Gas Incontinence Research Articles

CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION.

SUMMARYAnterior rectal resection is a standard surgical procedure for treating carcinomas of rectum and distal sigmoid colon. In many cases of anterior rectal resection, postoperatively some level of fecal incontinence may occur. The aim of our study was to evaluate the impact of the colorectal anastomosis level on anorectal functional disorder. In our prospective study, the participants were patients diagnosed with carcinoma of rectum or distal sigmoid colon. All patients underwent standard open or laparoscopic anterior rectal resection. Six months after the surgery, the function of anorectum was evaluated in all participants. Finally, 38 patients were analyzed, including 13/38 (34.2%) patients with high rectal anastomosis, 11/38 (28.9%) with mid rectal anastomosis and 14/38 (36.8%) with low rectal anastomosis. Patients with a lower level of anastomosis had a statistically significantly greater number of stools, higher urgency and discrimination impairment, more pronounced solid, liquid and gas incontinence, and greater need for diapers (p<0.05 all). Therefore, patients with lower anastomosis had a statistically significant impairment of their quality of life and higher Wexner score (p<0.001 for both analyses). Our study results suggested reduced neorectal capacity to be the main pathophysiological factor for the development of postoperative anorectal function impairment.

Nigam′s Modified Roeder′s Knot in Cutting Seton in High Fistula-in-ano Prevents Rethreading and Reapplication of Seton

Background: Fistula-in-ano is known for its recurrence and other complications after surgery, especially in high fistulae cases. Use of a cutting seton is an accepted mode of treatment for high fistula-in-ano cases. Nigam's modified Roeder's knot (NMRK) makes the cutting seton adjustable. The aim of our study is to investigate the results of NMRK application in cutting seton in relation to reapplication, rethreading, postoperative inconvenience to the patient, and postoperative complications. Objectives: To determine whether the NMRK in cutting seton reduces the chances of seton reapplication and postoperative complications in high fistula-in-ano. Design: Squire---Quality Improvement Study. Setting: Patients admitted in various hospitals in Gurugram, Haryana, India. Materials, Methods, and Main Outcome Measures: Eighty high fistula-in-ano patients underwent fistulactomies using the NMRK in both the cutting and adjustable setons between January 2001 and January 2019. Informed consent was obtained from each patient. The patients were evaluated for seton reapplication, inconvenience, recurrence, fecal incontinence, and other postoperative complications. Sample Size: Eighty high fistula-in-ano patients underwent fistulactomies using the NMRK in both the cutting and adjustable setons Results: In our series, no patient suffered fecal incontinence. Three patients (3.75%) had gas incontinence, which gradually stopped within 2 weeks. Most of the setons took 4– 6 weeks to drop. The healing time was 6– 8 weeks for majority of the patients. Two patients (2.50%) developed recurrence after surgery. No patient required readmission or anesthesia for seton reapplication. Conclusion: If the cutting seton with the NMRK is retightened every week, then the drop time of the seton and the total healing time decrease, resulting in reduced incidence of inconvenience, pain, fecal incontinence, and recurrence. Rethreading or reapplication of seton is not required. Limitations: Our study includes only uncomplicated high fistula-in-ano cases. It also excludes complex fistulae, watercan perineum, and fistulae with inflammatory bowel disease or cancer. Conflict of Interest: None. Keywords: Cutting seton, fecal incontinence, fistula-in-ano, Nigam's modified Roeder's knot, recurrence

Laparoscopic pelvic organ suspension with mesh: a modified technique and primary results

BackgroundPelvic organ prolapse recurrence rate is an important issue which impacts the patient's quality of life and results in a new surgical procedure. We use a new technique of laparoscopic pelvic organ suspension (rectal suspension) for pelvic organ prolapse treatment in our center. We evaluated the results of this technique, three months after surgery and at the time of study reporting. MethodsAll patients with pelvic organ prolapse for whom laparoscopic pelvic organ prolapse had been done were evaluated. Data were collected from the patient's charts and their short term follow up 3 months after the surgery and their last follow up visit. Demographic, history, physical examination, Wexner's fecal incontinence score and Altomare's Obstructed Defecation Syndrome score, post-operation complications and patient's satisfaction were analyzed, retrospectively. ResultsAll patients were female with a mean age of 57±11.43 years (range 32–86 years). Mean BMI was 26.1±3.73. Nine patients had rectal bleeding (31%), 18 had prolonged or difficult defecation (62%), 16 had rectal prolapse (55.2%), 11 had gas incontinence (37.9%), 9 had liquid stool incontinence (31%), 5 had stool incontinence (17.2%), 9 had vaginal prolapse (31%), 23 had constipation (79.3%), 9 complaint of pelvic pain (31%), 9 had urge or stress urinary incontinence (31%) and 13 had dyspareunia (44.8%). ConclusionsIn conclusion, we believe this procedure has good results in short term follow up (3 months after surgery), but a high recurrence rate in the middle term follow up. Therefore, this procedure is no longer recommended.

Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis.

Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review. Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI. Out of the2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3months often resolved at 1year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes. There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.

Comparison of postoperative bowel function between patients undergoing transanal and laparoscopic total mesorectal excision

To compare the effects of transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laparoscopic TME) on patients' postoperative long-term bowel function. A retrospective cohort study was used in this study. We analyzed the clinical data of 134 patients with locally advanced mid-low rectal cancer, who underwent transanal TME or laparoscopic TME in the TaLaR randomized controlled trial at the Sixth Affiliated Hospital, Sun Yat-sen University from April 2016 to November 2017. Inclusion criteria included age of 18 to 80 years old, distance from tumor low margin to anal edge ≤10 cm, preoperative staging of T1-3NxM0, and single rectal adenocarcinoma. Exclusion criteria included local recurrence, distant metastases, abdominoperineal resection, unreduced stoma, new stoma, less than 1 year after protectomy or stoma reduction, or preoperative poor anal function or incontinence. Patients were divided into taTME group and laparoscopic TME group. The taTME group received hybrid transanal and transabdominal approach performed simultaneously. The effects of surgical procedures on postoperative bowel function were evaluated with LARS (low anterior resection syndrome) scale, where 0-20 was defined as " no LARS" , 21-29 as " minor LARS" , and 30-42 as " major LARS" . Univariate and multivariate logistic regression analyses were performed to determine the risk factors associated with major LARS, with surgical approach as a pre-selected variate. A total of 107 patients were included. Of the 54 patients in the taTME group, 35 were male, median age was 57.2 (26.0-77.0) years old, and 22 cases had a tumor less than 5 cm from anal verge. Of the 53 patients in the laparoscopic TME group, 35 were male, median age was 62.0 (33.0-73.0) years old, and 25 cases had a tumor less than 5 cm from anal verge. All baseline clinical data including age, gender, preoperative staging, and tumor height were comparable between the two groups (all P>0.05). All operations in both groups were performed successfully. The operation time, intra-operative blood loss, postoperative anastomotic complication, postoperative hospital stay were comparable between the two groups (all P>0.05), except for a lower diverting stoma rate in the taTME group [37.0% (20/54) vs. 64.2% (34/53), χ²=7.866, P=0.005]. Of the 107 patients, 27 (25.2%) had no LARS, 32 (29.9%) had minor LARS, and 48 (44.9%) had major LARS, after a median follow-up of 17.2 (12.1-30.4) months. No significant difference was found between the two groups in overall bowel function [major LARS: 48.1% (26/54) vs. 41.5% (22/53), Z=-0.994, P=0.320]. Compared with the laparoscopic TME group, the taTME group experienced worse clustering of stools [68.5% (37/54) vs. 45.3% (24/53), Z=-2.354, P=0.019]. However, there were no significant differences between the two groups in terms of gas incontinence, liquid stool incontinence, frequency of defecation, and urgency (all P>0.05). Multivariate analysis identified preoperative radiotherapy (OR=5.073, 95% CI: 1.336 to 19.259, P=0.017) and anastomotic height (OR=3.633, 95% CI: 1.501 to 8.802, P=0.004) as independent risk factors for major LARS, but no impact of taTME on LARS (OR=1.442, 95% CI: 0.638 to 3.261, P=0.379). Compared with laparoscopic TME, taTME has similar outcomes of postoperative long-term bowel function. Preoperative radiotherapy and anastomotic height, but not surgical approach, are independent risk factors for postoperative bowel function.

Long-Term Outcomes of Ligation of the Inter-Sphincteric Fistula Tract Plus Bioprosthetic Anal Fistula Plug (LIFT-Plug) in the Treatment of Trans-Sphincteric Perianal Fistula.

BackgroundThe ligation of the inter-sphincteric fistula tract plus bioprosthetic anal fistula plug (LIFT-plug) is a new procedure in the treatment of trans-sphincteric perianal fistulas. The aim of this study was to evaluate its long-term outcomes.Material/MethodsClinical data of 78 patients with trans-sphincteric perianal fistula who were managed by the LIFT-plug technique between March 2014 to October 2016 were analyzed retrospectively. The operation time, healing rate, postoperative complications, recurrences, and length of stay were reviewed.ResultsNo serious complications occurred during the operation in all patients. The median follow-up was 30 months (16 to 47 months), clinical healing of the anal fistula occurred in 75 patients (96.2%). The median operative time was 25 minutes (18 to 45 minutes). The mean complete healing time was 16 days (9 to 46 days). The median healing time for the external anal fistula opening was 2 weeks (range, 2 to 3 weeks), and the inter-sphincteric groove incision healing time was 4 weeks (range, 3 to 7 weeks). The median hospital stay after operation was 5 days. Fistula recurred in 2 patients because of spontaneous expulsion of the plug at 7 days post-surgery; perianal abscess occurred in 1 patient. The anal function was evaluated in 70 patients of the 78 patients. Perfect control of continence was recorded for 97.1% of the patients (68 out of 70 patients). Two patients were identified to a rare complication of gas incontinence (Wexner score 1).ConclusionsLIFT-plug procedure for the treatment of trans-sphincteric fistulas is a simple procedure with a high healing rate, minimal invasiveness, quick healing, and without disturbance to anal function. LIFT-plug is an ideal procedure for trans-sphincteric fistula.

Evaluation of the results of patients who had undergone lateral internal sphincterotomy due to chronic anal fissure: analysis of 281 cases

Introduction and purpose: Pharmacological and surgical treatment options are available for the treatment of chronic anal fissure (CAF). Pharmacological treatments include treatment modalities such as glyceryl trinitrate, calcium channel blockers and alpha-adrenoreceptor antagonists. Surgical treatment options include anal dilatation and sphincterotomy, and among many sphincterotomy procedures open lateral internal sphincterotomy (open LIS) is now considered the gold standard. The aim of this study was to investigate the demographic data, complaints, early and late complications of patients who have undergone LIS due to chronic anal fissure and to contribute to the literature. Material and method: Data of 281 patients who have undergone open LIS operation between 2013-2018 due to chronic anal fissure that did not respond to conservative treatment were analyzed retrospectively. Age, gender, complaint (pain, bleeding, constipation, itching), follow-up period and postoperative complication (infection, bleeding, pain, fistula, gas or stool incontinence) data of the patients were evaluated retrospectively. Patients with gas or fecal incontinence were evaluated with Wexner incontinence score. Results: Out of 281 patients, 197 were female (70.1%), 84 were male (29.9%). Female / male ratio was 2.34. The mean age was 40.31 ± 13.59 (min 18-max 84) years. The mean follow-up period was 24.53 (min 6 - max 67) months. In 248 (88.3%) patients, pain was noted during defecation, while bleeding was noted in 208 (74%) patients, constipation was noted in 133 (47.3) patients and perianal itching was noted in 91 (32.4%) patients. In 7 (2.5%) patients, infection occurred at the site of operation. Perianal fistula was seen in one patient (0.4%), recurrence was seen in 12 (4.3%), transient gas incontinence was seen in 4 (1.8%) and fecal incontinence was seen (0.35%) in 1 patient. Seven patients who had developed infection responded to oral antibiotic treatment and none of them developed abscesses. Result: As a result, open LIS operation is an efficient and effective surgical treatment method for the treatment of CAF.

CLINICAL AND MANOMETRIC ASSESMENT OF FUNCTIONAL STATE OF ANAL SPHINCTER IN PATIENTS AFTER FISTULECTOMY WITH PRIMARY SPHINCTEROPLASTY

AIM: to evaluate changes of anorectal manometry parameters and clinical symptoms of fecal incontinence 3 months after fistulectomy with primary sphincteroplasty. MATERIALS AND METHODS: fifty-two patients (37 males) with complex anal fistulae of cryptoglandular origin underwent fistulectomy and primary sphincteroplasty. The fistulas were recurrent in 13 (25 %) cases, 8 (15,4 %) patients had preoperative fecal incontinence. Fecal incontinence Wexner score was 0,46 (0-8) before surgery. Anorectal manometry was performed before and 3 months after surgery. RESULTS: three months days after surgery mean and maximum resting anal pressure were not significantly low compared with the baseline. In patients with initially normal data before the surgery (n=22), resting anal pressure was significantly lower (before surgery M=56,1 ± 7,6 [46,1-69,0], after surgery 45,5 ± 8,8 [38,0-63,0], p=0,006, Wilcoxon test). There were no significant changes in squeezing anal pressure. Resting anal pressure has become below the normal after surgery in 13 (59.1 %) patients. Clinical symptoms of fecal incontinence was detected in 10 patients postoperatively (gas incontinence and soiling). Fecal incontinence Wexner score was 1,64 (0-11) after surgery (p=0,007). CONCLUSION: fistulectomy with primary sphincteroplasty leads to change of resting anal pressure basically in patients with initially normal pressure and mainly - in patients with anterior fistulas. Fecal incontinence symptoms after with surgery produced 26,3 % patients. These data confirm the need of individual approach when choosing the method of surgical treatment of analfistulae.

Treatment of chronic anal fissure: Is open lateral internal sphincterotomy (LIS) a safe and adequate option?

Anal fissure which is defined as a longitudinal tear in anoderm under the dentate line is one of the most common benign diseases of anorectal area, and due to the severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. There are several treatment methods such as medical substances and surgical procedures. In this retrospective study, we aimed to evaluate the safe and adequate option of lateral internal sphincterotomy (LIS) in chronic anal fissure treatment. This study is a retrospective study in which 417 patients who were treated for chronic anal fissure were included. Of 417 patients included in the study, 228 (54.7%) were female and the mean±SD age was 36.1±8.96 years (ranging from 17 to 73 years). Major complaints of patients; pain, bleeding, constipation, pruritus, perianal discharge. Recurrence occurred in 15 patients (3.6%) (12 males, three females) and eight patients (1.9%) developed incontinence (four with gas, four with soiling and seven females, one male). The complaints of all patients with gas incontinence and a patient with fluid incontinence regressed, whereas three patients had permanent fluid incontinence. LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Outcomes of Management of Anal and Perianal Suppuration at Niamey National Hospital, Niger

Bakground: Anal and perianal sepsis is common anorectal disorders found in surgical practice. This study aims to report epidemiological aspects and outcomes of management of anal and perianal suppuration. Methods: This was a retrospective study from January 2011 to June 2016 at Niamey National Hospital. Patients operated on for anal and perianal suppuration of non-specific anorectal origin were included. Results: During the study period, we collected 141 cases of anal and perianal suppurations. The average age of our patients was 42±8.8 years. The sex ratio was 3.27 in favor of men. The origin of the patients was urban in 73.8% of the cases. The history of diabetes mellitus was found in 14.2% (n=20). Anal fistulas and anal abscesses (n=115) were simple in 46% (n=53) and complex in 54% (n=62). A fistulectomy with the placement of an elastic seton was performed for 41.13% of cases (n=58) and fistulotomy in 29.78%. The evolution of 6 months was marked by a recurrence in 10.63% (n = 15), the anal incontinence of gas at 9.21% (n=13). Deaths (n=4) were recorded in patients with Fournier’s gangrene. Uncomplicated therapeutic success was 80.13% (n=113). Conclusion: The surgical treatment of anal fistula (the main cause of anal and perianal suppuration) aims to eradicate the suppuration and to preserve the anal continence. The fistulotomy done in the context of the management of a simple fistula gives a better outcome. Incontinence-related complications and relapses must impose thoroughness and patience in the surgical treatment of complex fistulas.

Outcome of Hemorrhoidectomy with the Ligasure in Comparison with the Traditional open Method

OBJECTIVETo compare the operative time and outcomes of Ligasure hemorrhoidectomy with that of the traditional open hemorrhoidectomy.METHODOLOGYA total of 49 patients were included in this study. Out of which 24 were in the Ligasure group and 25 in the open group. The main objective or the primary variable was to assess the operative time for the excision of a single hemorrhoidal lesion, the need for morphine, for post operative pain relief and any other complications such as preoperative bleeding and the time to return to work. The data like age, sex, type of Haemorrhoidectomy, type of complicating etc. were recorded in already prepared proforma. The data was analysed through computer program SPSS10.RESULTSThe demographic data were comparable between the two groups. The time spent in excision of a solitary hemorrhoidal lesion was significantly shorter in the Ligasure group compared to the open group (8.25 min Vs 16.75 min ) and this difference was found to be statistically significant (p&lt;0.001). Operative bleeding was also significantly lower than the open method of Haemorrhoidectony. Other parameters like post operative pain, opioid requirement, urinary retention and chronic complications like anal stenosis and gas incontinence were not significant. There was no difference in the period of convalescence and return to work between the two groups.CONCLUSIONHemorrhoidectomy with the Ligasure entails a shorter surgical time and could be associated with a lesser pain besides being safer.

Interview-based versus self-reported anal incontinence using St Mark's incontinence score.

St Mark's incontinence score (SMIS) was originally designed and validated for use in an interview setting (iSMIS), and there is conflicting evidence for the validity of the self-administered SMIS (sSMIS). Our objective was to compare self-administered and interview-based reports of anal incontinence (AI) symptoms. A total of 147 women reported symptoms of AI on a sSMIS before inclusion in a clinical study investigating the effect of conservative treatment for AI 1year after delivery. After clinical investigations, an iSMIS was completed by one of two consultant surgeons blinded to the sSMIS results. The correlation and agreement among the individual items of the iSMIS and the sSMIS were assessed using Spearman's rho and weighted kappa statistics, respectively. The mean iSMIS and sSMIS reported was 4.0 (SD: 3.6) and 4.3 (SD: 4.0), respectively. Spearman's rho showed a strong relationship between the two total SMIS scores (r=0.769, n=147, p<0.001), and explained variance was 59% (r2=0.591). Except for the individual item about gas incontinence, women reported more frequent AI symptoms on the sSMIS than on the iSMIS. The assessment of consistency among the individual items of the iSMIS and sSMIS showed substantial agreement (κ≥0.60) for all items except for fair agreement for the item about formed stool incontinence (κ=0.22), and moderate for the item about any change in lifestyle (κ=0.5). The level of consistency between the two methods of reporting anal incontinence symptoms suggests that theSt Mark's score may be used as both an interview-based and a self-administered incontinence score.

Évaluation de la qualité de vie et des symptômes avant et après prise en charge chirurgicale des fistules rectovaginales

Rectovaginal fistula requires a complex management because it has an important psychological impact associated with impaired quality of life of patients. Thus, the aim of our study was to evaluate the improvement of the quality of life of patients after surgical management. This is a retrospective study. We included patients operated between 2009and 2014for the treatment of a rectovaginal fistula, whose data were available and who agreed to answer a questionnaire. We evaluated the satisfaction of short-term and long-term patients on the answer to the basic PFDI-20and PFIQ-7questionnaires. We then evaluated whether there was an improvement in symptoms and quality of life after surgery. Nine patients were included but only 4patients completed the PFDI-20and PFIQ-7questionnaires. Fistula was secondary to either surgical intervention (44%, n=4) or complicated perineal tear (44%, n=4) or unknown cause (11%, n=1). After surgery, we found the short term a significant decrease in stool incontinence, as there was no stool incontinence (0/5) in the postoperative period, while preoperatively 55% (5/9) (P=0.03). Postoperatively, 33% (3/9) of the patients had genital discomfort and 44% (4/9) had gas incontinence compared to 0% preoperatively (P=0.2and P=0.6). There appears to be an improvement in pelvic static disorders after surgical management. However, we found a slight improvement in nauseous leucorrhoea in the immediate postoperative period, as the prevalence decreased from 33% (3/9) preoperatively to 22% (2/9) postoperatively (P>0.9). In the long term, we observed an improvement in the sensation of perineal heaviness and gas incontinence because only 25% (1/4) of the 75% (3/4) preoperative patients still showed slight discomfort (P=0.5). The quality of life and the emotional state of the patients were no altered postoperatively. Indeed, preoperatively, 50% (2/4) of the patients reported anxiety compared to 0% (0/4) postoperatively (P=0.4). Similarly, 75% (3/4) complained of a decrease in their quality of life (social, sports, etc.) preoperatively compared with 0% (0/4) postoperatively (P>0.9). A simple surgical management of rectovaginal fistulas would allow a significant decrease in stool incontinence and improved quality of life and their emotional state, which confirms the beneficial effect of this therapeutic strategy. 4.

SPHINCTEROMETRY GRADATION OF ANAL SPHINCTER INSUFFICIENCY

PURPOSE. To determinate manometric parameters for different degrees of anal sphincter insufficiency (ASI) by the non-perfusion water sphincterometry with measurement device WPM Solar (MMS, The Netherlands). METHODS. The study included 228 patients with complaints of incontinence of various components of the intestinal contents. Among them were 94 (41,2%>) men, mean age 47,3±16,8 year, 134 (58,8%) women, mean age 49,1±15,9 year. The patients were divided according to the clinical classification of anal sphincter insufficiency (ASI) developed by Russian State Research Center of Coloproctology. Grade I was present in 112 (49,1%) patients complaining of gas incontinence. Grade II - in 80 (35,1%) patients with gas and liquid incontinence. Grade III - in 36 (15,8%) patients with all components incontinence. The Cleveland Clinic (Wexner) fecal incontinence score applied to all patients as the subjective assessment of the severity ASI. For an objective assessment of the anal sphincter insufficiency used sphincterometry. RESULT. This study has allowed to build a reliable reference intervals manometric and score (Wexner scale) parametrs for all grades ASI, separately for men and women First grade ASI (male/female): mean resting pressure - 32,8-42,0 / 36,3-40,0 mm Hg, max. squeeze pressure -115,0-120,0 / 97,4-109,0 mm Hg, mean squeeze pressure - 89,5-105,0 / 68,8-87,0 mm Hg, squeeze gradient - >79,5 / 73,6 mm Hg, score - 10,2 / > 10,8.

Clinical Management of Bowel Dysfunction After Low Anterior Resection for Rectal Cancer

The American Cancer Society estimated that 39,610 new cases of rectal cancer were diagnosed in the United States in 2015. Surgery is the primary treatment for rectal cancer, with the majority of patients undergoing sphincter-preserving surgery with low anterior resection. Although low anterior resection can prevent patients from having a permanent colostomy, bowel dysfunction may occur in 60% to 90% of patients. Bowel dysfunction symptoms may include fecal and gas incontinence, urgency, frequent bowel movements, clustering of stools, and difficulty emptying. The symptoms collectively are referred to as low anterior resection syndrome (LARS) and adversely affect quality of life. There are no specific therapies for management of LARS. This comprehensive literature review evaluates evidence-based, clinical nonsurgical interventions for symptom management of LARS and will assist advanced practitioners in recognizing symptoms and implementing clinical interventions in the outpatient setting for management of LARS.

Surgical management of anal stenosis: anoplasty with or without sphincterotomy

AimAnal stenosis is an uncommon complication of anorectal surgery, mostly resulting from circumferential hemorrhoidectomy or resection of the skin tag in surgical management of chronic anal fissure. The aim of anoplasty is to restore normal function to the anus by dividing the stricture and widening the anal canal. Internal sphincterotomy may cause gas incontinence and if we manage the stenosis without sphincterotomy it could be failed. Could we use anoplasty without sphincterotomy? MethodThe patients with anal stenosis were assigned in to two groups. The first group underwent Y-V anoplasty without partial lateral internal sphinctrotomy and the second one underwent Y-V anoplasty with partial lateral internal sphinctrotomy. ResultA total of 25 patients (10 male and 15 female) underwent anoplasty, 14 without partial lateral internal sphincterotomy and 11 patients with partial lateral internal sphincterotomy. The healing rate of stenosis was 91% and 93% in groups undergoing anoplasty without partial lateral internal sphinctrotomy and anoplasty with partial lateral internal sphictrotomy, respectively (p value 0.69). There was no significant change in both groups for post-operative incontinence complaints. ConclusionThe healing rate of anal stenosis was the same in the patients who underwent Y-V anoplasty with or without partial lateral internal sphinctrotomy. There was no significant change in post-operation incontinence between the two groups. Therefore, Y-V anoplasty would be a safe and simple surgical method in selected patients. Partial lateral internal sphinctrotomy procedure has been noticed in individual cases.

Long-term results of ligation of intersphincteric fistula tract (LIFT) for management of anal fistula

BackgroundLigation of intersphincteric fistula tract technique is a new sphincter saving method with good results in management of anal fistula, but few studies report long-term follow-up data. Material and methodsThis study investigated the use of ligation of intersphincteric fistula tract as a sphincter saving method based on long term results. This was a retrospective review of prospectively collected data. The study was conducted at two tertiary care university medical centers. 36 patients with complex fistula from January 2010 to January 2014 treated with classic ligation of intersphincteric fistula tract were retrospectively followed. Demographic data, previous repair attempts, the type of the fistula and score of fecal continence were collected. The procedure was performed by colorectal surgeons. Primary healing rate, failures and fecal incontinence score of patients were followed for 6–48 months. ResultsA total of 36 patients underwent ligation of intersphincteric fistula tract during 24 months. The mean age of the patients was 35 years and 50% had two previous attempts at surgery. A total of 25 patients (69/5%) had high transsphincteric fistula. The mean follow up was 27 months. Successful fistula closure was achieved in 63/8% of the patients (23 of 36). The mean time of recurrence was 4.5 weeks. Only one (2/77%) patient reported gas incontinence (score: 3) after the procedure. ConclusionThe recurrence rate and fecal incontinence were measured. The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe. Our study demonstrates favorable long-term results of ligation of intersphincteric fistula tract for management of complex anal fistulas.

Pulling Seton: Combination of mechanisms.

Background:Seton-based techniques are among popular methods for treating high type anal fistula. These techniques are categorized to cutting and noncutting regarding their mechanism of action. In this report we are about to describe a new technique, which is a combination of both mechanisms; we call it Pulling Seton.Materials and Methods:In this technique after determining internal and external orifice of fistula, fistulectomy is done from both ends to the level of external sphincteric muscle. Finally, a remnant of fistula, which remains beneath external sphincteric muscle is excised, and Seton is passed instead of it and tied externally. After the wound heals, patient is asked to pull down the Seton for 3–4 min, 4 times a day. We prospectively enrolled 201 patients with high type anal fistula in this study.Results:Seton gradually passes through external sphincteric muscle till it is displaced outwards or removed by a surgeon via a small incision. 94% of patients treated by this method accomplished their treatment completely without recurrence. None of the patients developed permanent fecal or gas incontinence. Only 5% of patients developed with recurrence of fistula. Since Seton traction is not permanent in this technique, Seton cuts external sphincter slowly, and minimal rate of incontinence is reported.Conclusion:Pulling Seton seems to be an efficient way in treating high type anal fistula with minimal rate of recurrence and complications such as incontinence and authors suggest further randomized studies to compare its efficacy with other Seton-based techniques.

Long-term anorectal, urinary and sexual dysfunction causing distress after radiotherapy for anal cancer: a Danish multicentre cross-sectional questionnaire study.

The objective of primary radiotherapy for anal cancer is to remove cancer while maintaining anorectal function. However, little is known about anorectal function among long-term survivors without colostomy. Using a cross-sectional questionnaire study, we examined symptoms and distress related to the dysfunction of pelvic organs after radiotherapy for anal cancer. A questionnaire regarding anorectal, urinary and sexual symptoms was sent to anal cancer patients without recurrence or colostomy, diagnosed during 1996-2003, and treated with curative intent (chemo)radiotherapy at three Danish centres. For each symptom we assessed frequency and severity and the level of symptom-induced distress (no, little, moderate or great distress). Of 94 eligible patients, 84 (89%) returned the completed questionnaire at a median of 33 months after radiotherapy. Incontinence for solid stools, liquid stools and gas occurred at least monthly in 31%, 54% and 79% of patients, respectively. Overall 40% of patients reported great distress from incontinence for solid or liquid stools at least monthly. Faecal urgency occurring at least monthly was experienced by 87% of patients and caused great distress in 43%. Stress, urge or another type of urinary incontinence occurred at least monthly in 45% and caused great distress in 21%. Urinary urgency occurred at least monthly in 48% but only caused great distress in 14%. Sexual desire was severely decreased in 58% and only 24% were satisfied with their sexual function. Distressing long-term anorectal and sexual dysfunction was common after radiotherapy for anal cancer, and morbidity due to urinary dysfunction was moderate.

Long-term effects of neoadjuvant chemoradiotherapy followed by sphincter-preserving resection on anal sphincter function in relation to quality of life among locally advanced rectal cancer patients: a cross-sectional analysis.

BackgroundThere is growing recognition for the consequences of rectal cancer treatment to maintain an adequate functional sphincter in the long-term rather than preserving the anal sphincter itself. This study aims to evaluate long-term effects of neoadjuvant chemoradiotherapy (nCRT) followed by sphincter-preserving resection on anal sphincter function in relation to quality of life (QoL) among locally advanced rectal cancer patients.MethodsTwenty-nine patients treated with nCRT followed by low anterior resection surgery were included in this study. Data on patient demographics, tumor location and symptoms of urgency and fecal soiling were recorded and evaluated with respect to Wexner Fecal Incontinence Scoring Scale, European Organization for Research and Cancer (EORTC) cancer-specific (EORTC QLQ-C30) and colorectal cancer-specific (EORTC QLQ-CR38) questionnaires and anorectal manometrical findings. Correlation of manometrical findings with Wexner Scale, EORTC QLQ-CR38 scores and EORTC QLQ-C30 scores was also evaluated.ResultsMedian follow-up was 45.6 months (ranged 7.5–98 months. Higher scores for incontinence for gas (p = 0.001), liquid (p = 0.048) and solid (p = 0.019) stool, need to wear pad (p = 0.001) and alteration in life style (p = 0.004) in Wexner scale, while lower scores for future perspective (p = 0.010) and higher scores for defecation problems (p = 0.001) in EORTC QLQ-CR38 were noted in patients with than without urgency. Manometrical findings of resting pressure (mmHg) was positively correlated with body image (r = 0.435, p = 0.030) and sexual functioning (r = 0.479, p = 0.011) items of functional scale, while rectal sensory threshold (RST) volume (mL) was positively correlated with defecation problems (r = 0.424, p = 0.031) items of symptom scale in EORTC QLQ-CR38 and negatively correlated with social function domain (r = −0.479, p = 0.024) in EORTC QLQ-C30. RST volume was also positively correlated with Wexner scores including incontinence for liquid stool (r = 0.459, p = 0.024), need to wear pad (r = 0.466, p = 0.022) and alteration in lifestyle (r = 0.425, p = 0.038).ConclusionThe high risk of developing functional anal impairment as well as the systematic registration of not only oncological but also functional and QoL related outcomes seem important in rectal cancer patients in the long-term disease follow-up.