Gas Incontinence Research Articles

Gatekeeper™ Prostheses Implants in the Anal Canal for Gas Incontinence and Soiling: Long-Term Follow-Up

Introduction: Although several treatments for faecal incontinence are available, gas incontinence (GI) and soiling are difficult to manage. The aim of this study is to evaluate Gatekeeper™ for this subtype of faecal incontinence. Methods: Prospective single-centre case series. Patients with mainly soiling and/or GI were treated with polyacrylonitrile prostheses. An evaluation was performed with a 3-week continence diary. St. Mark’s score and a Visual Analogue Scale (VAS) were used to study the patient’s continence perception and surgical satisfaction, at baseline and 1, 3, 6, 12, and 24 months postoperatively. 3D-Endoanal Ultrasound and Anorectal Manometry were performed at baseline and postoperatively. Results: A total of 13 patients were enrolled (11 women), aged (median (IQR)) 62 (13) years, and all implants were uneventful. A significant reduction in soiling and GI episodes was documented at 1 year, 7 (18) baseline days of soiling/3 weeks vs. 2 (4) (p = 0.002); 13 (13) baseline episodes of GI/3 weeks vs. 4 (10) (p = 0.01). This improvement was correlated with a significant increase in VAS (0–10), 3 (2, 5) baseline vs. 7 (1, 5) (p = 0.03), and maintained throughout the follow-up. There was complete remission or significant improvement defined as >70% reduction in gas and soiling days in 6 patients at 2 years follow-up. Soiling episodes were reduced ≥70% in 8/11 patients (72.7%). Nine (70%) patients would repeat the treatment. Conclusions: Gatekeeper™ is a safe, minimally invasive treatment for soiling and GI. A significant reduction in soiling and GI was observed in our series, with a better response to soiling. Most of the patients would repeat the treatment. Other studies are needed to confirm these findings in this subgroup of FI patients.

Effectiveness of 0.3 % nifedipine gel combined with 2.0 % lidocaine and BTA 80 U in treatment of chronic anal fissure. Pilot randomized study. Preliminary results

AIM: to improve the results of chronic anal fissure treatment. PATIENTS AND METHODS: the study included 22 patients randomized by random numbers generation method into 2 groups. Eleven patients were included in main group and were treated with 0.3 % nifedipine + 2.0 % lidocaine gel, 11 patients of the control group received injections of botulinum toxin A into the internal anal sphincter at a dose of 80 U (BTA 80). RESULTS: by day 30, there was a decrease of maximal resting pressure in anal canal (MRPAC) in both the main and control groups [p = 0.015 and p = 0.004, respectively] and the average resting pressure in anal canal (ARPAC) [p = 0.01 and p = 0.02, respectively]. There was no difference between the groups in pain severity both after stool and during the day (p = 0.5 and p = 0.6, respectively). On day 60, the defect was epithelized in 6/11 (54.6 %) patients of the study group and in 9/11 (81.8 %) patients of the BTA 80 group [p = 0.36], respectively. The reason of treatment failure in 4/11 (36.4 %) patients of the main group and 2/11 (18.2 %) patients of the control group was a preserved internal sphincter spasm. It was found that these patients used a lower amount of the drug product — 2.2 (1.8; 2.5) mg/day compared to 2.4 (1.9; 2.7) mg/day in other patients. On the day 30 after surgical treatment, complaints about gas incontinence were registered in 1/11 (9.1 %) patients of the main group and 1/11 (9.1 %) patients of the control group [p = 1]. Such a complication as external hemorrhoid thrombosis occurred only in 1/11 (9.1 %) patients in the BTA 80 group [p = 0.87]. CONCLUSION: the study results show that gel containing 0.3 % nifedipine and 2 % lidocaine produces an effect on the tone of the internal sphincter comparable to BTA. However, the lack of accurate dosage of the drug product and/or low patient compliance reduce the effectiveness of treatment and make the use of BTA preferable for medical relaxation of the internal sphincter.

Analysis of the incidence and symptomatology of low anterior resection syndrome after laparoscopic anterior resection for rectal cancer

Objective: This study aims to explore the temporal trend of Low Anterior Resection Syndrome (LARS) and its symptoms after laparoscopic anterior resection for rectal cancer. Methods: A retrospective cohort study design was employed. The study included primary rectal (adenocarcinoma) cancer patients who underwent laparoscopic anterior resection at Tongji Hospital, Huazhong University of Science and Technology, between January 1, 2010, and December 31, 2020. Complete medical records and follow-up data at 3, 6, 9, 12, and 18 months postoperatively were available for all patients. A total of 1454 patients were included, of whom 1094 (75.2%) were aged ≤65 years, and 597 (41.1%) were females. Among them, 1040 cases (71.5%) had an anastomosis-to-anus distance of 0-5cm, and 86 cases (5.9%) received neoadjuvant treatment. All patients completed the Chinese version of the LARS questionnaire and their LARS occurrence and specific symptom information were recorded at 3, 6, 9, 12, and 18 months postoperatively. Considering past literature and clinical experience, further subgroup analyses were performed to explore the potential impact factors on severe LARS, including anastomosis level, preoperative neoadjuvant therapy, postoperative adjuvant therapy, and the presence of preventive stoma. Results: The occurrence rates of LARS at 3, 6, 9, 12, and 18 months postoperatively were 78.5% (1142/1454), 71.4% (1038/1454), 55.0% (799/1454), 45.7% (664/1454), and 45.7% (664/1454), respectively (χ2=546.180, P<0.001). No statistically significant difference was observed between the 12-month and 18-month time points (P>0.05). When compared with the symptoms at 3 months, the occurrence rates of gas incontinence [1.7% (24/1454) vs. 33.9% (493/1454)], liquid stool incontinence [3.9% (56/1454) vs. 41.9% (609/1454)], increased stool frequency [79.6% (1158/1454) vs. 95.9% (1395/1454)], stool clustering [74.3% (1081/1454) vs. 92.9% (1351/1454)], and stool urgency [46.5% (676/1454) vs. 78.7% (1144/1454)] in the LARS symptom spectrum were significantly alleviated at 12 months (all P<0.05) and remained stable beyond 12 months (all P>0.05). With the extension of postoperative time, the incidence rates of severe LARS exhibited a decreasing trend in different subgroups, of anastomosis level, preoperative neoadjuvant therapy, postoperative adjuvant therapy, and the presence of preventive stoma, and reached stability at 12 months postoperatively (all P>0.05). Conclusion: LARS and its specific symptom profile showed a trend of gradual improvement over time up to 1 year postoperatively, and stabilized after more than 1 year. Increased stool frequency and stool clustering are the most common features of abnormal bowel dys function, which improve slowly after surgery.

Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review.

Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries. The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI). PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze. Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures. APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained. APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.

Nigam’s standardization of manual anal dilatation (Lord’s procedure)

Background: Standardisation of manual anal dilatation. It was a quality improvement study. Patients were admitted in various hospitals of Gurgaon, Haryana, India. Methods: Two hundred thirty-six patients of fissure in ano were treated by manual anal dilatation (Lord’s procedure) as per Nigam’s standardization between January 2010 and January 2022. Informed consent was obtained from each patient. All patients were evaluated for post procedure for complications. Two hundred thirty-six patients of fissure in ano were treated by manual anal dilatation (Lord’s procedure). Results: No patient developed faecal incontinence. Pain subsided immediately in all patients. No patient had non healing of anal fissure. Two patients had mild gas incontinence which resolved after 3-4 days. None of the patients required lateral sphincterotomy or fissurectomy. Most of the patients healed completely within three weeks. Conclusions: If manual anal dilatation is performed slowly, gently with controlled force for four minutes, as per Nigam’s standardisation then results are very good. This study includes patients of acute and chronic fissure in ano. The study excludes cases of anal cancer, stage III and IV haemorrhoids and inflammatory bowel disease.

Collagen treatment of complex anorectal fistula: 3 years follow-up.

Fistula in ano is a common anorectal disease in adults. Currently, surgery remains the definitive therapeutic approach, but in some cases, it can lead to serious complications as faecal or gas incontinence. Therefore, sphincter sparing treatments should be considered for complex fistulas. One of the sphincteric preserving treatment is the filling with a dermal extract commonly called "collagen glue" as Salvecoll-E® gel. This is a multicentric, prospective, observational study on the use of Salvecoll-E® gel in treatment of complex anal fistulas. We treated 70 patients from May 2016 to May 2017. In the first phase, we debrided the fistula tract using a loose seton kept for 4-6 weeks. In the second phase, the seton was removed and the fistula tract was filled with Salvecoll-E® gel. In this article, we report results at 36 months of follow-up. Fifty patients (71.4%) had completely healed fistula within 36 months of follow-up. Twenty-eight patients (28.2%) had recurrences. Among these failures, 65% were within 6 months. All low transphincteric fistulas healed. Recurrences occurred only in median and high transphincteric fistulas. No patient had a worsening of continence status measured with Cleveland Clinic Florida Incontinence Severity score. Salvecoll-E® gel is a recent finding among sphincter-sparing treatments. In this study, we demonstrate that it is a safe option in the treatment of complex fistulas. Final results are satisfactory and in line with the best results published in literature among mini-invasive treatments.

Prevalence of urinary incontinence and anal incontinence: an internet-based cross-sectional study of female Turkish University students.

The objective of this cross-sectional, epidemiological study was to characterize urinary tract and bowel symptom prevalence and the extent of discomfort/bother associated with them. Additionally, the authors aimed to explore factors associated with both conditions among Turkish female university students. Also, an insight into women's "communication regarding urinary incontinence and anal incontinence" with their family members was sought. This is an internet-based national cross-sectional study. A study-specific 30-item questionnaire containing validated measures of symptom prevalence and bother (Urogenital Distress Inventory questionnaire short form and Colorectal-Anal Distress Inventory) were incorporated into the survey. Out of a total of 2,125 e-mail invitations that were sent, 1,226 responded with data included in this analysis. The age and BMI of all respondents were 26.53 ± 10.082, 23.45 ± 6.609 respectively. Nine hundred and eighty-five (80.5%) respondents claimed that they did not suffer a UI episode in the last year, whereas 10 people (0.08%) claimed that they had a urinary incontinence episode every day. Three hundred and fifty-seven responders (29.1%) stated that they suffered from "gas incontinence," 6 (0.5%) stool incontinence, and 20 (1.6%) declared that they had episodes of both stool and gas incontinence. Five hundred and forty-four participants (44%) reported that they had family relatives with a problem of "urinary incontinence" and 576 (47%) stated they had a conversation on "urinary incontinence." Seventy-five of the responders (6.1%) stated that they had a family member with "anal incontinence" and 246 (20.1%) responded that they had a conversation regarding "anal incontinence" with them. We have demonstrated that the prevalence of UI was 19.5%. Twenty-nine percent stated they suffered "gas incontinence," 0.5% stool incontinence, and 1.6% declared that they had episodes of both stool and gas incontinence.

P598 The utility of the “Low Anterior Resection Syndrome SCORE” in assessing the postoperative outcomes of patients undergoing restorative proctocolectomy with ileal pouch anal-anastomosis for Ulcerative Colitis

Abstract Background Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) in a J-pouch configuration is the treatment of choice for patients with ulcerative colitis. Some patients who have undergone this surgery present symptoms including fecal or gas incontinence, urgency, clustering, and frequency, that occurs after anal sphincter-sparing surgery for the treatment of rectal cancer. There is a lack in standardization and evaluation of functional outcomes. Our aim is to evaluate the effectiveness of the LARS (low anterior resection syndrome) score in this cohort of patients. Methods We conducted a retrospective analysis of a prospectively maintained single center database. We assessed the quality of life by using the Inflammatory Bowel Disease Questionnaire (IBDQ-32). The functional bowel complaints were assessed using the LARS score. Results Between 2015 and 2020, 70 patients with ulcerative colitis underwent total colectomy and subsequent IPAA with J-Pouch configuration. Among these, 49 patients who closed the ileostomy and were followed for at least 6 months, were selected for the present study. Nineteen patients did not have the LARS; among 30 who complained the LARS, 17 had a major LARS (tab.1). The latter had a worse quality of life on the IBDQ-32 questionnaire, especially in relation to urgency and frequency (Fig.1). We compared the two scores using Spearman's test correlation coefficient, detecting a significant correlation (rho -0.7664185; p-value &amp;lt;0.005); a significant correlation between the urgency sub-category with LARS score (rho -0.6515759; p-value &amp;lt;0.005) and frequency (rho -0.6744705; p-value &amp;lt;0.005) was evaluated. Tab 1: Patients characteristics: Fig.1:IBDQ-32 value in different LARS categories Conclusion In our experience LARS score appears to be a useful, effective and simple tool to predict functional outcomes and QoL not only in oncological rectal sphincter-sparing surgery but also in functional surgery for ulcerative colitis.

The Role of Physiotherapy in Parity-Induced Flatus Incontinence: A Case Report

Gas incontinence also known as Flatus incontinence is a common postpartum anal incontinence which impairs social participation and also lacks established protocol of management. Symptom persistency has been reported after perineal muscles repair due to weakness/ loss in function of the pelvic floor muscles. This case report describes about the importance and effectiveness of Pelvic Floor Muscle Rehabilitation (PMR) in a 28year old primiparous woman, four months postpartum who presented with parity-induced flatus incontinence aggravated after sexual activities at a the Physiotherapy clinic of a state government owned hospital located in the south eastern part of Nigeria. Pelvic Muscle Rehabilitation (PMR) and Stabilization exercises were administered thirty minutes (30mins) to forty-five minutes (45mins) three times (3x), a week (1 week) for four weeks (4weeks). There was a significant reduction in Mark’s (Vaizey) score by more than 2 points at the end of the four weeks of physiotherapy intervention and also patient recorded improvement in all the domains of faecal incontinence quality of life scale, pelvic floor muscle strength (anal squeeze pressure) and pelvic floor muscle function (endurance and coordination).

Severity and impact of accidental bowel leakage two decades after no, one, or two sphincter injuries

Information about the long-term severity and subjective impact of anal incontinence in women after 1 or 2 consecutive obstetrical anal sphincter injuries is still scarce and contradictory. This study aimed to describe the severity and impact of anal incontinence among women with 2 previous deliveries 2 decades after birth and to analyze the relative effect of 1 vs 2 obstetrical anal sphincter injuries in comparison with no obstetrical anal sphincter injuries and the possible influence of obstetrical anal sphincter injury on other pelvic floor disorders. We linked prospectively registered data in the Swedish Medical Birth Register with information from a postal and web-based questionnaire in 2015. Statistics Sweden identified women with 2 vaginal births from 1992 to 1998, and a simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. To achieve equal-sized groups of women with 1 or 2 obstetrical anal sphincter injuries, the latter group was oversampled from 1987 to 2000. The final study cohorts consisted of 6760 women with no obstetrical anal sphincter injury, 357 women with 1 injury, and 324 women with 2 obstetrical anal sphincter injuries. Third- and fourth-degree perineal tears were grouped together for analysis. Anal incontinence was defined as either fecal or isolated gas incontinence, and fecal incontinence was defined as involuntary leakage of solid or liquid stool with or without concomitant gas. Frequencies of leakage of stool and gas were dichotomized into low frequency (less than once a month) and high frequency (several times a month or more often). Pairwise comparisons were analyzed using Fisher exact tests, Mantel-Haenszel statistics, and the Mann-Whitney U test. Trends were analyzed using Mantel-Haenszel statistics and the Spearman rank correlation test. Logistic regression models were used to obtain the age- and body-mass-index -adjusted odds ratios for outcomes. Statistical significance was set at P<.05. The response rate was 65.5% in the randomly selected cohort and 70.1% among women with 2 obstetrical anal sphincter injuries. Bothersome fecal incontinence occurred in 3.3% (212/6458) of women without obstetrical anal sphincter injury, in 10.4% (36/345) (adjusted odds ratio, 3.25; 95% confidence interval, 2.23-4.73) of those with 1 injury, and in 16.5% (52/315) (adjusted odds ratio, 5.16; 95% confidence interval, 3.69-7.22) of those with 2 obstetrical anal sphincter injuries (trend P<.0001). Fecal incontinence was perceived as bothersome in 28.2% (212/753) of women without an obstetrical anal sphincter injury compared with in 43.9% (36/82) and 46.0% (52/113) of those with 1 or 2 obstetrical anal sphincter injuries (trend P<.0001). Leakage of liquid stool occurred in 10.8% (724/6717) of those without injury, in 21.7% (77/355) of women with 1 injury, and 34.9% (113/324) of women with 2 obstetrical anal sphincter injuries (trend P<.0001). Incontinence affecting daily life was reported by 8.6% (577/6672) of women without injury and by 19.7% (69/351) and 29.6% (96/324) of women with 1 and 2 sphincter injuries, respectively (trend P<.0001). The mean Jorge-Wexner score was 2.44, 3.26, and 3.88 for women with no, 1, or 2 sphincter injuries (trend P<.0001). Among women with a Jorge-Wexner score of 6, >50% had bothersome anal incontinence. The adjusted odds ratio for the overall effect of 1 vs 2 obstetrical anal sphincter injuries on measures of anal incontinence was 2.19 (95% confidence interval, 1.68-2.85) and 3.91 (95% confidence interval, 3.06-5.00), respectively, when compared with no obstetrical anal sphincter injury (both P<.0001). Having 1 or 2 obstetrical anal sphincter injuries had no significant effect on other pelvic floor disorders or on lower urinary tract symptoms (P=.73 and P=.69). A consistent additive effect of 1 or 2 sphincter injuries on the severity and impact of anal incontinence was observed in women 2 decades after 2 vaginal births. This information is important for healthcare economics, clinical practice, and policy.

Incontinence after fistulotomy in low anal fistula: Can Kegel exercises help improve postoperative incontinence?

AimFistulotomy is the commonest procedure performed for low anal fistulas. The incidence of gas and urge incontinence after fistulotomy and whether Kegel exercises (KE) could help recover sphincter function after fistulotomy has not been studied before. Methods Patients operated by fistulotomy for low fistulas were recommended KE (pelvic contraction exercises) 50 times/day for one year postoperatively. Incontinence (solid, liquid, gas and urge) was evaluated objectively (Vaizeys scores) preoperatively [Pre-op Group], in the immediate postoperative period [Pre-KE Group] and at 6-months follow-up [Post-KE Group]. Incontinence scores in all three groups were compared to evaluate the efficacy of KE. Results101 MRI-documented low anal-fistula patients were included. There were 79 males (mean age 39.412.9 years) and median follow-up was 12 months (6-18months). Two patients were lost to follow-up. Fistulas healed in all the patients. Incontinence was present in 5/99 patients (mean incontinence scores-0.130.63) preoperatively and occurred in 20/99 (mean incontinence scores-1.032.18) patients postoperatively (Pre-KE Group). With KE, the incontinence improved completely in 10 and partially improved in other 10 (mean incontinence scores-0.311.09). Urge and gas incontinence accounted for most cases (80%). The mean incontinence scores deteriorated significantly after fistulotomy (pre-op vs pre-KE, p=0.000059, significant) but continence improved significantly with KE, thus the scores between pre-op and post-KE became comparable (pre-op vs post-KE, p=0.07, not significant).ConclusionsFistulotomy, even in low fistulas, can lead to significant increase in gas and urge incontinence. Regular Kegel exercises postoperatively can help recover lost sphincter function and can bring back continence comparable to preoperative levels.

Functional state of the obturator apparatus of the rectum after surgical treatment of grade 4 ­hemorrhoids with an ultrasonic scalpel

Background. Despite the improvement of surgical techniques for the treatment of chronic hemorrhoids, the problem of incontinence of the components of the intestinal contents in the postoperative period remains relevant.&#x0D; Aim. Evaluation of the functional state of the rectal obturator in patients with grade 4 hemorrhoids before and after surgical treatment with an ultrasonic scalpel.&#x0D; Material and methods. At the National Medical Research Centre for Coloproctology named after A.N. Ryzhikh of the Ministry of Health of Russia, 500 patients with grade 4 hemorrhoids operated on with an ultrasonic scalpel for the period 20152017 were examined using anorectal manometry (profilometry). The mean age of the patients was 49.212.4 years (from 22 to 65 years). At the same time, initially, 11/500 (2.2%) patients even before the operation had periodic complaints of gas incontinence (grade I anal sphincter insufficiency; 2.51.3 points on the Wexner scale). For statistical processing, the Student's t-test or the nonparametric single-sample Wilcoxon criterion were used.&#x0D; Results. On average, manometric indicators for the group before surgery were within the physiological norms. In 11 patients with complaints of incontinence, the pressure in the anal canal was initially reduced both at rest and during volitional contraction. At the same time, among the rest of the patients without any complaints of incontinence, 55/489 (11.2%) cases of subclinical (without manifestations) form of anal incontinence were identified only by a decrease in the manometric indicators of the sphincter rest tone, which made it possible to refer these patients to the group risk for the development of postoperative anal incontinence. After surgery, clinical complaints of gas incontinence appeared in 14/55 (25.5%) patients with subclinical anal sphincter insufficiency. In total, by the 45th day, anal incontinence according to complaints and the results of an objective study was registered in 25/500 (5.0%) patients.&#x0D; Conclusion. Clinical and instrumental signs of anal sphincter insufficiency after surgical treatment of stage 4 hemorrhoids with an ultrasonic scalpel were registered in 5.0% of cases, while in 2.2% they were at baseline (in patients with a decrease in intraanal pressure and complaints), and in 2,8% appeared after surgery (in patients with subclinical anal incontinence).

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery.

BACKGROUNDThe transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS). AIMTo ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division. METHODSPatients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10th postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey’s scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE. RESULTSOf 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test).CONCLUSIONDivision of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).

Quality of life of patients with locally advanced rectal cancer after neoadjuvant therapy and sphincter-preserving surgery

Objective: To investigate quality of life (QoL) of patients with locally advanced rectal cancer (LARC) who underwent low anterior resection with protective stoma under neoadjuvant therapy mode, and to explore the changes of QoL of patients from before neoadjuvant therapy to 12 months after stoma reversal. Methods: A descriptive case series study was carried out. A retrospective study was performed on patients with mid and low LARC who received complete neoadjuvant long course radiotherapy and chemotherapy, followed by radical low anterior resection (LAR) combined with protective stoma at Peking Union Medical College Hospital from December 2017 to January 2020. Inclusion criteria: (1) patients with rectal MRI assessment of mT3-4b or mN1-2 without distant metastasis (M0) before neoadjuvant therapy; (2) distance from tumor lower margin to the anal verge <12 cm; (3) rectal adenocarcinoma confirmed by biopsy before neoadjuvant therapy; (4) complete cycle of neoadjuvant therapy; (5) patients undergoing radical LAR with sphincter preservation and protective ostomy; (6) patients receiving follow-up for more than 12 months after stoma reversal. Exclusion criteria: (1) patients as grade Ⅳ to Ⅴclassified by the American Society of Anesthesiologists (ASA); (2) patients with multiple primary colorectal cancer; (3) patients with history of other malignant tumors in the past 5 years; (4) patients of emergency surgery; (5) pregnant or lactating women; (6) patients with history of severe mental illness; (7) patients with contraindication of MRI, radiotherapy, chemotherapy, or surgical treatment. A total of 83 patients were enrolled, including 51 males and 28 females with median age of 59 years and mean BMI of (24.4±3.1) kg/m(2). EORTC QLQ-CR29, international erectile function index (IIEF), Wexner constipation score and low anterior resection syndrome (LARS) score were applied to investigate the QoL of the patients before neoadjuvant therapy, 3 and 12 months after ostomy reversal, including rectal anal function and sexual function. M (P25, P75) was used for the scores of the scale. Results: (1) EORTC QLQ-CR29 score showed that before neoadjuvant therapy, before surgery, 3 months and 12 months after ostomy reversal, anxiety [64.4 (52, 0, 82.5), 75.3 (66.0, 89.5), 82.6 (78.5, 90.0), 83.6 (78.0, 91.0)] and concern about body image [76.8 (66.0, 92.0), 81.1 (76.5, 91.5), 85.5 (82.5, 94.0), 86.1 (82.0, 92.0)] were improved (all P<0.01); pelvic pain [5.4 (2.0, 8.0), 5, 0 (2.0, 7.8), 3.9 (1.0, 5.0), 3.0 (1.0, 5.0)], urinary incontinence [15.7 (7.0, 22.0), 11.1 (0, 17.5), 10.0 (0, 17.0), 9.9 (0, 16.0)], impotence [14.3 (4.2, 19.0), 12.2 (0, 16.8), 5.6 (0, 10.0), 5.2 (0.2, 8.0)], urinate [26.4 (13.0, 38.5), 13.9 (0, 20.0), 13.4 (2.5, 21.5), 13.2 (2.0, 20.0)] and mucous bloody stool [4.7 (3.0, 6.0), 2.6 (0, 5.0), 2.2 (0, 5.0), 1.9 (0, 4.0)] were improved as well (all P<0.01). The scores fluctuated in the improvement of male sexual function, abdominal pain, dry mouth, worry about body mass change, skin pain and dyspareunia, but the symptoms were significantly improved after ostomy reversal compared with before neoadjuvant therapy (all P<0.05). There were no significant changes in female sexual function, dysuria, dysgeusia and fecal incontinence after ostomy reversal compared with before neoadjuvant therapy (all P>0.05). (2) IIEF scale showed that all scores were similar before and after neoadjuvant therapy (all P>0.05). (3) Rectal and anal function scale revealed that before neoadjuvant therapy, before operation, 3 months and 12 months after stoma reversal, gas incontinence [3.1 (0, 4.0), 2.3 (0, 4.0), 1.8 (0, 4.0), 1.2 (0, 3.0)] and urgent defecation [7.2 (0, 11.0), 5.2 (0, 11.0), 2.9 (0, 9.0), 1.7 (0, 0)] were improved (all P<0.001). In terms of improving incomplete emptying sensation, the symptoms fluctuated, but the symptoms improved significantly after ostomy reversal compared with before neoadjuvant therapy (all P<0.05). While the symptoms of assistance with defecation [0 (0, 0), 0.7 (0, 1.0), 0.6 (0, 1.0), 0.7 (0, 1.0)] and defecation failure [0.2 (0, 0), 1.0 (0, 2.0), 0.8 (0, 1.5), 0.8 (0, 1.0)] showed a worsening trend (all P<0.001). Stratified analysis was performed on patients with different efficacy of neoadjuvant therapy to compare the changes in QoL before and after neoadjuvant therapy. Patients with less sensitive and more sensitive neoadjuvant therapy showed similar changes in function and symptoms. Patients with less sensitive therapy showed significant improvement in dysuria, urinary incontinence, skin pain and dyspareunia (all P<0.05), and the symptom of defecation frequency in more sensitive patients was significantly improved (P<0.05). Conclusions: For patients with LARC, neoadjuvant radiochemotherapy combined with radical LAR and protective stoma can improve QoL in many aspects. It is noted that patients show a worsening trend in the need for assistance with defecation and in defecation failure.

Therapeutic Effect of Changqiang Acupoint Injection on Children with Functional Fecal Incontinence

Objective: Functional fecal incontinence in children (FFIC), also known as functional fecal disorder in children, is a type of childhood diseases characterized by excretory dysfunction. In the study, we observed the clinical effect of Changqiang acupoint injection on functional fecal incontinence in children (FFIC) by randomized controlled clinical trials.&lt;br/&gt; Materials and methods: 140 children with functional fecal incontinence who met the screening criteria were respectively assigned into the treatment group (100 cases) and the control group (40 cases) according to the completely randomized controlled design. In the treatment group, Chuankezhi injection was administrated at the Changqiang acupoint once a week for three weeks (one course of treatment). In contrast, the subjects in the control group was instructed to receive sphincter exercise and defecation training, followed by an assessment on the therapeutic efficacy after one course of treatment.&lt;br/&gt; Results: The overall response rate of the two groups was 93.00% (93/100) and 57.50% (23/40), respectively, with a statistically significant difference (P&lt;0.01). The treatment group showed a performance superior to the control group based on the Cleveland Clinic Florida Fecal Incontinence Score System (CCF-FI) — dry stool incontinence, liquid incontinence, gas incontinence, lifestyle change, necessity of using pads or antidiarrheals, the ability to delay defecation, and the total score. The inter-group comparison revealed a statistically significant difference (P&lt;0.01).&lt;br/&gt; Conclusion: Changqiang acupoint injection has significant curative effect on FFIC as demonstrated by significant relief in the symptoms associated with fecal incontinence, and thus is considered as a useful approach to be widely applied in clinical practice.

The use of electromyography in the diagnosis and treatment of anal sphincter dysfunctions

Proper function of the anal sphincters largely depends on the integrity and efficiency of neural structures involved in controlling the maintaining stool and gas continence and compliant with the physiology and an individual’s will to empty the intestines. Nervous system disorders and injuries disrupt the bioelectrical activity of anal sphincters, the evaluation of which is important for both the treatment process and its outcomes. Electromyography, which is the only objective approach for assessing resting tone, the ability to maintain sphincter contraction and EMG biofeedback therapy, is the method of choice for assessing the bioelectrical activity of muscles. Electromyographic data significantly accelerate the diagnostic process and effective treatment implementation. If neurogenic aetiology of sphincter disorders is found, it is necessary to implement the rehabilitation process. The therapeutic approaches for neurogenic bowel dysfunction and stool or gas incontinence mainly include sphincter electrostimulation and/or biofeedback exercises, performed by patients at home, after training in the doctor’s office. The course of rehabilitation should be monitored as part of periodic follow-up EMGs.

OPTIMIZATION OF PARARECTAL FISTULA SURGICAL TREATMENT

The aim: To improve the results of treatment of complex PF by the ligation of the intersphincteric fistula tract (LIFT). Materials and methods: 27 patients with transsphincteric fistulas of the rectum of different complexity have been operated by two methods: by ligature method ("cutting seton") and by the ligation of the intersphincteric fistula tract (LIFT). Results: No early complications were noticed in patients who had been applied the technique of fistula ligation in the postoperative period. The pain syndrome was expressed insignificantly. The rehabilitation period was less than 12 days. Having analyzed the long-term results of the observation period lasting up to 26 months, we arrived at the conclusion that the choice of surgical treatment had little effect on the recurrence rate of pararectal fistula (21.4 and 15.38%, respectively). However, one LIFT patient had gas incontinence within 1 year of surgery in contrast to 4 patients who had had a cutting ligature method having anal incontinence for 1 year and 1 patient - during the observation period. Conclusions: Ligation of the fistula in the intersphincter tract is an effective sphincter-preserving operation, does not require additional equipment and expensive consumables, is characterized by minimal damage to the anal sphincter and a high percentage of closure of PF (84.6%). The recurrence rate does not exceed 15.38%.

Ligation of the Intersphincteric Fistula Traject with Placement of a Prosthesis: A New Technique in the Treatment of Fistula-in-Ano at Yaounde Central Hospital (Cameroon)

Background: Ligation of the inter-sphincter fistula tract associated with anal plug (LIFT-Plug) is a new anal fistula treatment procedure at the Yaoundé Central Hospital. A two-sided prosthesis piece bent in the shape of a cone is used here as an anal plug. The aim of this work was to evaluate the therapeutic results and the safety of this device. Patients and Methods: The clinical data of patients operated by the LIFT-Plug technique from January 1, 2020 to June 30, 2021 for a high anal fistula were analyzed prospectively. The variables evaluated were operative time, cure rate, postoperative complications and recurrence rate. Results: We included 28 patients with a mean age of 42 years. The sex ratio was 1.15. No patient presented preoperative continence disorder. The fistula was high trans-sphincteric in 89.3% of cases. The average duration of surgery was 55.2 minutes (45 to 66 minutes). The postoperative course was straightforward, although 60.7% of the patients had experienced tingling that resolved spontaneously. Three patients (10.7%) presented with transient gas incontinence (WIS of 4) which completely resolved after one month. All patients healed within a mean of 63.21 days (25 to 95 days). At the end of the 6-month follow-up, no case of recurrence had been recorded. Conclusion: The LIFT-Plug is a simple, safe and effective technique for the treatment of upper anal fistula without major impairment of continence despite delayed healing. The adapted two-sided prosthesis is a good alternative to the conventional anal plug.

Effectiveness and Prognosis: Drainage Skin-Bridge Sparing Surgery Combined with Fistulotomy versus Fistulotomy Only in the Treatment of Anal Fistula.

Objective This study intends to analyze the difference in the efficacy of drainage skin-bridge sparing surgery combined fistulotomy (DSCF) and fistulotomy alone. Methods 125 patients with anal fistula were enrolled as study subjects and randomly divided into control group (CG) and observation group (OG) by double-blind lottery. The CG received drainage skin-bridge sparing surgery with fistulotomy and the OG received fistulotomy only. Results The VAS scores of the trauma in the OG were lower than those in the CG on 1st day of surgery and 7 days after surgery (P < 0.05). The length of hospital stay and time to wound healing were shorter in the OG than in the CG (P < 0.05). The incidence of postoperative bleeding in the OG was 9.52%, which was lower than 22.58% in the CG (P < 0.05). The rectal examination scores were lower in the OG than in the CG at 3 and 5 days postoperatively (P < 0.05). The Wexner scores of solid incontinence (0 to 4), liquid incontinence (0 to 4), gas incontinence (0 to 4), pad wearing (0 to 4), and lifestyle alteration (0 to 4) in the OG were lower than those of the CG at 5 days postoperatively (P < 0.05). Voiding function scores were lower in the OG than in the CG at 2 and 3 days postoperatively (P < 0.05). Conclusions The efficacy of drainage skin-bridge sparing surgery combined fistulotomy is better than that of fistulotomy alone, which can accelerate postoperative healing, enhance urinary function, reduce postoperative bleeding, and improve anal function.

Fecal incontinence in nonpregnant nulliparous women aged 25 to 64 years-a randomly selected national cohort prevalence study

The extent to which fecal incontinence is associated with obstetrical history or pelvic floor injuries is still a controversial andunresolved issue. One crucial first step toward answering this question is the need to study fecal incontinence in nonpregnant, nulliparous women. The aim of this study was to present detailed, descriptive measures of the accidental leakage of liquid or solid stool and gas in a randomly selected, large national cohort of nonpregnant, nulliparous women aged 25 to 64 years. The Swedish Total Population Register identified the source population. Four independent, age-stratified, simple random samples in a total of 20,000 nulliparous women aged 25 to 64 years were drawn from 625,810 eligible women. Information was collected in 2014 using postal and web-based questionnaires. The 40-item questionnaire included questions about the presence and frequency of the leakage of solid and liquid stool and gas, which provided the basis for the generic terms fecal and anal incontinence. Statistical analyses of the differences between the groups were performed using the Fisher's exact test for dichotomous variables and the Mann-Whitney U-test for continuous variables. The trend between >2 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. When analyzing the trend between multiple ordered vs nonordered categorical variables, the Kruskal-Wallis test was used. The age-related probability and risk increase per 10 years for incontinence parameters was calculated from logistic regression models adjusted for body mass index. The study population was 9197 women, and the response rate was 52.2%, ranging from 44.7% in women aged 25 to 34 years to 62.4% among those from 55 to 64 years. All the types of incontinence, except severe isolated gas incontinence, increased with age up to 64 years. The estimated probability of fecal incontinence was 8.8% at age 25 years and 17.6% at age 64. The leakage of liquid stool was dominant, occurring in 93.1% (95% confidence interval, 91.4-94.5) of the women with fecal incontinence, whereas leakage of solid stool occurred in 33.9% (95% confidence interval, 31.1-36.7), of which approximately 80% also had concomitant leakage of liquid stool. The leakage of liquid stool increased markedly up to age 65, whereas the increase in the isolated leakage of solid stool was negligible across all ages (overall <0.4%). Liquid and solid stool, separate or in combination, co-occurred with gas in approximately 80%. The distribution pattern of the different types of leakage, single or combined, was similar in all the age groups. Both age and body mass index (kg/m2) were risk factors for fecal incontinence (P<.0001), with an interaction effect of P=.16. Abnormal stool consistency has been identified as the strongest risk factor for accidental bowel leakage. The same pattern characterized by a dominance of liquid stool and gas leakage, prevalent concomitant leakage of solid and liquid stool, and a negligible rate of isolated leakage of solid feces was observed across all ages. The low rates of isolated leakage of solid stool support the impression that dysfunction of the continence mechanism of the pelvic floor had a negligible role for bowel incontinence, which is essential information for comparison with women with birth-related injuries.