Long-term cost-effectiveness analysis of sacral neuromodulation in the treatment of severe faecal incontinence.

AIM: The aim of this study was to evaluate the long-term cost-effectiveness of sacral neuromodulation in the treatment of severe faecal incontinence as compared with symptomatic management. METHODS: In the public health field, a micro-costing evaluation method was conducted from the perspectives of the health system and the society. The incremental cost-effectiveness ratio was used as a decision index, and we considered various scenarios to evaluate the impact of the cost of symptomatic management and percutaneous nerve evaluation success rate in its calculation. Clinical data were retrieved from a consecutive cohort of 93 patients with severe faecal incontinence undergoing sacral neuromodulation after a failure of conservative (pharmacological and biofeedback) and/or surgical (sphincteroplasty) first-line treatments were considered. RESULTS: The long-term incremental cost-effectiveness ratio comparing sacral neuromodulation versus symptomatic management was 14347€/QALY and 28523€/QALY from the societal and health service provider's perspectives, respectively. If the definitive pulse generator implant success rate was 100%, incremental cost-effectiveness would correspond to 6831€/QALY and 16761€/QALY, respectively. CONCLUSIONS: Sacral neuromodulation may be considered a cost-effective technique in the long-term treatment of severe faecal incontinence from the societal and health care sector perspectives. Improving patient selection and determining the predictive outcome factors for successful sacral neuromodulation in the treatment of faecal incontinence would improve cost-effectiveness.

Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up.

PURPOSE: To examine long-term recurrence and anal continence of patients with anal fistula treated by fistulectomy and endorectal advancement flap repair. METHOD: Retrospective analysis of a prospective cohort of 115 patients (77.4% males, mean age 48.9 years) requiring 130 procedures, with a minimum follow-up of 10 years. Recurrence included reappearance of fistula after wound healing or presence of an abscess or chronic suppuration in the operated area at follow-up. Fecal incontinence was evaluated by the Cleveland Clinic Florida (CCF-FI) fecal incontinence scoring system. RESULTS: The mean and SD duration of the follow-up period was 155.5 (21.7) months. Recurrence developed in 31 (23.8%) cases, 28 (90.3%) of which within the first year, with a mean time to recurrence of 4.9 (2.9) months. The success rate was 76.2%. Anal continence was normal in 80% of patients before surgery, 63.8% at 1-year follow-up, and 71.5% at the end of follow-up (p < 0.001). Overall, continence worsened in 16.9% of cases. The mean (95% CI) CCF-FI score was 0.78 (0.35-1.21) preoperatively, 1.04 (0.64-1.43) at 1 year after surgery, 0.90 (0.52-1.29) at 5 years, and 1.16 (0.66-1.67) at the end of the study (p < 0.05). Neither recurrence nor continence was significantly associated with previous anal or fistula surgical procedures or complexity of the fistula. CONCLUSION: In this study, fistulectomy and endorectal advancement flap repair was associated with a long-term high rate of success. Most recurrences occurred within the first year and continence showed a mild deterioration over time. CLINICAL TRIAL REGISTRATION: Not applicable.

[Current status of the prevention and treatment of stoma complications. A narrative review]. / Estado actual de la prevención y tratamiento de las complicaciones de los estomas. Revisión de conjunto.

The aim of our study was to perform a review of the literature to assess the results of prevention and treatment of stoma complications. Medline, EMBASE medical database and the Cochrane Library were searched up to December 2012. Stomal complications are prevalent and associated with a worse quality of life and increased health-economic burdens. The most common complications are attributed to stoma construction. Attention to the finer technical points performed by experienced surgeons reduces morbidity. The use of mesh reduces the risk of parastomal hernia and recurrence rates in hernia repair. Preoperative stoma site marking and postoperative care by a stomatherapist are crucial for the patients' successful adaption, improving quality of life, promoting their independence and reducing the rates of complications.

Long-term outcomes of sacral neuromodulation for low anterior resection syndrome after rectal cancer surgery.

PURPOSE: This study assessed the long-term outcomes and quality of life in patients who underwent sacral neuromodulation (SNM) due to low anterior resection syndrome (LARS). METHODS: This single-center retrospective study, conducted from 2005 to 2021, included 30 patients (21 men; median age, 70 years) who had undergone total mesorectal excision with stoma closure and had no recurrence at inclusion. All patients were diagnosed with LARS refractory to conservative treatment. We evaluated clinical and quality-of-life outcomes after SNM through a stool diary, Wexner score, LARS score, the Fecal Incontinence Quality of Life (FIQL) questionnaire, and EuroQol-5D (EQ-5D) questionnaire. RESULTS: Peripheral nerve stimulation was successful in all but one patient. Of the 29 patients who underwent percutaneous nerve evaluation, 17 (58.62%) responded well to SNM and received permanent implants. The median follow-up period was 48 months (range, 18-153 months). The number of days per week with fecal incontinence episodes decreased from a median of 7 (range, 2-7) to 0.38 (range, 0-1). The median number of bowel movements recorded in patient diaries fell from 5 (range, 4-12) to 2 (range, 1-6). The median Wexner score decreased from 18 (range, 13-20) to 6 (range, 0-16), while the LARS score declined from 38.5 (range, 37-42) to 19 (range, 4-28). The FIQL and EQ-5D questionnaires demonstrated enhanced quality of life. CONCLUSION: SNM may benefit patients diagnosed with LARS following rectal cancer surgery when conservative options have failed, and the treatment outcomes may possess long-term sustainability.

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology.

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results.

INTRODUCTION: Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS: Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS: Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001). CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.

Economic burden of long-term treatment of severe fecal incontinence.

INTRODUCTION: Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy. METHODS: Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3); and colostomy stenosis (n=1). RESULTS: The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories). CONCLUSIONS: Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment.

Economic burden of long-term treatment of severe fecal incontinence. / Impacto económico del tratamiento a largo plazo de la incontinencia fecal grave.

INTRODUCTION: Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy. METHODS: Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3), and colostomy stenosis (n=1). RESULTS: The mean cumulative cost in 10 years per patient in each alternative was: € 10,972.9 symptomatic treatment (62% diapers); € 17,351.57 SNS (95.83% interventions; 81.6% devices); € 25,858.54 definitive colostomy (70.4% ostomy material and accessories). CONCLUSIONS: Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment.

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results. / Recidiva e incidencia de fístula tras el drenaje urgente de un absceso anal. Resultados a largo plazo.

INTRODUCTION: Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS: Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS: Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001) CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.

[Comparison of colostomies and ileostomies as diverting stomas after low anterior resection]. / Comparación de colostomías e ileostomías como estomas derivativos tras resección anterior baja.

OBJECTIVE: The aim of the present study was to evaluate two procedures (transverse colostomy and ileostomy) as diverting stomas after low anterior resection to determine whether one is superior to the other. MATERIAL AND METHOD: A literature review was performed to compare both stomas from construction to closure. RESULTS: Distinguishing between the complications specific to stoma construction from those caused by anterior resection is difficult. While the stoma is in place, transverse colostomy seems to be better tolerated. Colostomy closure seems to have more septic complications, although the real frequency of bowel obstruction after ileostomy closure remains to be determined. CONCLUSIONS: Given the characteristics of previous studies, the superiority of one diverting stoma over the other cannot be established. Ileostomy seems better tolerated by patients and is associated with a lower complication rate after closure (bowel obstruction remains to be evaluated). Randomized prospective studies with a larger number of patients are required to determine which of these procedures is superior.