Severe Fecal Incontinence Research Articles

Sacral nerve stimulation for the treatment of severe fecal incontinence: long-term quality of life and functional outcomes

The aim is to determine whether good functional and quality of life results of sacral nerve stimulation (SNS) in patients with severe fecal incontinence are maintained in the long-term. Consecutive cohort of patients with severe fecal incontinence not responding to conservative (drugs and/or biofeedback) or surgical (sphincteroplasty) treatment, undergoing SNS between 2002 and 2013. Patients with a definitive implant were individually assessed in consultation throughout the follow-up, until January 2016. Defeca-tory function was assessed by Wexner score and stool diary, and perceived quality of life by FIQL and EQ-5D question-naires. Acute percutaneous nerve evaluation (PNE) was performed on 93 patients; a temporary electrode was implanted in 91 (79.1% women, mean age 62.5 years), obtaining a good functional response in 64. A permanent implant was per-formed in 61 patients, with a mean follow-up of 78.1 months (SD: 35.4; range 1-161); at the end of the study 42 patients remained in follow-up. A significant decrease was observed in the number of days per week with an incontinent episode, from 4.98 (SD 2.1) to 1.25 (SD 1.7), and in Wexner score from 16.88 (SD 2.74) to 6.95 (SD 3.54). Specific FIQL and generic EQ-5D questionnaires showed a significant improvement in quality of life. Long-term functional and quality of life outcomes of SNS for the treatment of severe faecal incontinence is maintained, with individual follow-ups that reach 10 years.

Magnetic resonance imaging of the anal sphincter and spine in patients with anorectal malformations after posterior sagittal anorectoplasty: a late follow-up cross-sectional study.

We aimed to assess the association of fecal incontinence to the anatomy of the anal sphincter complex and lower bony spinal anomalies as investigated with magnetic resonance imaging (MRI) in adolescents and adults with anorectal malformations (ARM) after posterior sagittal anorectoplasty (PSARP). We conducted a cross-sectional study in 20 patients with ARM after PSARP. Anatomy of the anorectum and spine were examined with MRI and functional outcome assessed with the Wexner incontinence score. We included 20 patient (12 males) had a median age of 19.5years (14-27). One patient was excluded leaving 19 patients for outcome analysis. Fecal incontinence was found in 12 out of 19 patients (63%). Interposed fat was present in 9 patients (47%). The presence (r = 0.597, p = 0.012) and thickness of interposed fat (r = 0.832, p = 0.005) between the anal sphincter complex and bowel were positively correlated to the Wexner fecal incontinence score. No correlation was found between lower bony spinal anomalies and fecal incontinence. A positive correlation between interposed fat and higher Wexner fecal incontinence score was found indicating a more severe fecal incontinence but no other correlation between anatomy of the anal sphincter complex and neorectum to functional bowel outcome was observed.

Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries

The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory. This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries. Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components. The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204). The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.

Patient Characteristics and Treatments for Women With Moderately Severe Fecal Incontinence [36F

INTRODUCTION: Surgical treatments, such as sphincteroplasty or sacral neuromodulation, are available for fecal incontinence (FI). There has been increasing attention on the progress to surgical treatment for overactive bladder, but little is known about the progress towards this therapy for FI. METHODS: This was a retrospective chart review of all new patients presenting to an academic Urogynecology clinic with Wexner Incontinence Scale scores of 11-14 (equivalent to moderately severe FI). Demographics, prior treatments, and how long it took for patients to proceed to definitive treatment were collected. Our prior work described women with severe FI (Wexner score 15–20). With this study we sought to describe women with moderately severe FI and compare moderate to severe FI groups. RESULTS: From January 2014 to July 2017, 158 new patients with a Wexner score of 11-14 were seen in clinic. The mean age was 62.5 +/-12 years. The majority (n=117, 77%) had never had any treatment for FI. The most common treatment plan at the first visit was fiber and dietary modifications (n=59, 38%). Only 3 patients went on to surgical treatment. There were no significant differences between those with moderate versus severe FI in how many ultimate progressed to surgical therapy (3 versus 6) or the number of clinic visits until that decision was made (2 versus 3), all p&gt;.05. CONCLUSION: Very few patients progress to surgical treatment despite at least moderately severe FI. Further work is needed to facilitate timely delivery of definitive care for this patient population.

Application value of self-made perianal skin nursing strategy of device in the severe diarrhea or fecal incontinence

Objective To explore the application effect of self-made nursing strategy of device in the severe diarrhea or fecal incontinence. Methods A total of 60 patients with severe diarrhea or fecal incontinence were randomly divided into study group and control group according to the order of admission, each with 30 patients. The control group received traditional nursing strategy, while the study group was applied self-made perianal skin nursing strategy of device. The change of perianal skin injury, nursing workload and patients′ pain index of two groups were compared. Results The study group perianal skin injury, nursing workload and patients pain index were (0.40±0.11) points, (2.14±0.22) times/day, (1.36±0.40) points, which were better than (0.84±0.14) points, (3.58±0.29) times/day, (3.28±0.60) points in the control group (t=2.475, 3.934, 2.652, P<0.05). Conclusion self-made perianal skin nursing strategy of device could reduce the incidence of perianal skin injury, liberation of nursing work, reduce the pain of patients. Which is worthy of clinical application for its convenience. Key words: Perianal skin nursing; Self-made of device; Severe diarrhea; Fecal incontinence

Assessment of a novel artificial anal sphincter with constant force

Fecal incontinence caused by sphincter dysfunction is an unresolved problem which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Acticon Neosphincter still has safety and efficacy problems, which is the only device certified by the US Food and Drug Administration. The biomechanical compatibility is the key problem of artificial anal sphincter in the clinical application. This paper describes an artificial anal sphincter with superelastic shape memory alloys and its mechanical properties assessment in artificial intestine models. The new design was developed as a low invasive and constant force or pressure prosthesis with a simple structure to solve the problem of severe fecal incontinence in patients.

Does Implantation of an Artificial Soft Anal Band Provide an Opportunity for Improvement of Biopsychosocial Function in Patients with Severe Fecal Incontinence?

Introduction Severe fecal incontinence describes a condition of complete loss of control over fundamental physiological functions and loss of abilities to fulfil psychosocial functions by the patients. The last-step procedure, that is, to restore hope for improvement of biopsychosocial functioning and quality of life determined by the patient's health status is implantation of an artificial anal sphincter. Objective The study was a comparative analysis of the effect of the employed surgical procedure upon the degree of defecation control and quality of life indices in its behavioral, mental, and social aspects prior to and 3, 6, and 12 months postoperatively. The analysis also included the effect of the patient's individual style of coping with stress and the functional outcome of the procedure. Material and Methods The study included a group of 12 patients: 6 females and 6 males, aged from 36 to 60 years of life. The tools consisted of scoring systems that measured symptom intensity (FISI and Jorge and Wexner scale). In assessing the psychosocial functioning, the authors employed the Fecal Incontinence Quality of Life Scale (by Rockwood). The individual mode of coping with the disease was evaluated by using the CISS scale by Endler and Parker. Conclusions The analysis of results demonstrated that the procedure of implanting an artificial anal sphincter affected the “continence” (up to 50–60% postoperatively) and led to improvement in psychosocial functioning in all its assessed aspects, i.e., lifestyle, employment of precautionary measures, depression, anxiety, and embarrassment. It was also noted that due to the specific character of the procedure (the necessity to operate an artificial implant), better mean results in assessment of the procedure functionality were achieved by patients presenting the goal-concentrated mode rather than emotions-concentrated mode of coping with the disease. Thus, it seems justified to state that assessment of biopsychological functioning may be a good criterion of the procedure effectiveness.

Quality of life in 1870 patients with constipation and/or fecal incontinence: Constipation should not be underestimated

Quality of life is increasingly seen as important, but remains difficult to assess in patients with functional anorectal complaints. We aimed to quantify quality of life and to analyse the symptomatic descriptors associated with a poor outcome in patients with faecal incontinence (FI) and/or constipation. The characteristics of the patients, data from self-administered questionnaires and from physical examinations were evaluated prospectively for all cases of functional anorectal disease over a period of thirteen years. Functional anorectal disease included faecal incontinence (FI) and/or constipation. Patients with scores in the lowest quartile of the Gastrointestinal Quality of Life Index (GIQLI) were considered to have suffered severe alterations to their quality of life, and were compared with the other patients. In total, 1870 patients with functional anorectal disease were included (470 with a severely altered quality of life (GIQLI < 70)). Constipation predominated (1212/1870; 65.1%) and severe FI was frequent (761/1870; 40.9%). Severely altered quality of life was significantly associated with constipation (P = 0.0001), urinary urgency and incontinence (P = 0.0001), depression (P = 0.001), diabetes (P = 0.0224), severe FI (P = 0.0001), neurological disease (P = 0.0138) and liquid stools (P = 0.0002) in multivariate analysis. Several treatable factors are associated to an impaired quality of life in patients with functional anorectal disorders. Intervention studies are mandatory (stool consistency and frequency).

Functional Results and Quality of Life Following Magnetic Anal Sphincter Augmentation in Severely Incontinent Patients.

Magnetic anal sphincter augmentation is a novel surgical option in the treatment of severe fecal incontinence. This study aimed to analyze functional results, quality of life, and satisfaction after implantation in the mid-term, and to identify factors associated with success of this new treatment. All patients, who underwent magnetic anal sphincter augmentation procedure at a single center between December 2008 and January 2016, were consecutively included. Symptom severity [Cleveland Clinic Incontinence Score (CCIS)], quality of life [Fecal-Incontinence Quality of Life Questionnaire (FIQL)], bowel diary data, and patients' satisfaction were assessed before and after implantation. Forty-five patients (43 female), mean (s.d.) age 66.82 (±10.07), were followed for a median of 36 months (range 6-84). Two patients were explanted and 1 lost to follow-up. On a 3-week diary, major leakage rate significantly improved as did CCIS and FIQL. No significant difference was seen for flatus and minor leaks. Postoperative decrease of CCIS by ≥5.5 points correlated best with satisfaction, expressed by 22 patients (48% in intention-to-treat analysis). An independent predictive factor for success after implantation was no previous fecal incontinence surgical treatment. Satisfaction, functional, and quality of life outcomes improve significantly following magnetic anal sphincter augmentation.

Composite Antropyloric Valve and Gluteus Maximus Muscle Wrap for Neoanal Reconstruction: Initial Results.

Severe fecal incontinence has a significant negative impact on patient well-being. Current surgical methods of total anorectal reconstruction to substitute a colostomy have suboptimal results. A composite graft using antropyloric valve transposition and gracilis wrap has been described with good outcomes. However, this procedure requires extensive training of patients. Gluteus maximus, an accessory muscle for continence, may be better suited for this purpose. The purpose of this study was to evaluate the outcomes of composite antropylorus-gluteus graft for intractable fecal incontinence. Patients underwent a 3-stage procedure: antropyloric transposition with diversion stoma followed by gluteus wrap. Stoma was closed after ensuring the anatomic and functional integrity of the graft. This study was conducted at a single tertiary care institution. Patients who were on permanent colostomy for intractable incontinence or would have had one after abdominoperineal resection were included. Endoultrasonography, MRI, loopogram, saline holding test, anal manometry, St. Mark's fecal incontinence score, and personal interviews were used for measurement. Eleven patients underwent the procedure with a median follow-up of 16 months (range, 13-34 mo). Digital rectal examination revealed a resting tone with a distinct squeeze provided by the composite graft. Radiological imaging confirmed healthy grafts. There was a significant improvement in mean anal manometry values (resting pressure: preoperative = 10.25 mm Hg vs postoperative = 20.45 mm Hg; squeeze pressure: preoperative = 22.63 mm Hg vs postoperative = 105.18 mm Hg) and mean incontinence score postprocedure (preoperative = 22.8 vs postoperative = 8.6). On personal interview, majority of the patients were continent and expressed satisfaction with the procedure. The study was limited by its small sample size with no control group. Composite graft in patients with intractable fecal incontinence can serve as a viable novel method for total anorectal reconstruction. However, it should only be recommended for a highly select group of individuals in a surveillance setting. Its long-term outcomes remain to be determined as well as its risk versus benefit.

Long-Term Outcome after Dynamic Graciloplasty for Treatment of Persistent Fecal Incontinence in Patients with Anorectal Malformations.

Dynamic graciloplasty (DGP) has been used to treat severe fecal incontinence since the 1980s. Previous studies have shown an inferior outcome in patients with anorectal malformations (ARMs). Our experience has been that DGP has been appreciated by ARM -patients. The objective of the study was to evaluate the long-term outcome of DGP in our patients with ARM compared with patients with other underlying conditions. Twenty-three patients operated with DGP at our institution from 1996 to 2010 were sent validated bowel function and quality of life questionnaires. Eighteen of 23 responded. Seven had ARM and 11 had other etiologies of fecal incontinence. The mean follow-up time was 11.6 years (range, 5-17). Four of 7 of the patients with ARM and 8 of 11 of patients with other etiologies used their implants at follow-up. The Miller incontinence score was slightly higher for patients with ARMs, but they had less constipation and higher Fecal Incontinence Quality of Life (FIQL)- and 36-Item Short Form Health Survey (SF-36) scores. None of the differences were statistically significant. This study cannot confirm earlier reports in which DGP has an inferior outcome in patients with ARM. We therefore believe that the procedure should remain a treatment option for selected patients.

A biomechanical model of the human defecatory system to investigate mechanisms of continence.

This article presents a method to fabricate, measure and control a physical simulation of the human defecatory system to investigate individual and combined effects of anorectal angle and sphincter pressure on continence. To illustrate the capabilities and clinical relevance of the work, the influence of a passive-assistive artificial anal sphincter (FENIXTM) is evaluated. A model rectum and associated soft tissues, based on geometry from an anonymised computed tomography dataset, was fabricated from silicone and showed behavioural realism to the biological system and ex vivo tissue. Simulated stool matter with similar rheological properties to human faeces was developed. Instrumentation and control hardware were used to regulate injection of simulated stool into the system, automate balloon catheter movement through the anal canal, define the anorectal angle and monitor stool flow rate, intra-rectal pressure, anal canal pressure and puborectalis force. Studies were conducted to examine the response of anorectal angles at 80°, 90° and 100° with simulated stool. Tests were then repeated with the inclusion of a FENIX device. Stool leakage was reduced as the anorectal angle became more acute. Conversely, intra-rectal pressure increased. Overall inclusion of the FENIX reduced faecal leakage, while combined effects of the FENIX and an acute anorectal angle showed the greatest resistance to faecal leakage. These data demonstrate that the anorectal angle and sphincter pressure are fundamental in maintaining continence. Furthermore, it demonstrates that use of the FENIX can increase resistance to faecal leakage and reduce anorectal angles required to maintain continence. Physical simulation of the defecatory system is an insightful tool to better understand, in a quantitative manner, the effects of the anorectal angle and sphincter pressure on continence. This work is valuable in helping improve our understanding of the physical behaviour of the continence mechanism and facilitating improved technologies to treat severe faecal incontinence.

Effectiveness of sacral nerve stimulation in fecal incontinence after multimodal oncologic treatment for pelvic malignancies: a multicenter study with 2-year follow-up.

To assess whether sacral nerve stimulation (SNS) is an effective treatment for severe fecal incontinence (FI) after radiotherapy (RT)/chemoRT (CRT) in combination with pelvic surgery. A multicenter study was conducted on patients with FI that developed after multimodal therapy for pelvic tumors and was refractory to non-operative management, who were treated with SNS between November 2009 and November 2012. Data were prospectively collected and retrospectively analyzed. Cleveland Clinic FI score (CCFIS), FI episodes per week, FI Quality of Life (FIQoL), anorectal manometry and pudendal nerve terminal motor latency were evaluated before and after SNS. Eleven patients (seven females, mean age 67.3±4.8years) were evaluated in the study period. Multimodal treatments included surgery and CRT (four rectal, two cervical and one prostate cancers), surgery and RT (one cervical and two endometrial cancers) and CRT (one anal cancer). The mean radiation dose was 5.3Gy, and mean interval between the end of RT and onset of FI was 43.7±23months. Before SNS, the mean CCFIS and the mean number of FI episodes per week were 15.7±2.8 and 12.3±4.2, respectively. At 12-month follow-up, mean CCFIS improved to 3.6±1.8 (p=0.003) and the mean number of FI episodes decreased to 2.0±1.9 per week (p=0.003). These results persisted at 24-month follow-up. Significant improvement was also observed for each of the four domains of FIQoL at 12- and 24-month follow-up. Anorectal manometry values did not change significantly at follow-up. SNS is feasible and may be an effective therapeutic option for FI after multimodal treatment of pelvic malignancies.

A case report of moyamoya disease from nonendemic region of upper part of Brahmaputra Valley of North Eastern India

Moyamoya disease is a chronic nonatherosclerotic, noninflammatory cerebrovascular disease characterized by slow progressive stenosis of the intracranial vessels. The clinical presentations of moyamoya disease differ considerably for both children and adults. Interestingly, moyamoya disease continues to remain as an “unsolved mystery” till date, and its occurrence in the nonendemic region of the upper part of Brahmaputra Valley is rare. In this context, the author wishes to report the clinical study of an 18-year-old young adolescent boy exhibiting sudden-onset dizziness, severe excruciating headache, vomiting, abnormal behavior, and urinary and fecal incontinence.

Bowel Dysfunction Related to Spina Bifida: Keep It Simple

Although care of urological disorders in spina bifida is well established, there is yet no agreement on a standardized approach to bowel dysfunction in this population. The purpose of this study was to assess bowel dysfunction using validated instruments and the risk factors in adults with spina bifida. A multidisciplinary team prospectively collected patient data, focusing on anorectal and urological symptoms. The study was conducted with data from a French referral center for spina bifida. A total of 228 adults with spina bifida (sex ratio men:women, 92 (40%):136 (60%)) with a median age of 34.7 years (range, 26.8-44.7 y) were assessed. Factors associated with severe fecal incontinence (Cleveland Clinic Incontinence Score ≥9) and severe bowel dysfunction (Neurogenic Bowel Dysfunction score ≥14) were assessed in a multivariate analysis model. The prevalence rates of severe fecal incontinence and severe bowel dysfunction were 60% (130/217) and 42% (71/168). Bowel dysfunction was the second most common major concern of patients after lower urinary tract dysfunction. Male sex, obesity, urinary incontinence, and a Knowles-Eccersley-Scott symptom constipation score ≥10 were independently associated with severe fecal incontinence. Patients with soft stools had significantly less severe bowel dysfunction. Neither neurologic level nor other neurologic features of spina bifida were associated with severe fecal incontinence or severe bowel dysfunction. The recruitment of patients with spina bifida through a national referral center might have resulted in selection bias, and some data were missing especially regarding BMI and Neurogenic Bowel Dysfunction score (21% and 26% of missing data). The prevalence rates of severe fecal incontinence and severe bowel dysfunction in adults with spina bifida were high and were adequately perceived by the patients. The present study emphasized the association of bowel dysfunction and fecal incontinence with obesity, urologic disorders, and stool consistency rather than neurologic features. See Video Abstract at http://links.lww.com/DCR/A394.

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment.

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%–80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.

Fecal incontinence in patients with spina bifida: The target is the rectum.

The prevalence rate of severe fecal incontinence (FI) in adults with spina bifida (SB) is high. The physiological basis of FI in SB has not been clearly established, which contributes to inadequate care. The aim was to better characterize a large cohort of adults with special consideration of anorectal physiology. A multidisciplinary team from a French referral centre for SB prospectively collected data on patients who had an anorectal manometry. Factors associated with severe FI (Cleveland clinical incontinence score ≥ 9) were assessed in a multivariate analysis model. A total of 132 adults with SB (sex ratio M/F: 55 [41.7%]/77 [58.3%]; mean age of 38.2 [11.6] years old) were assessed. Among these patients, 83/132 (62.9%) suffered from severe FI. Rectal perception was not evaluable among 17 patients who had a latex allergy. Overall, 29/115 (25.2%) had maximal tolerable volume (MTV) > 330 mL or no sensation. The absence of anal canal sensitivity, MVT > 330 mL and the amplitude of the recto-anal inhibitory reflex (RAIR) >75% after a rectal isovolumic inflation of 50 mL were significantly associated with severe FI in the multivariate analysis model. Neither neurological level nor other neurological features were associated with severe FI. This study showed that FI in patients with SB is mainly associated with rectal abnormalities. This should be taken into consideration to improve incontinence management of patients with SB.

Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders

The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders.

Temperature-Controlled Delivery of Radiofrequency Energy in Fecal Incontinence: A Randomized Sham-Controlled Clinical Trial.

Controlled delivery of radiofrequency energy has been suggested as treatment for fecal incontinence. The aim of this study was to determine whether the clinical response to the radiofrequency energy procedure is superior to sham in patients with fecal incontinence. This was a randomized sham-controlled clinical trial from 2008 to 2015. This study was conducted in an outpatient clinic. Forty patients with fecal incontinence in whom maximal conservative management had failed were randomly assigned to receiving either radiofrequency energy or sham procedure. Fecal incontinence was measured using the Vaizey incontinence score (range, 0-24). The impact of fecal incontinence on quality of life was measured by using the fecal incontinence quality-of-life score (range, 1-4). Measurements were performed at baseline and at 6 months. Anorectal function was evaluated using anal manometry and anorectal endosonography at baseline and at 3 months. At baseline, Vaizey incontinence score was 16.8 (SD 2.9). At t = 6 months, the radiofrequency energy group improved by 2.5 points on the Vaizey incontinence score compared with the sham group (13.2 (SD 3.1), 15.6 (SD 3.3), p = 0.02). The fecal incontinence quality-of-life score at t = 6 months was not statistically different. Anorectal function did not show any alteration. Patients with severe fecal incontinence were included in the study, thus making it difficult to generalize the results. Both radiofrequency energy and sham procedure improved the fecal incontinence score, the radiofrequency energy procedure more than sham. Although statistically significant, the clinical impact for most of the patients was negligible. Therefore, the radiofrequency energy procedure should not be recommended for patients with fecal incontinence until patient-related factors associated with treatment success are known. See Video Abstract at http://links.lww.com/DCR/A373.

Assessment of Nutritional Status of Patients of Congenital Pouch Colon Following Definitive Surgery.

Purpose:To assess the nutritional status in 31 patients of congenital pouch colon (CPC) who had undergone definitive surgery and closure of a protective stoma, if any, at least 1 year earlier and were below 14 years age.Materials and Methods:The clinical history, demographic details, anthropometric measurements, and results of hematological and biochemical tests were recorded. In addition to collective data, analysis was also performed after grouping by age, subtype of CPC (Types I/II and Types III/IV CPC), and in Types I/II CPC patients, by whether the colonic pouch had been completely excised or else a segment preserved by tubular colorraphy (TC).Results:Severe fecal incontinence (FI) was common (64.52%). Anthropometry showed a significant malnutrition in 53.85–95.45% patients, especially stunting which was most prevalent in the 0–5 years age-group. Serum Vitamin B12, folate, and Vitamin D were lower than normal in 38.71%, 22.58%, and 74.19% patients, respectively, without statistically significant difference among the various groups studied. Patients with Types I/II CPC had a statistically significant higher incidence of anemia, low serum ferritin, and severe FI than patients with Types III/IV CPC. Patients with Types I/II CPC, managed by excision of the colonic pouch, had a higher incidence of severe FI, wasting, and thinness than those undergoing TC.Conclusions:On follow-up of the patients of CPC, anthropometry shows a high incidence of malnutrition, especially stunting in the 0–5 years age-group. There is an adequate adaptation of fluid-electrolyte homeostasis. Although Types I/II CPC patients have a significantly higher incidence of anemia and severe FI than Types III/IV CPC patients, long-term anthropometric parameters are similar. In Types I/II CPC, preservation of the colonic pouch by TC offers long-term benefit.