Systematic review of the prevalence of faecal incontinence.

BACKGROUND: Faecal incontinence (FI) is widely recognized as a significant problem in the community. Conjecture exists around the proportion of the population affected. This systematic review evaluated studies reporting the community prevalence of FI in terms of methodology, design and definitions. METHODS: MEDLINE, Embase, CINAHL, the Cochrane Collaboration and National Guideline databases were searched for studies investigating the prevalence of FI in community-based adults published from January 1966 to February 2015. Study data, including methodology, sample size, response rate, definition of FI and prevalence rates, were extracted on to a pro forma and appraised critically. Where possible, FI prevalence estimates were pooled. RESULTS: Thirty studies were analysed from 4840 screened articles. FI prevalence estimates varied from 1·4 to 19·5 per cent. This variation was explained by differences in data collection method and two factors within definitions of FI: type of stool and frequency of FI episodes. When these factors were accounted for, the FI prevalence at a threshold of at least once per month for liquid or solid stool was 8·3-8·4 per cent for face-to-face or telephone interviews, and 11·2-12·4 per cent for postal surveys. The pooled prevalence rate from studies for functional FI (defined by ROME II criteria) was 5·9 (95 per cent c.i. 5·6 to 6·3) per cent. CONCLUSION: When comparable methodologies and definitions are used, studies produce remarkably similar prevalence rates in different community populations. FI remains an unspoken symptom, with lower rates reported in personal interviews compared with anonymous postal questionnaires.

The use of local anaesthesia in haemorrhoidal banding: a randomized controlled trial.

AIM: Rubber band ligation is a common office procedure for the treatment of symptomatic haemorrhoids. It can be associated with pain and vasovagal symptoms. The effect of local anaesthetic use during banding was studied. METHOD: A single-blinded randomized controlled trial was carried out in the colorectal outpatient clinic. Patients presenting with symptomatic haemorrhoids suitable for banding were prospectively recruited and randomized to undergo the procedure with local anaesthetic or without (control). Submucosal bupivacaine was injected immediately after banding just proximal to the site. Vasovagal symptoms were assessed at the time of banding and pain scores (visual analogue scale) were recorded at the conclusion of the procedure, after 15 min, and on leaving the clinic. RESULTS: Seventy-two patients (40 local anaesthetic injection, group 1; 32 no injection, group 2) were recruited. The mean ages were 50 and 54 years respectively, the median duration of symptoms was 12 months in each group and the median number of haemorrhoids banded was three in each group. The mean pain score on leaving the clinic was 2.6 (95% CI 2.1, 3.1) in group 1 and 4.1 (95% CI 3.3, 5.0) (P = 0.04) in group 2. There were no complications related to local anaesthetic use. No significant difference in vasovagal symptoms was found (P = 0.832). CONCLUSION: Local anaesthetic injection at the time of banding is simple and safe. It may reduce patient discomfort following banding of haemorrhoids.

Determining levels of fecal incontinence in the community: a New Zealand cross-sectional study.

BACKGROUND: Fecal incontinence is a socially stigmatized condition, and its prevalence in the community has been problematic to quantify because of difficulty with its definition. OBJECTIVE: This study estimates the community prevalence of fecal incontinence in New Zealand by 3 scales of measurement: patient perceptions of a "problem with bowel control," their symptoms, and their quality of life. DESIGN/MAIN OUTCOME MEASURES: A postal survey of 2000 people, aged >18, randomly selected from the national electoral roll, was performed. This used a validated, reliability-tested, anonymous questionnaire, the Comprehensive Fecal Incontinence Questionnaire, incorporating the identification of a "problem with bowel control," the Fecal Incontinence Severity Index, and the Fecal Incontinence Quality of Life Scale. RESULTS: The response rate was 68.7%. A total of 14.7% (95% CI: 12.6-16.7) of participants "felt they had a problem with bowel control" and 12.4% (95% CI: 10.5-14.5) had fecal incontinence when defined using the Fecal Incontinence Severity Index table as "leakage of liquid or solid stool ≥ 1/month." In terms of quality of life, 26.8% of the population (95% CI: 24.2-29.4) noted some impairment on the Fecal Incontinence Quality of Life Scale. In total, 155 (13.2%) participants reported at least 2 of the 3 possible diagnostic measures, and this may provide a way to incorporate the 3 measures into a new definition of fecal incontinence. LIMITATIONS: This study incorporated a new "generic" question enquiring about an individual's perception of a bowel control problem and also introduced a "cutoff" value for Fecal Incontinence Quality of Life Scale to attempt to identify those with any impairment "due to accidental bowel leakage." CONCLUSIONS: This study helps to highlight some of the challenges involved with suitably identifying those who have fecal incontinence within the community. The prevalence rate of 13.2% represents a realistic measure of the burden of fecal incontinence in the general population, and further research in this area is recommended.

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery.

BACKGROUND: Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double-blind randomized trial. METHODS: Patients undergoing elective colorectal surgery or liver resection were randomized to oral CHO or placebo drinks to be taken on the evening before surgery and 2 h before induction of anaesthesia. Primary outcomes were postoperative length of hospital stay and fatigue measured by visual analogue scale. RESULTS: Sixty-nine and 73 patients were evaluated in the CHO and placebo groups respectively. The groups were well matched with respect to surgical procedure, epidural analgesia, laparoscopic procedures, fasting period before induction and duration of surgery. Postoperative changes in fatigue score from baseline did not differ between the groups. Median (range) hospital stay was 7 (2-35) days in the CHO group and 8 (2-92) days in the placebo group (P = 0.344). For patients not receiving epidural blockade or laparoscopic surgery (20 CHO, 19 placebo), values were 7 (3-11) and 9 (2-48) days respectively (P = 0.054). CONCLUSION: Preoperative CHO treatment did not improve postoperative fatigue or length of hospital stay after major abdominal surgery. A benefit is not ruled out when epidural blockade or laparoscopic procedures are not used. REGISTRATION NUMBER: ACTRN012605000456651 (http://www.anzctr.org.au).

Systematic review on ventral rectopexy for rectal prolapse and intussusception.

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

Stapled versus handsewn methods for ileocolic anastomoses.

BACKGROUND: Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. To our knowledge, this is the first systematic review specifically investigating ileocolic anastomosis. OBJECTIVES: To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. SEARCH STRATEGY: MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005. Abstracts presented to the following society meetings between 1970 and 2002 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. SELECTION CRITERIA: Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. DATA COLLECTION AND ANALYSIS: Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 4.2 Analysis version 1.0.5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer and inflammatory bowel disease as indication for ileocolic anastomoses were performed. MAIN RESULTS: After obtaining individual data from authors for studies that include other anastomoses, six trials (including one unpublished) with 955 ileocolic participants (357 stapled, 598 handsewn) were included. The three largest trials had adequate allocation concealment. Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=5/357, HS=36/598, OR 0.34 [0.14, 0.82] p=0.02). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significant fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). There were too few Crohn's disease patients to perform sub-group analysis. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. AUTHORS' CONCLUSIONS: Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.