Temperature-controlled radiofrequency energy (SECCA) to the anal canal for the treatment of faecal incontinence offers moderate improvement

Temperature-Controlled Delivery of Radiofrequency Energy in Fecal Incontinence: A Randomized Sham-Controlled Clinical Trial

BACKGROUND

Controlled delivery of radiofrequency energy has been suggested as treatment for fecal incontinence.

OBJECTIVE

The aim of this study was to determine whether the clinical response to the radiofrequency energy procedure is superior to sham in patients with fecal incontinence.

DESIGN

This was a randomized sham-controlled clinical trial from 2008 to 2015.

SETTING

This study was conducted in an outpatient clinic.

PATIENTS AND METHODS

Forty patients with fecal incontinence in whom maximal conservative management had failed were randomly assigned to receiving either radiofrequency energy or sham procedure.

MAIN OUTCOME MEASURES

Fecal incontinence was measured using the Vaizey incontinence score (range, 0-24). The impact of fecal incontinence on quality of life was measured by using the fecal incontinence quality-of-life score (range, 1-4). Measurements were performed at baseline and at 6 months. Anorectal function was evaluated using anal manometry and anorectal endosonography at baseline and at 3 months.

RESULTS

At baseline, Vaizey incontinence score was 16.8 (SD 2.9). At t = 6 months, the radiofrequency energy group improved by 2.5 points on the Vaizey incontinence score compared with the sham group (13.2 (SD 3.1), 15.6 (SD 3.3), p = 0.02). The fecal incontinence quality-of-life score at t = 6 months was not statistically different. Anorectal function did not show any alteration.

LIMITATIONS

Patients with severe fecal incontinence were included in the study, thus making it difficult to generalize the results.

CONCLUSIONS

Both radiofrequency energy and sham procedure improved the fecal incontinence score, the radiofrequency energy procedure more than sham. Although statistically significant, the clinical impact for most of the patients was negligible. Therefore, the radiofrequency energy procedure should not be recommended for patients with fecal incontinence until patient-related factors associated with treatment success are known. See Video Abstract at http://links.lww.com/DCR/A373.

Pathophysiology and Therapeutic Options for Fecal Incontinence

Fecal incontinence (FI), defined as the involuntary loss of solid or liquid feces through the anus is a prevalent condition with significant effects on quality of life. FI 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. The severity of incontinence can range from unintentional elimination of flatus to the complete evacuation of bowel contents. It is reported to affect up to 18% of the population, with a prevalence reaching as high as 50% in nursing home residents. However, FI is often underreported, thus obscuring its true prevalence in the general population. The options for treatment vary according to the degree and severity of the FI. Treatment can include dietary and lifestyle modification, certain medications, biofeedback therapy, bulking agent injections, sacral nerve stimulation as well as various types of surgery. In this article, we aim to provide a comprehensive review on the diagnosis and management of FI.

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.

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.

ACG clinical guideline: management of benign anorectal disorders

These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and/or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids. Each section reviews the definitions, epidemiology and/or pathophysiology, diagnostic assessment, and treatment recommendations of each entity. These recommendations reflect a comprehensive search of all relevant topics of pertinent English language articles in PubMed, Ovid Medline, and the National Library of Medicine from 1966 to 2013 using appropriate terms for each subject. Recommendations for anal fissure and hemorrhoids lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and supplemented with subsequent publications through 2013. We used systematic reviews and meta-analyses when available, and this was supplemented by review of published clinical trials.

Clinical response and sustainability of treatment with temperature-controlled radiofrequency energy (Secca) in patients with faecal incontinence: 3 years follow-up

BACKGROUND

Controlled delivery of radio frequent energy (Secca) has been suggested as treatment for faecal incontinence (FI).

OBJECTIVE

The objective of the study is to evaluate clinical response and sustainability of Secca for FI.

DESIGN

This is a prospective cohort study.

PATIENTS

This study involved patients who had failed full conservative management for FI.

INTERVENTIONS

This study was performed between 2005 and 2010.

MAIN OUTCOME MEASURES

FI was scored using the Vaizey score (VS). A clinically significant response to Secca was defined as ≥50 % reduction in incontinence score. Impact of FI on quality of life (QOL) was measured using the FIQL. Data was obtained at baseline, at 6 months and at 1 and 3 years. Anal endosonography and anal manometry were performed at 3 months and compared to baseline.

RESULTS

Thirty-one patients received Secca. During follow-up, 5/31 (16 %), 3/31 (10 %) and 2/31 (6 %) of patients maintained a clinically significant response after the Secca procedure. Mean VS of all patients was 18 (SD 3), 14 (SD 4), 14 (SD 4) and 15 (SD 4), at baseline, 6 months and 1 and 3 years. No increases in anorectal pressures or improvements in rectal compliance were found. Coping improved between baseline and t = 6 months. No predictive factors for success were found.

LIMITATIONS

This is a non-randomised study design.

CONCLUSION

This prospective non-randomised trial showed disappointing outcomes of the Secca procedure for the treatment of FI. The far minority of patients reported a clinically significant response of seemingly temporary nature. Secca might be valuable in combination with other interventions for FI, but this should be tested in strictly controlled randomised trials.

Temperature-controlled radiofrequency energy in patients with anal incontinence: an interim analysis of worldwide data

BACKGROUND

Controlled delivery of radiofrequency energy (SECCA procedure) as treatment for anal incontinence (AI) was introduced 15 years ago. Since then, several clinical studies have emerged. This article evaluates the clinical response and sustainability of SECCA for patients with AI.

METHODS

Only original clinical studies retrieved from PubMed and Medline were included. The outcome measures, faecal incontinence scores, definition of response, clinical results and anorectal evaluation were analysed.

RESULTS

Ten studies were included, which involved 150 original patients. Three studies reported a long-term follow-up. The one-year follow-up shows a moderate effect, which declines somewhat over time. Only minor temporary side-effects are reported and none of the patients declined treatment.

CONCLUSION

SECCA is a safe and well-tolerated procedure that is easy to perform without any serious short- or long-term complications, but with only a moderate clinical effect that declines over time. Results of randomized, sham-controlled controlled trials are awaited.

What's New in the Toolbox for Constipation and Fecal Incontinence?

Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut-brain-microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.

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.

The SECCA procedure for faecal incontinence: a review

AIM

The SECCA system is a treatment option for patients with faecal incontinence and was introduced into clinical practice in 2002. Clinical studies of radiofrequency energy to treat patients with faecal incontinence have been published. This article aimed to review all published series to assess the results of this treatment.

METHOD

Twelve studies were included. Outcomes analysed included quality of life, the Wexner incontinence score, anorectal manometry and endoanal ultrasound findings.

RESULTS

A total of 220 patients from 10 studies were included. In the majority of clinical studies, the SECCA procedure has been shown to be an effective treatment of mild-to-moderate faecal incontinence.

CONCLUSION

When patient selection is appropriate, this treatment has demonstrated clinically significant improvements in symptoms, as demonstrated by statistically significant reductions in the Wexner incontinence and quality of life scores.

Treatments of faecal incontinence: recommendations from the French national society of coloproctology

Faecal incontinence is common and significantly affects quality of life. Its treatment involves dietary manipulation, medical treatments, perineal rehabilitation or surgery. In this paper, the French National Society of Coloproctology offers recommendations based on the data in the current literature, including those on recently developed treatments. There is a lack of high quality data and most of the recommendations are therefore based either on grade of recommendation B or expert recommendation (Level 4). However, the literature supports the construction of an algorithm based on the available scientific evidence and expert recommendation which may be useful in clinical practice. The French National Society of Coloproctology proposes a decision-making algorithm that includes recent developments of treatment. The current recommendations support sacral nerve modulation as the key treatment for faecal incontinence. They do not support the use of sphincter substitutions except in certain circumstances. Transanal irrigation is a novel often successful treatment of faecal incontinence due to neurological disorders.

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.

Radiofrequency treatment for fecal incontinence: is it effective long-term?

OBJECTIVE

The aim of this study was to evaluate the short- and long-term outcome of the radiofrequency treatment for moderate to severe fecal incontinence.

DESIGN

This study is a retrospective review of a single-institution experience.

PATIENTS

Patients who underwent the radiofrequency procedure were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the complication rate, short- and long-term response, and the rate of subsequent intervention for incontinence.

RESULTS

Twenty-seven patients underwent 31 radiofrequency procedures (81% women; mean age, 64 years). Median length of symptoms was 3 years. Biofeedback had failed for 52% of patients, and 23% of patients had previous surgical intervention. Thirty-eight percent of patients had a sphincter defect. Minor complications were observed in 19% of the patients. A treatment response was noted in 78% of the patients (mean Cleveland Clinic Florida Fecal Incontinence Score: 16 (baseline) and 10.9 (3 months postoperatively)). However, a sustained long-term response without any additional intervention was noted in 22% of the patients, and 52% of the patients underwent or are awaiting additional intervention for persistent or recurrent incontinence (mean follow-up, 40 months).

LIMITATION

This study is limited by its retrospective nature and the limited number of subjects.

CONCLUSIONS

The radiofrequency procedure was safe, but a long-term benefit was noted in a minority of patients with moderate to severe fecal incontinence. Additional interventions were required in more than half of the patients. Larger studies are needed to determine the impact of various patient-related factors on the outcome of the radiofrequency treatment to identify the ideal patient for this therapy.

Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up?

PURPOSE

Fecal incontinence is a socially isolating disease that causes physical and psychologic distress. Radiofrequency delivered to the anal canal is a surgical modality for fecal incontinence that has been noted to be safe and potentially effective. The aim of this study was to evaluate improvement in fecal incontinence and quality of life after the radiofrequency procedure at 1-year follow-up.

METHODS

After institutional review board approval, patients with fecal incontinence for at least 3 months were prospectively recruited between March 2003 and June 2004. Patients enrolled in the study underwent the Secca procedure. The Cleveland Clinic Florida Fecal Incontinence Score and the Fecal Incontinence Quality of Life Questionnaire were completed at the first visit and then at 12-month follow-up. Wilcoxon signed rank test was used to analyze the difference between baseline and follow-up.

RESULTS

A total of 24 patients (23 females) were enrolled in the study, and 16 were available at the 12-month follow-up visit. The main causes of fecal incontinence were either idiopathic or included obstetric injury, aging, and trauma from previous anorectal surgeries. The mean operative time was 45.5 +/- 8.3 minutes, and the mean number of radiofrequency lesions in the anal canal was 65.5 +/- 13.8. There were 3 self-limited episodes of postoperative bleeding and 1 instance of constipation that was resolved with laxatives. There were no delayed complications. The mean Cleveland Clinic Florida Fecal Incontinence Score improved from a mean of 15.6 (+/- 3.2) at baseline to 12.9 (+/- 4.6) at 12 months (P = .035). The mean Fecal Incontinence Quality of Life Questionnaire score improved in all subsets except for the depression subscore.

CONCLUSION

Radiofrequency is a safe, minimally invasive tool for treating patients with fecal incontinence. Improvement in fecal incontinence and quality of life was maintained at 12 months without delayed morbidity. The actual significance of this improvement is yet to be determined.

PTQ™ anal implants for the treatment of faecal incontinence

Background

In North Queensland demand for conservative faecal incontinence treatments outweighs supply. Injectable bulking agents offer a safe and effective treatment for patients with internal anal sphincter (IAS) dysfunction.

Methods

Information, including age and sex, baseline incontinence score, quality of life, resting and squeeze pressures, was collected for 74 patients (37 men) who received intersphincteric PTQ™ injections. Postimplant satisfaction was assessed at 6-week review. Incontinence scores and satisfaction ratings were determined annually.

Results

At a median follow-up of 28 months, 52 patients (70 per cent) with IAS dysfunction who received PTQ™ anal implants as a treatment for faecal incontinence were continent and extremely satisfied with the result. The incontinence score in participants who remained incontinent was reduced significantly from 12 of 20 before implant to 3·5 of 20 at follow-up (P < 0·001). Migration rates improved with experience. The poorest results occurred in women with pudendal neuropathy, or patients who had previously received biofeedback treatment.

Conclusion

Implanted PTQ™ provides an effective solution to faecal incontinence in the short and mid term for patients with IAS dysfunction.

Temperature-controlled radio frequency energy delivery (Secca procedure) for the treatment of fecal incontinence: results of a prospective study

PURPOSE

Fecal incontinence (FI) is a debilitating condition that can be socially and personally incapacitating. A broad range of treatment options, often stepwise, are available, depending on severity. This prospective study reports a large single-centered series of patients who have benefited of temperature-controlled radio frequency (Secca) energy delivered to the anal canal.

MATERIAL AND METHODS

This investigation was a single-center, nonrandomized, prospective, clinical study of a single patient group with each serving as the control. All patients had experienced FI for at least 3 months and had attempted, but were not satisfied, with the results of medical and/or surgical therapies. The study aims to evaluate changes in FI symptom scores and quality of life between the baseline and follow-up intervals.

RESULTS

Between March 2005 and March 2006, 15 Secca procedures were performed. All 15 patients were alive and in contact with the investigational site at time of 12 months. There were no long term complications. The mean Wexner score improved from 14.07 (+/-4.5) at baseline to 12.33 (+/-4.6) at 1 year (p=0.02). The mean fecal incontinence quality of life of life score was only improved in the depression subscore. There were no changes in endoanal ultrasound and anorectal manometry.

CONCLUSION

This prospective trial confirmed the safety of the Secca procedure. Although we demonstrated a significant improvement in the Wexner Score, these clinical results have to be mitigated because most patients remained in the moderate incontinences category as defined by the scoring system and did not improved their quality of life excepted in the depression subscore.

Radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?

BACKGROUND

The present study was conducted to assess the efficacy and safety of the delivery of radiofrequency energy to the anal canal (the SECCA procedure).

METHODS

Eight patients with fecal incontinence underwent the SECCA procedure. The Fecal Incontinence Severity Index (FISI) score and the Fecal Incontinence-related Quality of Life (FIQL) scale were completed at baseline and after the procedure. Anorectal manometry and endoanal ultrasound also were conducted.

RESULTS

Seven of the 8 patients were women, and the median age of the patients was 59 years (range, 28-73 y). The mean FISI score and all of the parameters in the FIQL scale with the exception of the embarrassment scale measured at 6 months after the procedure was not improved significantly. We observed no changes in the anal manometry and endoanal ultrasound parameters. Complications associated with the procedure developed in 7 of the 8 patients, including anal bleeding, anal pain, and anal mucosal discharge.

CONCLUSIONS

The FISI score and FIQL scale were not improved significantly after the SECCA procedure, and considerable complications were associated with the procedure.

Referral for anorectal function evaluation is indicated in 65% and beneficial in 92% of patients

AIM: To determine the indicated referrals to a tertiary centre for patients with anorectal symptoms, the effect of the advised treatment and the discomfort of the tests.

METHODS: In a retrospective study, patients referred for anorectal function evaluation (AFE) between May 2004 and October 2006 were sent a questionnaire, as were the doctors who referred them. AFE consisted of anal manometry, rectal compliance measurement and anal endosonography. An indicated referral was defined as needing AFE to establish a diagnosis with clinical consequence (fecal incontinence without diarrhea, 3^rd degree anal sphincter rupture, congenital anorectal disorder, inflammatory bowel disease with anorectal complaints and preoperative in patients for re-anastomosis or enterostoma, anal fissure, fistula or constipation). Anal ultrasound is always indicated in patients with fistula, anal manometry and rectal compliance when impaired continence reserve is suspected. The therapeutic effect was noted as improvement, no improvement but reassurance, and deterioration.

RESULTS: From the 216 patients referred, 167 (78%) returned the questionnaire. The referrals were indicated in 65%. Of these, 80% followed the proposed advice. Improvement was achieved in 35% and a reassurance in 57% of the patients, no difference existed between patient groups. On a VAS scale (1 to 10) symptoms improved from 4.0 to 7.2. Most patients reported no or little discomfort with AFE.

CONCLUSION: Referral for AFE was indicated in 65%. Beneficial effect was seen in 92%: 35% improved and 57% was reassured. Advice was followed in 80%. Better instruction about indication for AFE referral is warranted.