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Milito P, Piozzi GN, Hussain MI, Dragani TA, Sorrentino L, Cosimelli M, Guaglio M, Battaglia L. Effect of neoadjuvant chemoradiation on anorectal function assessed with anorectal manometry: A systematic review and meta-analysis. TUMORI JOURNAL 2024:3008916241256544. [PMID: 38819198 DOI: 10.1177/03008916241256544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
AIM Improvement in oncological survival for rectal cancer increases attention to anorectal dysfunction. Diagnostic questionnaires can evaluate quality of life but are subjective and dependent on patients' compliance. Anorectal manometry can objectively assess the continence mechanism and identify functional sphincter weakness and rectal compliance. Neoadjuvant chemoradiotherapy is presumed to affect anorectal function. We aim to assess anorectal function in rectal cancer patients who undergo total mesorectal excision, with or without neoadjuvant chemoradiation, using anorectal manometry measurements. METHOD MEDLINE, Embase, and Cochrane databases were searched for studies comparing perioperative anorectal manometry between neoadjuvant chemoradiation and upfront surgery for rectal cancers. Primary outcomes were resting pressure, squeeze pressure, sensory threshold volume and maximal tolerable volume. RESULTS Eight studies were included in the systematic review, of which seven were included for metanalysis. 155 patients (45.3%) had neoadjuvant chemoradiation before definitive surgery, and 187 (54.6%) underwent upfront surgery. Most patients were male (238 vs. 118). The standardized mean difference of mean resting pressure, mean and maximum squeeze pressure, maximum resting pressure, sensory threshold volume, and maximal tolerable volume favored the upfront surgery group but without statistical significance. CONCLUSION Currently available evidence on anorectal manometry protocols failed to show any statistically significant differences in functional outcomes between neoadjuvant chemoradiation and upfront surgery. Further large-scale prospective studies with standardized neoadjuvant chemoradiation and anorectal manometry protocols are needed to validate these findings.
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Affiliation(s)
- Pamela Milito
- Department of Emergency and General Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Guglielmo Niccolò Piozzi
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Tommaso A Dragani
- Department of Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Guaglio
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Battaglia
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Tsunoda A, Kusanagi H. Subtotal fistulectomy and sliding anoderm flap: A new sphincter-sparing technique for anal fistula. Colorectal Dis 2024. [PMID: 38802995 DOI: 10.1111/codi.17018] [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: 11/20/2023] [Revised: 02/27/2024] [Accepted: 04/01/2024] [Indexed: 05/29/2024]
Abstract
AIM The underlying causes of failure or recurrence after ligation of the intersphincteric fistula tract are postulated to be refistulization, breakdown of the closure wound in the intersphincteric plane and faecal contents entering the internal opening, thereby causing recurrent infection. The aim of this study is to demonstrate the outcomes of subtotal fistulectomy with sliding anoderm flaps to prevent refistulization. METHOD This retrospective study used prospectively collected data. Patients with transsphincteric or intersphincteric fistulas were enrolled between August 2021 and July 2023. An anal manometric study was performed before and after surgery. Faecal incontinence was evaluated using the faecal incontinence severity index (FISI). Failure was defined as nonhealing of the surgical wound or fistula. RESULTS Fifty-one patients who underwent subtotal fistulectomy with a sliding anoderm flap were included. After a median follow-up of 12 months (range 4-27 months), primary healing was achieved in 49 patients (96%). Two patients experienced treatment failure, while none developed postoperative recurrence. The median healing time was 10 weeks (range 6-24 weeks). The FISI scores did not change significantly after the surgery. The median resting pressure significantly reduced after surgery [125 cmH2O (range 59-204 cmH2O) vs. 99 cmH2O (range 36-176 cmH2O); p = 0.0001]. The median squeeze pressure significantly decreased after surgery [356 cmH2O (range 137-579 cmH2O) vs. 329 cmH2O (range 72-594 cmH2O; p = 0.005)]. CONCLUSION Subtotal fistulectomy with a sliding anoderm flap showed excellent healing rates with no postoperative deterioration of anal function.
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Affiliation(s)
- A Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
| | - H Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
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Li SG, Mazor Y, Park CJ, Jones MP, Malcolm A. Faecal incontinence with concurrent disorders of gut-brain interaction: A worse outcome. United European Gastroenterol J 2024; 12:496-503. [PMID: 38412024 DOI: 10.1002/ueg2.12541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/22/2023] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Faecal incontinence is a common debilitating condition associated with poor quality of life that generates substantial economic strain on healthcare systems. OBJECTIVES We aimed to evaluate, in a tertiary referral population presenting with faecal incontinence, the impact of suffering additional disorders of gut-brain interaction (DGBI) on symptom severity, anxiety, depression and quality of life. METHODS Design: Retrospective cohort study. SETTING Tertiary referral Neurogastroenterology centre. PATIENTS All patients presenting with faecal incontinence from 2007 to 2020 were included. MAIN OUTCOME MEASURES The results from structured medical and surgical questionnaires including Rome III Integrative Questionnaire, Faecal Incontinence Severity Index, Hospital Anxiety and Depression Scale, SF-36, and anorectal physiology were analysed using Stata version 17. Patients were categorised into 3 groups: 0-1 additional DGBI, 2 DGBIs, and 3+ DGBI. Statistical significance was defined as p < 0.05 (two-tailed). KEY RESULTS Faecal incontinence patients (n = 249; mean age 63.4 ± 12.6 years; 93.6% female, 48.1% urge subtype) met diagnostic criteria for mean 2.2 additional DGBI each, mostly affecting bowel (n = 231, 42.4%) and anorectal (n = 150, 27.5%) regions. A greater number of DGBIs was associated with higher faecal incontinence symptom severity (p < 0.001), higher anxiety (p = 0.002) and depression (p = 0.003), and worse quality of life in areas of mental health (p = 0.037) and social effect (p < 0.001). Patients with a greater number of concurrent DGBI demonstrated a greater family history of gastrointestinal problems (p = 0.004). There were no associations found between a greater amount of DGBIs and anorectal physiology. CONCLUSIONS AND INFERENCES A greater number of additional DGBIs in faecal incontinence patients was associated with worse faecal incontinence symptoms, higher anxiety and depression scores, and worse quality of life but was unrelated to physiology. This highlights the need to proactively search for comorbid DGBI in patients presenting with faecal incontinence.
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Affiliation(s)
- Sarah G Li
- The University of Sydney, Sydney, New South Wales, Australia
- Neurogastroenterology Unit and Department of Gastroenterology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Hornsby Hospital, Sydney, New South Wales, Australia
| | - Yoav Mazor
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Calvin Joomann Park
- The University of Sydney, Sydney, New South Wales, Australia
- Neurogastroenterology Unit and Department of Gastroenterology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Michael P Jones
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Allison Malcolm
- The University of Sydney, Sydney, New South Wales, Australia
- Neurogastroenterology Unit and Department of Gastroenterology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Savarino EV, Chiarioni G. Improved diagnosis of faecal incontinence in the gastroenterology domain: The time to act has come. United European Gastroenterol J 2024; 12:425-426. [PMID: 38329403 DOI: 10.1002/ueg2.12546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Affiliation(s)
- Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giuseppe Chiarioni
- Il Cerchio Med Healthcare, Verona Centre, Verona, Italy
- UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Bola R, Guo M, Karimuddin A, Liu G, Phang PT, Crump T, Sutherland JM. An examination of rectal prolapse surgery patients' quality of life and symptoms using patient-reported outcome instruments: A prospective cohort study. Am J Surg 2024; 231:113-119. [PMID: 38355344 DOI: 10.1016/j.amjsurg.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/25/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND We measured changes in self-reported health and symptoms attributable to rectal prolapse surgery using patient-reported outcome (PRO) measures. METHODS A prospectively recruited cohort of patients scheduled for rectal prolapse repair in Vancouver, Canada between 2013 and 2021 were surveyed before and 6-months after surgery using seven PROs: the EuroQol Five-Dimension Instrument (EQ-5D-5L), Generalized Anxiety Disorder Scale (GAD-7), Pain Intensity, Interference with Enjoyment of Life and General Activity (PEG), Patient Health Questionnaire (PHQ-9), Fecal Incontinence Severity Index (FISI), Gastrointestinal Quality of Life Index (GIQLI), and the Fecal Incontinence Quality of Life Scale (FIQL). RESULTS We included 46 participants who reported improvements in health status (EQ-5D-5L; p < 0.01), pain interference (PEG; p < 0.01), depressive symptoms (PHQ-9; p = 0.01), fecal incontinence severity (FISI; p < 0.01), gastrointestinal quality of life (GIQLI; p < 0.01), and fecal incontinence quality of life (FIQL) related to lifestyle (p = 0.02), coping and behaviour (p = 0.02) and depression and self-perception (p = 0.01). CONCLUSION Surgical repair of rectal prolapse improved patients' quality of life with meaningful improvements in fecal incontinence severity and pain, and symptom interference with daily activities.
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Affiliation(s)
- Rajan Bola
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Michael Guo
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada; Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Ahmer Karimuddin
- Department of Surgery, Faculty of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - P Terry Phang
- Department of Surgery, Faculty of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Trafford Crump
- Department of Surgery, McGill University, Montreal, Canada
| | - Jason M Sutherland
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada.
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Swartz JL, Zifan A, Tuttle LJ, Sheean G, Tam RM, Mittal RK. Fecal incontinence patients categorized based on anal pressure and electromyography: Anal sphincter damage and clinical symptoms. Neurogastroenterol Motil 2024:e14810. [PMID: 38689439 DOI: 10.1111/nmo.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/01/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Disruption of external anal sphincter muscle (EAS) is an important factor in the multifactorial etiology of fecal incontinence (FI). OBJECTIVES We categorize FI patients into four groups based on the location of lesion in neuromuscular circuitry of EAS to determine if there are differences with regards to fecal incontinence symptoms severity (FISI) score, age, BMI, obstetrical history, and anal sphincter muscle damage. METHODS Female patients (151) without any neurological symptoms, who had undergone high-resolution manometry, anal sphincter EMG, and 3D ultrasound imaging of the anal sphincter were assessed. Patients were categorized into four groups: Group 1 (normal)-normal cough EMG (>10 μV), normal squeeze EMG (>10 μV), and normal anal squeeze pressure (>124 mmHg); Group 2 (cortical apraxia, i.e., poor cortical activation)-normal cough EMG, low squeeze EMG, and low anal squeeze pressure; Group 3 (muscle damage)-normal cough EMG, normal squeeze EMG, and low anal squeeze pressure; and Group 4 (pudendal nerve damage)-low cough EMG, low squeeze EMG, and low anal squeeze pressure. RESULTS The four patient groups were not different with regards to the patient's age, BMI, parity, and FISI scores. 3D ultrasound images of the anal sphincter complex revealed significant damage to the internal anal sphincter, external anal sphincter, and puborectalis muscles in all four groups. CONCLUSION The FI patients are a heterogeneous group; majority of these patients have significant damage to the muscles of the anal sphincter complex. Whether biofeedback therapy response is different among different patient groups requires study.
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Affiliation(s)
- Jessica L Swartz
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ali Zifan
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
| | - Lori J Tuttle
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | | | - Rowena M Tam
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ravinder K Mittal
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
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7
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Tsunoda A, Kusanagi H. Enhanced Approach to Treating Chronic Anal Fissures: Fissurectomy with Vertical Non-full-thickness Midline Sphincterotomy and Mucosal Advancement Flap. J Anus Rectum Colon 2024; 8:111-117. [PMID: 38689786 PMCID: PMC11056538 DOI: 10.23922/jarc.2023-072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/06/2024] [Indexed: 05/02/2024] Open
Abstract
Objectives Lateral internal sphincterotomy is a conventional surgical intervention for chronic anal fissures, yet the potential for postoperative anal incontinence underscores the need for an alternative approach. This study aimed to evaluate the outcomes of patients with chronic fissures who underwent a combination of fissurectomy, vertical non-full thickness midline sphincterotomy (VNMS), and mucosal advancement flap (MAF), as a means of mitigating the risk of incontinence. Methods This retrospective analysis included forty-six consecutive patients with chronic anal fissures, unresponsive to topical diltiazem, who underwent fissurectomy combined with VNMS and MAF between April 2018 and May 2023. Primary outcome measures encompassed fissure healing rates. Continence was assessed using the Fecal Incontinence Severity Index (FISI), and manometric assessments were conducted before the procedure and three months postoperatively. Results With a median follow-up of 27 months, there were no postoperative complications, and the overall fissure healing rate reached 96% (44/46). At three months post-procedure, FISI scores were reduced to 0, with no instances of fecal soiling. Anal resting pressure exhibited a significant reduction at 3 months [pre-op: 133 (95% CI, 128-150) vs. 3 mo: 109 (95% CI, 100-117) cmH2O; p = 0.01]. Similarly, maximum anal squeeze pressure showed a significant decrease three months post-surgery [pre-op: 317 cmH2O (95% CI, 294-380) vs. 3 mo: 291 cmH2O (95% CI, 276-359), p = 0.03]. Conclusions The combination of fissurectomy, VNMS, and MAF proved to be an effective approach for chronic anal fissures, yielding favorable medium-term outcomes without postoperative anal incontinence.
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Affiliation(s)
- Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
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8
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Hiramoto B, Flanagan R, Muftah M, Shah ED, Chan WW. Centrally Distributed Adiposity as a Modifiable Risk Factor for Fecal Incontinence: United States Population-based Analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00389-6. [PMID: 38657883 DOI: 10.1016/j.cgh.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/14/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND AIMS Fecal incontinence (FI) is highly prevalent with substantial impacts on quality of life and health care utilization. The impact of obesity on FI remains unclear, with differing conclusions using body mass index (BMI) as a risk factor. We aimed to determine the association between obesity and FI, and whether this relationship is dependent on the distribution of adiposity (waist circumference-to-height ratio [WHtR]). METHODS This was a population-based analysis of the National Health and Nutrition Examination Survey, including participants who responded to the bowel health survey in 2005 to 2010. FI was defined by the accidental bowel leakage of solid stool, liquid, or mucus at least once in the past month. Stepwise multivariable logistic regression models were constructed to assess risk factors for FI. RESULTS A total of 7606 participants were included, with an overall FI prevalence of 9.2%. When stratified by quartiles of body measurements, FI was increasingly prevalent from the 1st to the 4th quartile for both WHtR (range, 5.3%-12.5%) and BMI (range, 7.1%-10.5%). WHtR was associated with FI and was a stronger predictor than BMI in all quartiles of body measurement. On multivariable analysis, WHtR remained a significant predictor of FI comparing the 4th with the 1st quartile of body measurements (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.11-2.80; P = .017), whereas BMI was not. A WHtR cutoff of >0.592 optimized the Youden index in prediction of FI in the overall sample. CONCLUSION WHtR was independently associated with increased odds of FI in this nationally representative sample of United States adults, whereas BMI was not consistently correlated. This suggests bowel continence may depend more on how body mass is distributed.
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Affiliation(s)
- Brent Hiramoto
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Ryan Flanagan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Mayssan Muftah
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Eric D Shah
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Bottorff EC, Gupta P, Ippolito GM, Moore MB, Rodriguez GM, Bruns TM. Short-term Dorsal Genital Nerve Stimulation Increases Subjective Arousal in Women With and Without Spinal Cord Injury: A Preliminary Investigation. Neuromodulation 2024:S1094-7159(24)00059-X. [PMID: 38573280 DOI: 10.1016/j.neurom.2024.02.004] [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: 04/21/2023] [Revised: 12/23/2023] [Accepted: 02/13/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVES Female sexual dysfunction (FSD) affects an estimated 40% of women. Unfortunately, FSD is understudied, leading to limited treatment options for FSD. Neuromodulation has shown some success in alleviating FSD symptoms. We developed a pilot study to investigate the short-term effect of electrical stimulation of the dorsal genital nerve and tibial nerve on sexual arousal in healthy women, women with FSD, and women with spinal cord injury (SCI) and FSD. MATERIALS AND METHODS This study comprises a randomized crossover design in three groups: women with SCI, women with non-neurogenic FSD, and women without FSD or SCI. The primary outcome measure was change in vaginal pulse amplitude (VPA) from baseline. Secondary outcome measures were changes in subjective arousal, heart rate, and mean arterial pressure from baseline. Participants attended one or two study sessions where they received either transcutaneous dorsal genital nerve stimulation (DGNS) or tibial nerve stimulation (TNS). At each session, a vaginal photoplethysmography sensor was used to measure VPA. Participants also rated their level of subjective arousal and were asked to report any pelvic sensations. RESULTS We found that subjective arousal increased significantly from before to after stimulation in DGNS study sessions across all women. TNS had no effect on subjective arousal. There were significant differences in VPA between baseline and stimulation, baseline and recovery, and stimulation and recovery periods among participants, but there were no trends across groups or stimulation type. Two participants with complete SCIs experienced genital sensations. CONCLUSIONS To our knowledge, this is the first study to measure sexual arousal in response to short-term neuromodulation in women. This study indicates that short-term DGNS but not TNS can increase subjective arousal, but the effect of stimulation on genital arousal is inconclusive. This study provides further support for DGNS as a treatment for FSD.
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Affiliation(s)
- Elizabeth C Bottorff
- Biomedical Engineering Department, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | - Mackenzie B Moore
- Biomedical Engineering Department, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Gianna M Rodriguez
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Tim M Bruns
- Biomedical Engineering Department, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA.
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10
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Clemente N, Yagnik VD, James KCW. A new scoring system on the horizon to assess fecal incontinence: Garg Incontinence Scores (GIS). Updates Surg 2024; 76:723-724. [PMID: 38150156 DOI: 10.1007/s13304-023-01742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Nicola Clemente
- U.O. ChirugiaOspedale di Montebelluna (TV), AULSS 2 Marca Tevigiana, Treviso, Italy
| | - Vipul D Yagnik
- Department of Surgery, Banas Medical College and Research Institute, Palanpur, Gujarat, 385001, India
| | - Khaw C W James
- Department of Colorectal Surgery, Penang General Hospital, Penang, Malaysia.
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11
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McKenzie CM, Woolfolk CL, Rieger MM, White AB, Tuuli MG, Srinivas SK, Caughey AB, Tita A, Gregory WT, Richter HE, Cahill AG. Impact of the Duration of the Second Stage of Labor on Postpartum Pelvic Floor Symptoms. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:381-387. [PMID: 38484257 PMCID: PMC10947063 DOI: 10.1097/spv.0000000000001477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
IMPORTANCE The associated effect of duration of the second stage of labor (SSL) on pelvic floor symptoms development is not well studied. OBJECTIVE This study aimed to examine the association between duration of SSL and pelvic floor symptoms at 6 months postpartum among primiparous women. STUDY DESIGN A planned secondary analysis of a multicenter randomized trial evaluating the impact of immediate versus delayed pushing on vaginal delivery rates, maternal morbidity, and neonatal outcomes was conducted between 2014 and 2018. For pelvic floor arm participants, demographic, pelvic examination, and validated questionnaire data were collected postpartum. Primary outcome was change in Pelvic Floor Distress Inventory 20 (PFDI-20) score from immediate to 6 months postpartum. Secondary outcomes included changes in the Pelvic Floor Impact Questionnaire, Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire scores, and Pelvic Organ Prolapse Quantification measurements at 6 months postpartum. Participants were analyzed by SSL duration ≤60 minutes or >60 minutes. RESULTS Of the 2,414 trial participants, 767 (32%) completed pelvic floor assessments at 6 months. Pelvic Floor Distress Inventory 20 scores significantly improved at 6 months in the ≤60 minutes SSL group compared with >60 minutes SSL (-14.3 ± 48.0 and -3.2 ± 45.3, respectively; P = 0.04). Changes from immediate postpartum in total and subscale scores for other questionnaires at 6 months did not differ between groups. Prolapse stage did not differ between groups. Perineal body was significantly shorter in the >60 minutes SSL group (3.7 ± 0.7, 3.5 ± 0.8; P = 0.03). CONCLUSIONS Women with SSL >60 minutes experience less improvement in PFDI-20 scores at 6 months. Greater tissue and innervation trauma in those with SSL >60 minutes may explain persistently less improvement in PFDI-20 scores.
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Affiliation(s)
- Collin M McKenzie
- From the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, TX
| | - Candice L Woolfolk
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mary M Rieger
- From the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, TX
| | - Amanda B White
- From the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, TX
| | | | - Sindhu K Srinivas
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | | | - W Thomas Gregory
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | | | - Alison G Cahill
- From the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, TX
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Meyer I, Iriondo-Perez J, Dyer KY, Sung V, Ackenbom MF, Florian-Rodriguez M, Kim E, Mazloomdoost D, Carper B, Gantz MG. Correlation Between Mobile-Application Electronic Bowel Diary and Validated Questionnaires in Women with Fecal Incontinence. Int Urogynecol J 2024; 35:545-551. [PMID: 38206340 PMCID: PMC11023758 DOI: 10.1007/s00192-023-05711-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/28/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Despite growing interest in a mobile-app bowel diary to assess fecal incontinence (FI) symptoms, data are limited regarding the correlation between mobile-app diary and questionnaire-based outcomes. The primary aim is to determine whether percentage reduction in FI episodes (FIEs)/week recorded on a mobile-app diary correlates with changes in scores of validated FI-symptom measures from baseline to 12 weeks in women with FI undergoing percutaneous tibial nerve stimulation (PTNS) versus sham. METHODS This is a planned secondary analysis of a multicenter randomized trial in which women with FI underwent PTNS or sham. FIEs were collected using a mobile-app diary at baseline and after 12 weekly sessions. FI-symptom-validated measures included St. Mark's, Accidental Bowel Leakage Evaluation, FI Severity Index (FISI), Colorectal Anal Distress Inventory, Colorectal Anal Impact Questionnaire, FI Quality of Life, Patient Global Impression of Improvement (PGI-I), and Patient Global Symptom Control (PGSC) rating. Spearman's correlation coefficient (ρ) was computed between %-reduction in FIEs/week and change in questionnaire scores from baseline to 12 weeks. Significance was set at 0.005 to account for multiple comparisons. RESULTS Baseline characteristics of 163 women (109 PTNS, 54 sham) include mean age 63.4±11.6, 81% white, body mass index 29.4±6.6 kg/m2, 4% previous FI surgeries, 6.6±5.5 FIEs/week, and St. Mark's score 17.4±2.6. A significant correlation was demonstrated between %-reduction in FIEs/week and all questionnaires (p<0.005). A moderate-strength correlation (|ρ|>0.4) was observed for St. Mark's (ρ=0.48), FISI (ρ=0.46), PGI-I (ρ=0.51), and PGSC (ρ=-0.43). CONCLUSIONS In women with FI randomized to PTNS versus sham, a moderate correlation was noted between FIEs measured via mobile-app diary and FI-symptom-validated questionnaire scores.
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Affiliation(s)
- Isuzu Meyer
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | | | - Vivian Sung
- Alpert Medical School of Brown University, University/Women & Infants Hospital, Providence, RI, USA
| | - Mary F Ackenbom
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Edward Kim
- Department of Obstetrics & Gynecology, Division of Urogynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Marie G Gantz
- RTI International, Research for the NICHD Pelvic Floor Disorders Network, Triangle Park, NC, USA
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Liptak P, Duricek M, Banovcin P. Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step. World J Gastroenterol 2024; 30:516-522. [PMID: 38463021 PMCID: PMC10921147 DOI: 10.3748/wjg.v30.i6.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 01/15/2024] [Indexed: 02/05/2024] Open
Abstract
The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.
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Affiliation(s)
- Peter Liptak
- Clinic of Internal Medicine- Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, Martin 03601, Slovakia
| | - Martin Duricek
- Clinic of Internal Medicine- Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, Martin 03601, Slovakia
| | - Peter Banovcin
- Clinic of Internal Medicine- Gastroenterology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University, Martin 03601, Slovakia
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Julienne A, Gourcerol G, Amarenco G, Turmel N, Leroi AM, Desprez C. Fecal Incontinence Subtype Assessment (FI-SA): Validation of a new tool to distinguish among subtypes of fecal incontinence. Clin Res Hepatol Gastroenterol 2024; 48:102275. [PMID: 38158155 DOI: 10.1016/j.clinre.2023.102275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/13/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Three subtypes of fecal incontinence (FI) are described in the literature: urge, mixed and passive FI, but the relevance of this classification remains unknown. To our knowledge, no questionnaire has been validated in a general population of patients with FI to classify patients between the different subtypes of FI. The aim of the present study was to validate the Fecal Incontinence Subtype Assessment (FI-SA) questionnaire in a general population of patients with FI. METHODS All consecutive patients referred to our unit for physiological investigations of anorectal function in case of FI were included. A feasibility study was done to assess the acceptability, understanding, and the reproducibility of the FI-SA questionnaire. Its performance to correctly classify patients between subtypes of FI was evaluated in both a feasibility study and in a validation study, using clinical interview as gold standard. RESULTS The FI-SA questionnaire was found to be well accepted and easily understood by patients. Moreover, it was filled rapidly by patients, with a good reproducibility with an intra-class correlation coefficient of 0.97 and 0.87 for questions 1 and 2. Lastly, the accuracy of the FI-SA questionnaire to predict subtypes of FI was 93.3 % in the feasibility study (n = 30) and 81.1 % in the validation study (n = 100), in comparison with clinical interview as gold standard. CONCLUSION The FI-SA questionnaire could be used in the future to help standardize the methodology used among studies to evaluate the classification of patients in different subtypes of FI and ultimately to guide therapeutics.
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Affiliation(s)
- Audrey Julienne
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France
| | - Guillaume Gourcerol
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France; Normandie Univ, UNIROUEN, Nutrition, Brain and Gut Laboratory, INSERM 1073, F-76000 Rouen, France
| | - Gérard Amarenco
- Sorbonne Université, GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, 75020 Paris, France
| | | | - Anne-Marie Leroi
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France; Normandie Univ, UNIROUEN, Nutrition, Brain and Gut Laboratory, INSERM 1073, F-76000 Rouen, France; CHU Rouen, INSERM CIC-CRB 1404, F-76000 Rouen, France
| | - Charlotte Desprez
- CHU Rouen, Department of Digestive Physiology, F-76000 Rouen, France; Normandie Univ, UNIROUEN, Nutrition, Brain and Gut Laboratory, INSERM 1073, F-76000 Rouen, France.
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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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Tsarkov P, Tulina I, Sheikh P, Shlyk DD, Garg P. Garg incontinence scores: New scoring system on the horizon to evaluate fecal incontinence. Will it make a difference? World J Gastroenterol 2024; 30:204-210. [PMID: 38314129 PMCID: PMC10835531 DOI: 10.3748/wjg.v30.i3.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024] Open
Abstract
The main aim of this opinion review is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. The authors in the published article developed a new scoring system, Garg incontinence scores (GIS), for fecal incontinence (FI). FI is a chronic debilitating disease that has a severe negative impact on the quality of life of the patients. Rome IV criteria define FI as multiple episodes of solid or liquid stool passed into the clothes at least twice a month. The associated social stigmatization often leads to significant under-reporting of the condition, which further impairs management. An important point is that the complexity and vagueness of the disease make it difficult for the patients to properly define and report the magnitude of the problem to their physicians. Due to this, the management becomes even more difficult. This issue is resolved up to a considerable extent by a scoring questionnaire. There were several scoring systems in use for the last three decades. The prominent of them were the Cleveland Clinic scoring system or the Wexner scoring system, St. Marks Hospital or Vaizey's scores, and the FI severity index. However, there were several shortcomings in these scoring systems. In the opinion review, we tried to analyze the strength of GIS and compare it to the existing scoring systems. The main pitfalls in the existing scoring systems were that most of them gave equal weightage to different types of FI (solid, liquid, flatus, etc.), were not comprehensive, and took only the surgeon's perception of FI into view. In GIS, almost all shortcomings of previous scoring systems had been addressed: different weights were assigned to different types of FI by a robust statistical methodology; the scoring system was made comprehensive by including all types of FI that were previously omitted (urge, stress and mucus FI) and gave priority to patients' rather than the physicians' perceptions while developing the scoring system. Due to this, GIS indeed looked like a paradigm shift in the evaluation of FI. However, it is too early to conclude this, as GIS needs to be validated for accuracy and simplicity in future studies.
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Affiliation(s)
- Petr Tsarkov
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Inna Tulina
- Department of Oncologic Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Parvez Sheikh
- Department of Colorectal Surgery, Saifee Hospital, Mumbai 400004, Maharashtra, India
| | - Darya D Shlyk
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
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Koifman E, Armoni M, Gorelik Y, Harbi A, Streltsin Y, Duek SD, Brun R, Mazor Y. Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer. BMC Gastroenterol 2024; 24:31. [PMID: 38216868 PMCID: PMC10787434 DOI: 10.1186/s12876-023-03112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up. AIMS To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment. METHODS One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires. RESULTS 80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1-8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF. CONCLUSIONS A significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.
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Affiliation(s)
- E Koifman
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel.
| | - M Armoni
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - Y Gorelik
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - A Harbi
- Rambam Health Care Campus, Department of General Surgery, Haifa, Israel
| | - Y Streltsin
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - S D Duek
- Rambam Health Care Campus, Department of General Surgery, Haifa, Israel
| | - R Brun
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - Y Mazor
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
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Sun D, Lo KM, Chen SC, Leung WW, Wong C, Mak T, Ng S, Futaba K, Gregersen H. The rectum, anal sphincter and puborectalis muscle show different contraction wave forms during prolonged measurement with a simulated feces. Sci Rep 2024; 14:432. [PMID: 38172283 PMCID: PMC10764324 DOI: 10.1038/s41598-023-50655-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
Contractile patterns in rectum, puborectalis muscle and anal sphincter must be studied to understand defecation. Six subjects had contractile waveforms studied with Fecobionics. Symptom questionnaires, balloon expulsion test and anorectal manometry were done for reference. The Fecobionics bag was filled in rectum to urge-to-defecate volume and measurements were done for 4 h before the subjects attempted to evacuate the device. Pressures and bend angle (BA) variations were analyzed with Fast Fourier Transformation. Four normal subjects exhibited low frequency waves (< 0.06 Hz) for pressures and BA. The waves were uncoordinated between recordings, except for rear and bag pressures. Peak wave amplitudes occurred at 0.02-0.04 Hz. Pressures and the BA differed for peak 1 (p < 0.001) and peak 2 amplitudes (p < 0.005). The front pressure amplitude was bigger than the others (rear and BA, p < 0.05; bag, p < 0.005) for peak 1, and bigger than bag pressure (p < 0.005) and BA (p < 0.05) for peak 2. One subject was considered constipated with lower front pressure amplitudes compared to normal subjects and increased amplitudes for other parameters. The sixth subject was hyperreactive and differed from the other subjects. In conclusion, the rectum, anal sphincter and puborectalis muscle showed different contraction waves during prolonged measurements. The data call for larger studies to better understand normal defecation, feces-withholding patterns, and the implications on anorectal disorders.
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Affiliation(s)
- Daming Sun
- Chongqing Engineering Research Center of Medical Electronics and Information Technology, Chongqing University of Posts and Telecommunications, Chongqing, China
| | - Kar Man Lo
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA
| | - Ssu-Chi Chen
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kaori Futaba
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA.
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Varma R, Feuerhak KJ, Mishra R, Chakraborty S, Oblizajek NR, Bailey KR, Bharucha AE. A randomized double-blind trial of clonidine and colesevelam for women with fecal incontinence. Neurogastroenterol Motil 2024; 36:e14697. [PMID: 37890049 PMCID: PMC10842236 DOI: 10.1111/nmo.14697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/11/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Diarrhea and rectal urgency are risk factors for fecal incontinence (FI). The effectiveness of bowel modifiers for improving FI is unclear. METHODS In this double-blind, parallel-group, randomized trial, women with urge FI were randomly assigned in a 1:1 ratio to a combination of oral clonidine (0.1 mg twice daily) with colesevelam (1875 mg twice daily) or two inert tablets for 4 weeks. The primary outcome was a ≥50% decrease in number of weekly FI episodes. KEY RESULTS Fifty-six participants were randomly assigned to clonidine-colesevelam (n = 24) or placebo (n = 32); 51 (91%) completed 4 weeks of treatment. At baseline, participants had a mean (SD) of 7.5 (8.2) FI episodes weekly. The primary outcome was met for 13 of 24 participants (54%) treated with clonidine-colesevelam versus 17 of 32 (53%) treated with placebo (p = 0.85). The Bristol stool form score decreased significantly, reflecting more formed stools with clonidine-colesevelam treatment (mean [SD], 4.5 [1.5] to 3.2 [1.5]; p = 0.02) but not with placebo (4.2 [1.9] to 4.1 [1.9]; p = 0.47). The proportion of FI episodes for semiformed stools decreased significantly from a mean (SD) of 76% (8%) to 61% (10%) in the clonidine-colesevelam group (p = 0.007) but not the placebo group (61% [8%] to 67% [8%]; p = 0.76). However, these treatment effects did not differ significantly between groups. Overall, clonidine-colesevelam was well tolerated. CONCLUSIONS AND INFERENCES Compared with placebo, clonidine-colesevelam did not significantly improve FI despite being associated with more formed stools and fewer FI episodes for semiformed stools.
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Affiliation(s)
- Revati Varma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelly J Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Bottorff EC, Gupta P, Ippolito GM, Moore MB, Rodriguez GM, Bruns TM. Acute dorsal genital nerve stimulation increases subjective arousal in women with and without spinal cord injury: a preliminary investigation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.24.23288935. [PMID: 37163021 PMCID: PMC10168483 DOI: 10.1101/2023.04.24.23288935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Introduction Female sexual dysfunction (FSD) impacts an estimated 40% of women. Unfortunately, female sexual function is understudied, leading to limited treatment options for FSD. Neuromodulation has demonstrated some success in improving FSD symptoms. We developed a pilot study to investigate the short-term effect of electrical stimulation of the dorsal genital nerve and tibial nerve on sexual arousal in healthy women, women with FSD, and women with spinal cord injury (SCI) and FSD. Methods This study consists of a randomized crossover design in three groups: women with SCI, women with non-neurogenic FSD, and women without FSD or SCI. The primary outcome measure was change in vaginal pulse amplitude (VPA) from baseline. Secondary outcome measures were changes in subjective arousal, heart rate, and mean arterial pressure from baseline. Participants attended one or two study sessions where they received either transcutaneous dorsal genital nerve stimulation (DGNS) or tibial nerve stimulation (TNS). At each session, a vaginal photoplethysmography sensor was used to measure VPA. Participants also rated their level of subjective arousal and were asked to report any pelvic sensations. Results We found that subjective arousal increased significantly from before to after stimulation in DGNS study sessions across all women. TNS had no effect on subjective arousal. There were significant differences in VPA between baseline and stimulation, baseline and recovery, and stimulation and recovery periods among participants, but there were no trends across groups or stimulation type. Two participants with complete SCIs experienced genital sensations. Discussion This is the first study to measure sexual arousal in response to acute neuromodulation in women. This study demonstrates that acute DGNS, but not TNS, can increase subjective arousal, but the effect of stimulation on genital arousal is inconclusive. This study provides further support for DGNS as a treatment for female sexual dysfunction.
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Affiliation(s)
- Elizabeth C. Bottorff
- University of Michigan, Biomedical Engineering Department, Ann Arbor, MI, USA
- University of Michigan, Biointerfaces Institute, Ann Arbor, MI, USA
| | - Priyanka Gupta
- University of Michigan, Department of Urology, Ann Arbor, MI, USA
| | | | - Mackenzie B. Moore
- University of Michigan, Biomedical Engineering Department, Ann Arbor, MI, USA
| | - Gianna M. Rodriguez
- University of Michigan, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI, USA
| | - Tim M. Bruns
- University of Michigan, Biomedical Engineering Department, Ann Arbor, MI, USA
- University of Michigan, Biointerfaces Institute, Ann Arbor, MI, USA
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Tsunoda A, Kusanagi H. Mid-term outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids. Tech Coloproctol 2023; 27:1335-1343. [PMID: 37848640 DOI: 10.1007/s10151-023-02863-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/15/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for the treatment of internal hemorrhoids. ALTA therapy with rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study investigated the midterm outcomes of AM surgery in patients with hemorrhoids. METHODS Patients with grade III hemorrhoids who underwent AM surgery were enrolled in this retrospective analysis of prospectively collected data from a single institution. Cumulative success rates, postoperative symptoms, including pain scores, analgesic requirements, and postoperative complications, and patient satisfaction were assessed. RESULTS The median number of ALTA injection procedures was 3 (range 1-4), and the median total injection dose was 19 mL (range 7-32 mL). The median number of mucopexy procedures was 2 (range 1-4). The median postoperative pain score (0 = no pain at all, 10 = worst pain imaginable) at rest or during defecation were ≤2. The total dose of analgesics administered during the first two weeks after surgery was 1 (range 0-25). Six patients (5.3%) showed postoperative complications: five showed Clavien-Dindo (C-D) grade I and one showed C-D grade IIIa complications. Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively. Patient satisfaction scores, which were assessed using a 10-point scale, were ≥9 at each postoperative year. CONCLUSIONS AM surgery is an effective non-excisional surgery with satisfactory mid-term results for grade III hemorrhoids, and is associated with lower complication rates, postoperative analgesic requirements, and higher patient satisfaction.
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Affiliation(s)
- A Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa City, Chiba, Japan.
| | - H Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa City, Chiba, Japan
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Sylla P, Sands D, Ricardo A, Bonaccorso A, Polydorides A, Berho M, Marks J, Maykel J, Alavi K, Zaghiyan K, Whiteford M, Mclemore E, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Moshier E, Wexner SD. Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results. Surg Endosc 2023; 37:9483-9508. [PMID: 37700015 PMCID: PMC10709232 DOI: 10.1007/s00464-023-10266-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL, USA
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, The Oregon Clinic, Providence Cancer Center, Portland, OR, USA
| | - Elisabeth Mclemore
- Division of Colorectal Surgery, Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Sami Chadi
- Division of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre and University Health Network, Toronto, ON, Canada
| | - Sherief F Shawki
- Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alessio Pigazzi
- Division of Colorectal Surgery, Department of Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL, USA
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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23
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Greer JA, Heye KR, McGlynn A, Johansson S, Vaccaro CM. Association of Pelvic Floor Disorders, Perceived Psychological Stress, and Military Service in U.S. Navy Servicewomen: A Cross-Sectional Survey. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:966-973. [PMID: 37326238 DOI: 10.1097/spv.0000000000001374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
IMPORTANCE Pelvic floor disorders (PFDs) are linked to psychological stress and decreased work performance in civilian populations. Higher psychological stress is reported in female active-duty servicewomen (ADSW), which affects military readiness. OBJECTIVE This study sought to associate PFDs, work-related challenges, and psychological stress in ADSW. STUDY DESIGN We conducted a single-site, cross-sectional survey of ADSW seeking care in the urogynecology, family medicine, and women's health clinics between December 2018 and February 2020 using validated questionnaires to determine the prevalence of PFDs and the association with psychological stress, performance of military duties, and continued military service. RESULTS One hundred seventy-eight U.S. Navy ADSW responded; most were seeking care for PFDs. The reported prevalence rates of PFDs were as follows: urinary incontinence, 53.7%; pelvic organ prolapse, 16.3%; fecal incontinence, 73.2%; and interstitial cystitis/bladder pain syndrome, 20.3%. Active-duty servicewomen with PFDs were more likely to have higher psychological stress scores (22.5 ± 3.7 vs 20.5 ± 4.2, P = 0.002) and body composition failures (22.0% vs 7.3%, P = 0.012), yet more strongly consider remaining on active service if they reported urinary incontinence (22.8% vs 1.8%) or interstitial cystitis/bladder pain syndrome (19.5% vs 1.8%; all P ≤ 0.001). No significant differences were noted in physical fitness failures or other military duties. CONCLUSIONS For these U.S. Navy ADSW with PFDs, there was no significant difference in duty performance but reported psychological stress levels were higher. The presence of PFD was associated with women more strongly considering ongoing military service compared with other factors such as family, job, or career path.
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Affiliation(s)
| | - Kristen R Heye
- From the Division of Urogynecology, Gynecologic Surgery & Obstetrics Department, Naval Medical Center, Portsmouth, VA
| | - Andrea McGlynn
- Clinical Investigations Department, Naval Medical Center, Portsmouth, VA
| | - Shorty Johansson
- From the Division of Urogynecology, Gynecologic Surgery & Obstetrics Department, Naval Medical Center, Portsmouth, VA
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24
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Banday I, Malik AA, Khan MA, Parray F, Wani RA, Banday M, Zahoor H. Validation of Urdu Version of the Low Anterior Resection Syndrome (LARS) Score. Indian J Surg Oncol 2023; 14:909-917. [PMID: 38187850 PMCID: PMC10766916 DOI: 10.1007/s13193-023-01801-0] [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: 04/21/2023] [Accepted: 07/14/2023] [Indexed: 01/09/2024] Open
Abstract
Patients subjected to low anterior resection for rectal cancers experience a constellation of symptoms of disordered bowel function which leads to a detriment in the quality of life. The LAR syndrome (LARS) score is a self-administered questionnaire to identify and assess disordered bowel function after resective surgery. The objective of this study was to validate the Urdu version of the LARS score. The translation process was carried out in a fashion outlined by the original authors of the LARS score after obtaining proper permission. The validation of the translated version included the assessment of its reliability, convergent and discriminant validities, internal consistency, and confirmatory analyses. A total of 60 patients were enrolled in the study with a 95% power of study. The translated questionnaire was initially administered to a random subgroup of patients to verify the adequacy and degree of comprehension of questions. Then reproducibility was investigated by a test-retest procedure. An analysis was then done to determine the correlation between Urdu LARS score and a quality of life related question that was included along with the questionnaire. The Urdu version of the LARS score demonstrates a high convergent validity in terms of its correlation with self-reported quality of life. It also demonstrated its efficacy to discriminate between clinical variables expected to differ with regards to LARS. There was almost perfect agreement in the test and retest values demonstrating good reliability across all instruments. The Urdu version of the LARS score has proven to be a reliable and a valid tool for measuring LARS in the Urdu speaking population of the Indian subcontinent. Supplementary Information The online version contains supplementary material available at 10.1007/s13193-023-01801-0.
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Affiliation(s)
- Imad Banday
- Department of General and Minimal Invasive Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar India
| | - Ajaz Ahmad Malik
- Department of General and Minimal Invasive Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar India
| | - Mohammad Abrar Khan
- Department of General and Minimal Invasive Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar India
| | - Fazl Parray
- Colorectal Division, Department of General and Minimal Invasive Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar India
| | - Rauf Ahmad Wani
- Colorectal Division, Department of General and Minimal Invasive Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar India
| | - Meeran Banday
- Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar India
| | - Hanna Zahoor
- Department of Radiodiagnosis and Imaging, Acharya Shri Chander College of Medical Sciences, Sidhra, Jammu India
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25
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Wang Y, Li N, Zhou Q, Wang P. Fecal incontinence was associated with depression of any severity: insights from a large cross-sectional study. Int J Colorectal Dis 2023; 38:271. [PMID: 37991579 DOI: 10.1007/s00384-023-04563-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Current studies on the association between fecal incontinence (FI) and depression are very limited, and most of them are restricted to women or elderly patients. This study aims to evaluate in detail the association between FI and depression among US adults. METHODS 13,480 adults aged 20 years and older were selected from the National Health and Nutrition Examination Survey 2005-2010. Monthly loss of solid, liquid, or mucous stool was defined as FI. Clinical depression and depression severity were assessed by the validated Patient Health Questionnaide-9 (PHQ-9). Models of multivariate logistic regression were used to calculate adjusted odds ratios (ORs). A subgroup analysis was carried out to ensure that the results were stable. RESULTS After adjusting for covariates such as demographics, risk behaviors and associated comorbidities, the PHQ-9 score and clinical depression were both significantly associated with FI, with ORs and 95%CIs of 1.11 (1.10-1.13) and 3.01 (2.53-3.57). Depression of all severities was also significantly associated with FI. The ORs and 95%CIs of FI with mild depression, moderate depression, and moderately severe to severe depression were 2.29 (1.96-2.68), 3.44 (2.77-4.27) and 4.65 (3.61-6.00), respectively. Subgroup analyses showed no statistically significant interactions (P > 0.05). CONCLUSIONS In conclusion, FI significantly associated with depression of any severity. Like the elderly or female patients with FI, young and middle-aged or men with FI are also at high risk of depression and should also be the focus of depression screening and early intervention.
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Affiliation(s)
- Yan Wang
- Department of Oncology, China Academy of Chinese Medical Sciences Guang' anmen Hospital, 100053, Beijing, China
| | - Na Li
- Department of Anesthesiology, Hekou District People's Hospital, 257200, Dongying City, Shandong Province, China
| | - Qiang Zhou
- Department of Orthopedic Surgery, Hekou District People's Hospital, 257200, Dongying City, Shandong Province, China
| | - Pengfei Wang
- Department of Anorectal surgery, China Academy of Chinese Medical Sciences Xiyuan Hospital, 100091, Beijing, China.
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26
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Varghese C, Harvey X, Gharibans AA, Du P, Collinson R, Bissett IP, Stinear CM, O'Grady G, Paskaranandavadivel N. Clinical utility of trans-sacral magnetic stimulation-evoked sphincter potentials and high-density electromyography in pelvic floor assessment: Technical evaluation. Colorectal Dis 2023; 25:2257-2265. [PMID: 37800177 DOI: 10.1111/codi.16753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 10/07/2023]
Abstract
AIM Faecal incontinence is common and of multifactorial aetiologies, yet current diagnostic tools are unable to assess nerve and sphincter function objectively. We developed an anorectal high-density electromyography (HD-EMG) probe to evaluate motor-evoked potentials induced via trans-sacral magnetic stimulation (TSMS). METHOD Anorectal probes with an 8 × 8 array of electrodes spaced 1 cm apart were developed for recording HD-EMG of the external anal sphincter. These HD-EMG probes were used to map MEP amplitudes and latencies evoked via TSMS delivered through the Magstim Rapid2 (MagStim Company). Patients undergoing pelvic floor investigations were recruited for this IDEAL Stage 2a pilot study. RESULTS Eight participants (median age 49 years; five female) were recruited. Methodological viability, safety and diagnostic workflow were established. The test was well tolerated with median discomfort scores ≤2.5/10, median pain scores ≤1/10 and no adverse events. Higher Faecal Incontinence Severity Index scores correlated with longer MEP latencies (r = 0.58, p < 0.001) and lower MEP amplitudes (r = -0.32, p = 0.046), as did St. Mark's Incontinence Scores with both MEP latencies (r = 0.49, p = 0.001) and MEP amplitudes (r = -0.47, p = 0.002). CONCLUSION This HD-EMG probe in conjunction with TSMS presents a novel diagnostic tool for anorectal function assessment. Spatiotemporal assessment of magnetically stimulated MEPs correlated well with symptoms and offers a feasible, safe and patient-tolerable method of evaluating pudendal nerve and external anal sphincter function. Further clinical development and evaluation of these techniques is justified.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Xavier Harvey
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Armen A Gharibans
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Rowan Collinson
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Cathy M Stinear
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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27
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Zhang R, Luo W, Qiu Y, Chen F, Luo D, Yang Y, He W, Li Q, Li X. Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment. Cancers (Basel) 2023; 15:5011. [PMID: 37894378 PMCID: PMC10605930 DOI: 10.3390/cancers15205011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed. OBJECTIVE AND METHODS To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer. RESULTS The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy. CONCLUSIONS In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Qingguo Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
| | - Xinxiang Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
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28
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Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, Heikura IA, Melin A, Pensgaard AM, Stellingwerff T, Sundgot-Borgen JK, Torstveit MK, Jacobsen AU, Verhagen E, Budgett R, Engebretsen L, Erdener U. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med 2023; 57:1073-1097. [PMID: 37752011 DOI: 10.1136/bjsports-2023-106994] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.
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Affiliation(s)
- Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Naama Constantini
- Sports Medicine Center, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ida Aliisa Heikura
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anna Melin
- Department of Sport Science - Swedish Olympic Committee Research Fellow, Linnaeus University, Kalmar, Sweden
| | - Anne Marte Pensgaard
- Department of Sport and Social Sciences, Norwegian School of Sports Sciences, Oslo, Norway
| | - Trent Stellingwerff
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | | | | | | | - Evert Verhagen
- Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Lars Engebretsen
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Uğur Erdener
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
- World Archery, Lausanne, Switzerland
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29
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Ortenzi M, Guerrieri M, Saraceno F, Reggiani A, Lepiane P, Sileri P, Balla A. Prospective Italian validation of the Vaizey and Wexner and fecal incontinence severity index (FISI) questionnaires. Updates Surg 2023; 75:1617-1623. [PMID: 37368229 DOI: 10.1007/s13304-023-01567-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Several objective severity measurement questionnaires of the fecal incontinence (FI), are available to describe type, frequency and degree of FI, and their impact on quality of life, aiming to establish baseline scores measure response to treatment over time and allow comparison among patients treated using different strategies. Presently, despite their widespread use in clinical practice, none of these questionnaire have been validated in the Italian language. The aim is to test the translated Italian version of the Vaizey and Wexner and Fecal Incontinence Severity Index (FISI) questionnaires assessing their reliability and validity among Italian-speaking patients. Two researchers proficient in spoken English and Italian translated both questionnaires in the Italian language. They independently translated the two questionnaires from English and then they met to produce a single version of the two questionnaires, to solve any possible discrepancy. A forward-backward translation was then obtained by a professional bilingual translator, so as to define the final version of the questionnaires. The questionnaires were independently administered twice to 100 Italian-speaking patients by two different and independent raters. Cronbach's α of the first and second Vaizey and Wexner questionnaire was 0.755 and 0.727, respectively. While Cronbach's α of the first and second FISI questionnaire was 0.810 and 0.806, respectively. Spearman correlation and inter-rater reliability were 0.937 and 0.913 for Vaizey and Wexner questionnaire, respectively, and 0.915 and 0.871 for FISI questionnaire, respectively. Italian version of the Vaizey and Wexner and FISI questionnaires proved good consistency, reliability, reproducibility, showing good psychometric properties.
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Affiliation(s)
- Monica Ortenzi
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Federica Saraceno
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy
| | - Angelica Reggiani
- Department of General Surgery, Università Politecnica Delle Marche, Piazza Roma 22, 60121, Ancona, Italy
| | - Pasquale Lepiane
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy
| | - Pierpaolo Sileri
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Andrea Balla
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy.
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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30
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Ackerman KE, Rogers MA, Heikura IA, Burke LM, Stellingwerff T, Hackney AC, Verhagen E, Schley S, Saville GH, Mountjoy M, Holtzman B. Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs. Br J Sports Med 2023; 57:1136-1147. [PMID: 37752010 DOI: 10.1136/bjsports-2023-107359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/28/2023]
Abstract
In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred, Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.
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Affiliation(s)
- Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margot Anne Rogers
- Australian Institute of Sport, Bruce, South Australia, Australia
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, Australian Capital Territory, Australia
| | - Ida A Heikura
- Canadian Sport Institute-Pacific, Victoria, British Columbia, Canada
- Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Louise M Burke
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Trent Stellingwerff
- Canadian Sport Institute-Pacific, Victoria, British Columbia, Canada
- Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports and Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Stacey Schley
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace H Saville
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Bryan Holtzman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
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Garg P, Sudol-Szopinska I, Kolodziejczak M, Bhattacharya K, Kaur G. New objective scoring system to clinically assess fecal incontinence. World J Gastroenterol 2023; 29:4593-4603. [PMID: 37621752 PMCID: PMC10445003 DOI: 10.3748/wjg.v29.i29.4593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/09/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Several scoring systems are used to assess fecal incontinence (FI), among which, the most commonly used are Wexner and Vaizey's scoring systems. However, there are significant lacunae in these scoring systems, due to which they are neither accurate nor comprehensive. AIM To develop a new scoring system for FI that is accurate, comprehensive, and easy to use. METHODS A pro forma was made in which six types of FI were included: solid, liquid, flatus, mucous, stress, and urge. The weight for each FI was determined by asking a group of patients and laypersons to give a disability score to each type of FI from 0 to 100 (0- least, 100- maximum disability). The disability was assessed on a modified EQ-5D+ (EuroQol) description system, 4D3L (4 dimensions and 3 levels) for each FI. The average score of each FI was calculated, divided by 10, and rounded off to determine the weight of each FI type. The scores for the three levels of frequency of each FI were assigned as never = 0 (No episode of FI ever), occasional = 1 (≤ 1 episode of FI/ wk), and common = 2 (> 1 episode of FI/ wk), and was termed as frequency score. The score for each FI would be derived by multiplying the frequency score and the weight for that FI type. In the second phase of the study, a group of colorectal surgeons was asked to rank the six FI types in order of severity, and their ranking was compared with the patient and laypersons' rankings. RESULTS Fifty patients and 50 laypersons participated in the study. The weight was assigned to each FI (solid-8, liquid-8, urge-7, flatus-6, mucus-6, and stress-5), and an new scoring system was formulated. The maximum possible score was 80 (total incontinence), and the least 0 (no incontinence). The surgeons' ranking of FI severity did not correlate well with patients' and laypersons' rankings of FI, highlighting that surgeons and patients may perceive the severity of FI differently. CONCLUSION A new scoring system for FI was formulated, which was simple, logical, comprehensive, and easy to use, and eliminated previous shortcomings. Patients' and surgeons' perceptions of FI severity of FI did not correlate well.
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Affiliation(s)
- Pankaj Garg
- Colorectal Surgery, Garg Fistula Research Institute (GFRI), Panchkula 134113, Haryana, India
- Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India
| | - Iwona Sudol-Szopinska
- Department ofRadiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw 02-637, Poland
| | | | - Kaushik Bhattacharya
- Department of Surgery, MGM Medical College and LSK Hospital, Kishanganj 855107, Bihar, India
| | - Gurleen Kaur
- Department of Pharmacology, Adesh Medical College and Hospital, Shahbad 136143, Haryana, India
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Khomyakov E, Chernyshov S, Fomenko O, Rybakov E. Does transanal endoscopic microsurgery affect rectal function? Ann Coloproctol 2023; 39:326-331. [PMID: 36375444 PMCID: PMC10475803 DOI: 10.3393/ac.2022.00220.0031] [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: 03/30/2022] [Revised: 04/26/2022] [Accepted: 05/16/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) is the most standardized method for the local excision of rectal neoplasms. Unfortunately, local excisions of rectal lesions by means of TEM are not completely free from undesirable functional sequela. This study was performed to evaluate the risk factors of major loss of function after TEM. METHODS Eighty-nine patients underwent TEM between 2019 and 2020. Anorectal manometry was performed before the surgery and 3, 6, and 12 months after the surgery. The quality of life (QoL) was assessed using the Fecal Incontinence Quality of Life scale. RESULTS The major decrease in QoL was observed in women in 3 months after the surgery in terms of lifestyle and frustration domains (3.6 and 3.64 points, respectively). In 3 months after the surgery, there was a significant decrease in resting pressure both in male and female patients (P=0.01). This difference remained significant 6 months after the surgery (P=0.01). In 12 months after the surgery, resting pressure returned to the preoperative level in most patients (P=0.50). A significant decrease in manometric parameters appeared when the surgery time is more than 55 minutes (P=0.05), the tumor localization is lower than 3 cm from the anus (P=0.03), and the tumor size is over 3 cm (P=0.001). CONCLUSION The most significant risk factors for the development of functional disorders after TEM are surgery time of >55 minutes, tumor localization at <3 cm from the anal verge, and tumor size of >3 cm.
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Affiliation(s)
- Evgeniy Khomyakov
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | | | - Oksana Fomenko
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
| | - Evgeny Rybakov
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
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Thys E, Sasse K. Sacral Neuromodulation Therapy for Urinary and Fecal Incontinence in Patients With Multiple Sclerosis: Report of 6 Cases and Literature Review. Int J MS Care 2023; 25:163-167. [PMID: 37469331 PMCID: PMC10353694 DOI: 10.7224/1537-2073.2022-027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Urinary incontinence (UI) and fecal incontinence (FI) are challenging manifestations of multiple sclerosis (MS) that have historically been treated with limited success. Sacral neuromodulation (SNM) has provided successful resolution of UI and FI in the general population and in patients with neurologic conditions, including MS. We report on 6 patients with MS-related incontinence treated successfully with SNM and review the literature. METHODS Medical records were reviewed retrospectively to identify patients with MS seeking treatment for incontinence. Six patients were identified, and each is presented with follow-up assessment of the severity of UI or FI. RESULTS All 6 individuals with MS had severe incontinence that had been refractory to therapies that included medications and pelvic floor physical therapy. Five patients reported severe UI and 2 patients reported severe FI. Each patient was successfully treated with SNM, with large reductions of incontinence scores and improved quality of life. CONCLUSIONS In this case series, SNM was effective as a treatment for UI and FI among patients with MS. These findings confirm other published series that have reported the success of SNM in patients with MS with incontinence. Sacral neuromodulation should be considered as a potential treatment option for patients with MS and UI and/or FI.
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Affiliation(s)
- Erika Thys
- From the Reno School of Medicine, University of Nevada, Reno, NV, USA (ET, KS)
| | - Kent Sasse
- From the Reno School of Medicine, University of Nevada, Reno, NV, USA (ET, KS)
- Nevada Surgical Associates, Reno, NV, USA (KS)
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Maspero M, Hull T. Patient-Reported Outcomes in Colorectal Surgery. Clin Colon Rectal Surg 2023; 36:240-251. [PMID: 37223227 PMCID: PMC10202545 DOI: 10.1055/s-0043-1761607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment. Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening. This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Ju A, Wiltink L, Walker J, White K, Rutherford C. Supportive care interventions for managing gastrointestinal symptoms following treatment for colorectal cancer: a systematic review. J Cancer Surviv 2023:10.1007/s11764-023-01403-3. [PMID: 37280309 DOI: 10.1007/s11764-023-01403-3] [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: 12/05/2022] [Accepted: 05/09/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is prevalent in the developed world, with unhealthy lifestyles and diet contributing to rising incidence. Advances in effective screening, diagnosis, and treatments have led to improved survival rates, but CRC survivors suffer poorer long-term gastrointestinal consequences than the general population. However, the current state of clinical practice around provision of health services and treatment options remains unclear. PURPOSE We aimed to identify what supportive care interventions are available to manage gastrointestinal (GI) symptoms for CRC survivors. METHODS We searched Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PsycINFO, and CINAHL from 2000 to April 2022 for resources, services, programs, or interventions to address GI symptoms and functional outcomes in CRC. We extracted information about characteristics of supportive care interventions, the study design, and sample characteristics from included studies, and performed a narrative synthesis RESULTS: Of 3807 papers retrieved, seven met the eligibility criteria. Types of interventions for managing or improving GI symptoms included two rehabilitation, one exercise, one educational, one dietary, and one pharmacological. Pelvic floor muscle exercise may help to resolve GI symptoms more quickly in the post-operative recovery phase. Survivors may also benefit from rehabilitation programs through improved self-management strategies, especially administered soon after completing primary treatment. CONCLUSIONS/IMPLICATIONS FOR CANCER SURVIVORS Despite a high prevalence and burden of GI symptoms post-treatment, there is limited evidence for supportive care interventions to help manage or alleviate these symptoms. More, large-scale randomized controlled trials are needed to identify effective interventions for managing GI symptoms that occur post-treatment.
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Affiliation(s)
- Angela Ju
- School of Psychology, Sydney Quality of Life Office, The University of Sydney, Sydney, 2006, Australia.
| | - Lisette Wiltink
- School of Psychology, Sydney Quality of Life Office, The University of Sydney, Sydney, 2006, Australia
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jared Walker
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Kate White
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, Cancer Care Research Unit (CCRU), The University of Sydney, Sydney, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Claudia Rutherford
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, Cancer Care Research Unit (CCRU), The University of Sydney, Sydney, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
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Oruc M, Erol T. Current diagnostic tools and treatment modalities for rectal prolapse. World J Clin Cases 2023; 11:3680-3693. [PMID: 37383136 PMCID: PMC10294152 DOI: 10.12998/wjcc.v11.i16.3680] [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: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.
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Affiliation(s)
- Mustafa Oruc
- Department of General Surgery, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Timucin Erol
- Department of General Surgery, Hacettepe University School of Medicine, Ankara 06100, Turkey
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Dawes AJ, Mariscal JO, White PJ, Midura EF, Sirany AE, Lowry AC, Jensen CC, Thorsen AJ. Does Rectoanal Intussusception Limit Improvements in Clinical Outcome and Quality of Life After Sacral Nerve Stimulation for Fecal Incontinence? Dis Colon Rectum 2023; 66:831-839. [PMID: 36989066 DOI: 10.1097/dcr.0000000000002685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Sacral nerve stimulation is a treatment option for severe, medically refractory fecal incontinence, although its use in patients with anatomic abnormalities remains controversial. OBJECTIVE This study aimed to determine whether patients with rectoanal intussusception achieve similar benefits from device implantation to patients without rectoanal intussusception. DESIGN Retrospective review of a prospectively maintained database. Demographics and clinical data were collected for each patient, including preoperative pelvic floor testing. Defecographies were reanalyzed in a blinded manner. Preoperative rectoanal intussusception was determined on the basis of the Oxford system (grade III-IV vs not; grade V excluded). SETTINGS Academic-affiliated pelvic health center. PATIENTS All patients undergoing sacral nerve stimulation for fecal incontinence between July 2011 and July 2019. MAIN OUTCOME MEASURES Cleveland Clinic Florida Incontinence/Wexner Scores, Fecal Incontinence Severity Indices, and Fecal Incontinence Quality of Life Indices at 1 year. RESULTS One hundred sixty-nine patients underwent sacral nerve stimulation for fecal incontinence during the study period. The average age was 60.3 years and 91% were female. Forty-six patients (27.2%) had concomitant rectoanal intussusception (38 patients [22.5%] grade III and 8 patients [4.7%] grade IV). Before surgery, patients reported an average of 10.8 accidents per week and a Wexner score of 15.7, with no difference between patients with and without rectoanal intussusception ( p = 0.22 and 0.95). At 1 year after surgery, the average Wexner score was 9.5. There was no difference in postoperative Wexner scores (10.4 vs 9.2, p = 0.23) or improvement over time between patients with and without rectoanal intussusception (-6.7 vs -5.7, p = 0.40). Similarly, there was no difference in quality of life or frequency of incontinence to liquid or solid stool. LIMITATIONS Single-institution, moderate sample size, incomplete survey response. CONCLUSIONS Concomitant rectoanal intussusception does not appear to affect clinical outcomes or quality of life after sacral nerve stimulation for fecal incontinence. Appropriate patients with fecal incontinence and rectoanal intussusception can be considered for sacral nerve stimulation placement. See Video Abstract at http://links.lww.com/DCR/C192 . LA INTUSUSCEPCIN RECTOANAL LIMITA LAS MEJORAS EN EL RESULTADO CLNICO Y LA CALIDAD DE VIDA DESPUS DE LA NEUROESTIMULACION SACRA PARA LA INCONTINENCIA FECAL ANTECEDENTES:La neuroestimulación sacra es una opción de tratamiento para la incontinencia fecal grave refractaria al tratamiento médico, aunque su uso en pacientes con anomalías anatómicas sigue siendo controvertido.OBJETIVO:Determinar si los pacientes con intususcepción rectoanal logran beneficios similares de la implantación del dispositivo a los pacientes sin intususcepción rectoanal.DISEÑO:Revisión retrospectiva de una base de datos mantenida prospectivamente. Se recopilaron datos demográficos y clínicos de cada paciente, incluidas las pruebas preoperatorias del piso pélvico. Las defecografías se volvieron a analizar de forma ciega. La intususcepción rectoanal preoperatoria se determinó según el sistema de Oxford (grado III-IV vs. no; grado V excluido).ESCENARIO:Centro académico de salud pélvica.PACIENTES:Todos los pacientes sometidos a neuroestimulación sacra por incontinencia fecal entre julio de 2011 y julio de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Cleveland Clinic Florida Incontinence/Wexner Scores, Índices de gravedad de la incontinencia fecal, Índices de calidad de vida de la incontinencia fecal al año.RESULTADOS:169 pacientes se sometieron a neuroestimulación sacra por incontinencia fecal durante el período de estudio. La edad promedio fue de 60.3 años y el 91% eran mujeres. Cuarenta y seis pacientes (27.2%) tenían intususcepción rectoanal concomitante (38 [22.5%] grado III y 8 [4.7%] grado IV). Antes de la cirugía, los pacientes informaron un promedio de 10.8 accidentes por semana y una puntuación de Wexner de 15.7 sin diferencia entre pacientes con y sin intususcepción rectoanal (p = 0.22 y 0.95). Un año después de la cirugía, la puntuación promedio de Wexner fue de 9.5. No hubo diferencia en las puntuaciones de Wexner posoperatorias (10.4 frente a 9.2, p = 0.23) o mejoría con el tiempo entre los pacientes con y sin intususcepción rectoanal (-6.7 frente a -5.7, p = 0.40). De manera similar, no hubo diferencia en la calidad de vida o la frecuencia de incontinencia de heces líquidas o sólidas.LIMITACIONES:Institución única, tamaño de muestra moderado, respuesta de encuesta incompleta.CONCLUSIÓN:La intususcepción rectoanal concomitante no parece afectar los resultados clínicos o la calidad de vida después de la neuroestimulación sacra para la incontinencia fecal. Los pacientes apropiados con incontinencia fecal e intususcepción rectoanal pueden ser considerados para la neuroestimulación sacra. Consulte Video Resumen en http://links.lww.com/DCR/C192(Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Aaron J Dawes
- Section of Colon and Rectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford, California
| | - Juan O Mariscal
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Peter J White
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Emily F Midura
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Anne E Sirany
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ann C Lowry
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Lordêlo P, Barros J, Liony C, Dias CMCC, Ferreira J, Januário PG, Matos LN, Muniz CO, Silva LS, Brasil C. Novel Nonablative Radiofrequency Approach for the Treatment of Anal Incontinence: A Phase 1 Clinical Trial. Cureus 2023; 15:e40500. [PMID: 37333041 PMCID: PMC10273299 DOI: 10.7759/cureus.40500] [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] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
OBJECTIVE We aimed to describe the action, impact on quality of life, and side effects of perianal nonablative radiofrequency (RF) application in the treatment of anal incontinence (AI) in women. METHODS This was a pilot, randomized clinical trial conducted between January and October 2016. We enrolled women who consecutively attended the Attention Center of the Pelvic Floor (CAAP) with complaints of AI for more than six months. Nonablative RF was applied to the perianal region of the participants using Spectra G2 (Tonederm®, Rio Grande do Sul, Brazil). The reduced or complete elimination of the need for protective undergarments (diapers and absorbents) was considered a partial therapeutic response. RESULTS Nine participants reported treatment satisfaction, while one reported dissatisfaction with the nonablative RF treatment of AI based on the Likert scale. No patient interrupted treatment sessions because of adverse effects, although adverse effects occurred in six participants. However, the clinical and physical examination of the participants with burning sensations showed no hyperemia or mucosal lesions. CONCLUSIONS This study showed a promising reduction of fecal loss, participant satisfaction with treatment, and improved lifestyle, behavior, and depression symptoms with minimal adverse effects.
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Affiliation(s)
- Patrícia Lordêlo
- Obstetrics and Gynecology, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
| | - Juliana Barros
- Physical Medicine and Rehabilitation, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
| | - Claudia Liony
- Physical Medicine and Rehabilitation, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
| | | | - Janine Ferreira
- Physical Medicine and Rehabilitation, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
| | - Priscila G Januário
- Physiotherapy, Pelvic Floor Care Center, Bahia State University, Salvador, BRA
| | - Luana N Matos
- Medicine, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
| | - Camila O Muniz
- Medicine, Pelvic Floor Care Center, Salvador University, Salvador, BRA
| | - Laizza S Silva
- Physical Medicine and Rehabilitation, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
| | - Cristina Brasil
- Physiotherapy, Pelvic Floor Care Center, Bahiana School of Medicine and Public Health, Salvador, BRA
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Wang P, Wang Y, Jia X. Association between fecal incontinence and suicidal ideation in adult Americans: Evidence from NHANES 2005-2010. J Psychosom Res 2023; 170:111377. [PMID: 37229822 DOI: 10.1016/j.jpsychores.2023.111377] [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: 01/03/2023] [Revised: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Currently, research on the relationship between fecal incontinence (FI) and suicidal ideation is very limited. This study aims to evaluate whether FI is associated with suicidal ideation among US adults. METHODS In this cross-sectional study, 13,480 adults aged 20 years and older were selected from the National Health and Nutrition Examination Survey 2005-2010. Monthly loss of solid, liquid, or mucous stool was defined as FI. As part of the Patient Health Questionnaire-9, item 9 assessed suicidal ideation. Models of multivariate logistic regression were used to calculate adjusted odds ratios. A subgroup analysis was carried out to ensure that the results were stable. RESULTS It was found that FI was associated with an increased risk of suicidal ideation after controlling for baseline characteristics, risk behaviors, and comorbid conditions such as depression (OR: 1.60, 95%CI: 1.24-2.08, P < 0.001). In subgroup analyses, FI remained significantly associated with suicidal ideation among participants aged 45 years and older, with odds ratios and 95% confidence intervals of 1.62 (1.11-2.38) and 2.49 (1.51-4.13), respectively. For age category <45 years, the association between FI and suicidal ideation weakened (OR: 1.02, 95%CI: 0.60-1.75, P = 0.932). CONCLUSIONS In conclusion, this study showed that FI was significantly associated with suicidal ideation. Patients aged middle-aged and older are at high risk and should be the focus of screening and timely intervention for suicidal ideation.
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Affiliation(s)
- Pengfei Wang
- Department of Anorectal surgery, Xiyuan Hospital, China Academy of Chinese Medical Sciences, 1 Xiyuan Playground, Haidian District, Beijing, China
| | - Yan Wang
- Department of Oncology, Guang' anmen Hospital, China Academy of Chinese Medical Sciences, 5 Beixiange, Xicheng District, Beijing, China
| | - Xiaoqiang Jia
- Department of Anorectal surgery, Xiyuan Hospital, China Academy of Chinese Medical Sciences, 1 Xiyuan Playground, Haidian District, Beijing, China.
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Bordeianou LG, Thorsen AJ, Keller DS, Hawkins AT, Messick C, Oliveira L, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum 2023; 66:647-661. [PMID: 37574989 DOI: 10.1097/dcr.0000000000002776] [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: 02/18/2023]
Affiliation(s)
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Deborah S Keller
- Colorectal Center, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lucia Oliveira
- Anorectal Physiology Department of Rio de Janeiro, CEPEMED, Rio de Janeiro, Brazil
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Quinlivan A, McMahan ZH, Lee EB, Nikpour M. Gastrointestinal Tract Considerations: Part II: How Should a Rheumatologist Best Manage Common Lower Gastrointestinal Tract Complaints in Systemic Sclerosis? Rheum Dis Clin North Am 2023; 49:319-336. [PMID: 37028837 DOI: 10.1016/j.rdc.2023.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Lower gastrointestinal (GI) symptoms are a frequently encountered problem for clinicians managing patients with systemic sclerosis. The current management practices are focused on the treatment of symptoms with little information available on how to use GI investigations in daily practice. This review demonstrates how to integrate the objective assessment of common lower GI symptoms into clinical care with the aim of guiding clinical decision making. Understanding the type of abnormal GI function that is affecting a patient and determining which parts of the gut are impacted can help clinicians to target therapy more precisely.
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Affiliation(s)
- Alannah Quinlivan
- Department of Rheumatology, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria, 3065, Australia; Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| | - Zsuzsanna H McMahan
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, Suite 5200, Mason F. Lord Building, Center Tower, Baltimore, MD 21224, USA
| | - Eun Bong Lee
- Division of Rheumatology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria, 3065, Australia; Department of Medicine, The University of Melbourne at St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
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Wang H, Jiang HY, Zhang YX, Jin HY, Fei BY, Jiang JL. Mesenchymal stem cells transplantation for perianal fistulas: a systematic review and meta-analysis of clinical trials. Stem Cell Res Ther 2023; 14:103. [PMID: 37101285 PMCID: PMC10134595 DOI: 10.1186/s13287-023-03331-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/06/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Perianal fistulas, characterised as granulomatous inflammation of fistulas around the anal canal, are associated with significant morbidity resulting in a negative impact on quality of life and a tremendous burden to the healthcare system. Treatment of anal fistulas usually consists of anal surgery; however, results of closure rates are not satisfactory especially with complex perianal fistulas, after which many patients may suffer from anal incontinence. Recently, the administration of mesenchymal stem cells (MSCs) has shown promising efficacy. Herein, we aim to explore whether MSCs are effective for complex perianal fistulas and if they have either short-term, medium-term, long-term or over-long-term efficacy. Additionally, we want to elucidate whether factors such as drug dosage, MSC source, cell type, and disease aetiology influence treatment efficacy. We searched four online databases and analysed data based on information within the clinical trials registry. The outcomes of eligible trials were analysed with Review Manager 5.4.1. Relative risk and related 95% confidence interval were calculated to compare the effect between the MSCs and control groups. In addition, the Cochrane risk of bias tool was applied to evaluate the bias risk of eligible studies. Meta-analyses showed that therapy with MSCs was superior to conventional treatment for complex perianal fistulas in short-, long- and over-long-term follow-up phases. However, there was no statistical difference in treatment efficacy in the medium term between the two methods. Subgroup meta-analyses showed factors including cell type, cell source and cell dosage were superior compared to the control, but there was no significant difference between different experimental groups of those factors. Besides, local MSCs therapy has shown more promising results for fistulas as a result of Crohn's Disease (CD). Although we tend to maintain that MSCs therapy is effective for cryptoglandular fistulas equally, more studies are needed to confirm this conclusion in the future. SHORT CONCLUSION MSCs Transplantation could be a new therapeutic method for complex perianal fistulas of both cryptoglandular and CD origin showing high efficacy in the short-term to over-long-term phases, as well as high efficacy in sustained healing. The difference in cell types, cell sources and cell dosages did not influence MSCs' efficacy.
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Affiliation(s)
- H Wang
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, China
| | - H Y Jiang
- Life Spring AKY Pharmaceuticals, Changchun, China
| | - Y X Zhang
- Changchun University of Chinese Medicine, Changchun, China
| | - H Y Jin
- Department of Gastrointestinal Colorectal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - B Y Fei
- Department of Gastrointestinal Colorectal Surgery, China-Japan Union Hospital of Jilin University, Changchun, China.
| | - J L Jiang
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, China.
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Koutsouraki E, Theodoros K, Eleni G, Marianna K, Areti N, Ariadni K, Dimitrios M. Autonomic nervous system disorders in multiple sclerosis. J Neurol 2023:10.1007/s00415-023-11725-y. [PMID: 37084150 DOI: 10.1007/s00415-023-11725-y] [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: 01/13/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
Multiple sclerosis (MS) is a chronic progressive demyelinating disease of the central nervous system (CNS), which also affects the autonomic nervous system (ANS). Manifestations of MS in the ANS include urological, sexual, gastrointestinal, cardiovascular, and thermoregulatory disorders as well as increased fatigue. These problems are common yet are often underestimated due to the non-specificity of the symptoms and the limited evaluation of the ANS in the usual clinical practice. Most of these symptoms seem to be related to localized lesions in the CNS. However, the mechanisms by which these disorders are caused in MS have not been fully investigated, thus preventing any focused etiological treatment. The most common disorders of the ANS in MS represent a challenge for clinicians due to the variability of the clinical picture and our minimal data on their diagnosis and treatment. Early diagnosis and initiation of individualized treatment regimens, often in need of multiple approaches, seem to yield the best results in managing ANS dysfunction in MS patients.
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Affiliation(s)
- Effrosyni Koutsouraki
- First Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | | | | | | | | | - Koukoulidou Ariadni
- Nursing School, International University of Greece, Sindos, Thessaloniki, Greece
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Lefèvre AC, Serup-Hansen E, Storm KS, Wind KL, Kronborg C, Spindler KLG. One-Year Treatment-Related Side Effects and Quality of Life After Chemoradiotherapy in Squamous Cell Carcinoma of the Anus. Int J Radiat Oncol Biol Phys 2023; 115:1165-1177. [PMID: 36179989 DOI: 10.1016/j.ijrobp.2022.09.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Patient-reported outcome (PRO) and National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) data for patients with squamous cell carcinoma of the anus (SCCA) treated with modern radiation therapy (RT) are lacking. The primary aim of this study was to report bowel and bladder PRO and NCI-CTCAE for patients with SCCA 1 year after RT. METHODS AND MATERIALS From 2015 to 2020, we included patients in a prospective Danish national study. Data were collected before treatment (PT) and 1 year after treatment (1Y) using NCI-CTCAE version 4.0, as well as European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR29. We evaluated the combined PRO scores according to the European Organisation for Research and Treatment of Cancer scoring guidelines, and classified changes according to score difference from PT to 1Y as no change (0-5), minor (5-10), moderate (11-20), and major (>20). Raw scores were reported as frequencies of each of the scores: Not at all, a little, quite a bit, and very much. RESULTS Of the 270 patients, 81% had complete data sets, including PT and 1Y answers. Functional mean scores were equal to a matched normal population cohort at PT and 1Y. From PT to 1Y, C30 scores were stable despite minor improvements in global health status/quality of life (7.3), emotional functioning (9.3), insomnia (8.0), and appetite loss (7.8). For questionnaire CR29, bowel and bladder symptoms and sore skin improved with minor change (6.2), and buttocks, anal, or rectal pain improved with moderate change (18.3). Flatulence worsened moderately (12.6), and fecal incontinence had minor worsening (7.8). Agreement between PROs and NCI-CTCAE was generally only fair to moderate, especially for quantitative symptoms, such as pain (κ = 0.25). CONCLUSIONS For patients with SCCA who underwent definitive RT, only a few patients had high scores (indicating quite a bit or very much frequency of bother) regarding bowel and bladder symptoms.
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Affiliation(s)
- Anna Cecilie Lefèvre
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
| | | | | | - Karen Lycke Wind
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Camilla Kronborg
- Danish Center for Particle Therapy, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Karen-Lise Garm Spindler
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aarhus University Hospital, Denmark
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Tsunoda A, Takahashi T, Matsuda S, Kusanagi H. Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size. Int J Colorectal Dis 2023; 38:85. [PMID: 36977940 DOI: 10.1007/s00384-023-04373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). METHODS Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. RESULTS Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047). CONCLUSION The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.
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Affiliation(s)
- Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan.
| | - Tomoko Takahashi
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan
| | - Satoshi Matsuda
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan
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Weisman MH, Oleg Stens, Seok Kim H, Hou JK, Miller FW, Dillon CF. US Inflammatory Bowel Disease Prevalence: Surveillance Data from the U.S. National Health and Nutrition Examination Survey. Prev Med Rep 2023; 33:102173. [DOI: 10.1016/j.pmedr.2023.102173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
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Dos Santos GB, Sato TDO, Miwa-Cerqueira T, Bifani BE, Rocha APR, Carvalho C. Pelvic floor dysfunctions in women with fibromyalgia: A cross-sectional study. Eur J Obstet Gynecol Reprod Biol 2023; 282:1-6. [PMID: 36603313 DOI: 10.1016/j.ejogrb.2022.12.030] [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: 06/05/2022] [Revised: 10/17/2022] [Accepted: 12/29/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fibromyalgia (FM) is a rheumatic syndrome that causes musculoskeletal disorders and is associated with several problems that affect quality of life. As the musculoskeletal system is affected, it can have an impact on the pelvic floor muscles, leading to pelvic floor dysfunction (PFD). OBJECTIVE Investigate the occurrence of PFD, such as urinary incontinence (UI) and anal incontinence (AI), sexual problems, and pelvic organ prolapse (POP), in women with FM compared to a control group composed of women without FM; and investigate the association between FM and PFD. STUDY DESIGN This was an online cross-sectional survey. Demographic and anthropometric data, the description of PFD (UI, nocturia, AI, genital-pelvic pain/penetration disorder, and POP), and previous obstetric history were collected through a web-based questionnaire. The groups were compared using the independent t-test for quantitative variables and the chi-square test for categorical variables. The association between FM and PFD was tested using logistic regression analysis. RESULTS A total of 175 women answered the questionnaire (97 with FM and 78 healthy controls). The women with FM reported significantly more UI, mixed urinary incontinence, AI, POP, and vaginismus than the healthy controls (p ≤ 0.05). FM was associated with mixed urinary incontinence (OR: 2.6; 95 % CI: 1.1-6.4; p = 0.04), anal incontinence (OR: 2.9; 95 % CI: 1.3-6.1; p = 0.01), and flatus incontinence (OR: 2.6; 95 % CI: 1.2-5.4; p = 0.01). CONCLUSION The prevalence of PFD was significantly higher in women with FM compared to healthy women. Indeed, the women with FM were 2.6-fold to 2.9-fold more likely to report mixed urinary incontinence, anal and flatus incontinence than those in the control group. The present findings show possible impairment of the pelvic floor musculature in women with FM.
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Affiliation(s)
- Gabriel Bernardi Dos Santos
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, SP, Brazil; Physical Therapy Post-Graduate Program, Federal University of São Carlos, São Carlos, SP, Brazil
| | - Tatiana de Oliveira Sato
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, SP, Brazil; Physical Therapy Post-Graduate Program, Federal University of São Carlos, São Carlos, SP, Brazil.
| | - Tsugui Miwa-Cerqueira
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, SP, Brazil
| | - Bianca Escuer Bifani
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, SP, Brazil
| | - Ana Paula Rodrigues Rocha
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, SP, Brazil; Physical Therapy Post-Graduate Program, Federal University of São Carlos, São Carlos, SP, Brazil
| | - Cristiano Carvalho
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, SP, Brazil; Physical Therapy Post-Graduate Program, Federal University of São Carlos, São Carlos, SP, Brazil.
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Cwaliński J, Hermann J, Paszkowski J, Banasiewicz T. Minimally Invasive Treatment of Recurrent Anal Fistulas with Autologous Platelet-Rich Plasma Combined With Internal Orifice Closure. Surg Innov 2023; 30:28-35. [PMID: 35430904 DOI: 10.1177/15533506221086778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Minimally invasive procedures for the treatment of anal fistulas are gaining more and more popularity. For this purpose, Platelet-Rich Plasma (PRP) are administered to accelerate the healing process of various difficult wounds or lesions. The aim of this study was to evaluate preliminary results of PRP injection into the tissues adjacent to anal fistulas. PATIENTS AND METHODS A cohort of 42 patients with recurrent anal fistula, who underwent at least one cutting procedure previously, were enrolled into this preliminary and prospective trial. Closure of internal orifice was performed in all investigated patients, however, in 22 patients from group I, that procedure was combined with topical injection of PRP. In the postoperative period, the PRP administration could be repeated in case of incomplete fistula closure. Follow-up consisted of out-patient visits in a fortnight, 1, 2, and 12 months. RESULTS Complete closure of anal fistulas was achieved in 16 (75%) patients from group I and 10 (45,5%) patients from group II. The fistulas were healed in 9 patients from group I after single application of PRP. In the next 9 patients with incomplete fistula closure, the injection was repeated 2 to 4 times every fortnight leading finally to complete recovery in 6 of them. CONCLUSIONS Surgical fistula closure with local PRP application spares the anal sphincter and gives the opportunity to repeat the procedure several times if necessary. Treatment of recurrent anal fistulas with PRP can be considered as last resort therapy.
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Affiliation(s)
- Jarosław Cwaliński
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Jacek Hermann
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Jacek Paszkowski
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
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Tuuli MG, Gregory WT, Arya LA, Lowder JL, Woolfolk C, Caughey AB, Srinivas SK, Tita ATN, Macones GA, Cahill AG, Richter HE. Effect of Second-Stage Pushing Timing on Postpartum Pelvic Floor Morbidity: A Randomized Controlled Trial. Obstet Gynecol 2023; 141:245-252. [PMID: 36603202 DOI: 10.1097/aog.0000000000005031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/07/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess whether immediate or delayed pushing in the second-stage results in higher risk of pelvic floor morbidity. METHODS This study was a planned secondary aim of a multicenter randomized clinical trial that included nulliparous patients at 37 weeks of gestation or greater in labor with neuraxial analgesia. Participants were randomized in the second stage to initiate pushing immediately or wait 60 minutes before pushing. Participants had pelvic floor assessments at 1-5 days postpartum, 6 weeks postpartum, and 6 months postpartum. Rates of perineal lacerations, pelvic organ prolapse quantification (POP-Q) measures, and scores on validated symptom-specific distress and quality-of-life questionnaires (PFDI-20 [Pelvic Floor Distress Inventory], PFIQ [Pelvic Floor Impact Questionnaire], FISI [Fecal Incontinence Severity Index], and MMHQ [Modified Manchester Health Questionnaire]) were compared. It was estimated that 630 participants would provide more than 80% power to detect a 40% difference in second-degree or greater perineal lacerations and approximately 80% power to detect a 40% difference in stage 2 or greater pelvic organ prolapse (POP). RESULTS Among 2,414 participants in the primary trial conducted between May 19, 2014, and December 16, 2017, 941 (39%) had pelvic floor assessments: 452 immediate pushing and 489 delayed pushing. The mean age was 24.8 years, and 93.4% had vaginal delivery. There were no significant differences in perineal lacerations at delivery and POP at 6 weeks and 6 months postpartum. Changes from baseline in total and subscale scores for the PFDI-20, the PFIQ, and the MMHQ were not significantly different at 6 weeks postpartum and 6 months postpartum. The change in FISI score was higher in the immediate pushing group at 6 months (2.9±5.7 vs 2.0±4.5, difference 0.9, P =.01), but less than the minimum important difference of 4. CONCLUSION Among nulliparous patients in the second stage with neuraxial analgesia, immediate pushing, compared with delayed pushing, did not increase perineal lacerations, POP-Q measures, or patient-reported pelvic floor symptoms at 6 weeks and 6 months postpartum. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT02137200.
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Affiliation(s)
- Methodius G Tuuli
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, and Women & Infants Hospital of Rhode Island, Providence, Rhode Island; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; the Department of Obstetrics and Gynecology and the Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; the Department of Obstetrics and Gynecology and the Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Women's Health, Dell School of Medicine, University of Texas at Austin, Austin, Texas
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Lemos N, Fernandes GL, Ribeiro AM, Maia-Lemos PS, Contiero W, Croos-Bezerra V, Tomlison G, Faber J, Oliveira ASB, Girão MJBC. Rehabilitation of People With Chronic Spinal Cord Injury Using a Laparoscopically Implanted Neurostimulator: Impact on Mobility and Urinary, Anorectal, and Sexual Functions. Neuromodulation 2023; 26:233-245. [PMID: 35248460 DOI: 10.1016/j.neurom.2022.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/01/2021] [Accepted: 01/04/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study aimed to assess the impact of the laparoscopic implantation of neuromodulation electrodes (Possover-LION procedure) on mobility and on sexual, urinary, and anorectal functions of people with chronic spinal cord injury (SCI). MATERIAL AND METHODS Longitudinal analysis of 30 patients with chronic SCI (21 ASIA impairment scale (AIS) A, eight AIS B, and one AIS C) submitted to the Possover-LION procedure for bilateral neuromodulation of femoral, sciatic, and pudendal nerves. Assessments were performed before the surgical procedure and at 3, 6, and 12 months postoperatively. The primary outcome was evolution in walking, measured by the Walking Index for Spinal Cord Injury score, preoperatively and at 12 months. Secondary outcomes were changes in overall mobility (Mobility Assessment Tool for Evaluation of Rehabilitation score), urinary function and quality of life (Qualiveen questionnaire), and bowel (time for bowel emptying proceedings and Wexner's Fecal Incontinence Severity Index [FISI]) and sexual functions (International Index of Erectile Function for men and Female Sexual Function Index for women). Surgical time, intraoperative bleeding, and perioperative complications were also recorded. RESULTS Qualitatively, 18 of 25 (72%) patients with thoracic injury and 3 of 5 (60%) patients with cervical injury managed to establish a walker-assisted gait at one-year follow-up (p < 0.0001). A total of 11 (47.8%) have improved in their urinary incontinence (p < 0.0001), and seven (30.4%) improved their enuresis (p = 0.0156). The FISI improved from a median of 9 points preoperatively to 5.5 at 12 months (p = 0.0056). Of note, 20 of 28 (71.4%) patients reported an improvement on genital sensitivity at 12 months postoperatively (p < 0.0001), but this was not reflected in sexual quality-of-life questionnaires. CONCLUSIONS Patients experienced improved mobility and genital sensitivity and a reduction in the number of urinary and fecal incontinence episodes. By demonstrating reproducible outcomes and safety, this study helps establish the Possover-LION procedure as an addition to the therapeutic armamentarium for the rehabilitation of patients with chronic SCI. CLINICAL TRIAL REGISTRATION This study was registered at the WHO Clinical Trials Database through the Brazilian Registry of Clinical Trials-REBEC (Universal Tracking Number: U1111-1261-4428).
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Affiliation(s)
- Nucelio Lemos
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Canada; Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Gynecology and Neuropelveology, Increasing-Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil.
| | - Gustavo L Fernandes
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Gynecology and Neuropelveology, Increasing-Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil; Department of Obstetrics and Gynecology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Augusta M Ribeiro
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Gynecology and Neuropelveology, Increasing-Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil
| | - Priscila S Maia-Lemos
- Department of Gynecology and Neuropelveology, Increasing-Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil
| | - Wellington Contiero
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Gynecology and Neuropelveology, Increasing-Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil
| | - Victor Croos-Bezerra
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Gynecology and Neuropelveology, Increasing-Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil
| | - George Tomlison
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Jean Faber
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Acary S B Oliveira
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Manoel J B C Girão
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
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