Audit of sphincter repair. Factors associated with poor outcome

PRIMARY SPHINCTEROPLASTY COMPARING TWO DIFFERENT STITCHES IN ANAL FISTULA TREATMENT: EXPERIMENTAL STUDY IN RATS

BACKGROUND

Anal fistula is by definition the communication between the rectum or anal canal with the perineal region, which may be epithelialized and has cryptoglandular origin in 90% of cases. There are a large number of techniques for successfully treating trans-sphincteric fistulas of 20-50%, including primary sphincteroplasty, but it is not clear whether the material used would influence the outcome.

AIM

To analyze the efficacy of polydioxanone and polypropylene wire in primary post-fistulotomy sphincteroplasty in the treatment of trans-sphincteric fistulas in rats.

METHODS

Thirty Wistar rats had transfixation of the anal sphincter with steel wire, which remained for 30 days for the development of the anal fistula. After this period, it was removed and four groups were formed: A (control) without treatment; B (fistulotomy) submitted to such procedure and curettage only; C (polidioxanone) in which sphincteroplasty was performed after fistulotomy with polydioxanone wire; D (polypropylene) submitted to the same treatment as group C, but with polypropylene wire. After 30 days, euthanasia and removal of the specimens were performed for qualitative histopathological analysis, measurement of the area between the muscular cables edges and evaluation of the degree of local fibrosis.

RESULTS

There was persistence of the anal fistula in all animals of group A. There were no significant differences between groups B, C and D regarding the distance of the muscular cables (p=0.078) and the degree of fibrosis caused by the different treatments (p=0.373).

CONCLUSIONS

There was no difference between polydioxanone and polypropylene wires in post-fistulotomy primary sphincteroplasty, and this technique was not superior to simple fistulotomy in relation to the distance of the muscular cables nor did it present differences in relation to the degree of local fibrosis.

Systematic Review of Surgical Treatments for Fecal Incontinence

BACKGROUND

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

INTERVENTIONS

Surgical treatments for fecal incontinence were included interventions.

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Anterior sphincteroplasty for fecal incontinence: predicting incontinence relapse

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Suboptimal results after sphincteroplasty: another hazard of obesity

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Functional outcome after anal sphincter injury and treatment with mesenchymal stem cells

This research demonstrates the regenerative effects of mesenchymal stem cells (MSCs) on the injured anal sphincter by comparing anal sphincter pressures following intramuscular and serial intravascular MSC infusion in a rat model of anal sphincter injury. Fifty rats were divided into injury (n = 35) and no injury (NI; n = 15) groups. Each group was further divided into i.m., serial i.v., or no-treatment (n = 5) groups and followed for 5 weeks. The injury consisted of an excision of 25% of the anal sphincter complex. Twenty-four hours after injury, 5 × 10(5) green fluorescent protein-labeled MSCs in 0.2 ml of phosphate-buffered saline (PBS) or PBS alone (sham) were injected into the anal sphincter for i.m. treatment; i.v. and sham i.v. treatments were delivered daily for 6 consecutive days via the tail vein. Anal pressures were recorded before injury and 10 days and 5 weeks after treatment. Ten days after i.m. MSC treatment, resting and peak pressures were significantly increased compared with those in sham i.m. treatment (p < .001). When compared with the NI group, the injury groups had anal pressures that were not significantly different 5 weeks after i.m./i.v. treatment. Both resting and peak pressures were also significantly increased after i.m./i.v. MSC treatment compared with treatment with PBS (p < .001), suggesting recovery. Statistical analysis was done using paired t test with Bonferroni correction. Marked decrease in fibrosis and scar tissue was seen in both MSC-treated groups. Both i.m. and i.v. MSC treatment after injury caused an increase in anal pressures sustained at 5 weeks, although fewer cells were injected i.m. The MSC-treated groups showed less scarring than the PBS-treated groups, with the i.v. infusion group showing the least scarring.

[Direct sphincter repair: techniques, indications and results]

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

Fecal incontinence in the elderly: FAQ

Fecal incontinence (FI) is a common gastrointestinal (GI) complaint in patients aged 65 years and older. This evidence-based review article discusses the epidemiology, pathophysiology, evaluation, and management of FI in the geriatric population. We emphasize aging-related changes leading to and impacting evaluation and treatment of this symptom while incorporating the core geriatric principles of functional status and management aligned with patient preference and goals of care.

Overlapping sphincter repair: does age matter?

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTINGS

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

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

The study was limited by its retrospective nature.

CONCLUSIONS

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

Sphincteroplasty for fecal incontinence in the era of sacral nerve modulation

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

Anal sphincter repair for fecal incontinence: experience from a tertiary care centre

AIM

Structural anal sphincter damage may be secondary to obstetric anal sphincter injury, perineal trauma or anorectal surgery. We reviewed the spectrum of anal sphincter injuries and their outcomes in a tertiary care colorectal unit.

METHODS

Data of patients who underwent anal sphincter repair between 2004 and 2008 were analyzed retrospectively. Outcomes were compared with respect to etiology, type of repair, previous attempts at repair and manometry findings. Outcomes were defined as good or poor based on patient satisfaction as the primary criteria.

RESULTS

Thirty-four patients underwent anal sphincter repair. Twenty-two injuries were obstetric, eight traumatic, and four iatrogenic. All patients underwent overlap sphincteroplasty with six additional anterior levatorplasty and seven graciloplasty. Twenty-three (67.6%) patients had a good outcome while nine (26.4%) had a poor outcome. All patients who had augmentation anterior levatorplasty had a good outcome. Fifty percent of patients with a previous sphincter repair and 42.9% requiring augmentation graciloplasty had a poor outcome. Median resting and squeeze anal pressures increased from 57.5 to 70 cmH₂O and 90.25 to 111 cmH₂O in those with a good outcome.

CONCLUSIONS

Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

Evaluation of anal incontinence: minimal approach, maximal effectiveness

Anal incontinence is a symptom represented by the impaired ability to control the elimination of gas and stool, with an estimated incidence of 2.2 to 7.1% of the population. These numbers likely under-represent the true prevalence because physicians and patients are reluctant to discuss this problem. Evaluation of the patient with anal incontinence requires a fundamental knowledge of the etiologic factors. Careful history and physical examination is essential in every patient and can identify the cause of most cases of incontinence. Incontinence scoring systems are tools that provide objective data regarding the severity and quality of anal incontinence. Supplemental special tests for evaluating incontinence should be aimed at achieving three goals: (1) provide additional and confirmatory information regarding the diagnosis and cause of incontinence; (2) select appropriate treatment; and (3) predict treatment outcome. Numerous studies to evaluate anal incontinence exist; however, the most useful tests to achieve these goals are anal manometry, pudendal nerve terminal motor latency, and anal endosonography, because these studies can identify physiologic, neurologic, and anatomic abnormalities of the anorectum for which there may be effective treatments.

Overlapping sphincteroplasty: is it the standard of care?

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

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

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

Anterior sphincteroplasty for fecal incontinence: a single center experience in the era of sacral neuromodulation

PURPOSE

Anterior sphincteroplasty is the surgical treatment of choice for patients with fecal incontinence associated with an external anal sphincter defect. Recently it has been reported that patients with such a defect may also benefit from sacral neuromodulation. The success of this technique raises the question whether anterior sphincteroplasty still deserves a place in the surgical treatment of fecal incontinence. This study investigated the outcome of anterior sphincteroplasty in a large cohort of patients.

METHODS

A consecutive series of 172 patients underwent anterior overlapping sphincteroplasty. A standardized questionnaire concerning current continence status, overall satisfaction, and quality of life was used to assess the outcome.

RESULTS

Follow-up data were obtained from 75% of the 160 patients who were still alive at the time of the survey. After a median follow-up of 111 (range, 12-207) months, the outcome was still good to excellent in 44 patients (37%). In 28 patients (23%), the outcome was classified as moderate because these patients still experienced regular incontinence for stool. However, they were satisfied with their outcome because their incontinence episodes had been reduced by 50% or more. The outcome was poor in 40% of the patients. Predictors of worse outcome were older age (> or =50 years) at surgery, deep wound infection, and isolated external anal sphincter defects. Patients with follow-up of five or more years had the same outcome as patients with follow-up of fewer than five years.

CONCLUSION

Anterior sphincteroplasty results in an acceptable to excellent long-term outcome in 60% of patients, especially in those under the age of 50 years at surgery.

Continence disorders after anal surgery--a relevant problem?

SUBJECT

Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure.

METHODS

The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula.

RESULTS

Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0-50%, lateral sphincterotomy 0-45%, haemorrhoidal surgery 0-28%, lay open technique of anal fistula 0-64% and plastic repair of fistula 0-43%. Results vary considerably depending on what definition of "incontinence" was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum.

CONCLUSIONS

Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.

Surgical treatment of patients with constipation and fecal incontinence

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

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

OBJECTIVE

Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.

METHOD

Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n = 103; delayed, n = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes--probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.

RESULTS

Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated 2750 pounds, giving an ICER of 487 pounds per QALY. DS produced a gain of 3.73 QALYs for a cost of 2667 pounds, giving an ICER of 719 pounds per QALY. Both procedures fell below the 10,000 pounds per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.

CONCLUSION

If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.

Obesity and pelvic floor disorders: a systematic review

OBJECTIVE

To review the current literature and summarize the effect of obesity on outcomes of surgical treatment of pelvic floor disorders as well as the effect of weight loss on pelvic floor disorder symptoms.

DATA SOURCES

Relevant sources were identified by a MEDLINE search from 1966 to 2007 using the key words obesity, pelvic floor disorders, urinary incontinence (UI), fecal incontinence, and pelvic organ prolapse (POP). References of relevant studies were hand searched.

METHODS OF STUDY SELECTION

Relevant human observational studies, randomized trials, and review articles were included. A total of 246 articles were identified; 20 were used in reporting and analyzing the data. Meta-analyses were performed for topics meeting the appropriate criteria.

TABULATION, INTEGRATION, AND RESULTS

There is good evidence that surgery for stress UI in obese women is as safe as in their nonobese counterparts, but cure rates may be lower in the obese patient. Meta-analysis revealed cure rates of 81% and 85% for the obese and nonobese groups, respectively (P<.001; odds ratio [OR] 0.576, 95% confidence interval [CI] 0.426-0.779). Combined bladder perforation rates were 1.2% in the obese and 6.6% in the nonobese (P=.015; OR 0.277, 95% CI 0.098-0.782). There is little evidence on which to base clinical decisions regarding the treatment of fecal incontinence and POP in obese women, because few comparative studies were identified addressing the outcomes of prolapse surgery in obese patients compared with healthy-weight patients. Weight loss studies indicate that both bariatric and nonsurgical weight loss lead to significant improvements in pelvic floor disorder symptoms.

CONCLUSION

Surgery for UI in obese women is safe, but more trials are needed to evaluate its long-term effectiveness as well as treatments for both fecal incontinence and POP. Weight loss, both surgical and nonsurgical, should be considered in the treatment of pelvic floor disorders in the obese woman.

[Anal incontinence]

Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.

Morbid obesity adversely impacts pelvic floor function in females seeking attention for weight loss surgery

PURPOSE

This study was designed to determine the impact of excess body mass on the prevalence of pelvic floor disorders in morbidly obese females.

METHODS

A total of 358 morbidly obese females (body mass index (BMI) >or= 35 kg/m(2)) completed two validated, condition-specific, quality of life questionnaires of pelvic floor dysfunction, which assessed stress/impact in three main domains of pelvic floor disorders: pelvic organ prolapse, colorectal-anal, and urogenital incontinence. Prevalence and severity scores in the study population were compared with data from 37 age-matched nonobese controls (BMI

RESULTS

Mean age was 43 +/- 11 years vs. 42 +/- 12 years, and mean BMI was 50 +/- 10 kg/m(2) vs. 26 +/- 4 kg/m(2) (p = 0.02) in the study and control groups, respectively. Parity and past obstetric history were similar between the groups. Pelvic floor disorders were prevalent in 91 percent of the morbidly obese females compared with 22 percent in the control group (p < 0.001). Scores were statistically significantly higher in the study group for all studied stress/impact domains (p < 0.001 and p = 0.001, respectively). Further stratifications in the study group revealed a significant impact on pelvic floor disorders with increased age (p < 0.003 and p < 0.009 for stress/impact mean scores, respectively) and the presence of other comorbidities (p< 0.008, p < 0.03 for stress/impact prevalence, respectively). Additional increases in BMI > 35 kg/m(2) did not show increased adverse impacts on pelvic floor disorders symptoms.

CONCLUSION

More than 90 percent of morbidly obese females experience some degree of pelvic floor disorders, and 50 percent of these females report that symptoms adversely impact quality of life. In morbidly obese females, obesity is as important as obstetric history in predicting pelvic floor dysfunction.

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MESH Headings

• Adult
• Age Factors
• Bariatric Surgery/methods
• Body Mass Index
• California/epidemiology
• Fecal Incontinence/epidemiology
• Fecal Incontinence/etiology
• Fecal Incontinence/physiopathology
• Female
• Follow-Up Studies
• Humans
• Middle Aged
• Obesity, Morbid/epidemiology
• Obesity, Morbid/physiopathology
• Obesity, Morbid/surgery
• Patient Acceptance of Health Care/statistics & numerical data
• Pelvic Floor/physiopathology
• Prevalence
• Prognosis
• Quality of Life
• Severity of Illness Index
• Surveys and Questionnaires
• Urinary Incontinence/epidemiology
• Urinary Incontinence/etiology
• Urinary Incontinence/physiopathology
• Weight Loss

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Grants Collapse

Affiliation(s)

Nir Wasserberg Department of Surgery, Division of Colorectal and Pelvic Floor Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
Mark Haney
Patrizio Petrone
Manfred Ritter
Claudia Emami
Jason Rosca
Kim Siegmund
Howard S Kaufman

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Collaborators Collapse

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

OBJECTIVE

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Epiploic appendagitis--clinical characteristics of an uncommon surgical diagnosis

Background

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

Methods

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

Results

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

Conclusion

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

Effects of an Educational Workshop on Performance of Fourth-Degree Perineal Laceration Repair

OBJECTIVE

To develop a valid and reliable tool to objectively measure surgical skill necessary for repair of fourth-degree perineal lacerations and then to use this tool to measure improvement after a workshop.

METHODS

We measured baseline surgical ability and clinical knowledge of 26 residents (postgraduate year [PGY]-1 to PGY-4) using the Objective Structured Assessment of Technical Skills (OSATS) and a written examination. The OSATS consists of a global surgical skills assessment (OSATS-G), a procedure checklist (OSAT-C), and pass/fail grade. Five weeks after our baseline evaluation, a 1.5-hour workshop was administered to approximately half of the 26 residents (n=14). One week after this intervention, the residents were re-examined using the same assessment tools.

RESULTS

The OSATS demonstrated construct validity as scores on the examination increased on both the OSATS-G and the OSATS-C from PGY-1 through PGY-4 (P=.001 and P=.041, respectively). Reliability indices for the OSATS were high. Eighty-one percent of the residents failed the OSATS before intervention because of failure to identify and repair the internal anal sphincter. After educational intervention, senior residents improved on all assessments (OSATS-G, P=.041; OSATS-C, P=.004; written examination, P=.008), and all residents passed the OSATS.

CONCLUSION

A valid and reliable OSATS and written examination were developed to assess surgical skills, knowledge, and judgment necessary to properly manage fourth-degree perineal lacerations. Residents improved on the OSATS and the written examination after undergoing a structured educational workshop.

LEVEL OF EVIDENCE

II.

The effect of surgery on quality of life in patients with faecal incontinence of obstetric origin

OBJECTIVE

To evaluate the results of surgery in the treatment of faecal incontinence of obstetric origin and assess the effect of treatment on the quality of life of these patients.

PATIENTS AND METHODS

A consecutive series of 43 patients, who had undergone surgery for severe faecal incontinence of obstetric aetiology between March 1990 and March 2004, was studied. The following studies were carried out: clinical evaluation, anorectal manometry, anal endosonography (from 1996 on) and measurement of the pudendal nerve terminal motor latency. The degree of incontinence, both preoperative and at the end of follow-up was evaluated using the Cleveland Clinic Score (CCS). Quality of life assessment was made using the Fecal Incontinence Quality of Life Scale (FIQL).

RESULTS

The study was completed on 35 (87%) of the 43 patients. The mean age in the series was 53 years, (range 28-73). After an average follow-up of 50.4 months (range 4-132) the mean CCS had reduced significantly, passing from 16 (range 8-20) to 6 (range 0-18; P < 0.001). Pudendal neuropathy was found to be a factor of poor prognosis. The results of the quality of life questionnaire at the end of follow-up were: lifestyle 3.5 (SD 0.65), coping/behaviour 3.1 (SD 0.81), depression/self perception 3.7 (SD 0.75) and embarrassment 3.3 (SD 0.91). There is a statistically significant linear relationship between incontinence measured on the CCS and quality of life. For the 14 patients undergoing surgery since the publication of the FIQL questionnaire, it was possible to complete the questionnaire preoperatively, with significant improvement found on each of the four scales (lifestyle 1.7 vs 3.5; coping/behaviour 1.4 vs 3.2; depression 2.2 vs 3.8; embarrassment 1.8 vs 3.2; P < 0.001).

CONCLUSION

Surgical treatment of faecal incontinence of obstetric origin achieves good results in a high percentage of patients and has a positive effect on their quality of life. The existence of prolonged preoperative pudendal nerve motor latency indicates a poor prognosis.

Neurophysiological testing in anorectal disorders

The neurophysiological techniques currently available to evaluate anorectal disorders include concentric needle electromyography (EMG) of the external anal sphincter, anal nerve terminal motor latency (TML) measurement in response to transrectal electrical stimulation or sacral magnetic stimulation, motor evoked potentials (MEPs) of the anal sphincter to transcranial magnetic cortical stimulation, cortical recording of somatosensory evoked potentials (SEPs) to anal nerve stimulation, quantification of electrical or thermal sensory thresholds (QSTs) within the anal canal, sacral anal reflex (SAR) latency measurement in response to pudendal nerve or perianal stimulation, and perianal recording of sympathetic skin responses (SSRs). In most cases, a comprehensive approach using several tests is helpful for diagnosis: needle EMG signs of sphincter denervation or prolonged TML give evidence for anal motor nerve lesion; SEP/QST or SSR abnormalities can suggest sensory or autonomic neuropathy; and in the absence of peripheral nerve disorder, MEPs, SEPs, SSRs, and SARs can assist in demonstrating and localizing spinal or supraspinal disease. Such techniques are complementary to other methods of investigation, such as pelvic floor imaging and anorectal manometry, to establish the diagnosis and guide therapeutic management of neurogenic anorectal disorders.

Incontinencia fecal.Valoración del paciente. Tratamientos clásicos

Fecal incontinence is a very common disease but its exact prevalence is largely unknown. The condition gives rise to personal and social stigma with severe repercussions for the patient. It can be caused by a large number of physiopathologic disorders and consequently there is a wide variety of treatments. In this article we review the incidence and etiology of fecal incontinence, physical and instrumental examinations (with description of the components of the anorectal laboratory), traditional medical and surgical treatments and, lastly, the results of sphincteroplasties.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Obstetric anal sphincter injury ten years after: subjective and objective long term effects

OBJECTIVE

To establish the long term effects of obstetric anal sphincter rupture.

DESIGN

Prospective observational study.

SETTING

University hospital in Sweden.

POPULATION

Eighty-two women from a prospective study from 1990 to compare anorectal function after third degree tear.

METHODS

Women completed a structured questionnaire, underwent a clinical examination and anorectal manometry, endoanal ultrasound (EAUSG) with perineal body measurement.

MAIN OUTCOME MEASURES

Symptoms of anal incontinence, sexual symptoms, anal manometry scores and evidence of sphincter damage on EAUSG.

RESULTS

Five women had undergone secondary repair and three were lost to follow up. Fifty-one women (80%) completed the questionnaire. Twenty-six out of 46 (57%) of the original study group and 6/28 (20%) of the original controls were examined. Incontinence to flatus and liquid stool was more severe in the study group than in controls. Flatus incontinence was significantly more pronounced among women with subsequent vaginal deliveries. Mean maximal anal squeeze pressures were 69 mmHg in the partial rupture group and 42 mmHg in the complete rupture group (P= 0.04). Study group women with signs of internal sphincter injury reported more pronounced faecal incontinence and had lower anal resting pressures (24 mmHg) than those with intact internal sphincters (40 mmHg) (P= 0.01). Perineal body thickness of less than 10 mm was associated with incontinence for flatus and liquid stools, less lubrication during sex and lower anal squeeze pressures (58 mmHg vs 89 mmHg, P= 0.04).

CONCLUSIONS

Subjective and objective anal function after anal sphincter injury deteriorates further over time and with subsequent vaginal deliveries. Thin perineal body and internal sphincter injury seem to be important for continence and anal pressure.

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

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

Surgical treatment options for fecal incontinence

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

Physiologic variables that predict the outcome of treatment for fecal incontinence

Identification of physiologic factors that predict response to fecal incontinence therapy would be helpful in choosing the optimal treatment and advising patients on the likelihood of a successful outcome. However, few physiologic parameters have been consistently identified as important in predicting response to either biofeedback or surgery. The process of isolating these factors has been hampered by heterogeneity in the definition of fecal incontinence, lack of consensus on what constitutes a successful outcome, lack of follow-up data, variations in the way "standard" treatments are implemented, and lack of properly powered randomized controlled trials. Among the physiologic variables that studies have generally found to be predictive of successful outcomes in biofeedback treatment are the threshold for external anal sphincter contraction after treatment, the inclusion of sensory training in treatment, and a reduction in volume for the first sensation after treatment. Factors that have not been found to be important in predicting outcome following biofeedback retraining include the duration of fecal incontinence, pudendal nerve damage, patient age, symptom severity, pretreatment anal canal pressures, and results of anal ultrasonography. The presence of some degree of anorectal sensation is the only preoperative assessment that has been found to be predictive of response to surgical therapy. It is recommended that outcome measures for fecal incontinence be more clearly defined, that future biofeedback studies elaborate the predictive value of pretreatment anorectal sensation and the response to sensory retraining, and that postsurgical measurements such as anal squeeze pressure and sphincter length be taken into account.

Fecal incontinence: evaluation and treatment

Fecal incontinence affects men and women of all ages, leading to personal disability and high financial costs. The evaluation of the patient should clarify the pathophysiology of the symptoms and provide guidance in choosing the appropriate treatment. A comprehensive history and physical examination including endoscopic assessment is able to identify the cause of most cases of fecal incontinence. If necessary, functional methods can be used to confirm the diagnosis. Patient selection for suitable treatment is most important and should be based on clinical and physiologic findings. Conservative dietary or medical treatment is often effective, when the symptoms are mild. Biofeedback therapy is effective in most patients. It has no side effects and is well tolerated. Structural damage to the anus may be repaired by surgery, like sphincter repair, the best treatment of selective sphincter defects. Neoanal sphincters and artificial sphincters are the last possibility after failed surgery and before colostomy. They are less attractive because of technical difficulties and low success rate. A multidisciplinary approach to treatment has the potential to improve the outcome for patients with fecal incontinence.

Delayed sphincter repair for obstetric ruptures: analysis of failure

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Surgical treatment of anal incontinence]

Surgery is mandatory for fecal incontinence when medical treatments and reeducation by biofeedback are ineffective. Sphincter disruption is the most frequent cause. Sphincter repair with or without overlapping is indicated in the large majority of cases. Short-term results are good but result is not ever maintained with time. In case of failure, or when the defect concerns more than 180 degrees, it is necessary to use a substitutive technique. Artificial anal sphincter is often first proposed because of its apparent technical simplicity and because it is cheaper than dynamic graciloplasty. Results are excellent. Failures are due to local infection or device disfunction. Dynamic graciloplastie may be proposed in patients with severe perineal lesions, or failure of the other methods. Its results are also excellent, except for the patients having disordered rectal perception. Sacral nerve stimulation is limited to patients with idiopathic or neurologic incontinence. Because definitive implantation is done only following positive preoperative stimulation test, short-term results are very good.

Respective value of pudendal nerve terminal motor latency and anal sphincter electromyography in neurogenic fecal incontinence

Fecal incontinence may be related to a neurogenic injury. Electrodiagnostic tests including pudendal nerve terminal motor latency (PNTML) and external anal sphincter electromyography (AEMG) have been proposed to reveal anal nerve damage. The aim of this study was to assess the respective value of PNTML and AEMG in the diagnosis of fecal incontinence. This study included 80 women (range 23-85 years) with fecal incontinence secondary to obstetrical and/or surgical trauma. They were evaluated by performing PNTML and AEMG. The electrophysiological results were compared and interpreted in the light of anorectal manometry (ARM) results. Electrodiagnostic test abnormalities were found in 64 of 80 patients (80%), including 28 patients with abnormal results for both tests and 36 patients with only one abnormal test. Overall, a neurogenic AEMG pattern was found in 64% of patients and a prolonged PNTML in 51%. No correlation was found between PNTML value and either AEMG grade or ARM parameters, while AEMG grade strongly correlated with squeeze pressure measured by ARM. This study showed that AEMG and PNTML did not give redundant information and allowed to explicit the mechanisms of neurogenic fecal incontinence. We found that AEMG was more sensitive and more closely related to the anal functional status (ARM parameters) than PNTML. These electrodiagnostic tests, particularly AEMG as performed in everyday practice, are useful in the assessment of neurogenic fecal incontinence.

A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence

PURPOSE

This study was designed to determine whether anorectal physiology testing significantly altered patient management in the setting of fecal incontinence.

METHODS

Patients referred to the anorectal physiology laboratory for evaluation of fecal incontinence were prospectively interviewed and examined by a colon and rectal surgeon. A decision to treat either medically or surgically was reached. The patients underwent physiologic testing with transanal ultrasound, pudendal nerve terminal motor latency, and anorectal manometry. A panel of board-certified colon and rectal surgeons then reviewed the history and physical examination, as well as the anorectal physiology tests, of each patient and reached a consensus on management. Management plans before and after physiologic evaluation were compared.

RESULTS

Ninety patients (6 males) were entered into the study. The patients were divided in two groups: those with pretest medical management plans (n = 45) and those with pretest surgical management plans (n = 45). A change in management was noted in nine patients (10 percent). In the medical management group, the management changed from medical to surgical therapy in five patients. Transanal ultrasound detected anal sphincter defects in all patients who changed from medical to surgical management but in only 10 percent of those who remained under medical management (P = 0.0001). In the surgical management group, three patients (7 percent) changed from surgical to medical therapy and one patient (2 percent) changed from sphincteroplasty to neosphincter. Transanal ultrasound detected a limited anal sphincter defect in one patient (33 percent) who changed from surgical to medical management and a significant defect in all 41 patients (100 percent) who remained under surgical management (P = 0.003).

CONCLUSIONS

Anorectal physiology testing is useful in the evaluation of patients with fecal incontinence. Without the information obtained from physiologic testing, 11 percent of patients who may have benefited from surgery would not have been given this option, and 7 percent of patients could have potentially undergone unnecessary surgery. Transanal ultrasound is the study most likely to change a patient's management plan.

Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty

PURPOSE

Preoperative anorectal physiology studies have become part of the standard evaluation of fecal incontinence. This study was undertaken to see whether anorectal physiology results predicted surgical outcome after anterior sphincteroplasty.

METHODS

Between 1985 and 1994, 191 females with a mean age of 37 (range, 20-74) years underwent anterior sphincteroplasty for anal sphincter disruption. A follow-up questionnaire was sent to all patients, and there were 158 respondents (83 percent). Mean follow-up was 43 (range, 6-120) months. Obstetric injuries accounted for incontinence in 91 percent of the 158 patients who responded to the questionnaire. Mean duration of incontinence was 4.2 years (range, 3 months-51 years) before surgery. Preoperatively, patients were incontinent to solid stool (53 percent), liquid stool (33 percent), gas (3 percent), and unspecified (11 percent).

RESULTS

Subjectively, the results were as follows: 129 patients (82 percent) improved, 17 (11 percent) were initially improved but subsequently deteriorated, 7 (4 percent) were unchanged, and 5 (3 percent) were worse. Objectively, postoperative continence was classified as follows: excellent (normal) in 23 percent, good (incontinent to gas or minor stain) in 39 percent, fair (incontinent to stool an average of less than once per month) in 26 percent, and poor (incontinent to stool an average of greater than once per month) in 12 percent. Preoperative continence level (incontinent to solid vs. liquid stool) was predictive of postoperative continence classification. Preoperative anorectal manometry was not predictive of clinical outcome (n = 128). There was no significant difference in postoperative continence classification among patients with normal, unilaterally abnormal, and bilaterally abnormal pudendal latency (n = 89).

CONCLUSIONS

Clinical rather than manometric assessment predicts continence after anterior sphincteroplasty.

Preliminary results of an outcome tool used for evaluation of surgical treatment for fecal incontinence

PURPOSE

The lack of an outcome tool to evaluate the outcome of surgical and medical treatment for fecal incontinence makes interpretation of success difficult. The purpose of this study was to evaluate a preliminary outcome tool for fecal incontinence.

METHOD

Since 1994 an extensive database has prospectively been collected on all females undergoing an overlapping sphincter repair for fecal incontinence by a single surgeon. A simple incontinence form designed to examine outcome, developed by colon and rectal surgeons, was filled out preoperatively and postoperatively.

RESULTS

Of 206 females evaluated for surgical treatment of their fecal incontinence, 65 underwent surgical treatment from January 1994 until July 1999. The mean age was 49 (range, 23-80) years, and the mean follow-up was 10 (range, 1-50) months. When comparing each variable (problems holding gas, staining of undergarments, accidental bowel movements, and need to wear pads) and lifestyle issue (physical, social, and sexual activities) preoperatively and postoperatively, there was significant improvement in all areas. Three parameters were chosen (change in accidental bowel movements, improvement in two of three lifestyle areas, and improvement in one of three lifestyle areas) to examine individual items from the database and to determine if they affected outcome. No single variable has a significant effect on the outcome. A scoring system was devised from the questionnaire. From preoperatively to postoperatively, there was a median 14-point improvement that was statistically significant.

CONCLUSIONS

This preliminary tool to examine outcome for fecal incontinence measures parameters that are significantly improved by overlapping sphincteroplasty. More work is needed to refine and validate this tool because a standard outcome tool is needed for reporting the results of surgical treatment of fecal incontinence.

Surgical treatment of constipation and fecal incontinence

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

Treatment options for fecal incontinence

PURPOSE

Fecal incontinence is a socially devastating disorder which affects at least 2.2 percent of community dwelling adults and 45 percent of nursing home residents. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. The aim of this study was to develop a consensus on treatment options by convening a conference of surgeons, gastroenterologists, nurses, psychologists, and patient advocates.

METHOD

A 1-1/2 day conference was held in April, 1999. Experts from different disciplines gave overviews, followed by extended discussions. Consensus statements were developed at the end of the conference. This summary statement was drafted, circulated to all participants, and revised based on their input.

CONCLUSIONS

1) Diarrhea is the most common aggravating factor for fecal incontinence, and antidiarrheal medications such as loperamide and diphenoxylate or bile acid binders may help. Fecal impaction, a common cause of fecal incontinence in children and elderly patients, responds to combinations of laxatives, education, and habit training in approximately 60 percent. These causes of fecal incontinence can usually be identified by history and physical examination alone. 2) In patients who fail medical management or have evidence of sphincter weakness, anorectal manometry and endoanal ultrasound are recommended as helpful in differentiating simple morphologic defects from afferent and efferent nerve injuries and from combined structural and neurologic injuries. 3) Biofeedback is a harmless and inexpensive treatment which benefits approximately 75 percent of patients but cures only about 50 percent. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects. 4) External anal sphincter plication with or without pelvic floor repair is indicated when there is a known, repairable structural defect without significant neurologic injury. It is effective in approximately 68 percent. 5) Salvage operations are reserved for patients who can not benefit from biofeedback or levator-sphincteroplasty. These include electrically stimulated gracilis muscle transpositions and colostomy. 6) Antegrade enemas delivered through stomas in the cecum or descending colon reduce or eliminate soiling in approximately 78 percent of children with myelomeningocele; this operation may come to be more widely applied. 7) Investigational treatments include implanted nerve stimulators, artificial sphincters, and anal plugs. 8) Patient characteristics which influence choice of treatment include mental status, mobility impairment, and typical bowel habits. 9) Additional research is needed to better define the mechanisms responsible for fecal incontinence, to assess the efficacy of these treatments, to develop better treatments for nursing home residents, and to identify predictors of outcome.

Audit of anal-sphincter repair

OBJECTIVE

Structural damage of the anterior part of the anal sphincter is a major cause of faecal incontinence. Sphincter repair is the standard surgical treatment. This study was designed to analyse the results of anal sphincter repair, to identify possible predictors of outcome and to investigate the presence of bowel symptoms other than leakage at follow up.

PATIENTS AND METHODS

Fifty-five women (median age 39 years, range 24-73 years) who underwent anal sphincter repair between 1986 and 1997 at the University Hospital of Linköping answered a postal questionnaire. Current bowel function, degree of continence and the patients' functional result as worse, unchanged, some improvement, good or excellent were assessed. Good or excellent function was regarded as a successful result, the rest as failure. Age, duration of symptoms, type of surgery, morbidity and length of follow up were analysed in relation to outcome. Results of pre- and post-operative anal manometry, endoanal ultrasound, anal sphincter electromyography and pudendal nerve function were also analysed.

RESULTS

After a median (range) follow-up period of 40 months (5-137) months, 31 (56%) patients rated the result as either excellent (n=10) or good (n=21). Twenty-one (38%) patients rated the result as some improvement (n=14), unchanged (n=6) or worse (n=1). In three (5%) patients a colostomy was fashioned because of failure. Patients >50 years at surgery (n=18) had a worse outcome (P=0.001). Successful outcome was correlated to increased squeeze pressures post-operatively. The presence of post-operative urgency (P=0.01) and loose stools (P=0.02) was more common in patients with poor outcome. Eight patients became continent to formed and liquid stool.

Factors predictive of outcome after surgery for faecal incontinence

BACKGROUND

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

METHODS

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

RESULTS AND CONCLUSION

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