The Colorectal Development Unit: impact on functional outcome for the electrically stimulated gracilis neoanal sphincter

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTINGS

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

PATIENTS

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

MAIN OUTCOME MEASURE

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Percutaneous tibial nerve stimulation for the treatment of urge fecal incontinence

PURPOSE

Percutaneous tibial nerve stimulation has been shown to be an effective treatment in patients with urinary disorders, but its benefit in fecal incontinence is uncertain. This study aimed to assess the efficacy of percutaneous tibial nerve stimulation in the treatment of urge fecal incontinence.

METHODS

This prospective study, conducted over a 14-month period, assessed 31 patients with urge fecal incontinence treated with percutaneous tibial nerve stimulation. The outcomes measured were: 1) reduction in fecal incontinence episodes, 2) improvement in Cleveland Clinic incontinence scores, and 3) improvement in ability to defer defecation. All analysis was performed on an intention-to-treat basis.

RESULTS

The median follow-up was 9 months (range, 3-14). Twenty-one (68%) patients improved following percutaneous tibial nerve stimulation and remain satisfied with the clinical response. Median fecal incontinence episodes per week declined from 4 (range, 0-30) to 0 (range, 0-27) (P < .0001). Median Cleveland Clinic incontinence scores declined from 13 (range, 5-20) to 7 (range, 0-20) (P < .0001). Ability to defer defecation was improved significantly (P < .0001). No morbidity was encountered for any patient.

CONCLUSION

This preliminary study demonstrates that percutaneous tibial nerve stimulation is an effective and very well tolerated treatment for patients with urge fecal incontinence with particular improvement in reducing fecal urgency.

Surgical treatment of patients with constipation and fecal incontinence

Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.