[Sacral root neuromodulation as treatment for fecal incontinence. Preliminary results]. / Neuromodulación de raíces sacras como tratamiento de la incontinencia fecal. Resultados preliminares.

We present our initial experience in the treatment of fecal incontinence (FI) with sacral root neuromodulation (SRN) by reporting the results of a prospective study with 26 patients where baseline Wexner-Cleveland scale scores and ability to delay defecation were compared to results after one year with SRN. The initial study of patients included history taking, general examination, anal ultrasonography, and manometry, and a three-week diary of continence and quality of life specific for FI was used. Before SRN the mean baseline Wexner-Cleveland score was 15.00 +/- 1.81, and 62.50% of patients could only delay defecation for less than a minute. After a year with NRS the mean Wexner-Cleveland score was 4.87 +/- 2.54 (p = 0.0031), and 75.01% of patients could delay defecation above fifteen minutes (p = 0.0018). We also describe the surgical technique and its indications, and finally review the various therapeutical options for FI and show our algorithm for this condition. SRN is an effective technique for the treatment of FI in properly selected patients with no response to medical therapies (including biofeedback) or anatomic correction (sphincteroplasty), with efficacy, little morbidity, and a short hospital stay.

Is anal endosonography useful in the study of recurrent complex fistula-in-ano?

INTRODUCTION: performing anal endosonography in complex fistula-in-ano allows us to design a personalized surgical strategy in each case, thereby improving results. However, there are doubts in the literature as to its utility in recurrent complex fistulas. The aim of this study was to compare the utility of anal ultrasonography in the study of primary versus recurrent complex fistula-in-ano. PATIENTS AND METHOD: prospective study of patients diagnosed and treated for complex fistula-in-ano. Physical examination and anal ultrasonography provided data on primary track, internal opening, horseshoe extension and the presence of secondary tracks or cavities in a protocol designed specifically for the study. These assessments were subsequently contrasted with operative findings. RESULTS: we included 35 patients, 19 (54.3%) with primary complex anal fistulas and 16 (45.7%) with recurrent fistulas. According to the operative findings, fistulas were classified as high transsphincteric in 28 patients (80%), suprasphincteric in 6 (17.1%) and extrasphincteric in one patient (2.9%), with no differences between groups. Physical examination correctly classified 28 of the 35 fistulous tracks, in contrast to the 32 (91.4%) correctly described on ultrasonography (80%). We did not find any statistically significant differences between the primary and the recurrent fistula groups with regard to sensibility, positive predictive value and accuracy of the anal ultrasonography for any of the parameters studied. CONCLUSION: the accuracy of anal ultrasonography does not decrease in recurrent complex fistula-in-ano.

[Treatment of proctalgia fugax with botulinum toxin: results in 5 patients]. / Tratamiento de la proctalgia fugax con toxina botulínica: resultados en 5 pacientes.

INTRODUCTION: Proctalgia fugax can be defined as transitory but recurrent anal pain. Although its etiology remains unknown, an internal anal sphincter spasm seems to be the most likely, so that the different treatments focus on reducing the pressure of the internal anal sphincter. This study is aimed at evaluating the effectiveness of botulinum A toxin in the treatment of proctalgia fugax. PATIENTS AND METHODS: Prospective clinical trial of patients with proctalgia fugax treated with botulinum A toxin at the Outpatient Clinic attached to the Coloproctogy Unit, University Hospital of Elche, from January 1999 to January 2002. The patients included in the study underwent rectal digital examination, anuscopy, rectoscopy, anal manometry and ultrasonography, barium enema and pelvic CT scan to rule out any organic cause for anal pain. The treatment consisted of 25 IU of botulinum A toxin, with a supplementary dose of 50 IU in those patients with persistence of anal pain episodes within the next two months. The patients were reviewed on the first week, second month, sixth month and first and second year. Anal pain was measured by the patients, using a linear analogue scale from 0 to 10, and continence was assessed at every visit using the Cleveland Continence Grading Scale. RESULTS: Five patients were recluted for the study, with a predominance of females (4 vs. 1). Mean age was 45 years. Length of symptoms prior to the treatment was 13 months (range: 6-18 months). Only one female patient required a second dose of botulinum A toxin to handle the anal pain. All the patients healed and remained free of pain up to finishing the follow-up. There were no local complications. Anal manometry showed an increased MRP (mean resting pressure) in comparison to a control group of patients (114 mmHg vs. 66 mmHg; p < 0.001) that restore to normal values after the treatment (75.65 mmHg). As for the MSP (mean squeeze pressure), it showed no difference with respect to the control group nor did it vary after the treatment. CONCLUSION: Botulinum A toxin offers a high rate of healing with no associate morbidity in the treatment of proctalgia fugax.