Severe Fecal Incontinence Research Articles

Does the magnetic anal sphincter device compare favourably with sacral nerve stimulation in the management of faecal incontinence?

The magnetic anal sphincter (MAS) is a recent surgical innovation for severe faecal incontinence (FI). With its place in the treatment algorithm of FI yet to be defined, we report a nonrandomized comparison between MAS and sacral nerve stimulation (SNS) in a single-centre cohort of patients with FI. Data were reviewed from prospective databases. From December 2008 to December 2010, 12 women [median age 65 (42-76) years], having FI for a median of 6.5 years, were implanted with a MAS. Sixteen women, of similar age, preoperative function scores, aetiology and duration of incontinence, and implanted with a permanent SNS pulse generator during the same period, served as a reference group. The duration of hospital stay, complications, change in incontinence and quality of life scores and anal physiology were compared between the two groups. The duration of follow up was similar [MAS = 18 (8-30) months vs SNS = 22 (10-28) months; P = 0.318]. Four patients with MAS experienced a 30-day complication, and the device was removed from one patient in each group. A significant improvement in incontinence (P < 0.001) and quality-of-life scores (P < 0.04) occurred in both groups. Mean anal resting pressure increased significantly in patients implanted with a MAS (P = 0.027). In this single-centre nonrandomized cohort of FI patients, MAS was as effective as SNS in improving continence and quality of life, with similar morbidity. These results can now serve as a prelude to a randomized trial comparing the procedures.

Radiofrequency Treatment for Fecal Incontinence

The aim of this study was to evaluate the short- and long-term outcome of the radiofrequency treatment for moderate to severe fecal incontinence. This study is a retrospective review of a single-institution experience. Patients who underwent the radiofrequency procedure were included. The primary outcomes measured were the complication rate, short- and long-term response, and the rate of subsequent intervention for incontinence. Twenty-seven patients underwent 31 radiofrequency procedures (81% women; mean age, 64 years). Median length of symptoms was 3 years. Biofeedback had failed for 52% of patients, and 23% of patients had previous surgical intervention. Thirty-eight percent of patients had a sphincter defect. Minor complications were observed in 19% of the patients. A treatment response was noted in 78% of the patients (mean Cleveland Clinic Florida Fecal Incontinence Score: 16 (baseline) and 10.9 (3 months postoperatively)). However, a sustained long-term response without any additional intervention was noted in 22% of the patients, and 52% of the patients underwent or are awaiting additional intervention for persistent or recurrent incontinence (mean follow-up, 40 months). This study is limited by its retrospective nature and the limited number of subjects. The radiofrequency procedure was safe, but a long-term benefit was noted in a minority of patients with moderate to severe fecal incontinence. Additional interventions were required in more than half of the patients. Larger studies are needed to determine the impact of various patient-related factors on the outcome of the radiofrequency treatment to identify the ideal patient for this therapy.

Sacral nerve stimulation in patients with severe fecal incontinence after rectal resection

Oncologic resection of rectal cancer has been reported to be associated with a significant rate of fecal incontinence (FI). The risk is greater in patients with a resection less than 6–8 cm from the anal verge [1]. Sacral nerve stimulation (SNS) has been advocated as a safe and effective therapy for severe FI and shown to be associated with minimal morbidity [2]. In patients with FI after anterior resection (AR), SNS is has been used in few cases, with varying results [1, 3]. Between 2006 and 2009, four patients (one male, three female), with severe FI following neoadjuvant therapy and AR performed for rectal cancer, were treated in our hospital with SNS. The median age was 65.5 years (range 49–73 years). All patients had undergone chemoradiation before the operation. Total mesorectal excision and longitudinal coloplasty had been performed during the operation in all patients. The mean distance of the anastomosis from the anorectal ring was 5 cm (range 2–8 cm). The median history of FI following AR was 26.5 months (range 25–28 months). None presented tumor recurrence, local or distant. The incontinence status was classified according to the Wexner score [4]. All patients were treated with conservative treatment, including drugs, constipating diet and biofeedback physiotherapy for 2 years. Before surgery, in all patients, anorectal manometry and endoanal ultrasonography were performed (Table 1). The percutaneous test stimulation was performed under general anesthesia. The response of S2–S4 was tested on both sides. If contraction of the anal sphincters could be obtained by SNS, percutaneous electrodes (Medtronic 3050; Medtronic, Minneapolis, MN, USA) were implanted. The patients were subsequently tested by SNS for a 4-week period. Patients who became candidates for permanent implantation based on an improvement of their continence received the permanent stimulation generator (INTERSTIM II, 3058; Medtronic, Minneapolis, MN, USA) under general anesthesia. Differences were analyzed by the Wilcoxon test for paired data. All patients tested had contraction of the anal sphincters during the SNS 4-week test period. All patients had least a 50 % reduction in episodes of incontinence and were given a permanently implanted system. The Wexner score fell from a median score of 15.5 before SNS to 5.5 during permanent stimulation (p \ 0.005). There were no significant differences in sphincter pressures measured by anal manometry. The patients with associated urinary incontinence presented improvement in their symptoms. There was no cessation of clinical response during the follow-up, and no complications were observed. After colorectal or coloanal anastomoses at a lower location, about 30–60 % of patients develop anal dysfunction due to the loss of the rectum and internal sphincter. These patients develop clinical symptoms and signs, such as anterior resection syndrome, which includes stool frequency, urgency, fragmentation and soiling. These symptoms usually disappear approximately 1 year postoperatively [5]. Our results of SNS in patients with FI after P. Moya A. Arroyo A. Frangi F. Candela Polo R. Calpena Rico Department of Surgery, University General Hospital of Elche, Alicante, Spain

Botulinum A toxin as a treatment for overactive rectum with associated faecal incontinence

Rectal hypercontractility can lead to faecal incontinence (FI). Botulinum toxin (BT) has been used successfully for the treatment of bladder overactivity. This study aimed to evaluate the therapeutic value of intrarectal injections of BT in inhibiting colorectal contractions and relieving FI in patients suffering from FI as a result of overactive rectal contractions. A prospective open study was carried out in Rouen University Hospital. Six patients (four men and two women) with severe FI related to overactive rectal contractions underwent intrarectal submucosal injections of BT placed in three rows of 10, 1-ml injections (50 U/1 ml; Dysport(®)) starting 1 cm above the dentate line and repeated twice, at intervals of 5 cm proximally. The end-points included improvement in the FI score, in faecal incontinence quality of life (FIQL) and of manometric abnormality. All patients reported improvement in the FI score [18.2±1.1 at baseline vs 9.0±1.7 at 3 months (P=0.04)] and in FIQL. Rectal contractile activity was reduced. The frequency of contractions remained unaffected (28.1±6.6/h; P=0.46 vs baseline). High-amplitude contractions of >50 cmH(2)O were significantly decreased in all patients (16.6±3.9 vs 6.6±4.1/h; P=0.03). Patients with an 'overactive rectum' are a heterogeneous group, with varying causes of dysfunction. The dose of BT used was arbitrarily selected. Nevertheless, the study introduces a further therapeutic option in the treatment of FI caused by rectal overactivity.

An innovative model of autologous anorectal transplantation with pudendal nerve reconstruction

Fecal incontinence is an important public health problem that has a significant impact on the quality of life of individual patients. The prevalence of fecal incontinence in the United States ranges from 2 to 17%, but this may be an underestimation (1). The current treatments for severe fecal incontinence are often complex and have disappointing results (1). Anorectal transplantation may be a definitive method for restoring normal sphincter function in these patients. We and others have previously investigated anorectal transplantation in rats with promising results (2-4). However, there is a lack of pre-clinical large animal models to study the potential benefits of this procedure. In this paper, we describe an innovative surgical technique of anorectal autotransplantation, which allows for physiological studies without the immunologic effects related to allotransplantation. The technique was initially performed in three swine weighing 25-35 Kg. After general anesthesia, an abdominal and perineal incision was performed in which the rectum, anal sphincter, and skin surrounding the anus were procured en bloc. The graft's vascular pedicle contained the inferior mesenteric artery (IMA) with a patch of the aorta and inferior mesenteric vein (IMV), which was divided near the splenic vein (Figure 1A). The pudendal nerve was carefully isolated and transected. The graft was removed and immediately flushed with 250 ml of cold heparinized preservation solution through a catheter inserted in the IMA. The graft was then placed in a cooler with cold solution without heparin for a total of 20 minutes. The infrarenal aorta and vena cava were isolated and cross-clamped, and the graft was implanted by arterial and venous anastomoses between the IMA and the aorta (Figure 1B) and the IMV and vena cava (Figure 1C). After reperfusion (Figure 1D), the entire graft was placed inside the abdominal cavity, and the pudendal nerve was reconstructed (Figure 1E). Finally, the anus was placed in its original position, and the perineum was closed (Figure 1F). Digestive tract continuity was reestablished by an end-to-end colorectal anastomosis. The abdominal cavity was closed, and the animals were observed for an additional two hours. At the end of the experiment, the graft was removed for histological analysis. The average times for graft recovery and implantation (including vascular, nervous and GI reconstruction) were 57 and 99 minutes, respectively. No problems regarding graft perfusion were observed at the end of the experiment. Histological graft assessment showed normal aspects in one graft and mild ischemia-reperfusion injury in two. Figure 1 (A) An anorectal graft showing the inferior mesenteric artery (IMA) and vein (IMV) and the rectum (R). (B) The infrarenal aorta (Ao) and vena cava (IVC) were cross-clamped at the site of anastomosis. (C) The anastomoses between the Ao and IMA and between ... To the best of our knowledge, there is only one report of a pre-clinical model of anorectal transplantation (5). Those authors described the donor and recipient surgical technique in four swine allotransplantations, with a 25% rate of technical failure after a 24-hour observation period. The experimental model described in this paper mimics the surgical stress and potential effects of graft denervation of allotransplantation but precludes, for obvious reasons, the antigen-mediated immune response. In addition, the technical modifications were associated with a significant reduction in the surgical time and cost. Therefore, anorectal autotransplantation in swine is a feasible and relatively simple procedure that may be a relevant technique to study regeneration, anorectal physiology, and the potential benefits of this unique type of transplantation without the interference of immune-mediated effects.

The Artificial Bowel Sphincter

A report on the long-term results of a consecutive series of patients implanted with the Acticon Neosphincter. Data were reviewed from a prospective database. From May 1996 to Jan 2010, 52 patients (46 women), mean age 51.5 ± 14.8 years, with severe fecal incontinence for a mean of 10.6 ± 10.5 years, were implanted with 85 devices. All patients had failed conservative management, including 13 with unsuccessful prior surgical treatments. Indications for implantation were sphincter destruction (45), pudendal neuropathy (12), congenital malformation (7), and perineal colostomy (4). Preoperative assessment included anal endosonography, anorectal manometry, and electrophysiologic testing. Incontinence (Wexner) and Quality of Life scores were recorded prior to the procedure and at each follow-up visit, together with annual anal physiology assessments. Cumulative risks of device revision and explantation were evaluated using Kaplan-Meier survival curves. Mean follow-up was 64.3 ± 46.5 months (range, 2-169); 26 patients (50%) required revisions after a mean of 57.7 ± 35.0 months, with 73.1% due to a leaking cuff from a microperforation; 14 patients (26.9%) required definitive explantation after a mean of 14.6 ± 7.9 months, with the majority (42.9%) due to infection; and 9 patients were lost to follow-up. In 35 patients (67.3%) with an activated device, there were significant improvements in both median Wexner (P < 0.0001) and Quality-of-life scores (P = 0.0286). There was a significant difference between preoperative resting anal pressures and closed pressures at activation (P < 0.0001) and latest follow-up (P < 0.0001). With careful patient selection, meticulous surgical technique, and dedicated surveillance, favorable long-term results can be achieved with acceptable rates of revision and explantation.

Effectiveness of Biofeedback Therapy in the Treatment of Anterior Resection Syndrome After Rectal Cancer Surgery

Although anterior resection syndrome commonly occurs after anal sphincter-saving surgery, no standard treatment option is currently available. The aim of the present study was to evaluate the clinical effectiveness of biofeedback in patients with anterior resection syndrome after sphincter-saving surgery for rectal cancer. This study was a retrospective review of data collected during the course of treatment. Patients were treated at a teaching hospital (Asan Medical Center) in Seoul, Korea, from January 2003 through December 2008. Patients who received biofeedback therapy for anterior resection syndrome after rectal cancer surgery were included. The Cleveland Clinic Florida fecal incontinence score, number of bowel movements per day, a visual analog scale for assessing patient satisfaction, and anorectal manometry were used to assess outcome of biofeedback treatment. : After biofeedback therapy, significant improvements were observed in fecal incontinence score (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P = .010; maximum squeeze pressure, P = .006; rectal capacity, P = .003). Compared with patients who started biofeedback treatment less than 18 months after surgery, those who started biofeedback at 18 months or longer after surgery showed greater improvements in fecal incontinence score (P = .032). Only patients with fecal incontinence as the primary symptom showed significant improvements in all variables, including fecal incontinence score, P < .001; defecation frequency, P < .001; and anorectal manometry (maximum resting pressure, P = .027; maximum squeeze pressure, P = .021; rectal capacity, P = .004). Patients who received radiation therapy in addition to surgery reported a significantly higher satisfaction score than those receiving surgery alone (P = .041). This is a nonrandomized retrospective study. Anorectal manometry was not regularly performed in all patients. Biofeedback therapy produced significant clinical benefits for patients with severe fecal incontinence and may be an effective treatment for patients with anterior resection syndrome after surgery for rectal cancer.

Mejora de la calidad de vida en los pacientes con incontinencia fecal tratados con estimulación de raíces sacras

Introduction Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation. Methodology An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim ® 3023 implant after a subchronic stimulation phase with a good response. Results The initial mean number of leaks was 3.1 ± 1, and the final was 0.5 ± 0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator ( P<.001). The mean baseline health status score was 55.9 ± 13, and after neuromodulation it was 63.1 ± 13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator ( P<.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%). Conclusions Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.

The Magnetic Anal Sphincter Versus the Artificial Bowel Sphincter: a Comparison of 2 Treatments for Fecal Incontinence

Fecal incontinence is a debilitating ailment, and surgery offers the only recourse for the patients in whom conservative treatment fails. This study aims to report the first matched comparison between patients implanted with the magnetic anal sphincter and the artificial bowel sphincter. From December 2008 to June 2010, 10 female patients, median age 64.5 years (range, 42-76), with severe fecal incontinence for a median of 7.5 years (range, 1-40), were implanted with the magnetic anal sphincter. Ten female patients implanted with the artificial bowel sphincter were identified. Both groups were matched for age, etiology, duration of incontinence, and preoperative functional scores. Outcomes measures included length of hospitalization, complications, and changes in functional scores (anorectal physiology, incontinence, and quality of life). Patients with the magnetic anal sphincter had a shorter median operative time (62 vs 97.5 min, P = .0273), length of hospitalization(4.5 vs 10 days, P < .001), and follow-up duration (8 vs 22.5 mo, P = .0068), without a statistically significant difference in 30-day complications (4 vs 2, P = .628) and revision/explantation (1 vs 4, P = .830). Both groups achieved significant improvements in preoperative incontinence (P < .0002) and quality-of-life scores (P < .009). In a comparison of baseline resting anal pressures, patients with the artificial bowel sphincter had significantly higher pressures with the cuff inflated (P = .0082), and those with the magnetic anal sphincter had a significant increase as well (P = .0469). At the latest review, both groups had similar quality-of-life scores (P = .374); patients with the artificial bowel sphincter had higher (median) closed-cuff anal pressures compared with the anal resting pressure of those with a magnetic anal sphincter (89 vs 58.5 cmH2O, P = .0147), together with more constipation (4 vs 1, P = .830) and a trend toward better incontinence scores (P = .0625). This was a nonrandomized study with small patient numbers. In the short term, the magnetic anal sphincter is as effective as the artificial bowel sphincter in restoring continence and quality of life.

Advances in the Treatment of Fecal Incontinence

Fecal incontinence (FI) is a distressing condition affecting a great number of patients. Its etiology is often multifactorial and cannot always be determined despite anorectal physiology testing or anal sphincter imaging. Severity scores combined with quality-of-life scores are useful to evaluate and compare treatment outcomes. Medical treatment to regulate bowel transit is helpful but other medications, such as topical perianal agents or antidepressants, have failed to demonstrate any efficacy. Biofeedback is widely used even if its superiority over simple conservative treatment is not apparent in systematic reviews. A variety of injectable sphincter bulking agents have been proposed with modest results. The major advance in the treatment of FI is the advent of sacral nerve stimulation (sacral neuromodulation) supported by a growing body of solid evidence for short and midterm efficacy. Indications for sacral nerve stimulation are expanding continuously and in many centers include patients with sphincter defects. This has raised a debate around the place of sphincterplasty in the treatment of FI especially as long term follow-up studies show significantly declining success rates after 5-10 years. More complex reconstructive procedures, such as dynamic graciloplasty and artificial bowel sphincters are still valid options for severe FI with non-negligible morbidity but good outcomes in expert centers and motivated patients. This paper reviews the current status of the above-mentioned and other treatment options for FI.

High Prevalence of Hypovitaminosis D Among Patients with Fecal Incontinence

Purpose: Vitamin D deficiency is associated with muscle weakness. Fecal continent can be compromised by muscle weakness. In addition, patients with severe fecal incontinence try to stay close to their bathrooms. Hence this may result in insufficient sun exposure. The aim of this study was to compare the prevalence of hypovitaminosis D among patients with fecal incontinence FI with historical control. Methods: This is a cross sectional study. We compared the serum vitamin D (25- hyroxy-cholecalciferol) levels of 16 consecutive patients with fecal incontinence attending the gastroenterology clinic at a tertiary care center with historical control. Fecal incontinence was defined as recurrent uncontrolled passage of fecal material for at least one month. Patients with infectious diarrhea, anorectal surgery, chronic kidney and liver diseases which are known to lower vitamin D level were excluded from the study. Normal vitamin- D level was defined 30 ng per milliliter or greater. Vitamin D insufficiency was defined 20-29 ng per milliliter. Level below 20 ng per liter was defined as vitamin-D deficiency. The serum values of FI patients were compared with general population. Recent study by Bair et al from Utah found the prevalence of hypovitaminosis D in 27,686 participants to be around 63.5%. Results: We present the results of an ongoing study on vitamin D levels in patients with FI. To date, 16 patients with FI (Men=12) have been enrolled in the study. The median age was 58 years (age range (29-84). Mean body mass index was 30.9 (range 19.8-38.3). All patients except one had loose stool. The average duration of fecal incontinence was 41.2 months (range 1-240 months). The average frequency of fecal incontinence was 13.1 episodes/month (range 2-30 episodes/month). All patients with fecal incontinence had hypovitaminosis D (56% had vitamin deficiency and 44% with vitamin D insufficiency). The mean vitamin-D level in patients with fecal incontinence was 17.6 ng per millitier (range 5.4-23 ng per milliter). Compared to Bair et al study, hypovitaminosis D was significantly more common among patients with FI compared to general population (100% vs. 63.5%, P=0.002) (Table 1). Conclusion: In this small cohort study all patients with fecal incontinence had hypovitaminosis D. This is significantly higher than reported prevalence of hypovitaminosis D in general population. A prospective cross section study is warranted to determine if patients with fecal incontinence have a higher prevalence of vitamin-D deficiency compared to control group. Further research is required to determine whether hypovitaminosis D is a risk factor or a consequence of fecal incontinence.Table

Calidad de vida en pacientes con incontinencia fecal y su relación con la gravedad de la misma

Background Wexner's score is widely used to assess the severity of fecal incontinence (FI). The 36-item short form health survey (SF-36) and the Fecal Incontinence Quality of Life Scale (FIQLS), a disease-specific scale, are instruments measuring quality of life that have been validated into Spanish. Aim To evaluate quality of life in patients with FI by using the FIQL and SF-36 scales to correlate the results with the Wexner's score. Methods Wexner's score, SF-36 and FIQLS were completed by 73 patients. The cut-off point for severity, as previously published, was 9 (Wexner's score <9=mild FI; Wexner's score ≥9=severe FI). Results The scores for all SF-36 sub-scales were lower in patients with FI than in the healthy Spanish population (p<0.001). The mental component of the SF-36 correlated with the subscales of «behavior» and «embarrassment» of the FIQLS (p<0.05). Wexner's score correlated with all the domains of the FIQLS (p<0.01). The results for all the domains of the FIQLS were lower for the Wexner ≥ 9 group than for the Wexner <9 group (p<0.001). There was no significant correlation between Wexner's score and the SF-36. Age, urge and daily FI, comorbidity and anorectal surgery worsened different aspects of quality of life measured by the FIQLS. Conclusions Quality of life measured by the SF-36 and FIQLS was substantially impaired in patients with FI. The severity of FI correlated with FIQLS. Other factors such as age, type and frequency of FI should be considered when evaluating quality of life.

The First Teleautomatic Low‐Voltage Prosthesis With Multiple Therapeutic Applications: A New Version of the German Artificial Sphincter System

To date, there are no artificial sphincter prostheses for urinary or fecal incontinence that may be implemented elsewhere instead, for example, in the upper gastrointestinal tract. Conventional systems are conceptually similar but are constructed specifically for distinct applications and are manual in operation. The German Artificial Sphincter System (GASS) II is the evolution of a highly integrative, modular, telemetric sphincter prosthesis with more than one application. Redesigning and integrating multilayer actuators into the pump allows us to reduce the input voltage to -10 to +20 V (V(PP) = 30 V). This provides for a flow rate of 2.23 mL/min and a counterpressure stability of 260 mbar. Furthermore, multiple applications have become feasible due to our standardized connection system, therapy-specific compression units, and application-specific software. These innovations allow us to integrate not only severe fecal and urinary incontinence, erectile dysfunction, and therapy-resistant reflux disease, but also morbid adiposity into the gamut of therapeutic GASS applications.

Artificial Anal Sphincter for Severe Fecal Incontinence Implanted by a Transvaginal Approach: Experience With 32 Patients Treated at One Institution

Our aim was to evaluate medium-term results of transvaginal implantation of an artificial anal sphincter in a large series of patients. Women undergoing treatment for severe fecal incontinence at Rouen University Hospital, Rouen, France, from January 2003 through December 2007 were eligible for the study if the fecal incontinence had lasted for 6 months and if they had attempted other therapies without success. All patients received implantation of an artificial anal sphincter via a transvaginal approach. Incontinence was assessed with the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score). A total of 32 women entered the study. Their median age was 63 (range, 26-79) years. At entry, 20 (63%) had severe destruction and scarring of the perineum, which was a contraindication for implantation via a perineal approach. Nine patients (28.1%) had previously undergone implantation of an AAS which had been removed because of complications, and 5 had had a Pickrell procedure for anal agenesia. No deaths occurred during the study. The device was removed in a total of 9 patients (28.1%): in 7 because of septic adverse events within the first 6 months after the operation, in 1 because of poor function, and in 1 for psychological reasons despite good functional results. Implantation was successful in 23 patients (71.9%), and the device remained activated for a mean follow-up of 41 (range, 18-75) months, with a mean decrease in Cleveland Clinic incontinence score from 18.4 to 6.8 (P < .0001). None of the patients complained of dyspareunia. The transvaginal approach for implantation of an artificial anal sphincter permits treatment of women with fecal incontinence who have severe damage and scarring of the anterior perineum. This route provides an alternative for patients whose only therapeutic option would previously have been a defunctioning stoma.

Fecal incontinence in primary care: prevalence, diagnosis, and health care utilization

We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI. Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data. FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients. Increased screening of FI is needed.

Treatment of perianal sepsis and long-term outcome of recurrence and continence

The study investigated the fate of patients with perianal sepsis of cryptoglandular origin. All patients treated for perianal sepsis between January 1994 and December 2000 were retrospectively analysed regarding recurrence and faecal incontinence. Data collection was conducted by chart review and by telephone questionnaire using the Vaizey incontinence score. One hundred seventy-three (58%) of 300 patients were available for follow-up at a median period of 121 (77-171) months. Fistula-in-ano was diagnosed in 156 (90%) patients. After a single surgical procedure, 55 (32%) patients had no recurrence of perianal sepsis. In 118 (68%), recurrence required multiple procedures (median 3, range 2-19). If only a single incision and drainage was performed (n = 10, 6%), no faecal incontinence occurred. Drainage with fistulotomy (n = 45, 26%) induced mild incontinence in 9% and severe incontinence in 4%. After multiple procedures that were required in 118 (68%) patients, mild and severe faecal incontinence was found in 16% and 4% of them, respectively. Treatment of anal sepsis is associated with a high recurrence rate and a substantial risk of faecal incontinence.

Functional outcome after perineal stapled prolapse resection for external rectal prolapse

BackgroundA new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up.MethodsFrom December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour® Transtar™ stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores.Results32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (P < 0.0001). No new incidence of constipation was reported.ConclusionsThe PSP is an elegant, fast and safe procedure, with good functional results.Trial registrationISRCTN68491191

Stuhlinkontinenz

Fecal incontinence is underestimated in its prevalence. Therapeutic approaches vary; in mild-to-moderate cases, dietary changes and biofeedback sessions accompanied by specific medications can achieve a salutary effect. In cases of severe fecal incontinence, a conservative approach is ineffective and surgical intervention is indicated. However, several technical innovations and devices enable surgeons to offer patients reliable solutions for this functional disorder. While dynamic graciloplasty uses native muscle contraction ability to function as a new sphincter, the artificial bowel sphincter achieves the same goal by an inflatable cuff. A novel approach, which is suitable for selected patients with muscular and neurological defects alike, is the sacral nerve stimulator. It is crucial to choose the right procedure as determined by the underlying pathology.

Trait anxiety as an independent predictor of poor health‐related quality of life and post‐traumatic stress symptoms in rectal cancer

To determine the influence of trait anxiety on patient reports of health-related quality of life (HRQoL) and post-traumatic stress symptoms (PTSS) in a sample of rectal cancer survivors. Eighty patients who had been diagnosed with rectal cancer were assessed at two points in time in a longitudinal study. At Time 1, soon after initial treatment, participants completed the State-Trait Anxiety Inventory and the Temperament and Character Inventory Harm Avoidance scale, which were combined into a composite measure of trait anxiety. At Time 2, 2-5 years following Time 1, participants were assessed for HRQoL using the Functional Assessment of Cancer Therapy-Colorectal scale (FACT-C) and for PTSS using the Impact of Event Scale-Revised (IES-R). HRQoL and PTSS were generally favourable on average, although many of the patients reported faring poorly. Higher levels of trait anxiety were predictive of poorer scores on all of the FACT-C and the IES-R total and subscale measures. More severe faecal incontinence was associated with poorer scores on the FACT Emotional well-being subscale, the FACT-Colorectal Cancer Scale, and all of the IES-R scales. Males were more likely than females to have poorer scores on the FACT Social well-being subscale, and those patients who were further out from active treatment had more favourable scores on the FACT-Colorectal Cancer Scale. The presence of a colostomy did not impact HRQoL or PTSS. Trait anxiety had a significant influence on HRQoL and PTSS several years following diagnosis and treatment of rectal cancer.

Long‐term results of artificial bowel sphincter for the treatment of severe faecal incontinence. Are they what we hoped for?

This study evaluates the long-term morbidity, functional results and quality of life (QOL) after treatment of severe faecal incontinence (FI) with the Acticon Neosphincter (American Medical Systems, Minneapolis, Minnesota, USA). Between 1996 and 2002, 17 consecutive patients (14 female, 3 male; median age 46) underwent sphincter implantation. Clinical evaluation, incontinence severity and QOL were assessed. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed preoperatively and at several stages of follow-up. The study was completed in December 2007. Mean follow-up was 68 months (range: 3-133). Morbidity occurred in 100% of patients from which 65% required at least one re-operation. After the first implant, 11 devices had to be removed (65%). Seven patients had a new implant. At the final stage, Acticon was activated in 9 cases (53%). Severity of FI improved from a median of 17.5 preoperatively to 9 (P = 0.005), 5.5 (P = 0.005) and 10 (P = 0.092) at 6, 12 months and at the end of follow-up, respectively. There was a significant improvement in QOL in all postoperative controls (P < 0.05). Severity of FI did not show a correlation with QOL in the preoperative period, but did at 6, 12 months and at the end of follow-up. Mean maximum resting pressure significantly increased with the full anal cuff. There is a high rate of morbidity, surgical re-interventions and explants after Acticon implant. Patients should be clearly informed about this before surgery. However, patients who have not had Acticon Neosphincter explanted, experience a significant improvement in anal continence and QOL.