Disappointing long-term results of the artificial anal sphincter for faecal incontinence

Long-term outcome of sacral nerve stimulation for faecal incontinence

AIM

Sacral nerve stimulation (SNS) is a minimally invasive treatment for faecal incontinence (FI). We report our experience of patients who have undergone SNS for FI with a minimum of 5 years' follow-up. This is a single centre prospective observational study with the aim to assess the long-term function of SNS.

METHOD

All patients implanted with SNS were identified from our prospective database. The date of implantation, first and last clinic follow-up, surgical complications and St Mark's incontinence scores were abstracted and analysed.

RESULTS

From 1996 to 2014, 381 patients were considered for SNS. Of these, 256 patients met the study inclusion criteria. Median age at implantation was 52 years (range 18-81). The ratio of women to men was 205:51. Indications were urge FI (25%), passive FI (17.9%) and mixed FI (57%). The median of the incontinence score at baseline was 19/24 and this improved to 7/24 at the 6-month follow-up. Of the total cohort, 235 patients received a medium-term follow-up (median 110 months, range 12-270) with a median continence score of 10/24 which was also confirmed at the telephone long-term follow-up on 185 patients (132 months, range 60-276).

CONCLUSION

This study demonstrates that SNS is an effective treatment in the long term. SNS results in an improvement of validated scores for approximately 60% of patients; however, there is a significant reduction of efficacy over time due to underlying causes.

Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition

Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient’s neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark’s incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.

Regenerative medicine as a therapeutic option for fecal incontinence: a systematic review of preclinical and clinical studies

BACKGROUND

Fecal incontinence is the uncontrollable loss of stool and has a prevalence of around 7-15%. This condition has serious implications for patients' quality of life. Current treatment options show unsatisfactory results. A novel treatment option is therefore needed.

OBJECTIVE

This systematic review aims to perform a quality assessment and to give a critical overview of the current research available on regenerative medicine as a treatment for fecal incontinence.

STUDY DESIGN

A systematic search strategy was applied in PubMed, Cochrane Library, EMBASE, MEDLINE, Web of Science, and Cinahl from inception until March of 2018. Studies were found relevant when the animals or patients in the studied group had objectively determined or induced fecal incontinence, and the intervention must have used any kind of cells, stem cells, or biocompatible material, with or without the use of trophic factors. Studies were screened on title and consecutively on abstract for relevance by 2 independent investigators. The risk of bias of preclinical studies was assessed using the SYstematic Review Centre for Laboratory animal Experimentation risk of bias tool for animal studies, and for clinical studies the Cochrane risk of bias tool for randomized trials was used.

RESULTS

In all, 34 preclinical studies and 5 clinical studies were included. Animal species, type of anal sphincter injury, intervention, and outcome parameters were heterogenous. Therefore, a meta-analysis could not be performed. The overall risk of bias of the included studies was high.

CONCLUSION

The efficacy of regenerative medicine to treat fecal incontinence could not be determined due to the high risk of bias and heterogenicity of the available preclinical and clinical studies. The findings of this systematic review may result in improved study design of future studies, which could help the translation of regenerative medicine to the clinic as an alternative to current treatments for fecal incontinence.

Composite Antropyloric Valve and Gluteus Maximus Muscle Wrap for Neoanal Reconstruction: Initial Results

BACKGROUND

Severe fecal incontinence has a significant negative impact on patient well-being. Current surgical methods of total anorectal reconstruction to substitute a colostomy have suboptimal results. A composite graft using antropyloric valve transposition and gracilis wrap has been described with good outcomes. However, this procedure requires extensive training of patients. Gluteus maximus, an accessory muscle for continence, may be better suited for this purpose.

OBJECTIVE

The purpose of this study was to evaluate the outcomes of composite antropylorus-gluteus graft for intractable fecal incontinence.

DESIGN

Patients underwent a 3-stage procedure: antropyloric transposition with diversion stoma followed by gluteus wrap. Stoma was closed after ensuring the anatomic and functional integrity of the graft.

SETTINGS

This study was conducted at a single tertiary care institution.

PATIENTS

Patients who were on permanent colostomy for intractable incontinence or would have had one after abdominoperineal resection were included.

MAIN OUTCOME MEASURES

Endoultrasonography, MRI, loopogram, saline holding test, anal manometry, St. Mark's fecal incontinence score, and personal interviews were used for measurement.

RESULTS

Eleven patients underwent the procedure with a median follow-up of 16 months (range, 13-34 mo). Digital rectal examination revealed a resting tone with a distinct squeeze provided by the composite graft. Radiological imaging confirmed healthy grafts. There was a significant improvement in mean anal manometry values (resting pressure: preoperative = 10.25 mm Hg vs postoperative = 20.45 mm Hg; squeeze pressure: preoperative = 22.63 mm Hg vs postoperative = 105.18 mm Hg) and mean incontinence score postprocedure (preoperative = 22.8 vs postoperative = 8.6). On personal interview, majority of the patients were continent and expressed satisfaction with the procedure.

LIMITATIONS

The study was limited by its small sample size with no control group.

CONCLUSIONS

Composite graft in patients with intractable fecal incontinence can serve as a viable novel method for total anorectal reconstruction. However, it should only be recommended for a highly select group of individuals in a surveillance setting. Its long-term outcomes remain to be determined as well as its risk versus benefit.

Advances in the Surgical Treatment of Fecal Incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.

Challenges faced in the clinical application of artificial anal sphincters

Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials.

Faecal incontinence: Current knowledges and perspectives

Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools.

Sacral nerve stimulation for faecal incontinence and constipation in adults

BACKGROUND

Faecal incontinence (FI) and constipation are both socially-embarrassing and physically-disabling conditions that impair quality of life. For both, surgery may be required in a minority of people when more conservative measures fail. However, the invasiveness and irreversible nature of direct surgery on bowel and sphincter muscles, poor long-term outcomes and well-established compIications makes such procedures unappealing for these benign conditions. A less-invasive surgical option to treat faecal incontinence and constipation is direct, low-voltage stimulation of the sacral nerve roots, termed sacral nerve stimulation (SNS). SNS has become the first line surgical treatment for FI in people failing conservative therapies. Its value in the treatment of constipation is less clear.

OBJECTIVES

To assess the effects of sacral nerve stimulation using implanted electrodes for the treatment of faecal incontinence and constipation in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, the World Health Organization (WHO) ICTRP and handsearched journals and conference proceedings (searched 5 February 2015), EMBASE (1 January 1947 to 2015 Week 5), and the reference lists of retrieved relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials assessing the effects of SNS for faecal incontinence or constipation in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed the methodological quality of the included trials, and undertook data extraction.

MAIN RESULTS

Six crossover trials and two parallel group trials were included.Six trials assessed the effects of SNS for FI. In the parallel group trial conducted by Tjandra, 53 participants with severe FI in the SNS group experienced fewer episodes of faecal incontinence compared to the control group who received optimal medical therapy (mean difference (MD) -5.20, 95% confidence interval (CI) -9.15 to -1.25 at 3 months; MD -6.30, 95% CI -10.34 to -2.26 at 12 months). Adverse events were reported in a proportion of participants: pain at implant site (6%), seroma (2%) and excessive tingling in the vaginal region (9%).In the parallel group trial carried out by Thin, 15 participants with FI in the SNS group experienced fewer episodes of FI compared with the percutaneous tibial nerve stimulation (PTNS) group (MD -3.00, 95% CI -6.61 to 0.61 at 3 months; MD -3.20, 95% CI -7.14 to 0.74 at 12 months). Adverse events were reported in three participants: mild ipsilateral leg pain during temporary testing (n = 1); and stimulator-site pain following insertion of neurostimulator (n = 2).In the crossover trial by Leroi 7 of 34 recruited participants were excluded from the crossover due mainly to complications or immediate device failure. Twenty-four of the remaining 27 participants while still blinded chose the period of stimulation they had preferred. Outcomes were reported separately for 19 participants who preferred the 'on' and five who preferred the 'off' period. For the group of 19, the median (range) episodes of faecal incontinence per week fell from 1.7 (0 to 9) during the 'off' period to 0.7 (0 to 5) during the 'on' period; for the group of five, however, the median (range) rose from 1.7 (0 to 11) during the 'off' period compared with 3.7 (0 to 11) during the 'on' period. Four of 27 participants experienced an adverse event resulting in removal of the stimulator.In the crossover trial by Sørensen and colleagues, participants did not experience any FI episodes in either the one-week 'on' or 'off' periods.In the crossover trial by Vaizey, participants reported an average of six, and one, episodes of faecal incontinence per week during the 'off' and 'on' periods respectively in two participants with FI. Neither study reported adverse events.In the crossover trial by Kahlke, 14 participants with FI experienced significantly lower episodes of FI per week during the stimulator 'on' (1 (SD, 1.7)) compared with the 'off' period (8.4 (SD, 8.7)). Adverse events reported include: haematoma formation (n = 3); misplacement of tined lead (1); and pain at stimulator site (n = 1).Two trials assessed SNS for constipation. In the Kenefick trial, the two participants experienced an average of two bowel movements per week during the 'off' crossover period, compared with five during the 'on' period. Abdominal pain and bloating occurred 79% of the time during the 'off' period compared with 33% during the 'on' period. No adverse events occurred. In contrast, in the trial by Dinning with 59 participants, SNS did not improve frequency of bowel movements and 73 adverse events were reported, which included pain at site of the implanted pulse generator (32), wound infection (12), and urological (17) events.

AUTHORS' CONCLUSIONS

The limited evidence from the included trials suggests that SNS can improve continence in a proportion of patients with faecal incontinence. However, SNS did not improve symptoms in patients with constipation. In addition, adverse events occurred in some patients where these were reported. Rigorous high quality randomised trials are needed to allow the effects of SNS for these conditions to be assessed with more certainty.

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.

Dynamic article: composite antropyloric valve and gracilis muscle transposition for total anorectal reconstruction: a preliminary report

BACKGROUND

Technique and functional outcomes of anorectal reconstruction using an antropyloric graft have been reported previously. This technique had reasonable initial outcomes but lacked voluntary function.

OBJECTIVE

We hereby report the initial results of patients who underwent gracilis muscle wrapping around the perineally transposed antropyloric valve in an attempt to improve voluntary fecal control.

SETTING

This study was conducted at a single tertiary care institution.

PATIENTS

Eight adult patients (7 men and 1 woman) with a median age of 38 years (range, 19-51 years) underwent this procedure. Seven patients already had anorectal reconstruction with a transposed antropyloric valve, and 1 patient with severely damaged anal sphincter complex underwent single-stage composite antropylorus transposition with a gracilis muscle wrap.

MAIN OUTCOME MEASURES

The primary outcome measures were anatomical integrity and functional status of the composite graft in the perineum.

RESULTS

No operative mortality or serious procedure-related morbidity occurred in any patient. The median postoperative resting pressure was 29 mmHg (range, 22-38 mmHg) and squeeze pressure was 72.5 mmHg (range, 45-267 mmHg). There was a significant improvement in the squeeze pressure following surgery (p = 0.039). Also, the St. Mark's incontinence scores significantly improved in all patients and varied between 7 and 9 (p = 0.003). The ability to defer defecation and the reduced frequency of leakage accidents were the prime reasons for improved postgraciloplasty outcomes in these patients. On personal interviews, all patients who underwent this procedure were satisfied with the results of their surgery.

LIMITATIONS

A longer follow-up with a larger sample size is required. Quality-of-life data have not been evaluated in this study.

CONCLUSIONS

Gracilis muscle wrapping around a perineally transposed antropyloric valve is possible and improves the voluntary control and overall functional outcomes in a select group of patients with end-stage fecal incontinence requiring anal replacement (Supplemental Digital Content 1, http://links.lww.com/DCR/A173).

Long-term outcomes of sacral nerve stimulation for faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) has proven short- to medium-term effectiveness for the treatment of faecal incontinence (FI); fewer long-term outcomes have been presented and usually in small series. Here, the long-term effectiveness of SNS was evaluated in a large European cohort of patients with a minimum of 5 years' follow-up.

METHODS

Prospectively registered data from patients with FI who had received SNS for at least 5 years from ten European centres were collated by survey. Daily stool diaries, and Cleveland Clinic and St Mark's incontinence scores were evaluated at baseline, after implantation and at the last follow-up. SNS was considered successful when at least 50 per cent symptom improvement was maintained at last follow-up.

RESULTS

A total of 407 patients underwent temporary stimulation, of whom 272 (66·8 per cent) had an impulse generator implanted; 228 (56·0 per cent) were available for long-term follow-up at a median of 84 (i.q.r. 70-113) months. Significant reductions in the number of FI episodes per week (from median 7 to 0·25) and summative symptom scores (median Cleveland Clinic score from 16 to 7, St Mark's score from 19 to 6) were recorded after implantation (all P < 0·001) and maintained in long-term follow-up. In per-protocol analysis, long-term success was maintained in 71·3 per cent of patients and full continence was achieved in 50·0 per cent; respective values based on intention-to-treat analysis were 47·7 and 33·4 per cent. Predictive analyses determined no significant association between pretreatment variables and successful outcomes. Risk of long-term failure correlated with minor symptom score improvement during the temporary test phase.

CONCLUSION

SNS remains an effective treatment for FI in the long term for approximately half of the patients starting therapy.

Current status: new technologies for the treatment of patients with fecal incontinence

Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.

Novel artificial anal sphincter system based on transcutaneous energy transmission system tested in vivo

This paper proposes a novel artificial anal sphincter system (AASS) for severe fecal incontinence. The AASS is composed of an artificial anal sphincter (AAS), an external transcutaneous energy transmission system (TETS), and an external control device. The AAS is composed of a cuff, a micropump, a reservoir, and a remote control device. It is designed to be implanted into the body of the patient. The function of the AAS is to open and close the patient's natural anus. Patients suffering from loss of their natural sphincter lose rectal sensation and are thus unable to perceive imminent fecal incontinence. In order to restore rectal sensation, a pressure sensor in the AAS cuff is designed to detect pressure in the colon. The pressure reflects the present quantity of colon contents, allowing patients to control the AAS to open or close the anus according to the pressure. The TETS is designed to provide electrical energy to the implanted AAS without wire connections. The external control device is designed to receive the pressure information from the AAS and send the patient's command to the implanted device. This paper provides a thorough discussion of the design of the novel AASS and describes the performance of the AASS when tested in vivo on two Beagle dogs who were chosen to be the subjects for receiving the implant. The experimental results verified that the performance of the AASS met the functional requirements it was designed for; however, the trial also revealed some challenges to be further studied.

Preoperative constipation is associated with poor prognosis of rectal cancer: a prospective cohort study

Purpose

It is unknown whether patients with advanced rectal cancer develop severe constipation. Therefore, the objective of this study was to assess whether constipation severity is associated with pathologic progression of rectal cancer.

Methods

We analyzed 472 patients with rectal cancer who underwent elective surgical resection between January 2005 and December 2010. Constipation severity was prospectively evaluated in 407 patients (86.2%) using the Cleveland Clinic Constipation Score System. Linear regression analysis was performed to identify clinicopathologic variables associated with constipation. Kaplan-Meier analysis and Cox proportional hazard models were used to evaluate the prognostic value of constipation severity on disease-free and overall survival.

Results

Multivariable analysis showed that sex (regression coefficient [B] = 1.55; 95% confidence interval [CI], 0.79 to 2.60; P < 0.001), body mass index (B = -0.95; 95% CI, -1.83 to -0.64; P = 0.036), tumor size (B = 1.04; 95% CI, 0.20 to 1.88; P = 0.016), T stage (B = 0.75; 95% CI, 0.23 to 1.27; P = 0.005), and distant metastasis (B = 1.16; 95% CI, 0.03 to 2.30; P = 0.045) were associated with constipation severity. Severe constipation (score ≥ 8) was independently associated with 3-year disease-free survival (vs. scores of 0-3; hazard ratio [HR], 2.39; 95% CI, 1.15 to 4.98; P = 0.020) and 5-year overall survival (HR, 2.30; 95% CI, 1.23 to 4.30; P = 0.009) in multivariable analysis.

Conclusion

Our results suggest that preoperative constipation severity is associated with advanced pathologic stage and poor oncologic outcomes in patients with rectal cancer.

Technical and functional results of the artificial bowel sphincter for treatment of severe fecal incontinence: is there any benefit for the patient?

BACKGROUND

Fecal incontinence is a socially devastating problem that can be cured by the artificial bowel sphincter in selected cases.

OBJECTIVE

This study evaluates short- and long-term morbidity and functional results of the artificial bowel sphincter.

DESIGN

This study is a retrospective evaluation of consecutive patients.

SETTINGS

This study was conducted at 2 academic colorectal units.

PATIENTS

Between May 2003 and July 2010, all consecutive patients who underwent artificial bowel sphincter implantation for severe fecal incontinence were included in the study.

INTERVENTION

The artificial bowel sphincter was implanted through 2 incisions made in the perineum and suprapubic area.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, and 12, and then annually. Mortality, morbidity (early infection within the first 30 days after implant, and late thereafter), and reoperations including explantations were analyzed. Anal continence was evaluated by means of the Cleveland Clinic Florida score. Mean follow-up was 38 months (range, 12-98).

RESULTS

Between May 2003 and July 2010, 21 consecutive patients with a mean age of 51 years (range, 23-71) underwent surgery. There was no mortality. All patients presented with at least 1 complication. Infection or cutaneous ulceration occurred in 76% of patients, perineal pain in 29%, and rectal evacuation disorders in 38%. The artificial bowel sphincter was definitely explanted from 17 patients (81%). The artificial sphincter was able to be activated in 17 patients (81%), and continence was satisfactory at 1 year in those who still had their sphincter in place (n = 12).

CONCLUSION

There is a very high rate of morbidity and explantation after implantation of an artificial bowel sphincter for fecal incontinence. Four of 21 patients who still had an artificial sphincter in place had satisfactory continence at a mean follow-up of 38 months.

Perineal antropylorus transposition for end-stage fecal incontinence in humans: initial outcomes

BACKGROUND

Technical feasibility of perineal antropyloric valve transposition to reconstruct a severely damaged incontinent anal sphincter or to replace an excised anorectal sphincter has been reported previously.

OBJECTIVE

This study aimed to document the follow-up results of patients who underwent successful perineal antropyloric valve transposition for end-stage fecal incontinence.

SETTING

This study was conducted at a single tertiary care institution.

PATIENTS

Seventeen patients underwent the procedure. Eight patients had replacement (group 1) and 9 patients had augmentation (group 2) of the anal sphincter. Two patients in group 1 with early graft-related complications were excluded from further analysis, because they had the grafts excised.

MAIN OUTCOME MEASURES

The primary outcome measures were anatomical integrity and functional status of the graft in the perineum, fecal incontinence scores, and quality-of-life scores (SF-36) over a median follow-up of 18 months.

RESULTS

The transposed grafts had a definite tone on digital examination, were well visualized on perineal MRI, showed high-velocity vascular inflow on Doppler ultrasound study, and good vascularity on celiac CT angiography. Anal manometry showed a significant (p = 0.03) rise in the postoperative resting neosphincter pressures with good retention of barium proximal to pyloric valve on distal loopogram. The postoperative St Mark incontinence score improved in both groups and was significantly better in group 2 than in group 1. There was significant improvement in postoperative physical and mental component scores in both groups with higher scores in group 2 than in group 1 on follow-up.

LIMITATIONS

A longer follow-up with a larger sample size is required.

CONCLUSIONS

Antropyloric valve transposition can be used effectively for a selected group of patients with end-stage fecal incontinence. Patients undergoing anal sphincter augmentation have better outcomes in comparison with those having an excised sensate anorectum.

Artificial anal sphincter for severe fecal incontinence implanted by a transvaginal approach: experience with 32 patients treated at one institution

PURPOSE

Our aim was to evaluate medium-term results of transvaginal implantation of an artificial anal sphincter in a large series of patients.

METHODS

Women undergoing treatment for severe fecal incontinence at Rouen University Hospital, Rouen, France, from January 2003 through December 2007 were eligible for the study if the fecal incontinence had lasted for 6 months and if they had attempted other therapies without success. All patients received implantation of an artificial anal sphincter via a transvaginal approach. Incontinence was assessed with the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score).

RESULTS

A total of 32 women entered the study. Their median age was 63 (range, 26-79) years. At entry, 20 (63%) had severe destruction and scarring of the perineum, which was a contraindication for implantation via a perineal approach. Nine patients (28.1%) had previously undergone implantation of an AAS which had been removed because of complications, and 5 had had a Pickrell procedure for anal agenesia. No deaths occurred during the study. The device was removed in a total of 9 patients (28.1%): in 7 because of septic adverse events within the first 6 months after the operation, in 1 because of poor function, and in 1 for psychological reasons despite good functional results. Implantation was successful in 23 patients (71.9%), and the device remained activated for a mean follow-up of 41 (range, 18-75) months, with a mean decrease in Cleveland Clinic incontinence score from 18.4 to 6.8 (P < .0001). None of the patients complained of dyspareunia.

CONCLUSIONS

The transvaginal approach for implantation of an artificial anal sphincter permits treatment of women with fecal incontinence who have severe damage and scarring of the anterior perineum. This route provides an alternative for patients whose only therapeutic option would previously have been a defunctioning stoma.

Retention test in sacral nerve stimulation for fecal incontinence

INTRODUCTION

Sacral nerve stimulation has become an established treatment for patients with fecal incontinence. However, the mechanism of its action remains obscure. We aim to assess whether sacral nerve stimulation improves patients' ability to retain rectal content.

METHODS

Patients who had been treated successfully with sacral nerve stimulation underwent four retention tests during which the stimulator was turned either on or off. Both the patients and investigators were blinded to the status of the stimulator. The retention test results were assessed for interassessment agreement and for any differences between the on and off phases. Wexner scores, anorectal physiology tests, and patients' perceptions of stimulator settings were also recorded.

RESULTS

Nineteen patients (16 women; mean age, 57.5 years) took part in the study. Retention tests showed moderate interassessment agreement (weighted Cohen's kappa index, 0.45). There were no sharp differences in retained volume between the stimulator's on and off phases (median 50 (range, 0-300) mL vs. 50 (range, 0-300) mL; P = 0.85).

CONCLUSION

Sacral nerve stimulation does not alter patients' ability to retain rectal content. Further studies are needed to investigate the mechanism of sacral nerve stimulation.

Long-term results of artificial bowel sphincter for the treatment of severe faecal incontinence. Are they what we hoped for?

OBJECTIVE

This study evaluates the long-term morbidity, functional results and quality of life (QOL) after treatment of severe faecal incontinence (FI) with the Acticon Neosphincter (American Medical Systems, Minneapolis, Minnesota, USA).

METHOD

Between 1996 and 2002, 17 consecutive patients (14 female, 3 male; median age 46) underwent sphincter implantation. Clinical evaluation, incontinence severity and QOL were assessed. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed preoperatively and at several stages of follow-up. The study was completed in December 2007.

RESULTS

Mean follow-up was 68 months (range: 3-133). Morbidity occurred in 100% of patients from which 65% required at least one re-operation. After the first implant, 11 devices had to be removed (65%). Seven patients had a new implant. At the final stage, Acticon was activated in 9 cases (53%). Severity of FI improved from a median of 17.5 preoperatively to 9 (P = 0.005), 5.5 (P = 0.005) and 10 (P = 0.092) at 6, 12 months and at the end of follow-up, respectively. There was a significant improvement in QOL in all postoperative controls (P < 0.05). Severity of FI did not show a correlation with QOL in the preoperative period, but did at 6, 12 months and at the end of follow-up. Mean maximum resting pressure significantly increased with the full anal cuff.

CONCLUSION

There is a high rate of morbidity, surgical re-interventions and explants after Acticon implant. Patients should be clearly informed about this before surgery. However, patients who have not had Acticon Neosphincter explanted, experience a significant improvement in anal continence and QOL.

Constipation in 44 patients implanted with an artificial bowel sphincter

PURPOSE

Constipation with or without obstructed defecation (OD) is frequent in patients with artificial bowel sphincter (ABS). The aims of this study were (1) to evaluate the functional outcome of ABS based on postoperative constipation and (2) to assess pre-implantation data to predict post-implantation constipation.

MATERIALS AND METHODS

Thirteen men and 31 women were followed up. Both fecal incontinence and constipation with and without OD were assessed after implantation. Pre-implantation characteristics were compared in patients with and without postoperative constipation.

RESULTS

After implantation, nine patients (20.4%) had constipation without OD, 16 patients (36.4%) had OD, and 19 patients (43.2%) had neither of these. Incontinence was significantly more frequent in patients with postoperative constipation with or without OD. In these patients, an increase in preoperative constipation, anismus, and ultraslow waves was noted.

CONCLUSION

Constipation with and without OD is frequent after implantation and interfere with the functional outcome of ABS.

Long-term outcome of sacral nerve stimulation for fecal incontinence

PURPOSE

Sacral nerve stimulation is a safe and effective procedure for fecal incontinence. We investigated whether its efficacy is maintained long term.

PATIENTS AND METHODS

Sixty patients with fecal incontinence underwent permanent sacral nerve stimulation. Patients' data were prospectively recorded in the national registry of the Italian Group of sacral nerve stimulation. The severity of fecal incontinence was evaluated by the Wexner score, and data were collected in a bowel function diary. Quality of life was evaluated by the Italian version of the Medical Outcomes Survey Short Form (SF-36) questionnaire.

RESULTS

Fifty-two patients were available for long-term follow-up lasting at least 5 years. Compared with baseline, the Wexner score decreased significantly after definitive implantation (from 15 +/- 4 to 5 +/- 5, P < 0.001). At least 50 percent improvement in continence was achieved in 74 percent of the patients, and at least 70 percent improvement (median value) was achieved in 50 percent. The mean number of solid/liquid incontinence episodes decreased significantly from 0.5 (+/-0.5) to 0.1 (+/-0.3) per day (P = 0.004). Quality of life improved in all domains. The overall mean improvement in SF-36 scores was 39.8 percent. Both mean resting and squeeze anal pressures increased significantly, and maximum volume tolerated decreased significantly.

CONCLUSIONS

Sacral nerve stimulation maintains its efficacy long term, not only in regard to control of symptoms but also regarding quality of life.

Fecal incontinence treated with acupuncture--a pilot study

OBJECTIVES

Acupuncture has been used successfully for the treatment of urinary bladder dysfunction. The aim of this study was therefore to investigate if manual acupuncture might also affect fecal incontinence favorably.

METHODS

The study comprises 15 female patients, median age 60 years (39 -75). Before treatment and at regular intervals after acupuncture sessions the defects of anal continence were assessed. Ano-rectal function was assessed by means of recto anal manovolumetry. Each patient was submitted to one acupuncture treatment per week for a ten-week period. Subsequently, a control session was repeated once per month up to 7 months for six patients. A final functional assessment was performed at 18 months.

RESULT

Patients experienced a significant improvement in anal continence, the overall continence score which changed from 10 (3 -21) estimated before treatment to zero (0 - 7) (p<0.05) at 10 weeks. Patients with irregular bowel habits and/or loose stools reported significant improvement. On the manovolumetric variables a limited increase of resting from 25 (17-35) mmHg to 36 (20-42) mmHg, (p=0.05) and sustained squeeze anal pressure, changing from 41 (32-68) mmHg to 60 (40-100) mmHg (p<0.05) were reported. Rectal sensory function remained unchanged.

CONCLUSION

Acupuncture offers good opportunities for improving fecal incontinence. The mechanism of action is obscure but might be an effect of the "neuromodulation" of the recto-anal function similar to that explaining the favorable results achieved by sacral nerve stimulation. The concomitant regulation of disordered bowel habits may also contribute to the satisfactory results.

The artificial bowel sphincter for faecal incontinence: a single centre study

BACKGROUND AND AIMS

Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS).

MATERIALS AND METHODS

Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed.

RESULTS

Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8-106.3) months. The Williams score improved significantly after placement of the ABS (p<0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p=0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p=0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted.

CONCLUSION

The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.

Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature

Up until about 15 years ago the only realistic option for end-stage fecal incontinence was the creation of a permanent stoma. There have since been several developments. Dynamic graciloplasty (DGP) and artificial bowel sphincter (ABS) are well-established surgical techniques, which offer the patient a chance for continence restoration and improved quality of life; however, they are unfortunately associated with high morbidity and low success rates. Several trials have been done in an attempt to clarify the advantages and disadvantages of these methods and define their place in the second-line treatment of severe, refractory fecal incontinence. This review presents a critical and unbiased overview of the current status of neosphincter surgery according to the available data in the world literature.

The Colorectal Development Unit: impact on functional outcome for the electrically stimulated gracilis neoanal sphincter

OBJECTIVE

A Colorectal Development Unit (CDU) was established to treat patients with end stage faecal incontinence with the electrically stimulated gracilis neoanal sphincter (ESGN). The aim of this study was to investigate the impact of the CDU on functional outcome and complications.

METHODS

From March 1997 to March 2003, 53 patients underwent ESGN formation. Results were compared with 65 patients undergoing ESGN surgery prior to the establishment of the unit (pre-CDU) between 1988 and 1997, which were similar with regard to age, sex, aetiology and follow-up.

RESULTS

Thirty-three (70%) CDU patients had a good functional outcome defined as continence to solid and liquid stool, a significant improvement when compared to the pre-CDU group, successful in 29 (45%) (P = 0.01). Episodes of technical complications leading to stimulator replacement were significantly reduced, from 25 to 3 over time (P < 0.001). Severe septic episodes were significantly reduced from 21 to four (P = 0.003) but there was no significant change in the incidence of postoperative evacuatory dysfunction.

CONCLUSION

Since setting up a CDU, a successful outcome has been achieved in 33 (70%) of 47 patients undergoing ESGN surgery, which represents a significant improvement over time. This is probably related to improved patient assessment and selection, more reliable equipment and increased operative and peri-operative experience that come with a multidisciplinary team approach.

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.

A review of contemporary surgical alternatives to permanent colostomy

OBJECTIVES

To review the options available to patients with faecal incontinence with failed conservative treatment and/or failed anal sphincter repair and assessing the current indications and results of these options.

METHODS

A literature search of MEDLINE, EMBASE and Cochrane databases was performed using the relevant search terms.

RESULTS

Continent options for patients with severe or end stage faecal incontinence include the creation of a form of an anal neosphincter and more recently sacral nerve stimulation. Over half the patients, who are candidates, may benefit from these procedures, although long term results of sacral nerve stimulation are unknown. Dynamic graciloplasty improves the continence in 44-79% of the patients. The complications include frequent reoperations, high incidence of infection and obstructive defaecation. The success rates of artificial bowel sphincter vary between 24% and 79%. Once functional, the artificial bowel sphincter seems to improve the continence in the majority of the patients. Device removal due to infection, obstructive defaecation and pain is a frequent problem. Sacral nerve stimulation is claimed to result in improvement in continence in 35-100% of patients. The main risks in this procedure are infection, electrode displacement and pain.

CONCLUSIONS

All these procedures have high complication rates and have moderate success rates only. A major proportion of patients will need reoperations and hence high motivation is necessary for patients who undergo these procedures. A uniform standard for measurement of success is also necessary so that these procedures can be compared with each other.