Effects of perineal massage at different stages on perineal and postpartum pelvic floor function in primiparous women: a systematic review and meta-analysis.

BACKGROUND: Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women. METHODS: We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence. RESULTS: This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80). CONCLUSIONS: Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage. TRIAL REGISTRATION: CRD42023415996 (PROSPERO).

CONfidence: Developing an app to promote bladder and bowel health.

The CONfidence app was developed to address an unmet need for access to self-help advice and information for bladder and bowel incontinence. The app was developed by the Bladder and Bowel CONfidence Health Integration Team and Expert Self Care and this paper describes the evolution of this innovation to empower patients and the public with bladder and bowel leakage. The app is intended to provide a proactive approach to continence promotion and not replace formal healthcare. Crucial steps were identified to ensuring this resource was accessible and understandable for the intended audience including: input from national clinical experts and individuals with lived experience to co-produce content, clear definition of scope, technical expertise in app development, clear language avoiding jargon or medical terms, credibility assurance and a strategic plan for dissemination. The app is free to download and will remain so to ensure evidence-based continence advice can be in the palm of all with a smartphone. The CONfidence app has been downloaded approaching 7000 times and is in use in 10 countries. A continual effort is required to share this resource as disclosure of these symptoms is shrouded in secrecy and many people could benefit from its content.

[Transanal Endoscopic Microsurgery (TEM) is a surgical option to preserve fecal continence in selected low rectal cancers]. / Die Transanale Endoskopische Mikrochirurgie (TEM) ist eine chirurgische Option zur Erhaltung der Stuhlkontinenz bei ausgewählten tiefsitzenden Rektumkarzinomen.

INTRODUCTION: Despite its existence for more than 40 years, the TEM method has not become widespread. The main reasons are the high acquisition costs, the sophisticated technology and alternative procedures (especially radical resection procedures), which provide greater oncological safety. However, avoiding major abdominal surgery with the creation of a stoma and higher complication rates can outweigh the higher risk of recurrence for some patients. We examined the results using V-TEM with reduced acquisition costs in the resection of adenomas and carcinomas and discussed its importance by literature . METHOD: From 2003 to 2019, 154 patients with 170 findings were operated by V-TEM technology. Data on the operation and follow-up were collected and analyzed retrospectively. RESULTS: The median age was 67 years, 89 patients were male and 65 female. V-TEM was performed on 79 carcinomas, 77 adenomas and 14 other findings. The complication rate was 21.2 %. R0 resection was achieved in 78.8 %. The adenoma recurrence rate was 7.3 %, the overall recurrence rate for carcinomas 11.9 %, local recurrences were observed in 6.8 %. The disease-specific survival is 100 % at 5 years and 94.2 % at ten years. DISCUSSION: The successful use of TEM in adenomas and early carcinomas is undisputed. When treating carcinomas from a T1 high risk stage using TEM, recurrence rates higher than 10 % must be expected. Better results can be achieved with radical procedures, this is why they are considered the therapy of choice in these cases. However, there are no differences in terms of survival rates and TEM offers proven better postoperative quality of life. In particular, the combination of neoadjuvant procedures with TEM delivered promising results in more advanced stages. Further studies on TEM and the possibility of lower acquisition costs through modification to V-TEM could make the method more popular in the future.

Ligation of intersphincteric fistula tract (LIFT) for the treatment of anal fistula: a prospective observational study

Background: The ligation of intersphincteric fistula fract (LIFT) technique avoids postoperative anal continence disturbances and preserves quality of life. Methods: A total of 70 patients with anal fistula (AF) were treated in the Day Surgery Unit. The LIFT technique was the primary treatment in 63 patients. The other had previously undergone placement of a loose seton (two-step approach). The mean follow-up was 66.8 months. Statistical analysis was performed using contingency tables, the chi-square test, and the Student T-test. Results: The use of LIFT was successful in 40 patients (57.1%). However, 6 patients (8.6%) presented persistence of postoperative intersphincteric fistula, being successfully treated by fistulotomy. There were no differences in this technique's success rate between high and low AF (p = 0.45). The success rate of one-step LIFT, however, was significantly higher (p = 0.03). No disturbances of continence were observed. Conclusions: The LIFT technique has a role in the treatment of AF, is suitable for ambulatory surgery, and has a low complications rate. A two-step approach is not always needed. (AU)

OBSTETRIC INJURY OF THE RECTUM WITH INTACT ANAL SPHINCTER - TWO CASE REPORTS.

Background: Injury of the rectum with intact anal sphincter is an extremely rare but very serious complication of vaginal delivery. It is also called a "buttonhole" tear. Case: We present two cases of "buttonhole" tear/injury. Results: In one case, the injury was recognized at the time of delivery and adequately treated. In the other case the injury was not diagnosed on time and the patient was treated for complications on the 6th postpartal day. Conclusion: The consequences for the wellbeing of young mothers with perineal injury can be serious and affect social and sexual aspects of their lives. Adequate surgical treatment and postoperative care assure optimal results and prevent long term complications such as fistulas or fecal incontinence.

The effect of hybrid seton on anal continence and quality of life in transsphincteric fistulas. Long-term follow-up.

BACKGROUND: The aim of this study is to evaluate long-term results of hybrid seton on anal continence and quality of life in transsphincteric fistulas. METHODS: Between 2011-2013 eighty patients who completed 7-year follow-up among 154 patients who were operated for perianal fistula were included. Of the 50 patients participating, 42 (84%); 31 men, 11 women) returned all questionnaraires. The proctological findings of the patients were compared with the newly obtained ones retrospectively. Demographic characteristics of the patients, preoperative and postoperative 3rd month and 7th year Cleveland Clinic Incontinence Score, preoperative and postoperative 3rd month and 7th year Fecal Incontinence Quality of Life and seton fall times were assessed. RESULTS: Thirty (73.8%) of 42 patients were male and 11 (26.2%) were female. The mean age of male patients was 36.3 ± 10.3 (18-57), and the mean age of female patients was 41.2 ± 12.1 (25-64) years. The mean time drop off the elastic seton was 19 ± 2.40 days (range 12-30 days). The preoperative and postoperative 3rd month Fecal Incontinence Quality of Life values™ were compared and improvement in lifestyle quality at the postoperative 3rd month was found to be statistically significant (p <0.01). When the preoperative and postoperative 7th year were compared in terms of Fecal Incontinence Quality of Life, behavior, life style and depression improved positively (p <0.01). CONCLUSION: Hybrid seton in transsphincteric perianal fistula surgery is an effective and reliable method for preserving anal continence and improving quality of life. KEY WORDS: Anal fistula, Fecal incontinence, Quality of life.

Real world outcomes of lateral internal sphincterotomy vs botulinum toxin for the management of chronic anal fissures.

BACKGROUND: Lateral internal sphincterotomy (LIS) remains the gold standard surgical approach for the management of chronic anal fissures (CAF). The procedure however, is complicated by the risk of postoperative incontinence. Intrasphincteric Botulinum Toxin (BT) has gained popularity as an alternative approach, despite being inferior to LIS with regards to cure rates. In the real world, patients at high risk for postoperative incontinence are likely to be offered BT as a preliminary procedure. The aim of this study was to explore the real-world outcomes of LIS and BT for a cohort of CAF patients. METHODS: 251 consecutive patients treated with either BT or LS for CAF by a single surgeon were reviewed. Patients were offered BT as a preliminary procedure if they had risk factors for faecal incontinence, whereas all other patients underwent LIS. Primary outcomes included rates of recurrence and faecal incontinence. RESULTS: LIS was superior to BT with regards to recurrence rates throughout the mean follow up period of five years (5% vs 15%, p = 0.012). A total of 17 patients experienced a minor degree of flatal incontinence at the 6-week follow up, although there was no difference between LIS and BT (7% vs 6%, p = 1.000). Four LIS patients (2%) continued to experience some minor incontinence to flatus at the 12-month follow up and were managed with biofeedback. CONCLUSION: For patients with CAF, individualizing the treatment approach according to risk factors for incontinence could mitigate this risk in LIS. High risk patients should be offered BT as a preliminary procedure.

The role of obesity on urinary incontinence and anal incontinence in women: a review.

Obesity prevalence is increasing worldwide, with significant healthcare implications. We searched PubMed/MEDLINE, Embase and the Cochrane Library for articles registered until June 2020 to explore the relationship between obesity and urinary (UI) and anal incontinence (AI). Obesity is associated with low-grade, systemic inflammation and proinflammatory cytokine release, producing reactive oxygen species and oxidative stress. This alters collagen metabolism and, in combination with increased intra-abdominal pressure, contributes to the development of UI. Whereas in AI, stool consistency may be a factor. Weight loss can reduce UI and should be a management focus; however, the effect of weight loss on AI is less clear.

Oncologic and Functional Outcomes of Pelvic Perineal Reconstruction by Perineal Colostomy and Malone Procedure After Abdominoperineal Resection.

BACKGROUND: Abdominoperineal resection is the standard curative surgical technique for locally advanced adenocarcinoma of the lower rectum and squamous cell carcinoma of the anal canal after chemoradiotherapy. However, it requires a definitive abdominal colostomy that modifies the body appearance. OBJECTIVE: The study aim was to evaluate the combination of abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at the Toulouse Hospital Digestive Surgery Department. PATIENTS: All of the patients with advanced adenocarcinoma or squamous cell carcinoma who underwent abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema (n = 80) between December 1999 and December 2016 were included. MAIN OUTCOME MEASURES: The main outcome was the 5-year overall survival rate. RESULTS: The 5-year overall survival was 74.89% (95% CI, 62.91%-83.50%), and the median recurrence-free survival was 107.6 months (95% CI, 65.1-198.1 mo). The median follow-up was 91.0 months (95% CI, 70.4-116.6 mo). R0 resection was obtained in 64 patients (80.0%). The median Cleveland Clinic Incontinence Score (to assess the functional outcomes) was 9.0 (interquartile range, 1.0-18.0), and it was lower in patients with advanced adenocarcinoma than with squamous cell carcinoma (7.0 (interquartile range, 2.0-18.0) vs 11.0 (interquartile range, 1.0-17.0); p = 0.01). Eleven patients (13.8%) reported perineal stains during the night, and 19 patients (23.8%) needed drugs to reduce colon motility. The rate of severe complications (Clavien-Dindo >II) was 11.7% (n = 9). Definitive colostomy was performed in 15 patients (18.8%). LIMITATIONS: This retrospective study included a small number of patients from a single center. Moreover, the functional outcome was tested with self-report questionnaires (risk of response bias). CONCLUSIONS: This study suggests that abdominoperineal resection associated with perineal reconstruction by perineal colostomy and Malone antegrade continence enema is safe and may improve patient quality of life. See Video Abstract at http://links.lww.com/DCR/B629. RESULTADOS ONCOLGICOS Y FUNCIONALES DE LA RECONSTRUCCIN PLVIPERINEAL MEDIANTE COLOSTOMA PERINEAL Y PROCEDIMIENTO DE MALONE DESPUS DE LA RESECCIN ABDOMINOPERINEAL: ANTECEDENTES:La resección abdominoperineal es la técnica quirúrgica curativa estándar para el tratamiento del adenocarcinoma localmente avanzado del recto inferior y el carcinoma a células escamosas del canal anal, después de radio-quimioterapia. Sin embargo, requiere una colostomía abdominal definitiva que modifica la apariencia corporal.OBJETIVO:El propósito del presente estudio fue el evaluar la combinación de la resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone.DISEÑO:Estudio retrospectivo.AJUSTES:Servicio de Cirugía Digestiva del Hospital de Toulouse, Francia.PACIENTES:Se incluyeron todos los pacientes con adenocarcinoma avanzado o carcinoma de células escamosas que se sometieron a resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone (n = 80) entre diciembre de 1999 y diciembre de 2016.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue la tasa de sobrevida global a 5 años.RESULTADOS:La sobrevida global a 5 años fue de 74,89% (IC del 95%, 62,91 a 83,50) y la mediana de supervivencia libre de recurrencia fue de 107,6 meses (IC del 95%, 65,1 a 198,1). La mediana de seguimiento fue de 91,0 meses (IC del 95%, 70,4-116,6). La resección R0 se obtuvo en 64 pacientes (80,0%). La mediana de puntuación de la escala de incontinencia de la Cleveland Clinic (para evaluar los resultados funcionales) fue de 9,0 [1,0; 18,0], y fue menor en pacientes con adenocarcinoma avanzado que con carcinoma de células escamosas (7,0 [2,0; 18,0] versus 11,0 [1,0; 17,0]; p = 0,01). Once pacientes (13,8%) refirieron manchado perineal nocurno y 19 pacientes (23,8%) necesitaron fármacos para reducir la motilidad del colon. La tasa de complicaciones graves (Clavien-Dindo > II) fue del 11,7% (n = 9). Se realizó colostomía definitiva en 15 (18,8%) pacientes.LIMITACIONES:Este estudio retrospectivo incluyó un pequeño número de pacientes y de un solo centro. Además, el resultado funcional se probó con cuestionarios de autoinforme (riesgo de sesgo de respuesta).CONCLUSIONES:Este estudio sugiere que la resección abdominoperineal asociada con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone es segura y puede mejorar la calidad de vida de los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B629.

Long-term Evaluation of Fistulotomy and Immediate Sphincteroplasty as a Treatment for Complex Anal Fistula.

BACKGROUND: Fistulotomy with immediate sphincteroplasty is a technique that can heal fistulas and decrease fecal incontinence more effectively than fistulotomy alone, in selected patients. OBJECTIVE: We aimed to perform a long-term evaluation of fecal incontinence after fistulotomy and immediate sphincteroplasty in patients with complex anal fistula. DESIGN: This prospective study included patients undergoing fistulotomy and immediate sphincteroplasty for complex anal fistula from January 2000 to December 2010. SETTINGS: The study was conducted by 2 colorectal surgeons in the coloproctology unit of the General Hospital of Elche. PATIENTS: We included patients aged ≥18 years with complex anal fistulas of cryptoglandular origin. MAIN OUTCOME MEASURES: Main outcomes were recurrence and continence after fistulotomy and immediate sphincteroplasty, according to fistula tract height and preoperative continence status. RESULTS: A total of 107 patients were included; 68.2% were men, with a mean age of 48 years and mean fistula duration of 12.8 months. The range and median follow-up period were 84 to 204 and 96 months. Thirty-seven fistulas were not primary. The overall healing rate was 84.1%. Primary fistulas healed by the end of follow-up in 58 (82.9%) of 70 patients; recurrent fistulas healed in 32 (86.5%) of 37; high tracts healed in 31 (83.8%) of 37, and nonhigh fistulas healed in 59 (84.3%) of 70. Male sex (OR = 0.66 (95% CI, 0.20-2.13); p > 0.05) and recurrent fistulas (OR = 0.43 (95% CI, 0.11-1.68); p > 0.05) could have a protective effect against postoperative fecal incontinence; however, more studies with larger sample sizes are necessary to confirm this result, whereas high fistulas showed a 4-fold increased risk of incontinence (range, 1.22-13.06; p < 0.01). One in 5 high-tracts patients experienced continence deterioration. LIMITATIONS: This was a prospective study, and randomized clinical trials with more patients and longer follow-up are needed to compare fistulotomy and immediate sphincteroplasty with other sphincter-preserving techniques. CONCLUSIONS: Fistulotomy and immediate sphincteroplasty are good options for treating complex anal fistulas, especially for recurrent fistulas, men, and patients with nonhigh tracts, with acceptable recurrence and incontinence rates. See Video Abstract at http://links.lww.com/DCR/B498. EVALUACIN A LARGO PLAZO DE LA FISTULOTOMA Y LA ESFINTEROPLASTIA INMEDIATA COMO TRATAMIENTO PARA LA FSTULA ANAL COMPLEJA: ANTECEDENTES:La fistulotomía y la esfinteroplastia inmediata es una técnica que puede curar las fístulas y disminuir la incontinencia fecal de manera más efectiva que la fistulotomía sola, en pacientes seleccionados.OBJETIVO:Nuestro objetivo fue realizar una evaluación a largo plazo de la incontinencia fecal después de la fistulotomía y la esfinteroplastia inmediata en pacientes con fístula anal compleja.DISEÑO:Este estudio prospectivo incluyó pacientes sometidos a fistulotomía y esfinteroplastia inmediata por fístula anal compleja, desde enero de 2000 hasta diciembre de 2010.ENTORNO CLINICO:El estudio fue realizado por dos cirujanos colorrectales de la Unidad de Coloproctología del Hospital General de Elche.PACIENTES:Se incluyeron pacientes ≥ 18 años con fístulas anales complejas de origen criptoglandular.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron la recurrencia y la continencia después de la fistulotomía y la esfinteroplastia inmediata, de acuerdo con la altura del trayecto de la fístula y el estado de continencia preoperatoria.RESULTADOS:Se incluyeron un total de 107 pacientes; El 68,2% eran varones, con una edad media de 48 años y una duración media de la fístula de 12,8 meses. El rango y la mediana del período de seguimiento fue de 84-204 y 96 meses, respectivamente. Treinta y siete fístulas no fueron primarias. La tasa de curación general fue del 84,1%. Las fístulas primarias cicatrizaron al final del seguimiento en 58/70 (82,9%) pacientes; las fístulas recurrentes cicatrizaron en 32/37 (86,5%); los tractos altos cicatrizaron en 31/37 (83,8%) y las fístulas no altas cicatrizaron en 59/70 (84,3%). El sexo masculino (razón de posibilidades: 0,66 [0,20-2,13], p > 0,05) y las fístulas recurrentes (razón de posibilidades: 0,43 [0,11-1,68], p > 0,05) podrían tener un efecto protector contra la incontinencia fecal postoperatoria, sin embargo, más estudios con una muestra más grande son necesarios para confirmar este resultado. Fistulas altas mostraron un riesgo cuatro veces mayor de incontinencia ([1.22-13.06], p < 0.01). Uno de cada cinco pacientes con tractos altos experimentó un deterioro de la continencia.LIMITACIONES:Este fue un estudio prospectivo y se necesitan ensayos clínicos aleatorios con más pacientes y un seguimiento más prolongado para comparar la fistulotomía y la esfinteroplastia inmediata con otras técnicas de preservación del esfínter.CONCLUSIÓN:La fistulotomía y la esfinteroplastia inmediata son buenas opciones para el tratamiento de fístulas anales complejas, especialmente para fístulas recurrentes, varones y pacientes con tractos no altos, con tasas aceptables de recurrencia e incontinencia. Consulte Video Resumen en http://links.lww.com/DCR/B498.

Effect of Kegel exercises on the prevention of urinary and fecal incontinence in patients with prostate cancer undergoing radiotherapy.

PURPOSE: This is a nonrandomized experimental study conducted to evaluate the effect of Kegel exercises on the prevention of urinary and fecal incontinence in prostate cancer patients undergoing radiotherapy. METHOD: The study was conducted with 30 patients in the intervention group (IG) and 30 patients in the control group (CG). Data were collected using a patient information form, CTCAE, EORTC QLQ-C30, and a follow-up form reporting weekly Kegel exercises. Before radiotherapy, the IG was provided with Kegel exercise training via visual training material; exercises were performed under the supervision of the researcher, and the exercise pamphlet was handed out. During radiotherapy, weekly follow-ups were performed by face-to-face contact or phone calls. No similar application was provided to the CG. CTCAE and EORTC QLQ-C30 were evaluated three times (baseline, 4th and 8th weeks of exercises). RESULTS: At the end of the 4th week of exercises, 1st-grade urinary incontinence (UI) developed in the IG (10%) and in the CG (13.3%). At the end of the 8th week, 2nd-grade UI (3.3%) developed in the IG and 1st-grade (10%) and 2nd-grade UI (6.7%) developed in the CG. Fecal incontinence developed in neither group. At the end of the intervention, there was a significant improvement in Role, Social function and Global Health Status in the IG compared with the 4th week scores. In addition, less Fatigue, Diarrhea, Anorexia and Constipation scores were found compared with the baseline. CONCLUSION: Kegel exercises can be recommended as an approach in the prevention of urinary incontinence and to improve quality of life.

[Morphological criteria for surgical treatment of anorectal malformations in children]. / Morfologicheskie kriterii khirurgicheskogo lecheniya anorektal'nykh mal'formatsii u detei.

OBJECTIVE: To improve treatment outcomes in patients with anorectal malformations via research of morphological criteria and differentiated approach to surgical correction. MATERIAL AND METHODS: There were 37 children with various types of anorectal malformations for the period 2000-2019. We analyzed morphological features of atretic rectum wall, fistula, anastomosis with adjacent organs and skin of the perineum. RESULTS: Morphological research of anorectal malformations made it possible to differentiate treatment strategy and explain the causes of unsatisfactory results after perineal and abdominal-perineal proctoplasty. Incidence and severity of complications, as well as early disability were reduced that significantly improved postoperative quality of life. CONCLUSION: According to the morphological criteria, deeper mobilization of atretic rectum within at least 2.5-3 cm of the rectal «cone¼ with intact muscular wall is necessary. This approach was valuable to ensure adequate closure function of the rectum, prevent anal incontinence and restore normal appearance of the perineum. These achievements contributed to decrease in the incidence of admissions, redo surgeries and improvement of social adaptation in children.

Sacral neuromodulation for the prevention of a permanent stoma in patients with severe defecation disorder following intersphincteric resection.

PURPOSE: Severe defecation disorder occurs frequently in coloanal anastomosis for low rectal cancer, and may affect quality of life. Sacral neuromodulation (SNM) has been reported to be successful after rectal resection, but there are no results for patients treated with intersphincteric resection (ISR). METHODS: A retrospective single-center study of SNM was performed for patient with defecation disorder following ISR. Pre- and post-treatment bowel frequencies, fecal incontinence episodes, and Wexner, LARS and FIQL scores were assessed to evaluate the efficacy. A good response was defined as ≥ 50% reduction of bowel frequency per day or fecal incontinence episodes per week. RESULTS: 10 patients (7 males, mean age 67.5 years) underwent SNM. All patients had severe fecal incontinence with a median Wexner score of 15 (13-20) and a median LARS score of 41 (36-41). The Wexner score improved after SNM, but not significantly (p = 0.06). LARS and FIQL scores significantly improved after SNM (p = 0.02, p = 0.01). At the end of follow-up, the good response rate was 40%. Three cases without a good response required creation of a permanent stoma. CONCLUSION: Seven out of 10 patients did not require a permanent colostomy after SNM. SNM should be considered before performing a permanent colostomy.

Implant of Self-Expandable Artificial Anal Sphincter in Patients With Fecal Incontinence Improves External Anal Sphincter Contractility.

BACKGROUND: External anal sphincter contractility significantly contributes to control the passage of stool. An artificial anal sphincter placed into the intersphincteric space is a safe and effective procedure to treat fecal incontinence, even if its mechanism of action has not been fully elucidated. OBJECTIVE: The aim of this study was to evaluate external anal sphincter contractility changes after a self-expandable hyexpan prostheses was implanted into the intersphincteric space of the anal canal and clinical outcomes compared. DESIGN: This was a prospective clinical study. SETTINGS: The study was conducted at a university teaching hospital. PATIENTS: Consecutive patients affected by fecal incontinence for at least 6 months after failure of conservative treatment were included. INTERVENTIONS: All of the patients underwent 10-prostheses implantation and were examined preoperatively and postoperatively by endoanal ultrasound and anorectal manometry. MAIN OUTCOME MEASURES: Fecal incontinence symptoms were assessed by severity scores. The external anal sphincter muscle tension was calculated using a specific equation. RESULTS: Thirty-nine patients (34 women; median age = 68 y) were included in the study; no morbidity was registered. After a median follow-up period of 14 months, both the median maximum voluntary squeeze pressure and the median inner radius of the external anal sphincter significantly increased. A statistically significant increase of external anal sphincter muscle tension was detected. A decrease of any fecal incontinence symptom and an improvement in severity scores were observed at the last follow-up examination. The external anal sphincter contractility was significantly higher in patients reducing incontinence episodes to solid stool by >50% and improving their ability to defer defecation for >15 minutes. LIMITATIONS: This was a single-center experience with a relatively small and heterogeneous sample size, patients with a potentially more severe disease because our institution is a referral center, and an absence of quality-of-life evaluation. CONCLUSIONS: Artificial anal sphincter implantation improved the external anal sphincter muscle tension; there was a positive correlation between its increase and the clinical outcome. See Video Abstract at http://links.lww.com/DCR/B468. IMPLANTE DE ESFNTER ANAL ARTIFICIAL AUTOEXPANDIBLE EN PACIENTES CON INCONTINENCIA FECAL MEJORA LA CONTRACTILIDAD DEL ESFNTER ANAL EXTERNO: ANTECEDENTES:La contractilidad del esfínter anal externo contribuye significativamente al control del paso de las heces. Un esfínter anal artificial colocado en el espacio interesfinteriano es un procedimiento seguro y eficaz para tratar la incontinencia fecal, incluso si su mecanismo de acción no se ha definido por completo.OBJETIVO:El objetivo de este estudio fue evaluar los cambios en la contractilidad del esfínter anal externo después de la implantación de una prótesis de hyexpan autoexpandible en el espacio interesfinteriano del canal anal y comparar los resultados clínicos.DISEÑO:Estudio clínico prospectivo.ENTORNO CLINICO:El estudio se realizó en un hospital universitario.PACIENTES:Pacientes consecutivos afectados por incontinencia fecal durante al menos 6 meses, tras fracaso de tratamiento conservador.INTERVENCIONES:Todos los pacientes fueron sometidos a la implantación de 10 prótesis, y fueron examinados pre y postoperatoriamente mediante ecografía endoanal y manometría anorrectal.PRINCIPALES MEDIDAS DE VALORACION:Los síntomas de incontinencia fecal se evaluaron mediante puntuaciones de gravedad. La tensión del músculo del esfínter anal externo se calculó mediante una formula específica.RESULTADOS:Treinta y nueve pacientes (34 mujeres; mediana de edad 68 años) fueron incluidos en el estudio; no se registró morbilidad. Después de un período de seguimiento medio de 14 meses, tanto la presión de compresión voluntaria máxima media como el radio interior medio del esfínter anal externo aumentaron significativamente. Se detectó un aumento estadísticamente significativo de la tensión del músculo del esfínter anal externo. En el último examen de seguimiento se observó una disminución de cualquier síntoma de incontinencia fecal y una mejora en las puntuaciones de gravedad. La contractilidad del esfínter anal externo fue significativamente mayor en los pacientes que redujeron los episodios de incontinencia a heces sólidas en más del 50% y mejoraron la capacidad para diferir la defecación durante más de 15 minutos.LIMITACIONES:Experiencia de un solo centro; tamaño de muestra relativamente pequeño y heterogéneo; pacientes con una enfermedad potencialmente más grave porque nuestra institución es un centro de referencia; ausencia de evaluación de la calidad de vida.CONCLUSIONES:La implantación del esfínter anal artificial mejoró la tensión muscular del esfínter anal externo; hubo una correlación positiva entre su aumento y el resultado clínico. Consulte Video Resumen en http://links.lww.com/DCR/B468.

Randomized Pilot Study: Anal Inserts Versus Percutaneous Tibial Nerve Stimulation in Patients With Fecal Incontinence.

BACKGROUND: Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence in whom other conservative treatments have failed. OBJECTIVE: We aimed to compare anal inserts and percutaneous tibial nerve stimulation. DESIGN: This was an investigator-blinded randomized pilot study. SETTINGS: The study was conducted at a large tertiary care hospital. PATIENTS: Adult patients with passive or mixed fecal incontinence were recruited. INTERVENTIONS: Patients were randomly assigned to receive either the anal inserts or weekly percutaneous tibial nerve stimulation for a period of 3 months. MAIN OUTCOME MEASURES: The primary end point was a 50% reduction of episodes of fecal incontinence per week as calculated by a prospectively completed 2-week bowel diary. Secondary end points were St Mark's incontinence score, International Consultation on Incontinence Questionnaire-Bowel scores (for bowel pattern, bowel control, and quality of life), use of antidiarrheal agents, estimates of comfort and acceptability. RESULTS: Fifty patients were recruited: 25 were randomly assigned to anal inserts and 25 were randomly assigned to percutaneous tibial nerve stimulation. All completed treatment. A significant improvement of scores in the 2-week bowel diary, the St Mark's scores and the International Consultation on Incontinence Questionnaire-Bowel scores, was seen in both groups after 3 months of treatment. A reduction of ≥50% fecal incontinence episodes was reached by 76% (n = 19/25) by the anal insert group, compared with 48% (n = 12/25) of those in the percutaneous tibial nerve stimulation group (p = 0.04). The St Mark's fecal incontinence scores and the International Consultation on Incontinence Questionnaire-Bowel scores for bowel pattern, bowel control, and quality of life (p = 0.01) suggest similar improvement for each group. LIMITATIONS: A realistic sample size calculation could not be performed because of the paucity of objective prospective studies assessing the effect of the insert device and percutaneous tibial nerve stimulation. CONCLUSIONS: Both anal insert and percutaneous tibial nerve stimulation improved the symptoms of fecal incontinence after 3 months of treatment. The insert device appeared to be more effective than percutaneous tibial nerve stimulation. Larger studies are needed to investigate this further. See Video Abstract at http://links.lww.com/DCR/B460. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov No. NCT04273009. ESTUDIO PILOTO ALEATORIZADO DE INSERCIONES ANALES CONTRA LA ESTIMULACIN PERCUTNEA DEL NERVIO TIBIAL EN PACIENTES CON INCONTINENCIA FECAL: ANTECEDENTES:Las inserciones anales y la estimulación percutánea del nervio tibial (PTNS) se pueden ofrecer a las personas con incontinencia fecal que han fallado en otros tratamientos conservadores.OBJETIVO:Nuestro objetivo fue comparar inserciones anales y estimulación percutánea del nervio tibial.DISEÑO:Este fue un estudio piloto aleatorio ciego para investigadores.AJUSTE:El estudio se realizó en un hospital de atención terciaria.PACIENTES:Se reclutaron pacientes adultos con incontinencia fecal pasiva o mixta.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir inserciones anales o estimulación del nervio tibial percutáneo semanal durante un período de tres meses.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue una reducción del 50% de los episodios de incontinencia fecal por semana, según lo calculado mediante un diario intestinal de dos semanas completado de forma prospectiva. Los criterios de valoración secundarios fueron la puntuación de incontinencia de St Mark, las puntuaciones del ICIQ-B (para patrón intestinal, control intestinal y calidad de vida), uso de agentes antidiarreicos, estimaciones de comodidad y aceptabilidad.RESULTADOS:Se reclutaron 50 pacientes: 25 fueron asignados al azar a inserciones anales y 25 a PTNS. Todo el tratamiento completado. Se observó una mejora significativa de las puntuaciones en el diario intestinal de dos semanas, la puntuación de St Mark y la puntuación del ICIQ-B en ambos grupos después de 3 meses de tratamiento. Se alcanzó una reducción de ≥ 50% de los episodios de incontinencia fecal en un 76% (n = 19/25) en el grupo de inserción anal, en comparación con el 48% (n = 12/25) de los del grupo de estimulación percutánea del nervio tibial (p = 0,04). Las puntuaciones de incontinencia fecal de St Mark, las puntuaciones del ICIQ-B para el patrón intestinal, el control intestinal y la calidad de vida (p = 0,01) sugieren una mejora similar para cada grupo.LIMITACIONES:No se pudo realizar un cálculo realista del tamaño de la muestra debido a la escasez de estudios prospectivos objetivos que evaluaran el efecto del dispositivo de inserción y la estimulación percutánea del nervio tibial.CONCLUSIONES:Tanto la inserción anal como la estimulación percutánea del nervio tibial mejoraron los síntomas de incontinencia fecal después de 3 meses de tratamiento. El dispositivo de inserción parecia ser más efectivo que la estimulación percutánea del nervio tibial. Se necesitan estudios más amplios para investigar esto más a fondo. Consulte Video Resumen en http://links.lww.com/DCR/B460.NÚMERO DE REGISTRO DE PRUEBA:Clinicaltrials.gov No. NCT04273009.

Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study.

OBJECTIVE: Fistulotomy remains the gold standard for the surgical treatment of simple anal fistula, but may cause fecal incontinence and a characteristic anal 'keyhole' deformity. Although seemingly trivial, keyhole deformity may lead to bothersome symptoms such as anal pruritus and fecal soiling. This study aims to evaluate the efficacy of fistulectomy and primary sphincteroplasty (FIPS), a technique with immediate sphincter reconstruction, in the treatment of simple anal fistula and the prevention of keyhole deformity created by simple fistulotomy. METHODS: A retrospective study was performed on all consecutive patients who underwent FIPS for a simple anal fistula at our institution between January 2015 and August 2019. The primary outcome of the study was the rate of early postoperative wound dehiscence, which essentially transforms a FIPS into a simple fistulotomy and may lead to keyhole deformity. All patients received follow-up at regular intervals to evaluate fistula healing and the presence of keyhole deformity. RESULTS: FIPS was performed in 24 patients (median age: 52.8 years). After a median follow-up time of 3.0 (2.0, 6.3) months, the overall healing rate was 95.8% (23/24 patients). Six (25%) patients experienced early postoperative wound dehiscence resulting in the development of a keyhole deformity. Five of them were symptomatic (mainly soiling). Keyhole deformity was diagnosed at a median time of 6.0 (3.8, 7.5) months postoperatively. The occurrence of early wound dehiscence and subsequent keyhole deformity was associated with a posteriorly located fistula (p = .02). CONCLUSION: FIPS avoids the development of keyhole deformity in the majority of patients with simple anal fistula, but is less successful in posterior fistulas. Since FIPS is a very effective, fast and simple procedure, it should be considered a valid alternative for the treatment of every simple anal fistula.

Laparoscopically assisted anorectoplasty-Surgical procedures and outcomes: A literature review.

Anorectal malformation includes various types of anomalies. The goal of definitive surgery is achievement of fecal continence. Twenty years have passed since laparoscopically assisted anorectoplasty (LAARP) was reported by Georgeson. Since LAARP is gaining popularity, its long-term outcomes should be evaluated. Presently, there is no evidence regarding the optimal method of ligating and dividing the fistula correctly and creating the pull-through canal accurately. Rectal prolapse and remnant of the original fistula (ROOF) tend to develop more often in LAARP patients than in posterior sagittal anorectoplasty (PSARP) patients; however, robust evidence is not available. Prolapse may be prevented by suture fixation of the rectum to the presacral fascia; however, if prolapse occurs, the indication, timing, and the best method for surgical correction remain unclear. Most patients with ROOF are asymptomatic, and there is controversy regarding the indications for ROOF resection. This article aimed to detail the various modifications of the LAARP procedures reported previously and to describe the surgical outcomes, particularly focusing on rectal prolapse, ROOF, and fecal continence, by reviewing the literature. Functional outcomes after LAARP were almost similar to those noted after PSARP, and we have demonstrated that LAARP is not inferior to PSARP with respect to fecal continence. Although there is controversy regarding the application of LAARP for recto-bulbar cases, we believe that LAARP is still evolving, and we can achieve better outcomes by improving the procedure.

Caesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetric anal sphincter injury: the EPIC multicentre randomised trial.

OBJECTIVE: To determine whether planned caesarean section (CS) for a second delivery protects against anal incontinence in women with obstetric anal sphincter lesions. DESIGN: Randomised trial. SETTING: Six maternity units in the Paris area. SAMPLE: Women at high risk of sphincter lesions (first delivery with third-degree laceration and/or forceps) but no symptomatic anal incontinence. METHODS: Endoanal ultrasound was performed in the third trimester of the second pregnancy. Women with sphincter lesions were randomised to planned CS or vaginal delivery (VD). MAIN OUTCOME MEASURES: Anal incontinence at 6 months postpartum. Secondary outcomes were urinary incontinence, sexual morbidity, maternal and neonatal morbidities and worsening of external sphincter lesions. RESULTS: Anal sphincter lesions were detected by ultrasound in 264/434 women enrolled (60.8%); 112 were randomised to planned VD and 110 to planned CS. At 6-8 weeks after delivery, there was no significant difference in anal continence between the two groups. At 6 months after delivery, median Vaizey scores of anal incontinence were 1 (interquartile range 0-4) in the CS group and 1 (interquartile range 0-3) in the VD group (P = 0.34). There were no significant differences for urinary continence, sexual functions or for other maternal and neonatal morbidities. CONCLUSIONS: In women with asymptomatic obstetric anal sphincter lesions diagnosed by ultrasound, planning a CS had no significant impact on anal continence 6 months after the second delivery. These results do not support advising systematic CS for this indication. TWEETABLE ABSTRACT: Caesarean section for the second delivery did not protect against anal incontinence in women with asymptomatic obstetric anal sphincter lesions.

A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano: The FIAT Trial.

OBJECTIVE: To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano. SUMMARY BACKGROUND DATA: The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain. METHODS: Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates. RESULTS: Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY. CONCLUSIONS: The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.