Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature

Regenerative medicine as a therapeutic option for fecal incontinence: a systematic review of preclinical and clinical studies

BACKGROUND

Fecal incontinence is the uncontrollable loss of stool and has a prevalence of around 7-15%. This condition has serious implications for patients' quality of life. Current treatment options show unsatisfactory results. A novel treatment option is therefore needed.

OBJECTIVE

This systematic review aims to perform a quality assessment and to give a critical overview of the current research available on regenerative medicine as a treatment for fecal incontinence.

STUDY DESIGN

A systematic search strategy was applied in PubMed, Cochrane Library, EMBASE, MEDLINE, Web of Science, and Cinahl from inception until March of 2018. Studies were found relevant when the animals or patients in the studied group had objectively determined or induced fecal incontinence, and the intervention must have used any kind of cells, stem cells, or biocompatible material, with or without the use of trophic factors. Studies were screened on title and consecutively on abstract for relevance by 2 independent investigators. The risk of bias of preclinical studies was assessed using the SYstematic Review Centre for Laboratory animal Experimentation risk of bias tool for animal studies, and for clinical studies the Cochrane risk of bias tool for randomized trials was used.

RESULTS

In all, 34 preclinical studies and 5 clinical studies were included. Animal species, type of anal sphincter injury, intervention, and outcome parameters were heterogenous. Therefore, a meta-analysis could not be performed. The overall risk of bias of the included studies was high.

CONCLUSION

The efficacy of regenerative medicine to treat fecal incontinence could not be determined due to the high risk of bias and heterogenicity of the available preclinical and clinical studies. The findings of this systematic review may result in improved study design of future studies, which could help the translation of regenerative medicine to the clinic as an alternative to current treatments for fecal incontinence.

SECCA procedure for anal incontinence and antibiotic treatment: a case report of anal abscess

Background

Fecal Incontinence (FI) can seriously affect quality of life. The treatment of fecal incontinence starts conservatively but in case of failure, different surgical approaches may be proposed to the patient. Recently several not invasive approaches have been developed. One of these is the radiofrequency (RF) energy application to the internal anal sphincter.

Case presentation

We report a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years.

Conclusions

The complications post-SECCA procedure reported in literature are generally not serious and often self-limited, such as bleeding or anal pain. This is a case of an anal abscess.

We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy, with the aim to minimize the incidence of this complication.

Can surface electromyography improve surgery planning? Electromyographic assessment and intraoperative verification of the nerve bundle entry point location of the gracilis muscle

PURPOSE

To verify the precision of surface electromyography (sEMG) in locating the innervation zone of the gracilis muscle, by comparing the location of the IZ estimated by means of sEMG with in vivo location of the nerve bundle entry point in patients before graciloplasty procedure due to fecal incontinence.

METHODS

Nine patients who qualified for the graciloplasty procedure underwent sEMG on both gracilis muscle before their operations. During surgery the nerve bundle was identified by means of electrical stimulation. The distance between the proximal attachment and the nerve entry point into the muscle's body was measured. Both measurements (sEMG and in vivo identification) were compared for each subject.

RESULTS

On average, the IZ was located 65.5mm from the proximal attachment. The mean difference in location of the innervation zones in each individual was 10±9.7mm, maximal - 30mm, the difference being statistically significant (p=0.017). It was intraoperatively confirmed, that the nerve entered the muscle an average of 62mm from the proximal attachment. The largest difference between the EMG IZ estimation and nerve bundle entry point was 5mm (mean difference 2.8mm, p=0.767).

CONCLUSION

Preoperative surface electromyography of both gracilis muscles is a safe, precise and reliable method of assessing the location of the innervation zones of the gracilis muscles. The asymmetry of the IZ location in left and right muscles may be important in context of technical aspects of the graciloplasty procedure.

Design and Evaluation of an Intelligent Artificial Anal Sphincter System Powered by an Adaptive Transcutaneous Energy Transfer System

Objectives

The aim of this study was to optimize an intelligent artificial anal sphincter system (AASS) II for patients with severe fecal incontinence.

Methods

Redesigning and integrating a pressure sensor into the sphincter prosthesis allows us to reduce the sensor volume and makes it suitable for a chronic, ambulatory application. Furthermore, a close-loop frequency control method was designed for the transcutaneous energy transfer system. Finally, a longer working time of the implanted device was obtained by the low-power design of the hardware and software. The new model was implanted in 2 dogs and studied for periods of up to 5 weeks.

Results

The output voltage induced on the load of 30 Ω, for a variation range in k of 0.12 ~ 0.42, was maintained at approximately 6.8 V with a frequency control range of the 270 ~ 320 kHz. The minimum and maximum output voltages of the pressure sensor were found to be 1.7 V and 2.34 V, respectively, which corresponded to a pressure range of 90 ~ 120 kPa with maximum change rate of approximately 3.7% caused by the temperature variations. Moreover, compared with AASS I, the low-power design resulting in 94% reduction in power consumption.

Conclusions

The efficacy of the device in achieving continence and sensing the need to defecate was assessed in an animal model. The technical concept and the design of the AASS II turned out to be capable of fulfilling the medical requirements.

Dynamic versus Adynamic Graciloplasty in Treatment of End-Stage Fecal Incontinence: Is the Implantation of the Pacemaker Really Necessary? 12-Month Follow-Up in a Clinical, Physiological, and Functional Study

Purpose. The aim of the study is to compare functional results of end-stage fecal incontinence treatment with dynamic graciloplasty and adynamic graciloplasty augmented with transanal conditioning of the transposed muscle. Methods. A total of 20 patients were qualified for graciloplasty procedure due to end-stage fecal incontinence. 7 patients underwent dynamic graciloplasty (DGP), whereas 13 patients were treated with adynamic graciloplasty, with transanal stimulation in the postoperative period (AGP). Clinical, functional, and quality of life assessments were performed 3, 6, and 12 months after the procedures. Results. There were no intraoperative or early postoperative complications. The detachment of gracilis muscle tendon was observed in one patient in DGP group and two in AGP group. There was a significant improvement of Fecal Incontinence Quality of Life (FIQL) and Fecal Incontinence Severity Index (FISI) scores in both groups 12 months after procedure. Anorectal manometry showed improvement regarding basal and squeeze pressures in both groups, with significantly better squeeze pressures in AGP group. Conclusions. The functional effects in the DGP and AGP groups were similar. Significantly lower price of the procedure and avoidance of implant-related complication risk suggest the attractiveness of the AGP method augmented by transanal stimulation.

Long-term outcomes of sacral nerve stimulation for faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) has proven short- to medium-term effectiveness for the treatment of faecal incontinence (FI); fewer long-term outcomes have been presented and usually in small series. Here, the long-term effectiveness of SNS was evaluated in a large European cohort of patients with a minimum of 5 years' follow-up.

METHODS

Prospectively registered data from patients with FI who had received SNS for at least 5 years from ten European centres were collated by survey. Daily stool diaries, and Cleveland Clinic and St Mark's incontinence scores were evaluated at baseline, after implantation and at the last follow-up. SNS was considered successful when at least 50 per cent symptom improvement was maintained at last follow-up.

RESULTS

A total of 407 patients underwent temporary stimulation, of whom 272 (66·8 per cent) had an impulse generator implanted; 228 (56·0 per cent) were available for long-term follow-up at a median of 84 (i.q.r. 70-113) months. Significant reductions in the number of FI episodes per week (from median 7 to 0·25) and summative symptom scores (median Cleveland Clinic score from 16 to 7, St Mark's score from 19 to 6) were recorded after implantation (all P < 0·001) and maintained in long-term follow-up. In per-protocol analysis, long-term success was maintained in 71·3 per cent of patients and full continence was achieved in 50·0 per cent; respective values based on intention-to-treat analysis were 47·7 and 33·4 per cent. Predictive analyses determined no significant association between pretreatment variables and successful outcomes. Risk of long-term failure correlated with minor symptom score improvement during the temporary test phase.

CONCLUSION

SNS remains an effective treatment for FI in the long term for approximately half of the patients starting therapy.

A novel animal model for external anal sphincter insufficiency

PURPOSE

Reliable animal models are essential to evaluate future therapeutic options like cell-based therapies for external anal sphincter insufficiency. The goal of our study was to describe the most reliable model for external sphincter muscle insufficiency by comparing three different methods to create sphincter muscle damage.

METHODS

In an experimental animal study, female Lewis rats (200-250 g) were randomly assigned to three treatment groups (n = 5, each group). The external sphincter muscle was weakened in the left dorsal quadrant by microsurgical excision, cryosurgery, or electrocoagulation by diathermy. Functional evaluation included in vivo measurements of resting pressure, spontaneous muscle contraction, and contraction in response to electrical stimulation of the afferent nerve at baseline and at 2, 4, and 6 weeks after sphincter injury. Masson's trichrome staining and immunofluorescence for skeletal muscle markers was performed for morphological analysis.

RESULTS

Peak contraction after electrical stimulation was significantly decreased after sphincter injury in all groups. Contraction forces recovered partially after cryosurgery and electrocoagulation but not after microsurgical excision. Morphological analysis revealed an incomplete destruction of the external sphincter muscle in the cryosurgery and electrocoagulation groups compared to the microsurgery group.

CONCLUSIONS

For the first time, three different models of external sphincter muscle insufficiency were directly compared. The animal model using microsurgical sphincter destruction offers the highest level of consistency regarding tissue damage and sphincter insufficiency, and therefore represents the most reliable model to evaluate future therapeutic options. In addition, this study represents a novel model to specifically test the external sphincter muscle function.

Power flow control of TET system for a novel artificial anal sphincter system

This paper presents an adaptive transcutaneous energy transfer system (TETS) integrated with a novel elastic scaling artificial anal sphincter system (ES-AASS) for treating severe faecal incontinence (FI). The ES-AASS is based on a novel executive mechanism that uses a spring scalable structure to clamp the rectum. To deliver the correct amount of power (i.e. to match the load demand under variable coupling conditions or different operation stages of the implanted device) for internal battery charging and ensure safety for the human body, theoretical analysis was conducted as a control rule with respect to the relationship between the phase of driver signals and output voltage. An easy regulating procedure to stabilize output voltage with a phase shift controller is also presented. To validate the phase control rules, a prototype of the TETS was constructed and its performance was validated across the whole coupling coefficient range (0.09 ∼ 0.29) as well as load resistance (50 ∼ 120 Ω). The results show that the output voltage of the secondary side can be maintained at a constant 7 V with a phase regulation range of 78.7-178.2° and the proposed controller has reached a maximal end-to-end power efficiency of 74.2% at 1 W.

Emerging surgical therapies for faecal incontinence

Faecal incontinence is a common condition and is associated with considerable morbidity and economic cost. The majority of patients are managed with conservative interventions. However, for those patients with severe or refractory incontinence, surgical treatment might be required. Over the past 20 years, numerous developments have been made in the surgical therapies available to treat such patients. These surgical therapies can be classified as techniques of neuromodulation, neosphincter creation (muscle or artificial) and injection therapy. Techniques of neuromodulation, particularly sacral nerve stimulation, have transformed the management of these patients with a minimally invasive procedure that offers good results and low morbidity. By contrast, neosphincter procedures are characterized by being more invasive and associated with considerable morbidity, although some patients will experience substantial improvements in their continence. Injection of bulking agents into the anal canal can improve symptoms and quality of life in patients with mild-to-moderate incontinence, and the use of autologous myoblasts might be a future therapy. Further research and development is required not only in terms of the devices and procedures, but also to identify which patients are likely to benefit most from such interventions.

Electrically stimulated gracilis neosphincter for end-stage fecal incontinence: the long-term outcome

BACKGROUND

Electrically stimulated gracilis neosphincter is an established treatment for patients with end-stage fecal incontinence. Few data, however, describe its long-term efficacy.

OBJECTIVE

This study aimed to assess the long-term functional outcome associated with this procedure.

DESIGN

Patients who underwent gracilis neosphincter construction between1989 and 2001 were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiologic data were available for all patients.

SETTINGS

This study was conducted at an academic colorectal unit in a tertiary center.

PATIENTS

Sixty patients (median age, 42 years; 46 females) with fecal incontinence and a Williams continence score ≥5 were recruited to the study. The causes of incontinence included obstetric injury (n = 22), anal surgery (n = 17), atresia (n = 7), idiopathic incontinence (n = 6), anorectal excision (n = 4), and ileoanal pouch incontinence (n = 4).

MAIN OUTCOME MEASURE

The primary outcomes measured were the Williams continence score and the proportion of patients with a Williams score ≤3 who avoided permanent stoma formation.

RESULTS

Continence improved for the cohort postoperatively at 2 years (2(2-5); p < 0.001) but no significant difference was found between continence scores preoperatively and at 13 years (5(3-6); p = not significant). However, a sustained improvement at 13 years was noted for patients in the anal surgery (3(2-5);p < 0.001) and obstetric injury groups (4.5(3-6); p = 0.001). Twenty-six patients (43%) had a Williams score ≤3 and avoided permanent stoma after 13 years. Eighteen patients developed postoperative rectal evacuatory disorder; 10 of them required a conduit to facilitate colonic irrigation. Postoperative evacuatory disorder was more frequent in patients with a history of obstetric injury (p = 0.008).

LIMITATIONS

This study was limited by the lack of bowel diaries and quality-of-life scores.

CONCLUSION

Gracilis neosphincter is associated with clinically significant and sustained symptom improvement in patients with end-stage fecal incontinence secondary to obstetric injury or anal surgery. These data support the continued use of this procedure in highly selected patients.

Feedback control of TET system with variable coupling coefficients for a novel artificial anal sphincter

For treating severe faecal incontinence, the authors developed an intelligent artificial anal sphincter system (AASS) equipped with a feedback sensor that utilized a transcutaneous energy transfer system (TETS). To deliver the correct amount of power (i.e. to match the load demand under variable coupling conditions caused by changes in positioning between the coils due to fitting and changes in posture), a regulating method to stabilize output voltage with a closed loop variable-frequency controller was developed in this paper. The method via which the voltage gain characteristics of a voltage-fed series-tuned TETS were derived is also described. The theoretical analysis was verified by the results of the experiment. A numerical analysis method was used as a control rule with respect to the relationship between operating frequency and output voltage. To validate the feedback control rules, a prototype of the TET charging system was constructed, and its performance was validated with the coupling variation between 0.12-0.42. The results show that the output voltage of the secondary side can be maintained at a constant 7 V across the whole coupling coefficient range, with a switching frequency regulation range of 271.4-320.5 kHz, and the proposed controller has reached a maximal end-to-end power efficiency of 67.5% at 1 W.

Technical and functional results of the artificial bowel sphincter for treatment of severe fecal incontinence: is there any benefit for the patient?

BACKGROUND

Fecal incontinence is a socially devastating problem that can be cured by the artificial bowel sphincter in selected cases.

OBJECTIVE

This study evaluates short- and long-term morbidity and functional results of the artificial bowel sphincter.

DESIGN

This study is a retrospective evaluation of consecutive patients.

SETTINGS

This study was conducted at 2 academic colorectal units.

PATIENTS

Between May 2003 and July 2010, all consecutive patients who underwent artificial bowel sphincter implantation for severe fecal incontinence were included in the study.

INTERVENTION

The artificial bowel sphincter was implanted through 2 incisions made in the perineum and suprapubic area.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, and 12, and then annually. Mortality, morbidity (early infection within the first 30 days after implant, and late thereafter), and reoperations including explantations were analyzed. Anal continence was evaluated by means of the Cleveland Clinic Florida score. Mean follow-up was 38 months (range, 12-98).

RESULTS

Between May 2003 and July 2010, 21 consecutive patients with a mean age of 51 years (range, 23-71) underwent surgery. There was no mortality. All patients presented with at least 1 complication. Infection or cutaneous ulceration occurred in 76% of patients, perineal pain in 29%, and rectal evacuation disorders in 38%. The artificial bowel sphincter was definitely explanted from 17 patients (81%). The artificial sphincter was able to be activated in 17 patients (81%), and continence was satisfactory at 1 year in those who still had their sphincter in place (n = 12).

CONCLUSION

There is a very high rate of morbidity and explantation after implantation of an artificial bowel sphincter for fecal incontinence. Four of 21 patients who still had an artificial sphincter in place had satisfactory continence at a mean follow-up of 38 months.

Sacral nerve modulation and other treatments in patients with faecal incontinence after unsuccessful pelvic floor rehabilitation: a prospective study

OBJECTIVES

Sacral nerve modulation (SNM) is a minimally invasive technique for the treatment of faecal incontinence. This study investigates the results of SNM after negative outcome of a standardized pelvic floor rehabilitation (PFR) programme for the treatment of faecal incontinence.

METHOD

A prospective cohort study was performed between December 2001 and August 2007. Consecutive patients who visited the outpatient department for faecal incontinence were included in a multicentre study and treated with standardized PFR. Those with an unsuccessful result who were eligible for SNM were included in the present study. Failures at test stimulation or SNM received another treatment. Clinical outcome, Vaizey scores and Hirschsprung's disease/anorectal malformation quality-of-life (EQ-5D and HAQL) were assessed during follow-up in patients with SNM and in patients with other treatments (OT). Adverse events (AE) were documented.

RESULTS

Thirty-five patients (mean age 59.7 years; 31 females) were included. Twenty-one had a successful test stimulation and 19 patients proceeded to a SNM implant. Incontinence episodes per week decreased significantly from 11.1 +/- 11.7 to 1.9 +/- 2.6 during test stimulation (P < 0.0001) and SNM over 24.1 months follow-up. The overall success rate was 49% (17/35). The patients with unsuccessful test stimulation or SNM received OT. The Vaizey score improved in both SNM (18.2 +/- 3.5 vs 13.7 +/- 4.8; P = 0.004) and other treatment (18.2 +/- 3.5 vs 13.9 +/- 6.9; P = 0.019). The HAQL scale improved significantly during SNM in all subscales (P < 0.005), but not in the other treatment group. Eight AE occurred during test stimulation (23%) and six AE after permanent implantation (26%).

CONCLUSION

Sacral nerve modulation improves disease specific quality of life significantly compared with other treatment.

Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study

BACKGROUND

Sacral nerve stimulation has been approved for use in treating urinary incontinence in the United States since 1997, and in Europe for both urinary and fecal incontinence (FI) since 1994. The purpose of this study was to determine the safety and efficacy of sacral nerve stimulation in a large population under the rigors of Food and Drug Administration-approved investigational protocol.

METHODS

Candidates for SNS who provided informed consent were enrolled in this Institutional Review Board-approved multicentered prospective trial. Patients showing > or =50% improvement during test stimulation received chronic implantation of the InterStim Therapy (Medtronic; Minneapolis, MN). The primary efficacy objective was to demonstrate that > or =50% of subjects would achieve therapeutic success, defined as > or =50% reduction of incontinent episodes per week at 12 months compared with baseline.

RESULTS

A total of 133 patients underwent test stimulation with a 90% success rate, and 120 (110 females) of a mean age of 60.5 years and a mean duration of FI of 6.8 years received chronic implantation. Mean follow-up was 28 (range, 2.2-69.5) months. At 12 months, 83% of subjects achieved therapeutic success (95% confidence interval: 74%-90%; P < 0.0001), and 41% achieved 100% continence. Therapeutic success was 85% at 24 months. Incontinent episodes decreased from a mean of 9.4 per week at baseline to 1.9 at 12 months and 2.9 at 2 years. There were no reported unanticipated adverse device effects associated with InterStim Therapy.

CONCLUSION

Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with FI.

Autobionics: a new paradigm in regenerative medicine and surgery

The concept of bionics was developed 50 years ago and represented the development of engineering and technology based on natural biological systems. Traditional applications of bionics in healthcare include artificial bionic organs that apply engineering principles to replace or augment physiological functions by integrating electronic, mechanical or electromechanical components to inherent body tissues/organs (we term this as 'exobionics'). Recently, there has been a new wave of bio-inspired treatments that act through the reorganization of the existing biological organs in an individual to enhance physiology. Here, the technology does not replace biological tissue, but rather applies engineering principles to replace or augment physiological functions by the rearrangement and manipulation of inherent tissue/organs; we term this autobionics. Examples include: dynamic cardiomyoplasty (artificial heart pump using skeletal muscle), the Ross procedure (pulmonary autograft), dynamic graciloplasty (artificial sphincter) and metabolic gastric bypass (rearranging the gastrointestinal tract to modify gut- and pancreatic-hormone release). Autobionic therapies can be classified into dynamic, static and metabolic procedures. This results in tissue redesignation (one tissue used in place of another), tissue replacement and systems reorganization (rearranging inherent organ/tissue anatomy). In some cases autobionic procedures can enhance physiological function beyond normality and represents a new era in bio-inspired versatility.

Retrograde colonic irrigation for faecal incontinence after low anterior resection

BACKGROUND AND AIMS

This study aims to evaluate the therapeutic effect of retrograde colonic irrigation in patients with faecal incontinence after a low anterior resection for a rectal carcinoma.

MATERIALS AND METHODS

Patients with a previous low anterior resection, who were selected for treatment with retrograde colonic irrigation for faecal incontinence between 2005 and 2008, were included in the study. The data from the patients were gathered by chart research and an interview by phone.

RESULTS

Thirty patients were included in the study. Three patients died and one patient was not able to answer questions due to a cognitive disorder. The data of the remaining 26 patients were analysed. Five patients had already stopped with the retrograde colonic irrigation treatment due to side effects. Twelve of the 21 patients (57.46%) who still performed RCI became completely (pseudo)continent, three patients (14.2%) were incontinent for flatus and six patients (29.4%) were still incontinent for liquid stool. Five patients stopped with the retrograde colonic irrigation treatment due to side-effects.

CONCLUSION

Retrograde colonic irrigation is an effective method to treat patients with faecal incontinence after a low anterior resection for rectal carcinoma. Retrograde colonic irrigation is not invasive and has only mild side effects.

Factors associated with failure of the artificial bowel sphincter: a study of over 50 cases from Cleveland Clinic Florida

PURPOSE

This study investigated the risk factors related to artificial bowel sphincter infection, complications, and failure.

METHOD

Complications may occur at any time after artificial bowel sphincter implantation. Early-stage complication is defined as any complications that occurred before artificial bowel sphincter activation, whereas late-stage complications are defined as any complications that occurred after device activation. Assessment of the outcomes of all artificial bowel sphincter operations included evaluation of factors related to patient demographics, operative procedures, and postoperative events.

RESULT

From January 1998 to May 2007, 51 artificial bowel sphincter implantations were performed in 47 patients (43; 84.3% female) with a mean age of 48.8 +/- 12.5 (range, 19-79) years and a mean incontinence score of 18 +/- 1.4 (range, 0-20). In 24 patients (54.5%), the etiology of incontinence was secondary to imperforate anus; 15 (24.2%) patients had obstetric injury or anorectal trauma. Twenty-three (41.2%) artificial bowel sphincter implantations became infected, 18 (35.3%) of which developed early-stage infection, whereas 5 (5.9%) had late-stage infection. One patient in the latter group had associated erosion, and two patient had fistula formation. Late-stage complications continued to increase with time. Multivariate analysis revealed that the time between artificial bowel sphincter implantation and first bowel movement and a history of perineal sepsis were independent risk factors for early-stage artificial bowel sphincter infection.

CONCLUSION

The time from implantation to first bowel movement and history of perineal infection were risk factors for early-stage artificial bowel sphincter infection and failure. Late-stage failures were more often the result of device malfunction and indicated the need for mechanical refinement.

The artificial bowel sphincter for faecal incontinence: a single centre study

BACKGROUND AND AIMS

Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS).

MATERIALS AND METHODS

Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed.

RESULTS

Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8-106.3) months. The Williams score improved significantly after placement of the ABS (p<0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p=0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p=0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted.

CONCLUSION

The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.

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

BACKGROUND AND AIM

Faecal incontinence is a devastating complaint. Even after conservative treatment, many patients still remain incontinent. Few patients have a sphincter defect suitable for repair. Other emerging surgical therapies like dynamic gracilis plasty, neuromodulation or artificial bowel sphincter, carry side effects and show only moderate improvement. Temperature-controlled radiofrequency energy (SECCA) has shown promising results in the USA. Local tightening seems to be the mode of action with possible increased rectal sensitivity. We investigated the effectiveness of radiofrequency and possible changes in the anal sphincter with 3D-ultrasound in patients with faecal incontinence.

PATIENTS AND METHODS

Eleven women, mean age 61 years (49-73) with long-standing faecal incontinence were included. Patients with large sphincter defects and anal stenosis were excluded. The SECCA procedure was performed under conscious sedation and local anaesthesia. Oral antibiotics were given. In four quadrants on four or five levels (depending upon length of the anus) radiofrequency was delivered with multiple needle electrodes. Patients were evaluated at 0, 6 weeks, 3 and 6 months and 1 year. Three-dimensional anal ultrasound was performed at 0 (before and after the procedure), 6 weeks and 3 months. Anal manometry and rectal compliance measurement were performed at 0 and 3 months.

RESULTS

At 3 months, six of 11 patients improved, which persisted during follow-up of 1 year. The Vaizey score changed from 18.8 to 15.0 (P=0.03) and in those improved from 18.3 to 11.5 (P=0.03). Anal manometry and rectal compliance showed no significant changes, there was a tendency to increased rectal sensitivity concerning urge and maximal tolerated volume (both P=0.3). Responders compared with nonresponders showed no difference in test results. Side effects were local haematoma (2), bleeding 3 days (1), pain persisting 1-3 weeks (4) and laxatives-related diarrhoea during 1-3 weeks (4).

CONCLUSION

The SECCA procedure seems to be promising for patients with faecal incontinence with a persisting effect after 1 year. No significant changes in tests were found.

Anal plugs and retrograde colonic irrigation are helpful in fecal incontinence or constipation

AIM: To evaluate the feasibility, clinical effect and predicting factors for favorable outcome of treatment with anal plugs in fecal incontinence and retrograde colonic irrigation (RCI) in patients with fecal incontinence or constipation.

METHODS: Patients who received treatment with an anal plug or RCI between 1980 and 2005 were investigated with a questionnaire.

RESULTS: Of the 201 patients (93 adults, 108 children), 101 (50%) responded. Adults: anal plugs (8), five stopped immediately, one stopped after 20 mo and two used it for 12-15 mo. RCI (40, 28 fecal incontinence, 12 constipation), 63% are still using it (mean 8.5 years), 88% was satisfied. Younger adults (< 40 years) were more satisfied with RCI (94 % vs 65%, P = 0.05). Children: anal plugs (7), 5 used it on demand for an average of 2.5 years with satisfactory results, one stopped immediately and one after 5 years. RCI (26 fecal incontinence, 22 constipation), 90% are still using it (mean time 6.8 years) and felt satisfied. Children tend to be more satisfied (P = 0.001). Besides age, no predictive factors for success were found. There was no difference in the outcome between patients with fecal incontinence or constipation.

CONCLUSION: RCI is more often applied than anal plugs and is helpful in patients with fecal incontinence or constipation, especially for younger patients. Anal plugs can be used incidentally for fecal incontinence, especially in children.