Multicentre retrospective analysis of the outcome of artificial anal sphincter implantation for severe faecal incontinence

Regenerative medicine as a therapeutic option for fecal incontinence: a systematic review of preclinical and clinical studies

BACKGROUND

Fecal incontinence is the uncontrollable loss of stool and has a prevalence of around 7-15%. This condition has serious implications for patients' quality of life. Current treatment options show unsatisfactory results. A novel treatment option is therefore needed.

OBJECTIVE

This systematic review aims to perform a quality assessment and to give a critical overview of the current research available on regenerative medicine as a treatment for fecal incontinence.

STUDY DESIGN

A systematic search strategy was applied in PubMed, Cochrane Library, EMBASE, MEDLINE, Web of Science, and Cinahl from inception until March of 2018. Studies were found relevant when the animals or patients in the studied group had objectively determined or induced fecal incontinence, and the intervention must have used any kind of cells, stem cells, or biocompatible material, with or without the use of trophic factors. Studies were screened on title and consecutively on abstract for relevance by 2 independent investigators. The risk of bias of preclinical studies was assessed using the SYstematic Review Centre for Laboratory animal Experimentation risk of bias tool for animal studies, and for clinical studies the Cochrane risk of bias tool for randomized trials was used.

RESULTS

In all, 34 preclinical studies and 5 clinical studies were included. Animal species, type of anal sphincter injury, intervention, and outcome parameters were heterogenous. Therefore, a meta-analysis could not be performed. The overall risk of bias of the included studies was high.

CONCLUSION

The efficacy of regenerative medicine to treat fecal incontinence could not be determined due to the high risk of bias and heterogenicity of the available preclinical and clinical studies. The findings of this systematic review may result in improved study design of future studies, which could help the translation of regenerative medicine to the clinic as an alternative to current treatments for fecal incontinence.

Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013

BACKGROUND

Evidence-based guidelines for the management of neurological disease and lower bowel dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance.

AIMS

To update clinical management of neurogenic bowel dysfunction from the recommendations of the 4th ICI, 2009.

MATERIALS AND METHODS

A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and modifications applied to deliver evidence based conclusions and recommendations for the scientific report of the 5th edition of the ICI in 2013.

RESULTS

The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic bowel dysfunction. The pathophysiology is described in terms of spinal cord injury, multiple sclerosis, and Parkinson's disease. Assessment requires detailed history and clinical assessment, general investigations, and specialized testing, if required. Treatment primarily focuses on optimizing stool consistency and regulating bowel evacuation to improve quality of life. Symptom management covers conservative and interventional measures to promote good habits and assist stool evacuation, along with prevention of incontinence. Education is essential to achieving optimal bowel management.

DISCUSSION

The review offers a pragmatic approach to management in the context of complex pathophysiology and varied evidence base.

Advances in the Surgical Treatment of Fecal Incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.

Challenges faced in the clinical application of artificial anal sphincters

Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials.

Systematic Review of Surgical Treatments for Fecal Incontinence

BACKGROUND

No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments.

OBJECTIVE

The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults.

DATA SOURCES

Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources.

STUDY SELECTION

Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980-2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment-outcome combination.

INTERVENTIONS

Surgical treatments for fecal incontinence were included interventions.

MAIN OUTCOME MEASURES

Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured.

RESULTS

Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%-100%). Major surgical complications often required reoperation; few required permanent colostomy.

LIMITATIONS

Most evidence is intermediate term, with small patient samples and substantial methodologic limitations.

CONCLUSIONS

Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

Outcomes of Reimplantation of the Artificial Bowel Sphincter

BACKGROUND

Outcomes of artificial bowel sphincter reimplantation for severe fecal incontinence remain unknown.

OBJECTIVE

The purpose of this study was to evaluate the feasibility and outcomes of artificial bowel sphincter reimplantation versus implantation.

DESIGN

This was a retrospective review study.

SETTINGS

The study was conducted at a single institution.

PATIENTS

Patients with severe incontinence who underwent de novo implantation and re-implantation between January 1998 and December 2012 were included.

MAIN OUTCOME MEASURES

Complications, length of functional device time, success rates (functioning device at follow-up), patient demographics, comorbidities, etiology of incontinence, operative data, postoperative complications, and outcomes of initial implantation versus reimplantation were analyzed.

RESULTS

A total of 57 patients (mean age, 49.3 ± 13.5 years; 44 women) underwent implantation. Sixteen (28%) succeeded and 41 (72%) failed, requiring explantation; 17 of 41 patients underwent reimplantation; 5 had 2 reimplantations. There were 79 implantations and 50 explantations (63.3%) in total. Implantation and reimplantation procedures had similar lengths of operation, hospital stay, postoperative complications, and explantation rate. Most common reasons for device explantation were infection/erosion (27/50 (54%)) and malfunction (19/50 (38%)). Reasons for reimplantation included device malfunction/migration (17/22 (77.3%)) and/or infection/erosion (5/22 (22.7%)). Seven (41.2%) of 17 patients for whom reimplantation was attributed to noninfectious reasons had a functioning device, whereas only 1 (20.0%) of 5 who had reimplantation because of infection/erosion had a working device. At a median follow-up of 29.5 months (range, 1.0-215.0 months), 24 patients (42%) retained a functioning device (implantation = 16; reimplantation = 8). Success rates were not significantly different between initial implantation and reimplantation procedures (p = 0.755). There were no differences in the length of functional device time between implanted and reimplanted devices (p = 0.439).

LIMITATIONS

The study was limited by its retrospective nature and small sample size.

CONCLUSIONS

Artificial bowel sphincter implantation has a high failure rate, requiring explantation in 72% of patients in this study. Reimplantation was often possible, with a success rate of 47%. Selected reimplantation for noninfectious complications had better outcomes than did reimplantation for septic causes. Short- and long-term outcomes are comparable to initial implantation.

Current and emerging treatment options for fecal incontinence

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

Current status: new technologies for the treatment of patients with fecal incontinence

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.

Sphincteroplasty for anal incontinence

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.

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

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

Experience with a new prosthetic anal sphincter in three coloproctological centres

BACKGROUND

Fecal incontinence is a common and severely disabling disorder. For patients with severe fecal incontinence, surgery may prove to be the only adequate treatment option.

METHODS

This study reports on 43 patients that were treated with a prosthetic sphincter system between 2005 and 2009 in three coloproctological centres.

MAIN OUTCOME MEASURES

complications, anal pressures before and after surgery, fecal continence score.

RESULTS

The new artificial sphincter system significantly improves continence but leads to some complications in clinical practice. After implantation of the device, continence improved significantly (Keller & Jostarndt continence score 2.6 to 14.3 (P < 0.01)). With the band activated, resting pressure improved significantly as compared to baseline (10.7 mmHg vs. 66.1 mm Hg, P < 0.01). The same holds for anal sphincter squeeze pressure (32.2 mmHg versus 85.9 mm Hg, P < 0.01). Complications occurred in 21 patients (48.8%): 10 surgical and 13 technical. Two patients were affected by both technical and surgical problems. The median time of the occurrence was 3 months postop. In five patients difficulties arose within the first postoperative month leading to explantation of the device in three patients. 90% of complications occurred in the first year.

CONCLUSIONS

The soft anal band of AMI (AAS), a new artificial anal sphincter, improves severe anal incontinence, but it must be regarded as a last treatment option to avoid a stoma.

Technical and functional results of the artificial bowel sphincter for treatment of severe fecal incontinence: is there any benefit for the patient?

BACKGROUND

Fecal incontinence is a socially devastating problem that can be cured by the artificial bowel sphincter in selected cases.

OBJECTIVE

This study evaluates short- and long-term morbidity and functional results of the artificial bowel sphincter.

DESIGN

This study is a retrospective evaluation of consecutive patients.

SETTINGS

This study was conducted at 2 academic colorectal units.

PATIENTS

Between May 2003 and July 2010, all consecutive patients who underwent artificial bowel sphincter implantation for severe fecal incontinence were included in the study.

INTERVENTION

The artificial bowel sphincter was implanted through 2 incisions made in the perineum and suprapubic area.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, and 12, and then annually. Mortality, morbidity (early infection within the first 30 days after implant, and late thereafter), and reoperations including explantations were analyzed. Anal continence was evaluated by means of the Cleveland Clinic Florida score. Mean follow-up was 38 months (range, 12-98).

RESULTS

Between May 2003 and July 2010, 21 consecutive patients with a mean age of 51 years (range, 23-71) underwent surgery. There was no mortality. All patients presented with at least 1 complication. Infection or cutaneous ulceration occurred in 76% of patients, perineal pain in 29%, and rectal evacuation disorders in 38%. The artificial bowel sphincter was definitely explanted from 17 patients (81%). The artificial sphincter was able to be activated in 17 patients (81%), and continence was satisfactory at 1 year in those who still had their sphincter in place (n = 12).

CONCLUSION

There is a very high rate of morbidity and explantation after implantation of an artificial bowel sphincter for fecal incontinence. Four of 21 patients who still had an artificial sphincter in place had satisfactory continence at a mean follow-up of 38 months.

Artificial anal sphincter for severe fecal incontinence implanted by a transvaginal approach: experience with 32 patients treated at one institution

PURPOSE

Our aim was to evaluate medium-term results of transvaginal implantation of an artificial anal sphincter in a large series of patients.

METHODS

Women undergoing treatment for severe fecal incontinence at Rouen University Hospital, Rouen, France, from January 2003 through December 2007 were eligible for the study if the fecal incontinence had lasted for 6 months and if they had attempted other therapies without success. All patients received implantation of an artificial anal sphincter via a transvaginal approach. Incontinence was assessed with the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score).

RESULTS

A total of 32 women entered the study. Their median age was 63 (range, 26-79) years. At entry, 20 (63%) had severe destruction and scarring of the perineum, which was a contraindication for implantation via a perineal approach. Nine patients (28.1%) had previously undergone implantation of an AAS which had been removed because of complications, and 5 had had a Pickrell procedure for anal agenesia. No deaths occurred during the study. The device was removed in a total of 9 patients (28.1%): in 7 because of septic adverse events within the first 6 months after the operation, in 1 because of poor function, and in 1 for psychological reasons despite good functional results. Implantation was successful in 23 patients (71.9%), and the device remained activated for a mean follow-up of 41 (range, 18-75) months, with a mean decrease in Cleveland Clinic incontinence score from 18.4 to 6.8 (P < .0001). None of the patients complained of dyspareunia.

CONCLUSIONS

The transvaginal approach for implantation of an artificial anal sphincter permits treatment of women with fecal incontinence who have severe damage and scarring of the anterior perineum. This route provides an alternative for patients whose only therapeutic option would previously have been a defunctioning stoma.

Infection rates in a large investigational trial of sacral nerve stimulation for fecal incontinence

INTRODUCTION

Treatment options for patients with fecal incontinence (FI) are limited, and surgical treatments can be associated with high rates of infection and other complications. One treatment, sacral nerve stimulation (SNS), is approved for FI in Europe. A large multicenter trial was conducted in North America and Australia to assess the efficacy of SNS in patients with chronic fecal incontinence. The aim of this report was to analyze the infectious complication rates in that trial.

METHODS

Adult patients with a history of chronic fecal incontinence were enrolled into this study. Those patients who fulfilled study inclusion/exclusion criteria and demonstrated greater than two FI episodes per week underwent a 2-week test phase of SNS. Patients who showed a > or = 50% reduction in incontinent episodes and/or days per week underwent chronic stimulator implantation. Adverse events were reported to the sponsor by investigators at each study site and then coded. All events coded as implant site infection were included in this analysis.

RESULTS

One hundred twenty subjects (92% female, 60.5 +/- 12.5 years old) received a chronically implanted InterStim Therapy device (Medtronic, Minneapolis, MN, USA). Patients were followed for an average of 28 months (range 2.2-69.5). Thirteen of the 120 implanted subjects (10.8%) reported infection after the chronic system implant. One infection spontaneously resolved and five were successfully treated with antibiotics. Seven infections (5.8%) required surgical intervention, with infections in six patients requiring full permanent device explantation. The duration of the test stimulation implant procedure was similar between the infected group (74 min) and the non-infected group (74 min). The average duration of the chronic neurostimulator implant procedure was also similar between the infected (39 min) and non-infected group (37 min). Nine infections occurred within a month of chronic system implant and the remaining four infections occurred more than a year from implantation. While the majority (7/9) of the early infections was successfully treated with observation, antibiotics, or system replacement, all four of the late infections resulted in permanent system explantation.

CONCLUSION

SNS for FI resulted in a relatively low infection rate. This finding is especially important because the only other Food and Drug Administration-approved treatment for end-stage FI, the artificial bowel sphincter, reports a much higher rate. Combined with its published high therapeutic success rate, this treatment has a positive risk/benefit profile.

Factors associated with failure of the artificial bowel sphincter: a study of over 50 cases from Cleveland Clinic Florida

PURPOSE

This study investigated the risk factors related to artificial bowel sphincter infection, complications, and failure.

METHOD

Complications may occur at any time after artificial bowel sphincter implantation. Early-stage complication is defined as any complications that occurred before artificial bowel sphincter activation, whereas late-stage complications are defined as any complications that occurred after device activation. Assessment of the outcomes of all artificial bowel sphincter operations included evaluation of factors related to patient demographics, operative procedures, and postoperative events.

RESULT

From January 1998 to May 2007, 51 artificial bowel sphincter implantations were performed in 47 patients (43; 84.3% female) with a mean age of 48.8 +/- 12.5 (range, 19-79) years and a mean incontinence score of 18 +/- 1.4 (range, 0-20). In 24 patients (54.5%), the etiology of incontinence was secondary to imperforate anus; 15 (24.2%) patients had obstetric injury or anorectal trauma. Twenty-three (41.2%) artificial bowel sphincter implantations became infected, 18 (35.3%) of which developed early-stage infection, whereas 5 (5.9%) had late-stage infection. One patient in the latter group had associated erosion, and two patient had fistula formation. Late-stage complications continued to increase with time. Multivariate analysis revealed that the time between artificial bowel sphincter implantation and first bowel movement and a history of perineal sepsis were independent risk factors for early-stage artificial bowel sphincter infection.

CONCLUSION

The time from implantation to first bowel movement and history of perineal infection were risk factors for early-stage artificial bowel sphincter infection and failure. Late-stage failures were more often the result of device malfunction and indicated the need for mechanical refinement.

Neuromodulation for functional bowel disorders

In patients with functional bowel disorders not responding to maximal medical treatment, bowel lavage or biofeedback therapy, can nowadays be treated by sacral nerve neuromodulation (SNM). SNM therapy has evolved as a treatment for faecal incontinence and constipation. The exact working mechanism remains unknown. It is known that SNM therapy causes direct stimulation of the anal sphincter and causes changes in rectal sensation and several central nervous system areas. The advantage of SNM therapy is the ability to do a minimally invasive temporary screening phase to assess permanent stimulation outcome. Ideal candidates for SNM therapy are not known. Several studies have described positive and negative predictive factors, but the temporary screening remains the instrument of choice. Clinical results are good and as the technique is developing, fewer complications occur. New indications for SNM include constipation and anorectal or pelvic pain.

Oncologic and functional results after abdominoperineal resection plus pseudocontinent perineal colostomy for epidermoid carcinoma of the anus

PURPOSE

Surgical treatment for epidermoid carcinoma of the anus is reserved for patients after failure of primary chemoradiotherapy and consists of abdominoperineal resection with permanent iliac colostomy. The purpose of this study was to analyze the oncologic and the functional outcomes after abdominoperineal resection and pseudocontinent perineal colostomy for epidermoid carcinoma of the anus after external radiation at maximal doses (60 Gy).

METHODS

Between 1990 and 2006, 95 patients underwent abdominoperineal resection for an epidermoid carcinoma of the anus. Eighteen (19 percent) underwent construction of a pseudocontinent perineal colostomy. Functional results were evaluated prospectively at regular intervals.

RESULTS

Complete resection (R0) was obtained in 17 of 18 patients. After a median follow-up of 33 (range, 12-198) months, 15 of 18 patients were alive, and 11 were disease free. Five-year overall and disease-free survival rates were 67 and 53 percent, respectively. Functional outcomes were available for 16 patients. According to the Kirwan score, 15 were continent, and 13 did not require pad protection. Overall, 15 of 16 patients were satisfied.

CONCLUSION

Pelvic reconstruction with a pseudocontinent perineal colostomy does not compromise the beneficial effect of salvage surgery, seems to be safe and feasible even after a high dose of radiotherapy, and provides a high degree of satisfaction.

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.

Long-term outcome of sacral nerve stimulation for fecal incontinence

PURPOSE

Sacral nerve stimulation is a safe and effective procedure for fecal incontinence. We investigated whether its efficacy is maintained long term.

PATIENTS AND METHODS

Sixty patients with fecal incontinence underwent permanent sacral nerve stimulation. Patients' data were prospectively recorded in the national registry of the Italian Group of sacral nerve stimulation. The severity of fecal incontinence was evaluated by the Wexner score, and data were collected in a bowel function diary. Quality of life was evaluated by the Italian version of the Medical Outcomes Survey Short Form (SF-36) questionnaire.

RESULTS

Fifty-two patients were available for long-term follow-up lasting at least 5 years. Compared with baseline, the Wexner score decreased significantly after definitive implantation (from 15 +/- 4 to 5 +/- 5, P < 0.001). At least 50 percent improvement in continence was achieved in 74 percent of the patients, and at least 70 percent improvement (median value) was achieved in 50 percent. The mean number of solid/liquid incontinence episodes decreased significantly from 0.5 (+/-0.5) to 0.1 (+/-0.3) per day (P = 0.004). Quality of life improved in all domains. The overall mean improvement in SF-36 scores was 39.8 percent. Both mean resting and squeeze anal pressures increased significantly, and maximum volume tolerated decreased significantly.

CONCLUSIONS

Sacral nerve stimulation maintains its efficacy long term, not only in regard to control of symptoms but also regarding quality of life.

Surgical treatment of patients with constipation and fecal incontinence

Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.

The artificial bowel sphincter for faecal incontinence: a single centre study

BACKGROUND AND AIMS

Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS).

MATERIALS AND METHODS

Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed.

RESULTS

Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8-106.3) months. The Williams score improved significantly after placement of the ABS (p<0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p=0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p=0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted.

CONCLUSION

The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.

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.

Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique

PURPOSE

Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation.

METHODS

Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles' operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H(2)-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap.

RESULTS

During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P<0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P<0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6-40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux.

CONCLUSIONS

Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy.

[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.

A review of contemporary surgical alternatives to permanent colostomy

OBJECTIVES

To review the options available to patients with faecal incontinence with failed conservative treatment and/or failed anal sphincter repair and assessing the current indications and results of these options.

METHODS

A literature search of MEDLINE, EMBASE and Cochrane databases was performed using the relevant search terms.

RESULTS

Continent options for patients with severe or end stage faecal incontinence include the creation of a form of an anal neosphincter and more recently sacral nerve stimulation. Over half the patients, who are candidates, may benefit from these procedures, although long term results of sacral nerve stimulation are unknown. Dynamic graciloplasty improves the continence in 44-79% of the patients. The complications include frequent reoperations, high incidence of infection and obstructive defaecation. The success rates of artificial bowel sphincter vary between 24% and 79%. Once functional, the artificial bowel sphincter seems to improve the continence in the majority of the patients. Device removal due to infection, obstructive defaecation and pain is a frequent problem. Sacral nerve stimulation is claimed to result in improvement in continence in 35-100% of patients. The main risks in this procedure are infection, electrode displacement and pain.

CONCLUSIONS

All these procedures have high complication rates and have moderate success rates only. A major proportion of patients will need reoperations and hence high motivation is necessary for patients who undergo these procedures. A uniform standard for measurement of success is also necessary so that these procedures can be compared with each other.

A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence

BACKGROUND

Severe fecal incontinence remains a disabling condition for the patient and a major therapeutic challenge for the physician. A series of observational studies have indicated that placement of an artificial bowel sphincter is associated with marked improvement of continence and quality of life. We have performed a prospective, randomized, controlled trial to evaluate the effect of placement of an artificial bowel sphincter (Acticon Neosphincter) on continence and quality of life in a group of severely incontinent adults.

METHODS

Fourteen adults (male:female, 1:13; age range, 44-75 years) were randomized to placement of the artificial bowel sphincter or to a program of supportive care and were followed for six months from operation or entry into the study. The principal outcome measure was the level of continence, measured with the Cleveland Continence Score, which provides a scale from 0 to 20, representing perfect control through to total incontinence. Secondary outcome measures were perioperative and late complications in the artificial bowel sphincter group, and the changes in quality of life in both groups.

RESULTS

In the control group, the Cleveland Continence Score was not significantly altered, with an initial value of 17.1 +/- 2.3 and a final value of 14.3 +/- 4.6 at six months. The artificial bowel sphincter group showed a highly significant improvement, changing from 19.0 +/- 1.2 before placement to 4.8 +/- 4.0 at six months after placement. One patient in the artificial bowel sphincter group had failure of healing of the perineal wound and explantation of the device (14 percent explantation rate). There were two other significant perioperative events of recurring fecal impaction initially after placement in one patient and additional suturing of the perineal wound in another. There were major improvements in the quality of life for all measures in the artificial bowel sphincter group. There was significant improvement in all eight subscales of the Medical Outcome Study Short Form-36 measures. The American Medical Systems Quality of Life score was raised from 39 +/- 6 to 83 +/- 14 and the Beck Depression Inventory showed reduction from a level of mild depression (10.8 +/- 9.3) to a normal value (6.8 +/- 8.7). No significant changes in any of the quality of life measures occurred for the control group.

CONCLUSIONS

Through a prospective, randomized trial format, we have shown that placement of an artificial bowel sphincter is safe and effective when compared with supportive care alone. Perioperative and late problems are likely to continue to occur and between 15 percent and 30 percent of patients may require permanent explantation. For the remainder, the device is easy and discrete to use, highly effective in achieving continence, and able to generate a major improvement in the quality of life.

Disappointing long-term results of the artificial anal sphincter for faecal incontinence

Long term results of ABS disappointing

Dynamic graciloplasty in patients born with an anorectal malformation

PURPOSE

The aim of this study was to compare long-term results for patients born with an anorectal malformation and fecal incontinence treated with a dynamic graciloplasty with those for the total group of patients undergoing dynamic graciloplasty.

METHODS

Consecutive patients with fecal incontinence after surgical treatment of anorectal malformation and treated with dynamic graciloplasty were included in this study. Preoperative assessment was performed. Postoperative follow-up consisted of anorectal manometry and registration of defecation frequency, continence scores, and postponement time of defecation.

RESULTS

Twenty-eight patients with a median age of 25.5 years were included in the study. The median follow-up was 4 years. A high anorectal malformation was present in 89.3 percent of patients. Conventional graciloplasty had been previously performed in 36 percent. All patients were incontinent for stools. Median frequency of defecation was four times/day. Median postponement time of defecation was 0 minutes. Rectoanal inhibition reflex was present in 17 percent of patients. Median preoperative sensory threshold during balloon distention was 30 ml and median maximum urge threshold was 165 ml. Satisfactory continence was reached in 35 percent of patients, however, 7.1 percent of patients gained this continence score by additional bowel irrigation. Twenty-nine percent of patients were incontinent for loose stool, 36 percent were incontinent for formed stool. Satisfactory continence was achieved in only 18 percent of patients with a high anorectal malformation, compared with 100 percent in patients with a low anorectal malformation. In the total group of patients with dynamic graciloplasty, satisfactory continence was obtained in 76 percent. The sensitivity threshold in patients with a successful dynamic graciloplasty was lower than that in patients with a failing dynamic graciloplasty (45 vs. 24 ml, P = 0,06). When we compare median preoperative rectal sensitivity threshold in our study group with that in the total patient group with dynamic graciloplasty, statistical difference was established (P = 0.008). Postponement time (0 to 20 minutes) and anal squeeze pressure (81 to 120 mmHg) increased significantly after surgery. Patients with an anorectal malformation had significantly lower resting and stimulation pressure than that of the total group of patients, but the difference between resting and stimulation pressure in both groups was not significantly different (P = 0.33). The difference between resting and stimulation pressure was not significantly different between anorectal malformation patients with a failing dynamic graciloplasty and patients with a successful dynamic graciloplasty. Complications were noted in 57 percent of patients. Explantation of the dynamic graciloplasty was necessary in 32 percent of patients, mainly because of infection of the implant.

CONCLUSIONS

Results of dynamic graciloplasty for fecal incontinence are reasonable for this specific group of patients with limited treatment options. Despite functional dynamic graciloplasty, the results are worse than those for the total group of patients with dynamic graciloplasty. Rectal sensitivity and type of malformation are prognostic factors for outcome and can be used to select patients for treatment with dynamic graciloplasty, thereby improving treatment outcome.

Outcome after implantation of a novel prosthetic anal sphincter in humans

Background

A novel prosthetic anal sphincter (PAS) has been developed that aims to occlude by flattening and angulating the bowel, reproducing the action of the puborectalis muscle. The safety of the PAS has been confirmed in biomechanical, in vitro and long-term animal survival studies. The Medical Devices Agency approved implantation in 12 patients.

Methods

The PAS was placed in the pelvis around the anorectal junction via a transabdominal approach in 12 patients with severe faecal incontinence. The device was activated 6 weeks after surgery. Fibreoptic examination of the mucosa below the device was undertaken at various intervals during review.

Results

At a median follow-up of 59 (range 30–72) months nine of the 12 patients had a functioning PAS. There were no device-related infective complications after the initial operation but one patient developed pseudomembranous colitis and had the device removed. The PAS was effective in restoring continence in ten of 11 patients. Median (range) Cleveland Clinic continence scores improved from 16 (7–20) before to 3 (0–7) after surgery. In two patients the PAS was eventually removed owing to infection after revisional surgery. There was no clinical or histological evidence of gastrointestinal mucosal ischaemia.

Conclusion

The PAS was effective in restoring continence. There was no device-related infection after the initial operation, no device erosion and no clinical or histological evidence of gastrointestinal ischaemia.

Faecal incontinence in adults

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.

Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence

BACKGROUND

The aim was to determine the safety and effectiveness of the implantation of an artificial bowel sphincter for the treatment of severe faecal incontinence.

METHOD

Medical bibliographic databases, the internet and reference lists were searched from January 1966 to January 2003. Only the lowest level of evidence was available for inclusion in this systematic review. Case series and case reports were selected to assess safety, whereas only case series were selected to assess effectiveness.

RESULTS

Fourteen studies met the inclusion criteria. A number of safety issues were reported, including high explantation rates, and rates of adverse events owing to infection, device malfunction, ulceration and pain. Results in published reports were not analysed on an intention-to-treat basis. Continence, quality of life and manometry scores were reported for patients with a functioning device at the end of follow-up. These patients experienced a significant improvement in their level of continence. As no outcome data were presented for those with a non-functioning or explanted device, it is possible that such patients may have a worsened degree of incontinence or decreased quality of life.

CONCLUSION

Implantation of an artificial bowel sphincter is of uncertain benefit and may possibly harm many patients. Patient selection is therefore critical and should be enhanced by higher-quality research.

Artificial bowel sphincter in severe anal incontinence

OBJECTIVE

The artificial anal sphincter has been suggested as an alternative in the treatment of severe anal incontinence when conventional surgical methods are not possible or have failed. Experience in this procedure is still limited and the results have not yet been sufficiently established. The aim of this study is to evaluate the efficacy of the ACTICON (American Medical Systems, Minneapolis, MN) on patients operated upon in our Unit.

PATIENTS AND METHOD

In this prospective study an ACTICON sphincter was implanted in 10 patients (8 women) with an average age of 56 years and with an average period of severe anal incontinence of 151 months. The origin of incontinence was obstetric injury (n: 4), neuropathy (n: 3) and sphincteral injury from previous anal surgery (n: 3). The degree of continence was measured using the Fecal Incontinence Scoring System (FISS) and the pre- and postoperative anal manometric parameters at 6-month intervals. The average follow-up time for the efficacy of the implanted system was 29 months.

RESULTS

A total of 6 patients [60%] displayed complications in the immediate postoperative period: subaponeurotic reimplantation of the connecting tubes was necessary after infection of the abdominal wound (n:1); superficial dehiscence of the perianal wound (n: 2), infection of the perianal wound (n: 1) and perianal haematoma (n: 2) that were resolved by conservative treatment. For 3 patients [30%] the system was explanted, definitively in one and in 2 of them reimplanted successfully. At the end of the follow-up period, 9 patients [90%] still have an activated artificial sphincter. The score on the Fecal Incontinence System decreased significantly after the system was activated (P < 0.0001) and the pressure with the cuff closed was significantly higher than pre-operative anal pressure (P < 0.0001). All the patients are now continent for solid stool, 56% have occasional involuntary losses of gases and 33% occasionally have involuntary losses of gases and liquid stool. Only 2 patients [22%] have complete continence.

CONCLUSIONS

Our findings indicate that the ACTICON artificial anal sphincter is well tolerated and can be an effective alternative in the treatment of severe anal incontinence. Although complete continence is only achieved in a low percentage of cases, for the rest of the patients the ACTICON neosphincter reduces the symptoms considerably.

Development of an implantable artificial anal sphincter using a shape memory alloy

BACKGROUND/PURPOSE

The authors created a new artificial anal sphincter using a shape memory alloy (AS-SMA) to treat fecal incontinence and evaluated its validity.

METHODS

AS-SMA consists of 2 Ti-Ni plates to sandwich the intestine and generates a pressure of 55 mm Hg at its resting position. With the electric power supply, the 2 metals bend to form an almondlike shape making a maximum gap of 33 mm between each other at the temperature of 55 degrees C. The device was attached to the colostomy in a piglet and was operated several times a day for 1 month. Fecal continence, bowel movements, and general condition of the piglet were recorded. After the experiment, tissue damage around the device was investigated.

RESULTS

Fecal continence was obtained while the device was in the resting position. When it was operated, bowel movements were observed. The bowel movements to operations ratio was 82:105 (78%). During the experiment, the animal had neither abdominal distension nor vomiting. At the autopsy, there was mild inflammation and shallow burns around the device. No compression injury was detected.

CONCLUSIONS

AS-SMA achieved fecal continence of the colostomy. With reduction of the associated side effects, it would be a potential substitute for an impaired anal sphincter.

Novel surgical approaches to fecal incontinence: neurostimulation and artificial anal sphincter

Neurostimulation, neosphincters with neurostimulation, and implanted artificial sphincters are recently developed therapeutic options for patients with end-stage fecal incontinence. Of these approaches, sacral nerve electric stimulation appears to be the most promising because of its relative simplicity and low morbidity. However, it is best suited for patients with anatomically intact sphincters. The other procedures target patients with gross structural defects in the sphincter but are still in their infancy. In this article we discuss these techniques and review their rationale, mechanisms of action, indications, outcomes, and complications.

Fecal incontinence

The treatment of fecal incontinence is particularly gratifying because the loss of fecal control has a devastating effect on a patients lifestyle. One must consider the myriad factors that influence bowel control to properly diagnose and treat each patient. Physiology testing, particularly the use of ultrasound, is essential when treatment extends beyond dietary and medical management. Recent reports suggest that the success of typical treatments may diminish with time. This may indicate a greater need in the future for innovative options such as the artificial bowel sphincter or sacral stimulation.

Surgical intervention for faecal incontinence in women: an update

PURPOSE OF REVIEW

In this review we intend to overview the operations available for faecal incontinence with particular reference to recently published articles.

RECENT FINDINGS

Operations benefiting faecal incontinence in women are direct sphincter repair, dynamic graciloplasty, artificial anal sphincter and sacral nerve stimulation. Considerable benefit was demonstrated with these operations but not without complications. Studies with longer follow-up are required for better assessment of these operations.

SUMMARY

Surgery for faecal incontinence is indicated after failure of non-operative measures. Good results may be achieved.