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1.
Koch SM Uludağ O El Naggar K van Gemert WG Baeten CG 《International journal of colorectal disease》2008,23(2):195-200
Background and aims
Dynamic graciloplasty (DGP) improves anal continence and quality of life for most patients. However, in some patients, DGP fails and fecal incontinence is unsolved or only partially improved. Constipation is also a significant problem after DGP, occurring in 13–90%. Colonic irrigation can be considered as an additional or salvage treatment for defecation disorders after unsuccessful or partially successful DGP. In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP is investigated.Materials and methods
Patients with defecation disorders after DGP visiting the outpatient clinic of the University Hospital Maastricht were selected for colonic irrigation as additional therapy or salvage therapy in the period between January 1999 and June 2003. The Biotrol® Irrimatic pump or the irrigation bag was used for colonic irrigation. Relevant physical and medical history was collected. The patients were asked to fill out a detailed questionnaire about colonic irrigation.Results
Forty-six patients were included in the study with a mean age of 59.3?±?12.4 years (80% female). On average, the patients started the irrigation 21.39?±?38.77 months after the DGP. Eight patients started irrigation before the DGP. Fifty-two percent of the patients used the irrigation as additional therapy for fecal incontinence, 24% for constipation, and 24% for both. Irrigation was usually performed in the morning. The mean frequency of irrigation was 0.90?±?0.40 times per day. The mean amount of water used for the irrigation was 2.27?±?1.75 l with a mean duration of 39?±?23 min. Four patients performed antegrade irrigation through a colostomy or appendicostomy, with good results. Overall, 81% of the patients were satisfied with the irrigation. Thirty-seven percent of the patients with fecal incontinence reached (pseudo-)continence, and in 30% of the patients, the constipation completely resolved. Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation, abdominal cramps, and distended abdomen. Seven (16%) patients stopped the rectal irrigation.Conclusion
Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP.2.
Purpose
To study the distribution of subtypes and symptoms of fecal incontinence in the general Dutch population.Methods
We performed a cross-sectional study in a representative sample of the general Dutch population. All respondents (N?=?1259) completed the Groningen Defecation and Fecal Continence questionnaire. We assigned the respondents to a so-called healthy subgroup (n?=?1008) and a comorbidity subgroup (n?=?251). The latter subgroup comprised the respondents who reportedly suffered from chronic diseases and who had undergone surgery known to influence fecal continence. We defined fecal incontinence according to the Rome IV criteria.Results
The combination of urge fecal incontinence and soiling was the most frequent form of fecal incontinence in the total study group, the “healthy” subgroup, and the comorbidity subgroup (49.0, 47.3, and 51.5%). Passive fecal incontinence was the least frequent form of fecal incontinence in all three groups (4.0, 5.4, and 2.2%). The prevalence and severity of fecal incontinence was significantly higher in the comorbidity subgroup than in the “healthy” subgroup. Only in the comorbidity subgroup did the fecally incontinent respondents feel urge sensation significantly less often before defecating than their fecally continent counterparts (16.5 versus 48.8%, P?<?0.001).Conclusion
Urge fecal incontinence combined with soiling is commonest in the general Dutch population. Chronic diseases and bowel and pelvic surgery both increase and aggravate fecal incontinence.3.
Purpose
Pudendal nerve terminal motor latency (PNTML) testing is a standard recommendation for the evaluation of fecal incontinence. Its role in guiding therapy for fecal incontinence has been previously questioned. The aim of this study was to evaluate the relationship between PNTML testing and anorectal dysfunction.Methods
This was a retrospective analysis of data collected prospectively from patients who presented to a pelvic floor disorder center from 2007 to 2015. The relationship between PNTML (normal versus delayed) and anorectal manometry, fecal incontinence severity, and fecal incontinence-related quality of life scores was assessed using the Wilcoxon-Mann-Whitney test.Results
Two hundred sixty-nine patients underwent PNTML testing, and 91.1% were female (N?=?245) (median age 62.2 years). Normal PNTML was seen in 234 (87.0%) patients. Among 268 patients who underwent anorectal manometry, delayed PNTML was only significantly associated with median maximum anal squeeze pressure (P?=?0.04). Delayed PNTML was not associated with a decrease in median fecal incontinence severity or fecal incontinence-related quality of life scores (N?=?99).Conclusions
PNTML was only associated with median maximum anal squeeze pressure, and it was not associated with patient-reported severity of symptoms of fecal incontinence, changes in quality of life attributable to fecal incontinence, median mean resting anal pressure, or median maximum resting anal pressure. PNTML testing may not be relevant to current therapeutic algorithms for fecal incontinence and its routine use should be questioned.4.
Purpose
Fecal continence is maintained by voluntary and involuntary contraction of the anal sphincter, and voluntary contractions of puborectal muscle. We investigated whether the puborectal muscle can control fecal continence not only by voluntary contractions but also by involuntary contractions.Methods
We performed anorectal function tests in 23 healthy subjects. The anorectal pressure test was used to investigate voluntary contractions of the puborectal muscle. The balloon retention test was used to assess if the puborectal muscle can contract involuntarily.Results
During the balloon retention test, we observed an involuntary contraction of the puborectal muscle, which gradually increased during progressive filling of the rectum. The maximal involuntary contraction of the puborectal muscle was significantly stronger and longer than its maximal voluntary contraction (150 versus 70 mmHg, P?<?0.001 and 5.8 versus 1.5 min, P?<?0.001).Conclusions
We found that the puborectal muscle is able to contract involuntarily during rectal dilatation. It is a new regulatory mechanism, called the puborectal continence reflex, which controls fecal continence by involuntary contraction of the puborectal muscle. It seems to be initiated by dilatation at the level of the puborectal muscle. Presumably, the puborectal continence reflex protects many patients with anal sphincter dysfunctions from fecal incontinence.5.
Purpose
This study aims to evaluate pubovisceral muscle and anal sphincter defects in women with previous vaginal delivery and fecal incontinence and to correlate the findings with the severity of symptoms using the combined anorectal and endovaginal 3D ultrasonography with a new ultrasound scoring system.Methods
Consecutive female patients with previous vaginal delivery and fecal incontinence symptoms were screened. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale, and the extent of defects was assessed by an ultrasound score based on results of anorectal and endovaginal 3D ultrasound. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale.Results
Of 84 women with previous vaginal delivery and fecal incontinence, 21 (25%) had intact pubovisceral muscles and anal sphincters; 63 (75%) had a pubovisceral muscle or anal sphincter defect, or both. Twenty-eight (33%) had a pubovisceral muscle defect [23% with an external anal sphincter (EAS) defect or combined EAS/internal anal sphincter defects; 11% with intact anal sphincters]. Thirty-five (42%) had intact pubovisceral muscles and an anal sphincter defect. Compared with women with intact pubovisceral muscles/anal sphincter defects, patients with pubovisceral muscle defects had significantly higher incontinence scores and significantly higher ultrasound scores indicating more extensive defects. Incontinence symptoms correlated positively with the ultrasound score, measurements of sphincter defects, and area of the levator hiatus.Conclusions
Evaluation of both pubovisceral muscles and anal sphincters is important to identify defects and determine treatment for women with fecal incontinence after vaginal delivery. The severity of fecal incontinence symptoms is significantly related to the extent of defects of the pubovisceral muscles and anal sphincters.6.
Purpose
Transanal minimally invasive surgery (TAMIS) is gaining worldwide popularity as an alternative for the transanal endoscopic microsurgery (TEMS) method for the local excision of rectal polyps and selected neoplasms. Data on patient reported outcomes regarding short-term follow-up are scarce; data on functional outcomes for long-term follow-up is non-existent.Methods
We used the fecal incontinence severity index (FISI) to prospectively assess the fecal continence on the intermediate-term follow-up after TAMIS. The primary outcome measure is postoperative fecal continence. Secondary outcome measures are as follows: perioperative and intermediate-term morbidity.Results
Forty-two patients (m = 21:f = 21), median age 68.5 (range 34–94) years, were included in the analysis. In four patients (9.5%), postoperative complications occurred. The median follow-up was 36 months (range 24–48). Preoperative mean FISI score was 8.3 points. One year after TAMIS, mean FISI score was 5.4 points (p = 0.501). After 3 years of follow-up, mean FISI score was 10.1 points (p = 0.01). Fecal continence improved in 11 patients (26%). Continence decreased in 20 patients (47.6%) (mean FISI score 15.2 points, [range 3–31]).Conclusions
This study found that the incidence of impaired fecal continence after TAMIS is substantial; however, the clinical significance of this deterioration seems minor. The present data is helpful in acquiring informed consent and emphasizes the need of proper patient information.Functional results seem to be comparable to results after TEMS. Furthermore, we confirmed TAMIS is safe and associated with low morbidity.7.
Purpose
Rectal advancement flap is an accepted approach for treating complex fistula-in-ano. However, a diversity of technical modifications have been described. The aim of this study was to evaluate recurrence and fecal continence rates after performing rectal advancement flaps depending upon flap thickness (full-thickness, partial-thickness, or mucosal flaps) and treatment of the fistulous tract (core-out or curettage).Methods
Medline (PubMed, Ovid), the Cochrane Library database, and ClinicalTrials.gov were searched. Studies that involved patients with complex cryptoglandular fistulas who had been treated with rectal advancement flaps were included. The outcomes measured were recurrence and fecal continence. All of the statistical analyses were performed using Comprehensive Meta-Analysis software. A fixed model was used if there was no evidence of heterogeneity; otherwise, a random effects model was used.Results
Twenty-six studies were included (1655 patients). The pooled rate of recurrence was 21%. Full-thickness flaps showed the best results concerning recurrence (7.4%), partial flaps revealed 19% and mucosal flaps 30.1%. Core-out and curettage had a similar recurrence (19 vs 21%). Regarding anal incontinence, the pooled rate was 13.3%. Mucosal- and partial-thickness flaps showed similar rates (9.3 vs 10.2%), while full-thickness flaps disturbed it in 20.4%. Most of these alterations were minor symptoms. Otherwise, core-out and curettage showed similar rates (14.3 vs 12%).Conclusions
1. Full-thickness rectal advancement flaps offer better results regarding the recurrence than mucosal or partial flaps. 2. All flaps cause some incontinence, which increases with the thickness of the flap. 3. The results did not suggest differences in recurrence and incontinence between core-out and curettage.8.
Purpose
Numerous studies have investigated the prevalence of constipation and fecal incontinence (FI) in the general population and, even though these disorders are known to co-occur, they were studied independently of each other. Our aim was to investigate the prevalence of constipation and FI, and their co-occurrence, in the general population in the Netherlands.Methods
We studied a cross-section of the Dutch population (N = 1259). All respondents completed the Groningen Defecation & Fecal Continence checklist. We defined constipation and FI in accordance with the Rome III criteria.Results
We found that 24.5% (95% CI, 22.1–26.8) suffered from constipation, 7.9% (95% CI, 6.4–9.4) suffered from FI, and 3.5% (95% CI, 2.5–4.5) suffered from both disorders. Constipated respondents were 2.7 times more likely to suffer from FI than non-constipated respondents (95% CI, 1.8–4.0). Moreover, 48.7% of the respondents with constipation, 35.0% with FI, and 38.6% in whom the disorders co-occurred qualified their bowel habits as either “good” or “very good”. We found that 49.4% of the respondents with constipation and 48.0% with FI had not discussed their complaints with anyone.Conclusions
Constipation and FI, isolated or co-occurring, are common disorders in the general population, even in young and healthy respondents. Since constipation and FI often co-occur, we recommend that patients who seek medical attention for either disorder should be examined for both. Moreover, constipation and/or FI are not always identified appropriately by patients. Therefore, physicians should take the initiative to diagnose and treat these disorders.9.
Background/aims
Fecal soiling (FS) is the staining of underwear without loss of significant amounts of fecal material. It is frequently associated with defecation disorders in children. The aim of this study was to search for psychological and clinical correlates of adult patients with soiling. Clinically, the complaint of staining is confused with that of fecal incontinence (FI) in the mind of both patients and attending physicians.Design
Observational studyPatients and method
We included 1454 consecutive outpatients (71% females). They filled out the Rome III questionnaire for functional gastrointestinal disorders (FGIDs); Beck depression inventory, and state and trait anxiety questionnaires; and Likert scales for constipation, diarrhea, bloating, and abdominal pain. Data were analyzed using ANOVA and logistic regression analysis.Results
Soiling was found in 123 patients (8.5%). They reported similar frequencies of esophageal, gastroduodenal, and abdominal pain as patients without soiling. In contrast, patients with soiling reported higher prevalence of IBS, such as IBS-Diarrhea, Mixed-IBS, functional diarrhea, functional constipation, and levator ani syndrome, and higher Likert scale for diarrhea, bloating, abdominal pain, and softer stools. The multivariable logistic regression analysis shows that patients with soiling have increased odds to report IBS (P?=?0.019; OR?=?1.958; 95% CI?=?[1.118–3.431]), functional diarrhea (P?=?0.040; OR?=?1.901; 95% CI?=?[1.028–3.513]), and high Diarrhea Likert scale (P?<?0.001; OR?=?1.215; 95% CI?=?[1.130–1.306]). No association was found with psychological evaluation.Conclusion
In FGID patients, soiling is not associated with psychological disorders and is mainly associated with IBS and functional diarrhea.10.
Angelo Restivo Luigi Zorcolo Giuseppe D’Alia Francesca Cocco Andrea Cossu Francesco Scintu Giuseppe Casula 《International journal of colorectal disease》2016,31(2):257-266
Introduction
Transanal endoscopic microsurgery (TEM) is a consolidated technique for the excision of rectal tumors. However, many aspects relating to its morbidity, risk of functional alterations, and therapeutic outcomes are still unclear. The aim of this study was to assess the rate of morbidity and fecal incontinence after TEM, and to identify associated risk factors.Methods
We prospectively recorded the clinical data of 157 patients who underwent TEM from 1996 to 2013. Among these, 89 patients answered a questionnaire for the assessment of fecal continence at a median follow-up time of 40 months.Results
Intraoperative and postoperative TEM complication rates were 3.8 and 20.4 %. The mortality rate was 0.6 %. A distance from the anal verge of more than 6 cm correlated with a higher risk of perforation, while patients with cancer were more likely to have postoperative bleeding. Incontinence was reported by 32 (36 %) patients, of which 7 (8 %) experienced transitory symptoms only, while 25 (28 %) reported persistent symptoms. We found a correlation between patients receiving preoperative radiotherapy (RT) and the development of fecal incontinence. The recurrence rate was 3 % (1/32) in pT1, 80 % (4/5) in pT2, and 100 % (1/1) in pT3. After radiotherapy, 7 % (1/9) showed a good response (pT0-1), and 18 % (2/7) showed no response (pT2-3).Conclusions
TEM is associated with low morbidity but the risk of developing functional alterations is not negligible and should be discussed with the patient before the operation. Good oncological outcomes are possible for early invasive cancers and for selected advanced cancers following a good response to preoperative RT.11.
Purpose
Percutaneous tibial nerve stimulation (pTNS) was originally developed to treat urinary incontinence. Recently, some case series have also documented its success in the treatment of fecal incontinence. Nevertheless, the mechanism underlying this effect remains unknown but may be related to changes in rectal capacity. The aim of this study was to investigate the success of pTNS for the treatment of fecal urge incontinence and assess the influence of rectal capacity on treatment efficacy.Methods
All patients undergoing pTNS for fecal incontinence between July 2009 and March 2014 were enrolled in a prospective, observational study consisting of a therapeutic regimen that lasted 9 months. Therapy success was defined as a reduction in the CCI (Cleveland Clinic incontinence) score of ≥50% and patient-reported success. Furthermore, quality of life (Rockwood’s scale) and changes in anorectal physiology were recorded.Results
Fifty-seven patients with fecal urge incontinence were eligible, nine of whom were excluded. The success rate was 72.5%. Incontinence events and urge symptoms were significantly reduced after 3 months and at the end of therapy. The median CCI score decreased from 12 to 4 (P < 0.0001), and the quality of life was significantly improved. However, rectal capacity was not significantly related to treatment success before or after therapy. No adverse events were observed.Conclusions
These results demonstrate that pTNS can improve the symptoms and quality of life of patients with fecal urge incontinence. However, the study fails to demonstrate a correlation between treatment success and changes in rectal capacity.12.
C. S. Inaba S. Sujatha-Bhaskar C. Y. Koh M. D. Jafari S. D. Mills J. C. Carmichael M. J. Stamos A. Pigazzi 《Techniques in coloproctology》2017,21(8):667-671
Background
Robotic ventral mesh rectopexy (RVMR) is an appealing approach for the treatment of rectal prolapse and other conditions. The aim of this study was to evaluate the outcomes of RVMR for rectal prolapse.Methods
We performed a retrospective chart review for patients who underwent RVMR for rectal prolapse at our institution between July 2012 and May 2016. Any patient who underwent RVMR during this time frame was included in our analysis. Any cases involving colorectal resection or other rectopexy techniques were excluded.Results
Of the 24 patients who underwent RVMR, 95.8% of patients were female. Median age was 67.5 years old (IQR 51.5–73.3), and 79.2% of patients were American Society of Anesthesiologists class III or IV. Median operative time was 191 min (IQR 164.3–242.5), and median length of stay was 3 days (IQR 2–3). There were no conversions, RVMR-related complications or mortality. Patients were followed for a median of 3.8 (IQR 1.2–15.9) months. Full-thickness recurrence occurred in 3 (12.4%) patients. Rates of fecal incontinence improved after surgery (62.5 vs. 41.5%, respectively) as did constipation (45.8 vs. 33.3%, respectively). No patients reported worsening symptoms postoperatively. Only one (4.2%) patient reported de novo constipation postoperatively.Conclusions
RVMR is a feasible, safe and effective option for the treatment of rectal prolapse, with low short-term morbidity and mortality. Multicenter and long-term studies are needed to better assess the benefits of this procedure.13.
Ericka Sohlberg Daniel Greenberg Ekene Enemchukwu 《Current Bladder Dysfunction Reports》2018,13(4):288-293
Purpose of Review
This article aims to review sacral and tibial neuromodulation outcomes in elderly patients. Safety and efficacy of these two neuromodulatory treatments for both urinary and fecal indications are addressed.Recent Findings
Recent data assessing sacral neuromodulation (SNM) for refractory overactive bladder and urge urinary incontinence (UUI) demonstrates that older patients have similar outcomes and complication rates when compared to the general population. For both urinary and fecal indications, SNM has been shown to significantly increase quality of life in older patients. Age has additionally not been a factor affecting tibial nerve stimulation outcomes.Summary
Limited data specifically addresses use of tibial and sacral neuromodulation in elderly patients. Available studies suggest that both treatment options are safe and effective in the older population for urinary and fecal indications, although further study is necessary.14.
Purpose of Review
Bladder and bowel dysfunction is a common pediatric disorder that involves lower urinary tract symptoms (LUTS) as well as constipation and/or encopresis. Effective treatment of constipation in these patients leads to resolution or improvement of urinary symptoms in the majority of cases. Because many of these children initially present to the urologist with the primary complaint of LUTS, it is important for the consulting specialist to be well-versed on the topic of constipation. This review aims to provide an evidence-based guide on the evaluation and management of constipation in children.Recent Findings
Recent papers have improved our knowledge on the utilization of interventions such as antegrade continence enemas and sacral nerve stimulation for more recalcitrant cases of constipation. Although there have been limited advancements in the use of pharmacologic therapies for the treatment of constipation in children, it is hoped that newer therapeutic agents proven effective for adult constipation will gain pediatric use over time.Summary
Present therapy for constipation in BBD is effective for the majority of patients. There is promise for further improvement in treatment options in the near future.15.
Matas?Jakubauskas Valdemaras?Jotautas Eligijus?Poskus Saulius?Mikalauskas Gintare?Valeikaite-Tauginiene Kestutis?Strupas Tomas?Poskus
Purpose
Transanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence.Methods
Patients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more).Results
One hundred thirty-two patients were included in the study. Patients’ median follow-up time was 96 (12–168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18–82) vs. 68 (50–89) years; p?=?0.004), underwent longer operations (50 (10–140) vs. 60 (15–210) min; p?=?0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p?=?0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010–1.106; p?=?0.016).Conclusions
Fecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.16.
Background
Bowel disturbances have been identified as the most important risk factor for fecal incontinence (FI). However, few studies have evaluated the impact of fiber supplementation. Our aim was to assess the correlation between the improvement in stool consistency by fiber supplementation and the changes in urgency and number of FI episodes and in the QoL of patients with FI.Methods
Eighty-three patients who came to our institution with FI and/or fecal urgency associated with loose stools or diarrhea were prospectively included in the study The intervention included dietary advice and methylcellulose 500 mg every 8 h for 6 weeks. All assessments were carried out at baseline and 6 weeks after the start of the intervention, and included a Bristol Stool Scale, a 3-week bowel diary, the St Mark’s score, the Fecal Incontinence Quality of Life scale (FIQL) and a bowel satisfaction score.Results
Sixty-one patients completed the study. At baseline 50 reported episodes of urge incontinence, while 11 did not report FI episodes because they rarely left home to avoid leakage. The Bristol score improved to normal stools in 65.6% of patients after treatment. Bowel diaries showed a statistically significant reduction in the number of bowel movements, urge episodes, urge fecal incontinence episodes and soiling per week. The St Mark’s score and the bowel satisfaction score significantly improved after methylcellulose and overall deferment time also increased. FIQL significantly improved in two subdomains (lifestyle, coping/behavior). Thirty-one patients (51.7%) were discharged with methylcellulose as the only treatment.Conclusions
FI may significantly improve with methylcellulose in selected cases. Assessment of fecal consistency and initial treatment with methylcellulose could be started at primary care level to reduce the need for specialist referral.17.
Myeongsook Seo Segyeong Joo Kee Wook Jung Eun Mi Song Satish S. C. Rao Seung-Jae Myung 《Current gastroenterology reports》2018,20(12):57
Purpose of Review
To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques.Recent Findings
The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence.Summary
HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.18.
Aim
Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.Method
All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.Results
The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.Conclusion
Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.19.
Arnold Wald 《Current gastroenterology reports》2018,20(3):9
Purpose of Review
The purpose of this review is to highlight current and newer therapeutic approaches to treat fecal incontinence in patients who do not respond to conservative measures.Recent Findings
Neurostimulation techniques, injection of bulking agents, and radiofrequency energy delivery to the anal canal have been proposed and tested for fecal incontinence over the last decade. Sacral stimulation is both effective and durable and is now the most popular of the invasive techniques whereas percutaneous tibial stimulation, radiofrequency energy, and bulking agents are either less effective or their evaluation has been handicapped by suboptimal study designs. The precise indications for the new vaginal control device and anal plugs remain to be established. The magnetic anal sphincter is disappointing. Stem cell therapy is a potentially exciting approach, which is in its infancy.Summary
There continues to be an unmet need for innovative approaches to patients with fecal incontinence who do not respond to conservative measures. The efficacy of current and future therapies should be assessed using criteria more stringent than has been used in the past to provide a more realistic assessment of meaningful efficacy.20.
P. Moya P. Parra A. Arroyo E. Peña J. Benavides R. Calpena 《Techniques in coloproctology》2016,20(5):317-319