Long-Term Outcome of Overlapping Anal Sphincter Repair

PURPOSE: This study reviews the long-term outcome of overlapping anal sphincteroplasty for acquired anal incontinence. METHODS: Seventy-one consecutive patients underwent overlapping sphincteroplasty from 1989 to 1996. Current degree of continence and associated quality of life were determined by telephone interview using the Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale, as validated by The American Society of Colon and Rectal Surgeons. Both the patient-rated and the surgeon-rated Fecal Incontinence Severity Index scores were recorded. Demographic and perioperative data were obtained from patient charts. RESULTS: Forty-nine (69 percent) of the 71 patients, with a median age of 38.5 (range, 22–80) years, could be contacted at a median of 69 (range, 48–141) months after sphincter repair. Four patients were diverted at the time of follow-up. Twenty-four (54 percent) patients were incontinent to liquid or solid stool, and only six patients (14 percent) were totally continent. Fifteen patients (34 percent) had the best possible Fecal Incontinence Quality of Life score of 16. The median patient-rated and surgeon-rated Fecal Incontinence Severity Index scores were 20 (range, 0–61) and 20 (range, 0–57), respectively. The patient-rated score correlated to the surgeon-rated score (r = 0.98, P < 0.001) and the Fecal Incontinence Quality of Life score (r = 0.64, P < 0.001). CONCLUSION: Years after sphincter repair surgery more than half of the patients are incontinent to liquid or solid stool. The American Society of Colon and Rectal Surgeons-validated Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores are useful and complementary tools for evaluation of fecal incontinence.     

Results of Lateral Internal Sphincterotomy for Chronic Anal Fissure With Particular Reference to Quality of Life

Purpose The aim of this study was to investigate the effects of lateral internal sphincterotomy on quality of life in patients with chronic anal fissure using the Gastrointestinal Quality of Life Index and the Fecal Incontinence Quality of Life Scale. Methods Adult patients with chronic anal fissure underwent lateral internal sphincterotomy with the open technique. Two hundred forty-four patients completed the Gastrointestinal Quality of Life Index questionnaire at admission and at 12 months postoperatively. The Fecal Incontinence Severity Index score was calculated preoperatively and at 2 and 12 months postoperatively. The Fecal Incontinence Quality of Life Scale was administered to any patient who had a Fecal Incontinence Severity Index score greater than 0 at 12 months postoperatively. Results The mean preoperative Gastrointestinal Quality of Life Index score was 118.34 ± 6.33, which developed to 140.74 ± 2.38 postoperatively (P< 0.001). At the two-month follow-up, 18 patients (7.38 percent) had a Fecal Incontinence Severity Index score greater than 0. By 12 months, the number of patients with Fecal Incontinence Severity Index score greater than 0 was reduced to seven (2.87 percent). These seven patients had a Gastrointestinal Quality of Life Index score similar to that of the group with postoperative Fecal Incontinence Severity Index score of 0, and only three patients (1.22 percent) had evident deterioration in the Fecal Incontinence Quality of Life Scale. The 12-month total Gastrointestinal Quality of Life Index score of the three patients who developed anal abscess/fistula after sphincterotomy (139.33 ± 3.21) was similar to the Gastrointestinal Quality of Life Index score of those without complications. However, the Gastrointestinal Quality of Life Index score of the recurrent cases (111.53 ± 3.53) was apparently low. Conclusion The gastrointestinal quality of life improved significantly following lateral internal sphincterotomy, regardless of the surgical complications or postoperative disturbances of continence. Only 1.2 percent of the patients experienced deterioration in Fecal Incontinence Quality of Life Scale. Read at the Cukurova Colo-Proctology and Stomatherapy Congress, Adana, Turkey, April 14 to 16, 2005. Reprints are not available.     

Fecal incontinence severity index after fistulotomy: a predictor of quality of life

PURPOSE: The purpose of this study was to use the Fecal Incontinence Severity Index to assess fecal incontinence after fistulotomy and to correlate the Fecal Incontinence Severity Index score with quality-of-life measures. METHODS: A retrospective chart review was performed on consecutive patients undergoing fistulotomy by a single colon and rectal surgeon at a university hospital from 1991 to 1999. Demographics, fistula anatomy, surgical technique, and length of follow-up were recorded. Mailed questionnaires and telephone interviews were conducted to determine the Fecal Incontinence Severity Index score, pad usage, lifestyle restriction, and psychosocial factors. A linear regression model was used to determine the relationship of clinical factors with Fecal Incontinence Severity Index. One-way ANOVA was used to correlate Fecal Incontinence Severity Index with quality-of-life measures. RESULTS: Of 110 patients who underwent fistulotomy, 96 (88 percent) had complete follow-up. Mean age was 48 (range, 17–84) years, and 68 percent were male. Follow-up was less than two years in 26 percent, two to five years in 39 percent, and more than five years in 35 percent. Of these patients, 41 percent had intersphincteric fistulas, whereas 59 percent had transsphincteric fistulas. Median Fecal Incontinence Severity Index score was 6, with a mean of 13 (maximum Fecal Incontinence Severity Index = 61); 36 percent had a Fecal Incontinence Severity Index score of zero. Linear regression revealed that only the amount of external sphincter divided correlated with Fecal Incontinence Severity Index score (P = 0.05). Quality-of-life measures strongly correlated with Fecal Incontinence Severity Index by analysis of variance (P < 0.01 for pad usage, lifestyle restriction, depression, and embarrassment), with substantial quality-of-life drop-off documented with Fecal Incontinence Severity Index >30. CONCLUSION: The Fecal Incontinence Severity Index is an excellent tool to gauge quality of life after fistulotomy. Fecal Incontinence Severity Index scores >30 predict a detrimental effect on quality of life.     

Incontinence After Lateral Internal Sphincterotomy: A Prospective Study and Quality of Life Assessment

PURPOSE: Lateral internal sphincterotomy is an effective treatment for chronic anal fissures; however, the risk of "incontinence" has generated interest in pharmacologic approaches that are far less effective and may be poorly tolerated. This study was designed to objectively define the risk of incontinence with sphincterotomy using the Fecal Incontinence Severity Index and assess the implications for quality of life using the Fecal Incontinence Quality of Life Scale. METHODS: A prospective study was undertaken on all patients undergoing lateral internal sphincterotomy for a chronic anal fissure by a single surgeon at a university teaching hospital from January 1, 2000 to September 30, 2002. All patients had failed at least six weeks of nonoperative management. Patient demographics and use of nitroglycerin were noted. The Fecal Incontinence Severity Index was measured preoperatively and at a six-week postoperative visit when fissure healing and postoperative complications were assessed. The Fecal Incontinence Quality of Life Scale was administered to patients with an incontinence score>0. RESULTS: Thirty-five patients (15 males) underwent sphincterotomy during the study period. Thirty-one of 35 had failed nitrates: 10 because of unacceptable side effects, and 21 because of lack of efficacy. Thirty-two patients returned for their six-week postoperative visits, and two completed their questionnaires by telephone. One patient was lost to follow-up. Mean age was 41.2 (range, 21-67) years. Thirty of 32 (94 percent) evaluable fissures had healed by six weeks, one healed by three months, and the other required V-Y anoplasty. There were two minor complications. Three patients had postoperative deterioration in their continence score. Quality of life deteriorated in only one patient. CONCLUSIONS: Lateral internal sphincterotomy is a safe and effective treatment for chronic anal fissures that only occasionally impairs continence and rarely diminishes quality of life.     

Quality of life measures for fecal incontinence and their use in children

BACKGROUND: Fecal incontinence is a common problem within society from childhood through to the elderly. Its clinical assessment has focussed on severity and frequency of soiling episodes but it is increasingly recognized to have an impact on physical, psychological and social well-being (quality of life [QOL]). This is likely to be particularly important in childhood. The aim of the present study was to critically evaluate the development and application of disease-specific QOL measures, focusing particularly on their use in children. METHODS: Generally recognized disease-specific QOL measures for fecal incontinence were identified and their generation and validation were critically evaluated. RESULTS: Six instruments were identified: Ditesheim and Templeton QOL Scoring System, Manchester Health Questionnaire, Hirschsprung's Disease/Anorectal Malformation Quality of Life Questionnaire (HAQL), Gastrointestinal Quality of Life Index (GIQLI), Fecal Incontinence TyPE Specification, and the Fecal Incontinence Quality of Life Scale (FIQL). Although the FIQL appeared to be the better tool for adults with fecal incontinence because it was brief and had the best validity and reliability, it needed further modification to become appropriate for use in children. In particular, items relating to sexual activity were inappropriate. CONCLUSION: Neither the FIQL nor other disease-specific instruments met basic psychometric standards for use in children with fecal incontinence. Substantial revision of currently available instruments will be required to meet the needs of this population.     

Continence Alterations After Ileal Pouch-Anal Anastomosis Do Not Diminish Quality of Life

PURPOSE: This study was conducted to compare continence after double-stapled ileal pouch-anal anastomosis and laparoscopic cholecystectomy using the Fecal Incontinence Severity Index and to assess the impact on quality of life using the Fecal Incontinence Quality of Life Scale. METHODS: Fifty-five patients randomly selected from a prospective pelvic pouch database were matched with regard to age and gender with patients who had undergone laparoscopic cholecystectomy during the same time interval by the same surgeon. Patients were mailed the two questionnaires, which were reviewed by an independent observer. Demographics, duration since surgery, and functional results were recorded. The Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores were compared by the analysis of variance method. RESULTS: Fifty-one pelvic pouch and 50 laparoscopic cholecystectomy patients were able to be contacted and completed both of the measuring tools. For the pouch patients, the median number of bowel movements per day was six (range, 2–15), with two patients reporting more than occasional nighttime incontinence. Mean incontinence scores were higher for the pelvic pouch patients than for the laparoscopic cholecystectomy patients (17.8 vs. 10.7; P = 0.03). However, the quality-of-life scores were very similar: lifestyle (3.8 vs. 3.83; P = 0.88), depression/self-perception (3.81 vs. 3.83; P = 0.94), embarrassment (3.76 vs. 3.8; P = 0.84), and behavior/coping (3.57 vs. 3.71; P = 0.5). CONCLUSION: Although continence is clearly altered after pelvic pouch surgery, quality of life is extremely well preserved.     

Fecal incontinence quality of life scale

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.     

Anal physiology testing in fecal incontinence: is it of any value?

Introduction  

The prognostic value of postoperative manometry in fecal incontinence is still controversial. The aims of this study were to establish if Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL) scores correlate with anal manometry and endoanal ultrasound findings and to define if there is any prognostic value in performing anal manometry after patients are surgically treated for fecal incontinence.     

Sphincter Defects Are Not Associated With Long-Term Incontinence Following Ileal Pouch-Anal Anastomosis

INTRODUCTION Frequent loose stools test the integrity of sphincter function in patients undergoing ileal pouch-anal anastomosis. The authors hypothesized that women with anal sphincter defects were more likely to experience incontinence episodes than women with intact sphincter muscles following ileal pouch-anal anastomosis.METHODS From 1996 to 1998, 42 women with a mean age of 42 (range, 22–63) years were prospectively evaluated by anorectal manometry and endoanal ultrasound before pouch surgery. Forty women underwent a stapled ileal pouch-anal anastomosis and two underwent a handsewn anastomosis. All patients considered themselves continent of stool before the procedure. A postoperative survey including the Cleveland Clinic Florida scale, Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life scale was sent to study participants.RESULTS Nineteen women with an obstetrical history had significant sphincter defects associated with significant lower mean resting pressure, mean squeeze pressure, and shorter anal canal length (3 vs. 3.7 cm, P = 0.0007). Thirty-five women (83 percent) responded resulting in a mean follow-up of 62 (range, 49-72) months. Fourteen responders (mean age, 46 years) had sphincter defects but no significant difference was found in Cleveland Clinic Florida scale, Fecal Incontinence Severity Index, or Fecal Incontinence Quality of Life scale scores when compared with those without defects.CONCLUSION Although almost all women reported episodes of seepage, marked sphincter defects associated with low anal pressures and shorter anal canal length did not affect anal function following pouch surgery. This study supports the findings that continent women with significant sphincter defects on ultrasound evaluation may be considered for restorative proctocolectomy.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 22 to 26, 2003.     

Transanal Endoscopic Microsurgery: A Prospective Evaluation of Functional Results

PURPOSE Local excision is a commonly used technique for many benign and selected malignant rectal lesions. Compared with radical resection, it is associated with decreased morbidity and mortality and improved functional results. Transanal endoscopic microsurgery is gaining popularity because of its ability to access the upper rectum and its precise excision techniques. However, the functional consequences have not been extensively studied.METHODS All patients subject to transanal endoscopic microsurgery prospectively completed preoperative and postoperative (6 weeks) surveys including Fecal Incontinence Severity Index, Fecal Incontinence Quality of Life, number of bowel movements per 24 hours, and ability to defer defecation. All data were collected by an independent research coordinator. Demographics, operative details, and complications were also collected prospectively.RESULTS Forty-one patients successfully underwent transanal endoscopic microsurgery. Fourteen patients had malignant lesions and 27 had benign lesions. Two patients required abdominoperineal resection based on postoperative diagnosis. Thirty-nine patients have completed follow-up and were available for review. Mean length of surgery was 64 minutes and length of stay was 0.9 day. Average distance from the anal verge to the proximal tumor margin was 11.4 cm and mean tumor size was 8.75 cm. Twenty-three patients had full-thickness excision with primary closure, ten had full-thickness excision without closure, five had partial-thickness excision, one had an excision of a mass in the anovaginal septum, and one had resection of an anastomotic stricture. Each patient served as his own control. Preoperative and postoperative number of bowel movements per 24 hours were 2.0 and 2.0, respectively. Preoperative vs. postoperative urgency (ability to defer defecation less than ten minutes) was unchanged. Mean preoperative and postoperative Fecal Incontinence Severity Index scores were 2.4 (range, 0–43) and 2.4 (range, 0–17), respectively (higher scores indicate worse function). In addition, the four parameters measured by the Fecal Incontinence Quality of Life survey were unchanged when preoperative and postoperative data were compared.CONCLUSIONS Transanal endoscopic microsurgery allows precise excision of tumors throughout the rectum. However, it involves inserting a 40-mm-diameter operating proctoscope and significant operating times. Despite this, as measured by ability to defer defecation, number of bowel movements per 24 hours, Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life survey, transanal endoscopic microsurgery has no detrimental affect on fecal continence.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.Reprints are not available.     

Perineal Puborectalis Sling Operation for Fecal Incontinence: Preliminary Report

PURPOSE This study was designed to evaluate the safety, efficacy, and impact on quality of life of the perineal puborectalis sling operation for fecal incontinence.METHODS Since August 2001, we performed the perineal puborectalis sling operation on eight patients with idiopathic fecal incontinence. A specially designed polyester mesh sling was introduced along the puborectalis muscle, from a posterior perianal incision, running to a small suprapubic incision. The ends were tied together with moderate tension. Patients were evaluated with the Fecal Incontinence Severity Index, the Cleveland Clinic Score of Incontinence, and the Fecal Incontinence Quality of Life Scale. Manometry and defecography were performed before and six months after the operation.RESULTS Eight patients (7 females; mean age, 63 (range, 44–77) years) were evaluated. A wound infection developed in one patient, which subsided with antibiotics. A rectal ulcer developed in one patient, necessitating sling removal. In the remaining seven patients, the Fecal Incontinence Severity Index improved from 27 to 9, and the Cleveland Clinic Score of Incontinence improved from 13 to 5 (P < 0.05). All parameters in the Fecal Incontinence Quality of Life Scale improved: lifestyle from 2.1 to 3.6; coping/behavior from 1.5 to 3.4; depression/self perception from 2.3 to 3.7; and embarrassment from 2 to 3.6 (P < 0.05). No significant difference was found between preoperative and postoperative maximum resting pressure and maximum squeeze pressure. However, the median anorectal angle on defecography after the operation was significantly reduced (P < 0.05).CONCLUSIONS We believe that the perineal puborectalis sling operation is technically feasible, with low morbidity, and can be an effective procedure for idiopathic fecal incontinence.Supported by grants, equipment, and drugs from Yufu Itonaga Co. Ltd., Tokyo, Japan.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Comparison of Quality of Life and Anorectal Function After Artificial Sphincter Implantation

PURPOSE: Quality of life, a major outcome parameter in the treatment of anal incontinence, has not been assessed after artificial sphincter implantation. The purpose of this single-center, prospective, nonrandomized study was to assess quality-of-life differences in patients before and after artificial sphincter implantation and compare them with clinical incontinence scores and anal manometry. METHODS: Quality of life was assessed in 16 patients (14 females; mean age, 43 years) consecutively implanted with an Acticon NeosphincterTM. The Fecal Incontinence Quality of Life Scale, a quality-of-life instrument specifically designed for analysis of anal incontinence, included 27 items grouped in four domains: lifestyle, coping/behavior, depression/self-perception, and embarrassment. Fecal Incontinence Quality of Life Scale score (0 to 1, with 1 indicating better quality of life) was calculated preoperatively and postoperatively and compared with the Fecal Incontinence Score (on a scale of 0 to 120, with 120 being complete incontinence), an evacuation score, and maximal resting pressure. RESULTS: At a mean (standard deviation) of 25 (15) months,12 patients had an activated device, and 11 had satisfactory anorectal function. Significant improvement was observed postoperatively in the four separate quality-of-life domains. Mean (standard deviation) Fecal Incontinence Quality of Life Scale scores increased from 0.44 (0.14) preoperatively to 0.86 (0.18), 0.94 (0.06), and 0.83 (0.16) at 6, 12, and 24 months after implantation, respectively. For the same time periods, the mean (standard deviation) Fecal Incontinence Scores were 105 (14), 24 (26), 32 (35), and 32 (28), respectively (P< 0.05). A linear correlation was found between the improvement over time in quality of life measured by the Fecal Incontinence Quality of Life Scale and clinical evaluation of incontinence measured by the Fecal Incontinence Score (r2 = 0.97; P = 0.03). Mean (standard deviation) maximal resting pressure increased similarly from 42 (24) cm H2O preoperatively to 97 (23) cm H2O at the end of follow-up (P < 0.0001). CONCLUSION: After artificial sphincter implantation, quality of life as assessed by a new Fecal Incontinence Quality of Life Scale instrument was significantly improved. These results correlated with clinical assessment of anal incontinence and were associated with a significant increase in maximal anal resting pressure on manometry.     

Correlating the Fecal Incontinence Quality-of-Life Score and the SF-36 to a proposed Ostomy Function Index in patients with a stoma

Quality of life is affected by the creation of a stoma. To assess the validity of the Ostomy Function Index in patients with a stoma, a prospective survey was conducted from July 2000 to September 2001 among patients participating in local United Ostomy Association chapters (N = 99; 55 with a colostomy and 44 with an ileostomy). The Short Form 36 general health survey, Fecal Incontinence Quality of Life Scale, and the proposed Cleveland Clinic Florida Ostomy Function Index were used to assess general health and stoma function in patients with an ostomy. The average proposed function index score (7 = excellent function, 35 = poor function) was 11.97 (range 7 to 22). The proposed function Index correlated with the Fecal Incontinence Quality of Life Scale and the physical and mental component scales of the SF-36 (P < 0.05). The correlation between the proposed function index and the Fecal Incontinence Quality of Life Scale was stronger in colostomy than in ileostomy patients. With the exception of the SF-36 role-emotional domain in ileostomy patients, the function index correlated with all SF-36 scales (P <0.05) in both patient groups. The results of this study suggest that ostomy function is variable and correlates with quality of life and that the Fecal Incontinence Quality of Life Scale offers a limited assessment of quality of life in colostomy patients. The Cleveland Clinic Florida Ostomy Function Index offers an objective assessment of ostomy function that reflects on quality of life. Additional studies to refine measurement of quality of life in stoma patients are warranted.     

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence

PURPOSE: The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS: The Fecal Incontinence Severity Index is based on a type × frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS: Surgeons and patients had very similar weightings for each of the type × frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS: Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.Supported by a contract between the University of Minnesota Clinical Outcomes Research Center and The American Society of Colon and Rectal Surgery and the Minnesota Colon and Rectal Foundation.     

Incontinence After a Lateral Internal Sphincterotomy: Are We Underestimating It?

PURPOSE This study was designed to assess the long-term outcomes and quality of life of patients who have undergone a sphincterotomy for chronic anal fissure.METHODS The medical records of patients who underwent this operation between 1992 and 2001 were reviewed. A questionnaire was mailed to assess their current status, along with the Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index surveys.RESULTS A total of 298 patients were identified (158 males; 53 percent; mean age, 46.9 years; mean follow-up, 4.3 years). Postal survey response was 62 percent. Recurrence of the fissure occurred in 17 patients (5.6 percent) of whom 9 (52 percent) were females. Significant factors that resulted in recurrence were initial sphincterotomy performed in the office and local anesthesia (P < 0.001). When comparing office records and response to the postal survey, significantly more patients had flatal incontinence than that recorded in their medical records (P < 0.001). Twenty-nine percent of females who had a vaginal delivery recorded problems with incontinence to flatus (P = 0.04). Temporary incontinence was reported in 31 percent of patients and persistent incontinence to gas occurred in 30 percent. Stool incontinence was not a significant finding. The overall quality-of-life scores were in the normal range, whereas the median Fecal Incontinence Severity Index score was 12.CONCLUSIONS Recurrence after lateral internal sphincterotomy may be higher after local anesthesia or office procedure. Females who have two or more previous vaginal deliveries should be warned about possible flatal incontinence. Long-term flatal incontinence that is not reported to the caregiver may occur in up to one-third of patients and could be permanent.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.Reprints are not available.     

Septic Complications after Restorative Proctocolectomy do not Impair Functional Outcome: Long-Term Follow-Up from a Specialty Center

Purpose  After restorative proctocolectomy, 7 to 8 percent of patients may have a pouch leak. Concern exists that pouch leak may be associated with impaired functional outcome. We evaluated patients who underwent restorative proctocolectomy to determine whether pouch leak adversely affected long-term functional outcome and quality of life. Methods  We queried our prospectively maintained database of patients who underwent restorative proctocolectomy for demographic and clinical data. We sent a long-term outcome questionnaire to patients, including the validated Fecal Incontinence Severity Index and Cleveland Global Quality of Life scores. Pouch leak was identified by clinical or radiographic evidence of leak. Patients with leak were compared with those without to determine the impact on long-term functional outcome or quality of life. Results  A total of 817 patients were available for follow-up and 374 patients (46 percent) completed questionnaires. The group with (n = 60; 16 percent) and without (n = 314; 84 percent) leak had similar demographics. The median Fecal Incontinence Severity Index score (15.3 vs. 14.7, P = 0.77), Cleveland Global Quality of Life score (0.79 vs. 0.81, P = 0.48), and bowel movements per 24 hours (7.92 vs. 7.88, P = 0.92) were similar. The pouch loss/permanent ileostomy rate was higher in those who leaked (13.3 vs. 0.9 percent, P < 0.001). Conclusions  Anastomotic leak after restorative proctocolectomy does not adversely affect long-term quality of life or functional outcome. However, pouch loss/permanent ileostomy is significantly more likely in patients who have had an anastomotic leak. Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 7 to 11, 2008. Reprints are not available.     

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index

PURPOSE: The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS: The Fecal Incontinence Severity Index is based on a type x frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS: Surgeons and patients had very similar weightings for each of the type x frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS: Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.     

Impact of late anorectal dysfunction on quality of life after pelvic radiotherapy

Purpose

Anorectal dysfunction is common after pelvic radiotherapy. This study aims to explore the relationship of subjective and objective anorectal function with quality of life (QoL) and their relative impact in patients irradiated for prostate cancer.

Methods

Patients underwent anal manometry, rectal barostat measurement, and completed validated questionnaires, at least 1 year after prostate radiotherapy (range 1–7 years). QoL was measured by the Fecal Incontinence Quality of Life scale (FIQL) and the Expanded Prostate Cancer Index Composite Bowel domain (EPICB)-bother subscale. Severity of symptoms was rated by the EPICB function subscale.

Results

Anorectal function was evaluated in 85 men. Sixty-three percent suffered from one or more anorectal symptoms. Correlations of individual symptoms ranged from r?=?0.23 to r?=?0.53 with FIQL domains and from r?=?0.36 to r?=?0.73 with EPICB bother scores. They were strongest for fecal incontinence and urgency. Correlations of anal sphincter pressures, rectal capacity, and sensory thresholds ranged from r?=?0.00 to r?=?0.42 with FIQL domains and from r?=?0.15 to r?=?0.31 with EPICB bother scores. Anal resting pressure correlated most strongly. Standardized regression coefficients for QoL outcomes were largest for incontinence, urgency, and anal resting pressure. Regression models with subjective parameters explained a larger amount (range 26–92 %) of variation in QoL outcome than objective parameters (range 10–22 %).

Conclusions

Fecal incontinence and rectal urgency are the symptoms with the largest influence on QoL. Impaired anal resting pressure is the objective function parameter with the largest influence. Therefore, sparing the structures responsible for an adequate fecal continence is important in radiotherapy planning.     

Assessing depression in primary care with the PHQ-9: Can it be carried out over the telephone?

BACKGROUND: Telephone assessment of depression for research purposes is increasingly being used. The Patient Health Questionnaire 9-item depression module (PHQ-9) is a well-validated, brief, self-reported, diagnostic, and severity measure of depression designed for use in primary care (PC). To our knowledge, there are no available data regarding its validity when administered over the telephone. OBJECTIVE: The aims of the present study were to evaluate agreement between self-administered and telephone-administered PHQ-9, to investigate possible systematic bias, and to evaluate the internal consistency of the telephone-administered PHQ-9. METHODS: Three hundred and forty-six participants from two PC centers were assessed twice with the PHQ-9. Participants were divided into 4 groups according to administration procedure order and administration procedure of the PHQ-9: Self-administered/Telephone-administered; Telephone-administered/Self-administered; Telephone-administered/Telephone-administered; and Self-administered/Self-administered. The first 2 groups served for analyzing the procedural validity of telephone-administered PHQ-9. The last 2 allowed a test-retest reliability analysis of both self- and telephone-administered PHQ-9. Intraclass correlation coefficient (ICC) and weighted kappa (for each item) were calculated as measures of concordance. Additionally, Pearson's correlation coefficient, Student's t-test, and Cronbach's alpha were analyzed. RESULTS: Intraclass correlation coefficient and weighted kappa between both administration procedures were excellent, revealing a strong concordance between telephone- and self-administered PHQ-9. A small and clinically nonsignificant tendency was observed toward lower scores for the telephone-administered PHQ-9. The internal consistency of the telephone-administered PHQ-9 was high and close to the self-administered one. CONCLUSIONS: Telephone and in-person assessments by means of the PHQ-9 yield similar results. Thus, telephone administration of the PHQ-9 seems to be a reliable procedure for assessing depression in PC.     

Comparison of Functional Results and Quality of Life Between Intersphincteric Resection and Conventional Coloanal Anastomosis for Low Rectal Cancer

PURPOSE: The technique of intersphincteric resection permits sphincter preservation with good oncologic results in very low rectal cancer. This study aimed to investigate functional results and quality of life after intersphincteric resection compared with conventional coloanal anastomoses.METHODS: From 1990 to 2000, 170 patients underwent total mesorectal excision with coloanal anastomosis for low rectal tumors. Questionnaires were obtained from 77 patients alive without colostomy: 37 had a conventional coloanal anastomosis and 40 had intersphincteric resection. Both groups were similar according to age, gender, anastomotic stenosis, colonic pouch, anastomotic leakage, preoperative radiotherapy, and follow-up (median, 56 months). Assessment included one functional and two quality-of-life questionnaires: the SF-36 Health Status and the Fecal Incontinence Quality of Life score.RESULTS: There was no difference in stool frequency, fragmentation, urgency, dyschesia, and alimentary restriction between patients with and without intersphincteric resection. Patients with intersphincteric resection had significantly worse continence (Wexner score, 10.8 vs. 6.9; P < 0.001) and needed more antidiarrheal drugs (60 vs. 35 percent; P = 0.04) than those without. Compared with conventional coloanal anastomoses, quality of life was altered by intersphincteric resection for the subscale embarrassment (P < 0.01) in the Fecal Incontinence Quality of Life score, whereas no difference of quality of life was observed with SF-36.CONCLUSIONS: Compared with conventional coloanal anastomoses, patients with intersphincteric resection have a higher risk of fecal incontinence and a slightly altered quality of life.Presented at the meeting of the Société Française de Chirurgie Digestive, Lyon, France, December 11 to 12, 2003.Reprints are not available.