Elastomer implants in faecal incontinence: a blind, randomized placebo-controlled study

Gatekeeper™ Prostheses Implants in the Anal Canal for Gas Incontinence and Soiling: Long-Term Follow-Up

Introduction: Although several treatments for faecal incontinence are available, gas incontinence (GI) and soiling are difficult to manage. The aim of this study is to evaluate Gatekeeper™ for this subtype of faecal incontinence. Methods: Prospective single-centre case series. Patients with mainly soiling and/or GI were treated with polyacrylonitrile prostheses. An evaluation was performed with a 3-week continence diary. St. Mark's score and a Visual Analogue Scale (VAS) were used to study the patient's continence perception and surgical satisfaction, at baseline and 1, 3, 6, 12, and 24 months postoperatively. 3D-Endoanal Ultrasound and Anorectal Manometry were performed at baseline and postoperatively. Results: A total of 13 patients were enrolled (11 women), aged (median (IQR)) 62 (13) years, and all implants were uneventful. A significant reduction in soiling and GI episodes was documented at 1 year, 7 (18) baseline days of soiling/3 weeks vs. 2 (4) (p = 0.002); 13 (13) baseline episodes of GI/3 weeks vs. 4 (10) (p = 0.01). This improvement was correlated with a significant increase in VAS (0-10), 3 (2, 5) baseline vs. 7 (1, 5) (p = 0.03), and maintained throughout the follow-up. There was complete remission or significant improvement defined as >70% reduction in gas and soiling days in 6 patients at 2 years follow-up. Soiling episodes were reduced ≥70% in 8/11 patients (72.7%). Nine (70%) patients would repeat the treatment. Conclusions: Gatekeeper™ is a safe, minimally invasive treatment for soiling and GI. A significant reduction in soiling and GI was observed in our series, with a better response to soiling. Most of the patients would repeat the treatment. Other studies are needed to confirm these findings in this subgroup of FI patients.

Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration

INTRODUCTION

The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

METHODS

These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus.

RESULTS

These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients.

CONCLUSION

These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Fabrication and Analysis of Polydimethylsiloxane (PDMS) Microchannels for Biomedical Application

In this research work, Polydimethylsiloxane (PDMS) has been used for the fabrication of microchannels for biomedical application. Under the internet of things (IoT)-based controlled environment, the authors have simulated and fabricated bio-endurable, biocompatible and bioengineered PDMS-based microchannels for varicose veins implantation exclusively to avoid tissue damaging. Five curved ascending curvilinear micro-channel (5CACMC) and five curved descending curvilinear micro-channels (5CDCMC) are simulated by MATLAB (The Math-Works, Natick, MA, USA) and ANSYS (ANSYS, The University of Lahore, Pakistan) with actual environments and confirmed experimentally. The total length of each channel is 1.6 cm. The diameter of both channels is 400 µm. In the ascending channel, the first to fifth curve cycles have the radii of 2.5 mm, 5 mm, 7.5 mm, 10 mm, and 2.5 mm respectively. In the descending channel, the first and second curve cycles have the radii of 12.5 mm and 10 mm respectively. The third to fifth cycles have the radii of 7.5 mm, 5 mm, and 2.5 mm respectively. For 5CACMC, at Reynolds number of 185, the values of the flow rates, velocities and pressure drops are 19.7 µLs−1, 0.105 mm/s and 1.18 Pa for Fuzzy simulation, 19.3 µLs−1, 0.1543 mm/s and 1.6 Pa for ANSYS simulation and 18.23 µLs−1, 0.1332 mm/s and 1.5 Pa in the experiment. For 5CDCMC, at Reynolds number 143, the values of the flow rates, velocities and pressure drops are 15.4 µLs−1, 0.1032 mm/s and 1.15 Pa for Fuzzy simulation, 15.0 µLs−1, 0.120 mm/s and 1.22 Pa for ANSYS simulation and 14.08 µLs−1, 0.105 mm/s and 1.18 Pa in the experiment. Both channels have three inputs and one output. In order to observe Dean Flow, Dean numbers are also calculated. Therefore, both PDMS channels can be implanted in place of varicose veins to have natural blood flow.

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.

A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults

AIM

To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults.

METHODS

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI.

RESULTS

The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQ^TM versus Durasphere^®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions.

CONCLUSIONS

The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Autologous Myoblasts for the Treatment of Fecal Incontinence: Results of a Phase 2 Randomized Placebo-controlled Study (MIAS)

OBJECTIVE

The aim of this study was to evaluate the efficacy of intrasphincteric injections of autologous myoblasts (AMs) in fecal incontinence (FI) in a controlled study.

SUMMARY OF BACKGROUND DATA

Adult stem cell therapy is expected to definitively cure FI by regenerating damaged sphincter. Preclinical data and results of open-label trials suggest that myoblast therapy may represent a noninvasive treatment option.

METHODS

We conducted a phase 2 randomized, double-blind, placebo-controlled study of intrasphincteric injections of AM in 24 patients. The study compared outcome after AM (n = 12) or placebo (n = 12) injection using Cleveland Clinic Incontinence (CCI), score at 6 and 12 months. Patients in the placebo group were eligible to receive frozen AM after 1 year.

RESULTS

At 6 months, the median CCI score significantly decreased from baseline in both the AM (9 vs 15, P = 0.02) and placebo (10 vs 15, P = 0.01) groups. Hence, no significant difference was found between the 2 groups (primary endpoint) at 6 months. At 12 months, the median CCI score continued to ameliorate in the AM group (6.5 vs 15, P = 0.006), while effect was lost in the placebo group (14 vs 15, P = 0.35). Consequently, there was a higher response rate at 12 months in the treated than the placebo arm (58% vs 8%, P = 0.03). After delayed frozen AM injection in the placebo group, the response rate was 60% (6/10) at 12 months.

CONCLUSIONS

Intrasphincteric AM injections in FI patients have shown tolerance, safety, and clinical benefit at 12 months despite a transient placebo effect at 6 months.

Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial

AIM

The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS).

METHOD

This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores.

RESULTS

Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77).

CONCLUSION

SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.

Libertas: a phase II placebo-controlled study of NRL001 in patients with faecal incontinence showed an unexpected and sustained placebo response

PURPOSE

Faecal incontinence (FI) is distressing, significantly reduces quality of life (QoL) and has few pharmacological treatments. The α1-adrenoceptor agonist NRL001 (1R,2S-methoxamine hydrochloride) improves anal sphincter tone. NRL001 efficacy was evaluated by changes in Wexner scores at week 4 vs. baseline in NRL001-treated patients compared with placebo. Impact of NRL001 on QoL and safety were also assessed.

METHODS

Four hundred sixty-six patients received NRL001 (5, 7.5 or 10 mg) or placebo as suppository, once daily over 8 weeks. Wexner score, Vaizey score and QoL were analysed at baseline, week 4 and week 8. FI episodes and adverse events were recorded in diaries.

RESULTS

At week 4, mean reductions in Wexner scores were -3.0, -2.6, -2.6 and -2.4 for NRL001 5, 7.5, 10 mg and placebo, respectively. All reduced further by week 8. As placebo responses also improved, there was no significant treatment effect at week 4 (p = 0.6867) or week 8 (p = 0.5005). FI episode frequency improved for all patients, but not significantly compared with placebo (week 4: p = 0.2619, week 8: p = 0.5278). All patients' QoL improved, but not significantly for all parameters (p > 0.05) except depression/self-perception at week 4 (p = 0.0102) and week 8 (p = 0.0069), compared with placebo. Most adverse events were mild and judged probably or possibly related to NRL001.

CONCLUSIONS

All groups demonstrated improvement in efficacy and QoL compared with baseline. NRL001 was well-tolerated without serious safety concerns. Despite the improvement in all groups, there was no statistically significant treatment effect, underlining the importance of relating results to a placebo arm.

Faecal incontinence: Current knowledges and perspectives

Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools.

Multicentre observational study of the Gatekeeper for faecal incontinence

Background

A variety of therapeutic approaches are available for faecal incontinence. Implantation of Gatekeeper™ prostheses is a new promising option. The primary endpoint of this prospective observational multicentre study was to assess the clinical efficacy of Gatekeeper™ implantation in patients with faecal incontinence. Secondary endpoints included the assessment of patients' quality of life, and the feasibility and safety of implantation.

Methods

Patients with faecal incontinence, with either intact sphincters or internal anal sphincter lesions extending for less than 60° of the anal circumference, were selected. Intersphincteric implantation of six prostheses was performed. At baseline, and 1, 3 and 12 months after implantation, the number of faecal incontinence episodes, Cleveland Clinic Faecal Incontinence, Vaizey and American Medical Systems, Faecal Incontinence Quality of Life Scale and Short Form 36 Health Survey scores were recorded. Endoanal ultrasonography was performed at baseline and follow‐up.

Results

Fifty‐four patients were implanted. After Gatekeeper™ implantation, incontinence to gas, liquid and solid stool improved significantly, soiling was reduced, and ability to defer defaecation enhanced. All faecal incontinence severity scores were significantly reduced, and patients' quality of life improved. At 12 months, 30 patients (56 per cent) showed at least 75 per cent improvement in all faecal incontinence parameters, and seven (13 per cent) became fully continent. In three patients a single prosthesis was extruded during surgery, but was replaced immediately. After implantation, prosthesis dislodgement occurred in three patients; no replacement was required.

Conclusion

Anal implantation of the Gatekeeper™ in patients with faecal incontinence was effective and safe. Clinical benefits were sustained at 1‐year follow‐up.

Gatekeeper^TM effective

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.

[Management of postpartum anal incontinence: A systematic review]

AIM

To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management.

MATERIALS AND METHODS

A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery.

RESULTS

The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years).

CONCLUSION

Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

Anti-fouling Coatings of Poly(dimethylsiloxane) Devices for Biological and Biomedical Applications

Fouling initiated by nonspecific protein adsorption is a great challenge in biomedical applications, including biosensors, bioanalytical devices, and implants. Poly(dimethylsiloxane) (PDMS), a popular material with many attractive properties for device fabrication in the biomedical field, suffers serious fouling problems from protein adsorption due to its hydrophobic nature, which limits the practical use of PDMS-based devices. Effort has been made to develop biocompatible materials for anti-fouling coatings of PDMS. In this review, typical nonfouling materials for PDMS coatings are introduced and the associated basic anti-fouling mechanisms, including the steric repulsion mechanism and the hydration layer mechanism, are described. Understanding the relationships between the characteristics of coating materials and the accompanying anti-fouling mechanisms is critical for preparing PDMS coatings with desirable anti-fouling properties.

Initial results of a new bulking agent for fecal incontinence: a multicenter study

BACKGROUND

Anal incontinence is a common and multifactorial pathology that affects patients' lives and imposes considerable socioeconomic consequences.

OBJECTIVE

The aim of this study is to evaluate the efficacy of a bulking agent, polyacrylate-polyalcohol (PP), in terms of diminishing the severity of incontinence and improving the patient's quality of life, assessing any adverse events.

DESIGN

Data were obtained through a prospective, nonconsecutive, multicenter, noncomparative, postmarket study with a maximum expected follow-up of 3 years. Four investigational centers from Argentina and Brazil participated in this study.

SETTINGS

Injections of the bulking agent were administered in the operating room of tertiary hospitals.

PATIENTS

Fifty-eight patients were enrolled. Five patients were lost to follow-up. Of the remaining 53 patients, 41 (77.4%) were females. All patients scored between 6 and 12 on the Cleveland Clinic Florida-Fecal Incontinence Score as part of the inclusion criteria.

INTERVENTIONS

The injection of the bulking agent (PP) was administered under intravenous sedation in the submucosa of the anal canal through the perianal skin to generate a bulk.

MAIN OUTCOME MEASURES

The primary efficacy end point was the Cleveland Clinic Florida-Fecal Incontinence Score (or Jorge and Wexner index). The Rockwood-Fecal Incontinence Quality of Life index was also recorded. The treatment was considered successful if patients achieved a postoperative improvement of at least 50% on the Cleveland Clinic Florida-Fecal Incontinence Score.

RESULTS

Successful treatment was met by 60.4% of the patients according to the last follow-up data. Quality-of-life indices showed consistently significant improvements.

LIMITATIONS

Selection bias and the lack of a control group to evaluate the potential placebo effect of this novel bulking agent were limitations of this study. Because of the eligibility criteria, the resulting patient sample is representative of only a limited portion of the population with fecal incontinence at all 4 centers involved in this study.

CONCLUSIONS

The injection technique was easy to perform, safe, and ideal for use as an outpatient procedure. This bulking agent (PP) significantly improved continence and quality of life in selected patients.

Current and emerging treatment options for fecal incontinence

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

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.

Perineal retraining improves conservative treatment for faecal incontinence: a multicentre randomized study

BACKGROUND

Anal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment.

METHODS

Patients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from -5 to +5) defined success.

RESULTS

Overall, 157 patients were included; 80 in the control group (75% females, mean age 60.1 ± 13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9 ± 10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p<0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14-4.80]; p=0.021).

CONCLUSIONS

Perineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence.

Treatments of faecal incontinence: recommendations from the French national society of coloproctology

Faecal incontinence is common and significantly affects quality of life. Its treatment involves dietary manipulation, medical treatments, perineal rehabilitation or surgery. In this paper, the French National Society of Coloproctology offers recommendations based on the data in the current literature, including those on recently developed treatments. There is a lack of high quality data and most of the recommendations are therefore based either on grade of recommendation B or expert recommendation (Level 4). However, the literature supports the construction of an algorithm based on the available scientific evidence and expert recommendation which may be useful in clinical practice. The French National Society of Coloproctology proposes a decision-making algorithm that includes recent developments of treatment. The current recommendations support sacral nerve modulation as the key treatment for faecal incontinence. They do not support the use of sphincter substitutions except in certain circumstances. Transanal irrigation is a novel often successful treatment of faecal incontinence due to neurological disorders.

Surgical approaches to fecal incontinence in the adult

Surgical treatment of anal incontinence is indicated only for patients who have failed medical treatment. Sphincterorraphy is suitable in case of external sphincter rupture. In the last decade, sacral nerve stimulation has proven to be a scientifically validated solution when no sphincter lesion has been identified and more recently has also been proposed as an alternative in cases of limited sphincter defect. Anal reconstruction using artificial sphincters is still under evaluation in the literature, while indications for dynamic graciloplasty are decreasing due to its complexity and high morbidity. Less risky techniques involving intra-sphincteric injections are being developed, with encouraging preliminary results that need to be confirmed especially in the medium- and long-term. Antegrade colonic enemas instilled via cecostomy (Malone) can be an alternative to permanent stoma in patients who are well instructed in the techniques of colonic lavage. Stomal diversion is a solution of last resort.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (for example pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH METHODS

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 6 March 2013), the Cochrane Colorectal Cancer Group Specialised Register (searched 6 March 2013), CENTRAL (2013, issue 1) and EMBASE (1 January 1998 to 6 March 2013) were undertaken. The British Journal of Surgery (1 January 1995 to 6 March 2013), Colorectal Diseases (1 January 2000 to 6 March 2013) and the Diseases of the Colon and Rectum (1 January 1995 to 6 March 2013) were specifically handsearched. The proceedings of the Association of Coloproctology of Great Britain and Ireland annual meetings held from 1999 to 2012 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Nine trials were included with a total sample size of 264 participants. Two trials included a group managed non-surgically. One trial compared levatorplasty with anal plug electrostimulation and one compared an artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but the numbers were small. The other trial showed no difference in the primary outcome measures.Seven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, and total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

AUTHORS' CONCLUSIONS

The review is striking for the lack of high quality randomised controlled trials on faecal incontinence surgery that have been carried out in the last 10 years. Those trials that have been carried out have focused on sacral neuromodulation and injectable bulking agents, both reported in separate reviews. The continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Comparison of bulking agents in the treatment of fecal incontinence: a prospective randomized clinical trial

BACKGROUND

We sought to compare two synthetic injectable bulking agents, with known efficacy (PTQ™: a silicone biomaterial and Durasphere(®): pyrolytic carbon-coated beads), in the form of a randomised clinical trial.

METHODS

Circumferential injection of either agent was performed under local anesthesia and sedation as a day-case procedure. The primary outcome measure was the Wexner incontinence scale. Secondary measures were the short-form 36 (SF-36) quality of life assessment and manometry (maximum resting and squeeze pressures). Follow-up was at 6 weeks, 6 and 12 months.

RESULTS

Thirty-five patients were randomised, 17 to PTQ(®) and 18 to Durasphere(®). Early closure of the trial occurred, due to the removal of the agent PTQ(®), from the Australian Pharmaceutical Benefits scheme. Wexner incontinence scores were significantly better than baseline, in both groups, at 6 weeks and 6 months (P < 0.05), although the improvements were not significant at 12 months. There was no significant improvement for either agent, from baseline, in mean SF-36 scores at any follow-up sessions. There was no significant difference between the two bulking agents, with regard to both Wexner and SF-36 scores, at any of the follow-up sessions. Complications occurred in one patient in the PTQ group (perianal abscess) and did not occur in any of the patients in the Durasphere group.

CONCLUSIONS

This trial appears to show that both synthetic agents PTQ(®) and Durasphere(®) are effective and safe, although long-term improvement is limited. In this trial, there appears to be no difference in efficacy between the two agents, over a 12-month follow-up period.

Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial

OBJECTIVE

The objective is to test if the injection of a bulking agent in the anal canal is superior to sphincter training with biofeedback in the treatment of anal incontinence.

BACKGROUND

Anal incontinence is traditionally treated with conservative measures, such as pads and constipating medicine. If this fails, sphincter training with biofeedback is often offered before more advanced surgical procedures are considered. The injection of a bulking agent in the anal canal is a relatively new and promising treatment option.

METHODS

In a randomized, controlled, evaluator-blinded trial, 126 adult patients with anal incontinence were randomly assigned to a transanal, submucosal injection of 4 x 1 mL of dextranomer in hyaluronic acid or to sphincter training with biofeedback. The primary outcome was severity of incontinence, evaluated by St Mark's score for incontinence (0 = continence to 24 = complete incontinence) assessed at 2 years after the start of treatment. A mixed models analysis was applied.

RESULTS

Of the 126 participants, 64 patients were randomly assigned to anal injections, and among them the mean St Mark's score improved from 12.9 (95% CI: 11.8-14.0) at baseline to 8.3 (95% CI: 6.7-9.8) at the end of follow up. Among the 62 patients who were assigned to sphincter training with biofeedback, there was a corresponding improvement in St Mark's score from 12.6 (95% CI: 11.4-13.8) to 7.2 (95% CI: 7.2-8.8). Comparisons of St Mark's scores between the groups showed no differences in effect between treatments.

CONCLUSION

The efficacy of anal injections and biofeedback in treating anal incontinence did not differ in this randomized, single-blinded, controlled trial.

Injectable collagen for the treatment of fecal incontinence: long-term results

BACKGROUND

Fecal incontinence is a distressing condition that is difficult to treat. Injection of bulking agents has been used to treat passive fecal incontinence. However, no long-term results are available.

OBJECTIVE

The aim of this study was to assess the long-term clinical effectiveness of intra-anal injection of collagen for passive fecal incontinence.

DESIGN

This research is a retrospective cohort study from a prospectively collected database

SETTING

This investigation took place in a high-volume tertiary colorectal department.

PATIENTS

All patients who underwent intra-anal injection of collagen for passive fecal incontinence with internal sphincter dysfunction between January 2006 and December 2009 were included in the study. Data including demographic details, preoperative anorectal physiology, and outcome measures were collected prospectively and maintained in a database

MAIN OUTCOME MEASURES

The primary outcomes measured were the Cleveland Clinic Florida incontinence score and the responses to a subjective patient satisfaction questionnaire before the procedure and at subsequent follow-up visits. Data were analyzed by using SPSS v19.0.

RESULTS

One hundred patients (70 female; mean age, 61 years (range, 36-82)) were followed up for a minimum duration of 36 months. Fifty-six patients (56%) had an improvement in fecal incontinence score from a mean of 14 (range, 9-18) to a mean of 8 (range, 5-14). A total of 68% reported subjective improvement in symptoms. Thirty-eight patients (38%) required a repeat injection of collagen, and a further 15 patients required a third injection. The median interval between the first and final injection was 12 months (range, 4-16 months). Age was the only independent predictor of successful outcome (p = 0.032). There was no morbidity.

LIMITATIONS

This study was limited by its nonrandomized retrospective design.

CONCLUSIONS

Injection of collagen into the internal anal sphincter is simple, safe, and effective in patients with passive fecal incontinence, although repeat injections are necessary in approximately half of the patients.

Perianal injectable bulking agents as treatment for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a complex and distressing condition with significant medical and social implications. Injection of perianal bulking agents has been used to treat the symptoms of passive faecal incontinence. However, various agents have been used without a standardised technique and the supposed benefit of the treatment is largely anecdotal with a limited clinical research base.

OBJECTIVES

To determine the effectiveness of perianal injection of bulking agents for the treatment of faecal incontinence in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (25 May 2012), ZETOC (3 May 2012), clinical trials registries (3 May 2012) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing the use of injectable bulking agents for faecal incontinence with any alternative treatments or placebo were reviewed to evaluate the therapeutic effects. Case-control and cohort studies were also reviewed to assess risks and complications associated with the treatments.

DATA COLLECTION AND ANALYSIS

Two review authors (YM and CN) assessed the methodological quality of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures.

MAIN RESULTS

Five eligible randomised trials with a total of 382 patients were identified. Four of the trials were at an uncertain or high risk of bias.Most trials reported a short term benefit from injections regardless of the material used, including placebo saline injection. One study demonstrated dextranomer in stabilised hyaluronic acid (NASHA Dx) to be more effective than sham injection but with more adverse effects. Dextranomer in stabilised hyaluronic acid (NASHA Dx) was better than sham injections at six months (65/136, 48% versus 48/70, 69% participants not improved, defined as less than 50% reduction in incontinence episodes, RR 0.70, 95% CI 0.55 to 0.88; with more incontinence free days (3.1 days compared with 1.7 in the sham treatment group, MD 1.40 days, 95% CI 0.33 to 2.47). Another study comparing silicone material (PTQ™) to saline injections was too small to demonstrate a clinical benefit compared to the control injection of normal saline.A silicone biomaterial (PTQ™) was shown to provide some advantages and was safer in treating faecal incontinence than carbon-coated beads (Durasphere®) in the short term.Similarly, there were short term benefits from injections delivered under ultrasound guidance compared with digital guidance.No long term evidence on outcomes was available and further conclusions were not warranted from the available data. None of the studies reported patient evaluation of outcomes and thus it is difficult to gauge whether the improvement in incontinence scores matched practical symptom improvements that mattered to the patients.

AUTHORS' CONCLUSIONS

One large randomised controlled trial has shown that this form of treatment using dextranomer in stabilised hyaluronic acid (NASHA Dx) improves continence for a little over half of patients in the short term. However, the number of identified trials was limited and most had methodological weaknesses.

Anal bulking agents for faecal incontinence

The aim of this review was to assess and evaluate reports of studies on the efficacy of anal bulking agents used in the treatment of faecal incontinence. A systematic review of the literature was carried out to identify studies that have reported on the use of anal bulking agents. A variety of biomaterials have been employed for anal bulking. These include autologous fat, bovine glutaraldehyde cross-linked collagen, carbon-coated zirconium oxide beads, dextranomer microspheres in a gel, hydrogel cross-linked with polyacrylamide, polydimethylsiloxane elastomer in a gel, porcine dermal collagen and synthetic calcium hydroxylapatitie ceramic microspheres. Although the ideal site of injection (submucosal or intramuscular) and the mechanism of action remain the subject of debate, most published studies report a significant improvement in continence in at least 50% of subjects with mild to moderate symptoms with little or no associated morbidity.We concluded that anal bulking agents may be used to alleviate symptoms of faecal seepage and soilage.

Transcutaneous electrical tibial nerve stimulation in the treatment of fecal incontinence: a randomized trial (CONSORT 1a)

OBJECTIVES

The objective of this study was to show that although transcutaneous electrical tibial nerve stimulation (TENS) is being increasingly used to treat fecal incontinence (FI), its efficacy has never been proved using controlled trials.

METHODS

In this randomized, double-blind, sham-controlled trial, 144 patients aged 30-82 years from nine centers were randomly assigned to receive either active or sham stimulations for 3 months. The primary end point was the response to treatment based on the number of incontinence and urgency episodes. Secondary end points were severity scores, quality of life scores, delay to postpone defecation, patient self-assessment of treatment efficacy, physician assessment of TENS efficacy, anorectal manometry, and adverse events.

RESULTS

No statistically significant difference was seen between active and sham TENS in terms of an improvement in the median number of FI/urgency episodes per week. Thirty-four patients (47%) who received the active TENS treatment exhibited a >30% decrease in the FI severity score compared with 19 patients (27%) who received the sham treatment (odds ratio 2.4, 95% confidence interval 1.1-5.1, P=0.02). No differences in delay to postpone defecation, patient self-assessment of treatment efficacy, or anorectal manometry were seen between the two groups. The evaluating physicians rated the active stimulations as more effective than the sham stimulations (P=0.01). One minor therapy-related adverse event was observed (1.5%) (see Supplementary Consort 1b).

CONCLUSIONS

We failed to demonstrate any benefit of TENS on our primary end-point.

The use of Permacol® injections for the treatment of faecal incontinence

The aim of this study is to assess the safety and efficacy of Permacol(®) implant for the treatment of idiopathic faecal incontinence using a novel injection technique. Patients with idiopathic passive faecal incontinence were selected for trans-submucosal injection of Permacol(®) after assessment by anorectal physiology and endoanal ultrasonography. Clinical assessment and St. Mark's Incontinence Score were used to evaluate efficacy before and at two time points (1 and 2 years) after treatment. Rockwood Score were also used to determine quality of life before and after treatment. The Friedman and Chi-square tests were used to compare continuous and categorical data, respectively. A p value of <0.05 was deemed significant. Thirty-eight patients (24 female), median age 66 years, were recruited. At maximum clinical follow-up (median of 9 months), response to Permacol(®) injections was categorised as excellent, good, fair and poor in 12, 5, 4 and 17 patients, respectively. St. Mark's Score improved in 72 and 63 % of patients at 1 and 2 years, respectively. However, a smaller proportion of patients (39 and 27 %, respectively) achieved a 50 %, or more, improvement in Mark's Score. All four domains of Rockwood Quality of Life Score improved on first and second year follow-up, however, only two domains, coping and embarrassment, were statistically significant. Permacol(®) injection improved symptoms by >50 % in 39 and 27 % of patients on short and medium-term follow-ups, respectively. The trans-submucosal technique for injection of Permacol(®) in this study was safe with no significant adverse outcomes.

A prospective non-randomized two-centre study of patients with passive faecal incontinence after birth trauma and patients with soiling after anal surgery, treated by elastomer implants versus rectal irrigation

AIM

This study is a prospective evaluation of patients with passive faecal incontinence and patients with soiling treated by elastomer implants and rectal irrigation.

PATIENTS AND METHODS

Patients with passive faecal incontinence after birth trauma resulting from a defect of the internal sphincter and patients with soiling after previous anal surgery were included. All patients underwent endo-anal ultrasound, magnetic resonance imaging, and anal manometry. The patients with passive faecal incontinence were initially treated by anal sphincter exercises and biofeedback therapy during half a year. The patients completed incontinence scores, a quality of life questionnaire, and a 2-week diary card.

RESULTS

The elastomer group consisted of 30 males and 45 females with a mean age of 53 years (25-77). The rectal irrigation group consisted of 32 males and 43 females with a mean age of 50 years (25-74). At 6 months follow-up, 30 patients with soiling of the rectal irrigation group and only nine patients of the elastomer group were completely cured (p = 0.02). Only three patients with passive faecal incontinence were cured in the rectal irrigation group and none in the elastomer group. Three distal migrations of elastomer implants required removal at follow-up.

CONCLUSIONS

After patients had performed anal sphincter exercises, no clear improvement of passive faecal incontinence was obtained by elastomer implants or rectal irrigation. However, rectal irrigation is far more effective than elastomer implants in patients with soiling.

Novel bulking agent for faecal incontinence

BACKGROUND

Various injectable bulking agents have been used for the treatment of faecal incontinence (FI). However, encouraging early results are not maintained over time. This study aimed to assess short- and medium-term results of a new bulking agent for the treatment of FI.

METHODS

The Gatekeeper(™) prosthesis comprises a thin solid polyacrylonitrile cylinder that becomes thicker, shorter and softer within 24 h after implantation. Fourteen patients with FI underwent treatment with Gatekeeper(™) under local anaesthesia. Four prostheses were implanted in the intersphincteric space in each patient, under endoanal ultrasound guidance. Number of episodes of major FI, Cleveland Clinic FI score (CCFIS), Vaizey score, anorectal manometry, endoanal ultrasonography (EUS), health status and quality of life (Short Form 36 and Faecal Incontinence Quality of Life questionnaires) were assessed before and after treatment.

RESULTS

Mean(s.d.) follow-up was 33·5(12·4) months. There were no complications. There was a significant decrease in major FI episodes from 7·1(7·4) per week at baseline to 1·4(4·0), 1·0(3·2) and 0·4(0·6) per week respectively at 1-month, 3-month and last follow-up (P = 0·002). CCFIS improved significantly from 12·7(3·3) to 4·1(3·0), 3·9(2·6) and 5·1(3·0) respectively (P < 0·001), and Vaizey score from 15·4(3·3) to 7·1(3·9), 4·7(3·0) and 6·9(5·0) respectively (P = 0·010). Soiling and ability to postpone defaecation improved significantly, and patients reported significant improvement in health status and quality of life. At follow-up, manometric parameters had not changed and EUS did not demonstrate any prosthesis dislocation.

CONCLUSION

The Gatekeeper(™) anal implant seemed safe, reliable and effective. Initial clinical improvement was maintained over time, and follow-up data were encouraging.

Treatment of fecal incontinence - review of observational studies (OS) and randomized controlled trials (RCT) related to injection of bulking agent into peri-anal tissue

PURPOSE: Novel treatments are needed to augment medical therapy for fecal incontinence. METHODS: Medline and Google search (fecal incontinence and injection treatment), English publications. RESULTS: Twenty-two observational studies and 4 randomized controlled trials were identified. OS mostly with limited sample sizes reported promising results. Repeated injection was necessary in some patients. Effect on anal sphincter pressures was highly variable. Significant improvements in the length of anal high-pressure zone, asymmetry index and maximum tolerable rectal volume were suggested. Four randomized controlled trials (n=176) revealed: 1. Short-term benefits from injection of Bioplastique under ultrasound guidance compared with digital guidance; 2. Silicone biomaterial (PTQ) provided some advantages and was safer than carbon-coated beads (Durasphere); 3. PTQ did not demonstrate clinical benefit compared to control injection of saline; 4. There was significant improvement at 6 weeks post injection, but no difference between Bulkamid and Permacol. A 2010 Cochrane review, however, noted that these data were inconclusive due to limited number and methodological weaknesses. CONCLUSION: Further studies are warranted to assess patient-centered outcomes (e.g. adequate relief) in addition to the attenuation of severity of incontinence symptoms in ambulatory patients. In nursing home residents, cost-effectiveness studies combining injection treatment and prompted voiding (to mitigate constraints of immobility and dementia) in preventing peri-anal skin complications deserves to be considered.

Systematic review of perianal implants in the treatment of faecal incontinence

BACKGROUND

Injectable bulking agents have been used with varying success for the treatment of faecal incontinence. This systematic review aimed to investigate the various injectable agents and techniques used for the treatment of faecal incontinence, and to assess their safety and efficacy.

METHODS

Thirty-nine publications were identified and studied. The following variables were pooled for univariable analysis: type, location, route of bulking agents, and the use of ultrasound guidance, antibiotics, laxatives and anaesthetics. Predictors of the development of complications and successful outcomes were identified by multivariable logistic regression analysis.

RESULTS

A total of 1070 patients were included in the analysis. On multivariable analysis, the only significant predictor of the development of complications was the route of injection of bulking agents (odds ratio 3·40, 95 per cent confidence interval 1·62 to 7·12; P = 0·001). Two variables were significant predictors of a successful short-term outcome: the use of either PTQ(®) (OR 5·93, 2·21 to 16·12; P = 0·001) or Coaptite(®) (OR 10·74, 1·73 to 65·31; P = 0·001) was associated with a greater likelihood of success. Conversely, the use of local anaesthetic was associated with a lower likelihood of success (OR 0·18, 0·05 to 0·59; P = 0·005). Failure to use laxatives in the postoperative period resulted in a poorer medium- to longer-term outcome (OR 0·13, 0·06 to 0·25; P = 0·001).

CONCLUSION

This systematic review has identified variations in the practice of injection of bulking agents that appear to influence the likelihood of complications and affect the outcomes after treatment.

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.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH STRATEGY

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 26 November 2009), the Cochrane Colorectal Cancer Group Specialised Register (searched 26 November 2009), CENTRAL (The Cochrane Library 2009) and EMBASE (1 January 1998 to 30 June 2009) were undertaken. The British Journal of Surgery (1 January 1995 to 30 June 2009) Colorectal Diseases (1 January 2000 to 30 June 2009) and the Diseases of the Colon and Rectum (1 January 1995 to 30 June 2009) were specifically handsearched. The proceedings of the UK Association of Coloproctology meeting held from 1999 to 2009 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Thirteen trials were included with a total sample size of 440 participants. Two trials included a group managed non-surgically. One trial compared levator with anal plug electrostimulation and one compared artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but numbers were small. The other trial showed no difference in primary outcome measures.Eleven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, injection of silicone, hydrogel, physiological saline, carbon beads or collagen bulking agents, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are also considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

AUTHORS' CONCLUSIONS

Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Perianal injectable bulking agents as treatment for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a complex and distressing condition with significant medical and social implications. Injection of perianal bulking agents has been used to treat the symptoms of passive faecal incontinence. However, various different agents have been used without a standardised technique and the supposed benefit of the treatment is largely pragmatic with a limited clinical research base.

OBJECTIVES

To determine the effectiveness of perianal injection of bulking agents for the treatment of faecal incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 10 June 2009), ZETOC (searched 18 July 2009), clinical trials registries (searched 18 July 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing use of injectable bulking agents for faecal incontinence with any alternative treatments or placebo were reviewed to evaluate the therapeutic effects. Case-control and cohort studies were also reviewed to assess risks and complications associated with the treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the methodological quality of eligible trials and independently extracted data from included trials using a range of pre-specified outcome measures.

MAIN RESULTS

Four eligible randomised trials were identified with a total of 176 patients. All trials but one were at an uncertain or high risk of bias. Most trials reported a short term benefit from injections regardless of the material used as outcome measures improved over time. A silicone biomaterial (PTQ), was shown to provide some advantages and was safer in treating faecal incontinence than carbon-coated beads (Durasphere(R)) in the short term. Similarly, there were short term benefits from injections delivered under ultrasound guidance compared with digital guidance. However, PTQ did not demonstrate obvious clinical benefit compared to control injection of normal saline. No long term evidence on outcomes was available and further conclusions were not warranted from the available data.

AUTHORS' CONCLUSIONS

A definitive conclusion cannot be drawn regarding the effectiveness of perianal injection of bulking agents for faecal incontinence due to the limited number of identified trials together with methodological weaknesses. Within the available data, however, we found no reliable evidence for effectiveness of one treatment over another in improving faecal incontinence. Larger well-designed trials with adequate numbers of subjects using reliable validated outcome measures are needed to allow definitive assessment of the treatment for both effectiveness and safety.

MR evaluation of PDMS injections in head and neck tissues: a pilot study

OBJECTIVES

To describe the magnetic resonance (MR) appearance of polydimethylsiloxane (PDMS) injections in the head and neck region.

STUDY DESIGN

Retrospective review of MR images from a case series.

METHODS

MR images of 10 patients, who underwent PDMS injections at our department, were reviewed. Data from imaging were collected and analyzed.

RESULTS

After injection, PDMS can be identified in MR images, particularly in T2-weighted images in the early stages. Its MR characteristics are similar to silicone in other regions, but with time, its appearance can change.

CONCLUSIONS

The integration of PDMS with tissues may also be reflected in changes in MR appearance, as a result of an increased amount of fibrous tissue in the region injected. Radiologists and ENT specialists may benefit from knowledge of the MR characteristics and variability in appearance of PDMS in human tissues for improving image interpretation.

Systematic review on the efficacy and safety of injectable bulking agents for passive faecal incontinence

OBJECTIVE

The aim of this study was to systematically review all published evidence to determine the efficacy and safety of injectable bulking agents for passive faecal incontinence (FI) in adults.

METHOD

Electronic searches were performed for MEDLINE, EMBASE, ISI Web of Knowledge and other relevant databases. Hand searching of relevant conference proceedings was undertaken. Studies were considered if they met the predefined inclusion criteria of more than ten adult patients and receiving an injectable bulking agent for passive FI with a validated means of assessing preoperative and postoperative incontinence.

RESULTS

Thirteen case series studies and one randomized placebo-controlled trial (RCT) were included with a total of 420 patients. Two completed RCTs with placebo control were identified but results were unobtainable. Coaptite, Contigen, Durasphere, EVOH and PTQ injections were assessed with 24, 73, 83, 21 and 208 patients respectively. Most studies reported a statistically significant improvement in incontinence scores and quality of life. No statistically significant difference was found between the treatment and placebo arms in the RCT. No serious adverse events were reported.

CONCLUSIONS

Currently there is little evidence for the effectiveness of injectable bulking agents in managing passive FI. The inability to obtain results from two further RCTs concerned the reviewers and hindered their ability to make strong recommendations. The identified injectable bulking agents appear to be safe with only minor complications reported.

Anal submucosal carbon bead injection for treatment of idiopathic fecal incontinence: a preliminary report

PURPOSE

Submucosal injection of bulking agents is a treatment option for idiopathic fecal incontinence. This study sought to assess whether the injection of carbon beads can significantly improve anal continence.

METHODS

Consecutive patients presenting with fecal incontinence were evaluated with standardized incontinence grading and quality-of-life grading scores, by anoproctoscopy, endoanal ultrasound, and anomanometry before, 3, 6, 12, and 24 months after injection. Injection therapy was performed in patients with anatomically intact anal sphincters. Patients kept a two-week incontinence diary. Data were obtained from a two-year follow-up period.

RESULTS

Eleven women with a mean age of 66 (range, 56 to 74) years met the inclusion criteria. Mean incontinence score was 12.27 +/- 0.97 at baseline, 6.82+/-1.64 at three-month, 6.73 +/- 1.47 at six-month, 5.91 +/- 0.95 at one-year, and 4.91 +/- 0.87 at two-year follow-up (P = 0.003). Quality-of-life items like coping and embarrassment improved significantly from baseline 2.3 to 3 at three months and 2.8 at six months (P < 0.05). Anomanometry showed a trend toward increase in measured pressures. No major complications occurred.

CONCLUSIONS

The injection of carbon beads via an intersphincteric approach is a promising new treatment option for old patients with idiopathic fecal incontinence.

Intersphincteric injected silicone biomaterial implants: a treatment for faecal incontinence

INTRODUCTION

The aim of this study was to evaluate the functional efficacy of intersphincteric injected silicone biomaterial (PTQ) in patients with faecal incontinence.

METHOD

Prospective study of 33 consecutively included patients (male-female ratio: 9:24); median age 53 years (range: 21-75 years) with faecal incontinence of varied aetiology. The PTQ was injected under general anaesthesia with antibiotic cover. All patients had anorectal manometry, endoanal ultrasonography and responded to faecal incontinence severity questionnaire (Wexner score) and SF-36 short-form health survey questionnaire before and 3 months postoperatively. At time of final follow-up, the continence status and quality of life questionnaire were reassessed.

RESULTS

The mean follow-up was 12.9 months (range: 3-22 months). The Wexner Continence Score was significantly reduced short term from 12.7 to 11.0 (P = 0.03) and long term to 10.4 (P = 0.02). The long-term effect on liquid stool incontinence continued to improve significantly (P < 0.01). Six patients (18%) reported major improvement in Wexner Continence Score at the time of final follow-up. Anorectal manometry was not affected except for the maximum tolerable rectal volume, which was significantly reduced (P < 0.05). The SF-36 short-form questionnaire showed no significant improvement in quality of life after treatment with PTQ.

CONCLUSIONS

Treatment with intersphincteric injection of PTQ implants can provide an improvement in anal continence in patients with faecal incontinence of varied aetiology. However, the improvement is mainly limited to soiling and minor leakage. A majority of patients still have severe incontinence, both short- and long-term.

[Anal incontinence]

Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.