Surgical approaches to fecal incontinence in the adult

Stoma reversal in functional bowel disease: managing patient choice

INTRODUCTION

This study aims to assess the rate of stoma reversal in patients who have undergone stoma formation with permanent intent for functional bowel disorder. We also assessed the incidence of malignancy in defunctioned bowel.

METHODS

This is a retrospective study of the outcomes of patients undergoing planned permanent stoma formation for functional bowel disorder over a 10-year period at a single tertiary centre.

RESULTS

Of 92 patients included in the study, 11 (12%) requested and underwent stoma reversal following stoma formation for functional bowel disorder. Of 84 patients with defunctioned bowel left in situ, two (2%) developed bowel malignancy during our study period.

CONCLUSIONS

Stoma formation may be necessary for patients with incontinence and constipation when conservative treatments fail. Some patients have very firm views about the need for a stoma, but a significant proportion of patients do not cope with a stoma and request reversal, therefore patient selection and pre-procedure counselling are important. The risk of developing malignant disease in the defunctioned colon is potentially significant, and consideration should be given to appropriate surveillance in this group of patients. Evidence for stoma formation in functional gastrointestinal disorders is lacking; this study reports outcomes in a large cohort of patients over a long period, and highlights areas where further research and practice guidelines are needed. If large numbers of patients are undergoing stoma reversal posing significant mortality and morbidity risks, this suggests that patient selection and preoperative counselling need refinement.

An artificial anal sphincter based on a novel clamping mechanism: Design, analysis, and testing

An artificial anal sphincter is a device to help patients with fecal incontinence rebuild the ability to control the excrement through the anus. In this article, an artificial anal sphincter based on a novel clamping mechanism (AASNCM) is proposed to improve the safety and reliability. The AASNCM, which is powered by a transcutaneous energy transfer system, consists of a novel clamping mechanism, a receiving coil and a control unit. According to design requirements, the novel clamping mechanism model was established. After that, its kinematics and dynamics were analyzed. The results of force tests on the prototype AASNCM show that the maximum values of clamping force and expanding force are 15.859 and 31.029 N, respectively. Comparing the experimental results with theoretical analysis, a good match can be concluded. Finally, in vitro experiments were conducted, and have verified the safety and reliability of the proposed AASNCM.

Management and consequences of obstetrical anal sphincter injuries: Review

Obstetrical anal sphincter injuries (OASI), formerly referred to as "complete" or "incomplete" perineal tears, are a frequent complication of childbirth. They can lead to intestinal consequences (anal incontinence, ano-genital fistula) or sexual consequences (dyspareunia, genital pain). The complexity of management of OASI lies in the multi-factorial nature of these consequences but also in the frequently lengthy interval before their appearance, often long after childbirth. Indeed, while 2.4% of women in childbirth develop OASI, up to 61% of them will present with anal incontinence15 to 25 years after childbirth. Immediate or delayed repair of the sphincter and perineum within a few hours of injury is therefore the rule, but there is no consensus on longer-term management. The patient must be educated on preventive actions (avoidance of pushing or straining, regularization of stool transit, muscle strengthening, etc.). Early detection of anal incontinence leads to prompt management, which is more effective. This review aims to synthesize the information necessary to provide clear and up-to-date patient information on OASI (risk factors and prevalence), the management of OASI, and the management of eventual complications in the setting of dedicated specialty consultations. Dedicated "post-OASI" consultations by a specialist in ano-perineal pathologies could therefore become a first step in the development of care for women, particularly by removing the "shameful" nature of the symptoms.

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study

BACKGROUND

The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial.

OBJECTIVE

To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury.

DESIGN AND SETTING

Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail.

METHODS

The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes.

RESULTS

The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001).

CONCLUSION

Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation

AIM

Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect.

METHOD

Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS).

RESULTS

Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06).

CONCLUSION

Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

Internal anal sphincter: Clinical perspective

OBJECTIVE

To summarise current knowledge of Internal anal sphincter.

BACKGROUND

The internal anal sphincter (IAS) is the involuntary ring of smooth muscle in the anal canal and is the major contributor to the resting pressure in the anus. Structural injury or functional weakness of the muscle results in passive incontinence of faeces and flatus. With advent of new assessment and treatment modalities IAS has become an important topic for surgeons. This review was undertaken to summarise our current knowledge of internal anal sphincter and highlight the areas that need further research.

METHOD

The PubMed database was used to identify relevant studies relating to internal anal sphincter.

RESULTS

The available evidence has been summarised and advantages and limitations highlighted for the different diagnostic and therapeutic techniques.

CONCLUSION

Our understanding of the physiology and pharmacology of IAS has increased greatly in the last three decades. Additionally, there has been a rise in diagnostic and therapeutic techniques specifically targeting the IAS. Although these are promising, future research is required before these can be incorporated into the management algorithm.

Fecal Incontinence: Epidemiology, Impact, and Treatment

Fecal incontinence (FI) is a chronic and debilitating condition that carries a significant health, economic, and social burden. FI has a considerable psychosocial and financial impact on patients and their families. A variety of treatment modalities are available for FI including behavioral and dietary modifications, pharmacotherapy, pelvic floor physical therapy, bulking agents, anal sphincteroplasty, sacral nerve stimulation, artificial sphincters, magnetic sphincters, posterior anal sling, and colostomy.

Sacral nerve stimulation--hidden costs (uncovered)

AIM

The aim of this study is to determine the occurrence of surgical revision in a cohort of patients treated with sacral nerve stimulation (SNS) for faecal incontinence and constipation and to establish the types of procedures performed and indications for surgery.

METHOD

From the years 2002 to 2014, 125 patients were identified who had undergone permanent SNS therapy with 36 (28.8 %) patients requiring surgical intervention postimplantation. These cases were retrospectively reviewed (range of follow-up 1-99 months).

RESULTS

Over a total of 1512 months of SNS treatment, 51 unplanned surgical procedures were required in 36 patients. At present, 48 procedures have been performed at an average of 2.6 years following implantation and three patients are awaiting surgery. Lead-related problems accounted for 30 (58.8 %) procedures at an average of 1.7 years affecting 22 patients. Battery and implantable pulse generator-related problems attributed to 13 procedures (25.5 %) in 12 patients at an average of 5.0 years. Battery depletion occurred in seven patients at an average of 5.4 years. Surgical revision was required to replace, remove, or resite various components of the SNS system. Indications for surgery included lead damage, pain and loss or lack of SNS efficacy. Explantation was warranted in six patients due to poor SNS efficacy, pain, infection and facilitation of a magnetic resonance imaging scan. This was performed at an average of 1.6 years.

CONCLUSION

A considerable proportion of patients treated with SNS therapy require surgical revision. These unplanned procedures are associated with substantial unexpected costs that financially burden SNS services.

[Management of postpartum anal incontinence: A systematic review]

AIM

To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management.

MATERIALS AND METHODS

A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery.

RESULTS

The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years).

CONCLUSION

Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop

This is the second of a two-part summary of a National Institutes of Health conference on fecal incontinence (FI) that summarizes current treatments and identifies research priorities. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback, often recommended as first-line treatment after conservative management fails, produces satisfaction with treatment in up to 76% and continence in 55%; however, outcomes depend on the skill of the therapist, and some trials are less favorable. Electrical stimulation of the anal mucosa is ineffective, but continuous electrical pulsing of sacral nerves produces a ≥50% reduction in FI frequency in a median 73% of patients. Tibial nerve electrical stimulation with needle electrodes is promising but remains unproven. Sphincteroplasty produces short-term clinical improvement in a median 67%, but 5-year outcomes are poor. Injecting an inert bulking agent around the anal canal led to ≥50% reductions of FI in up to 53% of patients. Colostomy is used as a last resort because of adverse effects on quality of life. Several new devices are under investigation but not yet approved. FI researchers identify the following priorities for future research: (1) trials comparing the effectiveness, safety, and cost of current therapies; (2) studies addressing barriers to consulting for care; and (3) translational research on regenerative medicine. Unmet patient needs include FI in special populations (e.g., neurological disorders and nursing home residents) and improvements in behavioral treatments.

Anal incontinence: long-term alterations in the incidence and healthcare usage

OBJECTIVE

The aim of the study was to determine the alterations in the occurrence of incontinence and how subjects suffering from incontinence seek and receive healthcare services over a 10-year follow-up period.

METHODS

Postal questionnaires (Wexner Incontinence Score, Fecal Incontinence Quality of Life Scale, a questionnaire to investigate the management of fecal incontinence and the frequency of urinary incontinence) were sent to subjects who had reported anal incontinence in our population-based study in 2003. For each incontinent person (n = 155) from the 2003 series, we identified two control subjects (n = 310) who did not suffer from incontinence.

RESULTS

Of the initially incontinent, 47 (58%) had remained incontinent after a follow up of 10 years. Almost 80% of the incontinent subjects in 2012 were female. Of the 152 initially continent, 12 (7.9%) had developed symptoms, all of whom were females. Urinary incontinence was present in approximately 60% of incontinent subjects. The majority (57.8%) of the subjects still incontinent in 2012 felt that they needed help for the complaint, but only 30.9% had received any, and only 7.4% received any benefit. The most common treatment was medication. The subjective incontinence impaired the quality of life.

CONCLUSION

Incontinence is a chronic long-lasting disorder. The current management of anal incontinence is not satisfactory. The primary healthcare system should be more aware of the nature of this condition to find and offer treatment for the patients.