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Martínez Hernández A, Aliaga Hilario E, Coret Franco A, Laguna Sastre JM. Anal sphincter injury by bullfighting trauma. Tech Coloproctol 2023; 28:5. [PMID: 38071670 DOI: 10.1007/s10151-023-02893-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Andreu Martínez Hernández
- Department of General and Visceral Surgery, General University Hospital, Castellón, Spain.
- Professor of General Surgery at Jaume I University, Castellón, Spain.
| | - Elena Aliaga Hilario
- Department of General and Visceral Surgery, General University Hospital, Castellón, Spain
| | - Alba Coret Franco
- Department of General and Visceral Surgery, General University Hospital, Castellón, Spain
- Professor of General Surgery at Jaume I University, Castellón, Spain
| | - José Manuel Laguna Sastre
- Department of General and Visceral Surgery, General University Hospital, Castellón, Spain
- Professor of General Surgery at Jaume I University, Castellón, Spain
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Mongardini FM, Cozzolino G, Karpathiotakis M, Cacciatore C, Docimo L. Short- and long-term outcomes of sphincteroplasty for anal incontinence related to obstetric injury: a systematic review. Updates Surg 2023; 75:1423-1430. [PMID: 37516713 DOI: 10.1007/s13304-023-01609-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
Anal incontinence is a frequent pathological condition with devastating impact on quality of life. The prevalence is approximately 15% of the population, with higher incidence reported in the elderly and multiparous women, and several factors have a major role in its pathogenesis, such as anatomical sphincter defects (Glasgow and Lowry in Dis Colon Rectum 55(4): 482-490, 2012), delivery injuries, and colorectal, uro-gynecological, and perineal surgery. The direct surgical approach is the gold standard treatment for fecal incontinence, especially through anterior sphincteroplasty, although a permanent defect of continence persists over time. The aim of our study is to evaluate, throughout a systematic review of the literature, the short- and long-term outcomes of sphincteroplasty performed for obstetric injuries anal incontinence. A systematic review of the studies published in the literature from January 2000 to December 2021 was performed in accordance with the PRISMA guidelines. Of the 2543 studies extrapolated, only eight fulfilled the inclusion criteria and were admitted represented by retrospective and prospective studies. The data analyzed from the included studies were number and mean age of the female population, and incontinence improvement with preoperative and postoperative short- and long-term outcomes, as reported by QoL questionaries and incontinence scores. Overall 355 patients with obstetric sphincter damage underwent sphincteroplasty with an anterior external sphincter overlapping procedure. A consistent improvement in fecal incontinence at short-term follow-up with relative improvement in QoL was reported. In 7 of 8 studies, the authors found a progressive worsening of the incontinence symptoms on the long-term follow-up. However, it is not clear whether the decrease in long-term continence results is parallel to a simultaneous decrease in QoL scores. Nevertheless, compared to the preoperative findings, the improvement was maintained in the long-term follow-up. Despite the limited data in the literature, a properly performed sphincteroplasty can guarantee a consistent improvement of the continence in short term with encouraging outcomes, especially for solid stool continence, in long time. We believe that anterior sphincteroplasty, as a low cost, feasible, and safe procedure, still has a role in the treatment of fecal incontinence for obstetric injury. Further large cohort randomized clinical trials are necessary to validate these results.
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Affiliation(s)
- Federico Maria Mongardini
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giovanni Cozzolino
- Department of Advanced Medical and Surgical Sciences, University of Campania L. Vanvitelli, 80138, Naples, Italy
| | - Menelaos Karpathiotakis
- Department of Surgical Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Chiara Cacciatore
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ludovico Docimo
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
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Brusciano L, Brillantino A, Pellino G, Marinello F, Baeten CIM, Digesu A, Naldini G, Gambardella C, Lucido FS, Sturiale A, Gualtieri G, Riss S, Docimo L. Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function. Updates Surg 2023; 75:1187-1195. [PMID: 37442886 PMCID: PMC10359216 DOI: 10.1007/s13304-023-01570-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/27/2023] [Indexed: 07/15/2023]
Abstract
Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients' baseline median Cleveland Clinic Incontinence Score was 15 (10-18); it decreased to 2 (1-4) and 1 (1-2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.
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Affiliation(s)
- Luigi Brusciano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Franco Marinello
- Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Coen IM Baeten
- Department of Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | - Alex Digesu
- Department of Urogynaecology, Imperial College NHS Healthcare, London, UK
| | - Gabriele Naldini
- Proctology and Perineal Surgical Unit - Proctology and Pelvic Floor Multidisciplinary Clinical Center, Universitary Hospital of Pisa, Pisa, Italy
| | - Claudio Gambardella
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Saverio Lucido
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alessandro Sturiale
- Proctology and Perineal Surgical Unit - Proctology and Pelvic Floor Multidisciplinary Clinical Center, Universitary Hospital of Pisa, Pisa, Italy
| | - Giorgia Gualtieri
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefan Riss
- Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
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Farag A, Mashhour AN, Raslan MM, Khalifa AS, Elbarmelgi MY. The Functional Luminal Imaging Probe (FLIP): A Good Tool for Adjustment of anal Canal Dimensions During Operative Management of Fecal Incontinence. Surg Innov 2023:15533506231157438. [PMID: 36790084 DOI: 10.1177/15533506231157438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
PURPOSE Fecal incontinence is a troublesome problem in the field of colorectal surgery. The main aim of this study was to adjust the anal canal resistance during operative management of anal incontinence using Endo-FLIP. METHODS This was a prospective cohort study held at Cairo university hospital. Hundred forty-eight incontinent patients treated by different surgical procedures were included. During the procedure the Endo-FLIP was applied to adjust the anal canal dimensions (ACL and ACD) so the ACR could be adjusted based on the flow equation. These were also assessed pre-operatively with Endo-FLIP system and the flow equation calculator. The clinical severity of the disease and outcome after surgical procedures were assessed and correlated to the physiologic parameters. RESULTS ACL, ACD and ACR had had significant correlations to the degree of incontinence (P < .001). ACL, ACD and ACR showed statistically significant change with primary repair and gluteus maximus transposition operations. After treatment of fecal incontinence, in good responders' group, the mean resting anal canal resistance increased significantly to 4649.05 ± 1161.49 (postoperative) while in poor responders' group it was 1919.9 ± 1077.73. CONCLUSIONS The Endo-flip can be used to measure the anal canal geometric parameters (ACL and ACD) and then anal canal resistance could be calculated by the flow equation - pre-and post-operatively- which help the adjustment of the surgical repair of sphincter injury in fecal incontinence patients which may improve the surgical outcome.
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Affiliation(s)
- Ahmed Farag
- 63527Cairo University Kasr Alainy Faculty of Medicine, Egypt
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Complications Following Posterior Colporrhaphy With and Without Anal Sphincteroplasty: An Analysis of Cases in the National Surgical Quality Improvement Program Database. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1257-1261. [PMID: 36368595 DOI: 10.1016/j.jogc.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We aimed to compare postoperative complications for patients undergoing posterior colporrhaphy with or without sphincteroplasty. METHODS A retrospective cohort of women undergoing posterior colporrhaphy with or without anal sphincteroplasty was completed using the National Surgery Quality Improvement Program (NSQIP) database (2012-2019). The primary outcome was a composite of important surgical complications, including wound complications, blood transfusion, hospital stay >48 hours, reoperation, readmission, and urinary tract infection. Multivariable logistic regression was used to adjust for important potential confounders, including age, BMI, diabetes, and anterior prolapse surgery. RESULTS A total of 5079 patients were included. Of these, 82 patients underwent a concurrent sphincteroplasty. The primary composite outcome occurred in 10.4% of patients having posterior colporrhaphy versus 19.5% having posterior colporrhaphy with sphincteroplasty. On multivariable analysis there was no increased odds of complication associated with concomitant anal sphincteroplasty (1.58, 95% CI 0.89-2.90, P = 0.12). CONCLUSION Nearly one in five women who have posterior colporrhaphy with anal sphincteroplasty had an important surgical complication. Higher complication rates may be related to patient factors, as this was not observed after adjustment for patient factors and additional surgical procedures. Sphincteroplasty may be considered with posterior colporrhaphy in select women.
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Barisic G, Andjelkov K, Rosic J, Miladinov M, Kotur-Stеvuljevic J, Dinic T, Jelenkovic J, Krivokapic Z. Application of nanofat for treatment of traumatic faecal incontinence after sphincteroplasty - A pilot study. Colorectal Dis 2022; 24:1054-1062. [PMID: 35426481 DOI: 10.1111/codi.16148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/14/2022] [Accepted: 04/07/2022] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate whether the application of nanofat containing stem cells improves continence in women who had previously undergone anal sphincteroplasty with unsatisfactory long-term outcomes. METHOD This prospective pilot study included nine women with various degrees of anal incontinence who had previously undergone anal sphincteroplasty due to obstetric trauma. In all patients, the Wexner Incontinence Score (WS) and Faecal Incontinence Quality of Life Score (FIQLS), as well as anal manometry and endoanal ultrasound measurements, were performed before the procedure and during follow-up. In all patients, liposuction was performed and 50 ml of raw lipoaspirate was obtained and processed using a NanoFat Kit device. Approximately 20 ml of the mechanically emulsified and filtrated fat was obtained and the anal sphincter complex was infiltrated with it. Patient follow-up was conducted in person or via telephone 6 and 12 months after the procedure. RESULTS The squeeze pressure was significantly increased 6 months after the procedure (p = 0.01). The external anal sphincter measured at the 12 o'clock position was significantly thicker (p = 0.04). A significant decrease in the WS was observed both 6 and 12 months after the procedure compared with baseline values (p < 0.05 for both). CONCLUSION This study is the first to show that the application of nanofat as an injectable product improves continence in patients with unsatisfactory results after sphincteroplasty, suggesting it to be a promising and effective therapeutic tool. The procedure is safe and can be easily performed as an ambulatory procedure.
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Affiliation(s)
- Goran Barisic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Digestive Surgery - First Surgical Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Jovana Rosic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Miladinov
- Clinic for Digestive Surgery - First Surgical Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Tanja Dinic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelenko Jelenkovic
- COVID Hospital Batajnica, University Clinical Center of Serbia, Belgrade, Serbia
| | - Zoran Krivokapic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Digestive Surgery - First Surgical Clinic, University Clinical Center of Serbia, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
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Multimodal Management of Fecal Incontinence Focused on Sphincteroplasty: Long-Term Outcomes from a Single Center Case Series. J Clin Med 2022; 11:jcm11133755. [PMID: 35807037 PMCID: PMC9267180 DOI: 10.3390/jcm11133755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023] Open
Abstract
The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985−2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60−173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS > 15 vs. 2.5% postoperatively; p < 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair.
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Markaryan DR, Lukyanov AM, Garmanova TN, Agapov MA, Kubyshkin VA. [Postpartum fecal incontinence. State of the problem]. Khirurgiia (Mosk) 2022:127-132. [PMID: 35658144 DOI: 10.17116/hirurgia2022061127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.
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Affiliation(s)
| | - A M Lukyanov
- Lomonosov Moscow State University, Moscow, Russia
| | | | - M A Agapov
- Lomonosov Moscow State University, Moscow, Russia
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Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am 2022; 51:71-91. [PMID: 35135666 DOI: 10.1016/j.gtc.2021.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.
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Affiliation(s)
- Stacy Menees
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA
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Mittal RK, Tuttle LJ. Anorectal Anatomy and Function. Gastroenterol Clin North Am 2022; 51:1-23. [PMID: 35135656 DOI: 10.1016/j.gtc.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Anatomy of pelvic floor muscles has long been controversial. Novel imaging modalities, such as three-dimensional transperineal ultrasound imaging, MRI, and diffusion tensor imaging, have revealed unique myoarchitecture of the external anal sphincter and puborectalis muscle. High-resolution anal manometry, high-definition anal manometry, and functional luminal imaging probe are important new tools to assess anal sphincter and puborectalis muscle function. Increased understanding of the structure and function of anal sphincter complex/pelvic floor muscle has improved the ability to diagnose patients with pelvic floor disorders. New therapeutic modalities to treat anal/fecal incontinence and other pelvic floor disorders will emerge in the near future.
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Affiliation(s)
- Ravinder K Mittal
- Department of Medicine/Gastroenterology, University of California, San Diego, ACTRI, 9500 Gilman Drive, MC 0061, La Jolla, CA 92093-0990, USA.
| | - Lori J Tuttle
- Department of Medicine/Gastroenterology, University of California, San Diego, USA; San Diego State University, San Diego, CA, USA
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Disorders of anorectal motility: Functional defecation disorders and fecal incontinence. J Visc Surg 2022; 159:S40-S50. [DOI: 10.1016/j.jviscsurg.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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García Fernández N, Navarro Morales L, Reyes Díaz ML, Ramallo Solís I, María Jiménez Rodríguez R, De la Portilla De Juan F. Sphincteroplasty for the treatment of faecal incontinence after an obstetric injury - a video vignette. Colorectal Dis 2021; 23:2199-2200. [PMID: 33942479 DOI: 10.1111/codi.15701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/20/2021] [Accepted: 04/25/2021] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - María Luisa Reyes Díaz
- Colorectal Unit, Department of Surgery, University Hospital Virgen del Rocíıo, Seville, Spain
| | - Irene Ramallo Solís
- Colorectal Unit, Department of Surgery, University Hospital Virgen del Rocíıo, Seville, Spain
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13
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Cerdán-Santacruz C, Cano-Valderrama Ó, Cerdán-Miguel J. Traumatic deficient perineum: surgical management and outcome from a single center. Int Urogynecol J 2021; 33:651-658. [PMID: 33914119 DOI: 10.1007/s00192-021-04803-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/12/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair. METHODS Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS. RESULTS There were 20 patients (median age 55.5 years; range 29-81 years) with a median duration of incontinence symptoms of 174 (range 1-540) months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322) months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients. CONCLUSIONS Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.
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Affiliation(s)
- Carlos Cerdán-Santacruz
- Colorectal Surgery Department at Clínica Santa Elena, Madrid, Spain.
- Colorectal Surgery Department at Hospital Universitario de la Princesa, Madrid, Spain.
| | - Óscar Cano-Valderrama
- General Surgery Department, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
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Long-term Fecal Incontinence, Recurrence, Satisfaction, and Regret After the Transobturator Postanal Sling Procedure. Female Pelvic Med Reconstr Surg 2021; 27:244-248. [PMID: 31425371 DOI: 10.1097/spv.0000000000000769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to assess long-term outcomes after the transobturator postanal sling (TOPAS) procedure for the treatment of fecal incontinence. Long-term recurrence, satisfaction and regret after transobturator postanal sling procedure support the ongoing use of this procedure for patients with fecal incontinence. METHODS Both a retrospective review of medical records and a prospective telephone survey were conducted. For the retrospective review of medical records, all patients who underwent the TOPAS procedure at our institution were eligible. Medical records were reviewed to assess for symptom resolution, retreatment, and complications. For the prospective telephone survey, patients who were conversant in English and had a valid contact information were eligible and were asked to complete questions on satisfaction, the Patient Global Impression of Improvement, the Wexner Symptom Severity Score, the Fecal Incontinence Qualify of Life Scale, and the modified Decision Regret Scale. RESULTS A total of 134 patients met the inclusion criteria for the retrospective medical record review. Patients were followed in clinic for a median of 24.0 months (interquartile range, 6.0-53.0). Overall, 75.4% reported improvement in fecal incontinence. There were 37 (27.6%) who required subsequent treatment for fecal incontinence. There were 67 patients eligible for the prospective telephone survey, of whom 46 (68.7%) agreed to participate. Median time between surgery and the telephone survey was 63.5 months (interquartile range, 36.0-98.0). Among these participants, 54.3% were satisfied and 60.9% would recommend the procedure to someone else. No adverse events were identified with long-term follow-up. CONCLUSIONS Our findings suggest that the TOPAS procedure remains a safe and effective therapy for the treatment of fecal incontinence with favorable long-term outcomes.
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Gehrich AP, McClellan E, Gillern S. Surgical repair of an obstetric cloaca with review of the literature. BMJ Case Rep 2021; 14:14/1/e234321. [PMID: 33500293 PMCID: PMC7839897 DOI: 10.1136/bcr-2020-234321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.
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Pla-Mart V, Martín-Arévalo J, Marti-Fernandez R, Moro-Valdezate D, Garcia-Botello S, Espi-Macias A, Minguez-Perez M, Ruiz-Carmona MD, Roig-Vila JV. LONG-TERM EVOLUTION OF CONTINENCE AND QUALITY OF LIFE AFTER SPHINCTEROPLASTY FOR OBSTETRIC FECAL INCONTINENCE. Ann Coloproctol 2020:ac.2020.09.16. [PMID: 32972098 PMCID: PMC8898632 DOI: 10.3393/ac.2020.09.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose This study was performed to evaluate the long-term evolution of continence and patient’s quality of life after surgical treatment for obstetric fecal incontinence. Methods A prospective longitudinal study was conducted including consecutive patients who underwent sphincteroplasty for severe obstetric fecal incontinence. The first phase analyzed changes in continence and impact on quality of life. The second phase studied the long-term evolution reevaluating the same group of patients 6 years later. Degree of fecal incontinence was calculated using the Cleveland Clinic Score (CCS). Quality of life assessment was carried out with the Fecal Incontinence Quality of Life scale. Results Thirty-five patients with median age of 55 years (range, 28 to 73 years) completed the study. Phase 1 results: after a postoperative follow-up of 30 months (4 to 132 months), CCS had improved significantly from a preoperative of 15.7 ± 3.1 to 6.1 ± 5.0 (P < 0.001). Phase 2 results: median follow-up in phase 2 was 110 months (76 to 204 months). The CCS lowered to 8.4 ± 4.9 (P = 0.04). There were no significant differences between phases 1 and 2 in terms of quality of life; lifestyle (3.47 ± 0.75 vs. 3.16 ± 1.04), coping/behavior (3.13 ± 0.83 vs. 2.80 ± 1.09), depression/self-perception (3.65 ± 0.80 vs. 3.32 ± 0.98), and embarrassment (3.32 ± 0.90 vs. 3.12 ± 1.00). Conclusion Sphincteroplasty offers good short-medium term outcomes in continence and quality of life for obstetric fecal incontinence treatment. Functional clinical results deteriorate over time but did not impact on patients’ quality of life.
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Affiliation(s)
- Vicente Pla-Mart
- Department of Surgery, University of Valencia, Valencia, Spain.,Colorectal Unit, General and Digestive Surgery Department, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain
| | - Jose Martín-Arévalo
- Colorectal Unit, General and Digestive Surgery Department, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain
| | - Rosa Marti-Fernandez
- Colorectal Unit, General and Digestive Surgery Department, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain
| | - David Moro-Valdezate
- Department of Surgery, University of Valencia, Valencia, Spain.,Colorectal Unit, General and Digestive Surgery Department, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain
| | - Stephanie Garcia-Botello
- Department of Surgery, University of Valencia, Valencia, Spain.,Colorectal Unit, General and Digestive Surgery Department, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain
| | - Alejandro Espi-Macias
- Department of Surgery, University of Valencia, Valencia, Spain.,Colorectal Unit, General and Digestive Surgery Department, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain
| | - Miguel Minguez-Perez
- Digestive Motility Unit, Department of Digestive Medicine, Hospital Clínico Universitario de Valencia, Valencia, Spain
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Kumar S, Medappil N, Singh SK, Chandra A. Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition. Ann Coloproctol 2020; 36:58-61. [PMID: 32146790 PMCID: PMC7069671 DOI: 10.3393/ac.2018.08.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/21/2018] [Indexed: 11/30/2022] Open
Abstract
Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient’s neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark’s incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.
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Affiliation(s)
- Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Noushif Medappil
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Sunil Kumar Singh
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
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18
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Weledji EP, Elong FA, Eyongeta DE. A Case of Low Rectovaginal Fistula of Obstetric Origin: Treatment by Fistulotomy and Reconstitution or Advancement Flap? Front Surg 2020; 7:2. [PMID: 32133369 PMCID: PMC7041408 DOI: 10.3389/fsurg.2020.00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/27/2020] [Indexed: 11/13/2022] Open
Abstract
Many small low rectovaginal fistulas represent incompletely healed (third degree) perineal lacerations i. e., involving the sphincters. An individualized, systematic approach to these fistulas based on their size, location, and etiology provides a more concise treatment plan. We report a case of a low rectovaginal fistula developed some years following forceps vaginal delivery. This was managed successfully by a fistulotomy in which the bridge of skin and scar tissue was divided, and the defect repaired as a classical third degree perineal laceration. On the background of coexisting or occult sphincter damage which usually follows obstetric trauma, a fistulotomy and immediate composite repair for small, low rectovaginal fistula may be advantageous and acceptable in a low resource setting where endoanal imaging and manometry are not available.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Felix Adolphe Elong
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Divine Enoru Eyongeta
- Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon
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19
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Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life. Tech Coloproctol 2020; 24:221-229. [PMID: 32020351 DOI: 10.1007/s10151-019-02146-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 12/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND An early secondary repair of the anal sphincter may be necessary if primary repair of obstetric anal sphincter injury (OASIS) is complicated by wound rupture or severe infection. The objective of this study was to assess the long-term functional outcomes, morbidity, and impact on quality of life (QoL) following an early secondary repair of OASIS. METHODS This retrospective cohort study was conducted at Aarhus University Hospital, Denmark. All women having a secondary repair of the anal sphincter within 21 days of delivery from February 1991 to February 2017 were included (n = 51). Complications were assessed by reviewing medical records. The patient-reported outcomes were assessed in 2018 by questionnaires. Primary outcome was Wexner score and St. Mark's score. Impact on QoL was assessed using the Fecal Incontinence Quality of Life Scale (FIQLS). RESULTS After a median follow-up time of 6.7 years (IQR 3.3-16.6), 34 women completed the questionnaire. The mean (SD) Wexner score was 5.2 ± 4.7 and the mean (SD) St. Mark's score was 6.8 ± 5.7. Women with a Wexner score ≥ 9 had a significantly lower QoL score in all domains of the FIQLS compared to women with a Wexner score < 9 (p < 0.001). Postoperative complications were experienced by 37%. Ten women developed a fistula of which nine required surgical treatment. CONCLUSIONS An early secondary repair of the anal sphincter can be performed within 21 days of delivery with functional long-term outcomes comparable to those following a late sphincter repair. However, there is an imminent risk of complications, mainly fistulas, which should be taken into consideration when choosing the ideal timing of the repair.
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20
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Kim CN. Usefulness of Patient-Reported Outcome Measures and Anorectal Physiologic Tests in Predicting Clinical Outcome for Fecal Incontinence. Ann Coloproctol 2020; 35:289-290. [PMID: 31937067 PMCID: PMC6968716 DOI: 10.3393/ac.2019.11.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Chang-Nam Kim
- Department of Surgery, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
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21
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Barbosa M, Glavind-Kristensen M, Moller Soerensen M, Christensen P. Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up. Colorectal Dis 2020; 22:71-79. [PMID: 31347749 DOI: 10.1111/codi.14792] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/07/2019] [Indexed: 12/12/2022]
Abstract
AIM Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury. METHOD This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale. RESULTS Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001). CONCLUSION At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.
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Affiliation(s)
- M Barbosa
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - M Glavind-Kristensen
- Pelvic Floor Unit, Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus N, Denmark
| | - M Moller Soerensen
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - P Christensen
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
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22
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Chandra A, Kumar S, Singh P, Dangi A, Gupta V, Gupta V. Endoscopic ultrasound-guided anal sphincteroplasty for fecal incontinence in women: A pilot study. Indian J Gastroenterol 2019; 38:534-541. [PMID: 32002831 DOI: 10.1007/s12664-019-00956-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/14/2019] [Indexed: 02/04/2023]
Abstract
Overlapping sphincteroplasty for anal sphincter injury is associated with suboptimal long-term results that can be implicated to incomplete repair and neurovascular damage during dissection. This study was done to evaluate endoscopic ultrasound-guided overlapping sphincteroplasty to ensure completeness of sphincter repair intraoperatively and also to protect the integrity of neurovascular bundles. Between January 2014 and October 2015, 15 consecutive women with damaged anal sphincters, who underwent endoscopic ultrasound-guided overlapping sphincteroplasty, were prospectively evaluated (group 1). A control group of seven women, who had undergone classical sphincteroplasty between August 2012 and December 2013, was retrospectively identified (group 2). Perioperative outcomes, anal manometry findings, and fecal incontinence scores of both the groups were analyzed. Median age of patients in group 1 was 28 years (range 21-45) whereas group 2 patients had a median age of 33 years (range 26-35). Group 1 patients were followed up for a median duration of 44 months (range 37-54), and the median follow up duration in group 2 was 62 months (range 55-70). Postoperative evaluation done at the last follow up revealed a marked improvement in anal squeeze pressures as well as St. Mark's incontinence score in both the groups compared with their preoperative status. However, there was no significant difference in the outcomes of both the groups. Use of intraoperative ultrasound ensures the completeness of sphincter repair and also decreases chances of neurovascular injury. However, no statistically significant difference in the outcome was found with the use of ultrasound-guided sphincteroplasty in the short-term.
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Affiliation(s)
- Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226 003, India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226 003, India.
| | - Prabhu Singh
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226 003, India
| | - Amit Dangi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226 003, India
| | - Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226 003, India
| | - Vivek Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226 003, India
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23
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Berg MR, Gregussen H, Sahlin Y. Long-term outcome of sphincteroplasty with separate suturing of the internal and the external anal sphincter. Tech Coloproctol 2019; 23:1163-1172. [PMID: 31773346 PMCID: PMC6890595 DOI: 10.1007/s10151-019-02122-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/15/2019] [Indexed: 01/09/2023]
Abstract
Background Sphincteroplasty is one of the treatment options for anal incontinence following obstetric injury. The aim of the study was to evaluate the long-term effect of sphincteroplasty with separate suturing of the internal and the external anal sphincter on anal continence. Methods A retrospective study was conducted on women who had sphincteroplasty for treatment of anal incontinence following obstetric injury. Women operated between January 1, 2011 and December 31, 2014 at Sykehuset Innlandet Hospital Trust Hamar, were invited to answer a questionnaire and participate in a clinical examination, including endoanal sonography. Results 111 (86.7%) women participated. Median postoperative follow-up was 44.5 months, and 63.8% of the participants experienced an improvement of at least three points in the St. Mark’s incontinence score. Fecal urgency and daily fecal leakage persisted in 39.4% and 6.4% of the participants, respectively. The internal anal sphincter improvement persisted in 61.8% of the participants, and there was a median reduction of their St. Mark’s score of 6.0 points between the preoperative value and the value at long-term follow-up. There was no significant change in the St. Mark’s score of patients with persistent dehiscence of the internal anal sphincter. Conclusions Sphincteroplasty, with separate suturing of the internal sphincter resulted in continence for stool maintained for at least 3 years in the majority of the patients, while there was an improvement in continence in nearly two-thirds.
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Affiliation(s)
- M R Berg
- Department of Colorectal Surgery, Innlandet Hospital Trust Hamar, Hamar, Norway. .,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway. .,Department of Colorectal Surgery, Innlandet Hospital Trust Hamar, Pb 4453, 2326, Hamar, Norway.
| | - H Gregussen
- Department of Colorectal Surgery, Innlandet Hospital Trust Hamar, Hamar, Norway
| | - Y Sahlin
- Department of Colorectal Surgery, Innlandet Hospital Trust Hamar, Hamar, Norway
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24
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Nelson RL, Go C, Darwish R, Gao J, Parikh R, Kang C, Mahajan A, Habeeb L, Zalavadiya P, Patnam M. Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis. Tech Coloproctol 2019; 23:809-820. [PMID: 31273486 DOI: 10.1007/s10151-019-02029-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review. METHODS Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI. RESULTS Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes. CONCLUSIONS There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.
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Affiliation(s)
- R L Nelson
- Epidemiology/Biometry Division, University of Illinois School of Public Health, Chicago, IL, USA.
| | - C Go
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Darwish
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - J Gao
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Parikh
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - C Kang
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - A Mahajan
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - L Habeeb
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - P Zalavadiya
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - M Patnam
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
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Kreydin EI, Chaudhry ZQ, Kazanjian KK, Lin AY. Anal Sphincteroplasty in the Minimally Invasive Era: Assessment of National Trends and Complications. Am Surg 2019. [DOI: 10.1177/000313481908500123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fecal incontinence is a debilitating and underreported condition. Despite introduction of novel therapies in recent years, anal sphincteroplasty (AS) remains the surgical choice for certain patients. Previous reports have primarily focused on single-surgeon or single-center experience with AS. The purpose of this study was to assess patient characteristics and perioperative outcomes of AS using a national cohort. Patients (n = 586) who underwent AS as a primary procedure between 2009 and 2015 were identified by the CPT code as recorded in the study and were evaluated and examined for association with 30-day complications. The number of sphincteroplasties performed decreased seven-fold between 2009 and 2015. Wound infection, wound dehiscence, and urinary tract infection were the most common complications, occurring in 30 (5.1%), 12 (2.1%), and 6 (1%) patients, respectively. Preoperative steroid use and surgeon specialty were associated with wound complications on multivariate analysis. We present the first national study of patients undergoing AS and identify factors that predispose to wound complications. In addition, we demonstrate that the number of anal sphincteroplasties performed in the United States is decreasing dramatically, likely because of novel therapy for fecal incontinence. We hope that this study will assist in patient counseling and call attention to preserving surgical training as utilization of AS rapidly declines.
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Affiliation(s)
- Evgeniy I. Kreydin
- Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Zaid Q. Chaudhry
- Department of Obstetrics and Gynecology, Citrus Valley Health Partners, West Covina, California
| | - Kevork K. Kazanjian
- Section of Colon and Rectal Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Anne Y. Lin
- Section of Colon and Rectal Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
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26
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Medium-term outcome of percutaneous tibial nerve stimulation in the treatment of fecal incontinence. Tech Coloproctol 2018; 22:875-879. [PMID: 30565161 DOI: 10.1007/s10151-018-1892-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 11/20/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Fecal incontinence (FI) is a multifactorial disease that affects patients' quality of life. The aim of this study was to evaluate the efficacy of posterior tibial nerve stimulation (PTNS) in the treatment of FI and to assess the medium-term results. METHODS A prospective cohort of patients with FI treated with PTNS between 2012 and 2014 was analysed. Endoluminal ultrasound and anorectal physiologic studies were performed in all patients. The efficacy of PTNS was assessed using a validated questionnaire (Cleveland Clinic Incontinence Score) at baseline, after treatment, and 2 years later. The Vaizey score was also used at 2-year follow-up to assess urge incontinence. RESULTS Fifty-six patients (38 females; mean age 59.7 years) with FI were treated. The causes of FI were mainly obstetric injury and previous colorectal surgery. A decrease of 50% from baseline CCIS was seen in 41.1% of patients after PTNS. One-third maintained a minimum of 50% decrease of their initial CCIS after 2 years. Comparing CCIS at baseline, after treatment, and at 2-year follow-up, a statistically significant difference was observed (p < 0.0001 and p < 0.0004 respectively). Medium-term improvement was not maintained in patients with passive and mixed FI, while it was maintained in those with urge incontinence. At 2 years, patients with mild incontinence maintained the greatest response. CONCLUSIONS PTNS is a safe, effective, non-invasive treatment for FI with good results in almost half of the patients at the end of the treatment. There is also an acceptable maintained response at 2-year follow-up. It seems to be most successful in patients with mild incontinence and urge incontinence.
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27
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Matzel KE, Bittorf B. Reprint of: Management of fecal incontinence: Surgical treatement. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Trébol J, Carabias-Orgaz A, García-Arranz M, García-Olmo D. Stem cell therapy for faecal incontinence: Current state and future perspectives. World J Stem Cells 2018; 10:82-105. [PMID: 30079130 PMCID: PMC6068732 DOI: 10.4252/wjsc.v10.i7.82] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/26/2018] [Accepted: 06/30/2018] [Indexed: 02/06/2023] Open
Abstract
Faecal continence is a complex function involving different organs and systems. Faecal incontinence is a common disorder with different pathogeneses, disabling consequences and high repercussions for quality of life. Current management modalities are not ideal, and the development of new treatments is needed. Since 2008, stem cell therapies have been validated, 36 publications have appeared (29 in preclinical models and seven in clinical settings), and six registered clinical trials are currently ongoing. Some publications have combined stem cells with bioengineering technologies. The aim of this review is to identify and summarise the existing published knowledge of stem cell utilization as a treatment for faecal incontinence. A narrative or descriptive review is presented. Preclinical studies have demonstrated that cellular therapy, mainly in the form of local injections of muscle-derived (muscle derived stem cells or myoblasts derived from them) or mesenchymal (bone-marrow- or adipose-derived) stem cells, is safe. Cellular therapy has also been shown to stimulate the repair of both acute and subacute anal sphincter injuries, and some encouraging functional results have been obtained. Stem cells combined with normal cells on bioengineered scaffolds have achieved the successful creation and implantation of intrinsically-innervated anal sphincter constructs. The clinical evidence, based on adipose-derived stem cells and myoblasts, is extremely limited yet has yielded some promising results, and appears to be safe. Further investigation in both animal models and clinical settings is necessary to drawing conclusions. Nevertheless, if the preliminary results are confirmed, stem cell therapy for faecal incontinence may well become a clinical reality in the near future.
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Affiliation(s)
- Jacobo Trébol
- General and Digestive Tract Surgery Department, Salamanca University Healthcare Centre, Salamanca 37007, Spain.
| | - Ana Carabias-Orgaz
- Anaesthesiology Department, Complejo Asistencial de Ávila, Ávila 05004, Spain
| | - Mariano García-Arranz
- New Therapies Laboratory, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Madrid 28040, Spain
| | - Damián García-Olmo
- General and Digestive Tract Surgery Department, Quiron-Salud Hospitals, Madrid 28040, Spain
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight current and newer therapeutic approaches to treat fecal incontinence in patients who do not respond to conservative measures. RECENT FINDINGS Neurostimulation techniques, injection of bulking agents, and radiofrequency energy delivery to the anal canal have been proposed and tested for fecal incontinence over the last decade. Sacral stimulation is both effective and durable and is now the most popular of the invasive techniques whereas percutaneous tibial stimulation, radiofrequency energy, and bulking agents are either less effective or their evaluation has been handicapped by suboptimal study designs. The precise indications for the new vaginal control device and anal plugs remain to be established. The magnetic anal sphincter is disappointing. Stem cell therapy is a potentially exciting approach, which is in its infancy. There continues to be an unmet need for innovative approaches to patients with fecal incontinence who do not respond to conservative measures. The efficacy of current and future therapies should be assessed using criteria more stringent than has been used in the past to provide a more realistic assessment of meaningful efficacy.
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Trébol J, Georgiev-Hristov T, Vega-Clemente L, García-Gómez I, Carabias-Orgaz A, García-Arranz M, García-Olmo D. Rat model of anal sphincter injury and two approaches for stem cell administration. World J Stem Cells 2018; 10:1-14. [PMID: 29391927 PMCID: PMC5785699 DOI: 10.4252/wjsc.v10.i1.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/26/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To establish a rat model of anal sphincter injury and test different systems to provide stem cells to injured area. METHODS Adipose-derived stem cells (ASCs) were isolated from BDIX rats and were transfected with green fluorescent protein (GFP) for cell tracking. Biosutures (sutures covered with ASCs) were prepared with 1.5 x 106 GFP-ASCs, and solutions of 106 GFP-ASCs in normal saline were prepared for injection. Anorectal normal anatomy was studied on Wistar and BDIX female rats. Then, we designed an anal sphincter injury model consisting of a 1-cm extra-mucosal miotomy beginning at the anal verge in the anterior middle line. The sphincter lesion was confirmed with conventional histology (hematoxylin and eosin) and immunofluorescence with 4', 6-diamidino-2-phenylindole (commonly known as DAPI), GFP and α-actin. Functional effect was assessed with basal anal manometry, prior to and after injury. After sphincter damage, 36 BDIX rats were randomized to three groups for: (1) Cell injection without repair; (2) biosuture repair; and (3) conventional suture repair and cell injection. Functional and safety studies were conducted on all the animals. Rats were sacrificed after 1, 4 or 7 d. Then, histological and immunofluorescence studies were performed on the surgical area. RESULTS With the described protocol, biosutures had been covered with at least 820000-860000 ASCs, with 100% viability. Our studies demonstrated that some ASCs remained adhered after suture passage through the muscle. Morphological assessment showed that the rat anal anatomy is comparable with human anatomy; two sphincters are present, but the external sphincter is poorly developed. Anal sphincter pressure data showed spontaneous, consistent, rhythmic anal contractions, taking the form of "plateaus" with multiple twitches (peaks) in each pressure wave. These basal contractions were very heterogeneous; their frequency was 0.91-4.17 per min (mean 1.6980, SD 0.57698), their mean duration was 26.67 s and mean number of peaks was 12.53. Our morphological assessment revealed that with the aforementioned surgical procedure, both sphincters were completely sectioned. In manometry, the described activity disappeared and was replaced by a gentle oscillation of basal line, without a recognizable pattern. Surprisingly, these findings appeared irrespective of injury repair or not. ASCs survived in this potentially septic area for 7 d, at least. We were able to identify them in 84% of animals, mainly in the muscular section area or in the tissue between the muscular endings. ASCs formed a kind of "conglomerate" in rats treated with injections, while in the biosuture group, they wrapped the suture. ASCs were also able to migrate to the damaged zone. No relevant adverse events or mortality could be related to the stem cells in our study. We also did not find unexpected tissue growths. CONCLUSION The proposed procedure produces a consistent sphincter lesion. Biosutures and injections are suitable for cell delivery. ASCs survive and are completely safe in this clinical setting.
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Affiliation(s)
- Jacobo Trébol
- Department of General and Digestive Tract Surgery, University Hospital "La Paz", Madrid 28046, Spain
| | - Tihomir Georgiev-Hristov
- Department of General and Digestive Tract Surgery, Villalba General Hospital, Madrid 28400, Spain
| | - Luz Vega-Clemente
- New Therapies Laboratory, Instituto de Investigación Sanitaria- Fundación Jiménez Díaz, Madrid 28040, Spain
| | - Ignacio García-Gómez
- Senior Research Associate, Hektoen Institute of Medicine, Chicago, Illinois 60612, United States
| | - Ana Carabias-Orgaz
- Department of Anaesthesiology, Complejo Asistencial de Ávila, Ávila 05004, Spain
| | - Mariano García-Arranz
- Scientific Head, New Therapies Laboratory, Instituto de Investigación Sanitaria- Fundación Jiménez Díaz, Madrid 28040, Spain
| | - Damián García-Olmo
- Head of Department, Department of General and Digestive Tract Surgery, Quiron-Salud Hospitals, Madrid 28040, Spain
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Long-Term Outcomes After Overlapping Sphincteroplasty for Cloacal-Like Deformities. Female Pelvic Med Reconstr Surg 2018; 25:271-278. [DOI: 10.1097/spv.0000000000000543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Trends in Surgeon-Level Utilization of Sacral Nerve Stimulator Implantation for Fecal Incontinence in New York State. Dis Colon Rectum 2018; 61:107-114. [PMID: 29215481 DOI: 10.1097/dcr.0000000000000941] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is a paucity of real-world data regarding surgeon utilization of sacral nerve stimulation for fecal incontinence compared with anal sphincteroplasty. OBJECTIVE This study aims to examine trends in sacral nerve stimulation use compared with sphincteroplasty for fecal incontinence and surgeon-level variation in progression to implantation of the pulse generator. DESIGN This is a population-based study. PATIENTS Patients with fecal incontinence between 2011 and 2014 in New York who underwent stage 1 of the sacral nerve stimulation procedure were selected. For the comparison with sphincteroplasty, patients with fecal incontinence who underwent anal sphincteroplasty between 2008 and 2014 were included. MAIN OUTCOME MEASURES The main outcomes after sacral nerve stimulation generator placement were unplanned 30-day admission, emergency department visit within 30 days, revision or explant of leads or generator, and 30-day mortality. RESULTS Six hundred twenty-one patients with fecal incontinence underwent a stage 1 procedure with 79.7% progressing to stage 2. There has been an increase in the number of sacral nerve stimulation cases per year as well as the number of surgeons performing the procedure. The rate of progression to stage 2 among patients treated by colorectal surgeons was 80.2% compared with 77.0% among those treated by noncolorectal surgeons. Among those who completed stage 2, there were 3 (0.5%) unplanned 30-day admissions, 24 (4.4%) emergency department visits within 30 days, and 0 mortalities within 30 days. Thirty-two (6.5%) patients had their leads or pulse generator revised or explanted. There was a significant decrease in annual sphincteroplasty cases and the number of providers performing the procedure starting in 2011. LIMITATIONS We lacked data regarding patient and physician decision making and the severity of disease. CONCLUSIONS Sacral nerve stimulation for fecal incontinence is increasing in popularity with an increasing number of surgeons utilizing sacral nerve stimulation for fecal incontinence rather than sphincteroplasty. See Video Abstract at http://links.lww.com/DCR/A450.
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Rodrigues FG, Chadi SA, Cracco AJ, Sands DR, Zutshi M, Gurland B, Da Silva G, Wexner SD. Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation. Colorectal Dis 2017; 19:456-461. [PMID: 27620162 DOI: 10.1111/codi.13510] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/18/2016] [Indexed: 12/15/2022]
Abstract
AIM Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect. METHOD Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS). RESULTS Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06). CONCLUSION Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.
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Affiliation(s)
- F G Rodrigues
- Cleveland Clinic Florida, Weston, Florida, USA.,National Council for Scientific and Technological Development (CNPq), Brasilia, Brazil
| | - S A Chadi
- Cleveland Clinic Florida, Weston, Florida, USA
| | - A J Cracco
- Cleveland Clinic Florida, Weston, Florida, USA
| | - D R Sands
- Cleveland Clinic Florida, Weston, Florida, USA
| | - M Zutshi
- Cleveland Clinic, Cleveland, Ohio, USA
| | - B Gurland
- Cleveland Clinic, Cleveland, Ohio, USA
| | - G Da Silva
- Cleveland Clinic Florida, Weston, Florida, USA
| | - S D Wexner
- Cleveland Clinic Florida, Weston, Florida, USA
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Khafagy WW, El-Said MM, Thabet WM, Aref SES, Omar W, Emile SH, Elfeki H, El-Ghonemy MS, El-Shobaky MT. Evaluation of anatomical and functional results of overlapping anal sphincter repair with or without the injection of bone marrow aspirate concentrate: a case-control study. Colorectal Dis 2017; 19:O66-O74. [PMID: 27943520 DOI: 10.1111/codi.13579] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 10/20/2016] [Indexed: 12/11/2022]
Abstract
AIM Overlapping anal sphincter repair (OASR) is used for treatment of faecal incontinence due to an external anal sphincter (EAS) defect; however, it is not the optimal treatment as its functional results tend to deteriorate significantly with time. The present study aimed to evaluate the effect of local injection of bone marrow aspirate concentrate (BMAC) on the outcome of OASR. METHOD We compared a prospective group of 20 patients with EAS defect who were managed with OASR and BMAC injection (group I) with a historical control group of an equal number of patients managed with OASR alone (group II). Patients were assessed preoperatively and during follow-up by the Wexner continence score and endoanal ultrasound. The primary end-points were the improvement of the continence level measured by the Wexner score and the residual EAS defect size measured by endoanal ultrasound. RESULTS At the end of follow-up, group I had significantly lower mean postoperative Wexner score (5.4 ± 7.6 vs 10.6 ± 7.4; P = 0.03) and smaller EAS defect percentage (12.2 ± 17.5 vs 18.3 ± 18.9). These findings were statistically significant in patients with a small preoperative EAS defect equal to or less than one-third of the anal circumference. Patients with larger preoperative EAS did not show a significant improvement of the continence level after repair in either group. CONCLUSION Augmenting OASR with local injection of BMAC in patients with faecal incontinence caused by an EAS defect, particularly a smaller defect, can improve both functional and anatomical outcomes of OASR.
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Affiliation(s)
- W W Khafagy
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - M M El-Said
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - W M Thabet
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - S E-S Aref
- Clinical Pathology Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - W Omar
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - S H Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - H Elfeki
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - M S El-Ghonemy
- Clinical Pathology Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - M T El-Shobaky
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
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Abstract
Fecal incontinence is a devastating condition, vastly under-reported, and may affect up to 18% of the population. While conservative management may be efficacious in a large portion of patients, those who are refractory will likely benefit from appropriate surgical intervention. There are a wide variety of surgical approaches to fecal incontinence management, and knowledge and experience are crucial to choosing the appropriate procedure and maximizing functional outcome while minimizing risk. In this article, we provide a comprehensive description of surgical options for fecal incontinence to help the clinician identify an appropriate intervention.
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Affiliation(s)
- Steven D Wexner
- a 1 Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Joshua Bleier
- b 2 University of Pennsylvania Health System, Department of Surgery, 800 Walnut St. 20th Floor, Philadelphia, PA 19106, USA
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Abstract
Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.
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Ghahramani L, Mohammadipour M, Roshanravan R, Hajihosseini F, Bananzadeh A, Izadpanah A, Hosseini SV. Efficacy of Biofeedback Therapy before and after Sphincteroplasty for Fecal Incontinence because of Obstetric Injury: A Randomized Controlled Trial. IRANIAN JOURNAL OF MEDICAL SCIENCES 2016; 41:126-31. [PMID: 26989283 PMCID: PMC4764962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
UNLABELLED Fecal incontinence is a challenging condition in that it exerts various psychosocial impacts on daily life. Different treatment modalities have been suggested for fecal incontinence. The present study aimed to evaluate the efficacy of biofeedback therapy in combination with surgery in the management of fecal incontinence. The present randomized controlled trial was performed on 27 women with a complaint of fecal incontinence because of delivery trauma. The patients underwent sphincteroplasty and levatorplasty via the same method by 2 colorectal surgeons. In Group I, biofeedback therapy was performed 3 months before and 6 months after the surgery; in Group II, biofeedback therapy was applied only 6 months after the surgery; and in Group III, only surgical management was performed. The results revealed a significant difference between the preoperative and postoperative Wexner scores of incontinence in all the 3 groups. Additionally, the difference between the preoperative and postoperative scores was significant only in Group I and Group III, but not in Group II. The reduction in the Wexner score was significantly less in Group III. However, no significant difference was observed between the 3 groups concerning the mean difference of preoperative and postoperative manometry. The present study revealed no significant role for biofeedback therapy alone in the improvement of manometric evaluation. However, the Wexner score, which is an indicator of patient satisfaction, increased with biofeedback therapy following sphincteroplasty. In general, surgical treatment is now reserved for selected patients with fecal incontinence and has recently been developed with biofeedback therapy. TRIAL REGISTRATION NUMBER IRCT201206039936N1.
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Affiliation(s)
- Leila Ghahramani
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mastoureh Mohammadipour
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence: Mastoureh Mohammadipour, MD; Colorectal Research Center, Faghihi Hospital, Zand Blvd., Shiraz, Iran Tel/Fax: +98 71 32306972
| | - Reza Roshanravan
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fahimeh Hajihosseini
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alimohammad Bananzadeh
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Izadpanah
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Vahid Hosseini
- Colorectal Research Center, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Wright B, Emmanuel A, Athanasakos E, Parmar N, Parker G, Green B, Tailby E, Chandler H, Cushnie J, Pembroke J, Saruchera Y, Vashisht A, Day R. Women's views on autologous cell-based therapy for post-obstetric incontinence. Regen Med 2016; 11:169-80. [PMID: 26876964 DOI: 10.2217/rme.15.88] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIM Fecal and urinary incontinence are devastating consequences of obstetric-related perineal injury. The aim of the present study is to determine acceptability to parous women of autologous cell-based therapy for fecal and urinary incontinence that arises due to pelvic diaphragm tearing during vaginal childbirth. MATERIALS & METHODS A multiple choice questionnaire survey was offered to 76 parous women at the Maternity Unit, University College Hospital, London, UK. Seventy completed questionnaires - response rate: 92%. RESULTS In total, 84% of women indicated a willingness to accept autologous cell-based therapy for obstetric injury-induced incontinence rather than surgery. CONCLUSION These observational data provide an indication of likely acceptance of autologous cell-based therapies for birth injury incontinence and will help with designing new therapeutic approaches.
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Affiliation(s)
- Bernice Wright
- Applied Biomedical Engineering Group, University College London, Rockefeller Building, 21 University Street, London, WC1E 6JJ, UK
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Eleni Athanasakos
- GI Physiology Unit, University College Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Nina Parmar
- Applied Biomedical Engineering Group, University College London, Rockefeller Building, 21 University Street, London, WC1E 6JJ, UK
| | - Georgina Parker
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Belinda Green
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Emma Tailby
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Heidi Chandler
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Julyette Cushnie
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - June Pembroke
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Yvonne Saruchera
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Arvind Vashisht
- University College Hospital, Elizabeth Garrett Anderson Wing, Institute for Women's Health, London, WC1E 6BD, UK
| | - Richard Day
- Applied Biomedical Engineering Group, University College London, Rockefeller Building, 21 University Street, London, WC1E 6JJ, UK
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Abstract
BACKGROUND Adverse events and complications have been reported after sacral neurostimulation for fecal incontinence, which may result in surgical revision and device explantation. Lead reimplantation may be feasible; however, available data regarding outcomes are less robust. OBJECTIVE The aim of this study was to determine the outcomes of sacral neurostimulation lead reimplantation for fecal incontinence. DESIGN This was a retrospective review of prospectively collected data. SETTINGS The study was conducted at 2 clinical sites from a single institution. PATIENTS Patients with fecal incontinence who underwent sacral neurostimulation implantation or reimplantation between 2011 and 2014 were included in the study. INTERVENTIONS Sacral neurostimulation reimplantation was the included intervention. MAIN OUTCOME MEASURES Change in the Cleveland Clinic Florida Fecal Incontinence Score (0 best; 20 worst) in reimplantation as compared with index implantation controls was the main measure. Secondary outcomes included the frequency and type of adverse events and complications. RESULTS A total of 112 patients underwent either sacral neurostimulation implantation or reimplantation between 2011 and 2014. Ninety-seven patients underwent an index percutaneous nerve stimulation trial, 93 of whom also underwent a stimulator implantation. Fifteen patients underwent lead reimplantation, with 5 performed before stimulator implantation and 10 after stimulator implantation. The index implanted and reimplanted groups had similar demographics, comorbidities, and complication profiles including explantation rates. The most common reason for reimplantation was lead related (6/15), including 4 lead migrations, 1 lead fracture, and 1 lead erosion. Significant decreases in the incontinence score were achieved in each group (index implantation: p < 0.001; reimplantation: p = 0.006). When comparing the efficacy of sacral neurostimulation therapy in decreasing the fecal incontinence score from baseline in each group, patients with an index implantation were found to have a more significant improvement in their incontinence score as compared with the reimplantation group (p = 0.047). LIMITATIONS This was a retrospective study. A large number of patients with incomplete functional assessment data were excluded from analysis. CONCLUSIONS The improvements in fecal incontinence are significantly better after index implantation than after reimplantation.
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Montroni I, Wexner SD. Reoperative surgery for fecal incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Short-term Outcomes of a Randomized Pilot Trial of 2 Treatment Regimens of Transcutaneous Tibial Nerve Stimulation for Fecal Incontinence. Dis Colon Rectum 2015; 58:974-82. [PMID: 26347970 DOI: 10.1097/dcr.0000000000000444] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fecal incontinence is a socially disabling condition that affects ≤15% of adults. Neuromodulatory treatments for fecal incontinence are now well established. Less invasive, cheaper, and more ambulatory forms of neuromodulation are under exploration. OBJECTIVE The purpose of this study was to assess the acceptability and safety of a new ambulatory tibial nerve stimulation device and to determine clinical effect size for 2 differing regimens of therapy. DESIGN This was a randomized, investigator-blinded, parallel-arm, 6-week pilot trial. SETTINGS The study was conducted at 7 United Kingdom trial centers. Patients were initially reviewed in the trial center, with subsequent applications of the device performed in the patients home setting. PATIENTS A total of 43 eligible patients (38 women) who failed conservative management of fecal incontinence were included in the study. INTERVENTION The study intervention involved twice-weekly, 1- versus 4-hour transcutaneous tibial nerve stimulation for 6 weeks (total of 12 treatments). MAIN OUTCOME MEASURES Standard fecal incontinence outcome tools (bowel diary, symptom severity score, and generic quality-of-life instruments) were used to collect data at baseline and at 2 weeks posttreatment cessation. RESULTS A total of 22 patients were randomly assigned to the 1-hour group and 21 to the 4-hour group. Improvements in fecal incontinence outcomes were observed for both groups, including median urge incontinence episodes per week at baseline and posttreatment (1-hour group 2.0 to 0.5 versus 4-hour group 4.0 to 1.0) and deferment time (1-hour group 2.0 to 2.0 minutes versus 4-hour group 0.5 to 5.0 minutes). Accompanying changes were observed in physical functioning domains of quality-of-life instruments. There were no adverse events, and the treatment was highly acceptable to patients. LIMITATIONS Limitations included the pilot design and lack of control arm in the study. Future trials would need to address these limitations. CONCLUSIONS This pilot study provides evidence that transcutaneous tibial nerve stimulation with a new ambulatory device is safe and acceptable for the management of fecal incontinence. Additional study is warranted to investigate clinical effectiveness.
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Pucciani F, Altomare DF, Dodi G, Falletto E, Frasson A, Giani I, Martellucci J, Naldini G, Piloni V, Sciaudone G, Bove A, Bocchini R, Bellini M, Alduini P, Battaglia E, Galeazzi F, Rossitti P, Usai Satta P. Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists. Dig Liver Dis 2015; 47:628-645. [PMID: 25937624 DOI: 10.1016/j.dld.2015.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/08/2015] [Accepted: 03/28/2015] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Filippo Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Italy.
| | | | - Giuseppe Dodi
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Ezio Falletto
- I Division of Surgical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Alvise Frasson
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Iacopo Giani
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | - Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Gabriele Naldini
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | | | - Guido Sciaudone
- General and Geriatric Surgery Unit, School of Medicine, Second University of Naples, Italy
| | - Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology - AORN "A. Cardarelli", Naples, Italy
| | - Renato Bocchini
- Gastrointestinal Physiopathology, Gastroenterology Department, Malatesta Novello Private Hospital, Cesena, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Gastroenterology, University of Pisa, Italy
| | - Pietro Alduini
- Digestive Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | | | - Piera Rossitti
- Gastroenterology Unit, S.M. della Misericordia University Hospital, Udine, Italy
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Rodríguez R, Alós R, Carceller MS, Solana A, Frangi A, Ruiz MD, Lozoya R. Incontinencia fecal posparto. Revisión de conjunto. Cir Esp 2015; 93:359-67. [DOI: 10.1016/j.ciresp.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 09/05/2014] [Accepted: 10/05/2014] [Indexed: 12/01/2022]
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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Review of the Diagnosis, Management and Treatment of Fecal Incontinence. Female Pelvic Med Reconstr Surg 2015; 21:8-17. [DOI: 10.1097/spv.0000000000000102] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Long-term outcome after overlapping anterior anal sphincter repair for fecal incontinence. Int J Colorectal Dis 2014; 29:1377-83. [PMID: 25185844 DOI: 10.1007/s00384-014-2005-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim was to assess long-term results and quality of life following anterior anal sphincter repair for anal incontinence. PATIENTS AND METHODS Twenty-three female patients underwent anterior anal sphincteroplasty over a 10-year period between January 1999 and January 2009 in a gynecological surgery department. Patients were asked to complete pre- and postoperative questionnaires comprising the Jorge and Wexner incontinence score. The secondary objective was to assess pre- and post-sphincteroplasty symptom severity and sexual quality of life. Mean follow-up was 87 months (median, 91.5 months). Kaplan-Meier time-to-event analysis was applied. RESULTS Mean age was 52 years (±15.2), and mean postoperative Jorge and Wexner score, 7.5/20 (±4.1). Seventeen patients (85 %) declared themselves satisfied by the repair; 12 (60 %) showed good fecal continence. Fecal incontinence had a negative impact on quality of life for 15 % and on sexuality for 50 % of patients. Kaplan-Meier analysis showed 85 % conservation of anal continence correction at 1 year, 74 % at 48 months, 67 % at 60 months, and 48 % at 84 months. CONCLUSIONS Overlapping anterior anal sphincter repair provided lasting improvement in fecal incontinence, with satisfactory long-term functional results. At 84 months' follow-up, 48 % of patients maintained good fecal continence, with a satisfaction rate of 85 %. Anal sphincteroplasty may be a first-line attitude in young female fecal incontinence patients with a recent sphincter defect following initially undiagnosed obstetric trauma and also restores perineal comfort.
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Wald A. New treatments for fecal incontinence: update for the gastroenterologist. Clin Gastroenterol Hepatol 2014; 12:1783-8. [PMID: 24534548 DOI: 10.1016/j.cgh.2014.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 02/07/2023]
Abstract
Fecal incontinence is one of the most emotionally devastating of all nonfatal conditions. Many patients do not respond satisfactorily to conservative measures, and there is a need for new and effective strategies when medical therapy fails. The development of sacral nerve stimulation and other forms of neuromodulation and the injection of biologically compatible substances into the anal sphincter complex have brought renewed enthusiasm for using these novel treatments in this underserved population. Because injectable bulking agents such as dextranomer in stabilized hyaluronic acid can be administered in an outpatient setting, this procedure is being marketed to both gastroenterologists and surgeons. This article reviews both sacral nerve stimulation and dextranomer bulking agents and compares their strengths and potential limitations in patients with fecal incontinence.
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Affiliation(s)
- Arnold Wald
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Abstract
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.
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