Injectable silicone biomaterial for faecal incontinence due to internal anal sphincter dysfunction

Effects of bacterial cellulose gel on the anorectal resting pressures in rats submitted to anal sphincter injury

The aim of this study is to evaluate if a gel of bacterial cellulose gel can revert the loss of anal resting pressure after anorectum sphincter injury in rat model, elected as a model to simulate fecal incontinence. Thirty-nine animals were equally divided into three groups: Control (CG), Sphincter injury plus Saline injection (SG) and Sphincter injury plus Bacterial Cellulose Gel injection (BCG). Anal pressure at rest was assessed for all animal in the three groups using anorectum manometry. Saline and Gel groups were subject to anorectum sphincter injury to reduce the anal pressure at rest. Fifteen days later Saline or Gel was injected into the anorectum, according to their groups. Sixty days later first manometry, the anorectum of all animals were removed and processed histologically. The CG group showed maintenance of their mean anorectal resting pressure levels; SG presented a fall in their mean anorectal resting pressure. The BCG presented a significant elevation of the mean anorectal resting pressure levels, surpassing the pressure of CG. The gel of bacterial cellulose remained at the injection site and was neovascularized, colonized by fibroblasts and dense conjunctive tissue. Those data suggest that BC can be used as a future filling agent treatment for fecal incontinence in clinical trial protocols.

Ultrasonographic evidence of Gatekeeper™ prosthesis migration in patients treated for faecal incontinence: a case series

BACKGROUND

Faecal incontinence (FI) is both a medical and social problem, with an underestimated incidence. For patients with internal anal sphincter damage, implantation of biomaterial in the anal canal is a recognised treatment option. One such material, Gatekeeper™, has previously shown promising short- and medium-term results without any major complications, including displacement. The main aim of the present study is to assess the degree to which displacement of Gatekeeper prostheses may occur and to determine whether this is associated with patient outcomes.

METHODS

Seven patients (six females) with a mean age of 55.6 years [50.5-57.2] and a mean FI duration of 6 ± 2 years were prospectively enrolled in the study. Each subject was anaesthetised and underwent implantation of six prostheses in the intersphincteric region, guided by endoanal 3D ultrasound (3D-EAU). Follow-up was performed at post-interventional months 1, 3, and 12 (median 12 ± 4 months), during which data were obtained from a defaecation diary, Wexner scale assessment, anorectal manometry (ARM), 3D-EAU, and a health status and quality of life questionnaire (FIQL).

RESULTS

At 3-month follow-up, 3D-EAU revealed displacement of 24/42 prostheses in 5/7 patients. Of these, 15 had migrated to the lower portion and 9 to the upper portion of the anal canal and rectum. Despite this migration, treatment was considered successful in 3/7 patients. In one patient, it was necessary to remove a prosthesis due to spontaneous extrusion.

CONCLUSIONS

We have shown that displacement of the Gatekeeper™ prosthesis occurs, but is not associated with poorer clinical outcomes.

Anal Sphincter Augmentation Using Biological Material

Introduction

The aim of this review is to provide an overview of the use of biological materials in the augmentation of the anal sphincter either as part of an overlapping sphincter repair (OSR) or anal bulking procedure.

Methods

A systematic search of PubMed was conducted using the search terms “anal bulking agents,” “anal sphincter repair,” or “overlapping sphincter repair.” Five studies using biological material as part of an overlapping sphincter repair (OSR) or as an anal bulking agent were identified.

Results

122 patients underwent anal bulking with a biological material. Anorectal physiology was conducted in 27 patients and demonstrated deterioration in maximum resting pressure, and no significant change in maximum squeeze increment. Quality of life scores (QoLs) demonstrated improvements at 6 weeks and 6 months, but this had deteriorated at 12 months of follow up. Biological material was used in 23 patients to carry out an anal encirclement procedure. Improvements in QoLs were observed in patients undergoing OSR as well as anal encirclement using biological material. Incontinence episodes decreased to an average of one per week from 8 to 10 preoperatively.

Conclusion

Sphincter encirclement with biological material has demonstrated improvements in continence and QoLs in the short term compared to traditional repair alone. Long-term studies are necessary to determine if this effect is sustained. As an anal bulking agent the benefits are short-term.

A general strategy for creating self-defending surfaces for controlled drug production for long periods of time

Infections associated with bacterial adhesion and subsequent biofilm formation constitute a grave medical issue for which conventional antibiotic therapies remain ineffective. Here, we introduce a new strategy employing nanotechnology to create smart surfaces with self-defending properties that result in controlled drug production and controlled release for long periods of time. Self-defending surfaces on solid supports are prepared by immobilizing polymer nanoreactors containing an encapsulated biocatalyst that can convert non-antibiotic substrates to an abiotic drug. For medical applications and biosensing, the immobilization method must fulfill specific criteria, and these were achieved by an immobilization strategy based on Schiff base formation between aldehyde groups on the outer surface of nanoreactors and amino groups on the solid support surface, followed by reductive amination. The resulting self-defending surfaces allow control of drug production at a specific rate for a specific period of time by adding predetermined amounts of substrate to the outer medium, minimization of dosages and therefore systemic toxicity, and limitation of the immune response. Such self-defending surfaces producing drugs offer a versatile strategy for the development of smart surfaces with improved stability and efficacy (by changing the biocatalyst) to serve as biosensors, antifouling surfaces, or smart packages.

Functional outcome after anal sphincter injury and treatment with mesenchymal stem cells

This research demonstrates the regenerative effects of mesenchymal stem cells (MSCs) on the injured anal sphincter by comparing anal sphincter pressures following intramuscular and serial intravascular MSC infusion in a rat model of anal sphincter injury. Fifty rats were divided into injury (n = 35) and no injury (NI; n = 15) groups. Each group was further divided into i.m., serial i.v., or no-treatment (n = 5) groups and followed for 5 weeks. The injury consisted of an excision of 25% of the anal sphincter complex. Twenty-four hours after injury, 5 × 10(5) green fluorescent protein-labeled MSCs in 0.2 ml of phosphate-buffered saline (PBS) or PBS alone (sham) were injected into the anal sphincter for i.m. treatment; i.v. and sham i.v. treatments were delivered daily for 6 consecutive days via the tail vein. Anal pressures were recorded before injury and 10 days and 5 weeks after treatment. Ten days after i.m. MSC treatment, resting and peak pressures were significantly increased compared with those in sham i.m. treatment (p < .001). When compared with the NI group, the injury groups had anal pressures that were not significantly different 5 weeks after i.m./i.v. treatment. Both resting and peak pressures were also significantly increased after i.m./i.v. MSC treatment compared with treatment with PBS (p < .001), suggesting recovery. Statistical analysis was done using paired t test with Bonferroni correction. Marked decrease in fibrosis and scar tissue was seen in both MSC-treated groups. Both i.m. and i.v. MSC treatment after injury caused an increase in anal pressures sustained at 5 weeks, although fewer cells were injected i.m. The MSC-treated groups showed less scarring than the PBS-treated groups, with the i.v. infusion group showing the least scarring.

Internal anal sphincter augmentation and substitution

There is an increasing recognition of the importance of internal anal sphincter (IAS) dysfunction presenting as passive faecal incontinence. This problem may manifest after anal sphincterotomy or following the more minimally invasive operations for haemorrhoids, as well as with advancing age. Because of the poor results of IAS plication and the beneficial outcomes with peri-urethral bulking agents in urology, these materials have been developed for use in IAS dysfunction. This review outlines the basic purported mechanisms of action, defining the materials in clinical use, their methods of deployment, complications and reported outcomes. There is still much that is unknown concerning the ideal agent or the volume and the technique of deployment, which will only be answered by powerful, prospective, randomized, controlled trials. The specific role of autologous stem cells designed to regenerate the sphincters in cases of functional impairment or muscle loss is yet to be seen.

Mesenchymal stem cells can improve anal pressures after anal sphincter injury

OBJECTIVE

Fecal incontinence reduces the quality of life of many women but has no long-term cure. Research on mesenchymal stem cell (MSC)-based therapies has shown promising results. The primary aim of this study was to evaluate functional recovery after treatment with MSCs in two animal models of anal sphincter injury.

METHODS

Seventy virgin female rats received a sphincterotomy (SP) to model episiotomy, a pudendal nerve crush (PNC) to model the nerve injuries of childbirth, a sham SP, or a sham PNC. Anal sphincter pressures and electromyography (EMG) were recorded after injury but before treatment and 10 days after injury. Twenty-four hours after injury, each animal received either 0.2 ml saline or 2 million MSCs labelled with green fluorescing protein (GFP) suspended in 0.2 ml saline, either intravenously (IV) into the tail vein or intramuscularly (IM) into the anal sphincter.

RESULTS

MSCs delivered IV after SP resulted in a significant increase in resting anal sphincter pressure and peak pressure, as well as anal sphincter EMG amplitude and frequency 10 days after injury. MSCs delivered IM after SP resulted in a significant increase in resting anal sphincter pressure and anal sphincter EMG frequency but not amplitude. There was no improvement in anal sphincter pressure or EMG with in animals receiving MSCs after PNC. GFP-labelled cells were not found near the external anal sphincter in MSC-treated animals after SP.

CONCLUSION

MSC treatment resulted in significant improvement in anal pressures after SP but not after PNC, suggesting that MSCs could be utilized to facilitate recovery after anal sphincter injury.

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.

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.

Quality of life and functional results of submucosal injection therapy using dextranomer hyaluronic acid for fecal incontinence

BACKGROUND AND AIM

The aim of this prospective study was to analyze safety and functional outcome of transanal submucosal injection of dextranomer hyaluronic acid ("bulking agents therapy") in patients with passive fecal incontinence.

METHODS

All patients who underwent transanal injection therapy were prospectively enrolled in this study. Inclusion criteria included fecal incontinence (internal anal sphincter dysfunction) after failed conservative treatment. The procedure was performed in a standardized technique, including submucosal injection of 4 × 1 mL dextranomer hyaluronic acid 5 mm above the dentate line. The primary endpoint focused on symptom improvement provided as the change in incontinence status and quality of life using validated scores (Wexner incontinence score, symptom-specific Fecal Incontinence Quality of Life [FIQoL] scale, and generic EQ-5D-Visual Analogue Scale [EQ-5D-VAS]).

RESULTS

Within the observation period (July 2007 to May 2009), a total of 21 patients (17 women) with passive fecal incontinence were treated. Neither morbidity nor adverse events were documented. Three months postoperatively, 61.1% (11/18) showed significant improvement of symptoms (reduction of incontinence episodes and soiling), which was sustained after 20 months in 55.6% (10/18). Wexner incontinence score decreased from 16.8 to 12.3 (P > .05). Significant improvement was documented for FIQoL and EQ-5D-VAS (P < .05).

CONCLUSION

The current results indicate that injection therapy using hyaluronic acid is an innovative and minimally invasive procedure with no morbidity. Although Wexner incontinence score is not significantly influenced, a significant improvement in quality of life was observed in more than 50% of patients.

An Open-Label, Noncomparative, Multicenter Study to Evaluate Efficacy and Safety of NASHA/Dx Gel as a Bulking Agent for the Treatment of Fecal Incontinence

Fecal incontinence (FI) is the involuntary loss of rectal contents through the anal canal. Reports of its prevalence vary from 1–21%. Studies, have demonstrated a positive effect on FI symptoms with injectable bulking agents. This study evaluated the safety and efficacy of NASHA/Dx gel in the treatment of FI. One hundred fifteen eligible patients suffering from FI received 4 injections of 1 mL NASHA/Dx gel. Primary efficacy was based on data from 86 patients that completed the study. This study demonstrated a ≥50% reduction from baseline in the number of FI episodes in 57.1% of patients at 6 months, and 64.0% at 12 months. Significant improvements (P < .001) were also noted in total number of both solid and loose FI episodes, FI free days, CCFIS, and FIQL scores in all 4 domains. The majority of the treatment related AEs (94.9%) were mild or moderate intensity, and (98.7%) of AEs resolved spontaneously, or following treatment, without sequelae. Results of this study indicate NASHA/Dx gel was efficacious in the treatment of FI. Treatment effect was significant both in reduction of number of FI episodes and disease specific quality of life at 6 months and lasted up to 12 months after treatment.

Anal incontinence improvement after silicone injection may be related to restoration of sphincter asymmetry

BACKGROUND

This study aimed to evaluate manometric parameters that may explain improvement in anal incontinence using a silicone bulking agent.

METHODS

Incontinent patients having internal sphincter defects were prospectively selected and injected with a silicone bulking agent. Manometry and endoanal ultrasound were performed before and 3 months after injections. Twenty continent healthy volunteers were used only for manometric comparison.

RESULTS

Thirty-five patients (28 females; mean age 60.3 years) and 20 controls entered this study. Patients had lower resting and squeeze pressures compared with controls (P < .05). Length of the high-pressure zone increased from 1 to 1.7 cm postinjection (P = .002). Asymmetry index showed a significant change postinjection (P < .001).

CONCLUSION

Despite considerable clinical improvement, no significant increase in manometric pressures was noted posttreatment. There was significant improvement in both high-pressure zone and asymmetry index, and these findings may explain the mechanism of action of the bulking agent injected.

Pharmacology of the internal anal sphincter and its relevance to faecal incontinence

1 The internal anal sphincter (IAS) has a spontaneous tone and is the main contributor to the maintenance of faecal continence. The spontaneous resting tone exhibited by the sphincter can be modified by neurotransmitters from the autonomic and enteric nervous systems. 2 In this review, the influence of the sympathetic and parasympathetic nervous systems on IAS tone are discussed and the putative roles of nitric oxide, carbon monoxide, vasoactive intestinal peptide and adenosine triphosphate in non-adrenergic non-cholinergic transmission are considered. 3 Faecal incontinence is a common condition that places a heavy financial burden on the health service and severely affects patients' quality of life. Resting anal pressure is reduced in patients with faecal incontinence and agents that increase sphincter tone tend to relieve symptoms. The results of clinical studies of the use of phenylephrine to treat faecal incontinence are reviewed. 4 It is concluded that the IAS is a potential target for drug development for the treatment of faecal incontinence.

Ten-year outcome after anal sphincter repair for fecal incontinence

PURPOSE

This study aimed to report at ten years on the results of the same cohort that had been studied at five years who had undergone an anal sphincter repair for fecal incontinence.

METHODS

Patients studied at five years were contacted after ten years and asked to fill out the Fecal Incontinence Quality of Life Scale, the Fecal Incontinence Severity Index, and the Bristol Stool Form Scale.

RESULTS

Thirty-one of 44 (71 percent) patients were contacted. Median follow-up time was 129 (range, 113 to 208) months. Median age at surgery was 44 (range, 22 to 80) years. No patients were fully continent at 129 months. Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores were correlated with the age at surgery. Older patients had lower Fecal Incontinence Quality of Life scores (P = 0.001), reflecting a lower quality of life, and a higher patient-rated Fecal Incontinence Severity Index score (P = 0.01) and a higher surgeon-rated Fecal Incontinence Severity Index score (P = 0.005), denoting more severe fecal incontinence. The Bristol Stool Form Scale, not utilized at 77 months, showed a correlation to patient-rated Fecal Incontinence Severity Index (P = 0.04) and surgeon-rated Fecal Incontinence Severity Index (P = 0.02). Fecal Incontinence Severity Index scores were significantly higher in women who had more than two vaginal births.

CONCLUSION

Continence after overlapping sphincter repair deteriorates in the long term. Long-term outcome was worse for patients who were older at the time of surgery or those with two or more vaginal births. The Bristol Stool Form Scale score correlates with the severity of incontinence, and may be used to guide the management of the patient's symptoms.

[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.

Carbon-coated microbeads anal injection in outpatient treatment of minor fecal incontinence

PURPOSE

Anal bulking agents are injected to pose a stronger obstacle to the involuntary passage of feces and gas. This prospective, multicenter study was designed to evaluate the safety and efficacy of Durasphere anal injection for the treatment of fecal incontinence.

PATIENTS AND METHODS

Thirty-three unselected patients with incontinence (24 females; mean age, 61.5 +/- 14 (range, 22-83) years) underwent anal bulking agent submucosal injection with carbon-coated microbeads (Durasphere) in the outpatient regimen. The causes of incontinence were obstetric lesions in 18.2 percent, iatrogenic in 36.4 percent, rectal surgery in 12.1 percent, and idiopathic in 33.3 percent. Previous unsuccessful treatments for fecal incontinence included diet and drugs in 16 patients, biofeedback training in 7 patients, sacral nerve modulation in 6 patients, sphincteroplasty in 2 patients, artificial bowel sphincter in 1 patient, and PTQ macroplastique bulking agent in 1 patient. Under local anesthesia and antibiotic prophylaxis, a mean of 8.8 (range, 2-19) ml of Durasphere were injected into the submucosa by using a 1.5-inch, angled, 18-gauge needle.

RESULTS

After a median follow-up of 20.8 (range, 10-22) months, the median Cleveland Clinic continence score decreased significantly from 12 to 8 (P < 0.001) and the median American Medical System score from 89 to 73 (P = 0.0074), but the Fecal Incontinence Quality of Life did not change significantly (74 to 76, P = not significant). Anal manometry significantly improved (resting pressure increasing from 34 to 42 mmHg; P = 0.008) and squeezing pressure from 66 to 79 mmHg (P = 0.04). Two patients complained of moderate anal pain for a few days after the implant, one patient had asymptomatic leakage of the injected material through a mucosa perforation, and two had distal migration of the Durasphere along the dentate line.

CONCLUSIONS

Anal bulking agent injection is a safe treatment and can mitigate the severity of fecal incontinence by increasing anal pressure but does not significantly improve the quality of life.

New options for the treatment of fecal incontinence

Fecal incontinence, the loss of anal sphincter control leading to the unwanted release of stool or gas, is a physical and psychological handicap that has a tremendous impact on an individual's quality of life. Although medical management is the mainstay of therapy for fecal incontinence, the main focus in this review is on invasive techniques with a goal of highlighting newer technologic and therapeutic advancements. While the standard surgical treatment for fecal incontinence still remains direct sphincter repair with an overlapping sphincteroplasty, this review concentrates specifically on biofeedback, the Procon incontinence device, local injection of synthetic materials, radio frequency energy (Secca procedure), antegrade colonic enemas, sphincteroplasty, gluteoplasty, graciloplasty both stimulated and non-stimulated, the artificial bowel sphincter, and sacral nerve stimulation.

Sphincter contractility after muscle-derived stem cells autograft into the cryoinjured anal sphincters of rats

PURPOSE

This study was designed to determine whether the injection of muscle-derived stem cells into the anal sphincter can improve functional properties in a fecal incontinence rat model.

METHODS

Cryoinjured rats were utilized as a fecal incontinence model. The gastrocnemius muscles of normal three-week-old female Sprague-Dawley rats were used for the purification of the muscle-derived stem cells. The experimental group was divided into three subgroups: normal control; cryoinjured; and muscle-derived stem cells (3 x 10(6) cells) injection group of cryoinjured rats. All groups were subsequently employed in contractility experiments using muscle strips from the anal sphincter, one week after preparation.

RESULTS

Contractility in the cryoinjured group was significantly lower than in the control after treatment with acetylcholine and KCl. In the muscle-derived stem cells injection group, contraction amplitude was higher than in the cryoinjured group but not significantly (20.5 +/- 21.3 vs. 17.3 +/- 3.4 g per gram tissue, with acetylcholine (10(-4) mol/l); 31 +/- 14.2 vs. 18.4 +/- 7.9 g per gram tissue, with KCl (10(-4) mol/l)). PKH-26-labeled transplanted cells were detected in all of the grafted sphincters. Differentiated muscle masses stained positively for alpha smooth muscle actin and myosin heavy chain at the muscle-derived stem cells injection sites.

CONCLUSIONS

This is the first study reporting that autologous muscle-derived stem cell grafts may be a tool for improving anal sphincter function.

Evolving therapy for fecal incontinence

BACKGROUND

Fecal incontinence is common and can be socially debilitating. Nonoperative management of fecal incontinence includes dietary modification, antidiarrheal medication, and biofeedback. The traditional surgical approach is sphincteroplasty if there is a defect of the external sphincter. Innovative treatment modalities have included sacral nerve stimulation, injectable implants, dynamic graciloplasty, and artificial bowel sphincter.

DISCUSSION

This review was designed to assess the various surgical options available for fecal incontinence and critically evaluate the evidence behind these procedures. The algorithm in the surgical treatment of fecal incontinence is shifting. Injectable therapy and sacral nerve stimulation are likely to be the mainstay in future treatment of moderate and severe fecal incontinence, respectively. Sphincteroplasty is limited to a small group of patients with isolated defect of the external sphincter. A stoma, although effective, can be avoided in most cases.

Long-term results of perianal silicone injection for faecal incontinence

OBJECTIVE

Perianal injection of bulking agents is a simple method for treating passive faecal incontinence. To date only short-term results of treatment are available. This study is the first to determine the efficacy of silicone biomaterial (PTQ; Uroplasty BV, Geleen, The Netherlands) injection in the long term.

METHOD

Six patients, median age 53 years at the time of injection with PTQ, were followed up at 61 months. A validated faecal incontinence score, treatment-specific questionnaire and SF-36 health survey questionnaire were completed.

RESULTS

At 61-month follow up one patient had undergone a colostomy for faecal incontinence. In the remaining five patients the incontinence score was little changed: 11 (8-20) vs 13 (9-19) [pre v at 61 months, median (range)]. However, there was a substantial improvement in physical and social function on the SF-36 scores. Satisfaction scores were high at a median 7 of 10 (range: 0-8). Subjectively, three patients were improved; one of these had undergone a further set of injections and one improved after a course of biofeedback. After the follow-up period one of the five patients had a colostomy for recto-vaginal fistula.

CONCLUSION

The results of perianal injection of PTQ for passive faecal incontinence are variable in the long term. More extensive evaluation in the short term, and possibly repeated treatment, may be required.

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

AIM

To test efficacy and safety of polydimethylsiloxane elastomer implants, a silicone biomaterial, in patients with severe faecal incontinence related to an impaired internal anal sphincter.

METHODS

Subjects were randomized to receive three injections of 2.5 mL of either physiological saline or polydimethylsiloxane elastomer. After local anaesthesia, an 18 gauge, 2.5-in needle was inserted through the perianal skin and laid down into the intersphincteric space. Treatment (saline or polydimethylsiloxane elastomer) was administered by means of a ratchet gun. Three injections of 2.5 mL each were performed in the area of the internal anal sphincter at 3, 7 and 11 o'clock positions. Main end point was the percentage of subjects in each treatment arm experiencing a successful treatment, defined as a Cleveland Clinic Florida-Faecal Incontinence score <8, 3 months after treatment. Secondary end points were quality of life scores, weekly number of faecal incontinence episodes, subject acceptance and adverse events rate. Both patients and end point assessments were blinded to treatment.

RESULTS

44 women (64.3 +/- 9 years) with a baseline Cleveland Clinic Florida-Faecal Incontinence score > or =8 were enrolled prospectively; 22 received polydimethylsiloxane elastomer and 22 saline treatment. Treatment was well tolerated. At 3 months, the percentage of subjects experiencing a successful treatment was not different between polydimethylsiloxane elastomer and saline groups (23% vs. 27%, respectively, P = 0.73). Moreover, Cleveland Clinic Florida-Faecal Incontinence score was not significantly different between polydimethylsiloxane elastomer and saline groups (11.7 +/- 4.7 vs. 11.4 +/- 4.5, respectively, P = 0.79).

CONCLUSIONS

Polydimethylsiloxane elastomer implants cannot be recommended for treatment of severe faecal incontinence related to impaired internal anal sphincter.

Pharmacotherapy for fecal incontinence: a review

Fecal incontinence is a common clinical problem that often is frustrating to the patient and treating physician. Nonsurgical management for fecal incontinence includes dietary manipulation, Kegel exercises, perianal skin care, and biofeedback therapy. Pharmacotherapies often are used to assist in management of fecal incontinence. A variety of pharmacotherapies have been utilized for the management of fecal incontinence; limited data from randomized, placebo-controlled trials are available. This is a review of the existing literature on clinical trials of several classes of drugs and other medical therapies that may be beneficial for patients with fecal incontinence. The information in this article was obtained by a MEDLINE search for all clinical trials of drug therapy for fecal incontinence. These treatments and the existing data on their use are summarized. Treatments reviewed include stool bulking agents, with an emphasis on the most promising effect obtained with calcium polycarbophil, constipating agents, including loperamide, codeine, amitriptyline, atropine, and diphenoxylate agents injected into the anal sphincter, drugs to enhance anal sphincter function, including topical phenylepherine and oral sodium valproate, and trials of fecal disimpaction. A new classification to easily remember the treatment categories for this condition, based on the "ABCs of treatment for fecal incontinence," has been introduced into the structure of this review.

External anal sphincter defects in patients with fecal incontinence: comparison of endoanal MR imaging and endoanal US

PURPOSE

To prospectively compare in a multicenter study the agreement between endoanal magnetic resonance (MR) imaging and endoanal ultrasonography (US) in depicting external anal sphincter (EAS) defects in patients with fecal incontinence.

MATERIALS AND METHODS

The study was approved by the medical ethics committee of all participating centers. A total of 237 consenting patients (214 women, 23 men; mean age, 58.6 years +/- 13 [standard deviation]) with fecal incontinence were examined from 13 different hospitals by using endoanal MR imaging and endoanal US. Patients with an anterior EAS defect depicted on endoanal MR images and/or endoanal US scans underwent anal sphincter repair. Surgical findings were used as the reference standard in the determination of anterior EAS defects. The Cohen kappa statistic and McNemar test were used to calculate agreement and differences between diagnostic techniques.

RESULTS

Agreement between endoanal MR imaging and endoanal US was fair for the depiction of sphincter defects (kappa = 0.24 [95% confidence interval: 0.12, 0.36]). At surgery, EAS defects were found in 31 (86%) of 36 patients. There was no significant difference between MR imaging and US in the depiction of sphincter defects (P = .23). Sensitivity and positive predictive value were 81% and 89%, respectively, for endoanal MR imaging and 90% and 85%, respectively, for endoanal US.

CONCLUSION

In the selection of patients for anal sphincter repair, both endoanal MR imaging and endoanal US are sensitive tools for preoperative assessment, and both techniques can be used to depict surgically repairable anterior EAS defects.

Intra-anal collagen injection for the treatment of faecal incontinence

Background

Intra-anal injectable agents have been used to treat faecal incontinence. The aim of this study was to report the experience of a cohort of patients who underwent intra-anal injection of collagen and to determine which patients benefited from the technique.

Methods

Data, including age, sex, incontinence score, classification of incontinence, baseline resting pressure and vector volume, were collected prospectively for 73 consecutive patients (59 women) undergoing intra-anal collagen injection. Patients were reviewed after treatment and incontinence scores documented. A proportion of patients also underwent repeat anorectal physiological testing 8 weeks after the procedure.

Results

At a median follow-up of 12 months after the intra-anal injection, 63 per cent of patients had an improved incontinence score and 73 per cent reported an overall improvement in symptoms. Logistic regression showed that older age and idiopathic faecal incontinence were predictors of a successful outcome (P = 0·042 and P = 0·048 respectively).

Conclusion

Intra-anal collagen injection appears to have a role in the treatment of faecal incontinence. The majority of patients can expect both objective and subjective improvement. The best results are achieved in older patients and in those with idiopathic incontinence.

Novel approaches in the treatment of fecal incontinence

The availability of novel techniques to treat end-stage FI gives hope for a better quality of life in patients who were traditionally treated by a permanent stoma. The diversity of causes of FI and the different modes of action of the various treatment modalities mandate a tailored, individualized approach in each case. A meticulous preoperative evaluation process is imperative in the course of the decision-making of which procedure to perform, with full awareness that a stoma still may be the best option for some patients who have end-stage FI.

Sacral nerve neuromodulation and fecal incontinence: Indications, technique, and results

This article reviews the use of sacral neuromodulation (SNM) for fecal incontinence. Six case series and one crossover study in which sacral neuromodulation had been used for people with fecal incontinence were selected for assessment. Primary outcomes included the number of fecal incontinent episodes per week, ability to defer defecation and quality of life. Following implantation, 41-75% of patients achieved complete fecal continence and 75-94% experienced improvement in incontinent episodes. The ability of patients to be able to defer defecation and fecal incontinence specific quality of life scores had also improved. There were 19 adverse events amongst 149 patients. The small crossover study reported increased episodes of fecal incontinence when the implantable pulse generator (IPG) was switched off. The evidence suggests that SNM achieves a significant improvement in patients with fecal incontinece resistant to conservative treatment. Follow-up indicates that improvements are maintained over the medium term.

Investigation and treatment of faecal incontinence

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Injectable silicone biomaterial (PTQ) to treat fecal incontinence after hemorrhoidectomy

PURPOSE

Passive fecal incontinence after hemorrhoidectomy may occur and is socially incapacitating. There has been no effective treatment for passive fecal incontinence caused by internal anal sphincter dysfunction. This case series reviewed the outcome of therapy with injectable silicone biomaterial (PTQ) in patients who had passive fecal incontinence after hemorrhoidectomy.

METHODS

From 2003 to 2004, seven patients referred with passive fecal incontinence after hemorrhoidectomy (Milligan-Morgan hemorrhoidectomy n = 5; stapled hemorrhoidectomy n= 2) were treated with injectable PTQ implants. All were assessed with anorectal physiology testing, Wexner continence score, and objective quality of life questionnaires before and after treatment.

RESULTS

The Wexner continence score improved significantly at three months (P= 0.016) after the injectable PTQ implant and continued to improve significantly for up to 12 months (P = 0.016). The global quality of life scores (Visual Analog Scale) showed similar improvement (P = 0.016 at 3 months; P = 0.016 at 12 months). Three domains (life style, coping behavior, and depression/self-perception) of Fecal Incontinence Quality of Life Scale were significantly improved. The manometric studies showed significant improvement in maximum resting anal canal pressures (P= 0.016) after the injectable PTQ implant.

CONCLUSIONS

The injectable silicone biomaterial is an effective treatment for passive fecal incontinence after hemorrhoidectomy providing good medium-term improvement in fecal incontinence and fecal incontinence-related quality of life.

Técnicas novedosas en el tratamiento de la incontinencia anal

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread.

Long-term outcome of postanal repair in the treatment of faecal incontinence

BACKGROUND

Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence.

OBJECTIVES

The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence.

PATIENTS AND METHODS

Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated.

RESULTS

Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively (P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse.

CONCLUSIONS

Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.

Injectable bulking agents for treating faecal incontinence

BACKGROUND

Reports of the use of injectable bulking agents for faecal incontinence are currently confined to a small number of pilot studies. However, the use of these agents is rapidly becoming widespread based on this limited knowledge.

METHODS

This review provides an overview of the products available and the methods of delivery based on the pilot studies, selected articles reporting experience of these agents in urology, plastic surgery and laryngology, and some animal studies.

RESULTS AND CONCLUSIONS

Although bulking agents have been used to treat urinary incontinence for over four decades, their use in faecal incontinence has so far been limited. The large choice of products now available and the lack of a defined injection strategy will hamper efforts to produce meaningful prospective randomized trials.

Neuromodulation for constipation and fecal incontinence

The evidence is consistent with permanent SNM substantially improving continence in patients with severe fecal incontinence resistant to medical treatment. This treatment has been used in patients in whom a major surgical intervention would normally have been the next stage in treatment and the option of a minimally invasive treatment, with the added advantage of testing before definitive implantation, has the potential to have a major impact on this patient group. The results of the early case series examining the use of SNM for constipation are encouraging. Patients who have failed maximal medical treatment for constipation pose considerable clinical difficulties, with current surgical treatments requiring a bowel resection or stoma formation. If SNM proves to be of benefit to a proportion of these patients, this will be of considerable importance in terms of their future treatment options. Fecal incontinence and idiopathic constipation are both conditions in which conservative treatment is the mainstay of treatment in most cases,but for a small proportion surgical intervention is warranted. The surgical procedures available,however, have a considerable invasive component with often little guarantee of symptom resolution. SNM is becoming more widely used for patients with fecal incontinence as series sizes get larger and follow-up longer. Its potential benefit in constipation has been shown in pilot studies but larger trials are still required.

Combined urinary and faecal incontinence

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9-19% (urinary) and 5-10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.

A review of contemporary surgical alternatives to permanent colostomy

OBJECTIVES

To review the options available to patients with faecal incontinence with failed conservative treatment and/or failed anal sphincter repair and assessing the current indications and results of these options.

METHODS

A literature search of MEDLINE, EMBASE and Cochrane databases was performed using the relevant search terms.

RESULTS

Continent options for patients with severe or end stage faecal incontinence include the creation of a form of an anal neosphincter and more recently sacral nerve stimulation. Over half the patients, who are candidates, may benefit from these procedures, although long term results of sacral nerve stimulation are unknown. Dynamic graciloplasty improves the continence in 44-79% of the patients. The complications include frequent reoperations, high incidence of infection and obstructive defaecation. The success rates of artificial bowel sphincter vary between 24% and 79%. Once functional, the artificial bowel sphincter seems to improve the continence in the majority of the patients. Device removal due to infection, obstructive defaecation and pain is a frequent problem. Sacral nerve stimulation is claimed to result in improvement in continence in 35-100% of patients. The main risks in this procedure are infection, electrode displacement and pain.

CONCLUSIONS

All these procedures have high complication rates and have moderate success rates only. A major proportion of patients will need reoperations and hence high motivation is necessary for patients who undergo these procedures. A uniform standard for measurement of success is also necessary so that these procedures can be compared with each other.

Systematic review of sacral nerve stimulation for faecal incontinence and constipation

BACKGROUND AND METHOD

This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies).

RESULTS

From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off.

CONCLUSION

SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.

Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective

PURPOSE

Fecal incontinence caused by a weak or disrupted internal anal sphincter is common but there has been no effective treatment. This prospective study evaluates the medium-term clinical effects of an injectable silicone biomaterial, PTP (Bioplastique), used to augment the internal anal sphincter.

METHOD

Eighty-two patients (64 females; median age, 66 years) with severe fecal incontinence and a low anal resting pressure caused by internal anal sphincter dysfunction (defect, n = 11; intact, n = 71) were randomized to PTP injection into intersphincteric space and internal anal sphincter with (Group A, n = 42) or without (Group B, n = 40) guidance by endoanal ultrasound. Both groups were similar in terms of age, gender, past anorectal surgery, duration of follow-up (median, 6 months; range, 1-12 months), and baseline continence score. Sixty-two percent of Group A and 55 percent of Group B had prolonged pudendal nerve terminal motor latency.

RESULTS

There was no significant complication. Two patients in Group A and four patients in Group B noted minor discomfort at injection sites. At one month postprocedure, endoanal ultrasound confirmed retention of silicone biomaterial without migration. In both groups, fecal continence was significantly improved by PTP implants 1 month after injection, but continued to improve significantly for up to 12 months in Group A and 6 months in Group B (P < 0.001). Improvement in fecal continence and maximum anal resting pressure was significantly greater in Group A, in whom injection was guided by endoanal ultrasound, than in Group B. At three months after injection, significantly more Group A patients than Group B patients achieved >50 percent improvement in Wexner's continence score (69 percent vs. 40 percent; P = 0.014). Ninety-three percent of Group A and 92 percent of Group B had >50 percent improvement in global quality of life scores (visual analog scale). At a median follow-up of 6 months, all domains of the fecal incontinence quality of life scale improved significantly in both groups; however, the physical function and mental health scores of Short Form-12 only improved in Group A. A prolonged pudendal nerve terminal motor latency had no effect on functional outcome in either group.

CONCLUSION

Injection of silicone biomaterial provided a marked improvement in fecal continence and quality of life in patients with internal sphincter dysfunction, despite the presence of pudendal neuropathy.

Faecal incontinence in adults

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.

Review article: Recent trends in diagnosis and treatment of faecal incontinence

The inability to control bowel discharge is not only common but extremely distressing. It has a negative impact on a patient's lifestyle, leads to a loss of self-esteem, social isolation and a diminished quality of life. Faecal incontinence is often due to multiple pathogenic mechanisms and rarely due to a single factor. Normal continence to stool is maintained by the structural and functional integrity of the anorectal unit. Consequently, disruption of the normal anatomy or physiology of the anorectal unit leads to faecal incontinence. Currently, several diagnostic tests are available that can provide an insight regarding the pathophysiology of faecal incontinence and thereby guide management. The treatment of faecal incontinence includes medical, surgical or behavioural approaches. Today, by using logical approach to management, it is possible to improve symptoms and bowel function in many of these patients.

A review of sacral nerve stimulation for the treatment of faecal incontinence

Sacral nerve stimulation is an emerging surgical technique that uses chronic low-level electrical stimulation, applied to the nerves of the sacral plexus, to produce a clinically beneficial physiological effect on the lower bowel, pelvic floor and anal canal. Faecal incontinence is common, maximal conservative therapy may improve some patients but many require surgery. Results are variable and often unsatisfactory and further options are limited, the traditional end-point being the formation of a colostomy. Sacral nerve stimulation appears to be an alternative treatment that is successful, has low morbidity, is maintained in the medium term and associated with an improved quality of life. The technique has the advantage of a minimally invasive test procedure with high predictive value and the surgery is minor. The underlying mechanism of action although predominately neurological in nature remains to be determined. Precise patient selection is currently unclear however, results are superior to other techniques.