Obesity is associated with increased prevalence and severity of pelvic floor disorders in women considering bariatric surgery

BackgroundAlthough an association between obesity and urinary incontinence (UI) has been reported, the association between obesity and other PFDs is less clear. The aim of this study was to determine the prevalence of pelvic floor disorders (PFDs), including stress urinary incontinence (SUI), urge urinary incontinence (UUI), pelvic organ prolapse (POP), and anal incontinence (AI), in obese women contemplating bariatric surgery compared with nonobese subjects at a tertiary care referral hospital.MethodsFrom September 2006 to December 2007, obese women contemplating bariatric surgery and nonobese women from general gynecology clinic completed a validated screening questionnaire for PFDs, the Sandvik urinary incontinence severity index, and the Rockwood fecal incontinence severity index.ResultsA total of 217 obese (mean body mass index of 50 ± 10 kg/m²) and 210 nonobese controls (mean body mass index 23 ± 3 kg/m²) were screened. The presence of any PFD occurred in 159 patients (75%) in the obese group compared with 89 nonobese patients (44%; P <.0001). More obese patients experienced SUI, UUI, and AI, but not POP. Obese patients also had more severe UI and AI. Obesity remained a significant risk factor for UI and AI, even after adjusting for baseline differences in demographics and medical conditions, with an adjusted odds ratio of 4.1 (95% confidence interval 2.3–7.8) and 2.1 (95% confidence interval 1.1–4.1), respectively.ConclusionThe prevalence of PFDs, including SUI, UUI, and all forms of AI, was greater in the obese and morbidly obese women contemplating bariatric surgery. Obesity was also associated with an increased severity of UI and AI. Obesity appears to confer a fourfold and twofold increased risk of UI and AI, respectively.     

Pelvic floor training improves faecal incontinence and obstructed defaecation despite the presence of rectal intussusception

Background

Rectal intussusception is often observed in patients with faecal incontinence and obstructed defaecation. The aim of this study is to assess if pelvic floor training improves faecal incontinence and obstructed defaecation in patients with rectal intussusception.

Methods

Case notes of all patients referred to Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018 for the management of faecal incontinence and obstructed defaecation and rectal intussusception were retrospectively reviewed using a prospectively maintained database. St Mark's faecal incontinence and Cleveland clinic constipation scores were obtained from patients before and after they underwent pelvic floor training.

Results

One hundred and thirty-one patients underwent pelvic floor training at Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018. Sixty-one patients had rectal intussusception (22 low-grade and 39 high-grade). Median St Marks score improved following pelvic floor training from 8 to 1 (P < 0.001). Median Cleveland Clinic constipation score improved from 8 to 5 (P < 0.001). In patients with low grade rectal intussusception, pelvic floor training improved median St Mark's score from 3 to 0 (P = 0.003), whereas Cleveland Clinic constipation score improved from 9 to 7 (P < 0.001). In patients with high-grade rectal intussusception, pelvic floor training improved median St Mark's score from 9 to 2 (P < 0.001), whereas median Cleveland Clinic constipation score improved from 8 to 4 (P < 0.001).

Conclusion

Pelvic floor training without biofeedback therapy improves faecal incontinence and obstructed defaecation. Improvement in symptoms is unrelated to rectal intussusception observed on proctography or at examination under anaesthesia in these patients.     

Treatment options to improve anorectal function following rectal resection: a systematic review

Aim Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery. Method Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life. Results The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re‐education (n = 7), colonic irrigation (n = 2) and sacral nerve stimulation (SNS) (n = 6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re‐education or SNS. Three studies reported improved quality of life after pelvic floor re‐education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS. Conclusion Conservative therapies such as pelvic floor re‐education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence‐based conclusions.     

Clinical and instrumental evaluation of pelvic floor disorders before and after bariatric surgery in obese women

BackgroundObesity, well known as a risk factor for several diseases, can also lead to pelvic floor dysfunction (PFD). However, scant data are available regarding PFD in obese individuals. Our study was designed to assess the prevalence, severity, and the quality of life (QOL) effect of PFD in obese women before and after bariatric surgery at a university hospital in Italy.MethodsA total of 100 obese (body mass index [BMI] ≥30 kg/m²) women completed 6 validated specific and QOL questionnaires about PFD. The patients were evaluated by physical examination, endoanal ultrasonography, rectal balloon distension test, and dynamic magnetic resonance imaging. Of the 100 patients, 87 were reassessed 12 months after bariatric surgery.ResultsThe prevalence of PFD was 81%, and 49% of patients reported that their symptoms adversely affected their QOL. Urinary incontinence (UI) was the most common disorder (61%) and was associated with the BMI (P = .04). Fecal incontinence and pelvic organ prolapse symptoms were reported by 24 and 56 patients, respectively. Urogenital prolapse and rectocele was documented in 15% and 74% of patients, respectively. After a mean BMI reduction of 10 kg/m², the prevalence of PFD decreased to 48% (P = .02), with a significant improvement in QOL. The prevalence of UI decreased to 9.2% (P = .0001) and was associated with the decrease in postoperative BMI (P = .04). The rate of resolution of the symptoms was 84%, 85%, and 74% for UI, fecal incontinence, and pelvic organ prolapse, respectively.ConclusionIn the present sample of obese women, PFD was common and adversely affected their QOL. A clear association was found between the BMI and UI. Weight loss resulted in improved UI, fecal incontinence, and symptoms of pelvic organ prolapse.     

Prevalence of Defaecatory Disorders in Morbidly Obese Patients Before and After Bariatric Surgery

Background

The prevalence of obesity is increasing worldwide and has lately reached epidemic proportions in western countries. Several epidemiological studies have consistently shown that both overweight and obesity are important risk factors for the development of various functional defaecatory disorders (DDs), including faecal incontinence and constipation. However, data on their prevalence as well as effectiveness of bariatric surgery on their correction are scant. The primary objective of this study was to estimate the effect of morbid obesity on DDs in a cohort of patients listed for bariatric surgery. We also evaluated preliminary results of the effects of sleeve gastrectomy on these disorders.

Patients and methods

A questionnaire-based study was proposed to morbidly obese patients having bariatric surgery. Data included demographics, past medical, surgical and obstetrics histories, as well as obesity related co-morbidities. Wexner Constipation Score (WCS) and the Faecal Incontinence Severity Index (FISI) questionnaires were used to evaluate constipation and incontinence. For the purpose of this study, we considered clinically relevant a WCS ??5 and a FISI score ??10. The same questionnaires were completed at 3 and 6?months follow-up after surgery.

Results

A total of 139 patients accepted the study and 68 underwent sleeve gastrectomy and fully satisfied our inclusion criteria with a minimum follow-up of 6?months. Overall, mean body mass index (BMI) at listing was 47?±?7?kg/m² (range 35?C67?kg/m²). Mean WCS was 4.1?±?4 (range 0?C17), while mean FISI score (expressed as mean±standard deviation) was 9.5?±?9 (range 0?C38). Overall, 58.9% of the patients reported DDs according to the above-mentioned scores. Twenty-eight patients (20%) had WCS ??5. Thirty-five patients (25%) had a FISI ??10 while 19 patients (13.7%) reported combined abnormal scores. Overall, DDs were more evident with the increase of obesity grade: Mean BMI decreased significantly from 47?±?7 to 36?±?6 and to 29?±?4?kg/m² respectively at 3 and 6?months after surgery (p?p?=?0.02). Similarly, the FISI score decreased from 10?±?8 to 3?±?4 and to 1?±?2 respectively at 3 and 6?months (p?=?0.0001).

Conclusions

Defaecatory disorders are common in morbidly obese patients. The risk of DDs increases with BMI. Bariatric surgery reduces DDs, mainly faecal incontinence, and these findings correlated with BMI reduction.     

Urinary Stress Incontinence Among Obese Women: Review of Pathophysiology Therapy

Obesity is a common condition among women in developed countries and has a major impact on stress urinary incontinence. Women suffering from obesity manifest increased intra-abdominal pressures, which adversely stress the pelvic floor and may contribute to the development of urinary incontinence. In addition, obesity may affect the neuromuscular function of the genitourinary tract, thereby also contributing to incontinence. Accordingly, thorough evaluation of obese women must be performed prior to the institution of treatment. Weight loss may relieve urinary incontinence, but definitive therapy via operative procedures is effective even in obese patients and should be recommended with confidence.     

Prevalence of Obesity Among Children and/or Grandchildren of Adult Bariatric Surgery Patients

Background  Clinical experience suggests that some adults who undergo bariatric surgery have children who are obese. Childhood obesity is associated with increased morbidity and mortality in later life. This study examined the prevalence of obesity among children and grandchildren (≤12 years of age) of adult bariatric surgery patients. Methods  Patients in a prospective database of morbidly obese patients who underwent bariatric surgery between January 2004 and May 2007 were recruited by phone and in clinic. Patient demographics, body mass index (BMI) at surgery, and survey data were collected. The survey included questions regarding their child/grandchild's body habitus, weight, and height. Child obesity was defined as BMI percentile ≥95. Statistical significance was set at p < 0.05. Results  One hundred twenty-two patients were enrolled in this study (77% women, mean BMI 49 kg/m²). One hundred thirty-four out of 233 children/grandchildren identified had complete data; 41% had a BMI percentile ≥95. Only 29% of these obese children were so identified by the adult respondents. Significantly more biological children/grandchildren were obese than nonbiological (p = 0.013), and significantly more biological children were obese than biological grandchildren (p = 0.027). Conclusions  This sample of bariatric surgery patients had a high proportion of obese preteen children/grandchildren. Obesity was most prevalent among biological children (vs. biological grandchildren and nonbiological children). Patients often did not recognize the degree of overweight in their children/grandchildren. Because families of bariatric surgery patients often include obese children, interventions aimed at all family members merit consideration.     

Defunctioning stomas in patients with locally advanced rectal cancer prior to preoperative chemoradiotherapy

Objective A literature search did not produce any evidence‐based objective criteria to determine which patients with locally advanced rectal cancer would benefit from a defunctioning stoma prior to neoadjuvant chemoradiotherapy. Our criteria for formation of a defunctioning stoma are: faecal incontinence and inability to cannulate the tumour at colonoscopy. The aim of this study was to examine whether these current criteria are appropriate. Method Forty‐nine consecutive locally advanced rectal cancer patients treated from February 2003 to November 2006 were identified from our colorectal database. All received long‐course chemoradiotherapy (Bossett regimen) and definitive surgery was performed 6–8 weeks later. Results Of the 49 patients, 31 presented with diarrhoea and two with faecal incontinence; nine patients were defunctioned by trephine stoma prior to treatment [cannulation impossible at colonoscopy (n = 8); faecal incontinence (n = 1)]. One patient with faecal incontinence refused early defunctioning stoma. Median hospital stay was 12 days (interquartile range: 7–30), and complications included pneumonia (n = 1) and peristomal cellulitis (n = 2). Of the 40 patients who went directly to neoadjuvant chemoradiotherapy, two subsequently required a defunctioning stoma for severe diarrhoeal symptoms during therapy. Eight patients had worsening diarrhoeal symptoms but tolerated treatment. Three patients, who had stoma formation, did not proceed to definitive surgery following neoadjuvant therapy: poor operative fitness (n = 2) and disease progression (n = 1). Conclusion Stenosis causing inability to cannulate the tumour at colonoscopy and faecal incontinence were the only objective indications for an early defunctioning stoma. Worsening diarrhoea during therapy (unless severe) did not appear to be a good indication for a defunctioning stoma.     

Systematic review on ventral rectopexy for rectal prolapse and intussusception

Objective This systematic review assesses the effectiveness of ventral rectopexy (VR) surgery for treatment of rectal prolapse (RP) and rectal intussusception (RI) in adults. Method MEDLINE, EMBASE, Scopus and other relevant databases were searched to identify studies. Randomized controlled trials or nonrandomized studies with more than 10 patients receiving ventral mesh rectopexy surgery were considered for the review. Results Twelve nonrandomized case series studies with 728 patients in total are included in the review. Seven studies used the Orr‐Loygue procedure (VR with posterior rectal mobilization to the pelvic floor) and five studies used VR without posterior rectal mobilization. Overall weighted mean percentage decrease in faecal incontinence (FI) rate was 45%. The weighted mean percentage decrease in constipation rate was 24%. Weighted mean recurrence rate was 3.4%. Conclusions There are limitations in published literature on VR. The available data indicate that VR has low recurrence and improves FI in patients suffering from these conditions. There is a greater reduction in postoperative constipation if VR is used without posterior rectal mobilization.     

Stapled transanal rectal resection and sacral nerve stimulation – impact on faecal incontinence and quality of life

Aim The aim of the study was to assess the impact of stapled transanal rectal resection (STARR) on pre‐existing faecal incontinence and quality of life in patients suffering from obstructive defaecation syndrome (ODS) and to evaluate the efficiency of sequential sacral nerve stimulation (SNS) for improvement of persistent incontinence after STARR. Method Thirty‐one patients with ODS and major faecal incontinence prior to STARR were prospectively enrolled. The outcome was measured using the Cleveland Clinic Constipation and Incontinence score (CCS, CCIS), Faecal Incontinence Qualities‐of‐Life Index (FIQL), Patient Assessment of Constipation Quality‐of‐Life (PAC‐QOL) and EuroQol visual analogue scale (EQ‐VAS). Results The overall levels of constipation (CCS from 13.1 ± 3.8 to 6.2 ± 5.4; P < 0.001) and incontinence (CCIS from 12.6 ± 3.2 to 9.4 ± 5.1; P = 0.005) were significantly improved after STARR; concordantly, the global and specific quality of life were significantly improved. Following postoperative constipation and incontinence, three different groups of patients were differentially referred to SNS. In group I (n = 16, 52%), both constipation (CCS from 12.6 ± 4.0 to 3.6 ± 1.9; P < 0.001) and incontinence (CCSI from 12.43 ± 3.2 to 5.1 ± 1.9; P < 0.001) were improved. In group II (n = 8, 25%), only constipation was improved (CCS from 12.3 ± 2.3 to 3.3 ± 2.2; P < 0.001), while incontinence persisted (CCIS from 12.8 ± 2.9 to 13.1 ± 3.1; P > 0.05). In group III (n = 7, 23%) there was no improvement at all. Sacral nerve stimulation was successfully carried out in six (85%) of seven patients in group II (post‐SNS CCSI 6.1 ± 1.7; P = 0.01) but failed in five of five patients in group III. Conclusion Stapled transanal rectal resection improves quality of life in ODS patients with both severe constipation and faecal incontinence. Sacral nerve stimulation may efficiently improve persisting incontinence after STARR in selected patients.     

Impact of bariatric surgery on cardiovascular and musculoskeletal morbidity

BACKGROUND: Obesity is currently recognized as a global epidemic. According to recent statistics, the prevalence of obesity increased from 13.8% of the Canadian population in 1978-1979 to 23.1% in 2004, and the prevalence of morbid obesity increased from .9% in 1978-1979 to 2.7% in 2004. Obesity is a known risk factor for highly prevalent chronic diseases, including cardiovascular and musculoskeletal disorders. The objective of the study was to assess the impact of bariatric surgery on cardiovascular and musculoskeletal morbidity. METHODS: This was an observational study that compared a cohort of 1035 morbidly obese patients treated with bariatric surgery at the Centre for Bariatric Surgery, McGill University Health Centre with a matched cohort of 5746 morbidly obese nonsurgically treated controls. Data were obtained from the Quebec provincial health insurance database (Régie de l'Assurance Maladie du Québec). Morbidity indicators included diagnoses or treatment for cardiovascular or musculoskeletal disorders. RESULTS: Patients who underwent bariatric surgery had a significant 62% mean reduction in excess weight and 32% mean reduction in body mass index (P < .001). Compared with the matched controls, patients who had undergone bariatric surgery had significantly lower rates of diagnoses and treatments related to cardiovascular and musculoskeletal conditions. CONCLUSIONS: These results indicate that bariatric surgery is effective in reducing weight and significantly reduces the risk of cardiovascular and musculoskeletal morbidity.     

What causes chronic idiopathic perineal pain?

Aim Chronic idiopathic perineal pain is poorly understood. Underlying structural abnormalities have been clinically suspected but rarely demonstrated objectively. The condition has been frequently considered to be a psychological disorder. We aimed to evaluate how commonly a structural explanation for such pain symptoms is present. Method Patients seen in a pelvic floor clinic with severe chronic functional anorectal pain that was classified as chronic idiopathic perineal pain (study group) were prospectively registered in a pelvic floor database and underwent pelvic floor work up (defaecating proctography, anorectal physiology and anal ultrasound +/‐ rectal examination under anaesthetic). A control group was formed by patients with obstructed defaecation, with or without faecal incontinence, with advanced posterior compartment prolapse. Results Of 59 patients with chronic idiopathic perineal pain [80% women; mean age 53 (range, 22–84) years], representing 5% of all pelvic floor presentations, 33 (56%) had chronic idiopathic perineal pain alone and 26 (44%) had chronic idiopathic perineal pain with obstructed defaecation. Thirty‐five (59%) had an underlying high‐grade internal rectal prolapse (73% with chronic idiopathic perineal pain + obstructed defaecation vs 48% with chronic idiopathic perineal pain alone; P < 0.05). Anorectal pain was present in 50% of 543 controls with advanced posterior compartment prolapse. Conclusion High‐grade internal rectal prolapse commonly underlies chronic idiopathic perineal pain, particularly when obstructed defaecation is present. Chronic anorectal pain is a common, under‐recognized subsidiary symptom in patients with advanced posterior compartment prolapse presenting primarily with obstructed defaecation or faecal incontinence.     

Treatment of enterocele by abdominal colporectosacropexy – efficacy on pelvic pressure

Objective Enterocele induces pelvic pressure, obstructed defaecation, lower abdominal pain and/or false urge to defaecate in patients. The aim of this study was to evaluate the efficacy of abdominal colporectosacropexy in these symptoms, especially on pelvic pressure. Methods Sixty‐two consecutive women with enterocele were included. All patients were symptomatic because they had: pelvic pressure (n = 62), obstructed defaecation (n = 40), lower abdominal pain (n = 8) or faecal incontinence (n = 16). Defaecography confirmed enterocele in all patients. The surgical procedure was performed by the same surgeon and was an abdominal colporectosacropexy with a nonabsorbable Prolene® mesh. After surgery, clinical evaluation (62/62 patients) and a telephone questionnaire (56/62 patients) were performed, respectively, 3 months and 27 ± 13 months after surgery. Results Defaecography showed rectal abnormalities associated with enterocele in 59/62 patients (rectocele, rectal prolapse). No recurrence of enterocele was observed 3 months after surgery, but 1 patient demonstrated recurrence 10 months after surgery. Pelvic pressure was less frequent after abdominal colporectosacropexy, than before surgery (P < 0.01): pelvic pressure totally disappeared in 41/56 patients, and partially in 10/56 patients. The number of patients with obstructed defaecation, lower abdominal pain, or faecal incontinence was not different before and 27 months after surgery. The number of patients with urinary incontinence was also not different before and after surgery (30 and 27 patients). Conclusions This study of a large number of patients with enterocele shows that abdominal colporectosacropexy improves pelvic pressure in most patients and does not modify urinary status.     

Comorbidity among the morbidly obese: a comparative study of 2002 U.S. hospital patient discharges.

BACKGROUND: Increased morbidity is associated with increasing severity of obesity. However, among morbidly obese patients, comorbid prevalence has been reported primarily in the bariatric surgical literature. This study compares demographic characteristics and selected comorbid conditions of morbidly obese patients discharged after surgical obesity procedures and morbidly obese patients discharged after all other hospital procedures. METHODS: The 2002 National Hospital Discharge Survey (a nationally representative sample of hospital discharge records) and the International Classification of Diseases, 9th Revision, Clinical Modification were used to identify and describe all morbidly obese patient discharges (n = 3,473) and to quantify the prevalence of selected obesity-related comorbid conditions. RESULTS: Compared with all other morbidly obese patients, the obesity surgery patients (n = 833) were younger (median, 42 vs 48 years; range, 17 to 67) and more female (82.3% vs. 63.7%), with higher rates of sleep apnea (24.0% vs. 11.8%), osteoarthritis (22.9% vs. 11.8%), and gastroesophageal reflux disease (27.7% vs. 11.7%) (all P < .001). The prevalence of type 2 diabetes mellitus was lower in the obesity surgery patients (16.1% vs. 24.3%; P = .003), whereas the rates of hypertension (45.9% vs. 41.0%; P = .13) and asthma (9.6% vs. 12.0%; P = .26) were similar in the two groups. CONCLUSIONS: Demographic characteristics and comorbid prevalence of morbidly obese patients discharged after obesity surgery are consistent with reports in the bariatric surgical literature. Obesity surgery patients had a higher prevalence of some comorbid conditions. Possible explanations for this include preferential diagnosis, differential diagnostic coding, or increased severity of morbid obesity. Advancing surgical and insurance guidelines for bariatric surgery will require clinical data that accurately describe and quantify the demographic distribution of obesity and the associated burden of disease.     

Prospective cohort study of high-volume transanal irrigation in patients with constipation and/or faecal incontinence

Aim

The aim of this work was to determine the clinical efficacy of high-volume transanal irrigation (TAI) in patients with constipation and/or faecal incontinence using validated symptom and quality of life questionnaires.

Method

This was a prospective cohort study of 114 consecutive patients with constipation and/or faecal incontinence (Rome IV defined) who started TAI. A comprehensive questionnaire was completed at baseline and 4, 12, 26 and 52 weeks’ follow-up. The primary objective was significant symptom reduction [≥30%; Cleveland Clinic Constipation Score (CCCS) and St Marks Incontinence Score (SMIS)] in those who continued TAI at 52 weeks. Secondary objectives were (1) continuation rates of TAI, (2) effect on quality of life (QoL) and (3) identification of predictors for continuation.

Results

A total of 59 (51.8%) patients with constipation, 26 (22.8%) with faecal incontinence and 29 (25.4%) with coexistent symptoms were included. At 52 weeks, 41 (36.0%) patients continued TAI, 63 (55.2%) stopped and 10 (8.8%) patients were lost to follow-up. In those who continued TAI at 52 weeks (n = 41), no reduction of constipation symptoms was observed. Median Patient Assessment of Constipation Quality of Life scores decreased on most domains, indicating QoL improvement. Reduction of faecal incontinence occurred in 5/9 (55.6%) patients with faecal incontinence and in 3/10 (30.0%) patients with coexistent symptoms. The median SMIS per-individual decreased in patients with coexistent symptoms (2; interquartile range 0–4; p = 0.023). Median Fecal Incontinence Quality of Life scores increased in most domains, indicating improved QoL. No clinical characteristics predicted continuation.

Conclusion

One-third (n = 41) of patients continued TAI at 52 weeks. In those who continued TAI at 52 weeks, symptoms of faecal incontinence (SMIS) were reduced but not constipation (CCCS). QoL related to both constipation and faecal incontinence improved. No clinical characteristics predicted continuation.     

Short-term results for laparoscopic ventral rectopexy using biological mesh for pelvic organ prolapse

Aim There is growing evidence that laparoscopic ventral rectopexy (LVR) is an effective treatment for pelvic organ prolapse and obstructive defaecation caused by rectocele. LVR is usually performed using synthetic mesh despite concerns about mesh erosion. We present our experience of using a porcine dermal collagen mesh (Permacol?) for LVR, which is the largest such case series to date. Method Data on 65 patients were collected prospectively from May 2008 to October 2010. Outcome measures were complications, recurrence, length of hospital stay, patient satisfaction, Wexner constipation score and Wexner incontinence score. Preoperative and postoperative scores were compared using the two‐tailed Wilcoxon signed rank test. P < 0.05 was considered statistically significant. Results There were statistically significant improvements in the Wexner constipation scores at 6 months and 1 year (both P < 0.0001) and in faecal incontinence scores at 6 months (P < 0.0001) and 1 year (P = 0.0002). There were no cases of mesh erosion or mesh‐related infection in our series. Recurrence of symptoms occurred in two patients (3.1%). Symptoms were rated as much better or better by 93% of patients at 6 months and this was sustained at 1 year (96%). Conclusion In the short term, LVR using biological mesh is safe and as effective as synthetic mesh, with high patient satisfaction. Constipation and faecal incontinence scores were both improved.     

Rectal irrigation: a useful tool in the armamentarium for functional bowel disorders

Aim The efficacy of rectal irrigation (RI) was assessed in patients with various functional bowel disorders. Method A prospective analysis was carried out of patients presenting to our functional bowel clinic from 2005 to 2009. The Cleveland Clinic Constipation and Incontinence Scores were used to assess outcomes following rectal irrigation. Patients were asked if they were satisfied with RI and would recommend it to a friend. Results Ninety‐one patients (80 female, median age 51 (17–78) years had undergone rectal irrigation for the following indications: chronic constipation (n = 32), slow transit constipation (n = 18), obstructed defaecation (n = 10), and faecal incontinence (n = 31). Of the 60 patients with constipation, 50 (83%) were available for follow up. Mean constipation scores improved from 18.72 to 11.45 following rectal irrigation (P = 0.001). Twenty‐five patients experienced failure of RI to control symptoms, 10 of whom were offered surgery. Of the patients with incontinence, 20 (67%) were available for follow up. Mean incontinence scores improved from 16.2 to 10.8 with rectal irrigation (P = 0.005). Twelve patients discontinued RI, the commonest reason being lack of improvement in symptoms. Seven of these patients were offered surgery. The only complication was in one patient with constipation who had minor rectal bleeding following irrigation, which was stopped. Conclusion Rectal irrigation can be a useful tool in the management of functional bowel disorders and should be tried prior to the consideration of any surgery. However, further work is needed to define the precise indications and patient selection criteria.     

Factors influencing changing bowel habits in patients undergoing sphincter-saving surgery for rectal cancer

A research survey research was conducted to identify factors affecting changes in bowel habits of rectal cancer patients undergoing sphincter-saving surgery and to provide basic information useful in nursing interventions supporting treatment for rectal cancer patients. The subjects were rectal cancer patients who had undergone sphincter-saving surgery over 2 years ago. The final analysis included 107 patients who had made outpatient visits to the colorectal surgery from 12th to 31st May, 2014. Collected data were processed with SPSS Version 21.0. Changes in bowel habits in the subjects were observed: frequent bowel movement in 74 patients (69.2%) and faecal incontinence in 48 (44.9%). Most of the patients used self-care to improve their bowel function including dietary modification (78.5%), regular exercise (72.0%) and pelvic floor exercise (34.6%). Frequent defecation was associated with adjuvant chemoradiation therapy (P < 0.001) and faecal incontinence was associated with age of ≥65 years (P = 0.019) and a group who underwent adjuvant radiation therapy (P < 0.001). It is necessary to give sufficient information about possible postoperative changes in bowel habits to patients with the risk factors before surgery.     

Body mass index and complications following major gastrointestinal surgery: a prospective,international cohort study and meta‐analysis

Aim

Previous studies reported conflicting evidence on the effects of obesity on outcomes after gastrointestinal surgery. The aims of this study were to explore the relationship of obesity with major postoperative complications in an international cohort and to present a meta‐analysis of all available prospective data.

Methods

This prospective, multicentre study included adults undergoing both elective and emergency gastrointestinal resection, reversal of stoma or formation of stoma. The primary end‐point was 30‐day major complications (Clavien–Dindo Grades III–V). A systematic search was undertaken for studies assessing the relationship between obesity and major complications after gastrointestinal surgery. Individual patient meta‐analysis was used to analyse pooled results.

Results

This study included 2519 patients across 127 centres, of whom 560 (22.2%) were obese. Unadjusted major complication rates were lower in obese vs normal weight patients (13.0% vs 16.2%, respectively), but this did not reach statistical significance (P = 0.863) on multivariate analysis for patients having surgery for either malignant or benign conditions. Individual patient meta‐analysis demonstrated that obese patients undergoing surgery for malignancy were at increased risk of major complications (OR 2.10, 95% CI 1.49–2.96, P < 0.001), whereas obese patients undergoing surgery for benign indications were at decreased risk (OR 0.59, 95% CI 0.46–0.75, P < 0.001) compared to normal weight patients.

Conclusions

In our international data, obesity was not found to be associated with major complications following gastrointestinal surgery. Meta‐analysis of available prospective data made a novel finding of obesity being associated with different outcomes depending on whether patients were undergoing surgery for benign or malignant disease.