Dynamic graciloplasty in patients born with an anorectal malformation

Non-dynamic graciloplasty is an effective treatment for patients with passive fecal incontinence

BACKGROUND

Fecal incontinence is a multifactorial problem and its etiology is complex. Various therapies are available and different success rates have been described. The aim of this study was to assess the effectiveness and safety of non-dynamic graciloplasty in patients with passive fecal incontinence.

METHODS

We retrospectively studied charts of patients with fecal incontinence treated with graciloplasty at our institution from November 2015 until June 2018. Patients were included according to the following criteria: (1) presence of predominantly passive fecal incontinence and (2) presence of a lax perineal body. Primary outcome was the effectiveness, defined as a significant reduction or absence of the complaints of passive fecal incontinence at 3, 6 and 12 months after surgery. Second, we studied the safety of the procedure evaluating the complications within 30 days after surgery.

RESULTS

Thirty-one patients met the inclusion criteria. Twenty-six of them, in addition to passive incontinence as the main symptom, had some degree of fecal urgency. The median age at the first visit to the outpatient clinic was 64.0 years (IQR 52-68). Most patients were female (n = 29, 94%). At 3 months after graciloplasty, 71% (22 of 31) of patients were successfully treated for their passive fecal incontinence. At 6 months, the success rate of the graciloplasty increased to 77%. At 12 months among the patients who were still seen in the clinic, the success rate was 58% (18/31). Two patients cancelled follow-up visits after 3 months, because of failure to control symptoms in 1 case. After 6 months, 9 patients were given the choice to do telephone follow-up only. Of these 11 patients without in-person follow-up, 10 were contacted 1 year after surgery and in 7 of them, the graciloplasty was effective in controlling their passive fecal incontinence for an overall success rate of 80% (25/31). Of the 26 patients with mixed passive and urge incontinence, 6 (23%) still complained of urge incontinence at 1 year. Of these patients with persistent urge incontinence, 6 underwent sacral nerve stimulation which was successful in 4. Two serious complications occurred within 30 days. A rectal perforation requiring temporary colostomy and a recto-vaginal fistula which was successfully repaired.

CONCLUSION

Non-dynamic graciloplasty is an effective treatment for passive fecal incontinence. Differentiation based on subtypes of fecal incontinence might be important for a pattern-specific approach to treatment. More research is necessary to determine the right indications for more invasive treatments of fecal incontinence.

Injectable bulking treatment of persistent fecal incontinence in adult patients after anorectal malformations

BACKGROUND/PURPOSE

Injectable bulking therapy has emerged as a treatment for fecal incontinence (FI), however there are no studies including adult patients with anorectal malformations (ARM). This study aimed to evaluate non-animal stabilized hyaluronic acid with dextranomer (NASHA/Dx) for the treatment of adult ARM patients with persistent FI.

METHODS

Seven adults with ARM and incontinence to loose stool at least once weekly and without rectal or mucosal prolapse were treated with anal NASHA/Dx injection. They were evaluated preoperatively, at 6 and 18 months with a bowel function questionnaire and a 2-week bowel diary as well as FIQL and SF-36 quality of life questionnaires.

RESULTS

Before treatment, the mean number of incontinence episodes over 2 weeks was 20.7 (median 16, range 8-52). At 6 months, the corresponding figures were 5.3 (median 4, range 0-19, p = 0.018), and at 18 months the figures were 4.3 (median 2, range 1-20, p = 0.018). An improved physical function in SF-36 from 74.3 at baseline to 86.4 at 6 months was noted (p = 0.04). No serious adverse events occurred.

CONCLUSIONS

NASHA/Dx is a promising treatment option for selected adult patients with persistent FI after ARM. Longer follow up of larger patient series and studies on patients in adolescence is needed.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level IV.

Long-term outcome after free autogenous muscle transplantation for anal incontinence in children with anorectal malformations

PURPOSE

Patients with high anorectal anomalies are often incontinent after reconstruction, particularly with the older forms of surgical treatment, that is, anorectal pull-through or Stephen's operations. In 1974, a new treatment for anal incontinence in children was introduced at the Akademiska Hospital: free autogenous muscle transplantation (FAMT) to the perirectal area. All the patients receiving FAMT were totally incontinent before the procedure and had no rectal sensitivity. The aim of this study was to evaluate the long-term functional outcome of this procedure.

METHODS

Twenty-two patients (17 males) operated on with FAMT below the age of 15 years were identified through records. One of the patients had died, and 2 were not available for follow-up. The remaining 19 were sent a validated bowel function questionnaire, and 15 (78.9%) of 19 patients responded (12 males). These 15 patients were compared with 15 patients with the same sex, age, and a similar malformation from our patient database.

RESULTS

At follow-up, after an average of 30 years postoperatively, 2 of 15 patients with FAMT had a stoma compared with 3 of 15 in the control group. The Miller incontinence score had a mean of 6.2 (median, 6; range, 0-15) in the FAMT group and 3.7 (median, 4; range, 0-12) in the control group. All patients in both groups could sense stool, and 11 of 13 patients in the FAMT group could distinguish between feces and flatus.

CONCLUSIONS

The patients with FAMT had a slightly inferior anorectal function compared with the controls. Considering they were all totally incontinent before FAMT, we conclude that FAMT has an acceptable effect 30 years postoperatively. Therefore, we find that FAMT could be an alternative for anorectal malformation patients who are totally incontinent.

Fecal incontinence

Fecal incontinence is a devastating problem for those afflicted. It can lead to embarrassment and social isolation. Treating the problem begins with a thorough history and physical examination. Further testing (such as anal physiology testing or anal endosonography) depends on the examination and treatment plan. Conservative medical therapies (such as dietary manipulation, medication to slow the stool, and biofeedback) are usually tried first. Surgery includes sphincter repair, SECCA, artificial bowel sphincter, and stoma. New therapies continue to evolve with the intention of further improving quality of life for these afflicted patients.

Bowel management for the treatment of pediatric fecal incontinence

Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process.

Anal incontinence

Anal incontinence is a life restricting condition that is sometimes challenging to treat. There is an equal gender prevalence, however women are more likely to present particularly early in life, as a result of obstetric injury. This is still one of the leading causes of anal incontinence and sphincter tears can be missed at the time of delivery. As a result, there is a heightened awareness for sphincter injury based on risk assessment, digital rectal examination and an endo-anal ultrasound. Surgical repair is still invaluable in the presence of disruption and salvage procedures for severe refractory incontinence such as the dynamic gracilloplasty and the artificial bowel sphincter continue to be perfected. Mini invasive procedures such as rectal irrigation and sacral neuromodulaton have had a successful outcome and we have had to depend less on the more invasive treatments. Above all there is a growing need to protect not only the baby but also the pelvic floor and anal sphincter from traumatic deliveries, through early risk assessment and research.

Improvement of continence with reoperation in selected patients after surgery for anorectal malformation

PURPOSE

Fecal incontinence is a serious complication after repair of anorectal malformations. We investigated whether reoperation can improve fecal continence.

METHODS

Medical records of 41 patients (40 children and one adult; 26 male and 15 female) who underwent reoperation after previous reconstruction of an anorectal malformation were reviewed for outcomes of bowel function. Type of primary corrective surgery performed, therapeutic measures, results of physical examination and barium enema, and reoperation procedures were evaluated. A questionnaire was administered to assess stool behaviour and level of continence at follow-up three or more years after secondary operation.

RESULTS

Secondary operations in males comprised posterior sagittal anorectoplasty (PSARP) in 16 patients, PSARP with antegrade continent enema in one patient, antegrade continent enema alone in 6, anoplasty in one, rectosigmoid resection in 1, and definitive colostomy in 1 patient. Secondary operations in females included PSARP alone in 4 patients, PSARP with total urogenital mobilization in 4, PSARP with vaginoplasty in 2, PSARP with vaginoplasty and antegrade continent enema in 2, and PSARP with vaginourethroplasty in 3. Of 41 patients 18 (44 percent) were continent at follow-up, 21 (51 percent) were clean with use of enemas, diet, or drug therapy. One patient had a definitive colostomy. One died after kidney transplantation.

CONCLUSIONS

Surgery is a good option for improving incontinence in selected patients previously operated for anorectal malformations. Posterior sagittal anorectoplasty is advocated to improve bowel control. Antegrade continent enema is a reliable therapeutic option to maintain clean patients with fecal incontinence.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

Imperforate anus: long- and short-term outcome

Anorectal malformations are common anomalies observed in neonates. Survival of these babies is currently achieved in most cases and improvements in operative technique, patient care, and better follow-up have led to improved functional results. A new, simplified classification system (Krickenbeck classification) and method of functional assessment has led to an improved understanding of these anomalies and has allowed for a better comparison of outcomes. Following successful anatomical repair and appropriate programs of bowel care, socially acceptable continence can be achieved in a majority of patients, especially those with an intact sacrum.

Colonic irrigation for defecation disorders after dynamic graciloplasty

BACKGROUND AND AIMS

Dynamic graciloplasty (DGP) improves anal continence and quality of life for most patients. However, in some patients, DGP fails and fecal incontinence is unsolved or only partially improved. Constipation is also a significant problem after DGP, occurring in 13-90%. Colonic irrigation can be considered as an additional or salvage treatment for defecation disorders after unsuccessful or partially successful DGP. In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP is investigated.

MATERIALS AND METHODS

Patients with defecation disorders after DGP visiting the outpatient clinic of the University Hospital Maastricht were selected for colonic irrigation as additional therapy or salvage therapy in the period between January 1999 and June 2003. The Biotrol(R) Irrimatic pump or the irrigation bag was used for colonic irrigation. Relevant physical and medical history was collected. The patients were asked to fill out a detailed questionnaire about colonic irrigation.

RESULTS

Forty-six patients were included in the study with a mean age of 59.3 +/- 12.4 years (80% female). On average, the patients started the irrigation 21.39 +/- 38.77 months after the DGP. Eight patients started irrigation before the DGP. Fifty-two percent of the patients used the irrigation as additional therapy for fecal incontinence, 24% for constipation, and 24% for both. Irrigation was usually performed in the morning. The mean frequency of irrigation was 0.90 +/- 0.40 times per day. The mean amount of water used for the irrigation was 2.27 +/- 1.75 l with a mean duration of 39 +/- 23 min. Four patients performed antegrade irrigation through a colostomy or appendicostomy, with good results. Overall, 81% of the patients were satisfied with the irrigation. Thirty-seven percent of the patients with fecal incontinence reached (pseudo-)continence, and in 30% of the patients, the constipation completely resolved. Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation, abdominal cramps, and distended abdomen. Seven (16%) patients stopped the rectal irrigation.

CONCLUSION

Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP.

Evolving therapy for fecal incontinence

BACKGROUND

Fecal incontinence is common and can be socially debilitating. Nonoperative management of fecal incontinence includes dietary modification, antidiarrheal medication, and biofeedback. The traditional surgical approach is sphincteroplasty if there is a defect of the external sphincter. Innovative treatment modalities have included sacral nerve stimulation, injectable implants, dynamic graciloplasty, and artificial bowel sphincter.

DISCUSSION

This review was designed to assess the various surgical options available for fecal incontinence and critically evaluate the evidence behind these procedures. The algorithm in the surgical treatment of fecal incontinence is shifting. Injectable therapy and sacral nerve stimulation are likely to be the mainstay in future treatment of moderate and severe fecal incontinence, respectively. Sphincteroplasty is limited to a small group of patients with isolated defect of the external sphincter. A stoma, although effective, can be avoided in most cases.

[Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]

Dynamic graciloplasty (DGP) and the Acticon Neosphincter (artificial bowel sphincter, ABS) are well-established therapeutic instruments in patients with severe fecal incontinence. However, the success rates in the literature must be interpreted with caution. The report presented here presents firstly a critical analysis of 1510 patients in 52 studies (29 DGP vs 23 ABS). The evidence of these studies was assessed using the Oxford EBM criteria. All data were statistically analysed. Up to 94% of the studies analysed show EBM levels of only >3b. Both procedures show significant improvements in postoperative continence scores (p<0.001) and a significant advantage of ABS over DGP. Nevertheless, they are associated with a high incidence of morbidity in the long term (infection rate ABS vs DGP 21.74% vs 35.1%, revision rate ABS vs DGP 37.53% vs 40.64%, and ABS explantation rates of 30%). Presently no therapeutic recommendation can be expressed based on the few data available. Furthermore, therapy should be performed in specialized centers and patients should be given a realistic picture of the critical outcome of both surgical techniques.

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

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

Explaining change over time in quality of life of adult patients with anorectal malformations or Hirschsprung's disease

PURPOSE

The aim of this study was to examine changes in the quality of life of adult patients with anorectal malformations or Hirschsprung's disease over a three-year interval and to identify demographic, clinical, and psychosocial variables that explain possible quality-of-life changes. Understanding the factors that affect changes in quality of life over time is particularly important to provide adequate care.

METHODS

Questionnaires were administered to 261 patients (77 percent), with a three-year interval. Background characteristics, including demographic and clinical variables, and psychosocial variables (i.e., self-esteem, mastery, social support, disease cognition) were measured on one occasion. Generic and disease-specific quality of life were measured twice.

RESULTS

On average patients indicated no change in quality-of-life level after three years. However, variance in the change scores revealed individual variation, indicating the presence of patients who improved and patients who deteriorated. Patients who were female, older, have other congenital diseases, or a stoma reported poorer quality of life over time. The psychosocial variable "disease cognition" most strongly affected the change in quality of life of patients with anorectal malformations or Hirschsprung's disease.

CONCLUSIONS

Our results could alert clinicians to patients who are at risk for quality-of-life deterioration and might therefore be in need for extra care. Our findings illustrate the importance of psychosocial functioning for enhancing the quality of life over time of these patients.

Técnicas novedosas en el tratamiento de la incontinencia anal

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread.

Fecal incontinence: an up-to-date critical overview of surgical treatment options

BACKGROUND

Surgery is the last resort for patients suffering from severe fecal incontinence. The armamentarium of surgical options for this condition has increased impressively during the last decade. Nevertheless, this fact seems to make neither patients nor surgeons feel more comfortable. Treatment of fecal incontinence still remains a challenge to modern medicine due to many specific sides of this problem.

AIMS

This article gives an up-to-date overview of existing operative treatment options.

METHODS

An unbiased review of relevant literature was performed to assess the role of all methods of surgical treatment for fecal incontinence available nowadays.

RESULTS

Recent studies have shown poor late results after primary sphincter repair and low predictive value for most preoperative diagnostic tests. New surgical options such as artificial devices and electrically stimulated muscle transpositions are doomed by low success rates and unacceptably frequent complications. That is why current attention has focused on non- or minimally invasive therapies such as sacral nerve stimulation and temperature-controlled radio-frequency energy delivery to the anal canal. However, all these innovative techniques remain experimental till enough high-evidence data are gathered for their objective evaluation.

CONCLUSION

Careful and detailed preoperative assessment to exactly determine the etiology of incontinence and individual approach remain the cornerstones of surgical treatment of fecal incontinence nowadays.