Anal Incontinence

Is the Quality of Life Better in Patients with Colostomy than Patients with Fecal Incontinence?
Colquhoun P, Kaiser R Jr, Efron J, Weiss EG, Nogueras JJ, Vernava AM 3rd, Wexner SD
World J Surg. 2006 Aug 29;.e-pub

BACKGROUND: A colostomy offers definitive treatment for individuals with fecal incontinence (FI). Patients and physicians remain apprehensive regarding this option because the quality of life (QOL) with a colostomy is presumably worse than living with FI. The aim of this study, therefore, was to compare the QOL of colostomy patients to patients with FI. METHODS: A cross-sectional postal survey of patients with FI or an end colostomy was undertaken. QOL measures used included the Short Form 36 General Quality of Life Assessment (SF-36) and the Fecal Incontinence Quality of Life score (FIQOL). RESULTS: The colostomy group included 39 patients and the FI group included 71 patients. The average FI score for FI group was 12 +/- 4.9 (0 = complete continence, 20 = severe incontinence). In the colostomy group the average colostomy function score was 12.9 +/- 3.8 (7 = good function, 35 = poor function). Analysis of the SF-36 revealed higher social function score in the colostomy group compared to the FI group. Analysis of the FIQOL revealed higher scores in the coping, embarrassment, lifestyle scales, and depression scales in the colostomy group compared to the FI group. CONCLUSION: A colostomy is a viable option for patients who suffer from FI and offers a definitive cure with improved QOL.

[Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence.]
Ruthmann O, Fischer A, Hopt UT, Schrag HJ
Chirurg. 2006 Aug 1;.
Dynamic graciloplasty (DGP) and the Acticontrade markNeosphincter (artificial bowel sphincter, ABS) are well-established therapeutic instruments in patients with severe fecal incontinence. However, the success rates in the literature must be interpreted with caution. The report presented here presents firstly a critical analysis of 1510 patients in 52 studies (29 DGP vs 23 ABS). The evidence of these studies was assessed using the Oxford EBM criteria. All data were statistically analysed. Up to 94% of the studies analysed show EBM levels of only >3b. Both procedures show significant improvements in postoperative continence scores (p<0.001) and a significant advantage of ABS over DGP. Nevertheless, they are associated with a high incidence of morbidity in the long term (infection rate ABS vs DGP 21.74% vs 35.1%, revision rate ABS vs DGP 37.53% vs 40.64%, and ABS explantation rates of 30%). Presently no therapeutic recommendation can be expressed based on the few data available. Furthermore, therapy should be performed in specialized centers and patients should be given a realistic picture of the critical outcome of both surgical techniques.

Outcome of antegrade continence enema procedures for faecal incontinence in adults.
Lefevre JH, Parc Y, Giraudo G, Bell S, Parc R, Tiret E
Br J Surg. 2006 Sep 4;.

BACKGROUND:: Faecal incontinence has major consequences. Colostomy has been the mainstay of therapy when other options fail. Operations such as the Malone procedure have been proposed as an alternative. The aim of this study was to evaluate the outcomes and quality of life of patients having a Malone procedure for the treatment of faecal incontinence. METHODS:: Charts of patients who had had a Malone procedure or equivalent between 1998 and 2004 were reviewed. The patients completed a Short Form (SF) 36 quality of life questionnaire. RESULTS:: The study included 25 patients (17 female; median age 47 years). In seven, the appendix was used; an ileoneoappendicostomy was performed in the other 18. Three patients were lost to follow-up; the remaining 22 were followed for a median (range) of 21 (1-61) months. Five patients had a cutaneous stenosis; another had the appendicostomy removed and replaced by a colostomy. Four patients no longer used the stoma for irrigation. All other patients were completely clean except one, who reported occasional night-time seepage. The mean SF-36 showed a good physical recovery (43.9) but persisting psychological distress (36.0). CONCLUSION:: The Malone procedure or equivalent achieves good results in the management of faecal incontinence, although psychological distress persists after surgery. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Association of Fecal Incontinence with Physical Disability and Impaired Cognitive Function.
Quander CR, Morris MC, Mendes de Leon CF, Bienias JL, Evans DA
Am J Gastroenterol. 2006 Sep 4;.

OBJECTIVES: Fecal incontinence is a common health problem for older people and is associated with significant morbidity and cost. In this study, we report on the association of fecal incontinence with physical disability and impaired cognitive function in a large bi-racial population of individuals aged 65 yr and older. METHODS: Study subjects are participants of the Chicago Health and Aging Project (CHAP), an ongoing study of older Chicago residents. A total of 6,099 participants completed the baseline in-home interview and assessments used in this analysis. Physical disability was assessed using a performance-based measure of basic physical functions and three commonly used self-report measures. Impaired cognitive function was assessed using a global measure of the averaged scores of four cognitive tests. The question used to determine the presence of fecal incontinence was: "In the past few months have you ever lost control of your bowels when you didn't want to?" RESULTS: In multiple logistic regression models adjusted for age, sex, and race, fecal incontinence was correlated with the presence of physical disability and impaired cognitive function on every measure. For example, using the performance-based measure of physical function, the odds of prevalent fecal incontinence were higher by 20% (OR 1.20, 95% CI 1.2-1.2) for each additional unit higher on the performance score, indicating a lower physical performance. The prevalence odds ratio for fecal incontinence was decreased by 51% for each one-point increase in the global cognitive score, indicating higher cognitive function. We found a statistically significant interaction between both race and physical disability and race and impaired cognitive function, such that the associations were stronger in blacks than in non-blacks. These associations remained after further adjustment for diabetes and stroke, and the intake of psychoactive medications. CONCLUSION: In urban, community-dwelling, older adults, fecal incontinence may be more common among persons with physical disability and impaired cognitive function.

RECTAL SENSORIMOTOR DYSFUNCTION IN WOMEN WITH FECAL INCONTINENCE.
Andrews C, Bharucha AE, Seide BM, Zinsmeister AR
Am J Physiol Gastrointest Liver Physiol. 2006 Aug 31;.

The rate and pattern of rectal distension affect rectal distensibility, perception, and anal relaxation in health. Because rectal urgency is a prominent symptom in fecal incontinence (FI), we assessed rectal distensibility, contractions, perception, and anal pressures during barostatic distention of a highly compliant polyethylene rectal balloon in 21 healthy, asymptomatic women (age 61 +/- 2 years, Mean +/- SEM) and 51 women with FI (60 +/- 2 years). The rectum was inflated and then deflated between 0 and 200 ml at 25, 50, and 100mL/min; a phase of sustained distention (SD), lasting 1 minute, separated inflation and deflation. The rectum was stiffer during rapid compared to slow rectal distention. This effect was more prominent at a lower volume (50 ml) and was also more pronounced in older subjects and in fecal incontinence. A rectal contractile response was observed not only during inflation, but also during SD and during deflation. During inflation, this contractile response was rate dependent in controls but not in FI. During rectal distention, the duration of perception, but not sensory thresholds was significantly longer in FI. However, the rate of distention did not affect rectal perception (i.e., sensory thresholds or duration of perception) during ramp distentions. Baseline anal pressures and the magnitude of anal relaxation during rectal distention were also reduced in FI. In addition to reduced rectal capacity and compliance, women with FI had an exaggerated rate-dependent reduction in rectal distensibility, lower sensory thresholds, and more prolonged perception, indicative of recto-anal dysfunctions. Key words: hypersensitivity, compliance, contractions, perception, rate.

Novel approaches in the treatment of fecal incontinence.
Person B, Kaidar-Person O, Wexner SD
Surg Clin North Am. 2006 Aug;86(4):969-86.

July

Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study.
Ripetti V
Tech Coloproctol. 2006 Jul;10(2):159-60; discussion 160.

Functional fecal soiling without constipation, organic cause or neuropsychiatric disorders?
Pakarinen MP, Koivusalo A, Rintala RJ
J Pediatr Gastroenterol Nutr. 2006 Aug;43(2):206-8.

BACKGROUND:: The aetiology of fecal incontinence in children has traditionally been attributed to idiopathic constipation, structural defects or neuropsychiatric disorders. We describe a new subgroup of otherwise healthy children who have fecal soiling without any underlying cause for the incontinence. METHODS:: The hospital records of children with fecal incontinence were screened to detect patients without any history, signs or symptoms of constipation or an organic, neurological or psychiatric cause for the incontinence. Anorectal manometry findings were compared with those of age-matched children with idiopathic constipation and soiling. RESULTS:: Eight boys and 5 girls were identified. The median age at diagnosis was 7.9 years. Soiling had lasted median of 4.1 years, occurred at least every other day in 9, at least once a week in 2 and occasionally in 2 and required change of underwear or use of protective pads. Abdominal x-ray and barium enema showed normal findings. Sacral x-ray and/or MRI of the spinal cord showed normal bony spine and spinal cord. Five children had coexisting night and/or daytime wetting. Impaired rectal sensation was the only identifiable abnormality that was detected. The median volume required for the first sensation was 45 mL (range, 15-100 mL; normal, <15 mL). Anorectal manometry alone was unable to differentiate patients with functional fecal soiling from those with idiopathic constipation associated soiling. The median follow-up time after the diagnosis was 9.1 months. Treatment of fecal soiling consisted of education, dietary modification or stimulatory laxatives to establish regular toileting routines. Treatment improved fecal continence in 6 out of 8 cases with follow-up longer than 6 months. CONCLUSIONS:: There is a small subgroup of children with fecal soiling who are otherwise healthy without constipation or any other underlying cause for the incontinence. These children seem to have isolated impairment of rectal sensation. In most, the prognosis is good with conservative treatment.

June

Risk factors for fecal incontinence: a population-based study in women.
Bharucha AE, Zinsmeister AR, Locke GR, Seide BM, McKeon K, Schleck CD, Melton LJ 3rd
Am J Gastroenterol. 2006 Jun;101(6):1305-12.

BACKGROUND: In women with "idiopathic" fecal incontinence (FI), consensus guidelines recommend anal sphincter imaging and surgical repair, when feasible, of anal sphincter defects believed to cause FI. However, the relative contributions of obstetric trauma and bowel symptoms to FI in the community are unknown. METHODS: To assess risk factors for FI during the past year, a previously validated questionnaire was mailed to an age-stratified random sample of 5,300 women residing in Olmsted County, Minnesota. RESULTS: Altogether, 2,800 women (53%) responded. The risk of fecal incontinence increased with age (odds ratio [OR] per decade 1.3, 95% CI 1.2-1.4). The risk of fecal incontinence was higher among women with rectal urgency (OR 8.3, 95% CI 4.8-14.3) whether or not they also had other bowel disturbances (i.e., constipation, diarrhea, or abdominal pain) or had a vaginal delivery with forceps or stitches (OR 9.0, 95% CI 5.6-14.4). Among women with FI, rectal urgency and age were also risk factors for symptom severity. In contrast, obstetric risk factors for anorectal trauma did not increase the risk for FI. The risk for FI was not significantly different among women with cesarean section, vaginal delivery with or without forceps or stitches, or anorectal surgery, compared with nulliparous women without any of these risk factors. CONCLUSIONS: Rectal urgency rather than obstetric injury is the main risk factor for FI in women. These observations reinforce the importance of behavioral, dietary, and pharmacological measures to ameliorate bowel disturbances before anal imaging in women with "idiopathic" FI.

Sacral neuromodulation in the treatment of severe anal incontinence. Forty consecutive cases treated in one institution.
Faucheron JL, Bost R, Duffournet V, Dupuy S, Cardin N, Bonaz B
Gastroenter ol Clin Biol. 2006 May;30(5):669-72.

INTRODUCTION: Sacral neuromodulation is a recognized therapeutic option in severe anal incontinence from neurogenic origins, when medical treatment has failed. METHODS: We report the results of this procedure applied in 40 consecutive patients operated on by a single surgeon from August 2001 to June 2004. Mean duration of incontinence was 5 years. There were 33 women and 7 men of mean age 59 (range 29-89). All patients had had medical treatment, 26 had had physiotherapy and 9 had been previously operated on for that problem. Neuromodulation consisted in a temporary electrical stimulation test followed by implantation of a stimulator in case of efficacy. RESULTS: Twenty nine patients had a positive test and were implanted. Ten had a negative test and one is waiting for implantation. From the 29 patients, 23 had uneventful postoperative course. Incontinence score varied from 17 before neuromodulation to 6 after in the 24 patients who were improved. Mean resting pressure, mean maximum squeeze pressure and mean duration of squeeze pressure did not change from pre to postoperative period. CONCLUSION: Sacral neuromodulation is a safe and efficacious procedure in properly selected anal incontinent patients. However, we observed no correlation between clinical and manometric data.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?
Oberwalder M, Dinnewitzer A, Baig MK, Nogueras JJ, Weiss EG, Efron J, Vernava AM 3rd, Wexner SD
Tech Coloproctol. 2006 Jun;10(2):94-7. Epub 2006 Jun 19.

BACKGROUND: Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects.METHODS: The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure.RESULTS: A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups.CONCLUSION: A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

May

Sacral spinal nerve stimulation for fecal incontinence: A viable therapeutic option for refractory incontinence.
Janec EM, Jonnalagadda S
Gastroenterology. 2005 Jul;129(1):388-9; discussion 389-90

Investigation and treatment of faecal incontinence.
Maslekar S, Gardiner A, Maklin C, Duthie GS
Postgrad Med J. 2006 Jun;82(968):363-71.

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Recent impact of anal sphincter injury on overall Caesarean section incidence.
Mahony R, O'herlihy C
Aust N Z J Obstet Gynaecol. 2006 Jun;46(3):202-4.

Abstract Introduction: Because of increasing recognition of obstetric anal sphincter injury and faecal incontinence, we examined the recent impact of these indications on our institutional Caesarean section incidence. Methods: Retrospective review of the indications for multiparous Caesarean section was performed at the National Maternity Hospital for the 4 years 2000-2003, inclusive, to identify women in whom previous anal sphincter injury was an indication. Individual charts were reviewed and data regarding the nature and extent of previous anal sphincter injury were obtained. Results: Among 17 586 consecutive multiparous deliveries, previous anal sphincter trauma constituted the indication for Caesarean delivery in 67 women, representing 0.4% of all multiparae, 2.9% of multiparous Caesarean sections and 1.3% of all Caesarean sections performed. Fifty (85%) of the 67 women who opted for prelabour Caesarean delivery following previous obstetric anal sphincter injury had symptoms of faecal incontinence (mean continence score 5, range 1-17). Conclusion: Notwithstanding recent increased awareness and documentation, anal sphincter problems represent a small influence on total Caesarean incidence.

Is an anal plug useful in the treatment of fecal incontinence in children with spina bifida or anal atresia?
Van Winckel M, Van Biervliet S, Van Laecke E, Hoebeke P
J Urol. 2006 Jul;176(1):342-4.

PURPOSE: We evaluated the efficacy and tolerance of the Conveen(R) anal plug in children with spina bifida or anal atresia with persistent fecal incontinence necessitating diapers despite bowel management. MATERIALS AND METHODS: Seven 4 to 12-year-old patients with high congenital imperforate anus and 9 who were 6 to 13 years old with spina bifida, no mental retardation and no involuntary urine loss on clean intermittent catheterization were included in the study. During a prospective, 6-week crossover descriptive study after a test period to find the most comfortable plug with a diameter of 37 or 45 mm patients and parents completed a diary with the number of soiling episodes, stool frequency, stool consistency and the number of diapers used during 3 weeks without and with the plug, respectively. They provided a final assessment of the device. RESULTS: Two of the 7 patients with congenital imperforate anus discontinued use because of pain and discomfort, 1 had a decrease in soiling episodes and 4 achieved full continence and needed no diapers while using 2 plugs daily (range 1 to 4). All patients preferred the smaller plug. Two of the 9 patients with spina bifida always lost the plug within 1 hour after introduction, 5 had a decrease in soiling episodes but continued to need diapers and 2 achieved full continence using 2 plugs daily (range 1 to 4). All patients preferred the larger plug. CONCLUSIONS: The Conveen(R) anal plug is an adjuvant treatment option for fecal incontinence in children with congenital imperforate anus or spina bifida, enabling a minority to stop using diapers. The Conveen(R) anal plug is not a universal solution for fecal incontinence problems in these patients.

Risk Factors for Anal Sphincter Tear in Multiparas.
Dipiazza D, Richter HE, Chapman V, Cliver SP, Neely C, Chen CC, Burgio KL
Obstet Gynecol. 2006 Jun;107(6):1233-1237.

OBJECTIVE: To assess maternal, newborn, and obstetric risk factors associated with anal sphincter tear in multiparous women. METHODS: This case-control study identified 18,779 multiparous vaginal deliveries from 1992 to 2004 from an obstetric automated record database at the University of Alabama at Birmingham. Two hundred eighty-four patients were selected, 145 cases and 139 controls. Variables from the index pregnancy and prior pregnancies were analyzed, and multivariable logistic regression models were constructed to determine significant predictor variables for anal sphincter tear in multiparous women. RESULTS: One hundred forty-five multiparous women with no history of cesarean delivery sustained a sphincter tear. Multivariable logistic regression showed a significant association with episiotomy (odds ratio [OR] 16.3, 95% confidence interval [CI] 7.7-34.4), shoulder dystocia (OR 7.9, CI 1.6-38), forceps delivery (OR 4.7, CI 2.0-11.2), and being married (OR 2.2, CI 1.1-4.6). A second exploratory model that included variables from previous pregnancies, showed that in addition to episiotomy (OR 34.6, CI 8.8-136), shoulder dystocia (OR 11.1, CI 1.3-95.2), forceps delivery (OR 6.1, CI 1.6-23.5), previous sphincter tear (OR 7.7, CI 1.2-48.7), and second stage of labor greater than 1 hour (OR 6.7, CI 1.1-42.5) were associated with tear. CONCLUSION: The strongest clinical risk factors for anal sphincter tear in multiparous women are episiotomy, shoulder dystocia, previous sphincter tear, prolonged second stage of labor, and forceps delivery. LEVEL OF EVIDENCE: II-2.

Repair Techniques for Obstetric Anal Sphincter Injuries: A Randomized Controlled Trial.
Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O'brien PM
Obstet Gynecol. 2006 Jun;107(6):1261-1268.

OBJECTIVE: To compare one-year outcomes of primary overlap versus end-to-end repair of the external anal sphincter after acute obstetric anal sphincter injury. METHODS: Women who sustained third-degree (3b = greater than 50% external anal sphincter thickness, 3c = internal sphincter injury) or fourth-degree (including anorectal epithelium) perineal tears were randomly allocated to either immediate primary overlap or end-to-end repair. They were prospectively followed up for 12 months postrepair with serial questionnaires. The primary outcome was fecal incontinence at 12 months. Secondary outcomes were fecal urgency, flatus incontinence, perineal pain, dyspareunia, quality of life, and improvement of anal incontinence symptoms. RESULTS: Thirty-two women were randomized to each group. At 12 months, 24% (6/25) in the end-to-end and none in the overlap group reported fecal incontinence (P = .009, relative risk [RR] 0.07, 95% confidence interval [CI] 0.00-1.21, number needed to treat 4.2). Fecal urgency at 12 months was reported by 32% (8/25) in the end-to-end and 3.7% (1/27) in the overlap group (P = .02, RR 0.12, 95% CI 0.02-0.86, number needed to treat 3.6). There were no significant differences in dyspareunia and quality of life between the groups. At 12 months, 20% (5/25) reported perineal pain in the end-to-end and none in the overlap group (P = .04, RR 0.08, 95% CI 0.00-1.45, number needed to treat 5). During 12 months, 16% (4/25) in the end-to-end and none in the overlap group reported deterioration of defecatory symptoms (P = .01). CONCLUSION: Primary overlap repair of the external anal sphincter is associated with a significantly lower incidence of fecal incontinence, urgency, and perineal pain. When symptoms do develop, they appear to remain unchanged or deteriorate in the end-to-end group but improve in the overlap group. LEVEL OF EVIDENCE: I.

Fecal Incontinence in Females Older Than Aged 40 Years: Who is at Risk?
Varma MG, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK, Beattie MS, Subak LL Group.
Dis Colon Rectum. 2006 Jun;49(6):841-51.

PURPOSE: This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years. METHODS: The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,109 randomly selected middle-aged and older females (average age, 56 years). Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year. RESULTS: Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form-36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m(2) (95 percent confidence interval)] with obesity [1.2 (1.1-1.3)], chronic obstructive pulmonary disease [1.9 (1.3-2.9)], irritable bowel syndrome [2.4 (1.7-3.4)], urinary incontinence [2.1 (1.7-2.6)], and colectomy [1.9 (1.1-3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4-0.9)]. CONCLUSIONS: Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.

Rectal Volume Tolerability and Anal Pressures in Patients With Fecal Incontinence Treated With Sacral Nerve Stimulation.
Michelsen HB, Buntzen S, Krogh K, Laurberg S
Dis Colon Rec tum. 2006 May 29;.

PURPOSE: Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation. METHODS: Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29-79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for "first sensation," "desire to defecate," and "maximal tolerable volume," rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up. RESULTS: Median Wexner incontinence score decreased from 16 (range, 6-20) to 4 (range, 0-12; P < 0. 0001). Median "first sensation" increased from 43 (range, 16-230) ml to 62 (range, 4-186) ml (P = 0.1), median "desire to defecate" from 70 (range, 30-443) ml to 98 (range, 30-327) ml (P = 0.011), and median "maximal tolerable volume" from 130 (range, 68-667) ml to 166 (range, 74-578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0-109) cm H(2)O to 38 (range, 0-111) cm H(2)O (P = 0.045). No significant increase in maximum squeeze pressure was observed. CONCLUSIONS: For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level.

April

Fecal Incontinence in Females Older Than Aged 40 Years: Who is at Risk?
Varma MG, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK, Beattie MS, Subak LL Group.
Dis Colon Rectum. 2006 May 10;.

PURPOSE: This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years. METHODS: The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,109 randomly selected middle-aged and older females (average age, 56 years). Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year. RESULTS: Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form-36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m(2) (95 percent confidence interval)] with obesity [1.2 (1.1-1.3)], chronic obstructive pulmonary disease [1.9 (1.3-2.9)], irritable bowel syndrome [2.4 (1.7-3.4)], urinary incontinence [2.1 (1.7-2.6)], and colectomy [1.9 (1.1-3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4-0.9)]. CONCLUSIONS: Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.

Anal sphincter lacerations and upright delivery postures-a risk analysis from a randomized controlled trial.
Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 25;.

OBJECTIVE: To evaluate obstetric sphincter lacerations after a kneeling or sitting position at second stage of labor in a multivariate risk analysis model. MATERIALS AND METHODS: Two hundred and seventy-one primiparous women with normal pregnancies and spontaneous labor were randomized, 138 to a kneeling position and 133 to a sitting position. Medical data were retrieved from delivery charts and partograms. Risk factors were tested in a multivariate logistic regression model in a stepwise manner. RESULTS: The trial was completed by 106 subjects in the kneeling group and 112 subjects in the sitting group. There were no significant differences with regard to duration of second stage of labor or pre-trial maternal characteristics between the two groups. Obstetrical sphincter tears did not differ significantly between the two groups but an intact perineum was more common in the kneeling group (p<0.03) and episiotomy (mediolateral) was more common in the sitting group (p<0.05). Three grade IV sphincter lacerations occurred in the sitting group compared to none in the kneeling group (NS). Multivariate risk analysis indicated that prolonged duration of second stage of labor and episiotomy were associated with an increased risk of third- or fourth-degree sphincter tears (p<0.01 and p<0.05, respectively). Delivery posture, maternal age, fetal weight, use of oxytocin, and use of epidural analgesia did not increase the risk of obstetrical anal sphincter lacerations in the two upright postures. CONCLUSION: Obstetrical anal sphincter lacerations did not differ significantly between a kneeling or sitting upright delivery posture. Episiotomy was more common after a sitting delivery posture, which may be associated with an increased risk of anal sphincter lacerations. Upright delivery postures may be encouraged in healthy women with normal, full-term pregnancy.

Intra-abdominal erosion of artificial bowel sphincter reservoir.
Tejirian T, Kaminski A, Abbas MA
Int J Colorectal Dis. 2006 May 3;.

March

Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature.
Belyaev O, Muller C, Uhl W
Surg Today. 2006;36(4):295-303.

Up until about 15 years ago the only realistic option for end-stage fecal incontinence was the creation of a permanent stoma. There have since been several developments. Dynamic graciloplasty (DGP) and artificial bowel sphincter (ABS) are well-established surgical techniques, which offer the patient a chance for continence restoration and improved quality of life; however, they are unfortunately associated with high morbidity and low success rates. Several trials have been done in an attempt to clarify the advantages and disadvantages of these methods and define their place in the second-line treatment of severe, refractory fecal incontinence. This review presents a critical and unbiased overview of the current status of neosphincter surgery according to the available data in the world literature.

Prevalence of anal incontinence according to age and gender: a systematic review and meta-regression analysis.
Pretlove SJ, Radley S, Toozs-Hobson PM, Thompson PJ, Coomarasamy A, Khan KS
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Mar 30;.

CONTEXT: Anal incontinence is increasingly being recognised as a significant cause of physical and psychological morbidity with implications for healthcare provision within the community. There is controversy about which population groups are most disadvantaged by this chronic condition. OBJECTIVES: The aim of this study was to evaluate the prevalence of this condition in the community according to age and gender, a systematic review was performed. Data sources: Data were from Embase, Medline, bibliographies of known articles and contact with experts. STUDY SELECTION: Studies were selected if data on anal incontinence could be extracted for participants over 15 years of age and living in the community. DATA EXTRACTION: Data were extracted using a piloted form on participants' characteristics, study quality and incontinence rates. DATA SYNTHESIS: Meta-analysis was used to combine data from multiple studies, and meta-regression evaluated the variation in rates according to age and gender in an analysis adjusted for study quality. RESULTS: There were 29 studies (69,152 participants), of which 5 met over half of the high quality criteria. The rate of solid and liquid faecal incontinence among people aged 15-60 years was 0.8% [95% confidence interval (CI) 0.3-1.9] in men and 1.6% (95% CI 0.8-3.1) in women. In those aged over 60, this increased to 5.1% (95% CI 3.4-7.6) in men and 6.2% (95% CI 4.9-8.0) in women. Meta-regression showed that age had a significant influence on rates of solid and liquid faecal incontinence (p=0.007), but not gender (p=0.368) or study quality (p=0.085). CONCLUSIONS: The rate of solid and liquid faecal incontinence in older people is significantly higher than their younger counterparts. Gender differences in rates did not reach statistical significance.

Diagnosis and management of obstetric anal sphincter injury.
Eogan M, O'herlihy C
Curr Opin Obstet Gynecol. 2006 Apr;18(2):141-146.

PURPOSE OF REVIEW: The purpose of this review is to outline optimum practice in diagnosis and management of obstetric anal sphincter injury. The review focuses briefly on prevention of the problem before outlining diagnosis of sphincter injury as well as immediate and long-term management of patients who have sustained such injuries. RECENT FINDINGS: Increasing vigilance is vital in order that sphincter injury is not overlooked; immediate radiological assessment may play a role in diagnosis. Optimum anal sphincter repair should be followed by oral laxative administration to maintain sphincter integrity. Biofeedback physiotherapy and sacral nerve stimulation show great promise in treatment of persistent symptoms. Optimum mode of delivery in future pregnancies is not clearly defined, and decisions should be individualized. SUMMARY: Because obstetric injury to the anal sphincter mechanism cannot always be prevented, efforts must focus on limiting its occurrence, documenting its severity and providing optimum therapy to women who have sustained it. Management includes routine postnatal review of at-risk women and antenatal assessment in future pregnancies to limit deterioration in continence after future deliveries.

Is severe perineal damage increased in women with prior anal sphincter injury?
Edwards H, Grotegut C, Harmanli OH, Rapkin D, Dandolu V
Obstet Gynecol. 2006 Apr;107(4 Suppl):27S-8S.

Fecal and Urinary Incontinence After Childbirth: The Childbirth and Pelvic Symptoms (CAPS) Study.
Borello-France DF, Burgio KL, Richter HE
Obstet Gynecol. 2006 Apr;107(4 Suppl):66S.

Modified perineoplasty and sphincteroplasty for the treatment of fecal incontinence: a case series.
Novi JM, Morgan MA
Obstet Gynecol. 2006 Apr;107(4 Suppl):47S.

Endoanal ultrasound compared to anorectal manometry for the evaluation of fecal incontinence: a study of the effect these tests have on clinical outcome.
Hill K, Fanning S, Fennerty MB, Faigel DO
Dig Dis Sci. 2006 Feb;51(2):235-40.

Tests for evaluating incontinence include endoanal ultrasound (EUS) and anorectal manometry. We hypothesized that EUS would be superior to anorectal manometry in identifying the subset of patients with surgically correctable sphincter defects leading to an improvement in clinical outcome in these patients. The purpose of this study was to compare these 2 techniques to determine which is more predictive of outcome for fecal incontinence. Thirty-five unselected patients with fecal incontinence were prospectively studied with EUS and anorectal manometry to evaluate the internal anal sphincter (IAS) and external anal sphincter (EAS). EUS was performed with Olympus GFUM20 echoendoscope and a hypoechoic defect in the EAS or IAS was considered a positive test. Anorectal manometry was performed with a standard water-perfused catheter system. A peak voluntary squeeze pressure of < 60 mm Hg in women and 120 mm Hg in men was considered a positive test. All patients were administered the Cleveland Clinic Continence Grading Scale at baseline and at follow-up. Improvement in fecal control was defined as a 25% or greater decrease in continence score. EUS versus manometry were compared with subsequent surgical treatment and outcome. P-values were calculated using Fisher's exact test. Patients (n = 32; 31 females) were followed for a mean 25 months (range 13-46). Sixteen patients had improved symptoms (50%). There was no correlation between EUS or anorectal manometry sphincter findings and outcome. Seven of 14 (50%) patients who subsequently underwent surgery versus 9 of 18 (50%) without surgery improved (P = .578). In long-term follow-up, approximately half of patients improve regardless of the results of EUS or anorectal manometry, or whether surgery is performed.

The Utility of Pudendal Nerve Terminal Motor Latencies in Idiopathic Incontinence.
Ricciardi R, Mellgren AF, Madoff RD, Baxter NN, Karulf RE, Parker SC
Dis Colon Rectum. 2006 Apr 10;.

PURPOSE: Pudendal nerve terminal motor latency testing has been used to test for pudendal neuropathy, but its value remains controversial. We sought to clarify the relationship of pudendal nerve terminal motor latency to sphincter pressure and level of continence in a cohort of patients with intact anal sphincters and normal pelvic floor anatomy. METHODS: We reviewed 1,404 consecutive patients who were evaluated at our pelvic floor laboratory for fecal incontinence. From this group, 83 patients had intact anal sphincters on ultrasound and did not have internal or external rectal prolapse during defecography. These patients were evaluated by pudendal nerve terminal motor latency testing, a standardized questionnaire, and anorectal manometry, which measured resting and squeeze anal pressures. Incontinence scores were calculated by using the American Medical Systems Fecal Incontinence Score. Values were compared by using the Fisher's exact test and Wilcoxon's rank-sum test; and significance was assigned at the P < 0.05 level. RESULTS: 1) Using a 2.2-ms threshold, 28 percent of patients had prolonged pudendal nerve terminal motor latency unilaterally and 12 percent bilaterally. 2) At a 2.4-ms threshold, 18 percent of patients had prolonged pudendal nerve terminal motor latency unilaterally and 8 percent bilaterally. 3) Bilaterally prolonged pudendal nerve terminal motor latency was significantly associated with decreased maximum mean resting pressure and increased Fecal Incontinence Score, but not decreased maximum mean squeeze pressure, at both 2.2-ms and 2.4-ms thresholds. 4) Unilaterally prolonged pudendal nerve terminal motor latency was not associated with maximum mean resting pressure, maximum mean squeeze pressure, or fecal incontinence score at either threshold. CONCLUSIONS: The majority of incontinent patients with intact sphincters have normal pudendal nerve terminal motor latency. Bilaterally but not unilaterally prolonged pudendal nerve terminal motor latency is associated with poorer function and physiology in the incontinent patient with an intact sphincter.

Relationship Between External Anal Sphincter Atrophy at Endoanal Magnetic Resonance Imaging and Clinical, Functional, and Anatomic Characteristics in Patients With Fecal Incontinence.
Terra MP, Deutekom M, Beets-Tan RG, Engel AF, Janssen LW, Boeckxstaens GE, Dobben AC, Baeten CG, de Priester JA, Bossuyt PM, Stoker J
Dis Colon Rectum. 2006 Apr 5;.

PURPOSE: External anal sphincter atrophy at endoanal magnetic resonance imaging has been associated with poor outcome of anal sphincter repair. We studied the relationship between external anal sphincter atrophy on endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence. METHODS: In 200 patients (mean Vaizey score, 18 (+/-2.9 standard deviation)) magnetic resonance images were evaluated for external anal sphincter atrophy (none, mild, or severe) by radiologists blinded to anorectal functional test results and details from medical history. Subgroups of patients with and without atrophy were compared for medical history, anal manometry, pudendal nerve latency testing, anal sensitivity testing, external anal sphincter thickness, and external anal sphincter defects. Whenever significant differences were detected, we tested for differences between patients with mild and severe atrophy. RESULTS: External anal sphincter atrophy was demonstrated in 123 patients (62 percent): graded as mild in 79 (40 percent), and severe in 44 patients (22 percent). Patients with atrophy were more often female (P < 0.001) and older (P = 0.003). They had a lower maximal squeeze (P = 0.01) and squeeze increment pressure (P < 0.001). Patients with severe atrophy had a lower maximal squeeze (P = 0.003) and squeeze increment pressure (P < 0.001) than patients with mild atrophy. These effects were not attenuated by potential confounding variables. Patients with atrophy could not be identified a priori by other characteristics. CONCLUSIONS: External anal sphincter atrophy at endoanal magnetic resonance imaging was depicted in 62 percent of patients, varying from mild to severe. Because increasing levels of atrophy were associated with impaired squeeze function, further studies are needed to evaluate whether grading atrophy is clinically valuable in selecting patients for anal sphincter repair.

The effects of low-frequency endo-anal electrical stimulation on faecal incontinence: a prospective study.
Healy CF, Brannigan AE, Connolly EM, Eng M, O'sullivan MJ, McNamara DA, Cusack C, Deasy JM
Int J Colorectal Dis. 2006 Mar 17;.

BACKGROUND AND AIMS: Faecal incontinence is a distressing problem that is often not amenable to surgical correction. Chronic low-frequency electrical stimulation of damaged axons is thought to reduce synaptic resistance, increase the size of motor units by axonal sprouting and increase the rate of conduction of the pudendal nerve. The aim of this study was to prospectively evaluate the effect of chronic low-frequency endo-anal electrical stimulation on faecal incontinence using a home-based unit and hospital-supervised therapy. MATERIALS AND METHODS: Forty-eight patients with faecal incontinence completed a prospective randomised trial. Patients were allocated randomly to one of two groups; group 1 was exposed to endo-anal pudendal nerve stimulation daily at home with a portable home unit, group 2 attended the physiotherapy department for endo-anal electrical stimulation under supervision. RESULTS: Continence scores improved significantly after treatment in both groups (p<0.001). Both groups showed improved manometric scores, although only group 1 showed significant improvement in both resting and squeeze pressures (mean total resting pressure 184-224 mmHg, p<0.001; mean total squeeze pressure 253-337 mmHg, p<0.001). This was also reflected by an improvement in quality of life in both groups. CONCLUSIONS: Low-frequency endo-anal electrical stimulation significantly improves continence scores and quality of life in patients with faecal incontinence not amenable to surgical correction. It leads to improved manometric values when carried out on a daily basis with a portable home unit.

Silence masks prevalence of fecal incontinence.
Kuehn BM
JAMA. 2006 Mar 22;295(12):1362-3.

February

Obstetric anal sphincter injury: How to avoid, how to repair: A literature review.
Power D
J Fam Pract. 2006 Mar;55(3):193-200.

Avoiding obstetrical injury to the anal sphincter is the single biggest factor in preventing anal incontinence among women. Any form of instrument delivery has consistently been noted to increase the risk of obstetric anal sphincter injury and altered fecal continence by between 2- and 7-fold. Routine episiotomy is not recommended. Episiotomy use should be restricted to situations where it directly facilitates an urgent delivery. A mediolateral incision, instead of a midline, should be considered for persons at otherwise high risk of obstetric anal sphincter injury. The internal anal sphincter needs to be separately repaired if torn. Women with injuries to the internal anal sphincter or rectal mucosa have a worse prognosis for future continence problems. All women, particularly those with risk factors for injury, should be surveyed for symptoms of anal incontinence at postpartum follow-up.

Laparoscopic cecostomy button placement for the management of fecal incontinence in children with Hirschsprung's disease and anorectal anomalies.
Yagmurlu A, Harmon CM, Georgeson KE
Surg Endosc. 2006 Feb 27;.

BACKGROUND: Antegrade colonic enemas offer a surgical solution for many children with chronic constipation and encopresis associated with Hirschsprung's disease and anorectal malformations. This study demonstrated the feasibility of a new laparoscopic technique for cecostomy button placement (LCBP) to allow antegrade enema treatment. METHODS: Charts of children with encopresis who underwent LCBP between 1999 and 2001 were reviewed. The age, weight, primary diagnosis, operative time, hospital stay, associated complications, follow-up duration, and outcome of the patients were recorded. The surgical technique used a "U-stitch" method and a chait tube or a standard gastrostomy button. A follow-up telephone survey was conducted to assess parental satisfaction and overall success in continence. RESULTS: Seven patients ages 4 to 12 years (mean, 7.3 +/- 1.3 years) and weighing 15 to 44 kg (mean, 24.5 +/- 4 kg) underwent LCBP over a 2-year period. The mean follow-up period was 15 +/- 4 months (range, 6-33 months). Four patients had anorectal malformations, and three patients had Hirschsprung's disease. For all the patients, LCBP was accomplished without any intraoperative complications. The mean operative time was 33 +/- 2 min, and the hospital stay was 2 to 5 days (mean, 3.8 +/- 0.5 days). The patients received one or two daily antegrade enemas, and none had accidental bowel movements. Episodes of soiling at night once or twice a week were observed with two children. Two patients had hypertrophic granulation tissue formation, which responded to topical therapy. The button was uneventfully changed twice in one patient because of mechanical malfunction. CONCLUSION: To manage overflow incontinence of children with anorectal malformations and Hirschsprung's disease, LCBP is a technically straightforward, effective, and reversible method for the placement of a cecostomy button.

Prevalence of anal incontinence in adults and impact on quality-of-life.
Damon H, Guye O, Seigneurin A, Long F, Sonko A, Faucheron JL, Grandjean JP, Mellier G, Valancogne G, Fayard MO, Henry L, Guyot P, Barth X, Mion F
Gastroenterol Clin Biol. 2006 Jan;30(1):37-43.

OBJECTIVE: To investigate the prevalence of anal incontinence in the general population and in patients consulting gastroenterologist and gynecologist practices in the Rhone Alpes area. METHODS: For the first study a questionnaire was sent to a sample of 2800 people selected randomly from the electoral roll. Another study of patients selected randomly among patients attending gynecology and gastroenterology consultations was performed. A Jorge & Wexner score above or equal to 5 was used to define anal incontinence. RESULTS: For the first study, a total of 706 questionnaires was analyzed: the prevalence of anal incontinence was 5.1% [95% CI: 3.6-7.0] and the scores of each dimension of the SF-12 Health Survey were significantly lower among incontinent people than among continent people. The prevalence was significantly higher for women (7.5% [5.0-10.7]) than for men (2.4% [1.1-4.7]). Eighty-four physicians returned 835 valid questionnaires. The prevalence was 13.1% [10.1-16.6] among patients attending gastroenterology consultations and 5.0% [3.1-7.6] among those attending gynecology consultations. For 84.8% of the incontinent patients, the physician was unaware of the patient's disorder. CONCLUSION: The prevalence figures we obtained coincide with data in the literature. This disorder is common and affects the patient's quality-of-life, but remains underestimated and under-diagnosed.

[Who suffers from fecal incontinence?]
Siproudhis L, Vilotte J
Gastroenterol Clin Biol. 2006 Jan;30(1):7-8.

Adaptation to Spanish Language and Validation of the Fecal Incontinence Quality of Life Scale.
Minguez M, Garrigues V, Soria MJ, Andreu M, Mearin F, Clave P
Dis Colon Rectum. 2006 Mar 8;.

PURPOSE: The aim of this study was to perform a psychometric evaluation of the Fecal Incontinence Quality of Life Scale in the Spanish language. METHODS: Eleven hospitals in Spain participated in the study, which included 118 patients with active fecal incontinence. All the patients filled out a questionnaire on the severity of their incontinence, a general questionnaire of health (Medical Outcomes Survey Short Form), and a Spanish translation of the Fecal Incontinence Quality of Life Scale (Cuestionario de Calidad de Vida de Incontinencia Anal), which consists of 29 items in four domains: lifestyle, behavior, depression, and embarrassment. On a second visit, patients repeated the Fecal Incontinence Quality of Life Scale. For each domain, an evaluation was made of temporal reliability, internal reliability, the convergent validity with the generic questionnaire of health, and the discriminant validity correlating the domains of Cuestionario de Calidad de Vida de Incontinencia Anal with the severity of fecal incontinence. RESULTS: For cultural adaptation, the answer alternatives for 14 items were modified. A total of 111 patients (94 percent) completed the study adequately. Temporal reliability (test-retest) was good for all domains except for embarrassment, which showed significant differences (P < 0.02). Internal reliability was good/excellent for all domains (Cronbach alpha >0.80, between 0.84 and 0.96). The four domains of Cuestionario de Calidad de Vida de Incontinencia Anal significantly correlated with the domains of the generic questionnaire on health (P < 0.01) and with the scale of severity of fecal incontinence (P < 0.001). All domains of Cuestionario de Calidad de Vida de Incontinencia Anal correlated negatively with the need to wear pads (P < 0.01) and with the presence of complete fecal incontinence. CONCLUSIONS: The Cuestionario de Calidad de Vida de Incontinencia Anal incorporates sufficient requirements of reliability and validity to be applied to patients with fecal incontinence.

Overlapping anal sphincter repair and anterior levatorplasty: effect of patient's age and duration of follow-up.
Evans C, Davis K, Kumar D
Int J Colorectal Dis. 2006 Mar 7;.

BACKGROUND AND AIMS: Anal sphincter repair can improve function in patients with faecal incontinence but it is unclear which benefit and its long-term efficacy has been questioned. This study aims to assess the functional outcome of a single surgeon series of overlapping anal sphincter repairs with anterior levatorplasty. METHOD: A retrospective study of 66 patients' case notes and anorectal physiology combined with an interview to assess their current continence and associated quality of life after surgery. RESULTS: Sixty-six female patients, mean age 62.8 years, mean follow-up 45.2 months, were assessed. Functional improvement in continence was seen in 77.1% of patients, which mirrored their subjective rating of surgery (62.7% -good/excellent). Continence grading scores improved from a mean (SD) 9.71 (4.82) pre-surgery to 5.55 (4.11) post-surgery. There was no statistical difference in functional results when stratified by age (<63 years or >/=63 years) or by follow-up [long-term (43-78 months) vs short-term (14-42 months)]. Post-surgical physiology data were not statistically improved compared to pre-surgery. CONCLUSIONS: Overlapping anal sphincter repair with anterior levatorplasty is an effective treatment for faecal incontinence. Patient age does not correlate with outcome, and symptoms do not deteriorate over time. Anorectal physiology results don't predict for symptomatic improvement in patients with faecal incontinence.

Injectable Silicone Biomaterial (PTQtrade mark) to Treat Fecal Incontinence After Hemorrhoidectomy.
Chan MK, Tjandra JJ
Dis Colon Rectum. 2006 Feb 22;.
PURPOSE: Passive fecal incontinence after hemorrhoidectomy may occur and is socially incapacitating. There has been no effective treatment for passive fecal incontinence caused by internal anal sphincter dysfunction. This case series reviewed the outcome of therapy with injectable silicone biomaterial (PTQ) in patients who had passive fecal incontinence after hemorrhoidectomy. METHODS: From 2003 to 2004, seven patients referred with passive fecal incontinence after hemorrhoidectomy (Milligan-Morgan hemorrhoidectomy n = 5; stapled hemorrhoidectomy n= 2) were treated with injectable PTQ implants. All were assessed with anorectal physiology testing, Wexner continence score, and objective quality of life questionnaires before and after treatment. RESULTS: The Wexner continence score improved significantly at three months (P= 0.016) after the injectable PTQ implant and continued to improve significantly for up to 12 months (P = 0.016). The global quality of life scores (Visual Analog Scale) showed similar improvement (P = 0.016 at 3 months; P = 0.016 at 12months). Three domains (life style, coping behavior, and depression/self-perception) of Fecal Incontinence Quality of Life Scale were significantly improved. The manometric studies showed significant improvement in maximum resting anal canal pressures (P= 0.016) after the injectable PTQtrade mark implant. CONCLUSIONS: The injectable silicone biomaterial is an effective treatment for passive fecal incontinence after hemorrhoidectomy providing good medium-term improvement in fecal incontinence and fecal incontinence-related quality of life.

January

Long-Term Outcome and Quality of Life After Continent Ileostomy.
Nessar G, Fazio VW, Tekkis P, Connor J, Wu J, Bast J, Borkowski A, Delaney CP, Remzi FH
Dis Colon Rectum. 2006 Feb 2;.

INTRODUCTION: This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy, identify factors associated with adverse outcomes, and compare changes in quality of life after removal of the reservoir. METHODS: The records of all patients (n = 330) undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed. Patient-related, intraoperative, and postoperative factors were evaluated as predictor variables of long-term pouch survival. Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale (n = 216). These were compared between patients with continent ileostomy (n = 181) and patients who underwent removal of the continent ileostomy and conversion to an end stoma (n = 35). RESULTS: The median patient follow-up was 11 (range, 1-27) years. The median revision-free pouch interval was 14 (95 percent confidence interval, 11-17) months. The 10-year and 20-year pouch survival was 87 and77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up. On multivariate analysis, Crohn's disease (hazard ratio = 4.5), female gender (hazard ratio = 2.4), fistula development (hazard ratio = 3), and body mass index (hazard ratio = 2.4 per 5 unit increase) were independent predictors of pouch failure. Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy. CONCLUSIONS: Despite the associated morbidity with continent ileostomy surgery, long-term results and quality of life were encouraging. Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy.

Selecting an outcome measure for evaluating treatment in fecal incontinence.
Deutekom M, Terra MP, Dobben AC, Dijkgraaf MG, Felt-Bersma RJ, Stoker J, Bossuyt PM
Dis Colon Rectum. 2005 Dec;48(12):2294-301.

PURPOSE: Various outcome measures exist to evaluate treatment in fecal incontinence, including descriptive, severity (fecal incontinence scoring systems), and impact (quality-of-life questionnaires) and diagnostic measures. We studied associations between changes after treatment for a number of outcome measures and compared them to patients' subjective perception of relief. METHODS: We analyzed data of 66 patients (92 percent female; mean age, 62 years) (Vaizey score, Wexner score, two impact scales, utility, resting pressure, and maximal incremental squeeze pressure) at baseline and after physiotherapy. In a standardized interview by phone, we asked patients to compare their situation before and after treatment. Correlations between changes in outcome measures were calculated. These changes were compared with patients' subjective perception. RESULTS: There was a high correlation between the changes in the Vaizey and the Wexner scores (r = 0.94, P < 0.01). Changes in Vaizey and Wexner scores correlated moderately with changes in maximum incremental squeeze pressure (r = -0.29, -0.30, both P < 0.05). Changes in utility and resting pressure were not correlated with changes in any of the other measurements (all r values between -0.086 and 0.18). Average severity scores (Vaizey and Wexner) were 1 point lower for patients who rated their situation as worse or equal (62 percent), 4 points lower for patients who reported their situation to be better (21 percent), and 9 points lower in patients who rated their situation much better (17 percent) (P < .05). CONCLUSION: Severity measures are best related to patients' subjective perception of relief.

Neoadjuvant radiochemotherapy for patients with locally advanced rectal cancer leads to impairment of the anal sphincter.
Theisen J, Kauer WK, Nekarda H, Schmid L, Stein HJ, Siewert JR
J Gastrointest Surg. 2006 Feb;10(2):309-14.

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