Randomized trial comparing three forms of pelvic floor repair for neuropathic faecal incontinence

A systematic review and network meta-analysis comparing treatments for faecal incontinence

BACKGROUND

Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI.

MATERIALS AND METHOD

A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method.

RESULT

Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo.

CONCLUSION

SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.

A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults

AIM

To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults.

METHODS

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI.

RESULTS

The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ^TM versus Durasphere^®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions.

CONCLUSIONS

The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Systematic Review of Surgical Treatments for Fecal Incontinence

BACKGROUND

No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments.

OBJECTIVE

The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults.

DATA SOURCES

Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources.

STUDY SELECTION

Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980-2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment-outcome combination.

INTERVENTIONS

Surgical treatments for fecal incontinence were included interventions.

MAIN OUTCOME MEASURES

Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured.

RESULTS

Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%-100%). Major surgical complications often required reoperation; few required permanent colostomy.

LIMITATIONS

Most evidence is intermediate term, with small patient samples and substantial methodologic limitations.

CONCLUSIONS

Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop

This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (for example pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH METHODS

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 6 March 2013), the Cochrane Colorectal Cancer Group Specialised Register (searched 6 March 2013), CENTRAL (2013, issue 1) and EMBASE (1 January 1998 to 6 March 2013) were undertaken. The British Journal of Surgery (1 January 1995 to 6 March 2013), Colorectal Diseases (1 January 2000 to 6 March 2013) and the Diseases of the Colon and Rectum (1 January 1995 to 6 March 2013) were specifically handsearched. The proceedings of the Association of Coloproctology of Great Britain and Ireland annual meetings held from 1999 to 2012 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Nine trials were included with a total sample size of 264 participants. Two trials included a group managed non-surgically. One trial compared levatorplasty with anal plug electrostimulation and one compared an artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but the numbers were small. The other trial showed no difference in the primary outcome measures.Seven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, and total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

AUTHORS' CONCLUSIONS

The review is striking for the lack of high quality randomised controlled trials on faecal incontinence surgery that have been carried out in the last 10 years. Those trials that have been carried out have focused on sacral neuromodulation and injectable bulking agents, both reported in separate reviews. The continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH STRATEGY

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 26 November 2009), the Cochrane Colorectal Cancer Group Specialised Register (searched 26 November 2009), CENTRAL (The Cochrane Library 2009) and EMBASE (1 January 1998 to 30 June 2009) were undertaken. The British Journal of Surgery (1 January 1995 to 30 June 2009) Colorectal Diseases (1 January 2000 to 30 June 2009) and the Diseases of the Colon and Rectum (1 January 1995 to 30 June 2009) were specifically handsearched. The proceedings of the UK Association of Coloproctology meeting held from 1999 to 2009 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Thirteen trials were included with a total sample size of 440 participants. Two trials included a group managed non-surgically. One trial compared levator with anal plug electrostimulation and one compared artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but numbers were small. The other trial showed no difference in primary outcome measures.Eleven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, injection of silicone, hydrogel, physiological saline, carbon beads or collagen bulking agents, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are also considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

AUTHORS' CONCLUSIONS

Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*

OBJECTIVE

Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period.

METHOD

Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months).

RESULTS

Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05).

CONCLUSION

Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-surgical interventions (e.g. pelvic floor muscle training, biofeedback, drugs, sacral nerve stimulation) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex or replace an absent/non-functioning sphincter.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (31 January 2006), the Cochrane Colorectal Cancer Group trials register (31 January 2006), the Cochrane Central Register of Controlled Trials (2006, Issue 1), PubMed (1 January 1950 to 31 January 2006) and EMBASE (1 January 1998 to 31 January 2006) were undertaken. The British Journal of Surgery (January 1995 to May 2006) Colorectal Diseases (January 2000-May 2006) and the Diseases of the Colon and Rectum (January 1995 to May 2006) were specifically handsearched. The proceedings of the Association of Coloproctology meeting held from 1999 to 2006 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Nine trials were included with a total sample size of 264 participants. Two trials included a group managed non-surgically. One trial compared levatorplasty with anal plug stimulation, one compared artificial bowel sphincter with best supportive care; numbers were small in both trials. The artificial bowel sphincter insertion was followed by significant improvements in at least one primary outcome but with high rates of significant morbidity. Seven studies compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Only one comparison had more that one trial (total pelvic floor versus postanal repair-44 participants) and no comparison showed any statistically significant difference in primary outcome measures, with wide confidence intervals.

AUTHORS' CONCLUSIONS

Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Selecting an outcome measure for evaluating treatment in fecal incontinence

PURPOSE

Various outcome measures exist to evaluate treatment in fecal incontinence, including descriptive, severity (fecal incontinence scoring systems), and impact (quality-of-life questionnaires) and diagnostic measures. We studied associations between changes after treatment for a number of outcome measures and compared them to patients' subjective perception of relief.

METHODS

We analyzed data of 66 patients (92 percent female; mean age, 62 years) (Vaizey score, Wexner score, two impact scales, utility, resting pressure, and maximal incremental squeeze pressure) at baseline and after physiotherapy. In a standardized interview by phone, we asked patients to compare their situation before and after treatment. Correlations between changes in outcome measures were calculated. These changes were compared with patients' subjective perception.

RESULTS

There was a high correlation between the changes in the Vaizey and the Wexner scores (r = 0.94, P < 0.01). Changes in Vaizey and Wexner scores correlated moderately with changes in maximum incremental squeeze pressure (r = -0.29, -0.30, both P < 0.05). Changes in utility and resting pressure were not correlated with changes in any of the other measurements (all r values between -0.086 and 0.18). Average severity scores (Vaizey and Wexner) were 1 point lower for patients who rated their situation as worse or equal (62 percent), 4 points lower for patients who reported their situation to be better (21 percent), and 9 points lower in patients who rated their situation much better (17 percent) (P < .05).

CONCLUSION

Severity measures are best related to patients' subjective perception of relief.

Long-term outcome of postanal repair in the treatment of faecal incontinence

BACKGROUND

Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence.

OBJECTIVES

The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence.

PATIENTS AND METHODS

Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated.

RESULTS

Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively (P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse.

CONCLUSIONS

Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.

Fecal incontinence: an up-to-date critical overview of surgical treatment options

BACKGROUND

Surgery is the last resort for patients suffering from severe fecal incontinence. The armamentarium of surgical options for this condition has increased impressively during the last decade. Nevertheless, this fact seems to make neither patients nor surgeons feel more comfortable. Treatment of fecal incontinence still remains a challenge to modern medicine due to many specific sides of this problem.

AIMS

This article gives an up-to-date overview of existing operative treatment options.

METHODS

An unbiased review of relevant literature was performed to assess the role of all methods of surgical treatment for fecal incontinence available nowadays.

RESULTS

Recent studies have shown poor late results after primary sphincter repair and low predictive value for most preoperative diagnostic tests. New surgical options such as artificial devices and electrically stimulated muscle transpositions are doomed by low success rates and unacceptably frequent complications. That is why current attention has focused on non- or minimally invasive therapies such as sacral nerve stimulation and temperature-controlled radio-frequency energy delivery to the anal canal. However, all these innovative techniques remain experimental till enough high-evidence data are gathered for their objective evaluation.

CONCLUSION

Careful and detailed preoperative assessment to exactly determine the etiology of incontinence and individual approach remain the cornerstones of surgical treatment of fecal incontinence nowadays.

Review article: the management of pelvic floor disorders

Anorectal disorders, such as faecal incontinence, defecation difficulty and conditions associated with anorectal pain, are commonly encountered in the practices of gastroenterologists, urogynaecologists and colorectal surgeons. The evaluation of these disorders has been very much improved by the development and wider availability of diagnostic tests, such as manometry, endo-anal ultrasound, static and dynamic pelvic magnetic resonance imaging and electromyography. After briefly reviewing the normal anatomy and physiology of the anorectum, the pathophysiology and diagnostic approaches to faecal incontinence, defecation disorders and functional anorectal pain are discussed. Until recently, the management of these disorders has been largely anecdotal. However, our therapeutic armamentarium has been expanded by pharmacological agents, such as nitrates, calcium channel blockers and botulinum toxin, as well as the development of novel techniques, such as sacral nerve stimulation. These and other pharmacological, behavioural and surgical approaches are reviewed with respect to the robustness of evidence to support their efficacy in patients with these disorders.

Systematic review of dynamic graciloplasty in the treatment of faecal incontinence

Background

The aim of this systematic review was to compare the safety and efficacy of dynamic graciloplasty with colostomy for the treatment of faecal incontinence.

Methods

Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase and Cochrane Library databases up until November 1999. Inclusion of papers depended on a predetermined protocol, independent assessments by two reviewers and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials and case series. Forty papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance.

Results

No high-level evidence was available and there were no comparative studies. Mortality rates were around 2 per cent for both graciloplasty and colostomy. Morbidity rates reported for graciloplasty appear to be higher than those for colostomy. Dynamic graciloplasty was clearly effective at restoring continence in between 42 and 85 per cent of patients, whereas colostomy is, by its design, incapable of restoring continence. However, dynamic graciloplasty is associated with a significant risk of reoperation.

Conclusion

While dynamic graciloplasty appears to be associated with a higher rate of complications than colostomy, it is clearly a superior intervention for restoring continence in some patients. It is recommended that a comparative, but non-randomized, study be undertaken to evaluate the safety of dynamic graciloplasty in comparison to colostomy, and that the procedure should be performed only in centres where it is carried out routinely.

Recent developments in the treatment of faecal incontinence

Many patients with faecal incontinence can be cured using a simple anal sphincter repair. Some patients are unsuitable for this either because the sphincter is absent, too extensively damaged or anal sphincter repair has failed. In these patients novel treatments have been introduced to augment, replace and stimulate the anal sphincter.

Clinical and economic evaluation of surgical treatments for faecal incontinence

BACKGROUND

Faecal incontinence affects 1-2 per cent of the adult population. While many patients can be managed successfully with conservative therapy, a small proportion require surgery. Improved imaging techniques and technological advances have led to the availability of a wide range of surgical treatments. Decision-makers increasingly require clinical and cost-effectiveness studies of surgical treatments for faecal incontinence. This review examines the practical aspects of undertaking such studies.

METHODS

The practical issues related to different aetiologies, different types of treatment, defining outcomes, the hidden costs of the condition and its treatment, the rapid changes in technology and issues of patient choice were all considered. A Medline search was undertaken to identify relevant publications, and the reference lists of identified papers were scanned manually.

RESULTS

There are few randomized controlled studies and those that have been performed have been limited in their scope. There has also been very limited health economic analysis undertaken. Strategies for conducting such studies, and the criteria they use, have been outlined.

CONCLUSION

Randomized trials have a limited role in this setting because of variations in aetiology, difficulty in standardizing procedures, continuing evolution of devices, small patient numbers, concerns for patient choice and the need for long-term follow-up. Issues to be addressed when evaluating interventions for faecal incontinence include choosing appropriate measures of surgical outcome, using new continence scoring systems and tools for quality-of-life assessment, and choosing appropriate cost perspectives and time horizons for economic evaluation.

Surgical treatment of constipation and fecal incontinence

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Neosphincters in the management of faecal incontinence

BACKGROUND

Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition.

METHODS

A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts.

RESULTS

The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the artificial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the artificial sphincter. Both of the above operations have been associated with implant-related infection and impaired evacuation.

CONCLUSION

Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres. Patients are likely to benefit from a plan that incorporates preoperative counselling and a selective approach.

Factors predictive of outcome after surgery for faecal incontinence

BACKGROUND

Surgical treatment of faecal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device.

METHODS

This article reviews the currently available surgical options for the treatment of faecal incontinence, discusses factors predictive of outcome, and includes an algorithm for treatment.

RESULTS AND CONCLUSION

Procedures such as postanal repair, direct sphincter repair and reefing are seldom used. Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma. Pudendal neuropathy seems to be a predictive factor of success, although this is not universally accepted. Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter. The success and morbidity rates with the stimulated graciloplasty and artificial bowel sphincter appear similar. The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for faecal incontinence. Presented as the Edinburgh Royal College of Surgeons invited lecture to the Association of Coloproctology of Great Britain and Ireland, Southport, UK, June 1999

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. Surgery is used in selected groupsof people when the structural and functional defects in the pelvic floor muscles or the anal sphincter complex can be corrected mechanically.

OBJECTIVES

To assess the effects of established surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aims were firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Colorectal Cancer Group trials register, the Cochrane Controlled Trials Register (Issue 2, 1999), Medline (up to March 1999), Embase (1998 up to January 1999), Sigle (1980 up to December 1996), Biosis (1998 up to March 1999), SCI (1998 up to March 1999), ISTP (1982 up to March 1999) and the reference lists of relevant articles. We specifically hand searched the British Journal of Surgery from 1995 to 1998 and the Diseases of the Colon and Rectum from 1995 to 1998. We also perused the proceedings of the Association of Coloproctology, meeting 1999. Date of the most recent literature searches: March 1999.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other then surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature, extracted data and assessed the methodological quality of eligible trials. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Four trials were included with a total sample size of 110 participants. All trials excluded women with anal sphincter defects detected by endoanal ultrasound examination. No trial included a group managed non-surgically. Two trials (56 participants) compared three approaches to pelvic floor repair (anterior levatorplasty, postanal repair and their combination total pelvic floor repair). One trial (30 participants) evaluated adding plication of the anal sphincter to total pelvic floor repair. The fourth trial (24 participants) compared a neosphincter procedure with total pelvic floor repair. No differences in the primary outcomes were detected, but data were few and inconsistently reported.

REVIEWER'S CONCLUSIONS

The small number of relevant trials identified together with their small sample sizes and other methodological weaknesses severely limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are needed.

Is electrostimulation of the pelvic floor an effective treatment for neurogenic faecal incontinence?

BACKGROUND

This study was designed to evaluate the results of electrostimulation of the pelvic floor for faecal incontinence.

METHODS

Twenty-four patients with neurogenic (n = 20) or idiopathic (n = 4) incontinence were treated on 12 occasions. Twenty were women, and the mean age was 63 years (range, 26-85 years). The result was evaluated at 3 and 12 months with a validated questionnaire and anorectal manometry.

RESULTS

Eleven patients (46%) reported improvement after 3 months, and the Miller's incontinence score was reduced (P < 0.01). Resting pressures, rectal compliance, and the length of the high-pressure zone were unchanged, but squeeze pressures tended to decrease. A lower threshold was seen for the rectoanal inhibitory reflex (RAIR) (P < 0.01), and the saline infusion test tended to show improved retention (P = 0.07). Nine of 13 patients followed up for 1 year claimed improvement. The most pronounced subjective improvement was seen in patients with moderate incontinence.

CONCLUSIONS

Electrostimulation was successful in a substantial proportion of the patients. The threshold for RAIR was lowered, and the saline infusion test tended to improve, but variables reflecting sphincter competence did not improve. Moderate incontinence was prognostically favourable, and electrostimulation might therefore be an alternative to surgery in this group.

A pilot study of total pelvic floor repair or gluteus maximus transposition for postobstetric neuropathic fecal incontinence

PURPOSE

The aim of this study was to report pilot data comparing the morbidity and functional outcome of total pelvic floor repair with gluteus maximus transposition for women with postobstetric fecal incontinence.

METHODS

This is a prospective, randomized trial of two surgical procedures in 24 women so far. Functional assessment was performed with use of a 20-point clinical incontinence score and patient questionnaire before and after operation. The physiologic parameters, before and after operation, included resting and squeeze anal pressures, length of the high pressure zone, anal and rectal mucosal sensitivity, and pudendal nerve latency.

RESULTS

So far, 12 patients have been treated by total pelvic floor repair and 12 by gluteus maximus transposition. Of these, three patients developed wound complications after gluteus maximus transposition compared with none after total pelvic floor repair. Among these cases there was a significant overall improvement in functional score (given as mean +/- standard deviation) after both total pelvic floor repair (13.1 +/- 2.7 vs. 6.6 +/- 4.5; P < 0.001) and gluteus maximus transposition (13.8 +/- 3.8 vs. 7.7 +/- 6.1; P < 0.01), although no difference existed between the groups. There was no change in any of the physiologic measurements after either operation, and preoperative measurements did not identify patients likely to do badly.

CONCLUSIONS

We conclude from these preliminary data that both total pelvic floor repair and gluteus maximus transposition significantly improve continence in women with postobstetric neuropathic fecal incontinence. Gluteus maximus transposition gives equivalent results to total pelvic floor repair. Neither procedure has any influence on anorectal physiologic parameters.

Management of colorectal-anal dysfunction

Although the majority of patients with low-grade anal incontinence and constipation should be treated medically, for some, efforts will be unsuccessful and surgical therapy will be in order. Full thickness rectal prolapse will, in all early cases, be treated surgically. This article outlines the surgical treatment options for patients with anal incontinence, rectal prolapse, and constipation. Optimal functional outcomes with surgical treatment are based on full physiologic evaluation and careful patient selection.

The recto-anal inhibitory reflex: abnormal response in diabetics suggests an intrinsic neuroenteropathy

As electrical stimulation of the rectum has been shown to result in reflex internal sphincter inhibition mediated by intrinsic nerves, we aimed to evaluate the integrity of these nerves in the rectum of diabetic patients. Anal canal pressure, recto-anal inhibitory reflex (RAIR) and continence were evaluated in 30 diabetic patients (male:female 13:17, median age 57 years, range 37-70) and these data were compared with similar data obtained from 22 age- and sex-matched healthy controls (male:female 9:13, median age 51 years, range 19-65 years). Median duration of diabetes was 8 years (range 3-30). Twelve (40%) of the 30 diabetics had impaired continence for gas (n = 12) and liquid faeces (n = 3). None of the controls had incontinence. Median maximum resting anal canal pressure (MRP) was: patients 30 mmHg (range 20-75 mmHg) versus controls 40 mmHg (range 20-105 mmHg, P = 0.61). Median maximum squeeze pressure (MSP) was 65 mmHg (range 30-150 mmHg) in patients versus 84mmHg (range 35-230 mm Hg) in controls (P = 0.59). Median threshold rectal mucosal electrosensation (RMES-T) was 27mA (5-40 mA) in patients versus 13 mA (5-28 mA) in controls (P = 0.03). Maximum tolerable rectal mucosal electrosensation was 40 mA (20-60) in patients versus 20 mA (10-30), in controls (P = 0.042, all comparisons using the Wilcoxon rank test). Recto-anal inhibitory reflex was present in eight, abnormal in five (one incontinent) and absent in 17 (11 incontinent) diabetics, while it was present in 18 and abnormal in four controls (test of proportion, P = 0.031). Blood glucose in diabetics on the day of the procedure was 98 mg/dL (70-165 mg/dL). Rectal mucosal electrosensitivity and RAIR were impaired in significantly more patients with diabetes than controls, implying impairment of intrinsic neuronal function. The recto-anal inhibitory reflex was either impaired or absent in all diabetic patients with incontinence.

A clinical approach to fecal incontinence

Fecal incontinence is the impaired ability to control gas or stool. It is a disabling and distressing condition. Its exact incidence and prevalence are unknown. It is a disorder about which patients are frequently reluctant to discuss, even with their physician. However, it is a common condition especially in older individuals, where the prevalence has been reported to approach 60%. In women, incontinence reaches 54% as a result of childbirth. Of the patients surgically treated, the female-to-male ratio is 4 to 1. In an epidemiological study to identify its community-based prevalence, the University of Illinois determined fecal incontinence existed in 2.2% of the general population. There is available treatment for fecal incontinence. Many patients improve with conservative treatment (constipating agents, antidiarrheal medications, dietary changes) or with biofeedback. For patients where conservative treatment has failed, surgical treatment (direct-apposition sphincter repair, overlapping sphincteroplasty, postanal repair, neosphincter procedures) may be successful.

Recent advances in the surgical treatment of faecal incontinence

BACKGROUND

Improved imaging and refined technology have led to a number of recent advances in the surgical treatment of faecal incontinence.

METHODS

Original articles, identified using a computer database (Medline), and recently published abstracts of meetings were selected on the basis of greatest clinical relevance; these were reviewed.

RESULTS

Ultrasonographic characterization has led to improved therapeutic strategies. Simple structural damage is readily identified and external sphincter repair results in a good outcome for a majority of patients. For more complex structural damage, or for the newly recognized primary internal sphincter degeneration, alternative treatment strategies are emerging. The electrically stimulated gracilis neosphincter and the artificial bowel sphincter offer good results. The latter may be a more simple operation. For structurally intact but weak sphincters, sacral nerve stimulation is a promising therapy. Other therapies, such as antegrade irrigation, may be helpful for patients with neurological disorders.

CONCLUSION

Better imaging, refined classification and new operations are leading to improved surgical techniques for faecal incontinence.

Pelvic floor procedures produce no consistent changes in anatomy or physiology

PURPOSE

Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence.

METHOD

Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test.

RESULTS

Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant.

CONCLUSION

Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.

Postanal repair for faecal incontinence: long-term follow-up

BACKGROUND

To determine the long-term outcome of postanal repair, and to assess whether the preoperative and physiological tests had any bearing on this outcome. Review included an opportunity for assessment with anal manometry and anal ultrasound.

METHOD

Review of all patients (n = 22) over a 10 year period from 1986 to 1996. Comparison was of pre-operative symptoms to symptoms at review. Correlation of outcome with pre-operative manometry and the results of manometry and ultrasound at review (n = 6) was determined.

RESULTS

Assessment was possible in 19 of the 22 patients. Follow-up ranged from 2 to 10 years (median, 8 years). Two had stomas created at 6 and 9 months and are considered failures. Seven patients considered the operation a success, in four it improved their symptoms and in six it was considered a failure. Comparison of pre- and postoperative symptoms scores found a statistically significant improvement (P = 0.0093; two-tailed Wilcoxon signed rank sum test). The outcome was not influenced by the results of pre-operative anal manometry. Anal ultrasound found five sphincter defects in six patients. Such defects did not preclude improvement from postanal repair.

CONCLUSIONS

Although the results showed improvement or success in only 11 (58%) of the patients this was felt to be important given that these patients may have few alternatives other than complicated procedures or a stoma. Postanal repair has a place in the management of faecal incontinence.

Long-term results of total pelvic floor repair for postobstetric fecal incontinence

PURPOSE

This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence.

METHOD

Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18-78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology.

RESULTS

Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome.

CONCLUSION

Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.

Rectovaginal fistulas. Therapeutic options

The management of RVF depends on size, location, and cause; anal sphincter function and overall health status of the patient; and the skill and judgment of the surgeon. Careful preoperative assessment of the fistula, surrounding tissues, and anal sphincter and exclusion of associated disease are essential. With thorough evaluation, thoughtful consideration of treatment options, and meticulous operative technique, patients can be assured of an optimal outcome. Success in treatment of patients with RVF should be measured not just in terms of successful closure of the fistula but also in terms of patient satisfaction with postoperative anal continence.

Evaluation of a questionnaire in the assessment of patients with faecal incontinence and constipation

BACKGROUND

A self-reported questionnaire may be a useful instrument in assessing patients with faecal incontinence and constipation.

METHODS

Reliability, discrimination, validity, and sensitivity were evaluated in 16 control subjects 36 patients with faecal incontinence, and in 38 with constipation. The reliability was measured by a test-retest procedure (kappa (kappa) statistics or Spearman rank test), and validity by comparing the questionnaire and a diary. Discrimination was assessed by comparing the patient groups with the controls, and sensitivity by comparing selected answers before and after treatment.

RESULTS

Overall reliability (faecal incontinence group, mean kappa = 0.57; constipation group, mean kappa = 0.60; controls, mean kappa = 0.95) and validity were judged acceptable. In the incontinence group occurrence of faecal incontinence per se was reproducible (kappa = 0.66), as was the need to wear a pad (kappa = 0.85). Stool frequency, percentage toilet time spent straining and digitation was reproducible in patients with constipation (kappa = 0.80, r = 0.56; p < 0.001, kappa = 0.83 respectively). Several items distinguished both patient groups from healthy controls (p < 0.05 to p < 0.001). Sensitivity to surgical treatment was seen in several items in both patient groups.

CONCLUSIONS

The questionnaire appears to be a valid measure of symptoms in faecal incontinence and constipation with sufficient discriminatory capacity.

Long-term results of anterior levatorplasty for fecal incontinence. A retrospective study

PURPOSE

To review the long-term results of anterior levatorplasty for fecal incontinence.

METHODS

Fifty-four women with obstetric trauma and 31 with idiopathic incontinence responded to a questionnaire 1.5 to 18.5 (median, 8.5) years after anterior levatorplasty. Results were classified as excellent, good, fair, or poor.

RESULTS

An excellent or good result was reported in 40 of 54 (74 percent) patients with an obstetric injury and in 14 of 31 (45 percent) patients in the idiopathic group (P < 0.01). The presence of a cloaca (P < 0.05) and a young age (P < 0.05) were associated with a favorable outcome in the obstetric and idiopathic group, respectively. Length of follow-up and preoperative severity of incontinence were not significantly related to outcome.

CONCLUSIONS

This study suggests that every second patient undergoing anterior levatorplasty for fecal incontinence has a successful result that is sustained in the long term. Obstetric trauma, presence of a cloaca, and young age are associated with a successful outcome.

External anal sphincter defects: correlation between pre-operative anal endosonography and intraoperative findings

In order to correlate operative findings with external anal sphincter (EAS) defects identified on anal endosonography (AES), 30 faecally incontinent patients undergoing overlapping sphincteroplasty or total pelvic floor repair were investigated by AES before and after surgery. Endosonic findings were correlated with the appearance of EAS at operation. 21 out of 22 defects seen at surgery had been pre-operatively detected by AES (one false negative). Post-operatively the sphincteroplasty was clearly evident on AES. In three cases of failure it showed an extensive hypoechoic area and these patients underwent dynamic graciloplasty. Endosonography is the method of choice for pre-operative imaging of EAS, having an established role in identifying sphincter defects and correlating well with intraoperative findings. Post-operatively, it has the potential to identify breakdown of the previous repair, allowing prompt surgical intervention. Endosonography is helpful in planning the best type of operation following sphincter injury and is useful in auditing the results of surgery.

Secondary surgery after failed postanal or anterior sphincter repair

Secondary surgery after failed postanal repair or anterior sphincter repair was performed in eight female patients. After failed postanal repair in five patients, anterior sphincter plication and levatorplasty was the secondary procedure. In two patients a defect of the anterior external sphincter was corrected and in two patients an extremely thin external sphincter was augmented. This contributed to an excellent result in three and a good result in one patient. No improvement was achieved in one patient without anterior defect. After failed anterior sphincter repair in three patients, postanal repair was the secondary procedure. A good result was obtained in one patient and failure in two. Secondary surgery failed postanal or anterior sphincter repair may have a good result in the majority of patients.