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Sarveazad A, Yari A, Babaei-Ghazani A, Mokhtare M, Bahardoust M, Asar S, Shamseddin J, Yousefifard M, Babahajian A. Combined application of chondroitinase ABC and photobiomodulation with low-intensity laser on the anal sphincter repair in rabbit. BMC Gastroenterol 2021; 21:473. [PMID: 34911454 PMCID: PMC8672605 DOI: 10.1186/s12876-021-02047-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022] Open
Abstract
Background Photobiomodulation with low-intensity laser (LIL) and chondroitinase ABC (ChABC) can repair damaged muscle tissue, so the aim of this study was to investigate the effect of co-administration of these two factors on anal sphincter repair in rabbits. Methods Male rabbits were studied in 5 groups (n = 7): Control (intact), sphincterotomy, laser, ChABC and laser + ChABC. 90 days after intervention were evaluated resting and maximum squeeze pressures, number of motor units, collagen amount, markers of muscle regeneration and angiogenesis. Results Resting pressure in the Laser + ChABC group was higher than the sphincterotomy, laser and ChABC groups (p < 0.0001). Maximum squeeze pressure in the all study groups was higher than sphincterotomy group (p < 0.0001). In the laser + ChABC and ChABC groups, motor unit numbers were more than the sphincterotomy group (p < 0.0001). Collagen content was significantly decreased in the laser (p < 0.0001) and laser + ChABC groups. ACTA1 (p = 0.001) and MHC (p < 0.0001) gene expression in the Laser + ChABC group were more than the laser or ChABC alone. VEGFA (p = 0.009) and Ki67 mRNA expression (p = 0.01) in the Laser + ChABC group were more than the laser group, But vimentin mRNA expression (p < 0.0001) was less than the laser group. Conclusion Co-administration of ChABCs and photobiomodulation with LIL appears to improve the tissue structure and function of the anal sphincter in rabbits more than when used alone. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-02047-2.
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Affiliation(s)
- Arash Sarveazad
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abazar Yari
- Department of Anatomy, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran.,Dietary Supplements and Probiotics Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Arash Babaei-Ghazani
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Tehran, Iran.,Department of Physical Medicine and Rehabilitation, University of Montreal Health Center, Montreal, Canada
| | - Marjan Mokhtare
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mansour Bahardoust
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siavash Asar
- Department of Anesthesiology, Kerman University of Medical Sciences, Kerman, Iran
| | - Jebreil Shamseddin
- Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, P.O Box: 14665-354, Tehran, Iran.
| | - Asrin Babahajian
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, P.O Box: 14665-354, Sanandaj, Iran.
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Dadhich P, Bohl JL, Tamburrini R, Zakhem E, Scott C, Kock N, Mitchell E, Gilliam J, Bitar KN. BioSphincters to treat Fecal Incontinence in Nonhuman Primates. Sci Rep 2019; 9:18096. [PMID: 31792260 PMCID: PMC6888838 DOI: 10.1038/s41598-019-54440-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/12/2019] [Indexed: 02/07/2023] Open
Abstract
Loss of anorectal resting pressure due to internal anal sphincter (IAS) dysfunctionality causes uncontrolled fecal soiling and leads to passive fecal incontinence (FI). The study is focused on immediate and long-term safety and potential efficacy of bioengineered IAS BioSphincters to treat passive FI in a clinically relevant large animal model of passive FI. Passive FI was successfully developed in Non-Human Primates (NHPs) model. The implantation of autologous intrinsically innervated functional constructs resolved the fecal soiling, restored the resting pressure and Recto Anal Inhibitory Reflex (RAIR) within 1-month. These results were sustained with time, and efficacy was preserved up to 12-months. The histological studies validated manometric results with the regeneration of a well-organized neuro-muscular population in IAS. The control groups (non-treated and sham) remained affected by poor anal hygiene, lower resting pressure, and reduced RAIR throughout the study. The pathological assessment of implants, blood, and the vital organs confirmed biocompatibility without any adverse effect after implantation. This regenerative approach of implanting intrinsically innervated IAS BioSphincters has the potential to offer a better quality of life to the patients suffering from FI.
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Affiliation(s)
- Prabhash Dadhich
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jaime L Bohl
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Riccardo Tamburrini
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Elie Zakhem
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Christie Scott
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Nancy Kock
- Department of Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Erin Mitchell
- Animal Resources Program, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - John Gilliam
- Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Khalil N Bitar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA.
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3
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Jeong H, Hwang SH, Kim HR, Ryu KO, Lim J, Yu HM, Yoon J, Kim CY, Jeong KY, Jung YJ, Jeong IS, Choi YG. Effectiveness of Autologous Fat Graft in Treating Fecal Incontinence. Ann Coloproctol 2019; 35:144-151. [PMID: 31288503 PMCID: PMC6625772 DOI: 10.3393/ac.2018.09.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/15/2018] [Indexed: 12/22/2022] Open
Abstract
Purpose The most common risk factor for fecal incontinence (FI) is obstetric injury. FI affects 1.4%–18% of adults. Most patients are unaware when they are young, when symptoms appear suddenly and worsen with aging. Autologous fat graft is widely used in cosmetic surgical field and may substitute for injectable bulky agents in treating FI. Authors have done fat graft for past several years. This article reports the effectiveness of the fat graft in treating FI and discusses satisfaction with the procedure. Methods Fat was harvested from both lateral thighs using 10-mL Luer-loc syringe. Pure fat was extracted from harvests and mixed with fat, oil, and tumescent through refinement. Fats were injected into upper border of posterior ano-rectal ring, submucosa of anal canal and intersphincteric space. Thirty-five patients with FI were treated with this method from July 2016 to February 2017 in Busan Hangun Hospital. They were 13 male (mean age, 60.8 years) and 22 female patients (mean age, 63.3 years). The Wexner score was checked before procedure. We evaluated outcome in outpatients by asking the patients. For 19 patients we checked the Wexner score after procedure. Results Symptom improved in 29 (82.9%), and not improved in 6 (17.1%). In 2 of 6 patients, they felt better than before procedure, although not satisfied. No improvement in 4. Mean Wexner score was 9.7 before procedure. There were no serious complications such as inflammation or fat embolism. Conclusion Autologous fat graft can be an effective alternative treatment for FI. It is safe and easy to perform, and cost effective.
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Affiliation(s)
| | | | - Hyoung Rae Kim
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - Kil O Ryu
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - Jiyong Lim
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - Hye Mi Yu
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - Jihoon Yoon
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - Chee Young Kim
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | | | - Young Jae Jung
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - In Seob Jeong
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
| | - Young Gil Choi
- Department of Surgery, Busan Hangun Hospital, Busan, Korea
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4
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Tiernan J, Bhatt A, Liska D. An Unusual Case of Submucosal Rectal Nodules. Gastroenterology 2018; 155:e5-e6. [PMID: 29885317 DOI: 10.1053/j.gastro.2018.05.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 05/21/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Jim Tiernan
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
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5
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Bohl JL, Zakhem E, Bitar KN. Successful Treatment of Passive Fecal Incontinence in an Animal Model Using Engineered Biosphincters: A 3-Month Follow-Up Study. Stem Cells Transl Med 2017; 6:1795-1802. [PMID: 28678378 PMCID: PMC5689776 DOI: 10.1002/sctm.16-0458] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/17/2017] [Indexed: 12/20/2022] Open
Abstract
Fecal incontinence (FI) is the involuntary passage of fecal material. Current treatments have limited successful outcomes. The objective of this study was to develop a large animal model of passive FI and to demonstrate sustained restoration of fecal continence using anorectal manometry in this model after implantation of engineered autologous internal anal sphincter (IAS) biosphincters. Twenty female rabbits were used in this study. The animals were divided into three groups: (a) Non‐treated group: Rabbits underwent IAS injury by hemi‐sphincterectomy without treatment. (b) Treated group: Rabbits underwent IAS injury by hemi‐sphincterectomy followed by implantation of autologous biosphincters. (c) Sham group: Rabbits underwent IAS injury by hemi‐sphincterectomy followed by re‐accessing the surgical site followed by immediate closure without implantation of biosphincters. Anorectal manometry was used to measure resting anal pressure and recto‐anal inhibitory reflex (RAIR) at baseline, 1 month post‐sphincterectomy, up to 3 months after implantation and post‐sham. Following sphincterectomy, all rabbits had decreased basal tone and loss of RAIR, indicative of FI. Anal hygiene was also lost in the rabbits. Decreases in basal tone and RAIR were sustained more than 3 months in the non‐treated group. Autologous biosphincters were successfully implanted into eight donor rabbits in the treated group. Basal tone and RAIR were restored at 3 months following biosphincter implantation and were significantly higher compared with rabbits in the non‐treated and sham groups. Histologically, smooth muscle reconstruction and continuity was restored in the treated group compared with the non‐treated group. Results in this study provided promising outcomes for treatment of FI. Results demonstrated the feasibility of developing and validating a large animal model of passive FI. This study also showed the efficacy of the engineered biosphincters to restore fecal continence as demonstrated by manometry. Stem Cells Translational Medicine2017;6:1795–1802
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Affiliation(s)
- Jaime L Bohl
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, North Carolina, USA
| | - Elie Zakhem
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Department of Molecular Medicine and Translational Sciences, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Khalil N Bitar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Department of Molecular Medicine and Translational Sciences, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Winston Salem, North Carolina, USA.,Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
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6
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Rydningen M, Dehli T, Wilsgaard T, Rydning A, Kumle M, Lindsetmo RO, Norderval S. Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial. Colorectal Dis 2017; 19:O134-O144. [PMID: 28211186 DOI: 10.1111/codi.13632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/09/2016] [Indexed: 02/08/2023]
Abstract
AIM The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS). METHOD This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores. RESULTS Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77). CONCLUSION SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.
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Affiliation(s)
- M Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Dehli
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Wilsgaard
- Department of Community Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - A Rydning
- Department of Gastroenterological Surgery, St Olav's Hospital, Trondheim, Norway
| | - M Kumle
- Department of Radiology, University Hospital of North Norway, Tromsoe, Norway.,Narvik University College, Narvik, Norway
| | - R O Lindsetmo
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - S Norderval
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway.,National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsoe, Norway
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7
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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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8
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Al-Abed YA, Ayers J, Ayantunde A, Praveen BV. Safety and Efficacy of Permacol Injection in the Treatment of Fecal Incontinence. Ann Coloproctol 2016; 32:73-8. [PMID: 27218098 PMCID: PMC4865468 DOI: 10.3393/ac.2016.32.2.73] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/02/2016] [Indexed: 11/23/2022] Open
Abstract
Purpose Permacol has been gaining popularity in recent times for the treatment of fecal incontinence (FI). This study aims to evaluate the safety and efficacy of anal submucosal Permacol injection in the treatment of FI. Methods All consecutive patients who underwent Permacol injection for FI over a 3-year period were included. Patients' data relating to obstetric history, anorectal/pelvic operations, type of FI, preoperative anorectal physiology results and follow-up details for outcome measures were collected. Preoperative and postoperative Cleveland Clinic Florida Incontinence Scores (CCFISs) were noted. Patients were surveyed by using a telephone questionnaire to assess the quality of life and other outcome measures. Data were analysed using SPSS ver.19.0. Results Thirty patients (28 females and 2 males) with a median age of 67 years were included in the study. Of those patients, 37%, 50%, and 13% were noted to have passive, mixed and urge FI, respectively. Six of the patients (20%) had repeat Permacol injections, 5 of whom had sustained responses to the first Permacol injection for a mean of 11 months. There was a significant improvement in the CCFIS from a baseline median of 12.5, mean 12.8 interquartile range [IQR], 6–20), to a median of 3.5, mean 4.8 (IQR, 0–20), P < 0.001. Of the patients surveyed by telephone 89% were satisfied with their overall experience and the improvement in their symptoms following Permacol injections. Conclusion This study has demonstrated that Permacol injection for the treatment of FI is safe and effective and has no associated major complications. However, the results are not permanent; consequently, a significant proportion of the patients with an initial response may require repeat injections.
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Affiliation(s)
- Yahya A Al-Abed
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
| | - Jennifer Ayers
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
| | - Abraham Ayantunde
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
| | - Bandipalyam V Praveen
- Department of Colorectal Surgery, Southend University Hospital, Westcliff on Sea, United Kingdom
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9
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Alam NN, Narang SK, Köckerling F, Daniels IR, Smart NJ. Anal Sphincter Augmentation Using Biological Material. Front Surg 2015; 2:60. [PMID: 26636089 PMCID: PMC4657277 DOI: 10.3389/fsurg.2015.00060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/02/2015] [Indexed: 12/21/2022] Open
Abstract
Introduction The aim of this review is to provide an overview of the use of biological materials in the augmentation of the anal sphincter either as part of an overlapping sphincter repair (OSR) or anal bulking procedure. Methods A systematic search of PubMed was conducted using the search terms “anal bulking agents,” “anal sphincter repair,” or “overlapping sphincter repair.” Five studies using biological material as part of an overlapping sphincter repair (OSR) or as an anal bulking agent were identified. Results 122 patients underwent anal bulking with a biological material. Anorectal physiology was conducted in 27 patients and demonstrated deterioration in maximum resting pressure, and no significant change in maximum squeeze increment. Quality of life scores (QoLs) demonstrated improvements at 6 weeks and 6 months, but this had deteriorated at 12 months of follow up. Biological material was used in 23 patients to carry out an anal encirclement procedure. Improvements in QoLs were observed in patients undergoing OSR as well as anal encirclement using biological material. Incontinence episodes decreased to an average of one per week from 8 to 10 preoperatively. Conclusion Sphincter encirclement with biological material has demonstrated improvements in continence and QoLs in the short term compared to traditional repair alone. Long-term studies are necessary to determine if this effect is sustained. As an anal bulking agent the benefits are short-term.
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Affiliation(s)
- Nasra N Alam
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
| | - Sunil K Narang
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
| | - Ferdinand Köckerling
- Department of Surgery, Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital , Berlin , Germany
| | - Ian R Daniels
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
| | - Neil J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital , Exeter , UK
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10
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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11
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Nasseri YY, Krott E, Van Groningen KM, Berho M, Osborne MC, Wollman S, Weiss EG, Wexner SD. Abnormalities in collagen composition may contribute to the pathogenesis of hemorrhoids: morphometric analysis. Tech Coloproctol 2014; 19:83-7. [PMID: 25381456 PMCID: PMC4315876 DOI: 10.1007/s10151-014-1238-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 09/29/2014] [Indexed: 01/14/2023]
Abstract
Purpose While hemorrhoidal disease is common, its etiology remains unclear. It has been postulated that disturbances in collagen lead to reduced connective tissue stability, and in turn to the development of hemorrhoidal disease. We aimed to compare the quality and quantity of collagen in patients with hemorrhoidal disease versus normal controls. Methods Specimens from 57 patients with grade III or IV internal hemorrhoids undergoing hemorrhoidectomy between 2006 and 2011 were evaluated. Samples from 20 human cadavers without hemorrhoidal disease served as controls. Quality of collagen was analyzed by collagen I/III ratio, and quantity of collagen was determined by collagen/protein ratio. The study group was subdivided into gender and age subgroups. Results The male:female ratios in the study and control groups were 30:27 and 10:10, respectively. Median age was significantly less in the study group [46.9 years (range 20–69)] compared to the control group [76 years (range 46–90)] with P < 0.05. Tissues from patients in the study group had significantly lower collagen I/III ratio as compared to the control group (4.4 ± 1.1 vs. 5.5 ± 0.6; P < 0.0001). Nevertheless, despite a trend toward lower collagen/protein ratio in the study group, it did not reach statistical significance (57 ± 42.4 vs. 73 ± 32.5 g/mg; P = 0.167). There was no difference in collagen I/III or collagen/protein ratios among different age groups and genders. Conclusions Hemorrhoidal tissues from patients with hemorrhoidal disease appear to have reduced mechanical stability as compared to normal controls.
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Affiliation(s)
- Y. Y. Nasseri
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - E. Krott
- Klinik für Allgemein-, Visceral-und Transplantationschirurgie, Universitätsklinikum Aachen, Aachen, Germany
| | - K. M. Van Groningen
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - M. Berho
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - M. C. Osborne
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - S. Wollman
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - E. G. Weiss
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - S. D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
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12
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Abstract
Faecal incontinence is a common condition and is associated with considerable morbidity and economic cost. The majority of patients are managed with conservative interventions. However, for those patients with severe or refractory incontinence, surgical treatment might be required. Over the past 20 years, numerous developments have been made in the surgical therapies available to treat such patients. These surgical therapies can be classified as techniques of neuromodulation, neosphincter creation (muscle or artificial) and injection therapy. Techniques of neuromodulation, particularly sacral nerve stimulation, have transformed the management of these patients with a minimally invasive procedure that offers good results and low morbidity. By contrast, neosphincter procedures are characterized by being more invasive and associated with considerable morbidity, although some patients will experience substantial improvements in their continence. Injection of bulking agents into the anal canal can improve symptoms and quality of life in patients with mild-to-moderate incontinence, and the use of autologous myoblasts might be a future therapy. Further research and development is required not only in terms of the devices and procedures, but also to identify which patients are likely to benefit most from such interventions.
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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: 29] [Impact Index Per Article: 2.9] [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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Abstract
PURPOSE OF REVIEW Fecal incontinence is a significant source of morbidity and decreased quality of life (QOL) for many. Until recent years, few therapies beyond medical management were available for patients. Surgical treatment of fecal incontinence has evolved from colostomy and direct repair of muscle defects to interventional techniques such as nerve stimulation and bulking agents. We review the most recent surgical options for the treatment of fecal incontinence within the context of established therapies. RECENT FINDINGS Overlapping sphincteroplasty is an established therapy that improves continence and QOL, although results deteriorate over time. Implanted artificial bowel sphincter has a 100% complication rate and 80% are explanted over time. Sacral nerve stimulation has minimal risk and more durable long-term improvement in continence. Less invasive versions of nerve stimulation are being researched. Injectable biomaterials have shown some promise, although durability of results is not clear. Novel therapies, including muscle cell transfer and pelvic slings are currently being investigated. SUMMARY Surgical therapies for fecal incontinence continue to evolve and show promise in improving QOL with a lower risk profile. Effective valuation of these therapies is currently limited by heterogeneous studies, short duration of follow up, and inconsistent outcome measures.
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Abstract
The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.
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Affiliation(s)
- Joshua I S Bleier
- Division of Colon and Rectal Surgery, Pennsylvania Hospital/Hospital of the University of Pennsylvania, University of Pennsylvania, 800 Walnut Street, 20th Floor, Philadelphia, PA 19106, USA.
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