Cleveland Clinic Incontinence Research Articles

Laparoscopic-assisted versus complete transanal pull-through using Swenson technique in treatment of Hirschsprung’s disease

BackgroundThe aim of this study is to compare outcomes for neonates and infants with Hirschsprung’s disease undergoing a laparoscopically assisted transanal pull-through (LAPT) with those undergoing a complete transanal pull-through (TERPT) using Swenson procedure in both groups.MethodForty patients with Hirschsprung’s disease were operated between January 2018 and January 2022. Twenty patients underwent transanal endorectal pull through TERPT while the other 20 patients underwent laparoscopic assisted pull through (LAPT) using Swenson procedure (TERPT) in both groups.Age at operation, presenting symptoms, operative time complications, and degree of continence were evaluated. Bowel functions were assessed using the Cleveland Clinic Incontinence Score.ResultsThe mean age of the patients at the time of operation were 18.9 months for the transanal group versus 21.3 months for the laparoscopic group. The mean follow-up period was 6 months, ranging from 3 to 12 months. The rate of enterocolitis occurred in 15% of cases in transanal group versus 10% of cases in the laparoscopic group. Constipation was found in 25% of cases of TERPT group versus 10% of cases in the LAPT group. The rates of normal continence (score 0:4) was 60% vs 50% for TERPT vs LAPT respectively while the rate of severe incontinence (score 15:20) was 20% vs 5% for TERPT vs LAPT respectively.ConclusionThe functional outcomes after LAPT was satisfactory in term of fecal soiling compared to trans anal approach this may be due to less pelvic dissection compared to transanal pull through.

Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study.

The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12months.

Radiological Changes After Resection Rectopexy in Patients with Rectal Prolapse—Influence on Clinical Symptoms and Quality of Life

BackgroundResection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients’ symptoms and quality of life. MethodsThe study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life. ResultsDefecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p < 0.05). The clinical symptoms and quality of life improved in both, the total population (n = 40) and in patients with improved radiological prolapse grade (n = 30): all clinical scores (p < 0.05), SF-36 (vitality, social role, mental health p < 0.05), and Fecal Incontinence Quality of Life Scale (lifestyle, coping, embarrassment p < 0.05). Patients without improved radiological findings showed no change in their symptoms or quality of life. ConclusionOur study demonstrates that the radiological prolapse grade is improved by resection rectopexy. Correction of the anatomic defect was associated with improvement in symptoms and quality of life. Defecography may therefore be useful in the postoperative assessment of persistent symptoms or reduced quality of life.

Percutaneous tibial nerve stimulation (pTNS): success rate and the role of rectal capacity.

Percutaneous tibial nerve stimulation (pTNS) was originally developed to treat urinary incontinence. Recently, some case series have also documented its success in the treatment of fecal incontinence. Nevertheless, the mechanism underlying this effect remains unknown but may be related to changes in rectal capacity. The aim of this study was to investigate the success of pTNS for the treatment of fecal urge incontinence and assess the influence of rectal capacity on treatment efficacy. All patients undergoing pTNS for fecal incontinence between July 2009 and March 2014 were enrolled in a prospective, observational study consisting of a therapeutic regimen that lasted 9months. Therapy success was defined as a reduction in the CCI (Cleveland Clinic incontinence) score of ≥50% and patient-reported success. Furthermore, quality of life (Rockwood's scale) and changes in anorectal physiology were recorded. Fifty-seven patients with fecal urge incontinence were eligible, nine of whom were excluded. The success rate was 72.5%. Incontinence events and urge symptoms were significantly reduced after 3months and at the end of therapy. The median CCI score decreased from 12 to 4 (P<0.0001), and the quality of life was significantly improved. However, rectal capacity was not significantly related to treatment success before or after therapy. No adverse events were observed. These results demonstrate that pTNS can improve the symptoms and quality of life of patients with fecal urge incontinence. However, the study fails to demonstrate a correlation between treatment success and changes in rectal capacity.

Internal Delorme's procedure for rectal outlet obstruction

The outcome of the internal Delorme's procedure (IDP) for obstructed defaecation was assessed. From October 2001 to March 2009, 167 patients with obstructed defaecation associated with rectal intussusception were operated on. Patients were selected on the basis of validated constipation and continence scores, clinical examination and defaecography. Seventy-six patients were treated by the IDP alone and 91 patients were treated by the IDP with a levatorplasty. Before surgery and after a mean±SD follow up of 3.0±1.5years, patients were assessed using the Cleveland Clinic Incontinence and Constipation Score (CCIS and CCCS), the Obstructed Defecation Score (ODS), faecal urgency and the Patient Assessment of Constipation Quality of Life (PAC-QoL) questionnaire. Seventeen (10.2%) patients developed a postoperative complication including fissure-in-ano (4.2%), proctalgia (3.0%), suture-line dehiscence with stenosis (1.8%) and Clostridium difficile colitis (1.2%). Faecal urgency changed from 22% to 17.6% (P=0.754). Tenesmus fell from 53.9% to 17.1% (P<0.001). The CCCS and the ODS fell by 50% or more in 82.6% and 73.7% of the patients, respectively. The CCIS did not worsen significantly in patients who remained incontinent, and 45.7% of the previously incontinent patients regained normal continence. The CCCS decreased from 11 to 3 (P<0.001) in the patients treated by the IDP and from 12 to 3 (P<0.001) in the patients treated by the IDP with levatorplasty. The overall recurrence rate was 5.4%. The PAC-QoL showed a reduction of anxiety/depression and of physical and psychological discomfort (P<0.001). The IDP is an effective and safe option for rectal outlet obstruction caused by rectal intussusception with excellent function and patient satisfaction.

Delorme's Procedure for Complete Rectal Prolapse: Does It Still Have It's Own Role?

PurposeAlthough there are more than a hundred techniques, including the transabdominal and the perineal approaches, for the repair of the rectal prolapsed, none of them is perfect. The best repair should be chosen not only to correct the prolapse but also to restore defecatory function and to improve fecal incontinence throughout the patient's lifetime. The aim of this retrospective review is to evaluate clinical outcomes of the Delorme's procedure for the management of the complete rectal prolapse.MethodsA total of 19 patients (13 females and 6 males) with complete rectal prolapses were treated by using the Delorme's procedure in St. Vincent's Hospital, The Catholic University of Korea, from February 1997 to February 2007. Postoperative anal incontinence was evaluated using the Cleveland Clinic Incontinence Score.ResultsAll 19 patients had incontinence to liquid stool, solid stool, and/or flatus preoperatively. Three (15.8%) patients reported recurrence of the rectal prolapse (at 6, 18, 29 months, respectively, after the operation). Information on postoperative incontinence was available for 16 of the 19 patients. Twelve of the 16 patients (75%) reported improved continence (5 [31.3%] were improved and 7 [43.7%] completely recovered from incontinence) while 4 patients had unchanged incontinence symptoms. One (6.3%) patient who did not have constipation preoperatively developed constipation after the operation.ConclusionThe Delorme's procedure is associated with a marked improvement in anal continence, relatively low recurrence rates, and low incidence of postoperative constipation. This allows us to conclude that this procedure still has its own role in selected patients.

Quality of life after laparoscopic resection rectopexy

This study evaluated continence, constipation, and quality of life (QoL) after laparoscopic resection rectopexy (LRR) for full-thickness rectal prolapse. Results were compared with existing data after perineal rectosigmoidectomy (PRS). From May 2003 to February 2008, consecutive patients suffering from full-thickness rectal prolapse undergoing LRR were retrospectively studied. A standardized questionnaire including the Cleveland Clinic Constipation and Incontinence Scores (CCCS and CCIS) as well as general and constipation-related QoL scores (EQ-5D and PAC-QOL) was administered. Results were compared with those after PRS. For statistic analysis, the Wilcoxon test (EQ-5D and EQ-VAS) and two-sample Student's t test (CCCS, CCIS, and PAC-QOL) were used for LRR, for the comparison of both procedures Mann-Whitney test (EQ-5D) and two-sample Student's t test (EQ-VAS, CCCS, CCIS, and PAC-QOL). Eighteen patients, 15 female, aged 58.1 (±20.2) years underwent LRR. Eleven patients completed follow-up. Postoperatively, neither functional outcome nor QoL improved. Two recurrences occurred, morbidity was n = 2, and mortality n = 1. In comparison, patients after PRS benefit from improved constipation, general QoL measures, status of health, and all dimensions of constipation-related QoL. Patients after LRR do not benefit from improved general nor constipation-related QoL nor improved functional results compared to PRS.

Selecting patients with faecal incontinence for anal sphincter surgery: the influence of irritable bowel syndrome

This was a prospective study to determine the prevalence of irritable bowel syndrome (IBS) in patients with faecal incontinence and to investigate the association of IBS positivity with sphincter dysfunction. Patients with faecal incontinence were referred for physiological assessment and further management. Those with an acute obstetric injury, rectal prolapse or previous anorectal surgery were excluded. One hundred and seventy-seven women were studied. Symptom questionnaires were used prospectively to identify IBS positivity using Rome 11 criteria and the Cleveland Clinic incontinence score. The prevalence of IBS was 44%. IBS patients had higher incontinence scores than non-IBS patients (11.0 vs 9.0, P < 0.01). A normal or high maximum resting anal pressure in an incontinent woman increased the chance of her having IBS by a factor of 2.6. The prevalence of IBS positivity in patients presenting with faecal incontinence was high. A normal or high anal resting pressure and a high incontinence score should raise the suspicion of IBS.