outlet obstruction; nevertheless, the double Stapled Trans-Anal Rectal Resection seems to be preferable due to less pain, absence of dyspareunia, reduced rectal sensitivity threshold volume and absence of residual rectocele at defecography.

[Results of overlapping sphincter repair in response to obstetric injury]

BACKGROUND

Obstetric trauma is one of the most common causes of faecal incontinence, and the standard therapy for clear sphincter defects is overlapping sphincter repair. We aimed to assess the short-term success rates of sphincter repair using modified V-Y plastic without covering colostomy and with primary closure of the perineum.

METHODS

Between November 1997 and March 2002, 21 patients were operated on for faecal incontinence due to obstetric trauma. Cleveland Clinic Incontinence Score (CCIS), patients' subjective assessment, and pathophysiological parameters were evaluated pre- and postoperatively.

RESULTS

At follow-up, 19 patients (90%) reported improvements in continence symptoms over their preoperative situations. Three patients (14%) classified themselves subjectively as fully continent, six (28%) as highly improved, ten (48%) as improved, and two (10%) as unchanged.

CONCLUSIONS

Our results indicate that faecal diversion is not necessary in sphincter repair and that primary perineal wound closure should be performed. Patients' subjective assessments and CCIS are suitable tools for evaluating improvements in faecal incontinence.

Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles

OBJECTIVE

To investigate whether botulinum toxin type A (BOTOX) injected into the levator ani muscles of women with objective pelvic floor muscle spasm decreases pain symptoms and improves quality of life.

DESIGN

A prospective cohort study.

SETTING

Outpatient clinic in a tertiary referral centre, Sydney, Australia.

SAMPLE

Twelve women, aged 18-55 years, with objective pelvic floor muscle hypertonicity and a minimum 2-year history of chronic pelvic pain were recruited.

METHODS

All women completed visual analog scale pain assessments; questionnaires relating to bladder and bowel symptoms and quality of life; and specific examinations. Forty units of BOTOX at three different dilutions were given bilaterally into the puborectalis and pubococcygeus muscles under conscious sedation.

RESULTS

Median visual analog scale scores were significantly improved for dyspareunia (80 vs 28; P=0.01) and dysmenorrhea (67 vs 28; P=0.03), with non-significant reductions in non-menstrual pelvic pain (64 vs 37) and dyschesia (47 vs 29). Pelvic floor muscles manometry showed a 37% reduction in resting pressure at week 4 and a 25% reduction was maintained at week 12 (P <0.0001). Quality of life scores (EQ-5D and SF-12) were improved from baseline at week 12, but did not reach statistical significance. Sexual activity scores were markedly improved, with a significant reduction in discomfort (4.8 vs 2.2; P=0.02) and improvement in habit (0.2 vs 1.9; P=0.03). These results were not influenced by dilution.

CONCLUSION

There is evidence from the present pilot study suggesting that women with pelvic floor muscles hypertonicity and pelvic pain may respond to BOTOX injections into the pelvic floor muscles. Further research into this novel treatment of chronic pelvic pain is strongly recommended.

Surgical treatment options for fecal incontinence

Although surgical therapy has been shown to be an effective treatment of anal incontinence, few properly controlled randomized studies have confirmed its efficacy or compared it with biofeedback or other less invasive forms of treatment. Overlapping sphincteroplasty, the most common procedure, seems to confer substantial benefits on patients with sphincter disruptions. However, recent data suggest that results following sphincteroplasty deteriorate with time. There is also disagreement about whether pudendal nerve conduction studies can be used to predict outcome after surgical repair. Salvage options for patients with refractory fecal incontinence include passive or electrically stimulated muscle transfer procedures, implantation of an inflatable artificial anal sphincter, and sacral nerve stimulation. Stimulated graciloplasty is the most commonly used muscle transfer procedure; good to excellent results are reported from a small number of high-volume centers, but multicenter trials with less experienced surgeons have shown a high morbidity rate associated with the procedure. The artificial anal sphincter provides good restoration of continence for most patients who retain the device, but a significant explantation rate due to infection or local complications remains problematic. Sacral nerve stimulation has shown promising early results with minimal associated morbidity. There is a critical need for controlled long-term studies that use objective data collection methods, standardized outcome measures, and validated quality-of-life assessment instruments.

Measuring fecal incontinence

The measurement of fecal incontinence is challenging. Because fecal incontinence is a symptom, the subjective perception of the patient must be the foundation of any evaluation of incontinence or the impact of incontinence. The lack of a criterion standard makes testing measures for reliability and validity more difficult. Despite this, many measures are available and can be divided into three broad categories: descriptive measures that do not provide summary scores; severity measures that assess the frequency and type of incontinence; and impact measures that assess the effect of incontinence on quality of life. The strengths and weaknesses of currently available measures are presented in this review.

Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the anal canal (Secca procedure) for the treatment of fecal incontinence

PURPOSE

This multicenter study evaluated the safety and efficacy of radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence.

METHODS

Fifty patients at five centers were enrolled. All reported fecal incontinence at least once per week for three months, and medical and/or surgical management failed to help their symptoms. At baseline and at six months, patients completed questionnaires (Cleveland Clinic Florida Fecal Incontinence score (0-20), fecal incontinence-related quality of life, Short Form-36, and visual analog scale) and underwent anorectal manometry, endoanal ultrasound, and pudendal nerve terminal motor latency testing. On an outpatient basis using local anesthesia, radio-frequency energy was delivered via an anoscopic device with multiple needle electrodes (Secca system) to create thermal lesions deep to the mucosa of the anal canal.

RESULTS

Forty-three females and seven males (aged 61.1 +/- 13.4 (mean +/- standard deviation); range, 30-80 years) were treated. Mean duration of fecal incontinence was 14.9 years. Treatment time was 37 +/- 9 minutes. At six months, the mean Cleveland Clinic Florida Fecal Incontinence score improved from 14.5 to 11.1 (P < 0.0001). All parameters in the Fecal Incontinence Quality of Life scales were improved (lifestyle (from 2.5-3.1; P < 0.0001); coping (from 1.9-2.4; P < 0.0001), depression (from 2.8-3.3; P = 0.0004); embarrassment (from 1.9-2.5; P < 0.0001)). Responders, as assessed by a systematic referenced analog scale, reported a median 70 percent resolution of symptoms. The mean Short Form-36 social function improved from 64.3 to 76 (P = 0.003). There were no changes in endoanal ultrasound or pudendal nerve terminal motor latency assessment, or in anal manometry. Complications included mucosal ulceration (one superficial, one with underlying muscle injury) and delayed bleeding (n = 1).

CONCLUSION

This multicenter trial demonstrates that radio-frequency energy can be safely delivered to the lower rectum and anal canal. The Secca procedure significantly improved the Cleveland Clinic Florida Fecal Incontinence score and the overall quality of life for most patients having undergone the procedure.

The functional and psychosocial impact of fecal incontinence on women with urinary incontinence

OBJECTIVES

The study was undertaken to determine the impact of fecal incontinence (FI) on functional status and quality of life in women with urinary incontinence (UI).

STUDY DESIGN

In 24 months 732 women completed a standardized assessment and questionnaire, including the Short Form (SF)-12 and Incontinence Quality of Life (I-QOL) scores. Analysis of variance was used to compare SF-12 scores between groups defined as having UI, FI, or both UI and FI. I-QOL scores in patients with UI or UI and FI were compared by using the Student t test.

RESULTS

Of the 732 patients enrolled, 425 patients had either UI (n = 342, 80%), FI (n = 18, 4%), or both (n = 65, 15%). Greater impairment in physical functioning was seen in the group with UI and FI (38.6; P =.027) compared with the group with UI (42.4). Significant decreases in I-QOL scores were seen for the group with UI and FI compared with those with UI (P <.005).

CONCLUSION

Fecal incontinence further reduces the functional status and quality of life of women with urinary incontinence.

Delayed sphincter repair for obstetric ruptures: analysis of failure

OBJECTIVE

The aim of this study was to examine the clinical results after anterior anal sphincter repair in patients with obstetric trauma and to evaluate possible risk factors for poor outcome.

PATIENTS AND METHODS

In years 1990-99 anterior anal sphincter repair for anal incontinence due to obstetric trauma was performed in 39 patients at Helsinki University Central Hospital. Clinical examination with Parks' classification and patients' questionnaire with endoanal ultrasound (EAUS) were done before and after surgery. Pudendal nerve terminal motor latency (PNTML) was measured postoperatively. The median follow-up time after the operation was 22 months (range 2-99).

RESULTS

The follow-up results of the patients' questionnaire for 12 patients (31%) were good, for 15 patients (38%) acceptable and for 12 patients (31%) poor. Postoperative EAUS showed sphincter overlap in 28 (72%) patients but a defect was still found in 11 (28%) patients. A defect found on postoperative EAUS correlated with poor clinical result according to Parks' (R = 0.8, P < 0.01) and patients' questionnaire results (R = 0.7, P < 0.01). Patients with poor clinical results (Parks III/IV) were statistically significantly older (median 63 years, range 26-73) than those with favourable results (Parks I/II) (median 45 years, range 27-79) (P < 0.05). Further, the duration of incontinence symptoms correlated with poor functional results (R=0.4, P < 0.05).

CONCLUSION

After obstetric trauma anterior anal repair gives acceptable short-term clinical results. EAUS investigation is easy and harmless to perform and should be used pre- and post-operatively. Advanced age, pre-operative signs of perineal descent, long-lasting severe incontinence symptoms and a persistent defect on postoperative EAUS seem to be related to poor clinical result.