Evolving therapy for fecal incontinence

Reconstructing the anal sphincters to reverse iatrogenic overstretching following a pull-through for Hirschsprung disease. One-year outcomes

BACKGROUND

In patients with Hirschsprung disease (HSCR), soiling may be related to anal sphincter damage following the initial pull-through. No optimal treatment has been developed for such patients, although enemas (rectal or antegrade) have been applied with some success. We present the one-year outcomes of a new technique for anal sphincter reconstruction.

METHODS

All patients with HSCR referred from other institutions for post pull-through soiling were studied. Seven patients with patulous sphincters underwent sphincter reconstruction. Six had a full preoperative evaluation and were included in the study. Their 12-month outcomes were assessed.

RESULTS

All six patients had soiling without voluntary bowel movements (VBMs). One patient was clean on Malone flushes when referred. Three underwent pre- and post-reconstruction non-sedated three-dimensional anorectal manometry, and objectively were able to close their sphincters following the reconstruction. All patients without Down syndrome (4 of 6) showed improvement in the abbreviated Baylor Continence Scale (4.5 vs. 0.75). One patient has achieved total bowel control without antegrade flushes, three now have VBMs which they did not have before but have occasional accidents and use antegrade flushes intermittently. They reported higher productivity, the ability to participate in sports and be away from home with confidence in their regimen. Two of 6 patients have Down syndrome and required a redo pull-through for other indications and underwent empiric sphincter reconstruction. For these two patients we do not have an outcomes assessment.

CONCLUSIONS

A new technique for sphincter reconstruction shows promising results in improvement of bowel control at one year.

LEVEL OF EVIDENCE

IV.

Bulking agents in gastrointestinal endoscopy: present applications and future advances

PURPOSE OF REVIEW

Bulking agents are inert materials injected into an organ to affect the physical properties of the organ for a therapeutic purpose. Various agents have been developed to aid in the treatment of diseases like gastroesophageal reflux disease (GERD), fecal incontinence, obesity, malignancy, hemostasis, and tissue dissection. Here, we review the state of the art in bulking agents in gastrointestinal endoscopy, past failures, current limitations, and where we see the field heading in the future.

RECENT FINDINGS

Though bulking agents have been trialed for various different gastrointestinal diseases, there are currently limited uses in gastrointestinal endoscopy. Though various agents have been trialed for GERD, numerous complications and adverse events have limited its current use. However, for the treatment of fecal incontinence endoscopic bulking agent therapy is a reasonable option. Though in early stages of exploration, bulking agent therapy for enteric protection from radiotherapy may be a promising tool to improve treatment of pancreatic cancer. Bulking agents for tissue dissection have substantially improved lifting agents and complex polyp removal. Bulking agent therapy has not really been explored for endoscopic bariatric therapy or hemostasis but may be a fruitful area for exploration in the future.

SUMMARY

Bulking agent therapy has been trialed for various gastrointestinal diseases with mixed success. There is currently a therapeutic roll in the endoscopic management of fecal incontinence and tissue dissection. A future role in the treatment of GERD, obesity, malignancy, and hemostasis seem feasible.

An evaluation of the long-term effectiveness of Gatekeeper™ intersphincteric implants for passive faecal incontinence

Background

Implantation of Gatekeeper™ prostheses presents an option for the treatment of passive faecal incontinence (FI). Whilst preliminary results are encouraging, long-term data regarding its sustained benefit are limited. The aim of this study was to assess and evaluate the long-term clinical function and quality of life of patients with passive faecal incontinence who were treated with Gatekeeper™ prostheses.

Methods

This was a single centre, single surgeon retrospective study of prospectively collected clinical data in patients with FI treated between June 2012 and May 2019. Patients with passive FI with symptoms refractory to conservative treatment and endoanal ultrasonography showing intact or disrupted internal anal sphincter were included. Formal clinical and quality of life assessments were carried out using the St. Mark’s Incontinence Score (SMIS) and Faecal Incontinence Quality of Life (FIQoL) questionnaires at baseline, 3 months, 6 months, 12 months and then annually. Endoanal ultrasonography was performed both before and after surgery.

Results

Forty patients (14 males, 26 females) with a median age of 62.5 (range 33–80) years were treated with the Gatekeeper™ implant. The majority of patients (87.5%) received six implants. There were no peri or post-operative complications. Prosthesis migration was observed in 12.5% patients. The median follow-up duration was 5 years (interquartile range (IQR) 3.25–6.00 years). A sustained improvement in median SMIS and FIQoL scores from baseline to follow-up was noted. Significant differences were observed between the median baseline SMIS score and last follow-up score of 16.00 (IQR 15.00–16.75) to 7.00 (IQR 5.00–8.00) respectively (p < 0.001), a 56.25% decrease. The overall median FIQoL score showed a significant improvement from 7.95 (IQR 7.13–9.48) to 13.15 (IQR 12.00–13.98) (p < 0.001) a 65.40% increase.

Conclusions

Gatekeeper™ implantation is a safe approach to treating passive FI and is minimally invasive, reproducible and has minimal complications. Long-term sustained clinical improvement is achievable beyond 5 years. Careful patient selection is paramount, as is consistency of technique and follow-up protocol.

Feasibility Study of Transanal Irrigation Using a Colostomy Irrigation System in Patients With Low Anterior Resection Syndrome

BACKGROUND

Low anterior resection syndrome has a negative impact on quality of life. Intestinal irrigation is a method of lavage consisting of a scheduled evacuation.

OBJECTIVE

This study aims to evaluate functional and quality-of-life outcomes in patients with low anterior resection syndrome after transanal irrigation using a colostomy irrigation system.

DESIGN

This was a prospective case series.

SETTINGS

This study presents a single-center experience at a tertiary oncological center in an upper-middle-income country.

PATIENTS

Patients classified as having minor or major low anterior resection syndrome 12 months after their operation were selected.

INTERVENTIONS

Transanal irrigation was performed using an ostomy irrigation kit. Questionnaires assessing patients' bowel function (low anterior resection syndrome and Wexner score) and quality of life (Short Form-36 questionnaire) were applied before and after treatment.

MAIN OUTCOME MEASURES

The primary outcomes were low anterior resection syndrome score and quality-of-life improvement after a 12-month treatment.

RESULTS

Of the 22 patients included, 20 had major and 2 had minor low anterior resection syndrome, with a median score of 39, especially high rates of incontinence for liquid stool (21; 95.5%), clustering (21; 95.5%), and urgency (17; 77.3%). All patients successfully completed the 3-day training, and there were no complications during the treatment. After the 12-month period, the median score was 8, with 90% of the patients classified as having "no syndrome" and great improvement in all domains of this score. The most improved quality-of-life sections were patient vitality (p = 0.025) and physical (p = 0.002), social (p = 0.001), and emotional aspects (p = 0.001).

LIMITATIONS

The study was limited by its small sample size and the limited follow-up period.

CONCLUSIONS

This study presents a safe implementation protocol of an ostomy irrigation device for transanal irrigation. It also adds to the literature that transanal irrigation is a safe, effective, and easily implemented procedure for patients with low anterior resection syndrome with a significant improvement in quality of life. See Video Abstract at http://links.lww.com/DCR/B563.ESTUDIO DE FACTIBILIDAD DE LA IRRIGACIÓN TRANSANAL UTILIZANDO EL SISTEMA DE IRRIGACIÓN PARA COLOSTOMÍA EN PACIENTES CON SÍNDROME DE RESECCIÓN ANTERIOR BAJAANTECEDENTES:El síndrome de resección anterior baja tiene un impacto negativo en la calidad de vida de los pacientes. La irrigación intestinal es un método de lavado que consiste en evacuaciones programadas.OBJETIVOS:Evaluar los resultados de la funcionalidad e impacto en la calidad de vida de los pacientes con síndrome de resección anterior y baja posterior a la irrigación transanal utilizando un sistema de irrigación de colostomía.DISEÑO:Es estudio prospectivo de una serie de casos.ESCENARIO:En este estudio se muestra la experiencia de un centro oncológico de tercer nivel en un país en vías de desarrollo.PACIENTES:Aquellos clasificados como síndrome con afección en menor o mayor grado doce meses después de la cirugía.METODO:Se efectuó irrigación transanal utilizando un equipo de irrigación de estomas. Se aplicaron cuestionarios para valorar la función intestinal de los pacientes (síndrome de resección anterior baja y la escala de Wexner) y para calidad de vida (Cuestionario Corto-36) antes y después del tratamiento.EVALUACION DE LOS RESULTADOS PRINCIPALES:Los principales resultados se obtuvieron de la escala del síndrome de resección baja y la mejoría en la calidad vida doce meses después de tratamiento.RESULTADOS:De los veintidós pacientes incluidos, veinte presentaron manifestaciones mayores del síndrome de resección baja y dos, manifestaciones menores. Con una media de treinta y nueve, se encontraron, especialmente, altos índices de incontinencia a líquidos (21; 95'5%) hiperdefecación "clustering" (21; 95'5%) y urgencia (17; 77'3%). Todos los pacientes completaron en forma satisfactoria el entrenamiento de tres días sin presentarse complicaciones durante el tratamiento. Al término del mes doce la media fue de ocho, con el 90% de los pacientes clasificados como "sin síndrome" y se observó una mejoría substancial en todos los puntos de la evaluación. Las secciones de calidad de vida que mostraron una mejoría significativa fueron: la vitalidad del paciente (p = 0'025), física (p = 0'002), social (p = 0'001) y emocional (p = 0'001).LIMITACIONES:El tamaño de la muestra es pequeño y el tiempo de seguimiento corto.CONCLUSIONES:Este estudio muestra la implementación de un protocolo seguro para la irrigación de estomas mediante un dispositivo transanal. Además contribuye con el concepto en la literatura de que la seguridad de la irrigación transanal es seguro, efectivo y facilmente reproducible para pacientes con síndrome de resección anterior baja con una mejoría significativa en la calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B563. (Traducción-Dr. Miguel Esquivel-Herrera).

A Cadaveric Study on the Efficacy of Surface Marking and Bony Landmarks Used in Sacral Neuromodulation

Background

Anatomical landmarks and surface markings have long been used in out-patient contexts for conducting percutaneous nerve evaluation procedures, but studies testing the reliability of these anatomical landmarks are scant. There have been reports where the procedure has failed. Could it be possible that the anatomical landmarks that are used are not reliable enough? To answer this question, we used this study to understand the reliability of these anatomical landmarks.

Methods

Twenty cadavers, 10 males and 10 females, were dissected in the sacral region; the landmarks were tested, and the angulation and curve made by the sacral 3 (S3) nerve were also studied.

Results

Sacral 3 was identified mainly at the four o’clock position on the right and at the eight o’clock position on the left side. The Sacral 3 foramen was found at a mean distance of 9.17 ± 0.23 cm from the tip of the coccyx. The mean distance of the lateral margin of S3 from the median sacral ridge was found to be 2.16 ± 0.07 cm.

Conclusion 

The landmark of 9 cm from the coccyx tip is a valid landmark for sacral neuromodulation (SNM) procedures. The tip of the lead should follow the curve of the nerve as close as possible at the four and eight o’clock positions on the right and left side, respectively. However, the length of the coccyx differs from person to person. The proximity of the adjacent foramina to each other and the variations in the emerging of the nerve are a few factors to be considered while performing SNM procedures. Further study with a larger sample is required in order to investigate the course of the nerve, and its relationship to response to SNM.

Implantable Agents for Fecal Incontinence: An Age-Matched Retrospective Cohort Analysis of GateKeeper versus SphinKeeper

Background. We aim to evaluate morphofunctional changes of the sphincter complex after GateKeeper (GK) and SphinKeeper (SK) procedures and correlate these with symptom improvement. Methods. Ten consecutive females undergoing SK implant were age-matched with a cohort of 10 females who previously underwent the GK procedure. Patients in the SK and GK groups underwent implantation of 10 and 6 prostheses, respectively. Muscle tension (Tm), expressed in millinewtons per centimetre squared, mN (cm²)^-1, was calculated using the equation Tm = P(r_i)(tm)^-1, where P is the average maximum squeeze pressure and r_i and tm the inner radius and thickness of the external anal sphincter, respectively. The pre- and postimplant changes in Tm and Cleveland Clinic Fecal Incontinence Score (CCFIS) were tested by linear and Poisson regression models, respectively. Results. The CCFIS significantly improved in both groups at 12-month postimplantation. Although not reaching statistical significance, symptom improvement after SK was 33% above that observed after GK (P = .088). Compared to the baseline, a significant increase in Tm was observed in both groups at 12 months (GK, 508.1 [478.8-568.0] vs 864.4 [827.0-885.8] mN (cm²)^-1; SK, 528.0 [472.7-564.0] vs 858.6 [828.0-919.6] mN (cm²)^-1, P = .005). Compared to the GK group, Tm was significantly higher in patients after SK implant (158.3 mN (cm²)^-1 [95% confidence interval, 109.6-207.0]; P < .001), after controlling for baseline values, at 12-month postimplantation. Conclusions. GK and SK are safe and effective treatments for FI with good short-term clinical outcomes. Comparative analysis showed superiority of SK over GK in terms of gain in Tm, with borderline significantly better improvement in symptoms. Larger studies are needed to confirm these findings.

Middle-term Outcomes of Gatekeeper Implantation for Fecal Incontinence

BACKGROUND

Intersphincteric injectable bulking agents are one of the current treatment options for fecal incontinence, failing behavioral and medical therapy. Gatekeeper showed promising short-term results, but long-term outcomes are unknown.

OBJECTIVE

The purpose of this study was to clinically evaluate a prospective cohort of fecal incontinence patients up to 36 months after implantation of Gatekeeper.

DESIGN

This was a prospective clinical study.

SETTINGS

The study was conducted at a large university tertiary care hospital.

PATIENTS

Consecutive female patients were eligible if fecal incontinence onset was ≥6 months before the first visit and symptoms were refractory to standard conservative measures.

INTERVENTIONS

All of the patients underwent implantation of 4 or 6 Gatekeeper prostheses. Three-dimensional endoanal ultrasonography and high-resolution anorectal manometry were performed preoperatively and postoperatively at 2 and 3 months after implantation.

MAIN OUTCOME MEASURES

The Cleveland Clinic Fecal Incontinence score was calculated at baseline and 1, 3, 12, 24, and 36 months postoperatively.

RESULTS

Twenty patients (all women; median age, 59 y) were enrolled, and all implants were uneventful. Postoperative endoanal ultrasonography showed normal prosthesis localization in 16 patients (80%). At manometry, mean anal resting pressure significantly improved (57.8 ± 7.5 mm Hg; p = 0.0004). Mean preoperative Cleveland Clinic Fecal Incontinence score was 12.4 ± 1.8, with significant improvements initially documented at 3 months (4.9 ± 1.5; p < 0.0001) and sustained up to 36 months (4.9 ± 1.7; p < 0.0001). Patients receiving only 4 (compared with 6) prostheses and those experiencing pudendal neuropathy (compared with those who did not) showed significantly higher Cleveland Clinic Fecal Incontinence score values in the middle term.

LIMITATIONS

The study was limited by its small sample size and absence of quality-of-life data.

CONCLUSIONS

Initial improvements after Gatekeeper implantation for fecal incontinence are sustained in the middle term. Accurate preoperative evaluation of coexistent clinical conditions that may negatively affect outcomes is recommended for patient selection. See Video Abstract at http://links.lww.com/DCR/B109. RESULTADOS A MEDIANO PLAZO EN LA IMPLANTACIÓN DE GATEKEEPER PARA LA INCONTINENCIA FECAL: Los agentes de volumen inyectables interesfintéricos, son opciones actuales de tratamiento para la incontinencia fecal, ante fallas de terapias conductuales y médicas. Gatekeeper mostró resultados prometedores a corto plazo, pero resultados a largo plazo aún son desconocidos.Evaluar clínicamente una cohorte prospectiva de pacientes con incontinencia fecal, hasta 36 meses después de la implantación de Gatekeeper.Estudio clínico prospectivo.El estudio se realizó en un gran hospital universitario de atención terciaria.Fueron elegibles pacientes femeninas consecutivas, si el inicio de la incontinencia fecal, fue al menos 6 meses antes de la primera visita, y que los síntomas fueron refractarios a las medidas conservadoras estandarizadas.Todas las pacientes fueron sometidas a implantación de 4 o 6 prótesis Gatekeeper. Se realizó ecografía endoanal de 3D y manometría anorrectal de alta resolución, antes de la implantación y después a los 2 y 3 meses.Se calculó el puntaje de incontinencia fecal de la Cleveland Clinic al inicio, y a los 1, 3, 12, 24 y 36 meses después de la operación.Se inscribieron veinte pacientes (todas mujeres; con edad media de 59 años), y todos los implantes transcurrieron sin incidentes. La ecografía endoanal postoperatoria, mostró localización normal de la prótesis en 16 (80%) pacientes. A la manometría, la presión media de reposo anal, mejoró significativamente (57.8 ± 7.5 mmHg, p = 0.0004). La puntuación media preoperatoria de la incontinencia fecal de la Cleveland Clinic, fue de 12.35 ± 1.75, con mejoras significativas documentadas inicialmente a los 3 meses (4.9 ± 1.5, p <0.0001) y sostenidas hasta los 36 meses (4.9 ± 1.7, p <0.0001). Los pacientes que recibieron solo 4 prótesis (en comparación con 6) y que padecían neuropatía pudenda (en comparación con aquellas que no la padecían), mostraron valores de puntaje de Incontinencia Fecal de la Clínica Cleveland, significativamente más altos en el mediano plazo.El tamaño pequeño de la muestra y la ausencia de datos en calidad de vida.Las mejoras iniciales después de la implantación de Gatekeeper para la incontinencia fecal, se mantienen en el mediano plazo. Para la selección de pacientes, se recomienda una precisa evaluación preoperatoria de las condiciones clínicas coexistentes, que puedan afectar negativamente los resultados. Consulte Video Resumen en http://links.lww.com/DCR/B109.

BioSphincters to treat Fecal Incontinence in Nonhuman Primates

Loss of anorectal resting pressure due to internal anal sphincter (IAS) dysfunctionality causes uncontrolled fecal soiling and leads to passive fecal incontinence (FI). The study is focused on immediate and long-term safety and potential efficacy of bioengineered IAS BioSphincters to treat passive FI in a clinically relevant large animal model of passive FI. Passive FI was successfully developed in Non-Human Primates (NHPs) model. The implantation of autologous intrinsically innervated functional constructs resolved the fecal soiling, restored the resting pressure and Recto Anal Inhibitory Reflex (RAIR) within 1-month. These results were sustained with time, and efficacy was preserved up to 12-months. The histological studies validated manometric results with the regeneration of a well-organized neuro-muscular population in IAS. The control groups (non-treated and sham) remained affected by poor anal hygiene, lower resting pressure, and reduced RAIR throughout the study. The pathological assessment of implants, blood, and the vital organs confirmed biocompatibility without any adverse effect after implantation. This regenerative approach of implanting intrinsically innervated IAS BioSphincters has the potential to offer a better quality of life to the patients suffering from FI.

Effectiveness of Autologous Fat Graft in Treating Fecal Incontinence

Purpose

The most common risk factor for fecal incontinence (FI) is obstetric injury. FI affects 1.4%–18% of adults. Most patients are unaware when they are young, when symptoms appear suddenly and worsen with aging. Autologous fat graft is widely used in cosmetic surgical field and may substitute for injectable bulky agents in treating FI. Authors have done fat graft for past several years. This article reports the effectiveness of the fat graft in treating FI and discusses satisfaction with the procedure.

Methods

Fat was harvested from both lateral thighs using 10-mL Luer-loc syringe. Pure fat was extracted from harvests and mixed with fat, oil, and tumescent through refinement. Fats were injected into upper border of posterior ano-rectal ring, submucosa of anal canal and intersphincteric space. Thirty-five patients with FI were treated with this method from July 2016 to February 2017 in Busan Hangun Hospital. They were 13 male (mean age, 60.8 years) and 22 female patients (mean age, 63.3 years). The Wexner score was checked before procedure. We evaluated outcome in outpatients by asking the patients. For 19 patients we checked the Wexner score after procedure.

Results

Symptom improved in 29 (82.9%), and not improved in 6 (17.1%). In 2 of 6 patients, they felt better than before procedure, although not satisfied. No improvement in 4. Mean Wexner score was 9.7 before procedure. There were no serious complications such as inflammation or fat embolism.

Conclusion

Autologous fat graft can be an effective alternative treatment for FI. It is safe and easy to perform, and cost effective.

A systematic review and network meta-analysis comparing treatments for faecal incontinence

BACKGROUND

Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI.

MATERIALS AND METHOD

A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method.

RESULT

Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo.

CONCLUSION

SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.

Bowel management program for pediatric postoperative fecal incontinence in China: A surgeon's experience

The purpose of this article is to report the status of the efficacy of and long-term adherence to the Bowel Management Program (BMP) for fecal incontinence (FI) postoperation in China.Children over 3 years of age with FI postoperation referred to our medical center were included in the study. Evaluations were performed before and 2 years after their clinic visit. The cost of bowel care, improvement in incontinence, health-related quality of life, and family functioning with the BMP were analyzed.A total of 48 children with FI were included in our study, of whom 38 were boys. The median treatment fee was 660.1 dollars. The complications included abdominal pain (4 patients, 8%), occasional vomiting (2 patients, 4%), and hypoglycemia (1 patient, 2%). The incontinence status and health-related quality of life improved significantly after the BMP. Despite the good outcome of the BMP, half of the patients discontinued the program.The BMP is an effective approach to manage FI and improve the patients' quality of life. Poor long-term adherence is currently the main challenge affecting the BMP application in China.

Evaluation of Trends in the Use of InterStim for Fecal Incontinence

BACKGROUND

Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI.

METHODS

The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location.

RESULTS

A total of 369 patients with FI underwent "Stage 1" of InterStim from 2011 to 2014. A total of 302 patients underwent "Stage 2," yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures.

CONCLUSIONS

InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Challenges faced in the clinical application of artificial anal sphincters

Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials.

Impact of the Bowel Management Program on the quality of life in children with fecal incontinence

PURPOSE

Evaluate the impact of implementing Bowel Management Program (BMP) on quality of life (QoL) in children with fecal incontinence (FI).

METHODS

Children 3-12 years referred to the Children's Treatment Center of FI were included and categorized accordingto the tendency to constipation (dilated colon; group 1) or diarrhea (non-dilated colon; group 2). Evaluations were performed before and after 3 months of BMP implementation. Perceptions from parents and children about QoL were assessed by the instrument PedsQL4.0 and the severity of FI by the fecal incontinence index (FII) of Wexner scale.

RESULTS

43 children (mean age of 7.7 ± 3.1) were studied. 32 (74.4 %) belonged to group 1 and 11 (25.6 %) to group 2. After 3 months of BMP, it was noticed a significant improvement of the FII (14.5 ± 3.7 versus 2.8 ± 2.5; p < 0.001) in both groups. QoL perception by the parents and children increased on PedsQL4.0 evaluation (p < 0.001). There was a medium inverse statistically significant correlation of the FII and the total PedsQL4.0 score among children and parents (r = -0.47, p = 0.009 and r = -0, 39, p = 0.03, respectively).

CONCLUSION

The BMP applied by a multidisciplinary dedicated team significantly improves the QoL of children with FI in the short-term period.

Safety and Efficacy of Permacol Injection in the Treatment of Fecal Incontinence

Purpose

Permacol has been gaining popularity in recent times for the treatment of fecal incontinence (FI). This study aims to evaluate the safety and efficacy of anal submucosal Permacol injection in the treatment of FI.

Methods

All consecutive patients who underwent Permacol injection for FI over a 3-year period were included. Patients' data relating to obstetric history, anorectal/pelvic operations, type of FI, preoperative anorectal physiology results and follow-up details for outcome measures were collected. Preoperative and postoperative Cleveland Clinic Florida Incontinence Scores (CCFISs) were noted. Patients were surveyed by using a telephone questionnaire to assess the quality of life and other outcome measures. Data were analysed using SPSS ver.19.0.

Results

Thirty patients (28 females and 2 males) with a median age of 67 years were included in the study. Of those patients, 37%, 50%, and 13% were noted to have passive, mixed and urge FI, respectively. Six of the patients (20%) had repeat Permacol injections, 5 of whom had sustained responses to the first Permacol injection for a mean of 11 months. There was a significant improvement in the CCFIS from a baseline median of 12.5, mean 12.8 interquartile range [IQR], 6–20), to a median of 3.5, mean 4.8 (IQR, 0–20), P < 0.001. Of the patients surveyed by telephone 89% were satisfied with their overall experience and the improvement in their symptoms following Permacol injections.

Conclusion

This study has demonstrated that Permacol injection for the treatment of FI is safe and effective and has no associated major complications. However, the results are not permanent; consequently, a significant proportion of the patients with an initial response may require repeat injections.

Identifying factors associated with clinical success in patients treated with NASHA(®)/Dx injection for fecal incontinence

Purpose

Injection with the bulking agent consisting of non-animal stabilized hyaluronic acid/dextranomer (NASHA^®/Dx) is well tolerated and efficacious for the treatment of fecal incontinence (FI); however, the patient population that may derive maximum benefit has not been established. This post hoc responder analysis assessed demographic and baseline characteristics predictive of responsiveness to NASHA/Dx treatment.

Methods

Adults with a Cleveland Clinic Florida fecal incontinence score (CCFIS) ≥10 were randomized to receive NASHA/Dx or sham treatment. The primary end point was response to treatment (ie, decrease from baseline of ≥50% in number of FI episodes) at 6 months; a prespecified secondary end point was change in fecal incontinence quality of life (FIQL) score at 6 months. Post hoc subgroup analyses were performed for baseline and demographic characteristics and prior FI treatments.

Results

Overall, response to treatment was significantly greater with NASHA/Dx versus sham injection (52.7% vs 32.1%; P=0.0089). All subgroups analyzed demonstrated evidence of improvement, favoring NASHA/Dx versus sham treatment for both response to treatment and change in the FIQL coping/behavior subscale score. For the primary end point, a significantly greater percentage of patients with CCFIS ≤15, FI symptoms ≤5 years’ duration, or obstetric causes of FI responded to NASHA/Dx treatment versus patients receiving sham treatment (51.1% vs 28.3%, P=0.0169; 55.4% vs 25.7%, P=0.0026; and 53.6% vs 23.1%, P=0.0191, respectively). The mean change in the FIQL coping/behavior score significantly favored NASHA/Dx versus sham treatment for patients with CCFIS ≤15 (P=0.0371), FI symptoms ≤5 years’ duration (P=0.0289), or obstetric causes of FI (P=0.0384). Patients without a history of specific FI treatments (eg, antidiarrheal medications, biofeedback, surgery) were more likely to respond to NASHA/Dx versus sham treatment for both end points.

Conclusion

Although all subgroups analyzed showed evidence of quantitative and qualitative benefit from NASHA/Dx therapy, patients with characteristics indicative of mild-to-moderate FI may exhibit the greatest benefit.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Redo sphincteroplasty: are the results sustainable?

Objective: This study aimed to investigate the long-term outcomes of patients who undergo redo sphincteroplasty (RS).

Methods: Patients with fecal incontinence (FI) who underwent RS between November 1988 and December 2011 were retrospectively identified from a prospective database. A questionnaire and telephone survey assessed current Cleveland Clinic Fecal Incontinence Score (CCFFIS; best 0, worst 20) and Fecal Incontinence Quality of Life (FIQoL; best 4.1, worst 1) scale. Success was defined as no further continence surgery, no stoma and CCFFIS <9 at completion of follow-up. The Wilcoxon and Mann-Whitney U tests were used for comparing quantitative variables. Bivariate logistic regression analysis was done to identify predictive factors for success.

Results: Fifty-six (66.7%) of 84 patients who underwent RS were available for evaluation at a median follow-up of 74 (range: 12–283) months. The mean CCFFIS decreased from 16.5 ± 3.7 to 11.9 ± 6.6 (P < 0.001) at last follow-up. Twelve patients (21.4%) underwent further continence surgery for failed sphincteroplasty, three (5.4%) of whom had a permanent stoma. Eighteen patients (32.1%) had a CCFFIS <9 at the completion of follow-up, and 16 (28.6%) had long-term success. Twenty-four patients evaluated for FIQoL had a mean value of 2.6 (range: 1.0–4.1). Postoperative CCFFIS was correlated with FIQoL (Spearman’s correlation coefficient = −0.854, P < 0.001). Logistic regression analysis did not reveal any significant predictive variables for success of RS.

Conclusion: Based on our criteria for success, the long-term success rate for RS over a median of 74 months is poor.

Validity of the ≥50% Response Threshold in Treatment With NASHA/Dx Injection Therapy for Fecal Incontinence

Objectives:

Many fecal incontinence (FI) studies define primary efficacy outcome as a decrease from baseline of ≥50% in the number of FI episodes; this threshold has never been validated. We aimed to establish the validity and responsiveness of ≥50% reduction in FI episodes (responder₅₀) as the threshold indicative of clinically meaningful response.

Methods:

Adults with a Cleveland Clinic Florida fecal incontinence score ≥10 were randomized to receive nonanimal stabilized hyaluronic acid/dextranomer (NASHA/Dx) injection or sham treatment in a 6-month trial. Validity and responsiveness of the primary end point were evaluated post hoc. The data were compared using different thresholds for defining a responder for a number of end points.

Results:

Data from 206 patients (NASHA/Dx, n=136; sham, n=70) were evaluated. Incremental patient response threshold increases showed that although the percentage of patients who achieved response decreased with increasing threshold, the difference between treatments remained significant up to an 80% response threshold (NASHA/Dx, 23% sham, 10% P=0.02). Response thresholds between 40% and 80% demonstrated evidence for convergent validity, with the strongest correlation with the number of FI episodes, the number of FI episodes when the patient was awake, and the number of FI-free days observed at ≥40% and ≥50% thresholds. Further examination of the responder₅₀ threshold indicated that, regardless of treatment (NASHA/Dx or sham), responders performed significantly better than nonresponders on nearly all secondary efficacy end points.

Conclusion:

This study demonstrates the responsiveness, validity, and clinical applicability of the ≥50% response threshold in clinical studies of patients with FI receiving treatment with NASHA/Dx.

Pelvic floor rehabilitation in the treatment of fecal incontinence

Fecal incontinence (FI) is a prevalent problem that can drastically affect quality of life. Pelvic floor rehabilitation is an important first-line treatment for patients with FI, and many published case reports and a small number of randomized controlled trials (RCTs) provide limited evidence for its efficacy. Pelvic floor rehabilitation approaches to the treatment of FI include pelvic floor muscle training, biofeedback, and volumetric training with rectal balloon catheters. Various forms of external electrical stimulation have also been described and may be of added benefit. Behavioral bowel retraining is an important part of a good rehabilitative approach as well. Pelvic floor rehabilitation treatment for FI is thought to be effective and safe, with reported success rates in a majority of studies at 50 to 80%. Many more high-quality RCTs are needed to define optimal treatment protocols.

An Evidence-Based Approach to the Evaluation, Diagnostic Assessment and Treatment of Fecal Incontinence in Women

Fecal incontinence (FI) is a debilitating disorder which negatively impacts quality of life. The etiology is often multifactorial and although most women with FI are able to be treated, many remain untreated because a significant proportion of women do not report their symptoms and seek care. The evaluation and treatment of FI can be also hindered by a lack of understanding of the mechanisms and current options. This article provides a review on the evidence-based evaluation and management for FI.

Long-term efficacy of NASHA Dx injection therapy for treatment of fecal incontinence

BACKGROUND

Injectable bulking treatment for fecal incontinence (FI) is intended to expand tissue in the anal canal and prevent fecal leakage. Use of injectable bulking agents is increasing because it can be performed in an outpatient setting and with low risk for morbidity. This study evaluated the long-term (36-month) clinical effectiveness and safety of injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA Dx) on FI symptoms.

METHODS

In a prospective multicenter trial, 136 patients with FI received the NASHA Dx bulking agent. Treatment success defined as a reduction in number of FI episodes by 50% or more compared with baseline (Responder50 ). Change from baseline in Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL), and adverse events were also evaluated.

KEY RESULTS

Successful decrease in symptoms was achieved in 52% of patients at 6 months and this was sustained at 12 months (57%) and 36 months (52%). Mean CCFIS decreased from 14 at baseline to 11 at 36 months (p < 0.001). Quality-of-life scores for all four domains improved significantly between baseline and 36 months of follow-up. Severe adverse events were rare and most adverse events were transient and pertained to minor bleeding and pain or discomfort.

CONCLUSIONS & INFERENCES

Submucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years.

Suboptimal results after sphincteroplasty: another hazard of obesity

BACKGROUND

This study aimed to investigate the outcomes of sphincteroplasty in obese patients.

METHODS

Patients with fecal incontinence (FI) who underwent sphincter repair were identified and divided into obese [body mass index (BMI) ≥ 30 kg/m(2)] and nonobese (BMI < 30 kg/m(2)) groups. Cleveland Clinic Florida FI Score (CCFFIS: 0 best and 20 worst) and FI quality of life (FIQoL) score (mean global FIQoL: 4.11 best and 1 worst) were recorded. Wilcoxon and Mann-Whitney U tests compared quantitative variables; Fisher's exact test was used for categorical variables.

RESULTS

Seventy-nine patients (78 females; mean age: 57 ± 15 years) were divided into obese (n = 15) and nonobese (n = 64) groups and were similar in age, etiology, physiologic parameters, and preoperative CCFFIS. Median follow-up was 64 (13-138) months. There were 3 (25 %) and 11 (17 %) complications in the obese and nonobese groups, respectively (p = 0.68), the most common being wound infection. Mean CCFFIS decreased from 16.0 ± 3.9 to 11.5 ± 6.5 in the obese (p < 0.001) and 16.2 ± 3.4 to 8.4 ± 5.0 in the nonobese groups (p < 0.001). Postoperative CCFFIS correlated with FIQoL (Spearman's correlation coefficient = -0.738, p < 0.001). Nonobese patients had significantly higher CCFFIS improvement (48 vs. 28 % p = 0.04) and a superior mean global FIQoL score (2.19 ± 0.9 vs. 2.93 ± 0.8, p < 0.01). Four (29 %) obese and 11 (17 %) nonobese patients required further surgery after failed sphincteroplasty (p = 0.45).

CONCLUSIONS

Risk of complications and need of further continence surgery were similar between obese and nonobese patients. However, obese patients experienced less improvement after sphincteroplasty.

What is the best option for failed sphincter repair?

AIM

This study aimed to evaluate the outcome of various procedures for patients with fecal incontinence following failed sphincteroplasty.

METHOD

Patients who underwent surgery for failed sphincteroplasty from January 2000 to June 2011 [corrected] were identified. They were assessed using the Fecal Incontinence Quality of Life (FIQoL) scale and the Cleveland Clinic Florida-Wexner Fecal Incontinence Score (CCFFIS).

RESULTS

Fifty-nine patients [97% females; median age 52 (25-81) years] were identified. They underwent either repeat sphincteroplasty (RS; n = 33), artificial bowel sphincter (ABS; n = 11) or sacral nerve stimulation (SNS; n = 15). The median follow-up was 31 (3-138) months. The RS group had a significantly wider external sphincter defect and had undergone fewer previous sphincteroplasties. The most common complication was infection. The incidence of complications was significantly higher after ABS (73%) compared with RS (24%) and SNS (33%) (P = 0.01). Seventeen (29%) patients required re-operation for complications or failure, with a lower rate in the RS group (P = 0.004). There was no difference in the rates of device removal after ABS or SNS. Ten (17%) patients underwent further surgery or re-implantation of the device with no difference between the groups. At follow-up, five (45%) ABS and 10 (67%) SNS patients retained a functioning device (P = 0.4). The mean postoperative CCFFIS decreased from 17.5 to 11.5 in the RS group, from 18.7 to 8.6 in the ABS group, and from 17.6 to 9.1 in the SNS group (P ≤ 0.02 for all). There were no differences in the improvement of CCFFIS or FIQoL scores among groups.

CONCLUSION

RS, ABS and SNS are associated with similar improvements in continence after failed sphincteroplasty. Due to increased complications and re-operation with ABS and SNS, RS may be the first step in managing these patients.

The magnetic anal sphincter in faecal incontinence: is initial success sustained over time?

AIM

In the short term, implantation of a magnetic anal sphincter (MAS) is a safe and effective treatment for faecal incontinence (FI). In this paper we show that the initial results stand the test of time and patient satisfaction remains high in the medium term.

METHOD

Data on 23 women [median age 64 (35-78) years] implanted with a MAS device between December 2008 and September 2012 were reviewed from a prospective database. Assessment was based on significant improvement of incontinence scores - the Cleveland Clinic Florida Incontinence Severity (CCF-IS) score, Faecal Incontinence Quality of Life (FIQoL) score - and patient satisfaction at 6, 12, 24 and 36 months after surgery.

RESULTS

The device was removed in two patients owing to complications. Median follow-up was 17.6 months. The median preoperative CCF-IS score was 15.2 and fell to 6.9, 7.7, 7.8 and 5.3 at 6, 12, 24 and 36 months, respectively. The median FIQoL score significantly (P < 0.001) improved from 1.97 preoperatively to 3.19, 3.11, 2.92 and 2.93, respectively, at the same time periods. The concordance of the CCF-IS and FIQoL scores was 91%. Sixteen of the 23 patients were satisfied but only 14 would have recommended the MAS to someone else. Lack of improvement was the main reason for dissatisfaction.

CONCLUSION

Good initial results tend to remain stable over time and about two-thirds of patients are satisfied after MAS implantation.

Experience with a new prosthetic anal sphincter in three coloproctological centres

BACKGROUND

Fecal incontinence is a common and severely disabling disorder. For patients with severe fecal incontinence, surgery may prove to be the only adequate treatment option.

METHODS

This study reports on 43 patients that were treated with a prosthetic sphincter system between 2005 and 2009 in three coloproctological centres.

MAIN OUTCOME MEASURES

complications, anal pressures before and after surgery, fecal continence score.

RESULTS

The new artificial sphincter system significantly improves continence but leads to some complications in clinical practice. After implantation of the device, continence improved significantly (Keller & Jostarndt continence score 2.6 to 14.3 (P < 0.01)). With the band activated, resting pressure improved significantly as compared to baseline (10.7 mmHg vs. 66.1 mm Hg, P < 0.01). The same holds for anal sphincter squeeze pressure (32.2 mmHg versus 85.9 mm Hg, P < 0.01). Complications occurred in 21 patients (48.8%): 10 surgical and 13 technical. Two patients were affected by both technical and surgical problems. The median time of the occurrence was 3 months postop. In five patients difficulties arose within the first postoperative month leading to explantation of the device in three patients. 90% of complications occurred in the first year.

CONCLUSIONS

The soft anal band of AMI (AAS), a new artificial anal sphincter, improves severe anal incontinence, but it must be regarded as a last treatment option to avoid a stoma.

[Treatment of sphincter insufficiency]

Surgical therapy of anal sphincter insufficiency is only indicated if it leads to symptoms and conservative treatment fails to achieve adequate symptom relief. Various new surgical options have evolved over the last decade but evidence of the efficacy varies substantially. Some have gained broader clinical acceptance based on the efficacy, ease of applicability and low risk profile. The paper aims to outline the currently commonly accepted and frequently applied surgical techniques for the treatment of anal sphincter insufficiency and the results, put these into the context of a treatment algorithm and to present novel techniques which carry potential for the future.

[Direct sphincter repair: techniques, indications and results]

L'incontinence anale est un handicap physique, psychique et social majeur qui a de nombreuses causes différentes. Les méthodes actuellement disponibles pour améliorer les symptômes de cette incontinence sont les méthodes médicales et de rééducation d'une part et les méthodes chirurgicales d'autre part. Quatre techniques chirurgicales répondent à ces objectifs pour la plupart des malades: la sphinctérorraphie, la neuromodulation des racines sacrées, et les deux techniques de substitution que sont le sphincter artificiel et la graciloplastie dynamisée. La réparation sphinctérienne directe est la technique la plus utilisée dans le traitement chirurgical de l'incontinence anale (IA) par lésion sphinctérienne. Cette technique est envisageable chez les malades ayant une incontinence fécale en rapport avec des lésions limitées du sphincter anal externe. La technique chirurgicale est simple (myorraphie par suture directe ou en paletot) et bien codifiée. Les résultats fonctionnels sont imparfaits et se dégradent avec la durée du suivi. Une continence parfaite après réparation sphinctérienne est rarement acquise de façon durable: le malade candidat à cette approche thérapeutique doit en être averti.

Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review

AIM

The long-term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect.

METHOD

The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow-up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life.

RESULTS

Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies.

CONCLUSION

Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long-term follow-up, although beset with difficulties, should be conducted.

Sacral transcutaneous electrical nerve stimulation in the treatment of idiopathic faecal incontinence

AIM

The aim of this study was to investigate the potential use of S3 transcutaneous electrical nerve stimulation (TENS) in the treatment of idiopathic faecal incontinence.

METHOD

Seventeen patients were treated by S3 TENS 2 h a day for 3 months. The outcome was evaluated by faecal incontinence severity index (FISI), faecal incontinence quality of life scale (FIQOL), 7-day bowel diary, anorectal physiology, patients' self-reported impression of improvement, bowel control and satisfaction with treatment on a visual analogue scale.

RESULTS

Seventeen patients (13 women) of mean age 67.2 years (52-80) were followed up for a mean of 19.7 months. The FISI improved in 69% after 3 months of TENS (P < 0.01), and all components of FIQOL improved. The number of incontinent episodes per week fell for incontinence to gas and stool (solid and/or liquid). There was no significant difference in the maximum resting pressure and squeeze pressure, but the mean rectal volume of first sensation (12.1 ml, P = 0.027) and first urge (25.0 ml, P = 0.054) fell, and the maximum tolerable volume (16.0 ml, P = 0.679) rose. The satisfaction score was ≥ 6/10 in all patients. Fifteen (88%) scored ≥ 6/10 for bowel control, and all patients scored ≥ 2 (scale: -5 to +5) for their impression of improvement.

CONCLUSION

S3 transcutaneous electrical nerve stimulation seems to be a promising noninvasive method to treat faecal incontinence. However, further study is required.

Modified dynamic gracilis neosphincter for fecal incontinence: an analysis of functional outcome at a single institution

BACKGROUND

We undertook a prospective longitudinal study of patients with end-stage fecal incontinence who were undergoing transposition of the gracilis muscle as a neo-anal sphincter with external low-frequency electrical stimulation of the nerve to the gracilis combined with biofeedback.

METHODS

A total of 31 patients (21 male, 10 female: median age: 22 years; range: 4-77 years) underwent this procedure for treatment of traumatic disruption (11 patients, 35%), congenital atresia (11 patients, 35%), iatrogenic injury (6-20%), and perineal sepsis (3 patients, 10%). The gracilis muscle was transposed at operation in an alpha or gamma configuration. Low-frequency (7 Hz) transcutaneous electrical stimulation commenced 2 weeks after operation and was continued for up to 12 weeks. Biofeedback therapy, which consisted of supervised neosphincter squeeze exercises, commenced simultaneously and continued for up to 28 weeks. Outcome was assessed by clinical examination, anal manometry, the Cleveland Clinic Florida continence score (CCFS), and the Rockwood quality of life scale (FIQL). Successful outcome was defined by improvement in clinical outcome, patient satisfaction, a positive result on anal manometry, and/or CCFS < 9, or FIQL > or = 4.

RESULTS

At median follow-up of 67 months, overall improvement was seen in 22 (71%). Maximum resting pressure (MRP) and maximum squeeze pressure (MSP) improved significantly after operation [MRP pre versus post, mean (SD), cm water-13.8 (9.6) versus 20.9 (11.3); P = 0.01; and MSP 36.6 (22.4) versus 95.4 (71.2), P = 0.001]. In a subset of 18 patients who showed improvement after operation, the CCFS score (mean, SD) improved from 19.2 (3.4) to 5.2 (5.6); P = 0.0001. FIQL (mean, SD) showed significant improvement in all four domains in 14 patients who reported improvement since the year 2000.

CONCLUSIONS

A modified dynamic gracilis neoanal sphincter for end-stage fecal incontinence helps restore and sustain continence with improvement in quality of life in the majority of patients. The procedure was most effective as augmentation in those who had suffered a traumatic injury, when compared with patients with congenital atresia and sepsis that had resulted in loss of the native anal sphincter.

Efficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: a randomised, sham-controlled trial

BACKGROUND

Injection of a bulking agent in the anal canal is an increasingly used treatment for faecal incontinence, but efficacy has not been shown in a controlled trial. We aimed to assess the efficacy of injection of dextranomer in stabilised hyaluronic acid (NASHA Dx) for treatment of faecal incontinence.

METHODS

In this randomised, double-blind, sham-controlled trial, patients aged 18-75 years from centres in USA and Europe were randomly assigned (2:1) to receive either transanal submucosal injections of NASHA Dx or sham injections. Randomisation was stratified by sex and region in blocks of six, and managed with a computer generated, real-time, web-based system. Patients and investigators were masked to assignment for 6 months when the effect on severity of faecal incontinence and quality of life was assessed with a 2-week diary and clinical assessments. The primary endpoint was response to treatment based on the number of incontinence episodes. A response to treatment was defined as a reduction in number of episodes by 50% or more. Patients in the active treatment group are still being followed up. This trial was registered with ClinicalTrials.gov, number NCT00605826.

FINDINGS

278 patients were screened for inclusion, of whom 206 were randomised assigned to receive NASHA Dx (n=136) or sham treatment (n=70). 71 patients who received NASHA Dx (52%) had a 50% or more reduction in the number of incontinence episode, compared with 22 patients who received sham treatment (31%; odds ratio 2·36, 95% CI 1·24-4·47, p=0·0089). We recorded 128 treatment-related adverse events, of which two were serious (1 rectal abscess and 1 prostatic abscess).

INTERPRETATION

Anal injection of NASHA Dx is an effective treatment for faecal incontinence. A refinement of selection criteria for patients, optimum injected dose, ideal site of injection, and long-term results might further increase the acceptance of this minimally invasive treatment.

FUNDING

Q-Med AB.

Sacral nerve stimulation for faecal incontinence: its role in the treatment algorithm

AIM

Indications for sacral nerve stimulation (SNS) for faecal incontinence have expanded over the last decade. This report aims to determine the clinical outcome of the current use of SNS in the treatment of faecal incontinence. Its objective is also to review the most recent role of SNS in patients with anal sphincter lesions.

METHOD

The literature was searched using Medline and Cochrane databases. The search was restricted to publications in English. For the analysis, studies with <25 patients were excluded. For SNS in patients with sphincter defects, all papers were included.

RESULTS

Thirteen publications on the clinical outcome of SNS were included. Nine papers were identified reporting the application of SNS in patients with a morphological sphincter lesion. The most common outcome measures of clinical efficacy were frequency of incontinence using the Cleveland Clinic Incontinence Score. All studies demonstrated highly improved function across all outcome measures and improvement was statistically significant in all. Outcomes remain stable at long-term follow up. In patients with sphincteric gaps ranging from 17 to 180°, SNS was clinically effective at short-term follow up. The size of the gap appears to have no impact on outcome.

CONCLUSION

SNS has evolved to become a clinical efficient therapy applicable across a wide spectrum of causes of faecal incontinence with reproducible results. SNS can be considered to be an essential part of the current surgical treatment algorithm for faecal incontinence.

Meta-analysis: sacral nerve stimulation versus conservative therapy in the treatment of faecal incontinence

AIM

Sacral nerve stimulation (SNS) has recently been used in the management of faecal incontinence (FI). This study compared SNS to conservative management with regards to functional and quality of life outcomes.

METHODS

Meta-analysis of studies published between 1995 and 2008 on SNS for FI was performed. Outcomes evaluated were functional, physiological and quality of life. A random-effects model was used and sensitivity analyses performed. Subgroup analyses were performed on age and sphincter status.

RESULTS

Thirty-four studies were included, reporting on 944 patients undergoing peripheral nerve evaluation; 665 underwent permanent SNS. Weekly incontinence episodes (weighted mean difference [WMD] -6.83; 95% confidence intervals [CI] -8.05, -5.60; p < 0.001) and incontinence scores (WMD -10.57; 95% CI -11.89, -9.24; p < 0.001) were significantly reduced with SNS; ability to defer defecation (WMD 7.99 min; 95% CI 5.93, 10.05; p < 0.001) was increased. Most SF-36 and FIQL domains improved following SNS, and mean anal pressures increased significantly (p < 0.001). Results remained consistent on sensitivity analysis. The under-56 years age group showed smaller functional but greater physiological and quality of life improvements. Results were similar between sphincter intact and impaired subgroups. The complication rate was 15% for permanent SNS, with 3% resulting in permanent explantation.

CONCLUSION

SNS results in significant improvements in objective and subjective measures for faecally incontinent patients.

New selective endoscopic sacral nerve root stimulation--an advance in the treatment of fecal incontinence

BACKGROUND

Fecal incontinence (FI) is a major part of illness and physical discomfort in the general population. Since the 1990s, sacral nerve stimulation has been well established in the treatment of neurogenic FI. The precise placement of the electrode is crucial for the success of the procedure. Eighty percent of the patients benefit from permanent treatment, but in 10-20% of the patients tested electrode placement proves impossible due to anatomical variations of the sacral foramina. In this study, we describe the technical requirements and a new method of electrode placement with reference to the anatomical (bone) landmarks in an animal model.

METHODS

With a small endoscope (Verres needle), we accessed the perirectal space to identify the nervous structures. A stimulated sphincter EMG was obtained for the experimental animals and muscle action potential (MAP/M-wave), latency time [ms], and the amplitude of the motor response [μV] were recorded. Electrodes were placed, the animals killed and dissected leaving the pelvic cavity untouched. The specimens were examined in a magnetic resonance scanner and in a multi-slice computed tomography scanner to detect the electrode material and possible surgical complications. After that the specimens were dissected.

KEY RESULTS

In all eight cases in the four animals tested, we were able to stimulate the sacral nerve as demonstrated by the EMG findings. No major surgical complications were observed for the procedure.

CONCLUSIONS & INFERENCES

Endoscopic sacral nerve root stimulation is a safe and effective method for delivering stimulation material in the pelvis of the sheep. It is a promising procedure to be tested in humans.

Function and morphology correlates of rectal nerve mechanoreceptors innervating the guinea pig internal anal sphincter

BACKGROUND

Mechanoreceptors to the internal anal sphincter (IAS) contribute to continence and normal defecation, yet relatively little is known about their function or morphology. We investigated the function and structure of mechanoreceptors to the guinea pig IAS.

METHODS

Extracellular recordings from rectal nerve branches to the IAS in vitro, combined with anterograde labeling of recorded nerve trunks, were used to characterize extrinsic afferent nerve endings activated by circumferential distension.

KEY RESULTS

Slowly adapting, stretch-sensitive afferents were recorded in rectal nerves to the IAS. Ten of 11 were silent under basal conditions and responded to circumferential stretch in a saturating linear manner. Rectal nerve afferents responded to compression with von Frey hairs with low thresholds (0.3-0.5 mN) and 3.4 ± 0.5 discrete, elongated mechanosensitive fields of innervation aligned parallel to circular muscle bundles (length = 62 ± 16 mm, n = 10). Anterogradely labeled rectal nerve axons typically passed through sparse irregular myenteric ganglia adjacent to the IAS, before ending in extensive varicose arrays within the circular muscle and, to a lesser extent, the longitudinal muscle overlying the IAS. Few (8%) IAS myenteric ganglia contained intraganglionic laminar endings. In eight preparations, mechanotransduction sites were mapped in combination with successful anterograde fills. Mechanotransduction sites were strongly associated with extensive fine varicose arrays within the circular muscle (P < 0.05), and not with any other neural structures.

CONCLUSIONS & INFERENCES

Mechanotransduction sites for low-threshold, slowly adapting mechanoreceptors innervating the IAS are likely to correspond to extensive fine varicose arrays within the circular muscle.

A prospective multicentre study to investigate percutaneous tibial nerve stimulation for the treatment of faecal incontinence

AIM

Percutaneous tibial nerve stimulation (PTNS) is a minimal invasive treatment that can be performed in the outpatient clinic. This is a pilot study to investigate PTNS in the treatment of faecal incontinence.

METHOD

  Percutaneous tibial nerve stimulation was performed by insertion of a needle electrode near the posterior tibial nerve. Patients were treated twice a week. Evaluation of faecal incontinence and quality of life was performed at baseline, 6 weeks, 3 months, 6 months and 1 year. Quality of life was estimated using SF-36 and FIQL questionnaires.

RESULTS

A total of 22 patients were included. The mean age was 60.4 ± 11.7 years. After 6 weeks, 18 continued the treatment; 13 patients had a > 50% decrease in incontinence episodes. Overall incontinence episodes fell from 19.6 ± 21.0 at baseline to 9.9 ± 15.5 (P = 0.082) at 6 weeks and to 3.6 ± 4.8 (P = 0.029) at 1 year. Postponement time and quality of life increased significantly during follow up.

CONCLUSION

Percutaneous tibial nerve stimulation is simple and can be used in the outpatient setting. Good results can be obtained and sustained during maintenance treatment.

Sacral nerve stimulation for fecal incontinence: causes of surgical revision from a series of 87 consecutive patients operated on in a single institution

PURPOSE

Sacral nerve stimulation is offered to patients presenting with fecal incontinence of neurological or idiopathic etiology, when medical management has failed. The purpose of this study was to investigate the causes of surgical revision following sacral nerve stimulation in consecutive patients who had received implants.

PATIENTS AND METHODS

From September 2001 to August 2009, 123 patients (105 women) of mean age 56 years were operated on for neurological (n = 104) or idiopathic (n = 19) fecal incontinence. The mean preoperative Cleveland Clinic score was 13/20 (range 6/20 to 19/20). Eighty-seven patients of 123 had a positive test and underwent stimulator implantation. Any stimulator dysfunction was prospectively studied.

RESULTS

Among the 87 patients, 36 had surgical revision of the device for the following reasons: device-related failure due to infection in 4 (successful reimplant in 4), electrode displacement in 2, electrode breakage in 2 (reimplantation of electrode in 4), and dysfunction owing to impedance increase of the system in 4; adverse stimulation with pain in 7 (stimulator repositioning in 4 and explantation in 3); battery depletion either spontaneously (n = 6) or owing to a MRI examination (n = 2); total or partial loss of clinical efficacy in 9 (removal of the generator and electrode).

CONCLUSION

Sacral nerve stimulation is a recognized treatment for fecal incontinence. The stimulator reoperation rate is high and is caused by stimulator dysfunction in 24% of cases.