Sphinkeeper™ for faecal incontinence: a preliminary report

Treatment options for postoperative faecal incontinence after colorectal surgery

Postoperative faecal incontinence is a common and challenging complication following colorectal surgery, significantly impacting patients' quality of life. This article provides an overview of the types of colorectal surgical interventions that may contribute to faecal incontinence and explores various treatment options, ranging from conservative management to surgery. Conservative approaches include dietary modifications, bowel training and pharmacological treatments such as bulking agents, antidiarrhoeal medications and biofeedback therapy. For patients with persistent symptoms, advanced therapies such as sacral and tibial nerve stimulation are considered. Surgical options including sphincter repair, pouch formation, artificial anal sphincter implant or colostomy may be required for severe cases. The article reviews the most common treatment modalities, emphasising the importance of an individualised approach. Multidisciplinary care involving colorectal surgeons, physiotherapists and gastroenterologists is essential for optimising outcomes. Ultimately, the management of postoperative faecal incontinence requires careful assessment of the underlying cause, severity of symptoms and patient preferences to guide treatment selection.

Endosonographic monitoring of Sphinkeeper® prostheses movements: does physical activity have an impact?

The Sphinkeeper® procedure for treating faecal incontinence (FI) may be associated with potential implant migration (IM) and dislocation (ID), with considerable variations regarding their occurrence and effects on consecutive functional outcome. This study assessed IM and ID following the Sphinkeeper® procedure and its correlation with physical activity. This was a prospective observational clinical study of ten patients undergoing Sphinkeeper® operation due to FI between August 2020 and November 2020 at the Medical University of Vienna. Patients were followed-up after 1, 2, 3 and 6 months and 1 year postoperatively. Each follow-up visit included endosonographic monitoring of protheses location and manometric examinations. Additionally, functional outcome and physical activity were assessed using validated standardized questionnaires. The median number of prostheses implanted was 10 (IQR 9-10). The St. Mark's incontinence (SMS) score improved significantly until the last follow-up (p = 0.049), without observing a significant effect on the physical SF-12 score. The median rate of implants leading to IM and ID was 3 (range 1-4) and 2 (range 1-2) after 3 months of follow-up. A strong association of deltaSMS with number of dislocated prostheses at one month after Sphinkeeper® implantation was observed (r = 0.654, p = 0.078). Physical activity, assessed by the international physical activity questionnaire, did not have an impact on the correct prosthesis placement (1 month: p = 0.527; 2 months: p = 0.886; 3 months: p = 0.180; 6 months: p = 0.111). IM and ID of Sphinkeeper® prostheses occurred frequently early after surgery and affected functional outcome negatively. Physical activity did not have an influence on the implants displacement.

Long-term outcome after SphinKeeper® surgery for treating fecal incontinence-who are good candidates?

PURPOSE

The efficacy of the novel SphinKeeper® procedure for the treatment of fecal incontinence (FI) is not yet well defined. This study aimed to assess long-term functional outcomes after SphinKeeper® surgery.

METHODS

We included 32 patients with FI (28 female), who were operated at a tertiary referral center between August 2018 and September 2021. Functional outcome and quality of life were evaluated prospectively using validated questionnaires before and after surgery. Additionally, endoanal ultrasound and anal manometry were conducted prior and after SphinKeeper® implantation. Predictive parameters for treatment success were defined.

RESULTS

The mean follow-up time was 22.62 ± 8.82 months. The St. Mark's incontinence score decreased significantly after surgery (median preoperative = 19 (IQR 17-22) versus median last follow-up = 12 (IQR 8-16), p = 0.001). Similarly, physical short-form health survey showed a significant improvement after SphinKeeper® implantation (p = 0.011). Patients with a higher degree of internal sphincter defect showed an improved objective therapy success (r = 0.633, p = 0.015) after SphinKeeper® operation, whereas the type and severity of FI had no impact on the functional outcome. Notably, a higher number of dislocated prostheses (r = 0.772, p = 0.015) showed a significant correlation with reduced improvement of incontinence.

CONCLUSION

The SphinKeeper® procedure showed a significant long-term functional improvement in over half of the patients. Patients with a higher internal sphincter defect benefited most, whereas dislocation of the prostheses was associated with less favorable results.

Artificial sphincters: An overview from existing devices to novel technologies

Artificial sphincters (ASs) are used to replace the function of the biological sphincters in case of severe urinary and fecal incontinence (UI and FI), and gastroesophageal reflux disease (GERD). The design of ASs is established on different mechanisms, e.g., magnetic forces or hydraulic pressure, with the final goal to achieve a implantable and durable AS. In clinical practice, the implantation of in-commerce AS is considered a reasonable solution, despite the sub-optimal clinical outcomes. The failure of these surgeries is due to the malfunction of the devices (between 46 and 51%) or the side effects on the biological tissues (more than 38%), such as infection and atrophy. Concentrating on this latter characteristic, particular attention has been given to the interaction between the biological tissues and AS, pointing out the closing mechanism around the duct and the effect on the tissues. To analyze this aspect, an overview of existing commercial/ready-on-market ASs for GERD, UI, and FI, together with the clinical outcomes available from the in-commerce AS, is given. Moreover, this invited review discusses ongoing developments and future research pathways for creating novel ASs. The application of engineering principles and design concepts to medicine enhances the quality of healthcare and improves patient outcomes. In this context, computational methods represent an innovative solution in the design of ASs, proving data on the occlusive force and pressure necessary to guarantee occlusion and avoid tissue damage, considering the coupling between different device sizes and individual variability.

Injection of aluminum potassium sulfate and tannic acid in the treatment of fecal incontinence: a single-center observational study

PURPOSE

Perianal injection of bulking agents is an attractive treatment option for patients with mild to moderate fecal incontinence (FI). Various bulking agents have been used for injection therapy, but the optimal injection materials and methods are yet to be standardized. This study aimed to evaluate the effects of injection therapy using aluminum potassium sulfate and tannic acid (ALTA) in the management of FI.

METHODS

This study included consecutive patients who underwent ALTA injection therapy for FI at our institution. The procedure was performed with the patient in the jackknife position, under caudal epidural anesthesia. The procedure consisted of a 4-step injection to the 3 main cushions and a multipoint injection to the remaining submucosa of the anal canal.

RESULTS

Seventy-seven patients (mean age, 76 years) were enrolled in the study. The mean Cleveland Clinic incontinence score of 11.9 ± 4.1 at baseline significantly improved to 7.3 ± 5.2 at 3 months following treatment. The mean maximal resting pressure also increased significantly 3 months after the intervention. Postoperative complications were observed in 3 patients (3.9%), and all events were mild. The mean duration of postoperative follow-up was 17.5 months. The cumulative recurrence-free rate at 3 years was 72.4%.

CONCLUSION

ALTA injection for FI is safe, easy to perform, and provides reasonable mid-term outcomes. Moreover, concomitant anorectal diseases that may be contraindicated by other injectable bulking agents could be treated simultaneously. Therefore, ALTA injection is a promising alternative in the absence of other injectable agents.

Sclerotherapy for III- and IV-degree hemorrhoids: Results of a prospective study

Background

In the last 2 years, anorectal surgery has been strongly affected and even surgery for urgent cases cannot be scheduled; also, patients with III- and IV-degree bleeding hemorrhoids should be treated conservatively. The aim was to evaluate the effectiveness of sclerotherapy in patients who had to postpone surgery.

Methods

We included all patients with III- and IV-degree bleeding hemorrhoids who underwent outpatient sclerotherapy. The visual analog scale and the hemorrhoid severity score were used at the baseline and at 4 weeks after the procedure with a telephone interview, and all patients were outpatient-evaluated 1 week, 1 month, and 1 year after the treatment. All pre- and postoperative data were recorded.

Results

From October 2020 to November 2021, 19 patients with III- (12 patients; 63%) and IV-degree (7 patients; 37%) bleeding hemorrhoids were enrolled. The mean operative time was 4.5 min, and no intraoperative complications occurred. One case of tenesmus and three failures were detected. Six months after the procedure, the overall success rate was 84%, although all of the patients enrolled reported persistent bleeding at the end of the study period. Of these, 5 patients (26%) were scheduled for surgery and 11 patients (58%) refused surgery and asked to undergo a re-do sclerotherapy.

Conclusion

Sclerotherapy with 3% polidocanol foam is a safe and effective procedure also in III- and IV-degree bleeding hemorrhoids. The long-term data on the length of the foam remain to be evaluated in additional studies.

Clinical effectiveness and safety of self-expandable implantable bulking agents for faecal incontinence: a systematic review

PURPOSE

The purpose of this systematic review is to evaluate whether self-expandable implantable vs non-self-expandable injectable bulking agents (second-line therapies) are equal/superior in terms of effectiveness (severity, quality of life [QoL]) and safety (adverse events) for faecal incontinence (FI).

METHODS

A systematic review was conducted, and five databases were searched (Medline via Ovid, Embase, Cochrane Library, University of York Centre for Reviews and Dissemination, and International Network of Agencies for Health Technology database). In-/exclusion criteria were predefined according to the PICOS scheme. The Institute of Health Economics risk of bias (RoB) tool assessed studies' internal validity. According to the Grading of Recommendations, Assessment, Development and Evaluation approach, the strength of evidence for safety outcomes was rated. A qualitative synthesis of the evidence was used to analyse the data.

RESULTS

The evidence consists of eight prospective single-arm, before-after studies (166 patients) fulfilling the inclusion criteria for assessing clinical effectiveness and safety of implantable bulking agents. FI severity statistically significantly improved in five of seven studies rated by the Cleveland Clinic FI Score and in three of five studies measured by the Vaizey score. Statistically significant improved disease-related QoL was found in one of five studies measured by the FI QoL Score and in one of two studies rated by the American Medical Systems score. Procedure-related adverse events occurred in 16 of 166 patients (i.e., intraoperative complications, anal discomfort and pain). Device-related adverse events occurred in 48 of 166 patients, including prostheses' dislodgement and removed/extruded prostheses. Studies were judged with moderate/high RoB. The strength of evidence for safety was judged to be very low.

CONCLUSION

Implantable bulking agents might be an effective and safe minimally invasive option in FI treatment if conservative therapies fail. FI severity significantly improved, however, effects on QoL need to be explored in further studies. Due to the uncontrolled nature of the case series, comparative studies need to be awaited.

A prospective trial of the THD SphinKeeper® for faecal incontinence

AIM

THD SphinKeeper® is an emerging surgical technique for faecal incontinence (FI). The safety, indications and efficacy of the procedure are still being investigated. The aim of this study is to present the first experience of SphinKeeper® in Australia.

METHOD

This was a prospective single-centre observational study of patients undergoing SphinKeeper® implantation between February 2018 and September 2019. Baseline demographics, intraoperative and postoperative complications, Cleveland Clinic Faecal Incontinence Score, St Mark's Incontinence Score, Faecal Incontinence Quality of Life score (FIQOL), anorectal manometry and endo-anal ultrasound were assessed preoperatively and 3 and 12 months after implantation.

RESULTS

Thirteen patients (2 male, 11 female) underwent implantation during the study period. Anal sphincter defects were present in 13 (76.9%) patients [external anal sphincter (EAS) defect, 2 (15.4%); internal anal sphincter (IAS) defect 4 (30.8%); EAS + IAS defect, 4 (30.8%)]. Median follow-up was 32 months (range 18-37 months). There were four complications: one intraoperative (rectal perforation) and three postoperative (one implant extrusion, two implants that required removal due to malposition). At 12 months, an average of 9/10 implants remained ideally placed in each patient. THD SphinKeeper® insertion was associated with an improvement in coping/behaviour as measured using FIQOL (p = 0.047). However, the procedure did not improve FI scores or anorectal manometry parameters.

CONCLUSION

In this study, SphinKeeper® marginally improved symptoms of FI but there was no significant impact on anorectal manometric measurements. Larger-scale studies are needed to determine the patient cohort most likely to benefit from this procedure.

Sphinkeeper Procedure for Treating Severe Faecal Incontinence-A Prospective Cohort Study

(1) Background: The Sphinkeeper implantation for faecal incontinence (FI) is a novel surgical procedure with limited data on its clinical efficacy. Therefore, we aimed to assess the functional outcome following Sphinkeeper surgery in patients with refractory FI. (2) Methods: Between 2018 and 2020, eleven consecutive patients (9 female) with FI met the inclusion criteria and were enrolled for surgery. Functional outcome and quality of life were evaluated by standard questionnaires pre- and post-surgery. Migration of protheses was demonstrated by 3D endoanal ultrasound. The median follow-up time was eight months (range 3–18 months). (3) Results: The median age was 75 years (range 46–89 years) with a median BMI of 27.4 (range 21.2–30.1). The median number of implanted prostheses per intervention was nine (range 9–10). We found no intraoperative or early postoperative complications. After two months, two prostheses in one patient had to be removed due to pain at the perianal skin site. The median St. Mark’s incontinence score decreased significantly from 22 to 13 points (p = 0.008). The SF-12 showed a significant improvement (35.9 versus 46.3) after surgery (p = 0.028). A migration of at least one prosthesis was observed in ten patients (91%). Six (60%) prostheses were found at the same level in another ten patients. (4) Conclusion: Sphinkeeper implantation is a promising surgical technique for patients with severe FI. The complication rate is low, and short-term functional improvement can be achieved even in severe forms of FI. Migration of implants commonly occurs.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

[Anal incontinence]

Anal incontinence describes the uncontrolled transanal passage of gaseous, solid or liquid intestinal contents. It can be a considerable psychosocial burden and impairment of the quality of life for those affected. The cause can be primary damage to the continence organ or incontinence can be a secondary symptom of other diseases. The detailed patient history and clinical examination document the severity of incontinence, impairment of quality of life and pathomorphological changes. The treatment is primarily conservative. A combination of conservative therapeutic approaches can often achieve satisfactory symptom relief. If conservative treatment remains insufficient, surgical measures can be considered. Sphincteroplasty and sacral neuromodulation are the preferred surgical interventions.

Surgical Treatment Alternatives to Sacral Neuromodulation for Fecal Incontinence: Injectables, Sphincter Repair, and Colostomy

Fecal incontinence is a prevalent health problem that affects over 20% of healthy women. Many surgical treatment options exist for fecal incontinence after attempts at non-operative management. In this article, the authors discuss surgical treatment options for fecal incontinence other than sacral neuromodulation.

Initial experience with SphinKeeper™ intersphincteric implants for faecal incontinence in the UK: a two-centre retrospective clinical audit

AIM

The SphinKeeper™ artificial bowel sphincter implant is a relatively new surgical technique for the treatment of refractory faecal incontinence. This study presents the first experience in two UK tertiary centres.

METHOD

This is a retrospective audit of prospectively collected clinical data in relation to technique, safety, feasibility and short-term effectiveness from patients undergoing surgery from January 2016 to April 2019. Baseline data, intra-operative and postoperative complications, symptoms [using St Mark's incontinence score (SMIS)] and radiological outcomes were analysed.

RESULTS

Twenty-seven patients [18 women, median age 57 years (range 27-87)] underwent SphinKeeper. In 30% of the patients, the firing device jammed and not all prostheses were delivered. There were no intra-operative complications and all patients were discharged the same or the following day. SMIS significantly improved from baseline [median -6 points (range -12 to +3); P < 0.00016] with 14/27 (51.9%) patients achieving a 50% reduction in the SMIS score. On postoperative imaging, a median of seven prostheses (range 0-10) were identified with a median of five (range 0-10) optimally placed. There was no relationship between number of well-sited prostheses on postoperative imaging and categorical success based on 50% reduction in SMIS (χ² test, P = 0.79).

CONCLUSION

SphinKeeper appears to be a safe procedure for faecal incontinence. Overall, about 50% patients achieved a meaningful improvement in symptoms. However, clinical benefit was unrelated to the rate of misplaced/migrated implants. This has implications for confidence in proof of mechanism and also the need for technical refinement.