Physiological and clinical outcome of anterior sphincteroplasty

Comparison of clinical outcomes between remodified Hanley procedure and modified Hanley procedure for high complex horseshoe fistula: a retrospective study

BACKGROUND

Treating high horseshoe anal fistula (HHAF) with the modified Halley procedure (MHP) often falls short when focusing solely on deep postanal space (DPAS) drainage. Our study underscores the significance of addressing deep posterior intersphincteric space (DPIS) drainage, prompting MHP modifications.

METHODS

We studied consecutive patients with HHAF treated with either MHP or remodified-MHP (Re-MHP) at Ningbo Medical Center of Lihuili Hospital from January 2018 to December 2021. Postoperative outcomes, encompassing complications, cure rates, pain, anal incontinence, and quality of life, were retrospectively assessed.

RESULTS

Cure rates for MHP and Re-MHP were 95.3% (41/43) and 82.1% (32/39), respectively, without statistical significance (χ2 = 3.7, P = 0.08). VAS-PS, CCF-IS, and QLAF-QS scores significantly increased postsurgery and gradually decreased. Notably, Re-MHP demonstrated significantly lower VAS-PS scores during the first postoperative week, lower QLAF-QS scores on the seventh day, and more drainage secretions on the first day (P < 0.05).

CONCLUSION

Simultaneously enhancing DPAS and DPIS drainage in Re-MHP can enhance the cure rates of HHAF patients while preserving minimally invasive attributes.

Botulinum toxin injection for chronic anal fissure: a prospective controlled study with long follow-up

BACKGROUND

Botulinum toxin is an effective therapeutic option for chronic anal fissure. However, there is no evidence about treatment standardization and long-term follow-up. We aimed to evaluate the short- and long-term efficacy and safety of botulinum toxin compared to close lateral internal sphincterotomy, with a 5-year follow-up.

METHODS

This was a prospective, controlled, single-center study conducted at University Hospital of Ferrara, Ferrara, Italy. The primary outcome was fissure healing at 1 month. Secondary outcomes were Quality-of-Life (QoL) at 1 month and after 5 years, and fissure recurrence at 6 months and 5 years.

RESULTS

A total of 59 patients received botulinum toxin injection (Botox), and 32 underwent lateral internal sphincterotomy. At 1 month after treatments, postoperative pain decreased faster and significantly more in the Botox group (30 vs. 60 mm; P<0.001); fissure re-epithelization was observed in 59.4% of the surgical group compared to 25.4% of Botox (P=0.0001). Anal sphincter pressures decreased more in surgical group (P=0.044), although severe anal incontinence was present only in this subset (6.2%; P=0.041). Compared to surgery, patients who received Botox had higher satisfaction rates (P<0.001). Fissure recurrence at 6 months was more common in Botox than surgical group (16.9% vs. 3.2%, respectively; P=0.053). The overall healing rate improved in all patients and persisted at 12 months and 5 years in both groups with overall high patient satisfaction despite mild anal incontinence in 21.8% in the surgery group (P<0.05).

CONCLUSIONS

Botox, rather than surgery, should be considered the first-line treatment for chronic anal fissure.

A Predictive Model to Identify the Effects of Transcutaneous Sacral Nerve Stimulation With Pelvic Floor Exercises in Fecal Incontinence After Surgery for Anorectal Malformation

INTRODUCTION

Although the combination of transcutaneous sacral nerve stimulation (tSNS) and pelvic floor exercises (PFEs) has shown significant effectiveness in treating fecal incontinence (FI) after surgery for congenital anorectal malformation (CARM), not all patients achieve satisfactory continence. Therefore, identifying which individuals will benefit from this method is crucial.

METHODS

A prospective cohort study enrolled 92 children with FI. All patients underwent tSNS with PFE treatment, and an improved outcome was defined as a Wexner score ≤4. A predictive model to identify the effects of tSNS with PFEs in FI was developed based on the analysis of magnetic resonance imaging and high-resolution anorectal manometry with area under the receiver-operating characteristic curve to evaluate the predictive value of external anal sphincter (EAS) thickness index and anal squeezing pressure (ASP).

RESULTS

tSNS with PFEs improved outcomes in 72 patients and led to poor outcomes in 20 (4 had their rectums deviate from the puborectalis muscle center or puborectal muscle ruptures while 16 lacked EAS with a lower ASP). The areas under the receiver-operating characteristic curve for EAS thickness index and ASP in predicting the effects of tSNS with PFEs were 0.915 (95% confidence interval 0.846-0.983, P = 0.000) and 0.886 (95% confidence interval 0.819-0.952, P = 0.000), respectively. By applying cutoff values of 0.076 for EAS thickness index and 21.95 mm Hg for ASP, tSNS with PFEs was found to be ineffective.

DISCUSSION

tSNS with PFEs is effective for most patients with FI after CARM surgery, except when the rectum deviates from the puborectal muscle center, puborectal muscle rupture occurs, or EAS is absent with a low ASP.

Benign Anorectal Disorder Management in Low-Resource Settings

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

Multimodal Management of Fecal Incontinence Focused on Sphincteroplasty: Long-Term Outcomes from a Single Center Case Series

The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985−2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60−173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS > 15 vs. 2.5% postoperatively; p < 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair.

REAL CLINICAL PRACTICE OF POSTPARTUM ANAL INCONTINENCE TREATMENT IN RUSSI

Aim: To evaluate the medical care quality provided to patients with fecal incontinence in practice; to investigate the patient care effectiveness; to identify the problems the patient and the doctor are faced during the postpartum anal incontinence (AI) treatment.

Methods: A questionnaire for surgeons was created using Google forms. It includes 22 questions about medical characteristics of patients with AI, used diagnostic methods, and treatment results. The answers were analyzed and presented as histograms.

Results: Totally 134 (17.4%) questionnaires were completed from September to November 2020. Labor was the most common AI cause (74.4%). The median age was 20-40 years, 37% of patients was >40 years, 8% – >60 years. The most common complaints were incontinence (70%) and decreased life quality (72%). Rectovaginal fistulas were diagnosed in 28% of cases. The sphincter complex lesion size, age and anorectal manometry results determined the treatment strategy. Only 8.8% of surgeons suggested sacral neurostimulation in case of the other methods inefficiency. Up to 16.7% of patients were offered to create stoma as the final treatment method.

Discussion: Our study is the first major survey for proctologists and surgeons in Russia, assessing the medical care of patients with postpartum AI. The results indicate insufficient attention to this problem; it requires educational and organizational solutions. Regional or federal centers where obstetrician and surgeons can work cooperatively could be extremely helpful to provide appropriate medical care to these patients and to improve the treatment quality for women with postpartum AI.

Long-Term Functional Outcome After Stapled and Excisional Hemorrhoidectomy

Stapled hemorrhoidectomy (SH) as described by Longo is a recently added option for hemorrhoid surgery. Interest in SH has been principally driven by the fact that conventional excision hemorrhoidectomy (EH) has been an extremely painful procedure because it involves excision of hemorrhoidal tissue along the extremely sensitive anoderm. SH, on the other hand, has been shown to be associated with decreased postoperative pain because it does not involve the sensate anal mucosa below the dentate line. To date there have been many randomized controlled studies comparing circular SH with traditional excision techniques. Despite proven early postoperative advantages for SH, the long-term benefits and effect on patient quality of life (QOL) compared with EH still remain to be debated. This study aimed to evaluate long-term patient outcomes via a validated health-related QOL survey. QOL measures were satisfactory in both groups across all subscales of physical health summary measures and mental health summary measures. This coincided with Wexner continence scores, which were also satisfactory, with a median of 0 in both groups. QOL, continence scores, and long-term symptom follow-up are similar in patients who undergo SH or EH.

A 10-year retrospective cohort study to assess objective and subjective outcomes of combined stapled transanal rectal resection and urogynecological surgery for pelvic floor dysfunction

PURPOSE

To assess the subjective and objective outcomes of combined stapled transanal rectal resection (STARR) and urogynecological surgery to treat pelvic organ prolapse, with a 10-year follow-up.

METHODS

This was a retrospective cohort study analyzing prospectively collected data from 53 consecutive patients who underwent combined stapled transanal rectal resection and urogynecological surgery, from 1 January 2005 to 31 December 2007 at a tertiary referral Pelvic Floor Unit of an Italian hospital.

RESULTS

Fifty-three patients with a median age of 60 years (interquartile range (IQR) 67-52t), underwent STARR and concomitant urogynecological surgery. No serious postoperative complications were recorded, and 37/53 women (70%) were evaluated at the 10-year follow-up visit. The cure rate was optimal in 34 women (64.1%). Regarding persistent and/or recurrent symptoms, five sexually-active patients (9%) reported dyspareunia only; obstructed defecation symptoms recurred in ten women (19%); urinary incontinence occurred in eight patients (15%); four patients (11%) reported persistent perineal pain; and two patients (5%) experienced both the urge to defecate and voiding dysfunction. At the 10-year follow-up, 14/27 patients (52%) stated that they would undergo the same operation again, if necessary. Furthermore, the survey found that patients would recommend the combined surgery.

CONCLUSION

The 10-year results of this study proved that combined rectal and urogynecological surgery is well tolerated, associated with low morbidity, and more effectively treats a distressing and debilitating condition vs separate surgeries for rectal and pelvic organ prolapse. We recommend complementing the relatively small scale of this study with randomized trials involving a sufficient number of patients, to provide more conclusive evidence on the cumulative long-term effects of combined surgery vs 2- or 3-stage surgery.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up

AIM

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury.

METHOD

This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale.

RESULTS

Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001).

CONCLUSION

At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

High-resolution anal manometry: Repeatability, validation, and comparison with conventional manometry

BACKGROUND

Accurate measurement of anal sphincter function is potentially of value in defining treatment of common pelvic floor disorders. The aim of this study was to establish repeatability and validate high-resolution anorectal manometry (HRAM) by comparison to conventional manometry (CM). Arising from this work would be definitive normal range data.

METHODS

Eighty healthy volunteers (40 female) underwent a test-retest repeatability study. A 16-channel water-perfused HRAM catheter was compared to an 8-channel conventional catheter using a station pull-through technique.

KEY RESULTS

High-resolution anorectal manometry had similar precision to conventional manometry when measuring resting pressure (intraclass correlation coefficient [ICC] 0.73 vs 0.68, HRAM vs CM) and squeeze increment (ICC 0.90 vs 0.94, HRAM vs CM). HRAM measured resting pressures 10% lower than CM and squeeze pressure 27% higher than CM.

CONCLUSIONS AND INFERENCES

High-resolution anorectal manometry is a valid technique with comparable precision to CM. HRAM measurements differ considerably to CM, and a new set of normal values must be used.

Functional anal canal length measurement using high-resolution anorectal manometry to investigate anal sphincter dysfunction in patients with fecal incontinence or constipation

BACKGROUND

Using high-resolution anorectal manometry, we aimed to evaluate the: (a) optimal threshold to measure functional anal canal length (FACL) with intra- and inter-observer variability; (b) relationship between abnormal FACL and other phenotypic findings; and (c) utility of FACL measurement to discriminate between healthy volunteers (HV) and patients with fecal incontinence (FI) or chronic constipation (CC).

METHODS

Consecutive patients referred for investigation of FI or CC in isolation were included. FACL was calculated at 5, 10, 20, 30, and 50 mm Hg above rectal pressure. 5th-95th percentile in HV defined limits of normality.

KEY RESULTS

FACL was analyzed in 192 patients with FI (154 females), 204 patients with CC (175 females), and 134 HV (101 females). The optimal threshold for measurement of FACL was 20 mm Hg. Using this threshold, observer reproducibility was very high (ICC 0.99, P < 0.0001). FACL was shorter in females with FI and longer in females with CC compared to HV (2.3 vs 2.9 cm; and 3.4 cm vs 2.9 cm; both P < 0.0001). Twenty percent of females and 13% males with FI had a short FACL, associated with older age, anal hypotonia or hypocontractility, and a atrophic internal anal sphincter. However, abnormal FACL in isolation was only found in 1/190 FI (0.5%) and 2/201 CC (1%) patients; all other patients had other abnormal manometric findings.

CONCLUSIONS AND INFERENCES

Considering overlap with other routinely evaluated manometric parameters, FACL measurement does not provide additional information in the diagnostic assessment of FI or CC.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up

AIM

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome.

METHOD

This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included.

RESULTS

Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence.

CONCLUSIONS

Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

Stapled Hemorrhoidopexy: Results at 10-Year Follow-up

BACKGROUND

Despite the advantages of stapled hemorrhoidopexy reported in the literature in terms of postoperative pain, hospital stay, and duration of convalescence, it was described to have a higher recurrence rate compared with conventional hemorrhoidectomy.

OBJECTIVE

The aim of this study was to evaluate clinical outcomes and patient satisfaction after stapled hemorrhoidopexy at 10-year follow-up.

DESIGN

This was a retrospective cohort analysis conducted on prospectively collected data.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse between January and December 2006 were included.

MAIN OUTCOME MEASURES

Patients satisfaction and recurrence rates were measured.

RESULTS

Eighty-six patients (45 men and 41 women; median age, 49 y (range, 31-74 y)) underwent stapled hemorrhoidopexy. Eight patients had urinary retention during the immediate postoperative period, and 2 patients required a reoperation for suture line bleeding. The median hospital stay was 12 hours (range, 12-96 h). No suture line dehiscence, rectovaginal fistula, pelvic sepsis, anal abscess, or anal stenosis was recorded during the follow-up. Seventy-seven patients (90%) completed the expected follow-up, with a median duration of 119.0 months (range 115.4-121.8 mo). Among them, 30 patients (39%) experienced a recurrent hemorrhoidal prolapse, 8 of whom needed a reoperation. Thirty-four patients (44%) reported urge to defecate with a median visual analog scale of 1 (range, 1-7). Six patients (8%) reported gas leakage at the last follow-up visit, whereas no liquid or solid stool leakage was recorded. Satisfaction rate at 10-year follow-up was 68%.

LIMITATIONS

The study was limited by its small sample size and lack of a control group.

CONCLUSIONS

The high recurrence rate and low patient satisfaction rate showed that stapled hemorrhoidopexy reduces its efficacy in the long-term. See Video Abstract at http://links.lww.com/DCR/A510.

Anatomy and mechanical properties of the anal sphincter muscles in healthy senior volunteers

BACKGROUND

A large proportion of age-related fecal incontinence is attributed to weakness or degeneration of the muscles composing the anal continence organ. However, the individual role of these muscles and their functional interplay remain poorly understood.

METHODS

This study employs a novel technique based on the combination of MR imaging and FLIP measurements (MR-FLIP) to obtain anatomical and mechanical information simultaneously. Unlike previous methods used to assess the mechanics of the continence organ, MR-FLIP allows inter-individual comparisons and statistical analysis of the sphincter morpho-mechanical parameters. The anatomy as well as voluntary and involuntary mechanical properties of the anal continence organ were characterized in 20 healthy senior volunteers.

RESULTS

Results showed that the external anal sphincter (EAS) forms a funnel-like shape with wall thickness increasing by a factor of 2.5 from distal (6 ± 0 mm) to proximal (15 ± 3 mm). Both voluntary and involuntary mechanical properties in this region correlate strongly with the thickness of the muscle. The positions of least compliance and maximal orifice closing were both located toward the proximal EAS end. In addition, maximal contraction during squeeze maneuvers was reached after 2 s, but high muscle fatigue was measured during a 7 s holding phase, corresponding to about 60% loss of the energy produced by the muscles during the contraction phase.

CONCLUSIONS

This work reports baseline parameters describing the morpho-mechanical condition of the sphincter muscle of healthy elderly volunteers. New parameters were also proposed to quantify the active properties of the muscles based on the mechanical energy associated with muscle contraction and fatigue. This information could be used to assess patients suffering from AI or for the design of novel implants.

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.

MR-FLIP: a new method that combines a functional lumen imaging probe with anatomical information for spatial compliance assessment of the anal sphincter muscles

AIM

Continence results from a complex interplay between anal canal (AC) muscles and sensorimotor feedback mechanisms. The passive ability of the AC to withstand opening pressure - its compliance - has recently been shown to correlate with continence. A functional lumen imaging probe (FLIP) is used to assess AC compliance, although it provides no anatomical information. Therefore, assessment of the compliance specific anatomical structures has not been possible, and the anatomical position of critical functional zones remains unknown. In addition, the FLIP technique assumes a circular orifice cross-section, which has not been shown for the AC. To address these shortcomings, a technique combining FLIP with a medical imaging modality is needed.

METHOD

We implemented a new research method (MR-FLIP) that combines FLIP with MR imaging. Twenty healthy volunteers underwent MR-FLIP and conventional FLIP assessment. MR-FLIP was validated by comparison with FLIP results. Anatomical markers were identified, and the cross-sectional shape of the orifice was investigated.

RESULTS

MR-FLIP provides compliance measurements identical to those obtained by conventional FLIP. Anatomical analysis revealed that the least compliant AC zone was located at the proximal end of the external anal sphincter (EAS). The cross-sectional shape of the AC was found to deviate only slightly from circularity in healthy volunteers.

CONCLUSION

The proposed method is equivalent to classical FLIP. It establishes for the first time direct mapping between local tissue compliance and anatomical structure, which is key to gaining novel insights into (in)continence. In addition, MR-FLIP provides a tool for better understanding conventional FLIP measurements in the AC by quantifying its limitations and assumptions.

Safety and feasibility of laparoscopic intersphincteric resection for a lower rectal tumor

The aim of the present study was to evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (ISR) for a lower rectal tumor in comparison with a case-control series of patients undergoing open ISR. Quality of life factors and anal function were also evaluated. Between July 2008 and April 2013, 103 patients with lower rectal cancer underwent laparoscopic surgery at the Surgical Oncology Department of Gifu University School of Medicine. A total of 25 patients with lower rectal cancer underwent ISR, and 19/25 patients who underwent laparoscopic ISR were compared with the control group of 6 patients who underwent open ISR. The technical feasibility and safety of ISR, and the short- and long-term outcomes following laparoscopic ISR were evaluated. Additional data associated with fecal incontinence conditions of the postoperative patients were evaluated using the Modified Fecal Incontinence Quality of Life scale. There was no recorded perioperative mortality, three complications were observed to occur in three patients and the morbidity rate was 15.8%. The postoperative complications detected included bleeding in one patient and ileus in two patients of the laparoscopic ISR group. The rate of severe complications of grade ≥3a was 15.8% and that of grade ≥3b was 5.3%. In the matched case-control study, blood loss was significantly lower in the laparoscopic ISR group. The median postoperative hospital stay was 14.1 days in the laparoscopic ISR group, which was significantly shorter compared with in the open ISR group (18.7 days). Cancer recurrence was detected in one (5%) patient in a single inguinal lymph node. No significant differences between the ISR and ultra-low anterior resection (ULAR) groups were observed in the maximum resting and maximum squeeze pressures; the outcomes for anal function and fecal incontinence were the same for ISR and ULAR. Thus, laparoscopic ISR for lower rectal cancer may provide a benefit in the early postoperative period without increasing morbidity or mortality.

Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation

AIM

Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect.

METHOD

Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS).

RESULTS

Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06).

CONCLUSION

Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

Pathophysiology and Therapeutic Options for Fecal Incontinence

Fecal incontinence (FI), defined as the involuntary loss of solid or liquid feces through the anus is a prevalent condition with significant effects on quality of life. FI can affect individuals of all ages and in many cases greatly impairs quality of life but, incontinent patients should not accept their debility as either inevitable or untreatable. The severity of incontinence can range from unintentional elimination of flatus to the complete evacuation of bowel contents. It is reported to affect up to 18% of the population, with a prevalence reaching as high as 50% in nursing home residents. However, FI is often underreported, thus obscuring its true prevalence in the general population. The options for treatment vary according to the degree and severity of the FI. Treatment can include dietary and lifestyle modification, certain medications, biofeedback therapy, bulking agent injections, sacral nerve stimulation as well as various types of surgery. In this article, we aim to provide a comprehensive review on the diagnosis and management of FI.

Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study

Purpose

This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer.

Methods

Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores.

Results

Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups.

Conclusion

Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Anterior sphincteroplasty for fecal incontinence: predicting incontinence relapse

PURPOSE

This study was designed to evaluate the efficiency of anterior sphincteroplasty in preventing fecal incontinence relapsing in 85 female patients.

METHODS

This observational study followed individuals for up to 10 years after intervention. Fecal incontinence relapse was analyzed using Generalized Linear Models and Kaplan-Meier tables. Bias due to informative censoring and missing data were assessed. Two postoperative cutoff Wexner scores (4 and 8) were used to classify individuals into continent or incontinent, and their model implications were examined.

RESULTS

The hazard of relapsing appeared constant over time. This led to exponential time-to-relapse functions, and a linear increase of cumulative hazard over time. Predicted median relapsing time was 33 years, and overall risk 0.09 ± 0.03, when using a cutoff Wexner score of 8 (moderate), and 5 years, overall risk 0.45 ± 0.05, when using a cutoff of 4 (mild). There was a potential underestimation in parameters (bias) due to informative censoring, i.e., individual with better prognoses were more likely to drop out before relapsing compared to those with worse prognoses. Thus, true relapsing times may be longer than our current estimates.

CONCLUSIONS

The predictive model can be used in practice for individual prognosis after intervention, based on preoperative Wexner scores. The effect of anterior sphincteroplasty on fecal incontinence does not seem to deteriorate over time. A consensus Wexner cutoff is necessary to compare data and interventions.

Long-term results after endoanal advancement flap repair for fistulas-in-ano. How important is the aetiology?

PURPOSE

The purpose of this study was to assess primary healing, recurrence and continence after endoanal advancement flap repair (EAFR).

PATIENTS AND METHODS

Seventy-seven patients with fistulas-in-ano of different etiologies received endoanal advancement flap repair between 1997 and 2009. This is a prospective, non-randomized, single-centre, single-surgeon study.

RESULTS

Follow-up data was available for 71 patients. 47.9 % had cryptoglandular fistulas. In 40.8 %, the fistulas were due to chronic inflammatory bowel disease. In 11.3 %, the fistula was a consequence of treatment for cancer. Primary healing was observed in 41 of the cases (57.7 %). The median time to recurrence was 27 months (mean 43.43 ± 48.11) and differed significantly across the patient groups: cryptoglandular origin 51 months (mean 57.09 ± 52.57), condition after cancer treatment 43 months (mean 31 ± 23.142), inflammatory bowel disease 11 months (mean 23.65 ± 32.47) (p < 0.01). Preoperatively, 31 (44.3 %) of the patients had impaired continence vs 30 (42.9 %) postoperatively. Overall, postoperative mean Cleveland Clinic incontinence score values improved significantly (preoperative 3.74 ± 4.558 vs postoperative 2.68 ± 4.752, p = 0.03).

CONCLUSIONS

Full-thickness endoanal advancement flap repair is a successful treatment option for a range of fistula etiologies. Overall, fistula aetiology proved to be prognostically more relevant than fistula location. Fistulas associated with chronic inflammatory bowel disease were found to have a significantly higher rate of recurrence and shorter time to recurrence at long-term follow-up. Repeat interventions do not negatively impact postoperative continence.

Long-term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury

AIM

More than 50% of women experience deteriorating continence over time following primary repair of obstetric anal sphincter injuries. The objectives of this study were to assess the function and morphology of the anal sphincters and pelvic floor in women with long-term faecal incontinence after sphincter repair (primary end-point) and to evaluate their correlation with severity of incontinence (secondary end-point).

METHOD

The participants in this prospective study were recruited from a cohort of all women who sustained third or fourth degree obstetric sphincter injury reconstruction (cases) from January 1976 to November 1991. The women who delivered immediately before and after each case, without sustaining obstetric damage, were included as controls. Cases and controls were stratified into three categories: (i) continent; (ii) minor incontinence; and (iii) severe incontinence. The function and morphology of the anal sphincters and pelvic floor were evaluated by MRI, three-dimensional endoanal ultrasonography and anorectal physiology tests.

RESULTS

Fifty-nine women (29 cases/30 controls; mean age 51/53 years; mean follow-up 23.7/24.1 years, respectively) were assessed. Morphologically, cases had a significantly shorter anterior external anal sphincter length compared with controls when evaluated by three-dimensional endoanal ultrasonography (8.6 vs 10.2 mm; P = 0.03). Functionally, cases with severe incontinence had a significantly shorter anterior sphincter length compared with cases with minor incontinence (7.7 vs 10.4 mm; P = 0.04). No correlation could be found between anal pressures and severity of incontinence in the case group.

CONCLUSIONS

Cases had a significantly shorter anterior external anal sphincter length. Functionally, anterior sphincter length correlated with increased severity of incontinence.

A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation

BACKGROUND

Sacral nerve stimulation (SNS) is now well established as a treatment for fecal incontinence (FI) resistant to conservative measures and may also have utility in the management of chronic constipation; however, mechanism of action is not fully understood. End organ effects of SNS have been studied in both clinical and experimental settings, but interpretation is difficult due to the multitude of techniques used and heterogeneity of reported findings. The aim of this study was to systematically review available evidence on the mechanisms of SNS in the treatment of FI and constipation.

METHODS

Two systematic reviews of the literature (performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses framework) were performed to identify manuscripts pertaining to (a) clinical and (b) physiological effects of SNS during the management of hindgut dysfunction.

KEY RESULTS

The clinical literature search revealed 161 articles, of which 53 were deemed suitable for analysis. The experimental literature search revealed 43 articles, of which nine were deemed suitable for analysis. These studies reported results of investigative techniques examining changes in cortical, gastrointestinal, colonic, rectal, and anal function.

CONCLUSIONS & INFERENCES

The initial hypothesis that the mechanism of SNS was primarily peripheral motor neurostimulation is not supported by the majority of recent studies. Due to the large body of evidence demonstrating effects outside of the anorectum, it appears likely that the influence of SNS on anorectal function occurs at a pelvic afferent or central level.

Suboptimal results after sphincteroplasty: another hazard of obesity

BACKGROUND

This study aimed to investigate the outcomes of sphincteroplasty in obese patients.

METHODS

Patients with fecal incontinence (FI) who underwent sphincter repair were identified and divided into obese [body mass index (BMI) ≥ 30 kg/m(2)] and nonobese (BMI < 30 kg/m(2)) groups. Cleveland Clinic Florida FI Score (CCFFIS: 0 best and 20 worst) and FI quality of life (FIQoL) score (mean global FIQoL: 4.11 best and 1 worst) were recorded. Wilcoxon and Mann-Whitney U tests compared quantitative variables; Fisher's exact test was used for categorical variables.

RESULTS

Seventy-nine patients (78 females; mean age: 57 ± 15 years) were divided into obese (n = 15) and nonobese (n = 64) groups and were similar in age, etiology, physiologic parameters, and preoperative CCFFIS. Median follow-up was 64 (13-138) months. There were 3 (25 %) and 11 (17 %) complications in the obese and nonobese groups, respectively (p = 0.68), the most common being wound infection. Mean CCFFIS decreased from 16.0 ± 3.9 to 11.5 ± 6.5 in the obese (p < 0.001) and 16.2 ± 3.4 to 8.4 ± 5.0 in the nonobese groups (p < 0.001). Postoperative CCFFIS correlated with FIQoL (Spearman's correlation coefficient = -0.738, p < 0.001). Nonobese patients had significantly higher CCFFIS improvement (48 vs. 28 % p = 0.04) and a superior mean global FIQoL score (2.19 ± 0.9 vs. 2.93 ± 0.8, p < 0.01). Four (29 %) obese and 11 (17 %) nonobese patients required further surgery after failed sphincteroplasty (p = 0.45).

CONCLUSIONS

Risk of complications and need of further continence surgery were similar between obese and nonobese patients. However, obese patients experienced less improvement after sphincteroplasty.

Treatment and outcome of patients suffering from perineal/perianal rhabdomyosarcoma: results from the CWS trials--retrospective clinical study

OBJECTIVE

To analyze the clinical course, treatment, complications, outcome, and quality of life (QOL) in patients with perineal/perianal rhabdomyosarcoma (PRMS) treated within the CWS-86, -91, -96, and -2002P trials.

BACKGROUND

Although multiple international study trials exist for the treatment of rhabdomyosarcoma, only very limited information is given on treatment, outcome, and QOL in PRMS.

METHODS

A total of 35 patients suffering from PRMS were treated with neoadjuvant chemotherapy. Local therapy with radiation and/or surgery was performed, followed by adjuvant chemotherapy. Functional long-term follow-up was evaluated by a gastrointestinal/QOL survey.

RESULTS

Thirty-two patients were evaluated (exclusion n = 3). Eight patients had embryonal histology, and 24 patients had alveolar histology. The median age was 108 months (median follow-up: 5.8 years). The 5-year overall survival was 47% (95% confidence interval: 29-64). Sixteen IRS (Intergroup Rhabdomyosarcoma Study) III and IV patients had locoregional lymph node involvement at diagnosis. Seven patients were treated with chemotherapy/surgery alone [5-year event-free survival (EFS): 85.7%]. Eleven patients received only radiochemotherapy (5-year EFS: 27.3%). Combined radiochemotherapy/surgery was used in 12 patients (5-year EFS: 63.6%). Two patients were treated only with chemotherapy and they died. Patients with embryonal histology had a significantly better 5-year EFS (87.5%) than patients with alveolar histology (39.1%; P = 0.013). Some patients reported symptoms of fecal incontinence. The median Wexner fecal incontinence score was 9 (possible range: 0-20), and the median QOL score was 90.5 (applicable range: 0-144).

CONCLUSIONS

The outcome of these patients remains unsatisfactory. Prognostic factors for a favorable outcome are tumor size of smaller than 5 cm, negative locoregional lymph nodes, age less than 10 years, low IRS group, and embryonal histology. Fecal incontinence seems to be a problem.

Emerging surgical therapies for faecal incontinence

Faecal incontinence is a common condition and is associated with considerable morbidity and economic cost. The majority of patients are managed with conservative interventions. However, for those patients with severe or refractory incontinence, surgical treatment might be required. Over the past 20 years, numerous developments have been made in the surgical therapies available to treat such patients. These surgical therapies can be classified as techniques of neuromodulation, neosphincter creation (muscle or artificial) and injection therapy. Techniques of neuromodulation, particularly sacral nerve stimulation, have transformed the management of these patients with a minimally invasive procedure that offers good results and low morbidity. By contrast, neosphincter procedures are characterized by being more invasive and associated with considerable morbidity, although some patients will experience substantial improvements in their continence. Injection of bulking agents into the anal canal can improve symptoms and quality of life in patients with mild-to-moderate incontinence, and the use of autologous myoblasts might be a future therapy. Further research and development is required not only in terms of the devices and procedures, but also to identify which patients are likely to benefit most from such interventions.

Surgical approaches to fecal incontinence in the adult

Surgical treatment of anal incontinence is indicated only for patients who have failed medical treatment. Sphincterorraphy is suitable in case of external sphincter rupture. In the last decade, sacral nerve stimulation has proven to be a scientifically validated solution when no sphincter lesion has been identified and more recently has also been proposed as an alternative in cases of limited sphincter defect. Anal reconstruction using artificial sphincters is still under evaluation in the literature, while indications for dynamic graciloplasty are decreasing due to its complexity and high morbidity. Less risky techniques involving intra-sphincteric injections are being developed, with encouraging preliminary results that need to be confirmed especially in the medium- and long-term. Antegrade colonic enemas instilled via cecostomy (Malone) can be an alternative to permanent stoma in patients who are well instructed in the techniques of colonic lavage. Stomal diversion is a solution of last resort.

Role of 0.4 % glyceryl trinitrate ointment after stapled trans-anal rectal resection for obstructed defecation syndrome: a prospective, randomized trial

PURPOSE

The anal fissure and spasm represent possible complications and causes of postoperative anal pain in patients that have undergone stapled trans-anal rectal resection (STARR). The etiology of these complications is still questioned such as the treatment modality. This study was designed to evaluate the effectiveness of topical glyceryl trinitrate (GTN) 0.4 % in determining decrease of incidence of postoperative anal spams and fissure and reduction of early postoperative pain.

METHODS

From a total of 243 patients referred for obstructed defecation syndrome (ODS) 104 (42.7 %) underwent STARR and were randomized to receive (Group 1) or not (Group 2) topical 0.4 % GTN ointment every 12 h for four postoperative weeks. Postoperative evaluation was made at 1, 6, and 12 months.

RESULTS

At 1 month follow-up, the incidence of anal spasm in Groups 1 and 2 was, respectively, 0 and 14.6 % (6/41) (p = 0.010; Fisher's exact test). The incidence of anal fissure was 4/41 (9.7 %) in Group 2 and 0/44 (0 %) in Group 1 (p = 0.05; Fisher's exact test). Significant differences in median visual analogue scale score between groups were found at 1 week and 1 month follow-up (1; 0-5 vs. 2; 0-7: p = 0.0104; Mann-Whitney U test).

CONCLUSION

Anal spasm and fissure may represent a cause of early postoperative anal pain in patients that have undergone STARR procedure for ODS. The use of topical GTN 0.4 % ointment in the early postoperative course seems to reduce the incidence of anal spasm and fissure and to improve the associated early postoperative pain.

Current management of fecal incontinence: Choosing amongst treatment options to optimize outcomes

The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life. Fecal incontinence is common, though it is often under-reported by patients. In addition to standard treatment options, new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity. Non-operative treatments include dietary modifications, medications, and biofeedback therapy. Currently used surgical treatments include repair (sphincteroplasty), stimulation (sacral nerve stimulation or posterior tibial nerve stimulation), replacement (artificial bowel sphincter or muscle transposition) and diversion (stoma formation). Newer augmentation treatments such as radiofrequency energy delivery and injectable materials, are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence. In general, more invasive surgical treatments are now reserved for moderate to severe fecal incontinence. Functional and quality of life related outcomes, as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient. General indications, techniques, and outcomes profiles for the various treatments of fecal incontinence are discussed in detail. Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.

Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence

AIM

Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long-term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long-term efficacy and safety of NASHA/Dx, assessed 24 months after treatment.

METHOD

This study was a 24-month follow-up assessment of patients treated with NASHA/Dx under open-label conditions. Data on FI episodes and quality of life measures were collected from diaries over the 28-day period immediately preceding the 24-month assessment. Adverse events were collected.

RESULTS

Eighty-three of 115 patients completed the 24-month follow-up assessment. At 24 months, 62.7% of patients were considered responders and experienced a ≥ 50% reduction in the total number of FI episodes. The median number of FI episodes declined by 68.8% (P < 0.001). Episodes of both solid and liquid stool incontinence decreased. The mean number of incontinence-free days increased from 14.6 at baseline to 21.7 at 24 months (P < 0.001). Incontinence scores and FI quality of life scores also showed significant improvements. The most common adverse events (AEs) were proctalgia (13.3%) and pyrexia (9.6%). The majority of AEs were mild to moderate, self-limited and resolved within 1 month of the injection.

CONCLUSION

NASHA/Dx is safe, effective and durable over a 24-month period with a majority of patients experiencing significant improvement in multiple symptoms associated with FI.

[Direct sphincter repair: techniques, indications and results]

L'incontinence anale est un handicap physique, psychique et social majeur qui a de nombreuses causes différentes. Les méthodes actuellement disponibles pour améliorer les symptômes de cette incontinence sont les méthodes médicales et de rééducation d'une part et les méthodes chirurgicales d'autre part. Quatre techniques chirurgicales répondent à ces objectifs pour la plupart des malades: la sphinctérorraphie, la neuromodulation des racines sacrées, et les deux techniques de substitution que sont le sphincter artificiel et la graciloplastie dynamisée. La réparation sphinctérienne directe est la technique la plus utilisée dans le traitement chirurgical de l'incontinence anale (IA) par lésion sphinctérienne. Cette technique est envisageable chez les malades ayant une incontinence fécale en rapport avec des lésions limitées du sphincter anal externe. La technique chirurgicale est simple (myorraphie par suture directe ou en paletot) et bien codifiée. Les résultats fonctionnels sont imparfaits et se dégradent avec la durée du suivi. Une continence parfaite après réparation sphinctérienne est rarement acquise de façon durable: le malade candidat à cette approche thérapeutique doit en être averti.

Biological implants in sphincter augmentation offer a good short-term outcome after a sphincter repair

AIM

Long-term results of the overlapping sphincter repair (OSR) have been disappointing, attributed to poor tissue quality that deteriorates with time. Biological grafts enforce tissues. The aim was to compare functional outcome and quality of life at 1 year with and without Permacol reinforcement to evaluate short-term benefit.

METHOD

From November 2007 to November 2008, women undergoing OSR using Permacol (group 1, n = 10) under institutional review board approval (safety trial) were age matched with patients from an institutional review board approved database (group 2, n = 10) who underwent the traditional OSR. Permacol mesh was placed under the two overlapped muscles. Group 2 underwent traditional repair. Preoperative and postoperative management of the groups was similar. The Fecal Incontinence Severity Index (FISI), the Cleveland Clinic Incontinence Score (CCFIS) and the Fecal Incontinence Quality of Life (FIQL) scale were used preoperatively and 1 year post-surgery.

RESULTS

No significant differences in demographics, symptom duration, number of vaginal deliveries, comorbidities and symptom severity were noted. Group 2 underwent concomitant procedures. Group 1 reported no complications. Group 2 reported urinary retention and dehiscence. A significant difference was found in preoperative and postoperative FIQL subscales of coping/behaviour between groups. However, comparing the pre and post scores, significant improvements on FISI (P = 0.02), the CCFIS (P = 0.005) and two subscales of FIQL (coping/behaviour, P = 0.02, and embarrassment, P = 0.01) were found in group 1. Patient satisfaction was higher in group 1.

CONCLUSION

Biologic tissue enhancers (Permacol) do not add morbidity. Sphincter augmentation results in significant improvement in continence and quality of life scores compared with the preoperative scores in the short term over traditional repair. Long-term studies are needed to determine if this effect is sustained.

Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review

AIM

The long-term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect.

METHOD

The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow-up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life.

RESULTS

Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies.

CONCLUSION

Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long-term follow-up, although beset with difficulties, should be conducted.

Five-item score for obstructed defecation syndrome: study of validation

The use of a dedicated score represents an essential tool for the clinical staging of obstructed defecation syndrome (ODS), for subsequent diagnostic and therapeutic options, and for the evaluation of the results. This study was designed to develop and validate a new, simple, and disease-specific scoring system for ODS. The questionnaire consists of 5 items: excessive straining, incomplete rectal evacuation, use of enemas and/or laxatives, vaginal-anal-perineal digitations, and abdominal discomfort and/or pain. Each item was graded from 0 to 5 with a score ranging from 0 (no symptoms) to 20 (very severe symptoms). A specific statistical analysis identifies the new score as a valuable and concise instrument, which demonstrates, overall, excellent concurrent validity, reproducibility, internal consistency, and discriminant validity for the diagnosis and grading of ODS. The use of this questionnaire may improve uniformity in clinical research and may allow a more precise evaluation of symptom severity and treatment effectiveness in ODS.

Trans-obturator colonic suspension during Altemeier's operation for full-thickness rectal prolapse: preliminary results with a new technique

AIM

With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed.

METHOD

Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure.

RESULTS

There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies.

CONCLUSION

The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrence.

Overlapping sphincter repair: does age matter?

BACKGROUND

The predictors of the outcomes following anal sphincteroplasty have not been well documented.

OBJECTIVE

The aim was to evaluate age as a predictor of functional outcome and quality of life after overlapping sphincter repair.

DESIGN

This study is a retrospective review of chart review followed by a prospective evaluation by the use of validated questionnaires.

SETTINGS

Patients were assigned to group A (≤ 60 years old) or group B (>60 years).

PATIENTS

Included were patients with obstetric sphincter injuries who underwent overlapping sphincteroplasty between 1996 and 2007.

MAIN OUTCOME MEASURES

The Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, the Cleveland Global Quality of Life scale, and a patient satisfaction questionnaire were used to assess outcome.

RESULTS

Three hundred twenty-one women underwent sphincteroplasty and 197 responded to this study, 146 (74.1%) patients in group A and 51 (25.9%) patients in group B. Median follow-up was 7.7 years (range, 4.7-10.0). The mean overall Fecal Incontinence Quality of Life Scale was 11.0 ± 3.5. Median Fecal Incontinence Severity Index score was 29.8 ± 15.9. Mean Cleveland Global Quality of Life scale was 0.7 ± 0.2. The 2 groups were comparable for BMI (p = 1.0), ethnic background (p = 0.8), smoking (p = 0.8), and follow-up duration (p = 0.9). Intergroup comparison showed no significant difference in the Fecal Incontinence Quality of Life Scale scores (p = 0.5) in all subscales: lifestyle (p = 0.8), coping behavior (p = 0.5), depression and self-perception (p = 0.2), and embarrassment (p = 0.1). No significant differences were noted in Fecal Incontinence Severity Index (p = 0.2), Cleveland Global Quality of Life scale (p =1.0), or postoperative satisfaction (p = 0.6).

LIMITATIONS

The study was limited by its retrospective nature.

CONCLUSIONS

Comparable long-term Fecal Incontinence Severity Index score and Fecal Incontinence Quality of Life Scale scores following overlapping sphincter repair suggest that age is not a predictor of outcome for overlapping sphincter repair. This procedure can be offered to both young and older patients.

Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer

PURPOSE

Neoadjuvant chemoradiotherapy for rectal cancer can result in complete disappearance of tumor and involved nodes. In patients without residual tumor on imaging and endoscopy (clinical complete response [cCR]) a wait-and-see-policy (omission of surgery with follow-up) might be considered instead of surgery. The purpose of this prospective cohort study was to evaluate feasibility and safety of a wait-and-see policy with strict selection criteria and follow-up.

PATIENTS AND METHODS

Patients with a cCR after chemoradiotherapy were prospectively selected for the wait-and-see policy with magnetic resonance imaging (MRI) and endoscopy plus biopsies. Follow-up was performed 3 to 6 monthly and consisted of MRI, endoscopy, and computed tomography scans. A control group of patients with a pathologic complete response (pCR) after surgery was identified from a prospective cohort study. Functional outcome was measured with the Memorial Sloan-Kettering Cancer Center (MSKCC) bowel function questionnaire and Wexner incontinence score. Long-term outcome was estimated by using Kaplan-Meier curves.

RESULTS

Twenty-one patients with cCR were included in the wait-and-see policy group. Mean follow-up was 25 ± 19 months. One patient developed a local recurrence and had surgery as salvage treatment. The other 20 patients are alive without disease. The control group consisted of 20 patients with a pCR after surgery who had a mean follow-up of 35 ± 23 months. For these patients with a pCR, cumulative probabilities of 2-year disease-free survival and overall survival were 93% and 91%, respectively.

CONCLUSION

A wait-and-see policy with strict selection criteria, up-to-date imaging techniques, and follow-up is feasible and results in promising outcome at least as good as that of patients with a pCR after surgery. The proposed selection criteria and follow-up could form the basis for future randomized studies.

Accuracy of measurement of puborectal contraction by perineal ultrasound in patients with faecal incontinence

AIM

The study aimed to determine the accuracy of measurement of puborectal contraction, measured by perineal ultrasound during anal voluntary contraction in patients with incontinence.

METHOD

Puborectalis sling contraction in 32 consecutive patients investigated for faecal incontinence was determined by two examiners on two occasions (four measurements per patient). The examiners were blinded to each other's results.

RESULTS

The mean anterior movement of the puborectalis sling was between 11 and 12 mm for both examiners on both occasions. The global intraclass correlation coefficient for examiners and occasions together was 0.92. The absolute agreement on the movement exceeding or not 8 mm was 87.5% (28 of 32), and the corresponding κ statistic was 0.84. The differences between the two experts were minimal.

CONCLUSION

The study confirms the reliability of puborectalis sling contraction measurement and its value as a preoperative predictive tool to assess the prognosis of sphincter repair for postdelivery faecal incontinence.

PPH-01 versus PPH-03 to perform STARR for the treatment of hemorrhoids associated with large internal rectal prolapse: a prospective multicenter randomized trial

PURPOSE

This multicenter randomized study was designed to compare the clinical and functional results of stapled transanal rectal resection (STARR) performed with 2 staplers (PPH-01 vs. PPH-03) in the treatment of hemorrhoidal disease associated with a large internal rectal prolapse.

METHODS

From a total of 937 patients, referred for hemorrhoidal disease in the 20 centers involved in the study, 425 (45.3%) with prolapsed hemorrhoids associated with a large internal rectal prolapse were randomized to undergo STARR with PPH-01 or PPH-03. Postoperative evaluation was made at 3, 6, and 12 months.

RESULTS

The incidence of bleeding at the stapled line was significantly lower in the PPH-03 group than in the PPH-01 group (58/207 [28.0%] vs. 145/201 [72.1%]; P < .0001); the mean number of hemostatic stitches was significantly higher in the PPH-01 than in the PPH-03 group (3.2 ± 0.1 vs. 1.8 ± 0.8; P < .0001). The mean operative time was 25.1 ± 11.5 minutes in the PPH-03 group and 38.1 ± 15.7 minutes in the PPH-01 group (P < .0001). No major complications occurred in either of the groups. At 12-month follow-up, the success rate in the 2 groups was 94.5% in the PPH01 group and 94.2% in the PPH03 group.

CONCLUSION

STARR performed for the treatment of hemorrhoidal disease associated with a large rectal prolapse is a safe and effective procedure. The use of the PPH-03 stapler instead of the PPH-01 guarantees a statistically significant reduction of intraoperative bleeding and a significant decrease of the operative time.

What is the benefit of a new stapler device in the surgical treatment of obstructed defecation? Three-year outcomes from a randomized controlled trial

PURPOSE

A randomized study was conducted to compare the clinical and functional outcomes of the stapled transanal rectal resection, using the traditional 2 circular staplers and a new, curved stapler device in patients with obstructed defecation caused by rectal intussusception and rectocele. Stapled transanal rectal resection gives good midterm results in patients with obstructed defecation syndrome, but the limited capacity of the casing of the circular stapler and the impossibility to control the positioning of the rectal wall and the firing of staples may result in incomplete removal of the prolapsed tissues, or serious complications. The new curved multifire stapler could avoid these drawbacks.

METHODS

From January to December 2006, 100 women were selected, with clinical examination, constipation score, colonoscopy, anorectal manometry, and perineography, and randomly assigned to 2 groups: 50 patients underwent stapled transanal rectal resection with 2 traditional circular staplers (STARR group) and 50 had the same operation with a new, curved multifire stapler (TRANSTAR group). Patients were followed up with clinical examination, constipation score, and colpocystodefecography, with the recurrence rate as the primary outcome measure.

RESULTS

Recurrence rates at 3 years were 12.0% in STARR group and 0 in the TRANSTAR group (P = .035). Operating time was significantly shorter in the STARR group (P = .008). Complications were 2 bleeds (4%) in the STARR group and 1 tear of the vagina in the TRANSTAR group. The incidence of fecal urgency was 34.0% in the STARR group and 14.0% in the TRANSTAR group (P = .035). All symptoms and defecographic parameters significantly improved after the operation (P < .001) without differences between groups.

CONCLUSIONS

The curved Contour Transtar stapler device did not appear to offer significant advantages over the traditional PPH-01 device during the operation or in the clinical and functional outcomes. However, the lower incidence of fecal urgency and recurrences might justify the higher cost of the new stapler.

An Open-Label, Noncomparative, Multicenter Study to Evaluate Efficacy and Safety of NASHA/Dx Gel as a Bulking Agent for the Treatment of Fecal Incontinence

Fecal incontinence (FI) is the involuntary loss of rectal contents through the anal canal. Reports of its prevalence vary from 1–21%. Studies, have demonstrated a positive effect on FI symptoms with injectable bulking agents. This study evaluated the safety and efficacy of NASHA/Dx gel in the treatment of FI. One hundred fifteen eligible patients suffering from FI received 4 injections of 1 mL NASHA/Dx gel. Primary efficacy was based on data from 86 patients that completed the study. This study demonstrated a ≥50% reduction from baseline in the number of FI episodes in 57.1% of patients at 6 months, and 64.0% at 12 months. Significant improvements (P < .001) were also noted in total number of both solid and loose FI episodes, FI free days, CCFIS, and FIQL scores in all 4 domains. The majority of the treatment related AEs (94.9%) were mild or moderate intensity, and (98.7%) of AEs resolved spontaneously, or following treatment, without sequelae. Results of this study indicate NASHA/Dx gel was efficacious in the treatment of FI. Treatment effect was significant both in reduction of number of FI episodes and disease specific quality of life at 6 months and lasted up to 12 months after treatment.

Disappointing long-term outcomes after stapled transanal rectal resection for obstructed defecation

BACKGROUND

The aim of this study was to assess both short and long-term functional outcomes and the quality of life of patients treated with stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS).

METHODS

Forty-six patients with ODS as a result of rectocele and/or rectal intussusceptions were treated with STARR. Data collected included demographics, OR time, pain score using a visual analog scale (VAS), and complications. The study included defecographic assessment and anal manometry [urge-to-defecate volume (UTDV) and maximum tolerable volume (MTV)], both done preoperatively and 1 year postoperatively. A modified obstructed-defecation syndrome questionnaire (MODS), constipation quality of life (PAC-QOL) score, and CCF continence score were all recorded preoperatively and every 6 months during follow-up.

RESULTS

Mean age of the patients was 48.4 years. Forty-five patients had mild postoperative pain (VAS = 1-2). Only one male patient had severe pain (VAS = 7). Three patients developed stenosis at the staple line 6 months after surgery and were dilated manually. Follow-up ranged from 18 to 48 months and the median follow-up was 42 months. The recurrence rate was 6.5% after 18 months, 10.8% after 36 months, and 13% after 42 months. Significant reduction in MTV and UTDV was recorded. MODS and PAC-QOL showed significant improvement after 6 months; this improvement was maintained for 18 months and then there was a rapid decline until the end of the follow-up period.

CONCLUSIONS

STARR is a safe surgical procedure that effectively restores the anatomy and function of the anorectum in patients with ODS. This correction improves functional and QOL scores; however, a high rate of symptomatic recurrence and QOL score decline are expected after 18 months.

Sphincteroplasty for fecal incontinence in the era of sacral nerve modulation

The role of sphincteroplasty in the treatment of patients with fecal incontinence due to anal sphincter defects has been questioned because the success rate declines in the long-term. A new emerging treatment for fecal incontinence, sacral nerve stimulation, has been shown to be effective in these patients. However, the success rate of sphincteroplasty may depend of several patient-related and surgical-related factors and the outcome from sphincteroplasty has been evaluated differently (with qualitative data) from that after sacral nerve stimulation (quantitative data using scoring systems and quality of life). Furthermore, the data available so far on the long-term success rate after sacral nerve modulation do not differ substantially from those after sphincteroplasty. The actual data do not support the replacement of sphincteroplasty with sacral nerve stimulation in patients with fecal incontinence secondary to sphincter defects.