What is the impact of fecal incontinence on quality of life?

Efficacy of Traditional Acupuncture Compared to Biofeedback Therapy in Fecal Incontinence: A Randomized Controlled Trial

BACKGROUND

Fecal incontinence has a devastating impact on quality of life and imposes a substantial socioeconomic burden. Best medical therapy, including biofeedback therapy, improves mild symptoms with minimal impact on moderate to severe symptoms. Surgical management for incontinence carries a degree of morbidity, resulting in low uptake and acceptability. Although acupuncture is common practice in Singapore for numerous medical conditions, its role in fecal incontinence is relatively novel. In our local context, however, acupuncture is accessible, inexpensive, and potentially well accepted as a treatment strategy.

OBJECTIVE

To determine the effectiveness of traditional Chinese medicine acupuncture, compared to biofeedback therapy, in the treatment of fecal incontinence. The secondary aim is to investigate the differences in quality of life after treatment.

DESIGN

Randomized controlled trial.

SETTING

Prospective, single-institution study.

PATIENTS

Patients with 2 or more episodes of fecal incontinence per week or St. Mark's incontinence score of 5 or higher were recruited. Patients were randomly assigned into biofeedback therapy, which included 3 sessions over 10 weeks, or 30 sessions of acupuncture over 10 weeks.

MAIN OUTCOME MEASURES

Incontinence episodes, St. Mark's score, and fecal incontinence quality-of-life scale.

RESULTS

Eighty-five patients were randomly assigned to biofeedback therapy (n = 46) or acupuncture (n = 39). Demographics and baseline clinical characteristics were not different ( p > 0.05). Overall median incontinence episodes were reduced in both, with the acupuncture arm reporting significantly fewer episodes at week 15 ( p < 0.001). Acupuncture also improved quality of life, with improvement in lifestyle, coping, depression, and embarrassment at week 15 ( p < 0.05). Although the St. Mark's score was significantly reduced in both arms at week 15 ( p < 0.001), the acupuncture arm's score was significantly lower ( p = 0.002).

LIMITATIONS

Longer follow-up is required.

CONCLUSIONS

Acupuncture is clinically effective and improves the quality of life in patients with fecal incontinence. See Video Abstract .

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov : NCT04276350.

EFICACIA DE LA ACUPUNTURA TRADICIONAL COMPARADA CON LA TERAPIA DE BIORRETROALIMENTACIN EN LA INCONTINENCIA FECAL UN ENSAYO CONTROLADO ALEATORIO

ANTECEDENTES:La incontinencia fecal tiene un impacto devastador en la calidad de vida e impone una carga socioeconómica sustancial. La mejor terapia médica, incluida la terapia de biorretroalimentación, mejora los síntomas leves, con un impacto mínimo sobre los síntomas moderados a graves. El tratamiento quirúrgico de la incontinencia conlleva un grado de morbilidad que resulta en una baja aceptación y aceptabilidad. Si bien la acupuntura es una práctica común en Singapur para numerosas afecciones médicas, su papel en la incontinencia fecal es relativamente novedoso. Sin embargo, en nuestro contexto local, la acupuntura es accesible, económica y potencialmente bien aceptada como estrategia de tratamiento.OBJETIVO:Determinar la efectividad de la acupuntura de la Medicina Tradicional China, en comparación con la terapia de biorretroalimentación en el tratamiento de la incontinencia fecal. El objetivo secundario es investigar las diferencias en la calidad de vida después del tratamiento.DISEÑO:Ensayo controlado aleatorio.AJUSTE:Estudio prospectivo de una sola institución.PACIENTES:Se reclutaron pacientes con >2 episodios de incontinencia fecal/semana o una puntuación de incontinencia de St. Mark's >5. Los pacientes fueron asignados aleatoriamente a una terapia de biorretroalimentación que incluyó 3 sesiones durante 10 semanas o 30 sesiones de acupuntura durante 10 semanas.PRINCIPALES MEDIDAS DE RESULTADO:Episodios de incontinencia, puntuación de St. Mark's y escala de calidad de vida de incontinencia fecal.RESULTADOS:Ochenta y cinco pacientes fueron asignados aleatoriamente a terapia de biorretroalimentación (n = 46) o acupuntura (n = 39). Las características demográficas y clínicas iniciales no fueron diferentes ( p > 0,05). La mediana general de episodios de incontinencia se redujo en ambos, y el grupo de acupuntura informó significativamente menos en la semana 15 ( p <0,001). La acupuntura también mejoró la calidad de vida, con mejoras en el estilo de vida, el afrontamiento, la depresión y la vergüenza en la semana 15 ( p <0,05). Mientras que la puntuación de St Mark se redujo significativamente en ambos brazos en la semana 15 ( p < 0,001), la puntuación del brazo de acupuntura fue significativamente menor (p = 0,002).LIMITACIONES:Se requiere un seguimiento más prolongado.CONCLUSIONES:La acupuntura es clínicamente efectiva y mejora la calidad de vida en pacientes con incontinencia fecal. (Traducción-Dr Yolanda Colorado ).

Urgency an important factor when assessing fecal incontinence

The aim of this study was to investigate if Low Anterior Resection Syndrome (LARS) score contributed with complementary information to Wexner score when assessing fecal incontinence (FI). The hypothesis was that LARS score would be likely to provide complementary information to Wexner score in the assessment of FI regardless of etiology. LARS score has been used as a complement to traditional scoring systems to assess bowel dysfunction, targeting FI among patients after radical cystectomy, in women with endometriosis, and in colorectal cancer patients. Wexner score as a single tool does not address the complexity of FI and urgency, a disabling symptom. A retrospective cohort study at a surgical outpatient clinic included patients diagnosed with FI who answered LARS and Wexner scores questionnaires at their first visit to the clinic between 1st January 2015 and 31st December 2018. Kendall's tau, Spearman rank correlation, Cohen's kappa, and scatterplots were analyzed for participants and specific subgroups to assess any correlation and agreement between answers to the two scoring systems. One hundred nineteen patients met the inclusion criteria, one hundred eight women and eleven men. Kendall's tau ranged from 0.32 to 0.39, indicating lack of correlation. Correlation coefficients using Spearman rank ranged from 0.36 to 0.55, i.e., only fair to moderate correlation. Kappa was 0.21-0.28, i.e., only slight to fair agreement. Distribution of LARS and Wexner scores in the scatterplot showed wide variability and lack of agreement. Combined use of both the Wexner and LARS scores provided complimentary information, and thus a more complete mapping of FI as well as taking all entities in consideration.

Incidence and risk factors of bowel dysfunction after minimally invasive rectal cancer surgery and discrepancies between the Wexner score and the low anterior resection syndrome (LARS) score

PURPOSE

Bowel dysfunction after sphincter-preserving-surgery (SPS) impacts quality of life. The Wexner score (WS) and the low anterior resection syndrome (LARS) score (LS) are instruments for assessing postoperative bowel dysfunction. We analyzed the incidence of and risk factors for each symptom and examined the discrepancies between the two scores.

METHODS

A total of 142 patients with rectal cancer, who underwent minimally invasive SPS between May, 2018 and July, 2019, were included. A questionnaire survey using the two scores was given to the patients 2 years after SPS.

RESULTS

Tumor location and preoperative radiotherapy were independent risk factors for major LARS. Intersphincteric resection with a hand-sewn anastomosis (HSA) was an independent risk factor for high WS. Among the patients who underwent HSA, 82% experienced incontinence for liquid stools, needed to wear pads, and suffered lifestyle alterations. Of the 35 patients with minor LARS, only 1 had a high WS, and 80.0% reported no lifestyle alterations. Among the 75 patients with major LARS, 58.7% had a low WS and 21.3% reported no lifestyle alterations.

CONCLUSION

The results of this study provide practical data to help patients understand potential bowel dysfunction after SPS. The discrepancies between the WS and LS were clarified, and further efforts are required to utilize these scores in clinical practice.

Distinguishing Clinical From Statistical Significances in Contemporary Comparative Effectiveness Research

OBJECTIVE

To determine the prevalence of clinical significance reporting in contemporary comparative effectiveness research (CER).

BACKGROUND

In CER, a statistically significant difference between study groups may or may not be clinically significant. Misinterpreting statistically significant results could lead to inappropriate recommendations that increase health care costs and treatment toxicity.

METHODS

CER studies from 2022 issues of the Annals of Surgery , Journal of the American Medical Association , Journal of Clinical Oncology , Journal of Surgical Research , and Journal of the American College of Surgeons were systematically reviewed by 2 different investigators. The primary outcome of interest was whether the authors specified what they considered to be a clinically significant difference in the "Methods."

RESULTS

Of 307 reviewed studies, 162 were clinical trials and 145 were observational studies. Authors specified what they considered to be a clinically significant difference in 26 studies (8.5%). Clinical significance was defined using clinically validated standards in 25 studies and subjectively in 1 study. Seven studies (2.3%) recommended a change in clinical decision-making, all with primary outcomes achieving statistical significance. Five (71.4%) of these studies did not have clinical significance defined in their methods. In randomized controlled trials with statistically significant results, sample size was inversely correlated with effect size ( r = -0.30, P = 0.038).

CONCLUSIONS

In contemporary CER, most authors do not specify what they consider to be a clinically significant difference in study outcome. Most studies recommending a change in clinical decision-making did so based on statistical significance alone, and clinical significance was usually defined with clinically validated standards.

Successful outcome following a multimodal pelvic rehabilitation program in a woman with neurogenic bladder and bowel dysfunction: A case report

BACKGROUND

Neurogenic bladder and bowel dysfunctions lead to physical, social, and emotional disability and affects one's quality of life. Initial treatment is conservative including several rehabilitation techniques such as pelvic floor muscle training, biofeedback, electrical stimulation, and posterior tibial nerve stimulation.

OBJECTIVE

In this case report, a 45-year-old woman with neurogenic bladder and bowel dysfunction was presented.

CASE DESCRIPTION

Her urinary and fecal incontinence symptoms began twenty years before this episode of care, after an incomplete spinal cord injury secondary to spinal ependymoma and syringomyelia. She discontinued medical treatments due to side effects and ceased intermittent catheterization. A multimodal pelvic rehabilitation program was administered consisting of posterior tibial nerve stimulation, active pelvic floor muscle training accompanied by biofeedback, and electrical stimulation of pelvic floor muscles.

OUTCOMES

There were clinically important favorable differences in the scores of King's health questionnaire (reductions in symptom severity from 25 to 18 and in each of the impact of incontinence, physical and social limitations, personal relationships, sleep/energy, and severity measures from 100 to 67), pelvic floor distress inventory (decreased from 257 to 146) and female sexual function index (increased from 15.1 to 25.1) after 12 weeks of a multimodal pelvic rehabilitation program. Manual muscle tests demonstrated improvements in pelvic floor muscle strength and endurance.

CONCLUSION

A 12-week multimodal pelvic rehabilitation program reduced urinary and fecal incontinence symptoms, together with improvements in her sexual life and alleviation of neuropathic pain.

Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries

AIM

Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV).

METHOD

A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria.

RESULTS

There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores.

CONCLUSION

OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.

Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step

The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.

Effects of Sleeve Gastrectomy on Pelvic Floor Disorders in Female Patients with Severe Obesity: a Prospective Study

INTRODUCTION

Obesity is associated with pelvic floor disorders (PFD). Sleeve gastrectomy (SG) is one of the most effective weight loss methods. Although SG has been found to improve urinary incontinence (UI) and overactive bladder (OAB), its impact on fecal incontinence (FI) remains controversial.

MATERIALS AND METHODS

This prospective, randomized study involved 60 female patients with severe obesity who were randomly assigned to two groups: the SG group and the diet group. The SG group underwent SG, while the diet group received a low-calorie, low-lipid diet for 6 months. The patients' condition was assessed before and after the study using three questionnaires: the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), the Overactive Bladder 8-Question Awareness Tool (OAB-V8), and the Wexner Score (CCIS).

RESULTS

After 6 months, the SG group had a significantly higher percentage of total weight loss (%TWL) compared to the diet group (p<0.01). Both groups showed a decrease in the ICIQ-FLUTS, OAB-V8, and CCIS scores (p<0.05). UI, OAB, and FI improved significantly in the SG group (p<0.05), but no improvement was observed in the diet group (p>0.05). The correlation between %TWL and PFD was statistically significant but weak, with the strongest correlation between %TWL and ICIQ-FLUTS score and the weakest correlation between %TWL and CCIS score (p<0.05).

CONCLUSIONS

We recommend bariatric surgery for the treatment of PFD. However, given the weak correlation between %TWL and PFD after SG, further research should explore factors other than %TWL that are effective in recovery, particularly in relation to FI.

The Mexican consensus on fecal incontinence

Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.

Long-term cost-effectiveness analysis of sacral neuromodulation in the treatment of severe faecal incontinence

AIM

The aim of this study was to evaluate the long-term cost-effectiveness of sacral neuromodulation in the treatment of severe faecal incontinence as compared with symptomatic management.

METHODS

In the public health field, a micro-costing evaluation method was conducted from the perspectives of the health system and the society. The incremental cost-effectiveness ratio was used as a decision index, and we considered various scenarios to evaluate the impact of the cost of symptomatic management and percutaneous nerve evaluation success rate in its calculation. Clinical data were retrieved from a consecutive cohort of 93 patients with severe faecal incontinence undergoing sacral neuromodulation after a failure of conservative (pharmacological and biofeedback) and/or surgical (sphincteroplasty) first-line treatments were considered.

RESULTS

The long-term incremental cost-effectiveness ratio comparing sacral neuromodulation versus symptomatic management was 14347€/QALY and 28523€/QALY from the societal and health service provider's perspectives, respectively. If the definitive pulse generator implant success rate was 100%, incremental cost-effectiveness would correspond to 6831€/QALY and 16761€/QALY, respectively.

CONCLUSIONS

Sacral neuromodulation may be considered a cost-effective technique in the long-term treatment of severe faecal incontinence from the societal and health care sector perspectives. Improving patient selection and determining the predictive outcome factors for successful sacral neuromodulation in the treatment of faecal incontinence would improve cost-effectiveness.

Co-occurrence of fecal incontinence with constipation or irritable bowel syndrome indicates the need for personalized treatment

BACKGROUND

This study aimed to compare the prevalence and symptoms of fecal incontinence (FI) in relation to irritable bowel syndrome (IBS-associated FI), constipation (constipation-associated FI), and isolation (isolated FI).

METHODS

Data were analyzed from 3145 respondents without organic comorbidities known to influence defecation function from the general Chinese population who filled in the online Groningen Defecation and Fecal Continence questionnaire. FI, IBS, and constipation were evaluated with the Rome IV criteria.

KEY RESULTS

The prevalence of FI was 10.5% (n = 329) in the non-comorbidity group. After multivariable logistic regression analysis, IBS (odds ratio [OR]: 12.55, 95% confidence interval [CI]: 9.06-17.36) and constipation (OR: 4.38, 95% CI: 3.27-5.85) were the most significant factors contributing to FI. Based on this finding, 106/329 (32.2%) had IBS-associated FI, 119/329 (36.2%) had constipation-associated FI, and 104/329 (31.6%) had isolated FI. Among the 329 FI respondents, there was a high prevalence of IBS and constipation-related symptoms, including abdominal pain (81.5%) and abdominal bloating (77.8%) for IBS and straining during defecation (75.4%), incomplete defecation (72.3%), defecation blockage (63.2%), anal pain during defecation (59.3%), and hard stools (24%) for constipation. The patients with IBS-associated FI asked for specialists' help less frequently than those with isolated FI. Interestingly, among the patients with constipation-associated FI, 56.3% used anti-diarrhea medicine.

CONCLUSIONS AND INFERENCES

The prevalence of IBS-associated FI, constipation-associated FI, and isolated FI is comparably high. It is important to diagnose and target the cause of FI to provide personalized and cause-targeting care instead of treating only the FI symptoms.

Transanal irrigation is a better choice for bowel dysfunction in adults with Spina bifida: A randomised controlled trial

AIM

To compare transanal irrigation with conservative bowel management for the treatment of bowel dysfunction in Spina bifida (SB) patients.

METHODS

Patients with SB and bowel dysfunction were randomly assigned to receive either transanal irrigation or conservative bowel management. The effectiveness of the treatment was defined as a decrease of 4 points in the neurogenic bowel dysfunction (NBD) score at week 10. Data on incontinence (Cleveland scores; Jorge-Wexner [JW]) and constipation (Knowles-Eccersley-Scott Symptom Constipation Score [KESS]) were recorded at 10 and 24 weeks after inclusion. Data were analysed on an intention-to-treat basis.

RESULTS

A total of 34 patients were randomised: 16 patients to conservative bowel management and 18 patients to transanal irrigation. A total of 19/31 (61%) patients improved at week 10, 13 (76%) in the transanal irrigation group versus six (43%) in the conservative group (p = 0.056). In the irrigation group, the decrease in NBD score was -6.9 (-9.9 to -4.02) versus -1.9 (-6.5 to -2.8) in the conservative group (p = 0.049 in univariate and p = 0.004 in multivariate analysis). The NBD, Cleveland (JW and KESS) and Rosenberg scores were significantly lower in the transanal irrigation group than in the conservative bowel management group at week 10.

CONCLUSIONS

This prospective, randomised, controlled, multicentre study in adult patients with SB suggests that transanal irrigation may be more effective than conservative bowel management.

Underdiagnosis of internal anal sphincter trauma following vaginal delivery

OBJECTIVE

Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic.

METHODS

This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane.

RESULTS

In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001).

CONCLUSIONS

One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Would Surgeons Like to Be Submitted to Anal Fistulotomy? An International Web-Based Survey

Traditional fistulotomy is the most performed surgical procedure in anal fistula surgery. We conducted an international online survey to explore colorectal surgeons' opinions and preferences on fistulotomy. Considering the healing and continence impairment rates reported in the literature, surgeons were invited to answer as a hypothetic patient susceptible to being submitted to fistulotomy for low and high anal fistula. A total of 767 surgeons completed the survey from 72 countries. The majority of respondents were consultants, having treated more than 20 anal fistulas in the last year. Most of them declared that anal fistula would be able to negatively affect quality of life and would be worried/anxious about it. Taking into account all aspects, 87.5% and 37.8% of respondents would agree to be treated with a fistulotomy in case of a low and high fistula, respectively, with an acceptance rate that varied worldwide. At multivariate analysis, factors correlated to the acceptance of anal fistulotomy were male gender (p = 0.003), practice of less than 20 fistula operations during last year (p = 0.020), and low fistula (p < 0.001). Surgeons recognized the extreme complexity of this approach. This study highlighted the necessity of an accurate patients' selection and the adoption of alternative strategy to reduce the risk of anal continence impairment.

Picking Up the Threads: Long-Term Outcomes of the Sutured Haemorrhoidopexy: A Retrospective Single-Centre Cohort Study

BACKGROUND

This study aimed to assess the short- and long-term safety and efficacy of the sutured haemorrhoidopexy (SH) in patients with haemorrhoidal disease (HD).

METHODS

A retrospective study was performed, assessing the following treatment characteristics: number of sutures needed; operation time; perioperative complications; postoperative pain; hospital stay. The short- and long-term postoperative complications, HD recurrence and data on current HD symptoms were assessed according to the Core Outcome Set for HD.

RESULTS

Between January 2009 and December 2021, 149 patients with HD underwent a SH. One-hundred and forty-five patients were included, with a mean age of 61 years (±12.8), of which 70 were women (48.3%). Patients were predominantly diagnosed with grade III (37.2%) HD and the median follow-up was nine years (5-11). Perioperative complications occurred in four cases (2.8%). In two patients (1.4%), short-term postoperative complications were reported, and in seven patients (6.2%), long-term complications were reported. The cumulative efficacy in terms of freedom of recurrence was 88.3% (95% CI, 83.1-93.5) at six months, 80.0% (95% CI, 73.5-86.5) at one year, and 67.7% (95% CI, 59.7-75.7) at five years.

CONCLUSIONS

Sutured haemorrhoidopexy is a safe treatment for patients with HD and can be proposed as a minimally invasive surgical treatment if basic and outpatient procedures fail.

Risk factors accounting for anal incontinence during the first year after vaginal delivery-A case control study in China

Introduction and hypothesis

Anal incontinence (AI) is a prevalent postpartum disorder. This study aims to investigate and quantify the risk factors for AI in the Chinese population during the first year following vaginal delivery.

Methods

The case control study was conducted at Peking University Third Hospital, including all women who delivered vaginally between January 1, 2014, and June 30, 2018. Participants were followed up by telephone interviews 1 year after delivery. AI was defined as the involuntary loss of flatus or feces using a retrospective Jorge and Wexner score above 0. Clinical data were retrieved from the medical record system. Univariate and multivariate analyses were applied to identify potential risk factors accounting for AI. Based on the logistic regression model, a nomogram was constructed to predict the probability of AI postpartum. Restricted cubic spline was utilized to explore potential non-linear relationships between birth weight and AI postpartum.

Results

Among the 140 AI and 421 none AI cases, we observed antepartum factors like every 100 g of birth weight gain (OR 1.39, 95% CI 1.30-1.49), while intrapartum factors like forceps-assisted vaginal delivery (OR 7.11, 95% CI 2.60-19.45), midline episiotomy (OR 13.11, 95% CI 1.71-100.89), second-degree perineal tear (OR 6.51, 95% CI 1.16-36.68), and third to fourth-degree perineal tear were independent risk factors for postpartum AI. Significantly, infant weighing over 3,400 g at birth increased the risk of AI postpartum. Based on logistic regression model, we constructed a nomogram to estimate the risk of AI 1 year after vaginal delivery.

Conclusion

Our findings indicated that during the first year following vaginal delivery, infant with birth weight of 3,400 g or more, forceps-assisted vaginal delivery, midline episiotomy, and second to fourth-degree perineal tear increased the risk of AI. As a result, it is essential to limit the routine use of forceps and midline episiotomy and to monitor fetal weight during prenatal care.

External kinesiology tape for improvement in fecal incontinence symptom bother in women: a pilot study

INTRODUCTION AND HYPOTHESIS

Fecal incontinence is a debilitating condition with a devastating impact on quality of life. Using a commercially available kinesiology band we developed an anal tape to be applied to the anus with the aim to determine its impact on symptom bother and quality of life.

METHODS

Four-week prospective, self-controlled, pilot study of patients with FI. The primary outcome was improvement in any of the four domains (lifestyle, coping/behavior, depression/self-perception, embarrassment) evaluated by the "Fecal Incontinence Quality of Life Scale." Secondary outcomes included improvement in frequency of incontinence events and safety. Days 0-14 served as control period and days 15-28 as study period. Patients were asked to rate their satisfaction and willingness to use the device in the future using a 10-cm continuous visual analog scale.

RESULTS

Twenty patients completed the study. Median age was 64 years; all patients were females. Significant improvements were observed in all domains of the Fecal Incontinence Quality of Life Scale from baseline to day 28 (p < 0.001 for all) and in three of four domains between day 15 and 28 (p < 0.04) but not between days 1 and 14. Five patients (25%) had a ≥ 50% improvement in incontinence events. Patients reported satisfaction and willingness to use the anal tape in the future. Other than mild difficulty to remove the anal tape, no adverse events were reported.

CONCLUSIONS

In this small pilot study, the use of the anal tape was safe and effective. The primary outcome of significant improvement in quality of life was achieved ( ClinicalTrials.gov ID:NCT02989545).

PUBLIC TRIAL REGISTRY

ClinicalTrials.gov identifier NCT02989545. https://clinicaltrials.gov/ct2/show/NCT02989545.

Faecal incontinence in inflammatory bowel disease: The Nancy experience

BACKGROUND

Faecal incontinence (FI) is a disabling condition in patients with inflammatory bowel disease (IBD). The diagnosis of FI is not easy as patients are reluctant to report this embarrassing symptom. The objectives of this study were to characterize the prevalence of FI in IBD patients using available scoring systems, and to identify associated risk factors.

METHODS

A FI clinic was implemented in routine practice between January 2020 and April 2021. FI was defined as a Wexner score ≥5. Factors associated with FI were analyzed.

RESULTS

A total of 319 consecutive patients with IBD were included. The prevalence of FI was 16.4% (53/319). Age >45 years at inclusion (Odd ratio (OR)=3.33, Confidence interval (CI) 95% 1.40-7.94), diarrhea (three stools at least per day) (OR=2.94, CI 95% 1.16-7.45), stool consistency according to the Bristol stool chart (OR=2.23, CI 95% 1.00-4.99), and abdominal pain (OR=2.24, CI 95% 1.10-4.53) were independently associated with FI in a multivariate model analysis.

CONCLUSIONS

Approximately one fifth of IBD patients reported FI in this real-world cohort, using an available scoring system. Increased age, diarrhea, stool consistency according to the Bristol stool chart, and abdominal pain were associated with FI. A systematic screening of FI would allow a better management of this disabling condition.

Pelvic Floor Rehabilitation After Rectal Cancer Surgery: A Multicenter Randomized Clinical Trial (FORCE Trial)

OBJECTIVE

To investigate the effects of PFR after LAR compared to usual care without PFR.

SUMMARY OF BACKGROUND DATA

Functional complaints, including fecal incontinence, often occur after LAR for rectal cancer. Controversy exists about the effectiveness of PFR in improving such postoperative functional outcomes.

METHODS

This was a multicenter, randomized controlled trial involving 17 Dutch centers. Patients after LAR for rectal cancer were randomly assigned (1:1) to usual care or PFR and stratified by sex and administration of neoadjuvant therapy. Selection was not based on severity of complaints at baseline. Baseline measurements were taken 3 months after surgery without temporary stoma construction or 6 weeks after stoma closure. The primary outcome measure was the change in Wexner incontinence scores 3 months after randomization. Secondary outcomes were fecal incontinence-related quality of life, colorectal-specific quality of life, and the LARS scores.

RESULTS

Between October 2017 and March 2020, 128 patients were enrolled and 106 randomly assigned (PFR n = 51, control n = 55); 95 patients (PFR n = 44, control n = 51) were assessable for final analysis. PFR did not lead to larger changes in Wexner incontinence scores in nonselected patients after LAR compared to usual care [PFR: -2.3, 95% confidence interval (CI) -3.3 to -1.4, control: -1.3, 95% CI -2.2 to -0.4, P = 0.13]. However, PFR was associated with less urgency at follow-up (odds ratio 0.22, 95% CI 0.06-0.86). Patients without near-complete incontinence reported larger Wexner score improvements after PFR (PFR: -2.1, 95% CI -3.1 to -1.1, control: -0.7, 95% CI -1.6 to 0.2, P = 0.045). For patients with at least moderate incontinence PFR resulted in relevant improvements in all fecal incontinence-related quality of life domains, while the control group deteriorated. These improvements were even larger when patients with near-complete incontinence were excluded. No serious adverse PFR-related events occurred.

CONCLUSION

No benefit was found of PFR in all patients but several subgroups were identified that did benefit from PFR, such as patients with urgency or with at least moderate incontinence and no near-complete incontinence. A selective referral policy (65%-85% of all patients) is suggested to improve postoperative functional outcomes for patients after LAR for rectal cancer.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5469, registered on 3 September 2015.

Economic burden of long-term treatment of severe fecal incontinence

INTRODUCTION

Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy.

METHODS

Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3); and colostomy stenosis (n=1).

RESULTS

The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories).

CONCLUSIONS

Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment.

Functional outcomes of intersphincteric resection in low rectal tumors

OBJECTIVES

Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection.

MATERIAL AND METHODS

This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed.

RESULTS

Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis.

CONCLUSION

In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

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

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

Altered epithelial barrier functions in the colon of patients with spina bifida

Our objectives were to better characterize the colorectal function of patients with Spina Bifida (SB). Patients with SB and healthy volunteers (HVs) completed prospectively a standardized questionnaire, clinical evaluation, rectal barostat, colonoscopy with biopsies and faecal collection. The data from 36 adults with SB (age: 38.8 [34.1-47.2]) were compared with those of 16 HVs (age: 39.0 [31.0-46.5]). Compared to HVs, rectal compliance was lower in patients with SB (p = 0.01), whereas rectal tone was higher (p = 0.0015). Ex vivo paracellular permeability was increased in patients with SB (p = 0.0008) and inversely correlated with rectal compliance (r = - 0.563, p = 0.002). The expression of key tight junction proteins and inflammatory markers was comparable between SB and HVs, except for an increase in Claudin-1 immunoreactivity (p = 0.04) in SB compared to HVs. TGFβ1 and GDNF mRNAs were expressed at higher levels in patients with SB (p = 0.02 and p = 0.008). The levels of acetate, propionate and butyrate in faecal samples were reduced (p = 0.04, p = 0.01, and p = 0.02, respectively). Our findings provide evidence that anorectal and epithelial functions are altered in patients with SB. The alterations in these key functions might represent new therapeutic targets, in particular using microbiota-derived approaches.Clinical Trials: NCT02440984 and NCT03054415.

Effects of probiotics on loperamide-induced constipation in rats

The role of probiotics in mitigating constipation, gut immunity, and gut microbiota has not been well studied. We aimed to evaluate the effects of probiotics on loperamide (LP)-induced constipation in Sprague-Dawley rats. Altogether, 150 male Sprague-Dawley rats (age 8 weeks) were used in the experiments following a 12-day acclimatisation period and were randomly divided into three treatment groups (groups 1, 2, and 3). Spastic constipation was induced via oral LP administration (3 mg/kg) for 6 days, 1 h before administering each test compound in groups 1 and 2. A probiotic solution (4 mL/kg body weight) was orally administered once a day for 6 days in group 2. In group 1, a phosphate buffer solution was orally administered once a day for 6 days, 1 h after each LP administration. In group 3, a phosphate buffer solution was orally administered once a day for 6 days. In the probiotic group, faecal parameters improved; faecal n-butyric acid, acetic acid, and IgA concentrations were increased; intestinal transit time was shortened; and disturbance of intestinal microbiota was inhibited. Our findings suggest that this probiotic was useful in improving various symptoms caused by constipation.

Quality of life, distress, and posttraumatic growth 5 years after colorectal cancer diagnosis according to history of inpatient rehabilitation

Purpose

In Germany, almost every other colorectal cancer (CRC) patient undergoes inpatient cancer rehabilitation (ICR), but research on long-term outcomes is sparse. We aimed to assess health-related quality of life (HRQOL), distress, and posttraumatic growth among former rehabilitants and non-rehabilitants as well as respective differences and to estimate disease-related quality of life deficits in both groups.

Methods

HRQOL (EORTC-QLQ-C30/CR29), distress (QSC-R10), and posttraumatic growth (PTGI) were assessed according to past ICR in patients 5-year post-CRC-diagnosis in the German DACHS study. Least square mean differences in HRQOL scores and elevated distress levels (QSC-R10 > 14 points) by ICR were estimated by confounder-adjusted linear and logistic regression, respectively. Differences in PTGI scales were tested for statistical significance. EORTC-QLQ-C30 reference scores from population controls were accessed from the LinDE study to estimate disease-related deficits in both treatment groups.

Results

49% of the included 1906 CRC survivors had undergone ICR. Rehabilitants reported lower HRQOL scores than non-rehabilitants in several dimensions of the EORTC-QLQ-C30/CR29. Differences were pronounced among younger survivors (< 70 years). In younger survivors, past ICR also predicted elevated distress. However, rehabilitants showed higher posttraumatic growth. When compared to 934 population controls, non-rehabilitants and older rehabilitants reported HRQOL scores (EORTC-QLQ-C30) similar to controls except higher levels of bowel dysfunctions, whereas younger rehabilitants experienced deficits regarding most scales (13/15).

Conclusion

Our findings suggest a high disease burden 5 years after diagnosis in particular among younger CRC survivors who had undergone ICR. Observed HRQOL deficits are possibly linked to the initial indication for ICR and rehabilitants may benefit from effective follow-up concepts after ICR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03865-3.

Measuring the impact of gastrointestinal inconvenience and symptoms on perceived health in the general population - validation of the Short Health Scale for gastrointestinal symptoms (SHS-GI)

OBJECTIVES

Gastrointestinal (GI) symptoms are intimately related to our wellbeing. The Short Health Scale for GI symptoms (SHS-GI) is a simple questionnaire to measure the impact of GI inconvenience and symptoms on quality of life. The aim was to validate the SHS-GI in a general population sample and to compare it with SHS-data across different patient groups.

METHOD

A subsample of 170 participants from a population-based colonoscopy study completed the Rome II questionnaire, GI diaries, psychological questionnaire (hospital anxiety and depression scale) and SHS-GI at follow-up investigation. Psychometric properties of SHS-GI as an overall score were determined by performing a confirmatory factor analysis (CFA). Spearman correlation between SHS total score and symptoms was calculated in the general population sample. SHS-GI data was compared with SHS data from patients with inflammatory bowel disease (IBD) and fecal incontinence (FI).

RESULTS

As expected, the general population rated their impact of GI inconvenience on quality of life as better than the patient populations in terms of all aspects of the SHS-GI. The CFA showed a good model fit meeting all fit criteria in the general population. Cronbach's alpha for the total scale was 0.80 in the general population sample and ranged from 0.72 in the FI sample to 0.88 and 0.89 in the IBD samples.

CONCLUSIONS

SHS-GI demonstrated appropriate psychometric properties in a sample of the normal population. We suggest that SHS-GI is a valid simple questionnaire suitable for measuring the impact of GI symptoms and inconvenience on quality of life in both general and patient populations.

Long-term evaluation of the impact of delivery modalities on anal continence in women with Crohn's disease

CONTEXT

Crohn's disease (CD) and sphincter injury during childbirth are two risk factors for anal incontinence (AI). The long-term risk of developing AI in women with CD after childbirth has never been studied.

GOAL

The main objective of the study is to assess the risk of developing severe AI after childbirth in women with CD.

METHODS

A retrospective study was performed in women with CD who gave birth in a French "Level 3" maternity hospital between 2000 and 2015. The primary endpoint was severe AI as defined by a Wexner score≥9 or a St. Mark's score≥9, at least five years after childbirth. The association between delivery route and occurrence of severe AI was assessed by univariate and multivariate analyses.

RESULTS

Forty-six women were included, 32 of whom were delivered vaginally and 14 by Caesarean section. Thirty-one percent of the women had severe AI according to the Wexner score, and 41% according to the St. Mark's score. Two factors were associated with severe AI: vaginal delivery and the occurrence of an obstetric perineal injury: (crude OR=8.89, 95% (CI: 1.03-76.57) and crude OR=4.16, 95% (CI: 1.06-16.27) respectively for AI defined by the Wexner score, and crude OR=6.8, 95% (CI: 1.30-35.41) and crude OR=4.3, 95% (CI: 1.23-15.2) for AI defined by the St. Mark's score). After adjusting for confounding factors, only vaginal delivery was associated with severe AI (adjusted OR=22.86, 95% CI: 1.52-931.28 for a Wexner score≥9 and adjusted OR=16. 11 (95% CI: 1.43-533.26) for a St Mark score≥9).

CONCLUSION

Vaginal birth was associated with the development of severe long-term AI in women with CD.

Inpatient rehabilitation therapy among colorectal cancer patients - utilization and association with prognosis: a cohort study

BACKGROUND

Inpatient rehabilitation therapy (IRT) is commonly offered to cancer patients during or after cancer treatment in Germany. However, little is known about utilization and long-term effects of this offer in colorectal cancer (CRC) patients. We aimed to assess IRT utilization, determinants of utilization and the association between IRT and survival in CRC patients.

MATERIALS AND METHODS

CRC patients diagnosed in 2005-2014 recruited in the population-based DACHS study in South West Germany were included. Determinants of IRT utilization were assessed by multivariable logistic regression. Hazard ratios (HRs) of the association of IRT with overall and disease-specific survival were estimated by adjusted Cox proportional hazards models. Modified landmark approach was applied to avoid immortal time biased results.

RESULTS

Among the included CRC patients (n = 3704), 43.6% underwent IRT. Patients who did not live in a relationship with a partner, worked as employee and who reported higher levels of physical activity were more likely to undergo IRT. Patients were less likely to undergo IRT if they had private health insurance, were diagnosed with cancer stage IV, received no or laparoscopic cancer surgery or were treated in a hospital with medium vs. high surgical volume. The median follow-up time was 4.4 years (post-landmark). Utilization of IRT was associated with better overall (HR 0.81, 95% confidence interval 0.72-0.92) and disease-specific survival (HR 0.72, 95% confidence interval 0.61-0.85).

CONCLUSION

Almost every other CRC patient underwent IRT. Next to clinical characteristics, identified social and lifestyle characteristics seemed to play an essential role in the decision-making. Use of IRT was associated with better overall and disease-specific survival.

Economic burden of long-term treatment of severe fecal incontinence

INTRODUCTION

Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy.

METHODS

Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3), and colostomy stenosis (n=1).

RESULTS

The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories).

CONCLUSIONS

Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment.

Randomized Pilot Study: Anal Inserts Versus Percutaneous Tibial Nerve Stimulation in Patients With Fecal Incontinence

BACKGROUND

Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence in whom other conservative treatments have failed.

OBJECTIVE

We aimed to compare anal inserts and percutaneous tibial nerve stimulation.

DESIGN

This was an investigator-blinded randomized pilot study.

SETTINGS

The study was conducted at a large tertiary care hospital.

PATIENTS

Adult patients with passive or mixed fecal incontinence were recruited.

INTERVENTIONS

Patients were randomly assigned to receive either the anal inserts or weekly percutaneous tibial nerve stimulation for a period of 3 months.

MAIN OUTCOME MEASURES

The primary end point was a 50% reduction of episodes of fecal incontinence per week as calculated by a prospectively completed 2-week bowel diary. Secondary end points were St Mark's incontinence score, International Consultation on Incontinence Questionnaire-Bowel scores (for bowel pattern, bowel control, and quality of life), use of antidiarrheal agents, estimates of comfort and acceptability.

RESULTS

Fifty patients were recruited: 25 were randomly assigned to anal inserts and 25 were randomly assigned to percutaneous tibial nerve stimulation. All completed treatment. A significant improvement of scores in the 2-week bowel diary, the St Mark's scores and the International Consultation on Incontinence Questionnaire-Bowel scores, was seen in both groups after 3 months of treatment. A reduction of ≥50% fecal incontinence episodes was reached by 76% (n = 19/25) by the anal insert group, compared with 48% (n = 12/25) of those in the percutaneous tibial nerve stimulation group (p = 0.04). The St Mark's fecal incontinence scores and the International Consultation on Incontinence Questionnaire-Bowel scores for bowel pattern, bowel control, and quality of life (p = 0.01) suggest similar improvement for each group.

LIMITATIONS

A realistic sample size calculation could not be performed because of the paucity of objective prospective studies assessing the effect of the insert device and percutaneous tibial nerve stimulation.

CONCLUSIONS

Both anal insert and percutaneous tibial nerve stimulation improved the symptoms of fecal incontinence after 3 months of treatment. The insert device appeared to be more effective than percutaneous tibial nerve stimulation. Larger studies are needed to investigate this further. See Video Abstract at http://links.lww.com/DCR/B460.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov No. NCT04273009.

ESTUDIO PILOTO ALEATORIZADO DE INSERCIONES ANALES CONTRA LA ESTIMULACIN PERCUTNEA DEL NERVIO TIBIAL EN PACIENTES CON INCONTINENCIA FECAL

ANTECEDENTES:Las inserciones anales y la estimulación percutánea del nervio tibial (PTNS) se pueden ofrecer a las personas con incontinencia fecal que han fallado en otros tratamientos conservadores.OBJETIVO:Nuestro objetivo fue comparar inserciones anales y estimulación percutánea del nervio tibial.DISEÑO:Este fue un estudio piloto aleatorio ciego para investigadores.AJUSTE:El estudio se realizó en un hospital de atención terciaria.PACIENTES:Se reclutaron pacientes adultos con incontinencia fecal pasiva o mixta.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir inserciones anales o estimulación del nervio tibial percutáneo semanal durante un período de tres meses.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue una reducción del 50% de los episodios de incontinencia fecal por semana, según lo calculado mediante un diario intestinal de dos semanas completado de forma prospectiva. Los criterios de valoración secundarios fueron la puntuación de incontinencia de St Mark, las puntuaciones del ICIQ-B (para patrón intestinal, control intestinal y calidad de vida), uso de agentes antidiarreicos, estimaciones de comodidad y aceptabilidad.RESULTADOS:Se reclutaron 50 pacientes: 25 fueron asignados al azar a inserciones anales y 25 a PTNS. Todo el tratamiento completado. Se observó una mejora significativa de las puntuaciones en el diario intestinal de dos semanas, la puntuación de St Mark y la puntuación del ICIQ-B en ambos grupos después de 3 meses de tratamiento. Se alcanzó una reducción de ≥ 50% de los episodios de incontinencia fecal en un 76% (n = 19/25) en el grupo de inserción anal, en comparación con el 48% (n = 12/25) de los del grupo de estimulación percutánea del nervio tibial (p = 0,04). Las puntuaciones de incontinencia fecal de St Mark, las puntuaciones del ICIQ-B para el patrón intestinal, el control intestinal y la calidad de vida (p = 0,01) sugieren una mejora similar para cada grupo.LIMITACIONES:No se pudo realizar un cálculo realista del tamaño de la muestra debido a la escasez de estudios prospectivos objetivos que evaluaran el efecto del dispositivo de inserción y la estimulación percutánea del nervio tibial.CONCLUSIONES:Tanto la inserción anal como la estimulación percutánea del nervio tibial mejoraron los síntomas de incontinencia fecal después de 3 meses de tratamiento. El dispositivo de inserción parecia ser más efectivo que la estimulación percutánea del nervio tibial. Se necesitan estudios más amplios para investigar esto más a fondo. Consulte Video Resumen en http://links.lww.com/DCR/B460.NÚMERO DE REGISTRO DE PRUEBA:Clinicaltrials.gov No. NCT04273009.

Long-term Fecal Incontinence, Recurrence, Satisfaction, and Regret After the Transobturator Postanal Sling Procedure

OBJECTIVES

The objective of this study was to assess long-term outcomes after the transobturator postanal sling (TOPAS) procedure for the treatment of fecal incontinence. Long-term recurrence, satisfaction and regret after transobturator postanal sling procedure support the ongoing use of this procedure for patients with fecal incontinence.

METHODS

Both a retrospective review of medical records and a prospective telephone survey were conducted. For the retrospective review of medical records, all patients who underwent the TOPAS procedure at our institution were eligible. Medical records were reviewed to assess for symptom resolution, retreatment, and complications. For the prospective telephone survey, patients who were conversant in English and had a valid contact information were eligible and were asked to complete questions on satisfaction, the Patient Global Impression of Improvement, the Wexner Symptom Severity Score, the Fecal Incontinence Qualify of Life Scale, and the modified Decision Regret Scale.

RESULTS

A total of 134 patients met the inclusion criteria for the retrospective medical record review. Patients were followed in clinic for a median of 24.0 months (interquartile range, 6.0-53.0). Overall, 75.4% reported improvement in fecal incontinence. There were 37 (27.6%) who required subsequent treatment for fecal incontinence. There were 67 patients eligible for the prospective telephone survey, of whom 46 (68.7%) agreed to participate. Median time between surgery and the telephone survey was 63.5 months (interquartile range, 36.0-98.0). Among these participants, 54.3% were satisfied and 60.9% would recommend the procedure to someone else. No adverse events were identified with long-term follow-up.

CONCLUSIONS

Our findings suggest that the TOPAS procedure remains a safe and effective therapy for the treatment of fecal incontinence with favorable long-term outcomes.

Can ultrasound 10 days after obstetric anal sphincter injury predict anal incontinence at long-term follow-up?

INTRODUCTION AND HYPOTHESIS

The objective was to investigate whether endoanal ultrasound (EAUS) performed 10 days after a primary repaired obstetric anal sphincter injury (OASIS) can predict the severity of anal incontinence (AI) in the long term.

METHODS

This prospective cohort study included women with a primary repaired 3b-degree tear, 3c-degree tear or fourth-degree tear at Aarhus University Hospital, Denmark, from 1 September 2010 to 31 May 2011. Clinical assessment and EAUS were performed on day 2, day 10, and day 20 after delivery. Functional outcomes were assessed using a questionnaire at the time of all clinical visits and at the long-term follow-up, 7 years after delivery. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score.

RESULTS

Ninety-six out of 99 women consented to participate. Five women had a secondary sphincter repair and were subsequently excluded from follow-up. Fifty-seven women underwent both EAUS 10 days after delivery and answered the long-term follow-up questionnaire. Median follow-up time was 7.7 years (IQR 7.4-7.8). Mean Wexner score was 4.4 ± 4.8 10 days after delivery and 2.5 ± 2.8 at follow-up; thus, the Wexner score improved over time (p = 0.01). Ultrasound sphincter defects were found in 82.6% of the women. Mean Starck score was 3.0 ± 1.8. The risk of AI was 0% (95% CI 0.0-30.8) if the Starck score was 0. No correlation was found between the Starck score and the Wexner score at follow-up.

CONCLUSIONS

We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.

Validation of a Novel Fecal Incontinence Scale: The Rapid Assessment Fecal Incontinence Score (RAFIS)

OBJECTIVE

The development and validation of a new version of the fecal incontinence (FI) scale "Rapid Assessment Fecal Incontinence Score" (RAFIS) incorporating domains for severity, type of stool loss, and global perception of the effect of incontinence on quality of life (QoL).

BACKGROUND

FI negatively impacts on QoL. Currently used incontinence questionnaires have outstanding limitations on the global assessment of the impact of the disease on QoL that patients perceive. We developed a new version of RAFIS with a more complete questionnaire.

MATERIALS AND METHODS

A 3-phase study was performed to evaluate the applicability and reliability of our questionnaire as a tool for assessing FI. Our score was completed by 98 patients (78 women; mean age: 57±13 y) who presented with FI and who were referred from 4 colorectal surgery centers. The RAFIS was assessed for internal consistency, test-retest reliability, and sensitivity to change. A multivariate analysis was performed. Comparisons were made with the Wexner Cleveland Clinic Incontinence Score and the Fecal Incontinence Quality of Life Scale.

RESULTS

The RAFIS showed good internal consistency and test-retest reliability, differentiating the severity of incontinence but not the etiology. There was a moderate-high correlation between the new scale and the reference scales. Sensitivity to change, compared with the Wexner Score, was moderate. Comparison with established QoL instruments showed a moderate negative correlation. Logistic regression of the RAFIS discriminated between mild and moderate-severe impact on QoL. No correlation was detected with the new score to the presence of an anal sphincter defect or sphincter hypotonia.

CONCLUSION

The RAFIS scale is easy to administer and compares well with other validated incontinence instruments.

Kegel Exercises, Biofeedback, Electrostimulation, and Peripheral Neuromodulation Improve Clinical Symptoms of Fecal Incontinence and Affect Specific Physiological Targets: An Randomized Controlled Trial

Background/Aims

Fecal incontinence (FI) is a prevalent condition among community-dwelling women, and has a major impact on quality of life (QoL). Research on treatments commonly used in clinical practice—Kegel exercises, biofeedback, electrostimulation, and transcutaneous neuromodulation—give discordant results and some lack methodological rigor, making scientific evidence weak. The aim is to assess the clinical efficacy of these 4 treatments on community-dwelling women with FI and their impact on severity, QoL and anorectal physiology.

Methods

A randomized controlled trial was conducted on 150 females with FI assessed with anorectal manometry and endoanal ultrasonography, and pudendal nerve terminal motor latency, anal/rectal sensory-evoked-potentials, clinical severity, and QoL were determined. Patients were randomly assigned to one of the following groups Kegel (control), biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel, treated for 3 months and re-evaluated, then followed up after 6 months.

Results

Mean age was 61.09 ± 12.17. Severity of FI and QoL was significantly improved in a similar way after all treatments. The effect on physiology was treatment-specific Kegel and electrostimulation + Kegel, increased resting pressure (P < 0.05). Squeeze pressures strongly augmented with biofeedback + Kegel, electrostimulation + Kegel and neuromodulation + Kegel (P < 0.01). Endurance of squeeze increased in biofeedback + Kegel and electrostimulation + Kegel (P < 0.01). Rectal perception threshold was reduced in the biofeedback + Kegel, electrostimulation + Kegel, and neuromodulation + Kegel (P < 0.05); anal sensory-evoked-potentials latency shortened in patients with electrostimulation + Kegel (P < 0.05).

Conclusions

The treatments for FI assessed have a strong and similar efficacy on severity and QoL but affect specific pathophysiological mechanisms. This therapeutic specificity can help to develop more efficient multimodal algorithm treatments for FI based on pathophysiological phenotypes.

Changes in health-related outcomes among colorectal cancer patients undergoing inpatient rehabilitation therapy: a systematic review of observational and interventional studies

BACKGROUND

Colorectal cancer (CRC) and its treatment can lead to several physical and psychosocial impairments. Cancer rehabilitation aims to reduce morbidity and improve quality of life. The objective of this review was to summarize and evaluate evidence on changes in health-related outcomes among CRC patients undergoing inpatient rehabilitation therapy and on the effectiveness of such treatment.

MATERIAL AND METHODS

We conducted a systematic literature search including the electronic databases Pubmed and Web of Science to find observational and interventional studies, which investigated changes in health-related outcomes among CRC patients undergoing multidisciplinary inpatient rehabilitation programs or treatment effects. Study findings were synthesized narratively.

RESULTS

Eleven studies were eligible and included in this review. Eight patient cohort studies addressed outcomes such as physical and functional status, fecal incontinence, anxiety and depression, and quality of life. Positive changes during rehabilitation therapy were observed for physical health (functional and physical status, fecal incontinence), and several dimensions of quality of life. Study findings concerning anxiety and depression were not conclusive. Studies that additionally conducted long-term follow-ups indicated that the improved health status after rehabilitative treatment waned over time. One RCT reported no effect of inpatient rehabilitation on distress and two randomized trials reported effects of exercise intensity on oxidative stress and immune response. Sample sizes were low (<100 included CRC patients) in eight studies and only the RCT included a comparison group (non-rehabilitants).

CONCLUSION

The scientific evidence level was very limited. Due to the lack of a comparison group in most studies, we were only able to evaluate changes during/after inpatient rehabilitation therapy but not the effectiveness of treatment. However, study findings suggest that physical health and functional independence improve during inpatient rehabilitation, but improvements wane over time. Further large representative studies, in particular RCTs with long-term follow-up, are essential to evaluate the effectiveness of inpatient rehabilitation and identify determinants of treatment success.

Metrics Used to Quantify Fecal Incontinence and Constipation

While fecal incontinence and constipation can be measured through physiological testing, the subjective experience of severity and impact on health-related quality of life lead to both being most effectively captured through patient-reported measures. Patient-reported measures of severity and impact help to determine baseline symptoms, guide clinical decision making, and compare various treatments. Here, we take pause to review the psychometric qualities that make effective instruments, and discuss some of the most commonly used instruments along with the reasons behind their use. In addition, we highlight the benefits of a standardized instrument designed to evaluate the major symptoms of patients presenting with pelvic floor disorders (including fecal incontinence and constipation). Ultimately, we aim to provide guidance in choosing appropriate instruments for clinical and research use.

An epidemiology study of fecal incontinence in adult Chinese women living in urban areas

Background:

Fecal incontinence (FI) has been shown to be a common symptom in Western countries; however, there is few researches focusing on its epidemic condition in Chinese women. We conducted this national population-based epidemiology study to estimate the prevalence and risk factors of FI among adult Chinese women living in urban regions.

Methods:

This is a subgroup analysis of a national population-based epidemiology study of FI. Total 28,196 adult women from urban regions of six provinces and municipalities participated in this research from 2014 to 2015. They finished the questionnaire under the direction of trained interviewers. FI was defined as accidental leakage of flatus and/or liquid or solid stool at least once in the past. The FI prevalence trend and risk factors were identified by the Cochran-Armitage test, Chi-square test, and multivariable logistic regression.

Results:

The prevalence of FI in adult females in urban China was 0.43% (95% confidence interval: 0.35%–0.51%). Among women with FI, 42.96%, 82.96%, and 42.22% reported having leakage of solid, liquid stool, and gas, respectively. The overall FI prevalence and the incidence rate of solid stool/liquid stool/gas leakage increased with age. The mean Wexner score was 4.0% and 12.0% FI patients reported Wexner score ≥9. Body mass index ≥24 kg/m², pelvic organ prolapses, chronic constipation, chronic cough, alcohol consumption, physical diseases including chronic bronchitis and cancer, gynecological diseases like gynecological inflammation are risk factors for FI. Vaginal delivery was the risk factor for FI in females with labor history.

Conclusions:

FI was not a common symptom in adult Chinese women living in urban areas and there were some potential modifiable risk factors.

Trial Registration:

Chinses Clinical Trial Registry: ChiCTR-OCS-14004675; http://www.chictr.org.cn/showproj.aspx?proj=4898

The severity of symptoms is insufficient to predict major alterations to quality of life of patients with fecal incontinence or chronic constipation

PURPOSE

Evaluate the impact of fecal incontinence (FI) and chronic constipation (CC) on the quality of life (QoL) in a large population and determine if a threshold of symptom scores was associated with alterations to QoL.

METHODS

A total of 422 outpatients with FI (n = 186), CC (n = 186), and mixed FI-CC (n = 50) referred for anorectal manometry were included prospectively. All patients completed a set of questionnaires to evaluate the severity of FI and CC (respectively Jorge and Wexner and KESS scores) and their impact on QoL (Gastrointestinal Quality of Life Index (GIQLI)).

RESULTS

The study population included 81.8% women. The QoL was altered to the same degree for both FI and CC, with significant more marked impairments in patients with mixed FI-CC (median GIQLI: 91 (71-108) vs. 91 (73-108) vs. 81 (57-97) respectively, p = 0.05). The symptom severity significantly but weekly correlated with the GIQLI score (r² = - 0.454 for FI and r² = - 0.483 for CC, p < 0.001). Thus, the large dispersion of the data flawed the identification of a threshold for symptom severity that could predict major impairment to QoL.

CONCLUSION

The QoL was equally altered for FI and CC. Although the symptom score severity was slightly but significantly associated with alterations to QoL, it was not possible to determine a threshold for symptom scores that predict an alteration to QoL. Therefore, the evaluation of QoL in parallel to the assessment of the symptom score is required to endorse the entire spectrum of the severity of CC or FI.

Assessing the benefit of reoperations in patients who suffer from fecal incontinence after repair of their anorectal malformation

BACKGROUND AND AIM

Patients with a previously repaired anorectal malformation (ARM) can suffer from complications which lead to incontinence. Reoperation can improve the anatomic result, but its impact on functional outcomes is unclear.

METHODS

We performed a retrospective cohort study of patients with a previously repaired ARM who underwent redo PSARP at our Center and compared results at initial assessment and 12 months after redo.

RESULTS

One hundred fifty-three patients underwent a redo PSARP for anoplasty mislocation (n=93, 61%), stricture (n=55, 36%), remnant of the original fistula (n=28, 18%), or rectal prolapse (n=11, 7%). Post-redo complications included stricture (n=33, 22%) and dehiscence (n=5, 3%). At 1-year post-redo, 75/153 (49%) are on laxatives only, of whom 57 (76%) are continent of stool. Of the remaining 78 (51%) patients, 61 (78%) are clean (≤1 accident per week) on enemas. Interestingly, 16/79 (20%) of patients with expected poor continence potential were continent of stool on laxatives. Overall, 118/153 (77%) are clean after their redo. Quality of life (76.7 vs. 83.8, p=0.05) and Baylor continence (29.2 vs. 17.7, p=<0.0001) scores improved.

CONCLUSION

Patients with fecal incontinence after an ARM repair can, with a reoperation, have their anatomy corrected which can restore continence for many, and improve their quality of life.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective cohort study.

LONG-TERM EVOLUTION OF CONTINENCE AND QUALITY OF LIFE AFTER SPHINCTEROPLASTY FOR OBSTETRIC FECAL INCONTINENCE

Purpose

This study was performed to evaluate the long-term evolution of continence and patient’s quality of life after surgical treatment for obstetric fecal incontinence.

Methods

A prospective longitudinal study was conducted including consecutive patients who underwent sphincteroplasty for severe obstetric fecal incontinence. The first phase analyzed changes in continence and impact on quality of life. The second phase studied the long-term evolution reevaluating the same group of patients 6 years later. Degree of fecal incontinence was calculated using the Cleveland Clinic Score (CCS). Quality of life assessment was carried out with the Fecal Incontinence Quality of Life scale.

Results

Thirty-five patients with median age of 55 years (range, 28 to 73 years) completed the study. Phase 1 results: after a postoperative follow-up of 30 months (4 to 132 months), CCS had improved significantly from a preoperative of 15.7 ± 3.1 to 6.1 ± 5.0 (P < 0.001). Phase 2 results: median follow-up in phase 2 was 110 months (76 to 204 months). The CCS lowered to 8.4 ± 4.9 (P = 0.04). There were no significant differences between phases 1 and 2 in terms of quality of life; lifestyle (3.47 ± 0.75 vs. 3.16 ± 1.04), coping/behavior (3.13 ± 0.83 vs. 2.80 ± 1.09), depression/self-perception (3.65 ± 0.80 vs. 3.32 ± 0.98), and embarrassment (3.32 ± 0.90 vs. 3.12 ± 1.00).

Conclusion

Sphincteroplasty offers good short-medium term outcomes in continence and quality of life for obstetric fecal incontinence treatment. Functional clinical results deteriorate over time but did not impact on patients’ quality of life.

Patient-Reported Outcome Measures in Colon and Rectal Surgery: A Systematic Review and Quality Assessment

BACKGROUND

There is growing interest in using patient-reported outcome measures to support value-based care in colorectal surgery. To draw valid conclusions regarding patient-reported outcomes data, measures with robust measurement properties are required.

OBJECTIVE

The purpose of this study was to assess the use and quality of patient-reported outcome measures in colorectal surgery.

DATA SOURCES

Three major databases were searched for studies using patient-reported outcome measures in the context of colorectal surgery.

STUDY SELECTION

Articles that used patient-reported outcome measures as outcome for colorectal surgical intervention in a comparative effectiveness analysis were included. Exclusion criteria included articles older than 11 years, non-English language, age <18 years, fewer than 40 patients, case reports, review articles, and studies without comparison.

MAIN OUTCOME MEASURES

This was a quality assessment using a previously reported checklist of psychometric properties.

RESULTS

From 2007 to 2018, 368 studies were deemed to meet inclusion criteria. These studies used 165 distinct patient-reported outcome measures. Thirty were used 5 or more times and were selected for quality assessment. Overall, the measures were generally high quality, with 21 (70%) scoring ≥14 on an 18-point scale. Notable weaknesses included management of missing data (14%) and description of literacy level (0%).

LIMITATIONS

The study was limited by its use of original articles for quality assessment. Measures were selected for quality analysis based on frequency of use rather than other factors, such as impact of the article or number of patients in the study.

CONCLUSIONS

Patient-reported outcome measures are widely used in colorectal research. There was a wide range of measures available, and many were used only once. The most frequently used measures are generally high quality, but a majority lack details on how to deal with missing data and information on literacy levels. As the use of patient-reported outcome measures to assess colorectal surgical intervention increases, researchers and practitioners need to become more knowledgeable about the measures available and their quality.

Quality of life and 3D-EUS assessment for anal incontinence after childbirth

BACKGROUND

the incidence of obstetric sphincter tears has risen to 15-30% and the prevalence of anal incontinence (AI) symptoms after childbirth may be as high as 40%. The present study evaluates the correlation between obstetric injuries detected by endoanal ultrasound (3D-EUS) and AI symptoms, as well as their impact on the quality of life (QOL) of women after childbirth.

METHODS

a prospective observational study was performed of pregnant women evaluated before (baseline) and three months after childbirth to ensure the integrity of the anal sphincters and to evaluate possible injuries. The Fecal Incontinence Quality of Life (FIQL) questionnaire and the Cleveland Clinic Score of Incontinence (Wexner) were completed before and after childbirth. The questionnaire results were correlated with an assessment of sphincter defects performed by 3D-EUS.

RESULTS

a total of 56 females were included in the study. Overall, 48% developed symptoms of AI after childbirth, with a significant decrease in their FIQL compared to the initial evaluation, 3.9 (0.05) vs 3.4 (0.8), respectively (p = 0.000). In addition, 42% of the cohort presented with some kind of obstetric sphincter defect on the 3D-EUS. Instrumental assisted delivery and the sphincter defects were the only two significant factors identified via multivariate analysis that were associated with a decrease in QOL (0.4, 95% CI, 0.07-0.8).

CONCLUSIONS

AI after childbirth was associated with a huge impact on QOL, especially in patients with sphincter injuries. A complete clinical evaluation, including 3D-EUS, is recommended to prevent, manage or treat AI in primiparous females.

Effect of oestrogen therapy on faecal incontinence in postmenopausal women: a systematic review

INTRODUCTION AND HYPOTHESIS

Faecal incontinence (FI) is prevalent in postmenopausal women. Oestrogen receptors have been identified in the anal sphincter and have been implicated in the pathogenesis and potential treatment. We sought to evaluate the literature regarding the impact of local and systemic oestrogen therapy on FI in postmenopausal women.

METHODS

A systematic review of all studies in postmenopausal women was performed to establish how oestrogen therapy affects FI. Eight articles were deemed eligible for inclusion following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Their quality was assessed using the Cochrane risk-of-bias tool (RoB-2) and Newcastle-Ottawa quality assessment scale.

RESULTS

One randomised controlled trial (RCT), two cohort studies, one observational and four cross-sectional studies were identified. The RCT showed an improvement in FI with anal oestrogen (p = 0.002), but this improvement was also observed in the placebo arm (p = 0.013) and no difference was seen between these groups. A prospective observational study demonstrated significant improvement with an oestrogen patch (p = 0.004), but had no control group. Conversely, a large prospective cohort study demonstrated an increased hazard ratio of FI with current (1.32; 95% CI, 1.20-1.45) and previous oestrogen use (1.26; 95% CI, 1.18-1.34) compared with non-users.

CONCLUSION

All studies had a high risk of bias and had conflicting views on the effects of oestrogen on FI in postmenopausal women. This review has identified the need for further research in this area by highlighting the paucity of good research for evidence-based practice. We believe that a further RCT of local oestrogen is mandated to draw a valid conclusion.

Use of Malone antegrade continence enemas in neurologic bowel dysfunction

INTRODUCTION

Patients with neurogenic bowel dysfunction (NBD) suffer severe constipation and/or fecal incontinence that are very difficult to treat. Most medication-based and interventional treatments have been unsuccessful. The goal of this study was to assess the medium-term effectiveness of the Malone procedure in all patients with NBD, as an alternative to colostomy.

PATIENTS AND METHODS

In this retrospective single-center study, 23 patients who underwent Malone's surgical treatment were analyzed. The main criteria were the usage of antegrade colonic enemas (ACE) after Malone's procedure at the most recent follow-up and comparison of quality of life scores before and after surgery.

RESULTS

The post-procedure mortality was zero, but an overall morbidity of 60% was observed, including minor complications (Clavien 1, 2) in 56%. The median follow-up was 33 months. At the most recent follow-up, the utilization rate of the neo-appendicostomy for ACE was 69.6%; 76.9% of the patients using ACE reported improvement in quality of life scores. Secondary colostomy was performed in 21.7% for functional failure of the Malone procedure.

CONCLUSION

The Malone procedure is a reliable technique that can be used in the therapeutic strategy for managing NBD patients with incontinence/constipation refractory to usual treatments. It should be considered as a therapeutic step to take before resorting to colostomy.

Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life

BACKGROUND

An early secondary repair of the anal sphincter may be necessary if primary repair of obstetric anal sphincter injury (OASIS) is complicated by wound rupture or severe infection. The objective of this study was to assess the long-term functional outcomes, morbidity, and impact on quality of life (QoL) following an early secondary repair of OASIS.

METHODS

This retrospective cohort study was conducted at Aarhus University Hospital, Denmark. All women having a secondary repair of the anal sphincter within 21 days of delivery from February 1991 to February 2017 were included (n = 51). Complications were assessed by reviewing medical records. The patient-reported outcomes were assessed in 2018 by questionnaires. Primary outcome was Wexner score and St. Mark's score. Impact on QoL was assessed using the Fecal Incontinence Quality of Life Scale (FIQLS).

RESULTS

After a median follow-up time of 6.7 years (IQR 3.3-16.6), 34 women completed the questionnaire. The mean (SD) Wexner score was 5.2 ± 4.7 and the mean (SD) St. Mark's score was 6.8 ± 5.7. Women with a Wexner score ≥ 9 had a significantly lower QoL score in all domains of the FIQLS compared to women with a Wexner score < 9 (p < 0.001). Postoperative complications were experienced by 37%. Ten women developed a fistula of which nine required surgical treatment.

CONCLUSIONS

An early secondary repair of the anal sphincter can be performed within 21 days of delivery with functional long-term outcomes comparable to those following a late sphincter repair. However, there is an imminent risk of complications, mainly fistulas, which should be taken into consideration when choosing the ideal timing of the repair.

Fecal incontinence after total mesorectal excision for rectal cancer-impact of potential risk factors and pelvic intraoperative neuromonitoring

BACKGROUND

Fecal incontinence frequently occurs after total mesorectal excision for rectal cancer. This prospective study analyzed predictive factors and the impact of pelvic intraoperative neuromonitoring at different follow-up intervals.

METHODS

Fifty-two patients were included undergoing total mesorectal excision for rectal cancer, and 29 under control of pelvic intraoperative neuromonitoring. Fecal incontinence was assessed using the Wexner Score at 3 and 6 months after stoma closure (follow-ups 1 and 2) as well as 1 and 2 years after surgery (follow-ups 3 and 4). Risk factors were identified by means of logistic regression.

RESULTS

New onset of fecal incontinence was significantly lower in the neuromonitoring group at each follow-up (follow-up 1: 2 of 29 patients (7%) vs. 8 of 23 (35%), (p = 0.014); follow-up 2: 3 of 29 (10%) vs. 9 of 23 (39%), (p = 0.017); follow-up 3: 5 of 29 (17%) vs. 11 of 23 (48%), p = 0.019; follow-up 4: 6 of 28 (21%) vs. 11 of 22 (50%), p = 0.035). Non-performance of neuromonitoring was found to be an independent predictor for fecal incontinence throughout the survey. Neoadjuvant chemoradiotherapy was an independent predictor in the further course 1 and 2 years after surgery.

CONCLUSIONS

Performance of pelvic intraoperative neuromonitoring is associated with significantly lower rates of fecal incontinence. Neoadjuvant chemoradiotherapy was found to have negative late effects. This became evident 1 year after surgery.