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Role of Autologous Fat Grafting in the Conservative Treatment of Fecal Incontinence in Children. J Clin Med 2023; 12:jcm12041258. [PMID: 36835794 PMCID: PMC9964968 DOI: 10.3390/jcm12041258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
Treatment of organic fecal incontinence in children, typical of anorectal malformations, is most often conservative; however, when necessary, it can be surgical. Autologous fat grafting, or lipofilling, can be used to improve fecal incontinence. We present our experience with the echo-assisted anal-lipofilling and its effects on fecal incontinence in children and on the quality of life of the entire family. Under general anesthesia, fat tissue was harvested according to the traditional technique, and processed in a closed system Lipogems® set. Injection of the processed adipose tissue was guided by trans-anal ultrasound assistance. Ultrasound and manometry were also used for follow-up. From November 2018, we performed 12 anal-lipofilling procedures in six male patients (mean age 10.7 years). Five children had a stable improvement in bowel function with Krickenbeck's scale scores going from soiling grade 3 pre-treatment in 100% of children to grade 1 post-treatment in 75% of them. No major post-operative complications developed. An increase in thickness of the sphincteric apparatus was shown at ultrasound during follow-up. The quality of life of the entire family, evaluated with a questionnaire, improved after the surgical treatment of the children. Anal-lipofilling is a safe and effective procedure to reduce organic fecal incontinence thereby benefiting both the patients and their families.
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Jabbar SAA, Camilleri-Brennan J. An evaluation of the long-term effectiveness of Gatekeeper™ intersphincteric implants for passive faecal incontinence. Tech Coloproctol 2022; 26:537-543. [PMID: 35593969 PMCID: PMC9213285 DOI: 10.1007/s10151-022-02630-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/02/2022] [Indexed: 11/26/2022]
Abstract
Background Implantation of Gatekeeper™ prostheses presents an option for the treatment of passive faecal incontinence (FI). Whilst preliminary results are encouraging, long-term data regarding its sustained benefit are limited. The aim of this study was to assess and evaluate the long-term clinical function and quality of life of patients with passive faecal incontinence who were treated with Gatekeeper™ prostheses. Methods This was a single centre, single surgeon retrospective study of prospectively collected clinical data in patients with FI treated between June 2012 and May 2019. Patients with passive FI with symptoms refractory to conservative treatment and endoanal ultrasonography showing intact or disrupted internal anal sphincter were included. Formal clinical and quality of life assessments were carried out using the St. Mark’s Incontinence Score (SMIS) and Faecal Incontinence Quality of Life (FIQoL) questionnaires at baseline, 3 months, 6 months, 12 months and then annually. Endoanal ultrasonography was performed both before and after surgery. Results Forty patients (14 males, 26 females) with a median age of 62.5 (range 33–80) years were treated with the Gatekeeper™ implant. The majority of patients (87.5%) received six implants. There were no peri or post-operative complications. Prosthesis migration was observed in 12.5% patients. The median follow-up duration was 5 years (interquartile range (IQR) 3.25–6.00 years). A sustained improvement in median SMIS and FIQoL scores from baseline to follow-up was noted. Significant differences were observed between the median baseline SMIS score and last follow-up score of 16.00 (IQR 15.00–16.75) to 7.00 (IQR 5.00–8.00) respectively (p < 0.001), a 56.25% decrease. The overall median FIQoL score showed a significant improvement from 7.95 (IQR 7.13–9.48) to 13.15 (IQR 12.00–13.98) (p < 0.001) a 65.40% increase. Conclusions Gatekeeper™ implantation is a safe approach to treating passive FI and is minimally invasive, reproducible and has minimal complications. Long-term sustained clinical improvement is achievable beyond 5 years. Careful patient selection is paramount, as is consistency of technique and follow-up protocol.
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Affiliation(s)
- S A A Jabbar
- Department of Colorectal Surgery, Forth Valley Royal Hospital, Larbert, Stirlingshire, Scotland, UK
| | - J Camilleri-Brennan
- Department of Colorectal Surgery, Forth Valley Royal Hospital, Larbert, Stirlingshire, Scotland, UK.
- Department of Surgery, University of Glasgow, Glasgow, Scotland, UK.
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Critical appraisal of international guidelines for the management of fecal incontinence in adults: is it possible to define what to do in different clinical scenarios? Tech Coloproctol 2021; 26:1-17. [PMID: 34767095 PMCID: PMC8587500 DOI: 10.1007/s10151-021-02544-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 10/28/2021] [Indexed: 11/10/2022]
Abstract
Fecal incontinence (FI) is a complex often multifactorial functional disorder which is associated with a significant impact on patients’ quality of life. There is a broad spectrum of symptoms, and degrees of severity and diverse patient backgrounds. Several treatment algorithms from different professional societies and experts are available in the literature. However, no consensus has been reached on several aspects of FI management. We performed a critical review of the most recently published guidelines on FI, emphasising the lack of consensus, highlighting specific topics mentioned in each of the guidelines that are not covered in the others and defining the treatment proposed in different clinical scenarios.
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Cavalcante ART, Lima RPD, Souza VSBD, Pinto FCM, Campos Júnior O, Silva JGMD, Albuquerque AVD, Aguiar JLDA. Effects of bacterial cellulose gel on the anorectal resting pressures in rats submitted to anal sphincter injury. Heliyon 2018; 4:e01058. [PMID: 30603694 PMCID: PMC6310775 DOI: 10.1016/j.heliyon.2018.e01058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/04/2018] [Accepted: 12/12/2018] [Indexed: 12/18/2022] Open
Abstract
The aim of this study is to evaluate if a gel of bacterial cellulose gel can revert the loss of anal resting pressure after anorectum sphincter injury in rat model, elected as a model to simulate fecal incontinence. Thirty-nine animals were equally divided into three groups: Control (CG), Sphincter injury plus Saline injection (SG) and Sphincter injury plus Bacterial Cellulose Gel injection (BCG). Anal pressure at rest was assessed for all animal in the three groups using anorectum manometry. Saline and Gel groups were subject to anorectum sphincter injury to reduce the anal pressure at rest. Fifteen days later Saline or Gel was injected into the anorectum, according to their groups. Sixty days later first manometry, the anorectum of all animals were removed and processed histologically. The CG group showed maintenance of their mean anorectal resting pressure levels; SG presented a fall in their mean anorectal resting pressure. The BCG presented a significant elevation of the mean anorectal resting pressure levels, surpassing the pressure of CG. The gel of bacterial cellulose remained at the injection site and was neovascularized, colonized by fibroblasts and dense conjunctive tissue. Those data suggest that BC can be used as a future filling agent treatment for fecal incontinence in clinical trial protocols.
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Abstract
Fecal incontinence is a devastating condition, vastly under-reported, and may affect up to 18% of the population. While conservative management may be efficacious in a large portion of patients, those who are refractory will likely benefit from appropriate surgical intervention. There are a wide variety of surgical approaches to fecal incontinence management, and knowledge and experience are crucial to choosing the appropriate procedure and maximizing functional outcome while minimizing risk. In this article, we provide a comprehensive description of surgical options for fecal incontinence to help the clinician identify an appropriate intervention.
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Affiliation(s)
- Steven D Wexner
- a 1 Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Joshua Bleier
- b 2 University of Pennsylvania Health System, Department of Surgery, 800 Walnut St. 20th Floor, Philadelphia, PA 19106, USA
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Al-Abed YA, Ayers J, Ayantunde A, Praveen BV. Safety and Efficacy of Permacol Injection in the Treatment of Fecal Incontinence. Ann Coloproctol 2016; 32:73-8. [PMID: 27218098 PMCID: PMC4865468 DOI: 10.3393/ac.2016.32.2.73] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/02/2016] [Indexed: 11/23/2022] Open
Abstract
Purpose Permacol has been gaining popularity in recent times for the treatment of fecal incontinence (FI). This study aims to evaluate the safety and efficacy of anal submucosal Permacol injection in the treatment of FI. Methods All consecutive patients who underwent Permacol injection for FI over a 3-year period were included. Patients' data relating to obstetric history, anorectal/pelvic operations, type of FI, preoperative anorectal physiology results and follow-up details for outcome measures were collected. Preoperative and postoperative Cleveland Clinic Florida Incontinence Scores (CCFISs) were noted. Patients were surveyed by using a telephone questionnaire to assess the quality of life and other outcome measures. Data were analysed using SPSS ver.19.0. Results Thirty patients (28 females and 2 males) with a median age of 67 years were included in the study. Of those patients, 37%, 50%, and 13% were noted to have passive, mixed and urge FI, respectively. Six of the patients (20%) had repeat Permacol injections, 5 of whom had sustained responses to the first Permacol injection for a mean of 11 months. There was a significant improvement in the CCFIS from a baseline median of 12.5, mean 12.8 interquartile range [IQR], 6–20), to a median of 3.5, mean 4.8 (IQR, 0–20), P < 0.001. Of the patients surveyed by telephone 89% were satisfied with their overall experience and the improvement in their symptoms following Permacol injections. Conclusion This study has demonstrated that Permacol injection for the treatment of FI is safe and effective and has no associated major complications. However, the results are not permanent; consequently, a significant proportion of the patients with an initial response may require repeat injections.
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Affiliation(s)
- Yahya A Al-Abed
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
| | - Jennifer Ayers
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
| | - Abraham Ayantunde
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
| | - Bandipalyam V Praveen
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
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Duelund-Jakobsen J, Worsoe J, Lundby L, Christensen P, Krogh K. Management of patients with faecal incontinence. Therap Adv Gastroenterol 2016; 9:86-97. [PMID: 26770270 PMCID: PMC4699277 DOI: 10.1177/1756283x15614516] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8-8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail.
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Affiliation(s)
- Jakob Duelund-Jakobsen
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Tage-Hansens Gade 2, 8000 Aarhus C, Denmark
| | - Jonas Worsoe
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Denmark
| | - Lilli Lundby
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Denmark
| | - Peter Christensen
- Pelvic Floor Unit, Department of Surgery P, Aarhus University Hospital, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
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Alam NN, Narang SK, Köckerling F, Daniels IR, Smart NJ. Anal Sphincter Augmentation Using Biological Material. Front Surg 2015; 2:60. [PMID: 26636089 PMCID: PMC4657277 DOI: 10.3389/fsurg.2015.00060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/02/2015] [Indexed: 12/21/2022] Open
Abstract
Introduction The aim of this review is to provide an overview of the use of biological materials in the augmentation of the anal sphincter either as part of an overlapping sphincter repair (OSR) or anal bulking procedure. Methods A systematic search of PubMed was conducted using the search terms “anal bulking agents,” “anal sphincter repair,” or “overlapping sphincter repair.” Five studies using biological material as part of an overlapping sphincter repair (OSR) or as an anal bulking agent were identified. Results 122 patients underwent anal bulking with a biological material. Anorectal physiology was conducted in 27 patients and demonstrated deterioration in maximum resting pressure, and no significant change in maximum squeeze increment. Quality of life scores (QoLs) demonstrated improvements at 6 weeks and 6 months, but this had deteriorated at 12 months of follow up. Biological material was used in 23 patients to carry out an anal encirclement procedure. Improvements in QoLs were observed in patients undergoing OSR as well as anal encirclement using biological material. Incontinence episodes decreased to an average of one per week from 8 to 10 preoperatively. Conclusion Sphincter encirclement with biological material has demonstrated improvements in continence and QoLs in the short term compared to traditional repair alone. Long-term studies are necessary to determine if this effect is sustained. As an anal bulking agent the benefits are short-term.
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Affiliation(s)
- Nasra N Alam
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
| | - Sunil K Narang
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
| | - Ferdinand Köckerling
- Department of Surgery, Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital , Berlin , Germany
| | - Ian R Daniels
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
| | - Neil J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
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Montroni I, Wexner SD. Reoperative surgery for fecal incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ratto C, Buntzen S, Aigner F, Altomare DF, Heydari A, Donisi L, Lundby L, Parello A. Multicentre observational study of the Gatekeeper for faecal incontinence. Br J Surg 2015; 103:290-9. [PMID: 26621029 PMCID: PMC5063193 DOI: 10.1002/bjs.10050] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/24/2015] [Accepted: 10/07/2015] [Indexed: 12/13/2022]
Abstract
Background A variety of therapeutic approaches are available for faecal incontinence. Implantation of Gatekeeper™ prostheses is a new promising option. The primary endpoint of this prospective observational multicentre study was to assess the clinical efficacy of Gatekeeper™ implantation in patients with faecal incontinence. Secondary endpoints included the assessment of patients' quality of life, and the feasibility and safety of implantation. Methods Patients with faecal incontinence, with either intact sphincters or internal anal sphincter lesions extending for less than 60° of the anal circumference, were selected. Intersphincteric implantation of six prostheses was performed. At baseline, and 1, 3 and 12 months after implantation, the number of faecal incontinence episodes, Cleveland Clinic Faecal Incontinence, Vaizey and American Medical Systems, Faecal Incontinence Quality of Life Scale and Short Form 36 Health Survey scores were recorded. Endoanal ultrasonography was performed at baseline and follow‐up. Results Fifty‐four patients were implanted. After Gatekeeper™ implantation, incontinence to gas, liquid and solid stool improved significantly, soiling was reduced, and ability to defer defaecation enhanced. All faecal incontinence severity scores were significantly reduced, and patients' quality of life improved. At 12 months, 30 patients (56 per cent) showed at least 75 per cent improvement in all faecal incontinence parameters, and seven (13 per cent) became fully continent. In three patients a single prosthesis was extruded during surgery, but was replaced immediately. After implantation, prosthesis dislodgement occurred in three patients; no replacement was required. Conclusion Anal implantation of the Gatekeeper™ in patients with faecal incontinence was effective and safe. Clinical benefits were sustained at 1‐year follow‐up. GatekeeperTM effective
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Affiliation(s)
- C. Ratto
- Proctology Unit, Department of Surgical SciencesCatholic UniversityRomeItaly
| | - S. Buntzen
- Department of Surgery PAarhus University HospitalAarhusDenmark
| | - F. Aigner
- Department of Visceral, Transplant and Thoracic SurgeryInnsbruck Medical UniversityInnsbruckAustria
- Department of General, Visceral and Transplant SurgeryCharité Universitätsmedizin BerlinCampus Virchow‐KlinikumBerlinGermany
| | - D. F. Altomare
- Department of Emergency and Organ Transplantation, General Surgery UnitUniversity of BariBariItaly
| | - A. Heydari
- Department of General SurgeryNuovo Ospedale Civile Sant'Agostino EstenseModenaItaly
| | - L. Donisi
- Proctology Unit, Department of Surgical SciencesCatholic UniversityRomeItaly
| | - L. Lundby
- Department of Surgery PAarhus University HospitalAarhusDenmark
| | - A. Parello
- Proctology Unit, Department of Surgical SciencesCatholic UniversityRomeItaly
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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Abstract
BACKGROUND Anal incontinence is a common and multifactorial pathology that affects patients' lives and imposes considerable socioeconomic consequences. OBJECTIVE The aim of this study is to evaluate the efficacy of a bulking agent, polyacrylate-polyalcohol (PP), in terms of diminishing the severity of incontinence and improving the patient's quality of life, assessing any adverse events. DESIGN Data were obtained through a prospective, nonconsecutive, multicenter, noncomparative, postmarket study with a maximum expected follow-up of 3 years. Four investigational centers from Argentina and Brazil participated in this study. SETTINGS Injections of the bulking agent were administered in the operating room of tertiary hospitals. PATIENTS Fifty-eight patients were enrolled. Five patients were lost to follow-up. Of the remaining 53 patients, 41 (77.4%) were females. All patients scored between 6 and 12 on the Cleveland Clinic Florida-Fecal Incontinence Score as part of the inclusion criteria. INTERVENTIONS The injection of the bulking agent (PP) was administered under intravenous sedation in the submucosa of the anal canal through the perianal skin to generate a bulk. MAIN OUTCOME MEASURES The primary efficacy end point was the Cleveland Clinic Florida-Fecal Incontinence Score (or Jorge and Wexner index). The Rockwood-Fecal Incontinence Quality of Life index was also recorded. The treatment was considered successful if patients achieved a postoperative improvement of at least 50% on the Cleveland Clinic Florida-Fecal Incontinence Score. RESULTS Successful treatment was met by 60.4% of the patients according to the last follow-up data. Quality-of-life indices showed consistently significant improvements. LIMITATIONS Selection bias and the lack of a control group to evaluate the potential placebo effect of this novel bulking agent were limitations of this study. Because of the eligibility criteria, the resulting patient sample is representative of only a limited portion of the population with fecal incontinence at all 4 centers involved in this study. CONCLUSIONS The injection technique was easy to perform, safe, and ideal for use as an outpatient procedure. This bulking agent (PP) significantly improved continence and quality of life in selected patients.
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Whitehead WE, Rao SSC, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterol 2015; 110:138-46; quiz 147. [PMID: 25331348 DOI: 10.1038/ajg.2014.303] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/05/2014] [Indexed: 12/11/2022]
Abstract
This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.
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Affiliation(s)
- William E Whitehead
- 1] Division of Gastroenterology and Hepatology, Department of Medicine, Chapel Hill, North Carolina, USA [2] Division of Urogynecology and Reconstructive Pelvic Floor Surgery, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Satish S C Rao
- Department of Gastroenterology, Georgia Regents University, Augusta, Georgia, USA
| | - Ann Lowry
- Colon and Rectal Surgery Associates, Ltd., St. Paul, Minnesota, USA
| | - Deborah Nagle
- Department of Colon and Rectal Surgery, Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Madhulika Varma
- Section of Colorectal Surgery, University of California, San Francisco, California, USA
| | - Khalil N Bitar
- Department of Regenerative Medicine, Wake Forest Institute for Regenerative Medicine, Winston Salem, North Carolina, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank A Hamilton
- National Institutes of Diabetes, Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland, USA
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Long-term evaluation of bulking agents for the treatment of fecal incontinence: clinical outcomes and ultrasound evidence. Tech Coloproctol 2014; 19:23-7. [PMID: 25381455 DOI: 10.1007/s10151-014-1236-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/03/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The injection of bulking agents into the anal canal has been reported to help patients with fecal incontinence. Although it has been advocated as a safe and effective option, substantial data concerning long-term efficacy are still lacking, and the resorption process of the implants has not yet been carefully studied. The aim of our study was to investigate the long-term outcomes of bulking agents for the treatment of fecal incontinence and the behavior of implanted materials in the anorectum. METHODS At a median follow-up of 7 years, 19 patients with idiopathic fecal incontinence who had received bulking agent implants were evaluated. Clinical, manometric and ultrasound assessments were carried out. RESULTS The clinical improvements that were achieved in the short term were not maintained over time. For each patient, the number of implants that could no longer be identified on ultrasound was significantly correlated with poorer clinical long-term outcomes. On average, only 14% of the originally injected volume was still detectable. CONCLUSIONS In the long term, perianally injected bulking agents seem to lose effectiveness. The ultrasound assessment suggests that the process of resorption is almost complete, and the implants are no longer effective in treating incontinence.
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Abstract
OBJECTIVE To review the management of fecal incontinence, which affects more than 1 in 10 people and can have a substantial negative impact on quality of life. METHODS The medical literature between 1980 and April 2012 was reviewed for the evaluation and management of fecal incontinence. RESULTS A comprehensive history and physical examination are required to help understand the severity and type of symptoms and the cause of incontinence. Treatment options range from medical therapy and minimally invasive interventions to more invasive procedures with varying degrees of morbidity. The treatment approach must be tailored to each patient. Many patients can have substantial improvement in symptoms with dietary management and biofeedback therapy. For younger patients with large sphincter defects, sphincter repair can be helpful. For patients in whom biofeedback has failed, other options include injectable medications, radiofrequency ablation, or sacral nerve stimulation. Patients with postdefecation fecal incontinence and a rectocele can benefit from rectocele repair. An artificial bowel sphincter is reserved for patients with more severe fecal incontinence. CONCLUSION The treatment algorithm for fecal incontinence will continue to evolve as additional data become available on newer technologies.
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Affiliation(s)
- Jennifer Y Wang
- General and Colorectal Surgeon at the San Jose Medical Center in CA. E-mail:
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Mellgren A, Matzel KE, Pollack J, Hull T, Bernstein M, Graf W. Long-term efficacy of NASHA Dx injection therapy for treatment of fecal incontinence. Neurogastroenterol Motil 2014; 26:1087-94. [PMID: 24837493 PMCID: PMC4371654 DOI: 10.1111/nmo.12360] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/07/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Injectable bulking treatment for fecal incontinence (FI) is intended to expand tissue in the anal canal and prevent fecal leakage. Use of injectable bulking agents is increasing because it can be performed in an outpatient setting and with low risk for morbidity. This study evaluated the long-term (36-month) clinical effectiveness and safety of injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA Dx) on FI symptoms. METHODS In a prospective multicenter trial, 136 patients with FI received the NASHA Dx bulking agent. Treatment success defined as a reduction in number of FI episodes by 50% or more compared with baseline (Responder50 ). Change from baseline in Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL), and adverse events were also evaluated. KEY RESULTS Successful decrease in symptoms was achieved in 52% of patients at 6 months and this was sustained at 12 months (57%) and 36 months (52%). Mean CCFIS decreased from 14 at baseline to 11 at 36 months (p < 0.001). Quality-of-life scores for all four domains improved significantly between baseline and 36 months of follow-up. Severe adverse events were rare and most adverse events were transient and pertained to minor bleeding and pain or discomfort. CONCLUSIONS & INFERENCES Submucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years.
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Affiliation(s)
- A Mellgren
- Division of Colon & Rectal Surgery, University of IllinoisChicago, IL, USA,Address for Correspondence
, Anders Mellgren, MD, PhD, UIC College of Medicine, Division of Colon & Rectal Surgery (MC 958), 840 South Wood Street 518 E CSB, Chicago, IL 60612., Tel: 312-996-2061; fax: 312-996-1214; e-mail:
| | - K E Matzel
- Friedrich-Alexander-University of Erlangen-NurembergErlangen, Germany
| | - J Pollack
- Department of Surgery, Danderyd HospitalStockholm, Sweden (deceased)
| | - T Hull
- Cleveland Clinic FoundationCleveland, OH, USA
| | | | - W Graf
- Institution of Surgical Sciences, Uppsala UniversityUppsala, Sweden
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17
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Abstract
The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.
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Affiliation(s)
- Joshua I S Bleier
- Division of Colon and Rectal Surgery, Pennsylvania Hospital/Hospital of the University of Pennsylvania, University of Pennsylvania, 800 Walnut Street, 20th Floor, Philadelphia, PA 19106, USA.
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Abstract
Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ~2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.
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Koh CE, Solomon MJ. Injectable bulking agents for passive faecal incontinence. Tech Coloproctol 2013; 17:343-4. [DOI: 10.1007/s10151-013-1018-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 11/24/2022]
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Claudio Wainstein G, Rodrigo Quera P, Maria Isabel QG. Incontinencia fecal en el adulto: Un desafio permanente. REVISTA MÉDICA CLÍNICA LAS CONDES 2013. [DOI: 10.1016/s0716-8640(13)70156-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2013:CD007959. [PMID: 23450581 DOI: 10.1002/14651858.cd007959.pub3] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Faecal incontinence is a complex and distressing condition with significant medical and social implications. Injection of perianal bulking agents has been used to treat the symptoms of passive faecal incontinence. However, various agents have been used without a standardised technique and the supposed benefit of the treatment is largely anecdotal with a limited clinical research base. OBJECTIVES To determine the effectiveness of perianal injection of bulking agents for the treatment of faecal incontinence in adults. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Register of trials (25 May 2012), ZETOC (3 May 2012), clinical trials registries (3 May 2012) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing the use of injectable bulking agents for faecal incontinence with any alternative treatments or placebo were reviewed to evaluate the therapeutic effects. Case-control and cohort studies were also reviewed to assess risks and complications associated with the treatments. DATA COLLECTION AND ANALYSIS Two review authors (YM and CN) assessed the methodological quality of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures. MAIN RESULTS Five eligible randomised trials with a total of 382 patients were identified. Four of the trials were at an uncertain or high risk of bias.Most trials reported a short term benefit from injections regardless of the material used, including placebo saline injection. One study demonstrated dextranomer in stabilised hyaluronic acid (NASHA Dx) to be more effective than sham injection but with more adverse effects. Dextranomer in stabilised hyaluronic acid (NASHA Dx) was better than sham injections at six months (65/136, 48% versus 48/70, 69% participants not improved, defined as less than 50% reduction in incontinence episodes, RR 0.70, 95% CI 0.55 to 0.88; with more incontinence free days (3.1 days compared with 1.7 in the sham treatment group, MD 1.40 days, 95% CI 0.33 to 2.47). Another study comparing silicone material (PTQ™) to saline injections was too small to demonstrate a clinical benefit compared to the control injection of normal saline.A silicone biomaterial (PTQ™) was shown to provide some advantages and was safer in treating faecal incontinence than carbon-coated beads (Durasphere®) in the short term.Similarly, there were short term benefits from injections delivered under ultrasound guidance compared with digital guidance.No long term evidence on outcomes was available and further conclusions were not warranted from the available data. None of the studies reported patient evaluation of outcomes and thus it is difficult to gauge whether the improvement in incontinence scores matched practical symptom improvements that mattered to the patients. AUTHORS' CONCLUSIONS One large randomised controlled trial has shown that this form of treatment using dextranomer in stabilised hyaluronic acid (NASHA Dx) improves continence for a little over half of patients in the short term. However, the number of identified trials was limited and most had methodological weaknesses.
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Affiliation(s)
- Yasuko Maeda
- Sir Alan Park’s Physiology Unit, St Mark’s Hospital, Harrow, UK.
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Kroesen AJ. [Pelvic floor and anal incontinence. Conservative therapy]. Chirurg 2013; 84:15-20. [PMID: 23329310 DOI: 10.1007/s00104-012-2348-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Conservative treatment of fecal incontinence and obstructive defecation can be treated by many conservative treatment modalities. This article presents the options of medication therapy, spincter exercises, electric stimulation, transcutaneous tibial nerve stimulation, anal irrigation and injection of bulking agents. These methods are presented with reference to the currently available literature but the evidence-based data level for all methods is low. For minor disorders of anorectal function these conservative methods can lead to an improvement of anorectal function and should be individually adapted.
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Affiliation(s)
- A J Kroesen
- Abteilung für Allgemein-, Viszeral- und Unfallchirurgie, Krankenhaus Porz am Rhein, Köln.
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Danielson J, Karlbom U, Wester T, Graf W. Efficacy and quality of life 2 years after treatment for faecal incontinence with injectable bulking agents. Tech Coloproctol 2012; 17:389-95. [PMID: 23224913 DOI: 10.1007/s10151-012-0949-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 11/07/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Stabilized non-animal hyaluronic acid/dextranomer (NASHA Dx) gel as injectable bulking therapy has been shown to decrease symptoms of faecal incontinence, but the durability of treatment and effects and influence on quality of life (QoL) is not known. The aim of this study was to assess the effects on continence and QoL and to evaluate the relationship between QoL and efficacy up to 2 years after treatment. METHODS Thirty-four patients (5 males, mean age 61, range 34-80) were injected with 4 × 1 ml NASHA Dx in the submucosal layer. The patients were followed for 2 years with registration of incontinence episodes, bowel function and QoL questionnaires. RESULTS Twenty-six patients reported sustained improvement after 24 months. The median number of incontinence episodes before treatment was 22 and decreased to 10 at 12 months (P = 0.0004) and to 7 at 24 months (P = 0.0026). The corresponding Miller incontinence scores were 14, 11 (P = 0.0078) and 10.5 (P = 0.0003), respectively. There was a clear correlation between the decrease in the number of leak episodes and the increase in the SF-36 Physical Function score but only patients with more than 75 % improvement in the number of incontinence episodes had a significant improvement in QoL at 24 months. CONCLUSIONS Anorectal injection of NASHA Dx gel induces improvement of incontinence symptoms for at least 2 years. The treatment has a potential to improve QoL. A 75 % decrease in incontinence episodes may be a more accurate threshold to indicate a successful incontinence treatment than the more commonly used 50 %.
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Affiliation(s)
- J Danielson
- Institution of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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Abstract
The aim of this review was to assess and evaluate reports of studies on the efficacy of anal bulking agents used in the treatment of faecal incontinence. A systematic review of the literature was carried out to identify studies that have reported on the use of anal bulking agents. A variety of biomaterials have been employed for anal bulking. These include autologous fat, bovine glutaraldehyde cross-linked collagen, carbon-coated zirconium oxide beads, dextranomer microspheres in a gel, hydrogel cross-linked with polyacrylamide, polydimethylsiloxane elastomer in a gel, porcine dermal collagen and synthetic calcium hydroxylapatitie ceramic microspheres. Although the ideal site of injection (submucosal or intramuscular) and the mechanism of action remain the subject of debate, most published studies report a significant improvement in continence in at least 50% of subjects with mild to moderate symptoms with little or no associated morbidity.We concluded that anal bulking agents may be used to alleviate symptoms of faecal seepage and soilage.
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Affiliation(s)
- N F S Watson
- The John Goligher Colorectal Unit, St James's University Hospital, Leeds, UK
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Hussain ZI, Lim M, Mussa H, Abbas K, Stojkovic S. The use of Permacol® injections for the treatment of faecal incontinence. Updates Surg 2012; 64:289-95. [PMID: 22948797 DOI: 10.1007/s13304-012-0176-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 07/30/2012] [Indexed: 12/21/2022]
Abstract
The aim of this study is to assess the safety and efficacy of Permacol(®) implant for the treatment of idiopathic faecal incontinence using a novel injection technique. Patients with idiopathic passive faecal incontinence were selected for trans-submucosal injection of Permacol(®) after assessment by anorectal physiology and endoanal ultrasonography. Clinical assessment and St. Mark's Incontinence Score were used to evaluate efficacy before and at two time points (1 and 2 years) after treatment. Rockwood Score were also used to determine quality of life before and after treatment. The Friedman and Chi-square tests were used to compare continuous and categorical data, respectively. A p value of <0.05 was deemed significant. Thirty-eight patients (24 female), median age 66 years, were recruited. At maximum clinical follow-up (median of 9 months), response to Permacol(®) injections was categorised as excellent, good, fair and poor in 12, 5, 4 and 17 patients, respectively. St. Mark's Score improved in 72 and 63 % of patients at 1 and 2 years, respectively. However, a smaller proportion of patients (39 and 27 %, respectively) achieved a 50 %, or more, improvement in Mark's Score. All four domains of Rockwood Quality of Life Score improved on first and second year follow-up, however, only two domains, coping and embarrassment, were statistically significant. Permacol(®) injection improved symptoms by >50 % in 39 and 27 % of patients on short and medium-term follow-ups, respectively. The trans-submucosal technique for injection of Permacol(®) in this study was safe with no significant adverse outcomes.
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Affiliation(s)
- Zeiad I Hussain
- Department of Colorectal Surgery, York Teaching Hospital, 1 Celtic Close, York, YO26 5QJ, UK.
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Aly EH. Colorectal surgery: current practice & future developments. Int J Surg 2012; 10:182-6. [PMID: 22406541 DOI: 10.1016/j.ijsu.2012.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 02/23/2012] [Indexed: 12/20/2022]
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