Cleveland Clinic Incontinence Score Research Articles

The Effect of Biofeedback Therapy on Anorectal Function After the Reversal of Temporary Stoma When Administered During the Temporary Stoma Period in Rectal Cancer Patients With Sphincter-Saving Surgery: The Interim Report of a Prospective Randomized Controlled Trial.

We evaluated the effect of biofeedback therapy (BFT) on anorectal function after stoma closure when administered during the interval of temporary stoma after sphincter-preserving surgery for rectal cancer.Impaired anorectal function is common after lower anterior resections, though no specific treatment options are currently available to prevent this adverse outcome.Fifty-six patients who underwent neoadjuvant chemoradiation therapy after sphincter-preserving surgery with temporary stoma were randomized into 2 groups: group 1 (received BFT during the temporary stoma period) and group 2 (did not receive BFT). To evaluate anorectal function, anorectal manometry was performed in all patients and subjective symptoms were evaluated using the Cleveland Clinic Incontinence Score. The present study is a report at 6 months after rectal resection.Forty-seven patients, including 21 in group 1 and 26 in group 2, were evaluated by anorectal manometry. Twelve patients (57.1%) in group 1 and 13 patients (50%) in group 2 were scored above 9 points of Cleveland Clinic Incontinence Score, which is the reference value for fecal incontinence (P = 0.770). With time, there was a significant difference (P = 0.002) in the change of mean resting pressure according to time sequence between the BFT and control groups.BFT during the temporary stoma interval had no effect on preventing anorectal dysfunction after temporary stoma reversal at 6 months after rectal resection. However, BFT might be helpful for maintaining resting anal sphincter tone (NCT01661829).

Fecal incontinence among nursing home residents: Is it still a problem?

BackgroundFecal incontinence (FI) is a significant health problem among the elderly, with a devastating effect on their quality of life. The aim of the present study was to describe the prevalence and severity of FI among nursing home residents, and to investigate factors associated with FI. MethodsThis was a cross-sectional study conducted in nursing homes in Ostrava, Czech Republic. Demographics and comorbidities were extracted from medical records of nursing homes. Data regarding incontinence were obtained via face-to-face interviews with residents or extracted from registered nurses’ accounts (regarding residents with severe cognitive impairment). ResultsIn total, 588 nursing home residents were enrolled into the study. FI was noted in 336 (57.1%) participating residents. The majority of FI residents (57.8%) reported FI episodes several times a week; daily FI episodes were found in 22.9% of the FI residents. The mean Cleveland Clinic Incontinence Score in FI residents was 17.2±1.8 (mean±SD). Factors associated with FI (statistically significant) were poor general health status (≥4 comorbidities), urinary incontinence, cognitive-function impairment (dementia), decreased mobility, and length of nursing home residency. There was no association between FI and age, sex, body mass index, or living with/without a partner. ConclusionsOur data indicate that FI is still a serious health problem—FI currently affects more than half of the nursing home residents in Ostrava, Czech Republic. The study outcomes (revealed high prevalence and seriousness of FI) emphasize the importance of close monitoring and appropriately managing FI in nursing home residents.

Transanal submucosal polyacrylamide gel injection treatment of anal incontinence: a randomized controlled trial.

The efficacious and safe use of transurethral injections of polyacrylamide hydrogel (Bulkamid(®)) in women with stress urinary incontinence suggests that it may be suitable also for treatment of anal incontinence. We aimed to determine the effectiveness and safety of polyacrylamide hydrogel when used as a transanal submucosal bulking agent in women with anal incontinence. Thirty women with a diagnosis of anal incontinence and a Cleveland Clinic Incontinence Score (CCIS) >10 were randomized to three different techniques of transanal submucosal injections using polyacrylamide hydrogel. Follow up was performed at 2, 6 and 12 months using CCIS and the Fecal Incontinence Quality of Life scale (FIQL). In all, 29 of the 30 women completed the follow up. Approximately half of the women requested a re-injection at the 6-month visit. The overall CCIS improved significantly from baseline (14.7. SD 2.5) to 1 year (12.4. SD 3.1) (p = 0.003). There was a significant improvement with regard to the occurrence of loose fecal incontinence (p = 0.014) but not for solid fecal incontinence (p = 0.28). At 1 year the FIQL domains of coping-behavior, depression, and embarrassment showed significant improvements (p = 0.012, p = 0.007 and p = 0.007, respectively). We recorded no adverse events related either to the injection technique or the biomaterial. There were no significant differences between the treatment groups in either CCIS or FIQL scores. Transanal submucosal injection of polyacrylamide hydrogel resulted in a modest although significant overall improvement in anal incontinence symptom scores with corresponding improvements in several domains of quality of life, regardless of injection volume.

Surgical Treatment of Anal Stenosis with Diamond Flap Anoplasty Performed in a Calibrated Fashion.

Regarding anoplasty for anal stenosis, it is not clear to what extent the final anal caliber should be targeted. The aim of this study was to investigate the results of diamond-flap anoplasty performed in a calibrated manner for the treatment of severe anal stenosis due to a previous hemorrhoidectomy. Prospectively prepared standard forms were evaluated retrospectively. Anoplasty with unilateral or bilateral diamond flaps was performed for moderate or severe anal stenosis, targeting a final anal caliber of 25 to 26 mm. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis staging (Milsom and Mazier), anal calibers (millimeter), the Cleveland Clinic Incontinence Score, and the modified obstructed defecation syndrome Longo score were recorded on pre-prepared standard forms, as well as postoperative complications and the time of return to work. From January 2011 to July 2013, 18 patients (12 males, 67%) with a median age of 39 years (range, 27-70) were treated. All of the patients had a history of previous hemorrhoidectomy. The number of previous corrective interventions was 2.1 ± 1.8 (range, 0-4), and 2 patients had a history of failed anoplasty. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24-26), and 25 ± 1 mm (range, 23-27) (p < 0.0001, for immediate postoperative and 12-month postoperative anal calibers compared with the intraoperative). Preoperative and 12-month postoperative Cleveland Clinic Incontinence Scores were 0.83 ± 1.15 (range, 0-4) and 0.39 ± 0.70 (range, 0-2) (p = 1.0). The clinical success rate was 88.9%. No severe postoperative complications were observed. This study was limited because it was a single-armed, retrospective analysis of prospectively designed data. Diamond-flap anoplasty performed in a standardized and calibrated manner is a highly successful method for the treatment of anal stenosis caused by previous hemorrhoidectomy.

A posterior anal sling for fecal incontinence: results of a 152-patient prospective multicenter study

The transobturator posterior anal sling (TOPAS) system is a posterior anal sling that is a minimally invasive, self-fixating polypropylene mesh intended to treat fecal incontinence (FI) in women who have failed conservative therapy. We are reporting 1-year outcome in a prospective, multicenter study under investigational device exemption, evaluating this new treatment modality. A total of 152 women were implanted with the TOPAS system at 14 centers in the United States. FI was assessed preoperatively and at the 12-month follow up with a 14-day bowel diary, Cleveland Clinic Incontinence Scores, and FI Quality of Life questionnaires. Treatment success was defined as reduction in number of FI episodes of ≥50% compared to baseline. Missing bowel diary data were considered treatment failures. The Wilcoxon signed rank test was used to compare changes observed at 12 months vs baseline. Mean age was 59.6 years old (SD 9.7). The mean duration of FI was 110 mo (range 8-712) months. Mean length of the implant procedure was 33.4 (SD 11.6) minutes. Mean EBL was 12.9 (SD 10.5) mL. Average follow-up was 24.9 months. At 12 months, 69.1% of patients met the criteria for treatment success, and 19% of subjects reported complete continence. FI episodes/wk decreased from a median of 9.0 (range 2-40) at baseline to 2.5 (range 0-40) (P < .001). FI days decreased from a median of 5.0 (range 1.5-7) at baseline to 2.0 (range 0-7) (P < .001) over a 7-day period. FI associated with urgency decreased from a median at baseline of 2.0 (range 0-26) to 0 (range 0-14.5) (P < .001). The mean Cleveland Clinic Incontinence Scores decreased from 13.9 at baseline to 9.6 at 12 months (P < .001). FI Quality of Life scores for all 4 domains improved significantly from baseline to 12 months (P < .001). A total of 66 subjects experienced 104 procedure- and/or device-related adverse events (AEs). Most AEs were short in duration and 97% were managed without therapy or with nonsurgical interventions. No treatment-related deaths, erosions, extrusions, or device revisions were reported. The most common AE categories were pelvic pain (n = 47) and infection (n = 26). Those subjects experiencing pelvic pain had a mean pain score (0-10 scale, 0 = no pain) during the 12-month follow-up of 1.2 (SD 2.4). The TOPAS system provides significant improvements in FI symptoms and quality of life with an acceptable AE profile and may therefore be a viable minimally invasive treatment option for FI in women.

Changes in Dynamic Pelvic Floor Magnet Resonance Imaging and Patient Satisfaction after Resection Rectopexy for Obstructed Defecation Syndrome.

Resection rectopexy (RR) provides good functional results and low recurrence rates for the treatment of obstructed defecation syndrome based on rectal prolapse and cul-de-sac syndrome, whereas little is known about changes in pelvic floor dynamics and patient satisfaction after surgery. Within three years 26 consecutive female patients were prospectively included. Indications for RR (22 laparoscopic, 3 primary open and 1 converted-to-open) were rectal prolapse III° in 11 patients and cul-de-sac syndrome in 15 patients. Patients' quality of life (QOL), fecal behavior and defecation-associated pain were investigated before and after surgical treatment using anamnesis and clinical examination, Rand 36-idem health survey (SF-36), Cleveland-Clinic Incontinence Score (CCIS) and the visual analog scale for defecation-associated pain (VAS). Dynamic pelvic floor magnet resonance imaging (dPF-MRI) was used for the investigation of changes in pelvic floor anatomy and function before and after surgery. RR improved the rate of fecal incontinence (p < 0.01) and CCIS (p = 0.01). The use of laxatives (p = 0.01), the need for self-digitation (p = 0.02) and VAS (p < 0.01) were decreased, leading to improvements in QOL (overall p < 0.01). RR led to shortening of the H-line but not of the M-line under rest (p < 0.01) and during defecation (p = 0.04). A rectocele was co-incident in all patients in dPF-MRI before surgery. RR led to a reduction (p < 0.01) and declined protrusion (p = 0.03) of the rectocele. This results in a decreased rate of cul-de-sac (p < 0.01) and increased rate of complete defecation (p < 0.01) after surgery. At the 36-month follow-up no recurrence was observed. RR promises high rates of patient satisfaction and improvement in pelvic floor anatomy in select patients. • RR improves the pelvic floor anatomy of patients suffering from ODS. • RR improves the QOL of patients suffering from ODS. • An improvement in pelvic floor anatomy led to an improved QOL. • RR is an adequate treatment for select patients suffering from ODS.

Correlation of three dimensional anorectal manometry and three dimensional endoanal ultrasound findings in primi gravida: a cross sectional study.

Background3-dimensional anorectal manometry (3DARM) and 3-dimensional endoanal ultrasound (3DEAUS) have not been used to assess the anal sphincter complex (ASC) in primi gravida. This study was conducted to identify any correlation that may exist between 3DARM and 3DEAUS.Methods We analyzed 3DARM and 3DEAUS data of 101 consecutive primi mothers assessed in the late second trimester or early 3rd trimester. 3DARM was performed using the Given Imaging® Manoscan system and 3DEAUS was performed with the Olympus® RU 12M-R1 probe and EU-ME1 ultrasound system.ResultsThe mean age was 24.7 (SD—5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD—18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD—52.96) mmHg. The mean length of the high pressure zone was 3.67 (SD—0.52) cm. On 3DEAUS, there were three characteristic segments of the ASC that were identified; upper, middle and lower. Mean thicknesses for both internal anal sphincter (IAS) and external anal sphincter (EAS) were identified for primi gravida. IAS was thicker anteriorly and at 9 o’ clock positions and EAS was thicker posteriorly. There was good correlation in the length of the ASC at each quadrant between 3DARM and 3DEAUS. There was no correlation between either RP or SP thickness of IAS or EAS at each level and quadrant.ConclusionCorrelation is seen only in the length of ASC at each quadrant. No correlation exist between RP or SP and thickness of IAS and EAS.

Antiperistaltic Side-to-Side Ileorectal Anastomosis Is Associated with a Better Short-Term Fecal Continence and Quality of Life in Slow Transit Constipation Patients

Background: Surgical treatment of refractory slow transit constipation (STC) is traditionally performed using end-to-side ileorectal anastomosis (SE-IRA) with total abdominal colectomy (TAC). Antiperistaltic side-to-side (SS) IRA is suggested to be a superior approach. Employing a well-characterized cohort of STC patients, we compared the postoperative outcomes of the 2 surgical approaches. Methods: A total of 42 patients underwent TAC for refractory idiopathic STC. Twenty patients were treated using traditional SE-IRA whereas 22 patients were treated using SS-IRA. Patients were evaluated at 3 and 6 months as well as at 1 and 2 years after surgery. Both groups were compared for patient characteristics, perioperative data and quality of life. Cleveland Clinic Incontinence Score (CCIS) and Gastrointestinal Quality of Life Index (GQILI) were adopted for evaluating postoperative recovery. Results: Both study groups were comparable with respect to general patient characteristics, disease severity and post-operative complications. Fewer than 30% of all patients reported substantial dissatisfaction with surgical outcomes in both the groups. The SS-IRA group was associated with a lower postoperative CCIS (p < 0.05) and a better GQILI (p < 0.05) than that of the SE-IRA group during early follow-up examinations. Conclusion: In this study, SS-IRA was superior to traditional SE-IRA for the treatment of STC with respect to post-operative outcomes, and especially during early follow-up.

Three-Dimensional Anorectal Manometry Findings in Primigravida.

Vaginal delivery is an identified risk factor for anal sphincter injury. Therefore, to identify postpartum injury, an antepartum value or a normal range is required. However, at present, the normal values of 3D manometry are not available for primigravida or pregnant mothers. Our study aims at describing normal values of 3D manometry in primigravida. We analyzed 3DARM data of 101 consecutive primigravid mothers in the third trimester. 3DARM was performed using the Given Imaging(®) ManoScan system. The mean age was 24.7 (SD 5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD 18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD 52.96) mmHg. The mean length of the high-pressure zone (HPZ) was 3.67 (SD 0.52) cm. Mean volumes for initial rectal sensation, urge, and discomfort were 50.36 (± 25.57), 76.70 (± 35.17), and 143.40 (± 66.26) ml, respectively. The pressure asymmetry was highest in the lower anal sphincter and lowest in the mid-sphincter. There was a statistically significant relationship between the HPZ and RP (Pearson ρ -0.23, p = 0.01), height (Pearson ρ 0.22, p = 0.028), and weight (Pearson ρ 0.25, p = 0.012). There were no statistically significant correlations between age, height, or weight with RP, SP, or balloon fill volumes. The characteristic appearance of the normal RP and SP was clearly visualized in all patients. Normal 3DARM values for Sri Lankan primigravid mothers have been established. These may be used as reference values by other investigators.

Fecal Incontinence and Quality of Life in Adults With Rectal Cancer After Lower Anterior Resection.

The purpose of this study was to explore the prevalence of fecal incontinence (FI) and its impact on health-related quality of life in rectal cancer patients following low anterior resection surgery for colorectal cancer. Descriptive, cross-sectional study. Patients who were diagnosed with rectal cancer and underwent low anterior resection were recruited from a 1264-bed hospital in southern Taiwan. Potential participants were mailed a questionnaire survey. They were followed up 8 to 16 months postoperatively. Some clinical data were collected via retrospective review of their medical records. Questionnaires were mailed to 172 patients, and 71 with colorectal cancer underwent low anterior resection and agreed to participate and completed questionnaires in the research, reflecting a return rate of 41%. Data were collected on demographic characteristics and disease-related variables. Participants were asked if they had experienced FI during the past week. Fecal incontinence health-related quality of life was measured using the Cleveland Clinic Incontinence Score (CCIS) and the Fecal Incontinence Quality of Life Index. Completion of the questionnaire required approximately 15 minutes. More than half of the 71 participants (n = 45; 63.4%) experienced incontinence of flatus, 42.3% (n = 30) reported incontinence of liquid stool, and 14.1% (n = 10) stated that they experienced incontinence of solid stool. Based on mean CCIS scores, 35.2% (n = 25) experienced moderate to severe FI. One-third wore pads to contain FI and 21.1% changed daily activities because of FI. Nearly two-thirds reported FI during the week prior to completing the research questionnaire. The average Fecal Incontinence Quality of Life Index cumulative score was significantly lower in the FI group (2.62 ± 0.61) than in the without-FI group (3.32 ± 0.77; P < .001), as were all subscale mean scores (all P < .01-.001). Fecal incontinence is prevalent among persons undergoing low anterior resection for colorectal cancer. Persons with FI report poor health-related quality of life compared to persons who retained fecal continence. Health care providers should assess these patients for FI and treat or refer those who experience this common problem.

Lateral internal sphincterotomy for surgically recurrent chronic anal fissure

BackgroundLateral internal sphincterotomy cures chronic anal fissure by preventing internal sphincter hypertonia. However, cutting sphincter predisposes to sphincter dysfunction, manifests as incontinence of gas, liquid, or stool. Surgeons, therefore, can be too cautious in its use, making ineffective superficial incisions or avoiding the operation altogether. This study is designed to confirm the role of redo lateral internal sphincterotomy in the treatment of surgically recurrent chronic anal fissure. MethodsPatients undergoing repeat lateral internal sphincterotomy for surgically recurrent chronic anal fissure were accessed from a prospectively maintained database. Chronicity was defined by symptoms persisting more than 3 weeks. Contralateral sphincterotomy was performed with electrocautery through a stab incision over the intersphincteric plane. The length of sphincter division was the same as the length of the fissure. Phone questionnaire was administered and fecal continence was assessed by modified Cleveland Clinic Incontinence Score. Patients were asked to rank their overall satisfaction with the operation, and pre- and postoperative quality of life. ResultsThere were 57 patients, 24 women and 33 men; mean age was 47.9 ± 14.8 years. Mean follow-up was 12.5 ± 4.2 years (range 6.2 to 25.2 years). Presenting symptoms included pain (100%), bleeding (80%), pruritus ani (39%), constipation (26%), and diarrhea. Fifty patients (90%) presented with 1 fissure, and 40 were posterior. Most procedures were performed on an outpatient basis. Fissure healing rate was 98%, and 2 patients (4%) developed minor incontinence postoperatively (one of gas, the other, gas and seepage). Overall satisfaction was 9.7 ± .9 out of 10 with a significant improvement in the quality of life from 5.7 ± 2.4 out of 10 to 9.3 ± 1.4 out of 10 (P < .001). ConclusionJudicious repeat lateral sphincterotomy cures recurrent chronic fissures with minimal risk of incontinence.

Minimally invasive treatment of traumatic high rectovaginal fistulas.

BackgroundWe propose a new minimally invasive technique by laparoscopic approach which minimizes parietal damage and allows precise location of the fistula, hence reduces blind dissection.MethodsTen consecutive patients suffering from a HRVF benefited from the described technique. Location and time frame were east of the Democratic Republic of Congo and September 2012 through January 2014. By laparoscopy, dissection of the mesorectum in the “holy plane” is taken posteriorly as distally on the sacrum as possible. Dissection subsequently continues laterally beyond the fistula in an effort to maximally circumvene the fistulous area where no plane of cleavage can be found. If the cleavage plane beyond the fistula addresses a healthy rectum, a suture of vaginal and rectal defect is performed. If the cleavage plane beyond the fistula involves significant laceration of the rectum, while leaving at least 2 cm of healthy rectum above the sphincter, rectal resection and colorectal anastomosis are performed. If the rectal laceration involves the distal 2 cm but halts short of the sphincter (large fistula), the pull-through technique is performed.ResultsOf ten participants, four had large HRVF and two presented significant fibrosis. Three underwent simple suture of rectal and vaginal defect, one rectal resection and six a “pull-through” technique. The median procedure time was 1h50 (1h00–3h30). There was no morbidity. None of the patients required protective ileostomy or colostomy. Nine patients were declared clinically cured with a median follow-up of 14.3 months (11–36). The Cleveland Clinic Incontinence Score was 20 in all patients before the treatment and was significantly (p = 0.004) reduced to 2.6 [0–20] after the treatment.ConclusionsThis minimally invasive technique allowed us to treat HRVF, including complex ones in ten patients without significant morbidity. Clinical success with a median follow-up of 14.3 months was 90 %.

Long-term results after endoanal advancement flap repair for fistulas-in-ano. How important is the aetiology?

The purpose of this study was to assess primary healing, recurrence and continence after endoanal advancement flap repair (EAFR). Seventy-seven patients with fistulas-in-ano of different etiologies received endoanal advancement flap repair between 1997 and 2009. This is a prospective, non-randomized, single-centre, single-surgeon study. Follow-up data was available for 71 patients. 47.9 % had cryptoglandular fistulas. In 40.8 %, the fistulas were due to chronic inflammatory bowel disease. In 11.3 %, the fistula was a consequence of treatment for cancer. Primary healing was observed in 41 of the cases (57.7 %). The median time to recurrence was 27 months (mean 43.43 ± 48.11) and differed significantly across the patient groups: cryptoglandular origin 51 months (mean 57.09 ± 52.57), condition after cancer treatment 43 months (mean 31 ± 23.142), inflammatory bowel disease 11 months (mean 23.65 ± 32.47) (p < 0.01). Preoperatively, 31 (44.3 %) of the patients had impaired continence vs 30 (42.9 %) postoperatively. Overall, postoperative mean Cleveland Clinic incontinence score values improved significantly (preoperative 3.74 ± 4.558 vs postoperative 2.68 ± 4.752, p = 0.03). Full-thickness endoanal advancement flap repair is a successful treatment option for a range of fistula etiologies. Overall, fistula aetiology proved to be prognostically more relevant than fistula location. Fistulas associated with chronic inflammatory bowel disease were found to have a significantly higher rate of recurrence and shorter time to recurrence at long-term follow-up. Repeat interventions do not negatively impact postoperative continence.

Sacral Nerve Modulation for Fecal Incontinence

Although sacral nerve modulation has become an important tool for the treatment of fecal incontinence, prospective, randomized data are still rare. To determine the effectiveness of sacral nerve modulation in a prospective randomized crossover study : Prospective randomized crossover study : Proctological Office and Department of Surgical Proctology at a private hospital. A total of 31 consecutive patients (31 women) aged 55 ± 12 years (median ± SD) with fecal incontinence were enrolled between February 2012 and December 2012. All patients underwent sacral nerve modulation through a staged implantation procedure between 2009-2011. After a median of 26.8 months following implantation, 16 of the 31 patients agreed to be randomized in a crossover design to stimulation ON or OFF, each for a 3-week period. After the two periods (ie, 6 weeks), while still blinded to the stimulator status, the patients chose which stimulation period (first or second) they preferred. The mode of stimulation corresponding to the selected period was then continued for 3 months (final period). Frequency of bowel movements, frequency of fecal incontinence and urgency episodes, severity scores, preference for ON or OFF. The frequency of fecal incontinence episodes and Cleveland Clinic Incontinence Score (CCIS) were both significantly lower in the ON period than the OFF period (p < 0.005) during the crossover phase of the study. All patients decided to stay in the ON mode for the final period and have continued in the ON mode until now. Small patient numbers. The significant improvement in fecal incontinence during the ON period, as compared to the OFF period, makes it unlikely that the observed benefits of sacral nerve modulation are due to a placebo effect.

Anorectal function and outcomes after transanal minimally invasive surgery for rectal tumors.

BACKGROUND:Transanal endoscopic microsurgery is a minimally invasive technique that allows full-thickness resection and suture closure of the defect for large rectal adenomas, selected low-risk rectal cancers, or small cancers in patients who have a high risk for major surgery. Our aim, in the given prospective study was to report our initial clinical experience with TAMIS, and to evaluate its effects on postoperative anorectal functions.MATERIALS AND METHODS:In 10 patients treated with TAMIS for benign and malignant rectal tumors, preoperative and postoperative anorectal function was evaluated with anorectal manometry and Cleveland Clinic Incontinence Score.RESULTS:The mean distance of the tumors from the anal verge was 5.6 cm, and mean tumor diameter was 2.6 cm. All resection margins were tumor free. There was no difference in preoperative and 3-week postoperative anorectalmanometry findings; only mean minimum rectal sensory volume was lower at 3 weeks after surgery. The Cleveland Clinic Incontinence Score was normal in all patients except one which resolved by 6 weeks after surgery.The mean postoperative follow-up was 28 weeks without any recurrences.CONCLUSION:Transanal minimally invasive surgery is a safe and effective procedure for treatment of rectal tumors and can be performed without impairing anorectal functions.

Magnetic anal sphincter augmentation in patients with severe fecal incontinence.

Fecal incontinence is a common, distressing condition with limited surgical options. This study examines the results of magnetic sphincter augmentation in patients with severe fecal incontinence. This was a single-center, prospective, nonrandomized investigation. This study was conducted in a private colorectal practice. The cohort included all of the patients implanted with magnetic sphincter augmentation between January 2012 and October 2013. Magnetic sphincter augmentation was studied. Adverse events, symptom severity, quality of life, bowel diary, and manometry data were collected. Eighteen patients (15 women), with mean age of 69 years (range, 31-91 years), were implanted with magnetic sphincter augmentation. Follow-up ranged from 353 to 738 days. Previous treatment consisted of peripheral nerve evaluation test in 10 patients (56%), 2 patients (11%) with previous permanent sacral nerve stimulation, and 1 patient (6%) with previous implantation of an artificial bowel sphincter. Implantation was successful in 17 (94%) of 18 patients. Five patients (29%) had postoperative pain, and 5 patients (29%) had temporary swelling and erythema in both gluteal regions after the implantation. No devices were explanted during the follow-up. Cleveland Clinic Incontinence Score decreased from a mean of 17.5 (range, 14.0-20.0) to 7.3 (range, 0-12.0), and Fecal Incontinence Quality of Life scores improved in all of the domains. Bowel diary results showed that 76% of the patients with implants experienced a ≥50% reduction in the number of fecal incontinence episodes per week. Manometry at 6 months after implantation showed increased mean resting and squeeze pressures. This study does not allow for comparison between surgical treatments and involves a limited number of patients. Magnetic sphincter augmentation shows consistent results for the treatment of severe fecal incontinence in this patient group. The surgical procedure is straightforward as compared with other implantable devices. The safety profile is acceptable. Magnetic sphincter augmentation is a promising new treatment with the potential to become a first-line surgical therapy for patients with severe fecal incontinence.

Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse.

Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients. A password-protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient-reported outcome measures were evaluated. Sixty-eight men of median age 35years and body mass index 26kg/m(2) underwent LVMR for external rectal prolapse (18) or Grade III-V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled 'chronic idiopathic pelvic pain' and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow-up was 42 (IQR 26-61) months. CCIS score improved from 4 (IQR 0-8) to 0 (IQR 0-0) (P<0.001) and the ODS score from 18.5 (IQR 16-22) to 6 (IQR 5-8) (P<0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ-22) at 3months (P=0.000). The QoL and the VAS for bowel symptoms were maintained at 4years. At the last follow-up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse. LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

Severe Perineal Lacerations in Obstetric Practice: The Effect of Institutional Practice Guidelines on Repair Failures in a Single Centre.

Background. There is a high incidence of failure after repair of severe perineal lacerations (SPLs). A tertiary referral hospital in the Caribbean introduced guidelines in an attempt to improve outcomes. We performed an audit of SPL repairs at this centre in an attempt to determine the effect on repair failure. Methods. All patients with SPL repairs between November 1, 2007, and December 30, 2012, were identified. The primary aim was to determine the incidence of failed repairs (wound dehiscence, anal sphincter disruption, rectovaginal fistula, and/or faecal incontinence). The Cleveland Clinic Incontinence Score (CCIS) was used to assess continence at discharge and 24 weeks after repair. Data were analyzed with SPSS version 12. Results. There were 8108 vaginal deliveries, 23 third-degree injuries, and 3 fourth-degree injuries. Three patients experienced a repair failure. Notably, 69% of surgeons chose an inappropriate suture for sphincter repair. Conclusions. Experienced operators are performing repairs, but there is a high prevalence of inappropriate suture choice for repairs. A targeted educational campaign may be necessary to remind clinicians of the best practice in repair techniques.

580P - Quality of Life and Bowel Function in Locally Advanced Rectal Cancer Patients Treated with an Intensified Neoadjuvant Regimen in the Expert-C Trial

ABSTRACT Aim: Intensified preoperative treatment regimens have been increasingly investigated in locally advanced rectal cancer. However, there are very limited data on the impact of these regimens on patient quality of life (QoL) and bowel function. We assessed patient QoL and bowel function in EXPERT-C, a randomised, phase II trial of neoadjuvant CAPOX followed by chemoradiotherapy (CRT), total mesorectal excision and adjuvant CAPOX ± cetuximab in MRI-defined, high-risk, locally advanced rectal cancer. Methods: Patient reported QoL was assessed using the EORTC QLQ-C30 and the colorectal cancer EORTC QLQ-CR29 questionnaire. Scores which differed by ≥10 percent points were considered clinically significant. Bowel incontinence was assessed using a modified Cleveland Clinic Incontinence Score (mCCIS) questionnaire. Results: Of 164 study patients, 157 (95.1%) completed a QLQ-C30 and a QLQ-CR29 questionnaire and 147 (89.6%) a mCCIS questionnaire, at baseline. Compared to baseline, QoL scores were worse for role functioning, fatigue, appetite loss, taste, hair loss, throughout neoadjuvant treatment, for nausea/vomiting and dry mouth during and/or after neoadjuvant chemotherapy (NACT), and for sore skin and impotence after CRT. QoL scores were better for blood and mucus in stool throughout neoadjuvant treatment, and for diarrhoea, stool frequency, faecal incontinence and buttock pain during NACT. A significant difference was observed between QoL scores after NACT and those after CRT for sexual interest in women, diarrhoea, sore skin and buttock pain (all worse after CRT). When the two treatment groups were analysed separately, patients who received cetuximab had worse QoL scores for body image, dry mouth and taste throughout neoadjuvant treatment and sexual interest in women after CRT compared to patients treated without cetuximab. Long-term QoL data and data on bowel function will be presented at the meeting. Conclusions: This is the first study reporting on QoL and bowel function in locally advanced rectal cancer patients treated with NACT followed by CRT. QoL and functional outcome should be important endpoints to use in clinical trials investigating intensified neoadjuvant treatment strategies. Disclosure: D. Cunningham: has received research funding from Amgen, Roche, Sanofi-Aventis, and Merck- Serono; A. Cervantes Ruiperez: has had advisory roles with Merck-Serono and Roche. He has received research funding from Roche and honoraria from Roche and Merck-Serono; I. Chau: has had advisory roles with Merck Serono, Roche, and Sanofi-Aventis. He has received research funding from Merck and Roche, and honoraria from Roche and Sanofi-Aventis. All other authors have declared no conflicts of interest.

Sacral neuromodulation for fecal incontinence and constipation in adult patients with anorectal malformation--a feasibility study in patients with or without sacral dysgenesis.

The aim of this study was to evaluate both the feasibility and effectiveness of sacral neuromodulation for fecal incontinence and constipation in adult patients who had undergone surgical repair of anorectal malformations (ARM). Patients with ARM with or without sacral dysgenesis who presented with fecal incontinence, constipation, or combined symptoms were treated with sacral nerve stimulation (SNS). Success of SNS was assessed by scores preoperatively and after a 3-week test period: Cleveland Clinic Incontinence Score (CCI), Surgical Working Group for Coloproctology (CACP) continence score, German version of the Fecal Incontinence Quality of Life Scale, and Cleveland Clinic Constipation Score (CCCS). The follow-up results of the patients who received a definitive pacemaker were used to evaluate the long-term effect of SNS in patients with ARM. Four patients with fecal incontinence and one patient with constipation (two males, three females; median age 24 years [13; 31]) were treated with SNS between May 2012 and May 2013. Four patients had a normal sacrum; one patient had a sacral dysgenesis. Preoperatively and after the test phase, median CACP continence scores were 8 [1; 10] and 11.5 [3; 16], median CCI 14 [12; 19] and 13 [11; 17], and median Fecal Incontinence Quality of Life Scale improved in all categories. For constipation, CCCSs were 16 and 7. Sacral neuromodulation is a feasible treatment modality for adult patients with ARM with a normally developed sacrum. Patients with sacrum dysgenesis are not suited for SNS because a definitive quadripolar electrode could not be anchored in the absence of a sacral bone.