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Dexter E, Walshaw J, Wynn H, Dimashki S, Leo A, Lindsey I, Yiasemidou M. Faecal incontinence-a comprehensive review. Front Surg 2024; 11:1340720. [PMID: 38362459 PMCID: PMC10867159 DOI: 10.3389/fsurg.2024.1340720] [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: 11/18/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date. Methods A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities. Result and discussion This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).
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Affiliation(s)
- Eloise Dexter
- Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Josephine Walshaw
- Leeds Institute of Medical Research, St James’ University Hospital, University of Leeds, Leeds, United Kingdom
- Department of Health Research, University of York, York, United Kingdom
| | - Hannah Wynn
- Upper Gastrointestinal Surgery, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Safaa Dimashki
- Plastic Surgery, Mid Yorkshire Teaching NHS Trust, Wakefield, United Kingdom
| | - Alex Leo
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ian Lindsey
- Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Marina Yiasemidou
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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Kim M, Oh BY, Lee JS, Yoon D, Kim YR, Chun W, Kim JW, Son IT. Differentiation of Adipose-Derived Stem Cells into Smooth Muscle Cells in an Internal Anal Sphincter-Targeting Anal Incontinence Rat Model. J Clin Med 2023; 12:jcm12041632. [PMID: 36836167 PMCID: PMC9959483 DOI: 10.3390/jcm12041632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE Studies on development of an anal incontinence (AI) model targeting smooth muscle cells (SMCs) of the internal anal sphincter (IAS) have not been reported. The differentiation of implanted human adipose-derived stem cells (hADScs) into SMCs in an IAS-targeting AI model has also not been demonstrated. We aimed to develop an IAS-targeting AI animal model and to determine the differentiation of hADScs into SMCs in an established model. MATERIALS AND METHODS The IAS-targeting AI model was developed by inducing cryoinjury at the inner side of the muscular layer via posterior intersphincteric dissection in Sprague-Dawley rats. Dil-stained hADScs were implanted at the IAS injury site. Multiple markers for SMCs were used to confirm molecular changes before and after cell implantation. Analyses were performed using H&E, immunofluorescence, Masson's trichrome staining, and quantitative RT-PCR. RESULTS Impaired smooth muscle layers accompanying other intact layers were identified in the cryoinjury group. Specific SMC markers, including SM22α, calponin, caldesmon, SMMHC, smoothelin, and SDF-1 were significantly decreased in the cryoinjured group compared with levels in the control group. However, CoL1A1 was increased significantly in the cryoinjured group. In the hADSc-treated group, higher levels of SMMHC, smoothelin, SM22α, and α-SMA were observed at two weeks after implantation than at one week after implantation. Cell tracking revealed that Dil-stained cells were located at the site of augmented SMCs. CONCLUSIONS This study first demonstrated that implanted hADSc restored impaired SMCs at the injury site, showing stem cell fate corresponding to the established IAS-specific AI model.
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Affiliation(s)
- Minsung Kim
- Department of Surgery, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang 14068, Republic of Korea
| | - Bo-Young Oh
- Department of Surgery, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang 14068, Republic of Korea
| | - Ji-Seon Lee
- Burn Institute, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea
| | - Dogeon Yoon
- Burn Institute, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea
| | - You-Rin Kim
- Burn Institute, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea
| | - Wook Chun
- Burn Institute, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea
- Department of Surgery, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea
| | - Jong Wan Kim
- Department of Surgery, Dontan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong-si 18450, Republic of Korea
| | - Il Tae Son
- Department of Surgery, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang 14068, Republic of Korea
- Institute for Regenerative Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang 14068, Republic of Korea
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3
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Frudinger A, Gauruder-Burmester A, Graf W, Lehmann JP, Gunnarsson U, Mihov M, Ihnát P, Kosorok P, Orhalmi J, Slauf P, Emmanuel A, Hristov V, Jungwirthova A, Lehur PA, Müller A, Amort M, Marksteiner R, Thurner M. Skeletal Muscle-Derived Cell Implantation for the Treatment of Fecal Incontinence: A Randomized, Placebo-Controlled Study. Clin Gastroenterol Hepatol 2023; 21:476-486.e8. [PMID: 35961517 DOI: 10.1016/j.cgh.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/08/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Fecal incontinence (FI) improvement following injection of autologous skeletal muscle-derived cells has been previously suggested. This study aimed to test the efficacy and safety of said cells through a multicenter, placebo-controlled study, to determine an appropriate cell dose, and to delineate the target patient population that can most benefit from cell therapy. METHODS Patients experiencing FI for at least 6 months were randomized to receive a cell-free medium or low or high dose of cells. All patients received pelvic floor electrical stimulation before and after treatment. Incontinence episode frequency (IEF), FI quality of life, FI burden assessed on a visual analog scale, Wexner score, and parameters reflecting anorectal physiological function were all assessed for up to 12 months. RESULTS Cell therapy improved IEF, FI quality of life, and FI burden, reaching a preset level of statistical significance in IEF change compared with the control treatment. Post hoc exploratory analyses indicated that patients with limited FI duration and high IEF at baseline are most responsive to cells. Effects prevailed or increased in the high cell count group from 6 to 12 months but plateaued or diminished in the low cell count and control groups. Most physiological parameters remained unaltered. No unexpected adverse events were observed. CONCLUSIONS Injection of a high dose of autologous skeletal muscle-derived cells followed by electrical stimulation significantly improved FI, particularly in patients with limited FI duration and high IEF at baseline, and could become a valuable tool for treatment of FI, subject to confirmatory phase 3 trial(s). (ClinicalTrialRegister.eu; EudraCT Number: 2010-021463-32).
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Affiliation(s)
- Andrea Frudinger
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
| | | | - Wilhelm Graf
- Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden
| | | | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Minko Mihov
- Medical Center Unimed EOOD, Sevlievo, Bulgaria
| | - Peter Ihnát
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Pavle Kosorok
- Department of Proctology, Iatros Medical Centre, Ljubljana, Slovenia
| | - Julius Orhalmi
- Department of Surgery, University Hospital Hradec Kralove, Faculty of Medicine in Hradec Kralove, Charles University, Prague, Czech Republic
| | - Petr Slauf
- Surgical Clinic 1, Faculty of Medicine, University Hospital Bulovka, Charles University, Prague, Czech Republic
| | - Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, London, United Kingdom
| | | | - Anna Jungwirthova
- Department of Gastroenterology, St. Anna Clinic, Prague, Czech Republic
| | - Paul-Antoine Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Andreas Müller
- GastroZentrum Hirslanden, Klinik Hirslanden, Zürich, Switzerland
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Balaphas A, Meyer J, Buchs NC, Modarressi A, Bühler LH, Toso C, Gonelle-Gispert C, Ris F. Isolation and Characterization of Stem Cells from the Anal Canal Transition Zone in Pigs. Dig Dis Sci 2023; 68:471-477. [PMID: 36125591 PMCID: PMC9905163 DOI: 10.1007/s10620-022-07690-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/30/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Utilization of autologous stem cells has been proposed for the treatment of anal incontinence despite a lack of understanding of their mechanism of action and of the physiological healing process of anal sphincters after injury. AIMS We aim to develop a technique allowing isolation and further study of local mesenchymal stem cells, directly from anal canal transition zone in pig. METHODS Anal canal was resected "en bloc" from two young pigs and further microdissected. The anal canal transition zone was washed and digested with 0.1% type I collagenase for 45 min at 37 °C. The isolated cells were plated on dishes in mesenchymal stem cell medium and trypsinized when confluent. Cells were further used for flow cytometry analysis and differentiation assays. RESULTS The anal canal transition zone localization was confirmed with H&E staining. Following culture, cells exhibited a typical "fibroblast-like" morphology typical of stem cells. Isolated cells were positive for CD90 and CD44 but negative for CD14, CD34, CD45, CD105, CD106, and SLA-DR. Following incubation with specific differentiation medium, isolated cells differentiated into adipocytes, osteoblasts, and chondrocytes, confirming in vitro multipotency. CONCLUSIONS Herein, we report for the first time the presence of mesenchymal stem cells in the anal canal transition zone in pigs and the feasibility of their isolation. This preliminary study opens the path to the isolation of human anal canal transition zone mesenchymal stem cells that might be used to study sphincters healing and to treat anal incontinence.
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Affiliation(s)
- Alexandre Balaphas
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Nicolas C Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Ali Modarressi
- Division of Plastic, Reconstructive and Aesthetic Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Leo H Bühler
- Faculty of Science and Medicine, Section of Medicine, University of Fribourg, Route Albert-Gockel 1, 1700, Fribourg, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Carmen Gonelle-Gispert
- Faculty of Science and Medicine, Section of Medicine, University of Fribourg, Route Albert-Gockel 1, 1700, Fribourg, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
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5
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Kishimoto S, Ishizuka M, Inoue KI, Yamanishi T, Shimizu T, Kaga K, Aoki T, Kubota K. Local transplantation of syngeneic adipose stromal vascular fraction ameliorates damaged anal sphincter function in a rat model of vaginal distension. Surgery 2022; 172:1093-1101. [PMID: 35973873 DOI: 10.1016/j.surg.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The adipose stromal vascular fraction contains abundant mesenchymal stem cells and is utilized for cell therapy of male stress urinary incontinence. The purpose of this paper was to explore the effect of local transplantation of the stromal vascular fraction on improvement of damaged anal sphincter function. METHODS A rat model of vaginal distension was used as a model of damaged anal sphincter function. The adipose stromal vascular fraction was separated from the inguinal fat of syngeneic green fluorescent protein transgenic rats and delivered into the internal anal sphincter of vaginal distension rats. The maximum resting pressure was evaluated during insertion and withdrawal of the catheter at 4 or 10 days after vaginal distension treatment to estimate anal sphincter function. Green fluorescent protein-transfected human-adipose-derived mesenchymal stem cells were transplanted into the internal anal sphincter of nude rats. Hematoxylin-eosin and Masson trichrome staining were performed to evaluate tissue damage and collagen synthesis. Transplanted cells were identified using a green fluorescent protein antibody and a human-specific antibody. Activation of the transplanted human-ADSC was evaluated by quantitative RT-PCR RESULTS: The mean maximum resting pressure (during catheter withdrawal) of vaginal distension rats was significantly lower than that of control rats, and stromal vascular fraction injection normalized it 4 days after treatment (control: 5.66 ± 0.98, vaginal distension: 4.04 ± 1.28, vaginal distension + stromal vascular fraction: 5.92 ± 1.28 [mmHg, control versus vaginal distension: P = .039; vaginal distension versus vaginal distension + stromal vascular fraction: P = .007]). Histological examination showed that vaginal distension disrupted the internal anal sphincter, and the transplanted syngeneic stromal vascular fraction survived for 10 days. Transplanted xenogeneic human-adipose-derived mesenchymal stem cells survived in the internal anal sphincter of nude rats for 4 and 10 days. Genes related to extracellular remodeling were up-regulated in the transplanted human-adipose-derived mesenchymal stem cells CONCLUSION: Syngeneic and heterotopic transplanted adipose-derived mesenchymal stem cells engrafted in the internal anal sphincter and ameliorated damaged anal sphincter function in a rat model of vaginal distension.
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Affiliation(s)
- Satoko Kishimoto
- Comprehensive Research Facilities for Advanced Medical Science, Research Center for Advanced Medical Science, Dokkyo Medical University, Tochigi, Japan
| | - Mitsuru Ishizuka
- Department of Urology, Continence Center, Dokkyo Medical University, Tochigi, Japan; Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan.
| | - Ken-Ichi Inoue
- Comprehensive Research Facilities for Advanced Medical Science, Research Center for Advanced Medical Science, Dokkyo Medical University, Tochigi, Japan
| | - Tomonori Yamanishi
- Department of Urology, Continence Center, Dokkyo Medical University, Tochigi, Japan
| | - Takayuki Shimizu
- Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Kanya Kaga
- Department of Urology, Continence Center, Dokkyo Medical University, Tochigi, Japan
| | - Taku Aoki
- Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Keiichi Kubota
- Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan
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6
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The Effect of Mesenchymal Stem Cells, Adipose Tissue Derived Stem Cells, and Cellular Stromal Vascular Fraction on the Repair of Acute Anal Sphincter Injury in Rats. Bioengineering (Basel) 2022; 9:bioengineering9070318. [PMID: 35877369 PMCID: PMC9311655 DOI: 10.3390/bioengineering9070318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Anal sphincter incontinence (ASI) can cause a serious decline in the quality of life and can cause a socioeconomic burden. Studies have shown that bone marrow mesenchymal stem cells (MSC) have significant therapeutic effects on ASI, but the cost and risk of MSC harvest limit their further application. In contrast, adipose tissue derived stem cells (ADSC) and cellular stromal vascular fraction (CSVF) as stem cell sources have multipotency and the advantage of easy harvest. Objective: Here we aim to investigate the effects of ADSC and CSVF on treating ASI and compare them to that of bone marrow MSC. Methods: Bone marrow MSC, ADSC, and CSVF were obtained and labeled with green fluorescent protein (GFP), and CSVF was labeled with DIL. Sprague Dawley (SD) rats were divided into 5 groups. Four groups were injected with 0.2 mL phosphate buffer saline (PBS), 1 × 107/0.2 mL of MSC, ADSC, or CSVF, respectively, after model establishment. The control group received no treatment. The repair was assessed by anal functional tests and immunostaining on day 5 and day 10 after injection. Results: MSC, ADSC, and CSVF significantly promoted tissue repair and the recovery of muscle contraction and electromyographic activity in ASI. The generation of myosatellite cells by injected MSC, ADSC, and CSVF was found in the wounded area. On day 5, CSVF showed highest therapeutic effect, while on day 10, MSC and ADSC showed higher therapeutic effects than CSVF. When comparing the effects of MSC and ADSC, ADSC was slightly better than MSC in the indexes of anal pressure, etc. Conclusion: ADSC and CVSF are alternative stem cell sources for ASI repair.
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Kim M, Oh BY, Lee JS, Yoon D, Chun W, Son IT. A systematic review of translation and experimental studies on internal anal sphincter for fecal incontinence. Ann Coloproctol 2022; 38:183-196. [PMID: 35678021 PMCID: PMC9263305 DOI: 10.3393/ac.2022.00276.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/10/2022] [Indexed: 12/05/2022] Open
Abstract
The complexity in the molecular mechanism of the internal anal sphincter (IAS) limits preclinical or clinical outcomes of fecal incontinence (FI) treatment. So far, there are no systematic reviews of IAS translation and experimental studies that have been reported. This systematic review aims to provide a comprehensive understanding of IAS critical role in FI. Previous studies revealed the key pathway for basal tone and relaxation of IAS in different properties as follows; calcium, Rho-associated, coiled-coil containing serine/threonine kinase, aging-associated IAS dysfunction, oxidative stress, renin-angiotensin-aldosterone, cyclooxygenase, and inhibitory neurotransmitters. Previous studies have reported improved functional outcomes of cellular treatment for regeneration of dysfunctional IAS, using various stem cells, but did not demonstrate the interrelationship between those results and basal tone or relaxation-related molecular pathway of IAS. Furthermore, these results have lower specificity for IAS-incontinence due to the included external anal sphincter or nerve injury regardless of the cell type. An acellular approach using bioengineered IAS showed a physiologic response of basal tone and relaxation response similar to human IAS. However, in both cellular and acellular approaches, the lack of human IAS data still hampers clinical application. Therefore, the IAS regeneration presents more challenges and warrants more advances.
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Affiliation(s)
- Minsung Kim
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Bo-Young Oh
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ji-Seon Lee
- Burn Institute, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dogeon Yoon
- Burn Institute, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Wook Chun
- Burn Institute, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.,Department of Surgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Il Tae Son
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea.,Institute for Regenerative Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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8
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Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am 2022; 51:71-91. [PMID: 35135666 DOI: 10.1016/j.gtc.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.
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Affiliation(s)
- Stacy Menees
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA
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9
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Eberspacher C, Mascagni D, Ferent IC, Coletta E, Palma R, Panetta C, Esposito A, Arcieri S, Pontone S. Mesenchymal Stem Cells for Cryptoglandular Anal Fistula: Current State of Art. Front Surg 2022; 9:815504. [PMID: 35252334 PMCID: PMC8889088 DOI: 10.3389/fsurg.2022.815504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/24/2022] [Indexed: 11/19/2022] Open
Abstract
Anal fistula is a common disease that needs surgical treatment to be resolved. Despite a variety of surgical options, the major problem is still to cure complex fistulas without any recurrence in the long-term follow-up but, at the same time, to avoid an impairment of continence. In recent years, one solution has been the application of mesenchymal stem cells derived from adipose tissue, especially in association with other treatments, such as the use of fibrin glue or the previous application of a seton. Their initial use in fistulas associated with Crohn's disease has shown encouraging results. In this non-systematic review our aim is to analyze the use in cryptoglandular fistulas: the rate of healing is not so high, and the number of studies is limited. Therefore, further randomized controlled trials are needed to establish their efficacy in the case of complex cryptoglandular anal fistulas and their possible complications.
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10
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Sun L, Billups A, Rietsch A, Damaser MS, Zutshi M. Stromal cell derived factor 1 plasmid to regenerate the anal sphincters. J Tissue Eng Regen Med 2022; 16:355-366. [PMID: 35092171 DOI: 10.1002/term.3283] [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: 04/08/2021] [Revised: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 11/09/2022]
Abstract
The aim of this study was to evaluate regeneration of a chronic large anal sphincter defect in a pig model after treatment with a plasmid encoding Stromal Cell Derived Factor-1(SDF-1). METHODS Under ethics approved protocol 19 age/weight matched Sinclair mini-pigs were subjected to excision of the posterior 50% of anal sphincter muscle and left to recover for 6 weeks. They were randomly allocated to receive either saline treatment (Saline 1 ml, n = 5), 1 injection of SDF-1 plasmid 2 mg/ml (1 SDF-1, n = 9) or 2 injections of SDF-1, 2 mg/ml each at 2 weeks intervals (2 SDF-1, n = 5). Euthanasia occurred 8 weeks after the last treatment. In vivo outcomes included anal resting pressures done under anesthesia pre-injury, pre-injection and before euthanasia (8 weeks after treatment). Anal ultrasound was done pre injury and pre-euthanasia. Tissues were saved for histology and analyzed quantitatively. Two way ANOVA followed by Holm-Sidak test and one way ANOVA followed by the Tukey test were used for data analysis, p < 0.05 was regarded as significant. RESULTS Posterior anal pressures at the 3 time points were not significantly different in the saline group. In contrast, post-treatment pressures in the 1 SDF-1 group pressures were significantly higher than both pre-injury (p = 0.001) and pre-treatment time points (p = 0.003). At the post-treatment time point, both 1 SDF-1 (p = 0.01) and 2 SDF-1 (p = 0.01) groups had significantly higher mean pressures compared to the saline group. Histology showed distortion of normal anatomy with patchy regeneration in the control group while muscle was more organized in both treatment groups. CONCLUSIONS Eight weeks after a single or two doses of SDF-1injected into a chronic anal sphincter injury improved resting anal pressures and regenerated muscle in the entire defect. SDF-1 plasmid is effective in treating chronic defects of the anal sphincter in a large animal and could be clinically translated.
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Affiliation(s)
- Li Sun
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alanna Billups
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Rietsch
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Margot S Damaser
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA.,Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Advanced Platform Technology Center, Cleveland, Ohio, USA
| | - Massarat Zutshi
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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11
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Trébol J, Georgiev-Hristov T, Pascual-Miguelañez I, Guadalajara H, García-Arranz M, García-Olmo D. Stem cell therapy applied for digestive anastomosis: Current state and future perspectives. World J Stem Cells 2022; 14:117-141. [PMID: 35126832 PMCID: PMC8788180 DOI: 10.4252/wjsc.v14.i1.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/21/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Digestive tract resections are usually followed by an anastomosis. Anastomotic leakage, normally due to failed healing, is the most feared complication in digestive surgery because it is associated with high morbidity and mortality. Despite technical and technological advances and focused research, its rates have remained almost unchanged the last decades. In the last two decades, stem cells (SCs) have been shown to enhance healing in animal and human studies; hence, SCs have emerged since 2008 as an alternative to improve anastomoses outcomes.
AIM To summarise the published knowledge of SC utilisation as a preventative tool for hollow digestive viscera anastomotic or suture leaks.
METHODS PubMed, Science Direct, Scopus and Cochrane searches were performed using the key words “anastomosis”, “colorectal/colonic anastomoses”, “anastomotic leak”, “stem cells”, “progenitor cells”, “cellular therapy” and “cell therapy” in order to identify relevant articles published in English and Spanish during the years of 2000 to 2021. Studies employing SCs, performing digestive anastomoses in hollow viscera or digestive perforation sutures and monitoring healing were finally included. Reference lists from the selected articles were reviewed to identify additional pertinent articles.
Given the great variability in the study designs, anastomotic models, interventions (SCs, doses and vehicles) and outcome measures, performing a reliable meta-analysis was considered impossible, so we present the studies, their results and limitations.
RESULTS Eighteen preclinical studies and three review papers were identified; no clinical studies have been published and there are no registered clinical trials. Experimental studies, mainly in rat and porcine models and occasionally in very adverse conditions such as ischaemia or colitis, have been demonstrated SCs as safe and have shown some encouraging morphological, functional and even clinical results. Mesenchymal SCs are mostly employed, and delivery routes are mainly local injections and cell sheets followed by biosutures (sutures coated by SCs) or purely topical. As potential weaknesses, animal models need to be improved to make them more comparable and equivalent to clinical practice, and the SC isolation processes need to be standardised. There is notable heterogeneity in the studies, making them difficult to compare. Further investigations are needed to establish the indications, the administration system, potential adjuvants, the final efficacy and to confirm safety and exclude definitively oncological concerns.
CONCLUSION The future role of SC therapy to induce healing processes in digestive anastomoses/sutures still needs to be determined and seems to be currently far from clinical use.
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Affiliation(s)
- Jacobo Trébol
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca 37007, Spain
- Departamento de Anatomía e Histología Humanas, Universidad de Salamanca, Salamanca 37007, Spain
| | - Tihomir Georgiev-Hristov
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Villalba, Madrid 28400, Spain
| | - Isabel Pascual-Miguelañez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Paz, Madrid 28046, Spain
| | - Hector Guadalajara
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Jiménez Díaz, Madrid 28040, Spain
| | - Mariano García-Arranz
- Grupo de Investigación en Nuevas Terapias, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Madrid 28040, Spain
- Departamento de Cirugía, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | - Damian García-Olmo
- Departamento de Cirugía, Universidad Autónoma de Madrid, Madrid 28029, Spain
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Jiménez Díaz y Grupo Quiron-Salud Madrid, Madrid 28040, Spain
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12
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Balaphas A, Meyer J, Meier RPH, Liot E, Buchs NC, Roche B, Toso C, Bühler LH, Gonelle-Gispert C, Ris F. Cell Therapy for Anal Sphincter Incontinence: Where Do We Stand? Cells 2021; 10:2086. [PMID: 34440855 PMCID: PMC8394955 DOI: 10.3390/cells10082086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/12/2022] Open
Abstract
Anal sphincter incontinence is a chronic disease, which dramatically impairs quality of life and induces high costs for the society. Surgery, considered as the best curative option, shows a disappointing success rate. Stem/progenitor cell therapy is pledging, for anal sphincter incontinence, a substitute to surgery with higher efficacy. However, the published literature is disparate. Our aim was to perform a review on the development of cell therapy for anal sphincter incontinence with critical analyses of its pitfalls. Animal models for anal sphincter incontinence were varied and tried to reproduce distinct clinical situations (acute injury or healed injury with or without surgical reconstruction) but were limited by anatomical considerations. Cell preparations used for treatment, originated, in order of frequency, from skeletal muscle, bone marrow or fat tissue. The characterization of these preparations was often incomplete and stemness not always addressed. Despite a lack of understanding of sphincter healing processes and the exact mechanism of action of cell preparations, this treatment was evaluated in 83 incontinent patients, reporting encouraging results. However, further development is necessary to establish the correct indications, to determine the most-suited cell type, to standardize the cell preparation method and to validate the route and number of cell delivery.
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Affiliation(s)
- Alexandre Balaphas
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
- Department of Surgery, Geneva Medical School, University of Geneva, 1205 Geneva, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Raphael P. H. Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Nicolas C. Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Bruno Roche
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Leo H. Bühler
- Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland; (L.H.B.); (C.G.-G.)
| | - Carmen Gonelle-Gispert
- Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland; (L.H.B.); (C.G.-G.)
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
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13
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de la Portilla F, Guerrero JL, Maestre MV, Leyva L, Mera S, García-Olmo D, Rodríguez A, Mata R, Lora F. Treatment of faecal incontinence with autologous expanded mesenchymal stem cells: results of a pilot study. Colorectal Dis 2021; 23:698-709. [PMID: 32986295 DOI: 10.1111/codi.15382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023]
Abstract
AIM Management of faecal incontinence (FI) remains challenging because no definitive optimal treatment for this condition has yet been determined. Regenerative medicine could be an attractive therapeutic alternative for treating FI. Here, we aimed to determine the safety and feasibility of autologous expanded mesenchymal stem cells derived from adipose tissue (AdMSCs) in the treatment of patients diagnosed with structural FI. METHOD This was a randomized, multicentre, triple-blinded, placebo-controlled pilot study conducted at four sites in Spain with 16 adults with FI and a sphincter defect. Autologous AdMSCs were obtained from patients from surgically excised adipose tissue. These patients were intralesionally infused with a single dose of 4 × 107 AdMSCs or a placebo while under anaesthesia. We assessed the safety and feasibility of the treatment as the cumulative incidence of adverse events and the treatment efficacy using the Cleveland Clinic Faecal Incontinence Score, Faecal Incontinence Quality of Life score and Starck criteria to classify sphincter defects and anorectal physiology outcomes. RESULTS Adipose tissue extraction, cell isolation and intralesional infusion procedures were successful in all the patients. There was only one adverse event connected to adipose tissue extraction (a haematoma), and none was associated with the injection procedure. There were no significant differences in any of the assessed clinical, manometric or ultrasonographic parameters. CONCLUSION This study indicates that this infusion procedure in the anal sphincter is feasible and safe. However, it failed to demonstrate efficacy to treat patients with structural FI.
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Affiliation(s)
- Fernando de la Portilla
- Coloproctology Clinical Management Unit, General and Gastrointestinal Surgery Division, Biomedical Research Institute (IBIS), Hospital Universitario Virgen del Rocio/CSIC University of Seville, Seville, Spain
| | - José Luis Guerrero
- Coloproctology Clinical Management Unit, General and Gastrointestinal Surgery Division, Biomedical Research Institute (IBIS), Hospital Universitario Virgen del Rocio/CSIC University of Seville, Seville, Spain
| | - Maria Victoria Maestre
- Coloproctology Clinical Management Unit, General and Gastrointestinal Surgery Division, Biomedical Research Institute (IBIS), Hospital Universitario Virgen del Rocio/CSIC University of Seville, Seville, Spain
| | - Laura Leyva
- GMP Cell Manufacturing Unit, Biomedical Research Institute of Malaga (IBIMA), Hospital Regional Universitario de Malaga, Málaga, Spain
| | - Santiago Mera
- Coloproctology Unit Clinical Management, Unit of General Surgery Division, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Damián García-Olmo
- Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Antonio Rodríguez
- GMP Cell Manufacturing Unit, Biomedical Research Institute of Malaga (IBIMA), Hospital Regional Universitario de Malaga, Málaga, Spain
| | - Rosario Mata
- Andalusian Network for Design and Translation of Advanced Therapies, Seville, Spain
| | - Fabiola Lora
- Andalusian Network for Design and Translation of Advanced Therapies, Seville, Spain
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14
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Abstract
Fecal incontinence can be a challenging and stigmatizing disease with a high prevalence in the elderly population. Despite effective treatment options, most patients do not receive care. Clues in the history and physical examination can assist the provider in establishing the diagnosis. Direct inquiry about the presence of incontinence is key. Bowel disturbances are common triggers for symptoms and represent some of the easiest treatment targets. We review the epidemiology and impact of the disease, delineate a diagnostic and treatment approach for primary care physicians to identify patients with suspected fecal incontinence and describe appropriate treatment options.
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Affiliation(s)
- Trisha Pasricha
- Division of Gastroenterology, Massachusetts General Hospital, Wang 5, Boston, MA 02114, USA; Department of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, CRP 9, Boston, MA 02114, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Wang 5, Boston, MA 02114, USA; Department of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, CRP 9, Boston, MA 02114, USA.
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15
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Li P, Ma X, Jin W, Li X, Hu J, Jiang X, Guo X. Effects of local injection and intravenous injection of allogeneic bone marrow mesenchymal stem cells on the structure and function of damaged anal sphincter in rats. J Tissue Eng Regen Med 2020; 14:989-1000. [PMID: 32537834 DOI: 10.1002/term.3079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 04/09/2020] [Accepted: 05/11/2020] [Indexed: 12/21/2022]
Abstract
Anal sphincter injury leads to damage to the anal structure and functions and has been identified as a major risk factor for fecal incontinence. Bone marrow mesenchymal stem cells (BMSCs) with capacities of multidifferentiation, paracrine, and low immunogenicity have been widely used in tissue repair and regeneration. The primary objective of this research was to compare the effects of different injection therapies of BMSCs on the injured anal sphincters. Ninety-six Sprague-Dawley female rats were randomly divided into four groups (n = 24 each): intravenous injection, local injection, sham operation, and normal control. For the first three groups, 25% removal of the anal sphincter complex was performed and 0.3-ml phosphate-buffered saline (PBS) (containing 107 green fluorescent protein-labeled allogeneic BMSCs) was given accordingly to the treatment group 24 h after operation for 7 consecutive days. The sham operation group was injected with 0.3-ml PBS only. All cases had undergone evaluation in the 1st, 7th, 14th, and 28th postoperative days. The rats were sacrificed on the 28th postoperative day, and the anal sphincters were dissected to be analyzed by morphological examination. At 14 days postoperatively, local injection of BMSC significantly improved the peak contraction pressure, electromyography amplitude, and frequency of the injured anal sphincter compared with tail vein, but there was no significant difference in resting pressure until 28 days after sphincterectomy. Masson staining results confirmed that the local injection group had significantly more new muscles on the wound. BMSC could remarkably improve peak contraction pressure, electromyography amplitude, and muscle fibers on the wound, and local injection is superior to intravenous injection.
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Affiliation(s)
- Peng Li
- Department of Anorectal, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaoying Ma
- School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Wenqi Jin
- Department of Anorectal, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaojia Li
- Department of Anorectal, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Hu
- Department of Anorectal, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaoxue Jiang
- Department of Anorectal Surgery, Shanghai Eighth People's Hospital, Shanghai, China
| | - Xiutian Guo
- Department of Anorectal, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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16
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Da Silva G, Sirany A. Recent advances in managing fecal incontinence. F1000Res 2019; 8. [PMID: 31448087 PMCID: PMC6676508 DOI: 10.12688/f1000research.15270.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 11/20/2022] Open
Abstract
Fecal incontinence (FI) is the uncontrolled passage of feces or gas in an individual who previously had control. The prevalence of the problem varies but can be as high as 50% of institutionalized individuals. The severity varies among individuals, but the negative impact on self-esteem and quality of life can have devastating effects. The goals of treatment are to decrease the frequency and severity of episodes as well as to improve quality of life. At present, several therapies, ranging from medical management to more invasive surgical interventions, are offered for the management of FI. In this article, we review the most recent advances in the management of FI.
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Affiliation(s)
- Giovanna Da Silva
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, 33331, USA
| | - Anne Sirany
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, 33331, USA
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17
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Keef KD, Cobine CA. Control of Motility in the Internal Anal Sphincter. J Neurogastroenterol Motil 2019; 25:189-204. [PMID: 30827084 PMCID: PMC6474703 DOI: 10.5056/jnm18172] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 12/14/2022] Open
Abstract
The internal anal sphincter (IAS) plays an important role in the maintenance of fecal continence since it generates tone and is responsible for > 70% of resting anal pressure. During normal defecation the IAS relaxes. Historically, tone generation in gastrointestinal muscles was attributed to mechanisms arising directly from smooth muscle cells, ie, myogenic activity. However, slow waves are now known to play a fundamental role in regulating gastrointestinal motility and these electrical events are generated by the interstitial cells of Cajal. Recently, interstitial cells of Cajal, as well as slow waves, have also been identified in the IAS making them viable candidates for tone generation. In this review we discuss four different mechanisms that likely contribute to tone generation in the IAS. Three of these involve membrane potential, L-type Ca2+ channels and electromechanical coupling (ie, summation of asynchronous phasic activity, partial tetanus, and window current), whereas the fourth involves the regulation of myofilament Ca2+ sensitivity. Contractile activity in the IAS is also modulated by sympathetic motor neurons that significantly increase tone and anal pressure, as well as inhibitory motor neurons (particularly nitrergic and vasoactive intestinal peptidergic) that abolish contraction and assist with normal defecation. Alterations in IAS motility are associated with disorders such as fecal incontinence and anal fissures that significantly decrease the quality of life. Understanding in greater detail how tone is regulated in the IAS is important for developing more effective treatment strategies for these debilitating defecation disorders.
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Affiliation(s)
- Kathleen D Keef
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, NV, USA
| | - Caroline A Cobine
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, NV, USA
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