Is the Quality of Life Better in Patients with Colostomy than Patients with Fecal Incontience?

Faecal incontinence-a comprehensive review

Introduction

Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date.

Methods

A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities.

Result and discussion

This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).

Descriptive Analysis of Surgical Outcomes and Stoma Formation for Treating Sacral and Anal Pressure Injuries in Spinal Cord Injury: A Retrospective Study of Selected Cases

Introduction

Pressure injuries (PIs) arise from sustained pressure on tissue, leading to reduced blood flow to the affected area. In patients with spinal cord injuries (SCIs), these PIs can significantly diminish their independence and overall quality of life. This research sought to assess the frequency of surgical complications in treatment regimens for large sacral PIs involving the anus. Specifically, the study focused on the incorporation of stoma formation in patients with SCIs.

Methods

A retrospective review identified 25 SCI patients who had extensive sacral PIs. These patients underwent intestinal stoma formation as a preparatory step before plastic reconstructive surgery to address the wounds between 2015 and 2020.

Results

Successful wound closure was achieved in all instances. Notably, each patient had experienced a minimum of three unsuccessful reconstructive surgeries elsewhere before this intervention. The observed rate of surgical complications aligned with findings from previous analogous studies.

Conclusion

While often viewed as a treatment of last resort, an intestinal stoma might serve as a valuable strategy, particularly for SCI patients with extensive PIs near the anal region, to promote the healing of such injuries. Tailored decision-making is essential to ensure the best possible patient outcomes.

Depression after stoma surgery: a systematic review and meta-analysis

BACKGROUND

Depression is the leading cause of global disability and can develop following the change in body image and functional capacity associated with stoma surgery. However, reported prevalence across the literature is unknown. Accordingly, we performed a systematic review and meta-analysis aiming to characterise depressive symptoms after stoma surgery and potential predictive factors.

METHODS

PubMed/MEDLINE, Embase, CINAHL and Cochrane Library were searched from respective database inception to 6 March 2023 for studies reporting rates of depressive symptoms after stoma surgery. Risk of bias was assessed using the Downs and Black checklist for non-randomised studies of interventions (NRSIs), and Cochrane RoB2 tool for randomised controlled trials (RCTs). Meta-analysis incorporated meta-regressions and a random-effects model.

REGISTRATION

PROSPERO, CRD42021262345.

RESULTS

From 5,742 records, 68 studies were included. According to Downs and Black checklist, the 65 NRSIs were of low to moderate methodological quality. According to Cochrane RoB2, the three RCTs ranged from low risk of bias to some concerns of bias. Thirty-eight studies reported rates of depressive symptoms after stoma surgery as a proportion of the respective study populations, and from these, the median rate across all timepoints was 42.9% 42.9% (IQR: 24.2-58.9%). Pooled scores for respective validated depression measures (Hospital Anxiety and Depression Score (HADS), Beck Depression Inventory (BDI), and Patient Health Questionnaire-9 (PHQ-9)) across studies reporting those scores were below clinical thresholds for major depressive disorder according to severity criteria of the respective scores. In the three studies that used the HADS to compare non-stoma versus stoma surgical populations, depressive symptoms were 58% less frequent in non-stoma populations. Region (Asia-Pacific; Europe; Middle East/Africa; North America) was significantly associated with postoperative depressive symptoms (p = 0.002), whereas age (p = 0.592) and sex (p = 0.069) were not.

CONCLUSIONS

Depressive symptoms occur in almost half of stoma surgery patients, which is higher than the general population, and many inflammatory bowel disease and colorectal cancer populations outlined in the literature. However, validated measures suggest this is mostly at a level of clinical severity below major depressive disorder. Stoma patient outcomes and postoperative psychosocial adjustment may be enhanced by increased psychological evaluation and care in the perioperative period.

The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer

PURPOSE

The present study assessed postoperative bowel dysfunction in Japanese patients with rectal cancer, including patients who underwent preoperative radiotherapy (RT).

METHODS

A total of 277 rectal cancer patients who underwent primary resection were included in the analyses. A questionnaire survey was administered using the low anterior resection syndrome (LARS) score and Wexner score. Scores were determined one year after rectal surgery or diverting ileostomy closure. The LARS score was categorized as minor LARS (21-29) and major LARS (30-42).

RESULTS

The proportions of patients with minor and major LARS were significantly larger and Wexner scores significantly higher in patients with distal tumors and a lower anastomosis level than in those with proximal tumors and a higher anastomosis level. Among the patients with lower rectal cancer, the proportions with minor and major LARS were similar between those with and without preoperative RT. The Wexner scores in patients with preoperative RT were significantly higher than in patients without RT. A distal tumor location and lower anastomosis level were independent risk factors of major LARS in multivariate analyses.

CONCLUSION

A distal tumor location, low anastomosis level, and preoperative RT might be associated with postoperative bowel dysfunction in rectal cancer patients.

Research on a Defecation Pre-Warning Algorithm for the Disabled Elderly Based on a Semi-Supervised Generative Adversarial Network

The elderly population in China is continuously increasing, and the disabled account for a large proportion of the elderly population. An effective solution is urgently needed for incontinence among disabled elderly people. Compared with disposable adult diapers, artificial sphincter implantation and medication for incontinence, the defecation pre-warning method is more flexible and convenient. However, due to the complex human physiology and individual differences, its development is limited. Based on the aging trend of the population and clinical needs, this paper proposes a bowel sound acquisition system and a defecation pre-warning method and system based on a semi-supervised generative adversarial network. A network model was established to predict defecation using bowel sounds. The experimental results show that the proposed method can effectively classify bowel sounds with or without defecation tendency, and the accuracy reached 94.4%.

Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration

INTRODUCTION

The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

METHODS

These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus.

RESULTS

These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients.

CONCLUSION

These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies

Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.

[Anal incontinence]

Anal incontinence describes the uncontrolled transanal passage of gaseous, solid or liquid intestinal contents. It can be a considerable psychosocial burden and impairment of the quality of life for those affected. The cause can be primary damage to the continence organ or incontinence can be a secondary symptom of other diseases. The detailed patient history and clinical examination document the severity of incontinence, impairment of quality of life and pathomorphological changes. The treatment is primarily conservative. A combination of conservative therapeutic approaches can often achieve satisfactory symptom relief. If conservative treatment remains insufficient, surgical measures can be considered. Sphincteroplasty and sacral neuromodulation are the preferred surgical interventions.

Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management

Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Surgical Treatment Alternatives to Sacral Neuromodulation for Fecal Incontinence: Injectables, Sphincter Repair, and Colostomy

Fecal incontinence is a prevalent health problem that affects over 20% of healthy women. Many surgical treatment options exist for fecal incontinence after attempts at non-operative management. In this article, the authors discuss surgical treatment options for fecal incontinence other than sacral neuromodulation.

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Colostomy and quality of life after spinal cord injury: systematic review

BACKGROUND

Spinal cord injury (SCI) has a significant impact on the quality of life (QoL) of affected patients. The aim of this review was to determine whether colostomy formation improves QoL in patients with SCI.

METHODS

The Cochrane Register, MEDLINE, Embase and CINAHL were searched using medical subject headings. The search was extended to the reference lists of identified studies, ClinicalTrials.gov and the WHO International Clinical Trials Registry. All clinical trials that included spinal injury and QoL, time spent on bowel care, and patient satisfaction with stoma were assessed.

RESULTS

A total of 15 studies were found (including 488 patients with a stoma), of which 13 were retrospective cross-sectional studies and two were case-control studies, one of which was prospective research. Nine of 11 studies focusing on QoL reported that patients' QoL was improved by the stoma, whereas the remaining two studies found no difference. Time spent on bowel care was significantly reduced in all 13 studies that considered this outcome, with patients reducing the average time spent on bowel care from more than 1 h to less than 15 min per day. All 12 studies assessing patient satisfaction with their stoma reported high patient satisfaction.

CONCLUSION

Stoma formation improves QoL, reduces time spent on bowel care, and increases independence. Stoma is an option that could be discussed and offered to patients with spinal cord injury.

The Artificial Bowel Sphincter in the Treatment of Fecal Incontinence, Long-term Complications

BACKGROUND

Fecal incontinence is a common and debilitating condition, of which the prevalence increases with age. Several medical and minimally invasive treatment modalities are available. However, for patients with greater sphincter defects, these treatments are often not sufficient. For these patients, the artificial bowel sphincter could be an alternative to colostomy. The artificial bowel sphincter has proven to be effective in the short term. Less is known whether the benefits sustain over time.

OBJECTIVE

The aim of this study was to assess the long-term outcome of the artificial bowel sphincter in patients with refractory fecal incontinence.

DESIGN

A retrospective record review was conducted in conjunction with questionnaires.

SETTING

This study was conducted in a tertiary hospital setting.

MAIN OUTCOME MEASURES

The primary end point was any complication. The secondary end point was fecal loss.

PATIENTS

The patients included were adults experiencing severe fecal incontinence treated with artificial bowel sphincter, operated on between 1997 and 2014.

RESULTS

Sixty-three patients were included in this study. After a median follow-up of 57 months (range, 1-198), the device had been explanted in 31 patients (49.2%; 95% CI, 36.5-62.0). In total, 101 reoperations were conducted, ranging from 1 to 6 reoperations per patient. The main reasons for revision were device failure and infection. At 5 years follow-up, 80% of the cohort had experienced a complication requiring surgery. Twenty-two (35%) patients had restored continence.

LIMITATIONS

This study was limited by its retrospective design and subjective secondary outcome.

CONCLUSION

Patients with severe end-stage fecal incontinence can benefit from artificial bowel sphincter, but this requires a large number of reoperations, and at least 20% of patients will eventually have a colostomy. Therefore, careful patient selection and the involvement of patients in decision making regarding the potential benefits and limitations of this technique are paramount. See Video Abstract at http://links.lww.com/DCR/B242. EL ESFÍNTER INTESTINAL ARTIFICIAL EN EL TRATAMIENTO DE LA INCONTINENCIA FECAL, COMPLICACIONES A LARGO PLAZO: La incontinencia fecal es una condición común y debilitante, cuya prevalencia aumenta con la edad. Se encuentran disponibles varias modalidades de tratamiento médico y mínimamente invasivo. Sin embargo, para pacientes con defectos del esfínter mayores, estos tratamientos a menudo no son suficientes. Para estos pacientes, el esfínter intestinal artificial (ABS) podría ser una alternativa a la colostomía. El esfínter intestinal artificial demostró ser efectivo a corto plazo. Se sabe menos si los beneficios se mantienen a lo largo del tiempo.El objetivo de este estudio fue evaluar el resultado a largo plazo del esfínter intestinal artificial en pacientes con incontinencia fecal refractaria.Se realizó una revisión retrospectiva de los registros junto con los cuestionarios.Realizado en un entorno de hospital de tercel nivel.El punto final primario fue cualquier complicación, el punto final secundario fue la pérdida fecal.Los pacientes incluidos fueron adultos que padecían incontinencia fecal severa tratados con esfínter intestinal artificial, operados entre 1997 y 2014.Sesenta y tres pacientes fueron incluidos en este estudio. Después de una mediana de seguimiento de 57 meses (rango 1-198), el dispositivo había sido explantado en 31 pacientes (49.2%; 95CI 36.5-62.0). En total, se realizaron 101 reoperaciones, que oscilaron de una a seis reoperaciones por paciente. Las principales razones para la revisión fueron la falla del dispositivo y la infección. A los cinco años de seguimiento, el 80% de la cohorte había experimentado una complicación que requería cirugía. 22 pacientes habían recuperado la continencia (35%).Diseño retrospectivo y resultado secundario subjetivo.Los pacientes con incontinencia fecal grave en etapa terminal pueden beneficiarse del esfínter intestinal artificial, pero esto requiere una gran cantidad de reoperaciones y al menos el 20% de los pacientes eventualmente tendrán una colostomía. Por lo tanto, la selección cuidadosa del paciente y la participación de los pacientes en la toma de decisiones con respecto a los posibles beneficios y limitaciones de esta técnica es primordial. Consulte Video Resumen en http://links.lww.com/DCR/B242.

[Surgical reconstruction of traumatic sphincter muscle defects]

BACKGROUND

Traumatic anal sphincter muscle defects often occur after childbirth and surgery and can lead to fecal incontinence that requires further treatment.

OBJECTIVE

The aim of this article is to illustrate the etiology of traumatic sphincter muscle defects, the treatment options of subsequent fecal incontinence and their evaluation on the basis of current studies.

MATERIAL AND METHODS

Selected studies are presented.

RESULTS

Fecal incontinence presenting with a traumatic sphincter muscle defect is often due to multiple factors especially in the aged and makes the use of extended diagnostic tools necessary; however, the subjective complaints do not always correlate with morphological or functional diagnostic findings. Besides reconstructive procedures, such as sphincteroplasty and graciloplasty, sphincter augmentation techniques and sacral nerve stimulation can also be applied in traumatic sphincter muscle defects that are often associated with a loss of efficacy in the long term or a high rate of adverse events.

CONCLUSION

The fecal incontinence associated with traumatic sphincter insufficiency represents a diagnostic and therapeutic challenge due to the multifactorial origin. It is not uncommon that patients have to undergo several surgical and conservative interventions.

Resting vector volume measured before ileostomy reversal may be a predictor of major fecal incontinence in patients with mid or low rectal cancer: a longitudinal cohort study using a prospective clinical database

PURPOSE

Despite a high incidence of fecal incontinence following sphincter-preservation surgery (SPS), there are no definitive factors measured before ileostomy reversal that predict fecal incontinence. We investigated whether vector volume anorectal manometry before ileostomy reversal predicts major fecal incontinence following SPS in patients with mid or low rectal cancer.

METHODS

This longitudinal prospective cohort study comprised 173 patients who underwent vector volume anorectal manometry before ileostomy reversal. The Fecal Incontinence Severity Index was measured 1 year after the primary SPS and classified as major incontinence (FISI score ≥ 25) or continent/minor incontinence (FISI score < 25). Multivariable logistic regression analysis was used to identify predictors of major incontinence.

RESULTS

Ninety-two patients (53.1%) had major incontinence. Although tumor stage, location, and neoadjuvant chemoradiotherapy were comparable, the major incontinence group had lower resting pressure (28.4 vs. 34.3 mmHg, P = 0.027), greater asymmetry at rest (39.1% vs. 34.1%, P = 0.002) and squeezing (34.2% vs. 31.4%, P = 0.046), shorter sphincter length (3.3 vs. 3.7 cm, P = 0.034), and lower resting vector volume (143,601 vs. 278,922 mmHg² mm, P < 0.001) compared with the continent/minor incontinence group. Resting vector volume was the only independent predictor of major incontinence (odds ratio = 0.675 per 100,000 mmHg² mm, 95% confidence interval, 0.532-0.823; P = 0.006).

CONCLUSIONS

This study revealed that resting vector volume before ileostomy reversal may predict major fecal incontinence. We suggest that the physiology of the anorectum should be discussed with patients before ileostomy reversal in patients at high risk of fecal incontinence.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Patient Decision-Making About Emergency and Planned Stoma Surgery for IBD: A Qualitative Exploration of Patient and Clinician Perspectives

BACKGROUND

Many inflammatory bowel disease (IBD) patients worry about stoma-forming surgery (SFS), sometimes enduring poor bowel-related quality of life to avoid it. Anticipation of SFS and whether expectations match experience is underreported. This qualitative study explored influences on patients' SFS decision-making and compared preoperative concerns with postoperative outcomes.

METHODS

We purposively recruited participants with IBD from UK hospital outpatient and community sources, and IBD clinicians from public hospitals. Four focus groups, 29 semistructured patient participant interviews, and 18 clinician interviews were audio recorded, transcribed, and analysed thematically. Participants had a current temporary, recently-reversed, or permanent stoma, or were stoma naive.

RESULTS

Four themes emerged: Preoperative concerns and expectations, Patient decision-making, Surgery and recovery, and Long-term outcomes. Participants and clinicians agreed about most preoperative concerns, that outcomes were often better than expected, and support from others with a stoma is beneficial. Patient decision-making involves multiple factors, including disease status. Some clinicians avoid discussing SFS, and the phrase 'last resort' can bias patient perceptions; others recommend early discussion, increasing dialogue when medical management becomes ineffective. The postoperative period is particularly challenging for patients. Stoma acceptance is influenced by personal perceptions and pre- and postoperative clinical and social support.

CONCLUSION

Patients need balanced information on all treatment options, including surgery, from an early stage. Early multidisciplinary team dialogue about SFS, and contact with others living well with a stoma, could enable informed decision-making. Life with a stoma is often better than anticipated, improving quality of life and control. Ongoing specialist nursing support aids recovery and adjustment.

Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders

The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Patient-centered outcomes to decide treatment strategy for patients with low rectal cancer

BACKGROUND

For patients with low-lying rectal cancer, the feasibility of anus-preserving surgery in combination with neoadjuvant chemoradiotherapy (NACRT) has been not well established from the perspective of patient-centered outcomes.

METHODS

We investigated 278 patients with low-lying rectal adenocarcinoma from 2005 to 2012. We compared their symptoms and QOL scores of patients who underwent anus-preserving surgery with (n = 88) and without (n = 143) NACRT according to the Wexner scale, EORTC QLQ C-30, CR29, and the modified fecal incontinence quality life scale (mFIQL). Furthermore, to assess the rationale for intersphincteric resection (ISR) with NACRT, we also compared QOL of patients who underwent ISR with NACRT (n = 31) and abdominoperineal resection (APR, n = 47).

RESULTS

The adjusted mean differences of the Wexner score estimates of the patients who underwent ISR and very low anterior resection (VLAR) with or without NACRT were 5.29 (P = 0.004) and 2.67 (P = 0.009), respectively. No significant difference was observed in the QOL scores of two treatment groups. Furthermore, there were no significant differences in the QOL or function scores of patients who underwent ISR with NACRT and APR.

CONCLUSION

The incontinence was significantly worse in patients who receive NACRT. However, there were no significant differences in their QOL or function scores. J. Surg. Oncol. 2016;114:630-636. © 2016 Wiley Periodicals, Inc.

Fecal incontinence: A review of current treatment options

Fecal incontinence affects patients of all sexes, races, and ethnicities; however, those affected often are afraid or too embarrassed to ask for help. Attention to risk factors and directed physical examinations can help healthcare providers diagnose and formulate treatment plans. Numerous diagnostic tests are available. Diligent follow-up is needed to direct patients to second-line therapies such as sacral nerve stimulation or surgical procedures.

Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review

Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.

Faecal incontinence: Current knowledges and perspectives

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

Management of patients with faecal incontinence

Faecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8-8.3% of the adult population. Individuals suffering from faecal incontinence often live a restricted life with reduced quality of life. The present paper is a clinically oriented review of the pathophysiology, evaluation and treatment of faecal incontinence. First-line therapy should be conservative and usually include dietary adjustments, fibre supplement, constipating agents or mini enemas. Biofeedback therapy to improve external anal sphincter function can be offered but the evidence for long-term effect is poor. There is good evidence that colonic irrigation can reduce symptoms and improve quality of life, especially in patients with neurogenic faecal incontinence. Surgical interventions should only be considered if conservative measures fail. Sacral nerve stimulation is a minimally invasive procedure with high rate of success. Advanced surgical procedures should be restricted to highly selected patients and only performed at specialist centres. A stoma should be considered if other treatment modalities fail.

Impact of fecal incontinence and its treatment on quality of life in women

Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.

The city of hope-quality of life-ostomy questionnaire: persian translation and validation

Background:

Since there is no disease-specific instrument for measuring quality-of-life (QOL) in Ostomy patients in Persian language.

Aim:

This study was designed to translate and evaluate the validity and reliability of City of Hope-quality of life-Ostomy questionnaire (COH-QOL-Ostomy questionnaire).

Subjects and Methods:

This study was designed as cross-sectional study. Reliability of the subscales and the summary scores were demonstrated by intra-class correlation coefficients. Pearson's correlations of an item with its own scale and other scales were calculated to evaluated convergent and discriminant validity. Clinical validity was also evaluated by known-group comparisons.

Results:

Cronbach's alpha coefficient for all subscales was about 0.70 or higher. Results of interscale correlation were satisfactory and each subscale only measured a single and specified trait. All subscales met the standards of convergent and discriminant validity. Known group comparison analysis showed significant differences in social and spiritual well-being.

Conclusion:

The findings confirmed the reliability and validity of Persian version of COH-QOL-Ostomy questionnaire. The instrument was also well received by the Iranian patients. It can be considered as a valuable instrument to assess the different aspects of health related quality-of-life in Ostomy patients and used in clinical research in the future.

Evaluation of the frequency and pattern of local recurrence following intersphincteric resection for ultra-low rectal cancer

INTRODUCTION

Abdomino-perineal resection has been the standard treatment for rectal tumors located ≤5cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome.

AIM

Is to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR).

PATIENTS & METHODS

Between the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2-5cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP).

RESULTS

Among the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0-5cm from the anal verge (median 2.3cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5 years (range 1-4.6 years). The 3 year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%.

CONCLUSION

Intersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.

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

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

Quality of life outcomes in patients living with stoma

Background:

Despite efforts to maintain the intestinal tissue and treat gastrointestinal disease, a large number of patients undergo ostomy surgery each year. Using stoma reduces the patient's quality of life (QOL) greatly. Although there are approximately 3000 patients in Iran; there is little information about the impact of stoma on their QOL.

Aims:

The study aims to evaluate QOL of stoma patients using a special measurement tool.

Settings and Design:

This survey was a cross-sectional study that was conducted on 102 random samples of stoma patients.

Materials and Methods:

The City of Hope Quality of Life-Ostomy Questionnaire was used for collecting demographic and clinical information and evaluating QOL.

Statistical Analysis Used:

Univariate and multiple regression analyses were performed to identify predictors of QOL.

Results:

The mean score for the overall QOL for stoma patients was 7.48 ± 0.9. 70% of patients were dissatisfied with sexual activities. More than half of them reported feelings of depression following stoma surgery. Univariate analysis indicated that factors such as the type of ostomy (temporary/permanent), the underlying disease that had led to the stoma, depression, problem with location of ostomy, and change in clothing style had significant effects on overall QOL and its subscales (P < 0.05). The results of the regression analyses showed that only depression and problem with the location of ostomy were statistically significant in predicting patients’ QOL and its subscales (P < 0.05).

Conclusions:

The findings demonstrated that living with stoma influences the overall aspect of QOL. Education for the patients and their families is important for improving the stoma patients’ QOL. Sexual and psychological consultation may also improve patients’ QOL.

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer

Background

Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR.

Methods

The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score.

Results

The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture.

Conclusions

The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

Modified dynamic gracilis neosphincter for fecal incontinence: an analysis of functional outcome at a single institution

BACKGROUND

We undertook a prospective longitudinal study of patients with end-stage fecal incontinence who were undergoing transposition of the gracilis muscle as a neo-anal sphincter with external low-frequency electrical stimulation of the nerve to the gracilis combined with biofeedback.

METHODS

A total of 31 patients (21 male, 10 female: median age: 22 years; range: 4-77 years) underwent this procedure for treatment of traumatic disruption (11 patients, 35%), congenital atresia (11 patients, 35%), iatrogenic injury (6-20%), and perineal sepsis (3 patients, 10%). The gracilis muscle was transposed at operation in an alpha or gamma configuration. Low-frequency (7 Hz) transcutaneous electrical stimulation commenced 2 weeks after operation and was continued for up to 12 weeks. Biofeedback therapy, which consisted of supervised neosphincter squeeze exercises, commenced simultaneously and continued for up to 28 weeks. Outcome was assessed by clinical examination, anal manometry, the Cleveland Clinic Florida continence score (CCFS), and the Rockwood quality of life scale (FIQL). Successful outcome was defined by improvement in clinical outcome, patient satisfaction, a positive result on anal manometry, and/or CCFS < 9, or FIQL > or = 4.

RESULTS

At median follow-up of 67 months, overall improvement was seen in 22 (71%). Maximum resting pressure (MRP) and maximum squeeze pressure (MSP) improved significantly after operation [MRP pre versus post, mean (SD), cm water-13.8 (9.6) versus 20.9 (11.3); P = 0.01; and MSP 36.6 (22.4) versus 95.4 (71.2), P = 0.001]. In a subset of 18 patients who showed improvement after operation, the CCFS score (mean, SD) improved from 19.2 (3.4) to 5.2 (5.6); P = 0.0001. FIQL (mean, SD) showed significant improvement in all four domains in 14 patients who reported improvement since the year 2000.

CONCLUSIONS

A modified dynamic gracilis neoanal sphincter for end-stage fecal incontinence helps restore and sustain continence with improvement in quality of life in the majority of patients. The procedure was most effective as augmentation in those who had suffered a traumatic injury, when compared with patients with congenital atresia and sepsis that had resulted in loss of the native anal sphincter.

Late stomal complications

Ostomy creation is a common surgical procedure performed by a variety of surgical specialties. Complications associated with stomas are frequent and run the gamut from technical, mechanical, physiologic, and psychologic. The impact of these complications ranges from simple inconvenience to life threatening. The majority of these complications may not occur for years following creation of the stoma. In this article, the author reviews many of the late complications associated with stomas and options regarding their management.

Impact of fecal incontinence on quality of life

AIM: To explore the impact of fecal incontinence (FI) on quality of life (QOL) of patients attending urogynecology and colorectal clinics (CCs).

METHODS: Cross-sectional study of 154 patients (27 male) with FI, who attended the clinics at a regional hospital in North Queensland, Australia in 2003 and 2004, and completed the Fecal Incontinence Quality of Life Scale (FIQL: 1 = very affected; 4 = not affected).

RESULTS: More than 22% of patients had their QOL affected severely by FI. Patients reported that they had not previously been asked about FI by a medical practitioner nor did they voluntarily disclose its presence. The median FIQL scores for all participants were: lifestyle = 3.24; coping = 2.23; depression = 2.42; and embarrassment = 2.33. Increasing frequency of soiling had a negative effect on all four FIQL scales (P < 0.001) as did the quantity of soiling (P < 0.01). Female CC patients had poorer FIQL scores than urogynecology clinic patients for lifestyle (P = 0.015), coping (P = 0.004) and embarrassment (P = 0.009), but not depression (P = 0.062), despite having experienced FI for a shorter period.

CONCLUSION: Failure to seek treatment for FI degrades the quality of patients’ lives over time. FI assessment tools should incorporate the quantity of fecal loss.

Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients

OBJECTIVE

The Fecal Incontinence Severity Index (FISI) is widely used in the assessment of patients with faecal incontinence, but the relationship between FISI and the measurements of quality of life, such as the Fecal Incontinence Quality of Life Scale (FIQL) and the Medical Outcomes Survey (SF-36) has not been evaluated previously. The aim of the present study was to evaluate the relationship between disease severity and quality of life in a large cohort of patients.

METHOD

Five hundred and two consecutive patients (84.4% female, mean age 56 years) were evaluated for faecal incontinence between May 2004 and October 2005. Patients completed FISI, FIQL and SF-36 questionnaires. Pearson's coefficients were determined for the relationships between FISI and subscales of FIQL and SF-36. Quality of life scores were compared between groups of patients with different levels of incontinence severity (mild, moderate, severe) using Student's t-test.

RESULTS

Sixty-eight per cent of patients were incontinent of solid stool, 62% of liquid stool, and 90% of gas or mucus. The average FISI score was 36 (0-61). Moderate correlations were found between FISI and all subscales in FIQL (negative 0.29 to 0.41; P < 0.0001). Weak correlations were found between FISI and the social functioning (-0.21) and mental health (-0.17) scales in SF-36 (P < 0.05). Scores on the FIQL differed significantly between mild, moderate and severe incontinence.

CONCLUSION

FISI was only moderately correlated with a disease-specific quality of life measurement (FIQL). Even though this supports the common assumption that the quality of life in the patients with faecal incontinence worsens with an increase in disease severity, it also stresses the need of measuring both variables to determine the true impact of any treatment.

Anorectal motor disorders

Anorectal motor disorders such as faecal incontinence, chronic anorectal pain and solitary rectal ulcer syndrome are common in the community. They cause psychological distress, affect quality of life, and pose a significant economic burden. In recent years, many strides have been made in the diagnostic criteria and in the mechanistic understanding of anorectal disorders. The use of innovative manometric, neurophysiological and radiological techniques have shed new light on the underlying pathophysiology. Also, it has been recognised that psychological dysfunction play an important role. However, there is a lack of consensus regarding what is abnormal, regarding the overlap between phenotypes and regarding optimal diagnostic approaches or tests. There has been little advance in drug therapy for these conditions. Although several treatments have been tried and appear promising, controlled trials are either lacking or have provided insignificant evidence. There is a need for improved medical, behavioural and surgical treatments for these conditions.