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Administration of an Anal Bulking Agent With Polyacrylate-Polyalcohol Copolymer Particles Versus Endoanal Electrical Stimulation With Biofeedback for the Management of Mild and Moderate Anal Incontinence: A Randomized Prospective Study. Dis Colon Rectum 2022; 65:917-927. [PMID: 35333803 DOI: 10.1097/dcr.0000000000002458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are few treatment options for mild-to-moderate anal incontinence with isolated internal anal sphincter defects or anal incontinence without muscle damage. Less-invasive techniques are generally favored. OBJECTIVE To compare the results between the use of an anal bulking agent with polyacrylate-polyalcohol copolymer particles and endoanal electrical stimulation with biofeedback in patients with mild or moderate anal incontinence. DESIGN This was a prospective parallel-group, single-institution, randomized clinical trial. SETTINGS This study was conducted in an ambulatory setting at the Colorectal Physiology Service of the Hospital das Clinicas, Medical School, University of Sao Paulo. PATIENTS This study included patients who had anal incontinence for >6 months with isolated internal anal sphincter muscle damage or absence of anatomical defects in the anorectal sphincter complex. INTERVENTIONS Anal bulking agent and endoanal electrical stimulation with biofeedback. MAIN OUTCOME MEASURES The primary outcome measure was the Cleveland Clinic Florida Fecal Incontinence Score, and the secondary outcome measures included quality of life, recommended procedures, and anorectal manometry. RESULTS There were no significant between-group differences in mean age, sex, BMI, stool consistency, and Cleveland Clinic Florida Fecal Incontinence Score (p = 0.20) at baseline. After 12 months, the Cleveland Clinic Florida Fecal Incontinence Score was found to be significantly improved in patients treated with the bulking agent compared to those treated with electrical stimulation (mean, 6.2 vs 9.2; p = 0.002), though the anorectal manometry parameters did not change significantly. The mean anal Cleveland Clinic Florida Fecal Incontinence Score declined by 4.2 points in the bulking agent group compared to a decline of 0.8 in the electrical stimulation group (mean difference in decline: 3.4 points; 95% CI, 1.2-5.5). Quality-of life evaluation showed similar results between groups comparing baseline parameters with 12-month follow-up. LIMITATIONS The short follow-up period of 1 year, atypical method of biofeedback, and unmatched baseline in some of the quality-of-life scales between the 2 groups limited this study. CONCLUSIONS In patients with mild or moderate anal incontinence, the Cleveland Clinic Florida Fecal Incontinence Score significantly improved in the bulking agent with polyacrylate-polyalcohol copolymer group compared with the endoanal electrical stimulation with biofeedback group. See Video Abstract at http://links.lww.com/DCR/B938. ADMINISTRACIN DE UN GEL ANAL CON PARTCULAS DE COPOLMERO DE POLIACRILATOPOLIALCOHOL VERSUS ESTIMULACIN ELCTRICA ENDOANAL CON EJERCICIOS ANALES BIOFEEDBACK PARA EL MANEJO DE LA INCONTINENCIA ANAL LEVE Y MODERADA UN ESTUDI PROSPECTIVO ALEATORIZADO ANTECEDENTES:Hasta la fecha, existen pocas opciones de tratamiento para la incontinencia anal de leve a moderada con defectos aislados del esfínter anal interno o la incontinencia anal sin daño muscular. Por lo general, se prefieren técnicas menos invasivas.OBJETIVO:El objetivo fue comparar los resultados entre el uso de un gel intra-anal con partículas de copolímero de poliacrilato-polialcohol y la estimulación eléctrica endoanal con ejercicios anales en pacientes con incontinencia anal leve o moderada.DISEÑO:Este fue un ensayo clínico aleatorio prospectivo de grupos paralelos, de una institución, realizado en cuatro etapas: base, procedimientos, postratamiento temprano y tardío.AJUSTE:Este estudio se realizó en el ambulatorio de Fisiología Colorrectal del Servicio de Coloproctología del Hospital das Clínicas, Facultad de Medicina, Universidad de São Paulo.PACIENTES:Paciente con incontinencia anal con más de 6 meses, con daño muscular aislado del esfínter anal interno o ausencia de defectos anatómicos en el esfínter anorrectal.INTERVENCIONES:Las intervenciones incluyeron la inyección del gel intra-anal y estimulación eléctrica endoanal con ejercicios anales.PRINCIPALES MEDIDAS DE RESULTADO:Indice de incontinencia fecal (Cleveland Clinic Florida), Indice de calidad de vida, los procedimientos recomendados y la manometría anorrectal.RESULTADOS:No hubo diferencias significativas entre los grupos en cuanto a la edad media, el sexo, el índice de masa corporal, la consistencia de las heces y la puntuación de incontinencia fecal (p = 0,20) al inicio del estudio. Después de 12 meses, la puntuación de incontinencia fecal mejoró significativamente en los pacientes tratados con el el gel intra-anal (media = 6,2) en comparación con los tratados con estimulación eléctrica (media = 9,2; p = 0,002), aunque los parámetros de manometría anorrectal no mejoraron significativamente. La puntuación anal media de incontinencia fecal disminuyó 4,2 puntos en el grupo del Gel intra-anal en comparación con 0,8 en el grupo de estimulación eléctrica (diferencia media en la disminución: 3,4 puntos; IC del 95%: 1,2 a 5,5). La evaluación de la calidad de vida mostró resultados similares entre los grupos que compararon los parámetros iniciales con un seguimiento de 12 meses.LIMITACIONES:Breve período de seguimiento de un año, métodos diferentes de ejercicios anales y línea de base sin igual en algunas de las escalas de calidad de vida entre los dos grupos.CONCLUSIONES:En pacientes con incontinencia anal leve y moderada, la puntuación de incontinencia fecal mejoró significativamente en el grupo de gel intra-anal con copolímero de poliacrilato-polialcohol en comparación con la estimulación eléctrica endoanal. Consulte Video Resumen en http://links.lww.com/DCR/B938. (Traducción- Dr Leonardo Alfonso Bustamante-Lopez).
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Ezra E, Danielsson JM, Graf W. A short- and long-term follow-up study of intersphincteric NASHA Dx implants for fecal incontinence. Tech Coloproctol 2022; 26:813-820. [PMID: 35752984 PMCID: PMC9458585 DOI: 10.1007/s10151-022-02645-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The bulking agent NASHA Dx injected into the submucosal layer is effective in the treatment of fecal incontinence (FI) at short-and medium-term follow-up but efficacy after injection in the intersphincteric location is unknown. The aim of this study was to determine the short- and long-term efficacy and safety of NASHA Dx injected into the intersphincteric location for FI. METHODS Patients were recruited from referrals to our Department for treatment of FI in November 2008-January 2010. Eligible patients were injected with 8 ml of NASHA Dx. Patients with a subtotal treatment effect were retreated after 2-4 weeks. The change in number of fecal incontinence episodes, the proportion of responders defined as at least 50% decrease in number of FI episodes and side effects were the main outcome measures. RESULTS Sixteen patients, 15 women and 1 man with a median age of 68, 5 (range 44-80) years and a median CCFIS of 15 (range 10-19) were included in the study. The median number of incontinence episodes decreased from 21.5 (range 8-61) at baseline to 10 (range 0-30) at 6 months (p = 0.003) and 6 (range 0-44) at 12 months (p = 0.05). The median number of incontinence episodes in the 11 patients completing the 10-year follow-up was 26.5 (range 0-68). The percentage of responders at 12 months and 10 years were 56% and 27%, respectively. Mild to moderate pain at the injection site was described by 69%. There was one case of mild infection, successfully treated with antibiotics and one implant had to be removed due to dislocation. CONCLUSIONS NASHA Dx as an intersphincteric implant improves incontinence symptoms in the short term with moderate side effects and can be used alone or as an adjunct to other treatment modalities. Long-term efficacy was observed in 27%.
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Affiliation(s)
- E Ezra
- Department of Surgical Sciences, Uppsala University Hospital, 751 85, Uppsala, Sweden.
| | - J M Danielsson
- Department of Women's and Children's Health, Uppsala University Hospital, 751 85, Uppsala, Sweden
| | - W Graf
- Department of Surgical Sciences, Uppsala University Hospital, 751 85, Uppsala, Sweden
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Ivatury SJ, Wilson LR, Paquette IM. Surgical Treatment Alternatives to Sacral Neuromodulation for Fecal Incontinence: Injectables, Sphincter Repair, and Colostomy. Clin Colon Rectal Surg 2021; 34:40-48. [PMID: 33536848 DOI: 10.1055/s-0040-1714285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Srinivas Joga Ivatury
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School of Medicine, Lebanon, New Hampshire
| | - Lauren R Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School of Medicine, Lebanon, New Hampshire
| | - Ian M Paquette
- University of Cincinnati Surgeons, College of Medicine, Cincinnati, Ohio
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Al-Bayati I, Saadi M, Elhanafi S, McCallum RW. Effectiveness of Bulking Agent (Solesta) Therapy in Fecal Incontinence in Patients Refractory to Conventional Therapies. Am J Med Sci 2017; 354:476-479. [DOI: 10.1016/j.amjms.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 08/28/2017] [Accepted: 09/03/2017] [Indexed: 01/14/2023]
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Midterm outcomes of injectable bulking agents for fecal incontinence: a systematic review and meta-analysis. Tech Coloproctol 2017; 21:203-210. [PMID: 28251356 DOI: 10.1007/s10151-017-1593-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Various bulking agents have been used to treat fecal incontinence. While short-term outcomes are attractive, there is still a lack of long-term data. The aim of this systematic review and meta-analysis was to investigate the midterm outcomes of treatment with injectable bulking agents and to identify predictive factors for improvement in incontinence. METHODS PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched using the terms injection, bulking agents, and fecal incontinence. Studies with a minimum follow-up of 1 year were included. The improvement rate in incontinence was calculated by percent change in validated fecal incontinence score (FIS) following injection treatment. To explore the impact of predictive factors on improvement in incontinence, univariate meta-regressions were conducted using the random-effect model. RESULTS A total of 889 patients in 23 articles were included. The weighted mean follow-up duration was 23.7 months (95% CI 19.3-28.2). Eleven different bulking agents were used. Four validated FISs were used. The Cleveland Clinic Fecal Incontinence score (CC-FIS) was used in 19 studies. Most studies reported a statistically significant improvement in FIS. The pooled mean preoperative CC-FIS (n = 637) was 12.4 (95% CI 11.4-13.3). The pooled mean CC-FIS at last follow-up (n = 590) was 7.7 (95% CI 6.1-9.3). The weighted mean difference in CC-FIS between preoperative visit and last follow-up was 4.9 (95% CI 4.0-5.8). Hence, the rate of improvement in incontinence was 39.5% based on CC-FIS. Meta-regression revealed that the perianal injection route and implants intact on endoanal ultrasonography were predictive of greater improvement in incontinence. The manometric data revealed that the initial increase in the mean resting pressure following injection was attenuated over time. The pooled rate of adverse events was 18.0% (95% CI 10.0-30.1). In most cases, adverse events were minor and resolved within a couple of weeks. CONCLUSIONS Administration of injectable bulking agents results in significant midterm improvement in FIS. Perianal injection route and implants intact on EAUS were predictive of higher improvement in incontinence. However, given the paucity of randomized controlled trials in the literature, further research is needed to improve the quality of the evidence.
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Long-term evaluation of bulking agents for the treatment of fecal incontinence: clinical outcomes and ultrasound evidence. Tech Coloproctol 2014; 19:23-7. [PMID: 25381455 DOI: 10.1007/s10151-014-1236-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/03/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The injection of bulking agents into the anal canal has been reported to help patients with fecal incontinence. Although it has been advocated as a safe and effective option, substantial data concerning long-term efficacy are still lacking, and the resorption process of the implants has not yet been carefully studied. The aim of our study was to investigate the long-term outcomes of bulking agents for the treatment of fecal incontinence and the behavior of implanted materials in the anorectum. METHODS At a median follow-up of 7 years, 19 patients with idiopathic fecal incontinence who had received bulking agent implants were evaluated. Clinical, manometric and ultrasound assessments were carried out. RESULTS The clinical improvements that were achieved in the short term were not maintained over time. For each patient, the number of implants that could no longer be identified on ultrasound was significantly correlated with poorer clinical long-term outcomes. On average, only 14% of the originally injected volume was still detectable. CONCLUSIONS In the long term, perianally injected bulking agents seem to lose effectiveness. The ultrasound assessment suggests that the process of resorption is almost complete, and the implants are no longer effective in treating incontinence.
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Abstract
OBJECTIVE To review the management of fecal incontinence, which affects more than 1 in 10 people and can have a substantial negative impact on quality of life. METHODS The medical literature between 1980 and April 2012 was reviewed for the evaluation and management of fecal incontinence. RESULTS A comprehensive history and physical examination are required to help understand the severity and type of symptoms and the cause of incontinence. Treatment options range from medical therapy and minimally invasive interventions to more invasive procedures with varying degrees of morbidity. The treatment approach must be tailored to each patient. Many patients can have substantial improvement in symptoms with dietary management and biofeedback therapy. For younger patients with large sphincter defects, sphincter repair can be helpful. For patients in whom biofeedback has failed, other options include injectable medications, radiofrequency ablation, or sacral nerve stimulation. Patients with postdefecation fecal incontinence and a rectocele can benefit from rectocele repair. An artificial bowel sphincter is reserved for patients with more severe fecal incontinence. CONCLUSION The treatment algorithm for fecal incontinence will continue to evolve as additional data become available on newer technologies.
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Affiliation(s)
- Jennifer Y Wang
- General and Colorectal Surgeon at the San Jose Medical Center in CA. E-mail:
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Ho Kim T, Heang Oh S, Kang SB, Ho Lee J. Myoblast differentiation on growth factor-immobilized polycaprolactone microparticles: a potential bioactive bulking agent for fecal incontinence. PURE APPL CHEM 2014. [DOI: 10.1515/pac-2014-0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractFecal incontinence (FI), caused by damage or weakness of the anal sphincter, is a devastating problem for patients experiencing the symptom. Although injectable bulking agents are accepted as a minimally invasive therapeutic technique to treat FI, their short-term efficacy and inability to enhance the anal sphincter function are considered as challenges in clinical practices. In this study, growth factor [nerve growth factor (NGF) and/or basic fibroblast growth factor (bFGF)]-immobilized polycaprolactone (PCL) microparticles were prepared as an injectable bioactive bulking agent that can provide a bulking effect (by microparticles) and stimulate myoblast differentiation or injured muscles around the anus (by the sustained release of growth factors) to enhance the sphincter function for the effective treatment of FI. Pluronic F127-entrapped PCL microparticles were prepared by an isolated particle-melting method. Two different growth factors (NGF and bFGF) were incorporated on the surfaces of the Pluronic F127-entrapped PCL microparticles via heparin binding. The growth factors immobilized on the microparticles were released in a sustained manner over 4 weeks. From cell cultures on the growth factor-immobilized microparticles, it was observed that the myoblasts adhered on the microparticle surfaces showed differences in differentiation into myotubes depending on the growth factor type. In particular, the dual NGF/bFGF-immobilized microparticle group was effective for myogenic differentiation in comparison with the single growth factor (NGF or bFGF)-immobilized groups. The dual NGF/bFGF-immobilized microparticles are suitable to be applied as an injectable bulking agent for the treatment of FI.
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Affiliation(s)
- Tae Ho Kim
- 1Department of Advanced Materials, Hannam University, Daejeon 305-811, Republic of Korea
| | - Se Heang Oh
- 2Department of Nanobiomedical Science, Dankook University, Cheonan 330-714, Republic of Korea
| | - Sung Bum Kang
- 3Department of Surgery, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea
| | - Jin Ho Lee
- 1Department of Advanced Materials, Hannam University, Daejeon 305-811, Republic of Korea
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Lam TJ, Visscher AP, Meurs-Szojda MM, Felt-Bersma RJF. Clinical response and sustainability of treatment with temperature-controlled radiofrequency energy (Secca) in patients with faecal incontinence: 3 years follow-up. Int J Colorectal Dis 2014; 29:755-61. [PMID: 24805249 DOI: 10.1007/s00384-014-1882-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Controlled delivery of radio frequent energy (Secca) has been suggested as treatment for faecal incontinence (FI). OBJECTIVE The objective of the study is to evaluate clinical response and sustainability of Secca for FI. DESIGN This is a prospective cohort study. PATIENTS This study involved patients who had failed full conservative management for FI. INTERVENTIONS This study was performed between 2005 and 2010. MAIN OUTCOME MEASURES FI was scored using the Vaizey score (VS). A clinically significant response to Secca was defined as ≥50 % reduction in incontinence score. Impact of FI on quality of life (QOL) was measured using the FIQL. Data was obtained at baseline, at 6 months and at 1 and 3 years. Anal endosonography and anal manometry were performed at 3 months and compared to baseline. RESULTS Thirty-one patients received Secca. During follow-up, 5/31 (16 %), 3/31 (10 %) and 2/31 (6 %) of patients maintained a clinically significant response after the Secca procedure. Mean VS of all patients was 18 (SD 3), 14 (SD 4), 14 (SD 4) and 15 (SD 4), at baseline, 6 months and 1 and 3 years. No increases in anorectal pressures or improvements in rectal compliance were found. Coping improved between baseline and t = 6 months. No predictive factors for success were found. LIMITATIONS This is a non-randomised study design. CONCLUSION This prospective non-randomised trial showed disappointing outcomes of the Secca procedure for the treatment of FI. The far minority of patients reported a clinically significant response of seemingly temporary nature. Secca might be valuable in combination with other interventions for FI, but this should be tested in strictly controlled randomised trials.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, P.O. box 7057, 1007 MB, Amsterdam, The Netherlands
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Kaiser AM, Orangio GR, Zutshi M, Alva S, Hull TL, Marcello PW, Margolin DA, Rafferty JF, Buie WD, Wexner SD. Current status: new technologies for the treatment of patients with fecal incontinence. Surg Endosc 2014; 28:2277-301. [PMID: 24609699 DOI: 10.1007/s00464-014-3464-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/28/2014] [Indexed: 12/13/2022]
Abstract
Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.
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Affiliation(s)
- Andreas M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA, 90033, USA,
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Abstract
Sphincteroplasty (SP) is the operation most frequently performed in patients suffering from moderate-to-severe anal incontinence (AI) who do not respond to conservative treatment. Other costly surgeries, such as artificial bowel sphincter (ABS) and electro-stimulated graciloplasty, have been more or less abandoned due to their high morbidity rate. Minimally invasive procedures are widely used, such as sacral neuromodulation and injection of bulking agents, but both are costly and the latter may cure only mild incontinence. The early outcome of SP is usually good if the sphincters are not markedly denervated, but its effect diminishes over time. SP is more often performed for post-traumatic than for idiopathic AI. It may also be associated to the Altemeier procedure, aimed at reducing the recurrence rate of rectal prolapse, and may be useful when AI is due either to injury to the sphincter, or to a narrowed rectum following the procedure for prolapse and haemorrhoids (PPH) and stapled transanal rectal resection (STARR). The outcome of SP is likely to be improved with biological meshes and post-operative pelvic floor rehabilitation. SP is more effective in males than in multiparous women, whose sphincters are often denervated, and its post-operative morbidity is low. In conclusion, SP, being both low-cost and safe, remains a good option in the treatment of selected patients with AI.
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Edden Y, Wexner SD. Therapeutic devices for fecal incontinence: dynamic graciloplasty, artificial bowel sphincter and sacral nerve stimulation. Expert Rev Med Devices 2014; 6:307-12. [DOI: 10.1586/erd.09.10] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Koughnett JAMV, Wexner SD. Current management of fecal incontinence: Choosing amongst treatment options to optimize outcomes. World J Gastroenterol 2013; 19:9216-9230. [PMID: 24409050 PMCID: PMC3882396 DOI: 10.3748/wjg.v19.i48.9216] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/17/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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Koh CE, Solomon MJ. Injectable bulking agents for passive faecal incontinence. Tech Coloproctol 2013; 17:343-4. [DOI: 10.1007/s10151-013-1018-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 11/24/2022]
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La Torre F, de la Portilla F. Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence. Colorectal Dis 2013; 15:569-74. [PMID: 23374680 DOI: 10.1111/codi.12155] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 12/15/2012] [Indexed: 02/08/2023]
Abstract
AIM Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long-term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long-term efficacy and safety of NASHA/Dx, assessed 24 months after treatment. METHOD This study was a 24-month follow-up assessment of patients treated with NASHA/Dx under open-label conditions. Data on FI episodes and quality of life measures were collected from diaries over the 28-day period immediately preceding the 24-month assessment. Adverse events were collected. RESULTS Eighty-three of 115 patients completed the 24-month follow-up assessment. At 24 months, 62.7% of patients were considered responders and experienced a ≥ 50% reduction in the total number of FI episodes. The median number of FI episodes declined by 68.8% (P < 0.001). Episodes of both solid and liquid stool incontinence decreased. The mean number of incontinence-free days increased from 14.6 at baseline to 21.7 at 24 months (P < 0.001). Incontinence scores and FI quality of life scores also showed significant improvements. The most common adverse events (AEs) were proctalgia (13.3%) and pyrexia (9.6%). The majority of AEs were mild to moderate, self-limited and resolved within 1 month of the injection. CONCLUSION NASHA/Dx is safe, effective and durable over a 24-month period with a majority of patients experiencing significant improvement in multiple symptoms associated with FI.
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Affiliation(s)
- F La Torre
- Department of Colorectal and Pelvic Surgery, Rome University, Rome, Italy.
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Abstract
BACKGROUND Fecal incontinence is a distressing condition that is difficult to treat. Injection of bulking agents has been used to treat passive fecal incontinence. However, no long-term results are available. OBJECTIVE The aim of this study was to assess the long-term clinical effectiveness of intra-anal injection of collagen for passive fecal incontinence. DESIGN This research is a retrospective cohort study from a prospectively collected database SETTING This investigation took place in a high-volume tertiary colorectal department. PATIENTS All patients who underwent intra-anal injection of collagen for passive fecal incontinence with internal sphincter dysfunction between January 2006 and December 2009 were included in the study. Data including demographic details, preoperative anorectal physiology, and outcome measures were collected prospectively and maintained in a database MAIN OUTCOME MEASURES The primary outcomes measured were the Cleveland Clinic Florida incontinence score and the responses to a subjective patient satisfaction questionnaire before the procedure and at subsequent follow-up visits. Data were analyzed by using SPSS v19.0. RESULTS One hundred patients (70 female; mean age, 61 years (range, 36-82)) were followed up for a minimum duration of 36 months. Fifty-six patients (56%) had an improvement in fecal incontinence score from a mean of 14 (range, 9-18) to a mean of 8 (range, 5-14). A total of 68% reported subjective improvement in symptoms. Thirty-eight patients (38%) required a repeat injection of collagen, and a further 15 patients required a third injection. The median interval between the first and final injection was 12 months (range, 4-16 months). Age was the only independent predictor of successful outcome (p = 0.032). There was no morbidity. LIMITATIONS This study was limited by its nonrandomized retrospective design. CONCLUSIONS Injection of collagen into the internal anal sphincter is simple, safe, and effective in patients with passive fecal incontinence, although repeat injections are necessary in approximately half of the patients.
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Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2013:CD007959. [PMID: 23450581 DOI: 10.1002/14651858.cd007959.pub3] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Faecal incontinence is a complex and distressing condition with significant medical and social implications. Injection of perianal bulking agents has been used to treat the symptoms of passive faecal incontinence. However, various agents have been used without a standardised technique and the supposed benefit of the treatment is largely anecdotal with a limited clinical research base. OBJECTIVES To determine the effectiveness of perianal injection of bulking agents for the treatment of faecal incontinence in adults. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Register of trials (25 May 2012), ZETOC (3 May 2012), clinical trials registries (3 May 2012) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing the use of injectable bulking agents for faecal incontinence with any alternative treatments or placebo were reviewed to evaluate the therapeutic effects. Case-control and cohort studies were also reviewed to assess risks and complications associated with the treatments. DATA COLLECTION AND ANALYSIS Two review authors (YM and CN) assessed the methodological quality of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures. MAIN RESULTS Five eligible randomised trials with a total of 382 patients were identified. Four of the trials were at an uncertain or high risk of bias.Most trials reported a short term benefit from injections regardless of the material used, including placebo saline injection. One study demonstrated dextranomer in stabilised hyaluronic acid (NASHA Dx) to be more effective than sham injection but with more adverse effects. Dextranomer in stabilised hyaluronic acid (NASHA Dx) was better than sham injections at six months (65/136, 48% versus 48/70, 69% participants not improved, defined as less than 50% reduction in incontinence episodes, RR 0.70, 95% CI 0.55 to 0.88; with more incontinence free days (3.1 days compared with 1.7 in the sham treatment group, MD 1.40 days, 95% CI 0.33 to 2.47). Another study comparing silicone material (PTQ™) to saline injections was too small to demonstrate a clinical benefit compared to the control injection of normal saline.A silicone biomaterial (PTQ™) was shown to provide some advantages and was safer in treating faecal incontinence than carbon-coated beads (Durasphere®) in the short term.Similarly, there were short term benefits from injections delivered under ultrasound guidance compared with digital guidance.No long term evidence on outcomes was available and further conclusions were not warranted from the available data. None of the studies reported patient evaluation of outcomes and thus it is difficult to gauge whether the improvement in incontinence scores matched practical symptom improvements that mattered to the patients. AUTHORS' CONCLUSIONS One large randomised controlled trial has shown that this form of treatment using dextranomer in stabilised hyaluronic acid (NASHA Dx) improves continence for a little over half of patients in the short term. However, the number of identified trials was limited and most had methodological weaknesses.
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Affiliation(s)
- Yasuko Maeda
- Sir Alan Park’s Physiology Unit, St Mark’s Hospital, Harrow, UK.
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Danielson J, Karlbom U, Wester T, Graf W. Efficacy and quality of life 2 years after treatment for faecal incontinence with injectable bulking agents. Tech Coloproctol 2012; 17:389-95. [PMID: 23224913 DOI: 10.1007/s10151-012-0949-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 11/07/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Stabilized non-animal hyaluronic acid/dextranomer (NASHA Dx) gel as injectable bulking therapy has been shown to decrease symptoms of faecal incontinence, but the durability of treatment and effects and influence on quality of life (QoL) is not known. The aim of this study was to assess the effects on continence and QoL and to evaluate the relationship between QoL and efficacy up to 2 years after treatment. METHODS Thirty-four patients (5 males, mean age 61, range 34-80) were injected with 4 × 1 ml NASHA Dx in the submucosal layer. The patients were followed for 2 years with registration of incontinence episodes, bowel function and QoL questionnaires. RESULTS Twenty-six patients reported sustained improvement after 24 months. The median number of incontinence episodes before treatment was 22 and decreased to 10 at 12 months (P = 0.0004) and to 7 at 24 months (P = 0.0026). The corresponding Miller incontinence scores were 14, 11 (P = 0.0078) and 10.5 (P = 0.0003), respectively. There was a clear correlation between the decrease in the number of leak episodes and the increase in the SF-36 Physical Function score but only patients with more than 75 % improvement in the number of incontinence episodes had a significant improvement in QoL at 24 months. CONCLUSIONS Anorectal injection of NASHA Dx gel induces improvement of incontinence symptoms for at least 2 years. The treatment has a potential to improve QoL. A 75 % decrease in incontinence episodes may be a more accurate threshold to indicate a successful incontinence treatment than the more commonly used 50 %.
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Affiliation(s)
- J Danielson
- Institution of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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Hussain ZI, Lim M, Mussa H, Abbas K, Stojkovic S. The use of Permacol® injections for the treatment of faecal incontinence. Updates Surg 2012; 64:289-95. [PMID: 22948797 DOI: 10.1007/s13304-012-0176-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 07/30/2012] [Indexed: 12/21/2022]
Abstract
The aim of this study is to assess the safety and efficacy of Permacol(®) implant for the treatment of idiopathic faecal incontinence using a novel injection technique. Patients with idiopathic passive faecal incontinence were selected for trans-submucosal injection of Permacol(®) after assessment by anorectal physiology and endoanal ultrasonography. Clinical assessment and St. Mark's Incontinence Score were used to evaluate efficacy before and at two time points (1 and 2 years) after treatment. Rockwood Score were also used to determine quality of life before and after treatment. The Friedman and Chi-square tests were used to compare continuous and categorical data, respectively. A p value of <0.05 was deemed significant. Thirty-eight patients (24 female), median age 66 years, were recruited. At maximum clinical follow-up (median of 9 months), response to Permacol(®) injections was categorised as excellent, good, fair and poor in 12, 5, 4 and 17 patients, respectively. St. Mark's Score improved in 72 and 63 % of patients at 1 and 2 years, respectively. However, a smaller proportion of patients (39 and 27 %, respectively) achieved a 50 %, or more, improvement in Mark's Score. All four domains of Rockwood Quality of Life Score improved on first and second year follow-up, however, only two domains, coping and embarrassment, were statistically significant. Permacol(®) injection improved symptoms by >50 % in 39 and 27 % of patients on short and medium-term follow-ups, respectively. The trans-submucosal technique for injection of Permacol(®) in this study was safe with no significant adverse outcomes.
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Affiliation(s)
- Zeiad I Hussain
- Department of Colorectal Surgery, York Teaching Hospital, 1 Celtic Close, York, YO26 5QJ, UK.
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Affiliation(s)
- Oliver Schwandner
- Department of Proctology, Clinic of General and Visceral Surgery, Brothers of Mercy Hospital Regensburg, Regensburg, Germany
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Abstract
OBJECTIVE The aim of this study was to evaluate the short- and long-term outcome of the radiofrequency treatment for moderate to severe fecal incontinence. DESIGN This study is a retrospective review of a single-institution experience. PATIENTS Patients who underwent the radiofrequency procedure were included. MAIN OUTCOME MEASURES The primary outcomes measured were the complication rate, short- and long-term response, and the rate of subsequent intervention for incontinence. RESULTS Twenty-seven patients underwent 31 radiofrequency procedures (81% women; mean age, 64 years). Median length of symptoms was 3 years. Biofeedback had failed for 52% of patients, and 23% of patients had previous surgical intervention. Thirty-eight percent of patients had a sphincter defect. Minor complications were observed in 19% of the patients. A treatment response was noted in 78% of the patients (mean Cleveland Clinic Florida Fecal Incontinence Score: 16 (baseline) and 10.9 (3 months postoperatively)). However, a sustained long-term response without any additional intervention was noted in 22% of the patients, and 52% of the patients underwent or are awaiting additional intervention for persistent or recurrent incontinence (mean follow-up, 40 months). LIMITATION This study is limited by its retrospective nature and the limited number of subjects. CONCLUSIONS The radiofrequency procedure was safe, but a long-term benefit was noted in a minority of patients with moderate to severe fecal incontinence. Additional interventions were required in more than half of the patients. Larger studies are needed to determine the impact of various patient-related factors on the outcome of the radiofrequency treatment to identify the ideal patient for this therapy.
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Pescatori M. Anal Abscesses and Fistulae. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:57-84. [DOI: 10.1007/978-88-470-2077-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Pescatori M. Fecal Incontinence. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:165-182. [DOI: 10.1007/978-88-470-2077-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Leung FW. Treatment of fecal incontinence - review of observational studies (OS) and randomized controlled trials (RCT) related to injection of bulking agent into peri-anal tissue. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:202-206. [PMID: 22586538 DOI: 10.4161/jig.1.4.19952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 12/16/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE: Novel treatments are needed to augment medical therapy for fecal incontinence. METHODS: Medline and Google search (fecal incontinence and injection treatment), English publications. RESULTS: Twenty-two observational studies and 4 randomized controlled trials were identified. OS mostly with limited sample sizes reported promising results. Repeated injection was necessary in some patients. Effect on anal sphincter pressures was highly variable. Significant improvements in the length of anal high-pressure zone, asymmetry index and maximum tolerable rectal volume were suggested. Four randomized controlled trials (n=176) revealed: 1. Short-term benefits from injection of Bioplastique under ultrasound guidance compared with digital guidance; 2. Silicone biomaterial (PTQ) provided some advantages and was safer than carbon-coated beads (Durasphere); 3. PTQ did not demonstrate clinical benefit compared to control injection of saline; 4. There was significant improvement at 6 weeks post injection, but no difference between Bulkamid and Permacol. A 2010 Cochrane review, however, noted that these data were inconclusive due to limited number and methodological weaknesses. CONCLUSION: Further studies are warranted to assess patient-centered outcomes (e.g. adequate relief) in addition to the attenuation of severity of incontinence symptoms in ambulatory patients. In nursing home residents, cost-effectiveness studies combining injection treatment and prompted voiding (to mitigate constraints of immobility and dementia) in preventing peri-anal skin complications deserves to be considered.
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Affiliation(s)
- Felix W Leung
- Medical and Research Services, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angels Healthcare System and David Geffen School of Medicine at UCLA, North Hills, CA, USA
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Abstract
BACKGROUND AND OBJECTIVE Sacral nerve stimulation is effective in the treatment of urinary incontinence and is currently under Food and Drug Administration review in the United States for fecal incontinence. Previous reports have focused primarily on short-term results of sacral nerve stimulation for fecal incontinence. The present study reports the long-term effectiveness and safety of sacral nerve stimulation for fecal incontinence in a large prospective multicenter study. DESIGN AND METHODS Patients with fecal incontinent episodes more than twice per week were offered participation in this multicentered prospective trial. Patients showing ≥ 50% improvement during test stimulation were offered chronic implantation of the InterStim Therapy system (Medtronic; Minneapolis, MN). The aims of the current report were to provide 3-year follow-up data on patients from that study who underwent sacral nerve stimulation and were monitored under the rigors of an Food and Drug Administration-approved investigational protocol. RESULTS One hundred thirty-three patients underwent test stimulation with a 90% success rate, of whom 120 (110 females) with a mean age of 60.5 years and a mean duration of fecal incontinence of 7 years received chronic implantation. Mean length of follow-up was 3.1 (range, 0.2-6.1) years, with 83 patients completing all or part of the 3-year follow-up assessment. At 3 years follow-up, 86% of patients (P < .0001) reported ≥ 50% reduction in the number of incontinent episodes per week compared with baseline and the number of incontinent episodes per week decreased from a mean of 9.4 at baseline to 1.7. Perfect continence was achieved in 40% of subjects. The therapy also improved the fecal incontinence severity index. Sacral nerve stimulation had a positive impact on the quality of life, as evidenced by significant improvements in all 4 scales of the Fecal Incontinence Quality of Life instrument at 12, 24, and 36 months of follow-up. The most common device- or therapy-related adverse events through the mean 36 months of follow-up included implant site pain (28%), paresthesia (15%), change in the sensation of stimulation (12%), and infection (10%). There were no reported unanticipated adverse device effects associated with sacral nerve stimulation therapy. CONCLUSIONS Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with fecal incontinence. These data support long-term safety and effectiveness to 36 months.
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Hussain ZI, Lim M, Stojkovic SG. Systematic review of perianal implants in the treatment of faecal incontinence. Br J Surg 2011; 98:1526-36. [PMID: 21964680 DOI: 10.1002/bjs.7645] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Injectable bulking agents have been used with varying success for the treatment of faecal incontinence. This systematic review aimed to investigate the various injectable agents and techniques used for the treatment of faecal incontinence, and to assess their safety and efficacy. METHODS Thirty-nine publications were identified and studied. The following variables were pooled for univariable analysis: type, location, route of bulking agents, and the use of ultrasound guidance, antibiotics, laxatives and anaesthetics. Predictors of the development of complications and successful outcomes were identified by multivariable logistic regression analysis. RESULTS A total of 1070 patients were included in the analysis. On multivariable analysis, the only significant predictor of the development of complications was the route of injection of bulking agents (odds ratio 3·40, 95 per cent confidence interval 1·62 to 7·12; P = 0·001). Two variables were significant predictors of a successful short-term outcome: the use of either PTQ(®) (OR 5·93, 2·21 to 16·12; P = 0·001) or Coaptite(®) (OR 10·74, 1·73 to 65·31; P = 0·001) was associated with a greater likelihood of success. Conversely, the use of local anaesthetic was associated with a lower likelihood of success (OR 0·18, 0·05 to 0·59; P = 0·005). Failure to use laxatives in the postoperative period resulted in a poorer medium- to longer-term outcome (OR 0·13, 0·06 to 0·25; P = 0·001). CONCLUSION This systematic review has identified variations in the practice of injection of bulking agents that appear to influence the likelihood of complications and affect the outcomes after treatment.
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Affiliation(s)
- Z I Hussain
- Department of Colorectal Surgery, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO26 5QJ, UK.
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Gié O, Christoforidis D. Advances in the Treatment of Fecal Incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pescatori M. Ascessi e fistole anali. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:57-83. [DOI: 10.1007/978-88-470-2062-7_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Pescatori M. Incontinenza fecale. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:165-183. [DOI: 10.1007/978-88-470-2062-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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An Open-Label, Noncomparative, Multicenter Study to Evaluate Efficacy and Safety of NASHA/Dx Gel as a Bulking Agent for the Treatment of Fecal Incontinence. Gastroenterol Res Pract 2010; 2010:467136. [PMID: 21234379 PMCID: PMC3017894 DOI: 10.1155/2010/467136] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Revised: 10/01/2010] [Accepted: 11/04/2010] [Indexed: 12/17/2022] Open
Abstract
Fecal incontinence (FI) is the involuntary loss of rectal contents through the anal canal. Reports of its prevalence vary from 1–21%. Studies, have demonstrated a positive effect on FI symptoms with injectable bulking agents. This study evaluated the safety and efficacy of NASHA/Dx gel in the treatment of FI. One hundred fifteen eligible patients suffering from FI received 4 injections of 1 mL NASHA/Dx gel. Primary efficacy was based on data from 86 patients that completed the study. This study demonstrated a ≥50% reduction from baseline in the number of FI episodes in 57.1% of patients at 6 months, and 64.0% at 12 months. Significant improvements (P < .001) were also noted in total number of both solid and loose FI episodes, FI free days, CCFIS, and FIQL scores in all 4 domains. The majority of the treatment related AEs (94.9%) were mild or moderate intensity, and (98.7%) of AEs resolved spontaneously, or following treatment, without sequelae. Results of this study indicate NASHA/Dx gel was efficacious in the treatment of FI. Treatment effect was significant both in reduction of number of FI episodes and disease specific quality of life at 6 months and lasted up to 12 months after treatment.
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Beggs AD, Irukulla S, Sultan AH, Ness W, Abulafi AM. A pilot study of ultrasound guided Durasphere injection in the treatment of faecal incontinence. Colorectal Dis 2010; 12:935-40. [PMID: 19438887 DOI: 10.1111/j.1463-1318.2009.01927.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM To assess injection of Durasphere under direct endoanal ultrasound guidance as a treatment for faecal incontinence. METHOD A total of 23 patients with varying degrees of persistent faecal leakage and/or soiling were recruited. Durasphere was injected in the intersphincteric plane under direct ultrasound guidance. All patients were given a general anaesthetic. Patients had ano-rectal physiology, endoanal ultrasound, continence scoring and quality of life measures assessed at 0, 1, 3, 6 and 12 months. RESULTS A total of 21 patients were followed up for at least 12 months, with two being excluded at the follow-up stage. Friedman two-way analysis of variance of the Cleveland Clinic Score, Faecal Incontinence Quality of Life Score and Diary Response Score demonstrated a significant sustained improvement. There was no significant improvement in number of bowel movements. There was a significant difference in anal squeeze pressure after therapy, but no significant difference in anal resting pressure. Six patients reported no improvement after Durasphere therapy. CONCLUSIONS Durasphere gave sustained improvements in quality of life and continence scores in this study group. Strict criteria are needed to ascertain suitability for Durasphere therapy.
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Affiliation(s)
- A D Beggs
- Colorectal Surgery Unit, Mayday University Hospital, Croydon, UK
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Probst M, Pages H, Riemann JF, Eickhoff A, Raulf F, Kolbert G. Fecal incontinence: part 4 of a series of articles on incontinence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:596-601. [PMID: 20838452 PMCID: PMC2936788 DOI: 10.3238/arztebl.2010.0596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 05/05/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aging of the population will make fecal incontinence an increasingly important socioeconomic problem in the coming decades. Already today, the cost to society of treating incontinence with inserts, diapers, and closed systems exceeds the total cost of all cardiac and anti-inflammatory medications. METHODS This article is based on a selective review of the literature and on clinical experience. No meta-analyses on this topic have yet been published. RESULTS Surveys in highly industrialized countries in the Western Hemisphere have shown that about 5% of the population suffers from fecal incontinence of varying degrees of severity. This condition will become more common, in both relative and absolute terms, in the coming decades. Various methods of care and therapy are currently available for fecal incontinence, yet many patients do not seek medical help for it because of embarrassment. Thus, its true prevalence is certainly higher than the surveys imply. CONCLUSION The challenge today, therefore, is not just to encourage patients to seek medical help early, but also to raise physicians' awareness of fecal incontinence and their readiness to treat it, so that they can provide competent individual counseling and treatment to all patients who suffer from it.
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Affiliation(s)
- Michael Probst
- Klinikum Ludwigshafen, Institut für Physikalische und Rehabilitative Medizin, Germany.
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Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2010:CD007959. [PMID: 20464759 DOI: 10.1002/14651858.cd007959.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Faecal incontinence is a complex and distressing condition with significant medical and social implications. Injection of perianal bulking agents has been used to treat the symptoms of passive faecal incontinence. However, various different agents have been used without a standardised technique and the supposed benefit of the treatment is largely pragmatic with a limited clinical research base. OBJECTIVES To determine the effectiveness of perianal injection of bulking agents for the treatment of faecal incontinence in adults. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Register of trials (searched 10 June 2009), ZETOC (searched 18 July 2009), clinical trials registries (searched 18 July 2009) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing use of injectable bulking agents for faecal incontinence with any alternative treatments or placebo were reviewed to evaluate the therapeutic effects. Case-control and cohort studies were also reviewed to assess risks and complications associated with the treatment. DATA COLLECTION AND ANALYSIS Two reviewers assessed the methodological quality of eligible trials and independently extracted data from included trials using a range of pre-specified outcome measures. MAIN RESULTS Four eligible randomised trials were identified with a total of 176 patients. All trials but one were at an uncertain or high risk of bias. Most trials reported a short term benefit from injections regardless of the material used as outcome measures improved over time. A silicone biomaterial (PTQ), was shown to provide some advantages and was safer in treating faecal incontinence than carbon-coated beads (Durasphere(R)) in the short term. Similarly, there were short term benefits from injections delivered under ultrasound guidance compared with digital guidance. However, PTQ did not demonstrate obvious clinical benefit compared to control injection of normal saline. No long term evidence on outcomes was available and further conclusions were not warranted from the available data. AUTHORS' CONCLUSIONS A definitive conclusion cannot be drawn regarding the effectiveness of perianal injection of bulking agents for faecal incontinence due to the limited number of identified trials together with methodological weaknesses. Within the available data, however, we found no reliable evidence for effectiveness of one treatment over another in improving faecal incontinence. Larger well-designed trials with adequate numbers of subjects using reliable validated outcome measures are needed to allow definitive assessment of the treatment for both effectiveness and safety.
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Affiliation(s)
- Yasuko Maeda
- Surgical Research Unit, Aarhus University Hospital, Tage-Hansens Gade 2, Aarhus, Denmark, 8000
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Luo C, Samaranayake CB, Plank LD, Bissett IP. Systematic review on the efficacy and safety of injectable bulking agents for passive faecal incontinence. Colorectal Dis 2010; 12:296-303. [PMID: 19320664 DOI: 10.1111/j.1463-1318.2009.01828.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The aim of this study was to systematically review all published evidence to determine the efficacy and safety of injectable bulking agents for passive faecal incontinence (FI) in adults. METHOD Electronic searches were performed for MEDLINE, EMBASE, ISI Web of Knowledge and other relevant databases. Hand searching of relevant conference proceedings was undertaken. Studies were considered if they met the predefined inclusion criteria of more than ten adult patients and receiving an injectable bulking agent for passive FI with a validated means of assessing preoperative and postoperative incontinence. RESULTS Thirteen case series studies and one randomized placebo-controlled trial (RCT) were included with a total of 420 patients. Two completed RCTs with placebo control were identified but results were unobtainable. Coaptite, Contigen, Durasphere, EVOH and PTQ injections were assessed with 24, 73, 83, 21 and 208 patients respectively. Most studies reported a statistically significant improvement in incontinence scores and quality of life. No statistically significant difference was found between the treatment and placebo arms in the RCT. No serious adverse events were reported. CONCLUSIONS Currently there is little evidence for the effectiveness of injectable bulking agents in managing passive FI. The inability to obtain results from two further RCTs concerned the reviewers and hindered their ability to make strong recommendations. The identified injectable bulking agents appear to be safe with only minor complications reported.
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Affiliation(s)
- C Luo
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Shawki S, Wexner SD. Newer Concepts in Fecal Incontinence: Injectables and Sacral Nerve Stimulation. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2009.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Abstract
Background
In North Queensland demand for conservative faecal incontinence treatments outweighs supply. Injectable bulking agents offer a safe and effective treatment for patients with internal anal sphincter (IAS) dysfunction.
Methods
Information, including age and sex, baseline incontinence score, quality of life, resting and squeeze pressures, was collected for 74 patients (37 men) who received intersphincteric PTQ™ injections. Postimplant satisfaction was assessed at 6-week review. Incontinence scores and satisfaction ratings were determined annually.
Results
At a median follow-up of 28 months, 52 patients (70 per cent) with IAS dysfunction who received PTQ™ anal implants as a treatment for faecal incontinence were continent and extremely satisfied with the result. The incontinence score in participants who remained incontinent was reduced significantly from 12 of 20 before implant to 3·5 of 20 at follow-up (P < 0·001). Migration rates improved with experience. The poorest results occurred in women with pudendal neuropathy, or patients who had previously received biofeedback treatment.
Conclusion
Implanted PTQ™ provides an effective solution to faecal incontinence in the short and mid term for patients with IAS dysfunction.
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Affiliation(s)
- L Bartlett
- School of Public Health, Tropical Medicine and Rehabilitation Science, James Cook University, Townsville, Queensland, Australia
| | - Y-H Ho
- School of Medicine and the Australian Institute of Tropical Medicine within the North Queensland Centre for Cancer Research, James Cook University, Townsville, Queensland, Australia
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Current world literature. Curr Opin Anaesthesiol 2009; 22:447-56. [PMID: 19417565 DOI: 10.1097/aco.0b013e32832cbfed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.
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de la Portilla F, Vega J, Rada R, Segovia-Gonzáles MM, Cisneros N, Maldonado VH, Espinosa E. Evaluation by three-dimensional anal endosonography of injectable silicone biomaterial (PTQ™) implants to treat fecal incontinence: long-term localization and relation with the deterioration of the continence. Tech Coloproctol 2009; 13:195-9. [DOI: 10.1007/s10151-009-0502-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 05/11/2009] [Indexed: 10/20/2022]
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Danielson J, Karlbom U, Sonesson AC, Wester T, Graf W. Submucosal injection of stabilized nonanimal hyaluronic acid with dextranomer: a new treatment option for fecal incontinence. Dis Colon Rectum 2009; 52:1101-6. [PMID: 19581853 DOI: 10.1007/dcr.0b013e31819f5cbf] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE NASHA Dx gel has been used extensively for treatments in the field of urology. This study was performed to evaluate NASHA Dx gel as an injectable anal canal implant for the treatment of fecal incontinence. METHODS Thirty-four patients (5 males, 29 females; median age, 61 years; range, 34 to 80) were injected with 4 x 1 ml of NASHA Dx gel, just above the dentate line in the submucosal layer. The primary end point was change in the number of incontinence episodes and a treatment response was defined as a 50 percent reduction compared with pretreatment. All patients were followed up at 3, 6, and 12 months. RESULTS The median number of incontinence episodes during four weeks was 22 (range, 2 to 77) before treatment, at 6 months it was 9 (range, 0 to 46), and at 12 months it was 10 (range, 0 to 70, P = 0.004). Fifteen patients (44 percent) were responders at 6 months, compared with 19 (56 percent) at 12 months. No long-term side effects or serious adverse events were reported. CONCLUSIONS Submucosal injection of NASHA Dx gel is an effective treatment for fecal incontinence. The effect is sustained for at least 12 months. The treatment is associated with low morbidity.
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Affiliation(s)
- Johan Danielson
- Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
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Johnson DA. Injectable treatment for GERD: the flight of the Phoenix? Gastrointest Endosc 2009; 69:324-6. [PMID: 19185692 DOI: 10.1016/j.gie.2008.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 10/20/2008] [Indexed: 02/08/2023]
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Aigner F, Conrad F, Margreiter R, Oberwalder M. Anal submucosal carbon bead injection for treatment of idiopathic fecal incontinence: a preliminary report. Dis Colon Rectum 2009; 52:293-8. [PMID: 19279426 DOI: 10.1007/dcr.0b013e318197d755] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Submucosal injection of bulking agents is a treatment option for idiopathic fecal incontinence. This study sought to assess whether the injection of carbon beads can significantly improve anal continence. METHODS Consecutive patients presenting with fecal incontinence were evaluated with standardized incontinence grading and quality-of-life grading scores, by anoproctoscopy, endoanal ultrasound, and anomanometry before, 3, 6, 12, and 24 months after injection. Injection therapy was performed in patients with anatomically intact anal sphincters. Patients kept a two-week incontinence diary. Data were obtained from a two-year follow-up period. RESULTS Eleven women with a mean age of 66 (range, 56 to 74) years met the inclusion criteria. Mean incontinence score was 12.27 +/- 0.97 at baseline, 6.82+/-1.64 at three-month, 6.73 +/- 1.47 at six-month, 5.91 +/- 0.95 at one-year, and 4.91 +/- 0.87 at two-year follow-up (P = 0.003). Quality-of-life items like coping and embarrassment improved significantly from baseline 2.3 to 3 at three months and 2.8 at six months (P < 0.05). Anomanometry showed a trend toward increase in measured pressures. No major complications occurred. CONCLUSIONS The injection of carbon beads via an intersphincteric approach is a promising new treatment option for old patients with idiopathic fecal incontinence.
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Affiliation(s)
- Felix Aigner
- Department of General and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria.
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Anal incontinence—sphincter ani repair: indications, techniques, outcome. Langenbecks Arch Surg 2008; 394:425-33. [DOI: 10.1007/s00423-008-0332-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Accepted: 03/31/2008] [Indexed: 01/27/2023]
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