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Desprez C, Vernon V, Gourcerol G, Tuech JJ, Bridoux V, Leroi AM. Botulinum toxin injections for treatment of faecal incontinence after rectal resection. Br J Surg 2024; 111:znae192. [PMID: 39090748 DOI: 10.1093/bjs/znae192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/26/2024] [Accepted: 07/10/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Charlotte Desprez
- Department of Digestive Physiology, Université de Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, CIC-CRB 1404, Rouen, France
| | | | - Guillaume Gourcerol
- Department of Digestive Physiology, Université de Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, CIC-CRB 1404, Rouen, France
| | | | - Valérie Bridoux
- Department of Digestive Surgery, Université de Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, Rouen, France
| | - Anne-Marie Leroi
- Department of Digestive Physiology, Université de Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, CIC-CRB 1404, Rouen, France
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Knowles CH. Parsimony prevails: Botulinum toxin and the overactive rectum. Lancet Gastroenterol Hepatol 2024; 9:98-100. [PMID: 38128555 DOI: 10.1016/s2468-1253(23)00355-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Charles H Knowles
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK; Cleveland Clinic London, London, UK.
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Leroi AM, Queralto M, Zerbib F, Siproudhis L, Vitton V, Amarenco G, Etienney I, Mion F, Bridoux V, Philip J, Brochard C, Damon H, Lacroix E, Gillibert A, Gourcerol G. Intrarectal injections of botulinum toxin versus placebo for the treatment of urge faecal incontinence in adults (FI-Toxin): a double-blind, multicentre, randomised, controlled phase 3 study. Lancet Gastroenterol Hepatol 2024; 9:147-158. [PMID: 38128556 DOI: 10.1016/s2468-1253(23)00332-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Non-randomised studies assessing intrarectal botulinum toxin type A (BoNTA) injections for faecal incontinence are promising. We aimed to evaluate the efficacy of BoNTA for the treatment of faecal incontinence in a randomised study. METHODS In this randomised, double-blind, placebo-controlled study, we included adult patients who had at least one urgency or faecal incontinence episode per week for at least 3 months and who had experienced a failure of conservative or surgical treatment from eight French specialist hospital units with the skills to manage patients with faecal incontinence. Patients were randomly assigned (1:1) by a central web form to receive intrarectal submucosal injections of either 200 units of BoNTA (Botox; Allergan, Irvine, CA, USA; BoNTA group) or an equivalent volume of saline (placebo group), stratified by Cleveland Clinic Severity scores (CCS score; ≥12 or <12). Patients, investigators, study site staff, and sponsor personnel were masked to treatment allocation up to the 6-month visit. The primary endpoint was the number of episodes of faecal incontinence and urgency per day assessed using 21-day patient bowel diaries 3 months after the treatment. The primary analysis was performed using a modified intention-to-treat (mITT) approach (ie, in all the randomised patients who had received a treatment) with adjustment for baseline faecal incontinence and urgency episodes. After the final data collection at 6 months after injections, patients were unmasked and offered the BoNTA treatment if they were in the placebo group (rescue therapy) without masking, with an additional 6 months of safety follow-up. This trial is registered with ClinicalTrials.gov, number NCT02414425. FINDINGS Between Nov 25, 2015, and Nov 25, 2020, we randomly assigned 200 patients to receive either BoNTA (n=100) or placebo (n=100) injections. Due to withdrawals before the injections, 96 patients were included in the BoNTA group and 95 patients were included in the placebo group (mITT analysis). The mean number of faecal incontinence and urgency episodes per day in the BoNTA group decreased from 1·9 (SD 2·2) at baseline to 0·8 (1·8) at 3 months after the injections, and from 1·4 (1·1) to 1·0 (1·0) in the placebo group, with a baseline-adjusted mean group difference at 3 months estimated at -0·51 (95% CI -0·80 to -0·21, p=0·0008). No serious treatment-related adverse events were reported in the trial. The most frequently reported non-serious adverse event (treatment related or not) following the BoNTA or placebo injections was constipation (reported in 68 [40%] of 169 patients who received the BoNTA injections and 38 [40%] of 95 patients who received placebo injections). INTERPRETATION BoNTA injections are an efficacious treatment for urge faecal incontinence. Further research will define the optimum selection criteria, dose, site of injection, re-injection frequency, and long-term results. FUNDING General Direction of Healthcare (French Ministry of Health).
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Affiliation(s)
- Anne-Marie Leroi
- Université de Rouen Normandie, Institut National de la Santé et de la Recherche Médicale (INSERM), ADEN UMR1073, Centre Hospitalier Universitaire (CHU) Rouen, Centre d'Investigation Clinique-Centre de Ressources Biologiques (CIC-CRB) 1404, Department of Digestive Physiology, Rouen, France.
| | - Michel Queralto
- Colproctology Unit, Clinique des Cèdres, Cornebarrieu, France
| | - Frank Zerbib
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Levêque, Department of Gastroenterology, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Laurent Siproudhis
- Department of Gastroenterology, Inphy CIC1414, CHU Rennes, Université de Rennes 1, Rennes, France
| | - Véronique Vitton
- Department of Gastroenterology, Hôpital Nord, Assistance-Publique Hôpitaux de Marseille, Aix-Marseille Université, France
| | - Gérard Amarenco
- Sorbonne Université, Groupe de Recherche Clinique (GRC) 001, GREEN GRC en Neuro-Urologie, Assistance Publique - Hôpitaux de Paris, Tenon Hospital, Paris, France
| | - Isabelle Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Francois Mion
- Université de Lyon, Department of Digestive Physiology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Valerie Bridoux
- Université de Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, Department of Digestive Surgery, Rouen, France
| | - Julie Philip
- Colproctology Unit, Clinique des Cèdres, Cornebarrieu, France
| | - Charlène Brochard
- Diseases of the Digestive Tract Department, Functional Digestive Explorations Division, Centre Hospitalier Régional Universitaire Pontchaillou, CIC1414, Université de Rennes 1, Rennes, France; INSERM U1235, Université de Nantes, Nantes, France
| | - Henri Damon
- Université de Lyon, Department of Digestive Physiology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Elie Lacroix
- Department of Biostatistics, CHU Rouen, Rouen, France
| | | | - Guillaume Gourcerol
- Université de Rouen Normandie, Institut National de la Santé et de la Recherche Médicale (INSERM), ADEN UMR1073, Centre Hospitalier Universitaire (CHU) Rouen, Centre d'Investigation Clinique-Centre de Ressources Biologiques (CIC-CRB) 1404, Department of Digestive Physiology, Rouen, France
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Sabiote L, Llorens E, Quiroz Y, Sierra L, Palou J, Bujons A. Is Onabotulinum Toxin-A Combined Injection in the Bowel Patch and the Bladder Remnant a Safe Alternative to Bladder Re-Augmentation? Urology 2021; 157:227-232. [PMID: 33848531 DOI: 10.1016/j.urology.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/20/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess both the safety and efficacy, in terms of symptomatic improvement, of botulinum toxin injections distributed in the bowel patch and the bladder remnant of failed augmented bladders. MATERIALS AND METHODS A retrospective study was performed on patients with augmented bladders who had presented with clinical and/or urodynamic failure and had received an onabotulinum1 toxin-A (BTX-A) injection at both the bowel and the bladder level due to refractoriness to oral treatment. The primary variable tested was safety, which was assessed by analysing the adverse effects according to the Clavien-Dindo classification. Subjective improvement was assessed by means of the Treatment Benefit Scale (TBS) as a secondary variable. RESULTS Eight patients who underwent a total of 23 procedures were analysed. The mean age at first injection was 23 years. The mean interval between bladder augmentation and first BTX-A injection was 65.11 months. The mean interval between BTX-A injections was 11.6 months. No adverse effects due to systemic absorption were recorded. The only postoperative complication was an afebrile urinary infection (Clavien-Dindo 2) in 2 out of 23 procedures (8.7%). Eighty-six percent (19/22) of the procedures yielded a symptomatic benefit (TBS 1 and 2). CONCLUSION Injection of onabotulinum toxin-A in both the bowel patch and the bladder remnant appears to be a safe and efficient technique for the symptomatic treatment of patients with bladder augmentation who have shown clinical and/or urodynamic failure in response to a conservative treatment. This procedure allows bladder re-augmentation to be delayed or even avoided.
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Affiliation(s)
- L Sabiote
- Fundació Puigvert, Barcelona, Spain.
| | | | - Y Quiroz
- Fundació Puigvert, Barcelona, Spain
| | - L Sierra
- Fundació Puigvert, Barcelona, Spain
| | - J Palou
- Fundació Puigvert, Barcelona, Spain
| | - A Bujons
- Fundació Puigvert, Barcelona, Spain
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D’Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 PMCID: PMC7707876 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D’Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Toia B, Pakzad MH, Hamid R, Wood DN, Greenwell TJ, Ockrim JL. The efficacy of onabotulinumtoxinA in patients with previous failed augmentation cystoplasty: Cohort series and literature review. Neurourol Urodyn 2020; 39:1831-1836. [PMID: 32572987 DOI: 10.1002/nau.24432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 11/08/2022]
Abstract
AIMS To investigate the role of onabotulinumtoxinA (BTX-A) injections in patients with failed augmentation cystoplasty for neuropathic or idiopathic detrusor overactivity (NDO or IDO). METHODS A retrospective review of all cystoplasty patients who underwent onabotulinumtoxinA injection at a tertiary center between 2008 and 2019 was performed. Details including indications and time from cystoplasty, video-urodynamic parameters, onabotulinumtoxinA dose, and clinical outcomes were analyzed. Telephone interview was performed for patients that requested repeat onabotulinumtoxinA injections. The interview included a modified PGIC7 and UDI6 questionnaires. A positive clinical response was considered improvement of overactive symptoms sufficient to merit repeat onabotulinumtoxinA injection and a modified PGIC7 of four or above. RESULTS Thirty patients were identified (11 men and 19 women). The indications for augmentation were IDO (n = 18) or NDO (n = 12). Mean age at the time of cystoplasty was 42 years (range, 10-61). Interval between cystoplasty and initial onabotulinumtoxinA was 98 months (range, 3-271). Video-urodynamics before onabotulinumtoxinA revealed low compliance in 13 patients, DO in 22 patients, and combined low compliance/DO in 10. The median maximum cystometric bladder capacity was 338 mL (range, 77-570 mL). Thirteen patients responded to onabotulinumtoxinA injections. Higher peak DO pressure was associated with a significantly higher chance that the patient would experience benefit from the injections P = .026). The patients that responded to onabotulinumtoxin A underwent a total of 115 procedures (mean, 8.8 injections) over a mean 88 months (range, 20-157 months). CONCLUSIONS Forty-three percent of patients responded well to intra-detrusor onabotulinumtoxinA injections. This avoided the need for more invasive surgery and had a positive impact on their quality of life.
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Affiliation(s)
- Bogdan Toia
- Department of Urology, University College London Hospital, London, UK
| | - Mahreen H Pakzad
- Department of Urology, University College London Hospital, London, UK
| | - Rizwan Hamid
- Department of Urology, University College London Hospital, London, UK
| | - Dan N Wood
- Department of Urology, University College London Hospital, London, UK
| | | | - Jeremy L Ockrim
- Department of Urology, University College London Hospital, London, UK
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Michel F, Ciceron C, Bernuz B, Boissier R, Gaillet S, Even A, Chartier-Kastler E, Denys P, Gamé X, Ruffion A, Normand LL, Perrouin-Verbe B, Saussine C, Manunta A, Forin V, De Seze M, Grise P, Tournebise H, Schurch B, Karsenty G. Botulinum Toxin Type A Injection After Failure of Augmentation Enterocystoplasty Performed for Neurogenic Detrusor Overactivity: Preliminary Results of a Salvage Strategy. The ENTEROTOX Study. Urology 2019; 129:43-47. [DOI: 10.1016/j.urology.2019.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 11/25/2022]
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Biardeau X, Haddad R, Chesnel C, Charlanes A, Hentzen C, Turmel N, Campagne S, Capon G, Fatton B, Gamé X, Jeandel C, Kerdraon J, Mares P, Mezzadri M, Petit AC, Peyronnet B, Soler JM, Thuillier C, Deffieux X, Robain G, Amarenco G, Manceau P. [Use of botulinum toxin A in pelvic floor dysfunctions in the elderly: A review]. Prog Urol 2019; 29:216-225. [PMID: 30621961 DOI: 10.1016/j.purol.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly. METHODS The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated. RESULTS Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended. CONCLUSION BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.
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Affiliation(s)
- X Biardeau
- Service d'urologie et d'andrologie, hôpital Claude-Huriez, université Lille, CHU Lille, 59000 Lille, France.
| | - R Haddad
- Service de médecine physique et réadaptation, hôpital Rotschild, 75012 Paris, France
| | - C Chesnel
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de neuro-urologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - A Charlanes
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de neuro-urologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - C Hentzen
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de neuro-urologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - N Turmel
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de neuro-urologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - S Campagne
- Service de gynécologie, CHU Estaing, 63003 Clermont-Ferrand, France
| | - G Capon
- Service d'urologie, centre hospitalier Pellegrin, 33076 Bordeaux, France
| | - B Fatton
- Service de gynécologie, CHU de Nîmes, 30000 Nîmes, France
| | - X Gamé
- Service d'urologie, transplantation rénale et andrologie, CHU Rangueil, 31000 Toulouse, France
| | - C Jeandel
- Service de gériatrie, CHU de Montpellier, 34000 Montpellier, France
| | - J Kerdraon
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Centre mutualiste de rééducation et réadaptation Kerpape, BP 78, 56275 Ploemeur cedex, France
| | - P Mares
- Service d'urologie, CHRU Carémeau, 30029 Nîmes cedex 9, France
| | - M Mezzadri
- Service de gynécologie, hôpital Lariboisière, AP-HP, 75010 Paris, France
| | - A-C Petit
- Centre de santé, 8, rue Neibecker, 93440 Dugny, France
| | - B Peyronnet
- Service d'urologie, CHU de Rennes, 35000 Rennes, France
| | - J-M Soler
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de médecine physique et réadaptation, centre Bouffard-Vercelli, 66290 Cerbère, France
| | - C Thuillier
- Service d'urologie, CHU de Grenoble, 38700 La Tronche, France
| | - X Deffieux
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de gynécologie, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France
| | - G Robain
- Service de médecine physique et réadaptation, hôpital Rotschild, 75012 Paris, France; GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France
| | - G Amarenco
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de neuro-urologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - P Manceau
- GRC 01, Green-groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne universités, AP-HP, 75020 Paris, France; Service de neuro-urologie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France; Service de neurologie, hôpital Avicennes, 93000 Bobigny, France
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- Groupe de recherche appliquée à la pathologie pelvi-périnéale des personnes âgées (GRAPPPA), 75020 Paris, France
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Darwish B, Roman H. Surgical treatment of deep infiltrating rectal endometriosis: in favor of less aggressive surgery. Am J Obstet Gynecol 2016; 215:195-200. [PMID: 26851598 DOI: 10.1016/j.ajog.2016.01.189] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/17/2016] [Accepted: 01/28/2016] [Indexed: 02/08/2023]
Abstract
Deep infiltrating endometriosis of the rectum is a severe disease concerning young women of reproductive age. Because it is a benign condition, aggressive surgical treatment and subsequent complications are not always accepted by young patients. Two surgical approaches exist: the radical approach, employing colorectal resection; and the conservative approach, based on rectal shaving or full-thickness disc excision. At present, the majority of patients with rectal endometriosis worldwide are managed by the radical approach. Conversely, as high as 66% of patients with colorectal endometriosis can be managed by either rectal shaving or full-thickness disc excision. Most arguments that used to support the large use of the radical approach may now be disputed. The presumed higher risk of recurrence related to conservative surgery can be balanced by a supposed higher risk of postoperative bowel dysfunction related to the radical approach. Bowel occult microscopic endometriosis renders debatable the hypothesis that more aggressive surgery can definitively cure endometriosis. Although most surgeons consider that radical surgery is unavoidable in patients with rectal nodules responsible for digestive stenosis, conservative surgery can be successfully performed in a majority of cases. In multifocal bowel endometriosis, multiple conservative procedures may be proposed, provided that the nodules are separated by segments of healthy bowel of longer than 5 cm. Attempting conservation of a maximum length of rectum may reduce the risk of postoperative anterior rectal resection syndrome and subsequent debilitating bowel dysfunction and impaired quality of life. Promotion of less aggressive surgery with an aim to better spare organ function has become a general tendency in both oncologic and benign pathologies; thus the management of deep colorectal endometriosis should logically be concerned, too.
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Benezech A, Bouvier M, Vitton V. Faecal incontinence: Current knowledges and perspectives. World J Gastrointest Pathophysiol 2016; 7:59-71. [PMID: 26909229 PMCID: PMC4753190 DOI: 10.4291/wjgp.v7.i1.59] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/31/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools.
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Roman H, Bridoux V, Tuech JJ, Marpeau L, da Costa C, Savoye G, Puscasiu L. Bowel dysfunction before and after surgery for endometriosis. Am J Obstet Gynecol 2013; 209:524-30. [PMID: 23583209 DOI: 10.1016/j.ajog.2013.04.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/25/2013] [Accepted: 04/04/2013] [Indexed: 01/28/2023]
Abstract
The relationship between deep fibrotic endometriosis of the rectum and digestive symptoms as well as the impact of surgical treatment on digestive complaints appears increasingly complex. With the exception of cases in which the disease leads to rectal stenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatory phenomena leading to irritation of the digestive tract and not necessarily the result of actual involvement of the rectum by the disease itself because they frequently occur in women free of rectal nodules. Functional or inflammatory bowel diseases and rectal hypersensitivity may be associated with pelvic endometriosis and consequently joepardize the hypothetical causal relationship between the presence of a rectal nodule and digestive complaints. Women treated surgically for rectal endometriosis may continue to experience postoperative digestive complaints, such as constipation. Despite successful surgery free of intra- and postoperative complications and significant improvement in well-being and pelvic pain, several unpleasant digestive symptoms may be incompletely cured by the surgery. Furthermore, de novo postoperative digestive complaints may occur after rectal surgery. Retrospective data suggest that performing colorectal resection is related to less favorable digestive functional outcomes than the use of conservative procedures such as shaving or full-thickness disc excision. These hypotheses need to be confirmed by prospective randomized trials comparing rectal radical and conservative approaches. Bearing in mind the complex relationship between rectal nodules, digestive symptoms and rectal surgery, particular care must be taken in the preoperative assessment of digestive function and in choosing the most suitable surgical procedure.
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Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril 2013; 99:1695-704. [PMID: 23465818 DOI: 10.1016/j.fertnstert.2013.01.131] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/05/2013] [Accepted: 01/21/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To compare delayed digestive outcomes in women managed by two different surgical philosophies: a radical approach mainly related to colorectal resection, and a conservative approach involving rectal shaving and rectal nodule excision. DESIGN "Before and after" comparative retrospective study. SETTING University tertiary referral center. PATIENT(S) Seventy-five patients managed by surgery for deep endometriosis infiltrating the rectum. INTERVENTION(S) Twenty-four women were managed during a period when surgeons pursued a radical philosophy toward treatment, and 51 women were managed during a period when a conservative philosophy was adopted. MAIN OUTCOMES MEASURE(S) Standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott Symptom Questionnaire, the Bristol Stool Score, and the Fecal Incontinence Quality of Life Score. RESULT(S) Preoperative patient characteristics, rectal nodule features, and associated localizations of the disease were comparable between the two groups. During the radical period, colorectal resection was carried out in 67% of patients, whereas during the second period only 20% of women underwent colorectal resection. Women managed according to the conservative philosophy had significantly improved results on the Knowles-Eccersley-Scott Symptom Questionnaire, Gastrointestinal Quality of Life Index, and depression/self-perception Fecal Incontinence Quality of Life Score, and significantly improved values for various items related to postoperative constipation: unsuccessful evacuatory attempts, feeling incomplete evacuation, abdominal pain, time taken to evacuate, difficulty evacuating causing a painful effort, and stool consistency. CONCLUSION(S) It seems that reducing the rate of colorectal resection leads to better functional outcomes in women presenting with rectal endometriosis, lending support to the conservative surgical philosophy over mandatory colorectal resection.
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Hotouras A, Chan CL. Re: Botulinum A toxin as a treatment for overactive rectum with associated faecal incontinence. Colorectal Dis 2012; 14:898-9. [PMID: 22564854 DOI: 10.1111/j.1463-1318.2012.03064.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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