Disparities in indications and outcomes reporting for pediatric tethered cord surgery: The need for a standardized outcome assessment tool.

PURPOSE: Tethered cord syndrome (TCS) is characterized by abnormal attachment of the spinal cord neural elements to surrounding tissues. The most common symptoms include pain, motor or sensory dysfunction, and urologic deficits. Although TCS is common in children, there is a significant heterogeneity in outcomes reporting. We systematically reviewed surgical indications and postoperative outcomes to assess the need for a grading/classification system. METHODS: PubMed and EMBASE searches identified pediatric TCS literature published between 1950 and 2023. Studies reporting surgical interventions, ≥ 6-month follow-up, and ≥ 5 patients were included. RESULTS: Fifty-five studies representing 3798 patients were included. The most commonly reported non-urologic symptoms were nonspecific lower-extremity motor disturbances (36.4% of studies), lower-extremity/back pain (32.7%), nonspecific lower-extremity sensory disturbances (29.1%), gait abnormalities (29.1%), and nonspecific bowel dysfunction/fecal incontinence (25.5%). Urologic symptoms were most commonly reported as nonspecific complaints (40.0%). After detethering surgery, retethering was the most widely reported non-urologic outcome (40.0%), followed by other nonspecific findings: motor deficits (32.7%), lower-extremity/back/perianal pain (18.2%), gait/ambulation function (18.2%), sensory deficits (12.7%), and bowel deficits/fecal incontinence (12.7%). Commonly reported urologic outcomes included nonspecific bladder/urinary deficits (27.3%), bladder capacity (20.0%), bladder compliance (18.2%), urinary incontinence/enuresis/neurogenic bladder (18.2%), and nonspecific urodynamics/urodynamics score change (16.4%). CONCLUSION: TCS surgical literature is highly variable regarding surgical indications and reporting of postsurgical outcomes. The lack of common data elements and consistent quantitative measures inhibits higher-level analysis. The development and validation of a standardized outcomes measurement tool-ideally encompassing both patient-reported outcome and objective measures-would significantly benefit future TCS research and surgical management.

Experimental assessment of a novel artificial anal sphincter with shape memory alloy.

BACKGROUND: Fecal incontinence caused by sphincter dysfunction is a difficult medical problem that has not been fully resolved. The artificial anal sphincter provides a new therapeutic strategy for fecal incontinence. In order to solve the biomechanical compatibility problem between the artificial anal sphincter and intestinal tissue in clinical application, a design of constant force artificial anal sphincter was assessed in this paper. METHODS: The constant force properties and safety of this novel device were evaluated by an experiment conducted in pig intestines with various thicknesses. The constant force characteristic of the device was evaluated by the intestinal pressure of the pig intestine. The safety of the device was evaluated by the surface contact stress of the pig intestine clamped by an artificial anal sphincter. RESULTS: The average measured value of the intestinal pressure of the pig intestines with three thicknesses is about 55.3 mm Hg, the maximum pressure difference is 1 mm Hg, and the fluctuation error of constant clamping load is about 1.8%. The constant clamping load fluctuation error of the four measuring points of the pig intestines with three thicknesses is less than 2%. Even if the thickness of the pig intestines is changed, the measured contact stress value is lower than 10 kPa, which may avoid bit damage for the intestinal tissue. CONCLUSIONS: This study demonstrates that the novel artificial sphincter has constant force properties and safety, which prevent ischemic necrosis of soft tissues caused by excessive pressure. Therefore, this study raises the possibility of the long-term efficacy of artificial anal sphincter.

Anal Sphincteroplasty in the Minimally Invasive Era: Assessment of National Trends and Complications.

Fecal incontinence is a debilitating and underreported condition. Despite introduction of novel therapies in recent years, anal sphincteroplasty (AS) remains the surgical choice for certain patients. Previous reports have primarily focused on single-surgeon or single-center experience with AS. The purpose of this study was to assess patient characteristics and perioperative outcomes of AS using a national cohort. Patients (n = 586) who underwent AS as a primary procedure between 2009 and 2015 were identified by the CPT code as recorded in the study and were evaluated and examined for association with 30-day complications. The number of sphincteroplasties performed decreased seven-fold between 2009 and 2015. Wound infection, wound dehiscence, and urinary tract infection were the most common complications, occurring in 30 (5.1%), 12 (2.1%), and 6 (1%) patients, respectively. Preoperative steroid use and surgeon specialty were associated with wound complications on multivariate analysis. We present the first national study of patients undergoing AS and identify factors that predispose to wound complications. In addition, we demonstrate that the number of anal sphincteroplasties performed in the United States is decreasing dramatically, likely because of novel therapy for fecal incontinence. We hope that this study will assist in patient counseling and call attention to preserving surgical training as utilization of AS rapidly declines.

Assessment of pediatric Malone antegrade continence enema (MACE) complications: Effects of variations in technique.

OBJECTIVE: The Malone antegrade continence enema (MACE) procedure is performed for patients with fecal incontinence and constipation who do not respond to medical therapy. The MACE procedure provides antegrade catheter access to the right colon and allows administration of enemas to help evacuate the bowel regularly. The objective of this study was to identify risk factors for surgical complications in children who undergo the MACE procedure. METHOD: Records from 97 pediatric patients who underwent MACE procedure were reviewed retrospectively. Data collected included age, sex, weight (obese/not obese), stomal location, presence of a permanent button/catheter in the stoma, open vs. laparoscopic surgery, and etiology of fecal incontinence/constipation. The complications reviewed included stomal stenosis, leakage, and stomal site infection. The relationships between the independent variables and complications were assessed using chi-square tests and Fisher's exact test. Statistical significance was set at p < 0.05. RESULTS: Overall, 66 (68%) patients had at least one complication. Twenty-three (23.7%) patients developed stomal stenosis, and 27 (27.8%) patients had significant stomal leakage. Insertion of a stomal button/catheter device was associated with an increased risk of developing stomal leakage and stomal infection. The presence of a stomal button/catheter was also associated with a decreased risk of stomal stenosis (Figure). The non-intubated, imbricated sub-population, preteen patients (<12 years old) experienced more stomal leakage than teenage patients. In this subgroup, patients with umbilical stomas also experienced more leakage than patients with right lower quadrant (RLQ) stomas. CONCLUSION: The prevalence rates of stomal complications in our study were consistent with previously reported series. In our study, however, stomal leakage had a higher prevalence in comparison with stomal stenosis. This seems to be related to the heterogeneity of the study group, which contained two variants of the MACE procedure; non-imbricated, intubated MACE and imbricated, non-intubated MACE. The use of stomal buttons in conjunction with MACE has previously been reported without changes in complication rates. We found the use of stomal buttons/catheters to be associated with changes in the prevalence of stomal complications. Stomal complications are common in the MACE procedure. The use of a permanent stomal button/catheter is associated with changes in the rates of stomal complications. While many find an umbilical stomal site is more cosmetically appealing, there is an increased risk of leakage with imbricated, non-intubated stomas. In the non-intubated, imbricated sub-population, the MACE procedure results in a higher risk of stomal leakage in preteen patients in comparison with teenage patients.

A prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy is associated with high survivability and low rates of fecal diversion.

OBJECTIVE: This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization. BACKGROUND: Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial. METHODS: We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality. RESULTS: Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%). CONCLUSIONS: Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.

Incontinência urinária e fecal: estudo sobre o uso de fraldas e insumos auxiliares / Fecal and urinary incontinence: study on the use of diapers and auxiliary products / Incontinencia fecal y incontinencia urinaria: estudio acerca de la utilización de pañales y productos auxiliares

TECNOLOGIA: Fraldas geriátricas e insumos auxiliares. INDICAÇÃO: Incontinência urinária e fecal. CARACTERIZAÇÃO DAS TECNOLOGIAS: Fralda geriátrica é um produto de higiene íntima usado por adultos, principalmente idosos, que não têm (ou perderam) o controle de suas necessidades fisiológicas. Insumos auxiliares são preparações utilizadas para prevenção e/ou tratamento de problemas decorrentes do uso das fraldas. PERGUNTA: Quais as indicações de uso de fraldas geriátricas e insumos auxiliares, quais são as alternativas terapêuticas a esses produtos e qual é o custo estimado da sua utilização crônica em comparação com alternativas terapêuticas disponibilizadas no SUS? Métodos: As indicações de uso das fraldas geriátricas, bem como de outras alternativas para o controle/tratamento das incontinências foram encontradas em busca na literatura científica e em guias de tratamento nacionais e estrangeiros. Para se ter uma noção do gasto público atual com fraldas geriátricas os preços desses produtos foram levantados de acordo com dados do Banco de preços em Saúde. Também foram pesquisados os preços de fraldas em 57 sítios eletrônicos de farmácias e drogarias, além de sites de compras coletivas e o Sistema de Atendimento ao Consumidor (SAC) dos fabricantes. Os tipos e preços dos insumos auxiliares foram pesquisados em três grandes redes de drogarias privadas, das quais uma está presente apenas no Estado de Minas Gerais. Além disso, como forma de contemplar aqueles produtos mais judicializados foram pesquisados os principais insumos auxiliares solicitados no JusBrasil. RESULTADOS: O gasto do SUS com procedimentos cirúrgicos e fisioterápicos é bem menor que o próprio subsídio dado à compra de fraldas geriátricas no programa "Aqui tem Farmácia Popular" e, portanto, deveriam ser recomendados com maior frequência, dependendo da condição de incontinência de cada indivíduo. Nesse parecer, constatou-se a necessidade do uso de produtos de barreira e hidratantes na prevenção e cuidado de dermatites e úlceras associadas à condição de incontinência, evidenciando a necessidade de maior financiamento por parte do SUS para garantir acesso a cremes, pomadas e loções (preventivas e/ou curativas), os quais, pela análise aqui conduzida, são bastante onerosos para o paciente. De acordo com os dados levantados nesse parecer, os valores estimados de gasto individual anual com fraldas geriátricas foram de R$1.674,04; R$1.827,81; R$1.439,31; e R$1.123,72, respectivamente para as fraldas tamanho extragrande, grande, médio e pequeno. Os produtos considerados auxiliares foram cremes, loções, pomadas, óleos e pastas, com propriedades oclusivas, hidratantes e de restauração da pele afetada por assaduras, decorrentes do uso de fraldas geriátricas. O gasto médio anual com insumos auxiliares foi estimado em R$2.255,78. Como alternativas terapêuticas foram consideradas a terapia medicamentosa, fisioterapia e procedimentos cirúrgicos, de acordo com levantamento bibliográfico e guias de tratamento da incontinência nacionais e estrangeiros. Os principais medicamentos foram a oxibutinina, tolterodina, darifenacina e toxina botulínica, os quais apresentaram valores estimados de custo anual médio de R$988,20; R$4.355,05; R$4.322,40; e R$3.979,14, respectivamente. Os procedimentos cirúrgicos ofertados pelo Sistema Único de Saúde foram pesquisados no SIGTAP (Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS) e apresentaram valores de ressarcimento que variaram de R$372,54 a R$457,67. De acordo com o SIGTAP o preço da sessão de fisioterapia para fins de controle da incontinência é R$4,67, sendo recomendadas 20 sessões por semana. CONSIDERAÇÕES FINAIS: Observou-se que a estimativa de gasto médio de pacientes com uso de fraldas e insumos auxiliares para o cuidado e tratamento das incontinências é elevado, podendo atingir R$2.255,78 por ano. O uso de fralda será necessário em caso de incontinência fecal e condicional no caso de incontinência urinária (IU). Na IU, o uso de fralda irá depender do tipo e gravidade da incontinência, estado físico e funcional da pessoa e se foram utilizadas opções de tratamento (reeducação, ingestão controlada de líquidos, fisioterapia, terapia ocupacional, medicamentos e cirurgias). De acordo com as evidências levantadas por esse PTC, parece haver uma subutilização de terapia medicamentosa, da fisioterapia e de procedimentos cirúrgicos e uma superutilização de fraldas geriátricas, as quais podem, em caso de uso desnecessário, contribuir para manter ou instituir a incontinência. De toda forma o SUS ainda não dispensa medicamentos recomendados para IU, insumos auxiliares ao tratamento e o valor do subsídio econômico fornecido aos pacientes é insuficiente para cobrir os gastos com as incontinências, nas situações onde o uso da fralda está adequadamente recomendado.(AU)

TECHNOLOGY: Adult diapers and auxiliary inputs. INDICATION: Urinary and fecal incontinence. TECHNOLOGY CHARACTERIZATION: Geriatric diaper is a hygiene product used by adults, especially the elderly, who do not have (or lost) control of your physiological needs. Auxiliary products are preparations and equipment used for prevention and / or treatment of problems emerging from the use of diapers. MAIN QUESTION: What are the indications for use of geriatric diapers and auxiliary products, which are therapeutic alternatives to these products and what is the estimated cost of its chronic use in comparison with therapeutic alternatives available through the Unified Health System (SUS ­ Sistema Único de Saúde)? METHODS: Indications for use of adult diapers, as well as other alternatives for the control / treatment of incontinence were found after search of scientific literature and national and international treatment guidelines. To get a sense of current public spending on adult diapers the prices of these products were raised in accordance with the Health price Bank. Also diaper prices were surveyed in 57 electronic sites of pharmacies and sites of collective shopping and the System of Customer Service of the manufacturers. The types and prices of auxiliary products were surveyed in three major networks of private drugstores, one of which is present only in the state of Minas Gerais. Furthermore, most solicited auxiliary products where searched in JusBrasil website. RESULTS: SUS spends with surgical and physical therapy procedures is much less than own subsidy given to the purchase of diapers in the program "Aqui tem farmácia popular" and therefore should be recommended more often, depending of each individual incontinence condition. Thus, there is the need for the use of barrier products and moisturizers in the prevention and care of dermatitis and ulcers associated with incontinence condition, highlighting the need for greater financial effort by the SUS in ensuring access to creams, ointments and lotions (preventive and / or curative), which, by the analysis undertaken here, are quite costly to the patient. According to our data, the estimated annual individual expenditure values with adult diapers were R$ 1674.04 ± 722.89; R$ 1827.81 ± 1179.24; R$ 1439.31 ± 724.88; and 1123.72 ± 521.21 respectively for the extra-large, large, medium and small size diapers. Auxiliary products are creams, lotions, ointments, oils and pastes, with occlusive properties, moisturizing and restoring the skin affected by diaper rash. Antifungal creams such as nystatin, were also classified as an auxiliary product. The estimated average annual expenditure on auxiliary products was R$ 2255.78 ± 3096.36. According to literature, national and foreign incontinence guides, drug therapy, physical therapy and surgical procedures were considered therapeutic alternatives. The main drugs are oxybutynin, tolterodine, darifenacin and botulinum toxin, which showed estimated annual average cost of R$ 988.20; R$ 4,355.05; R$ 4,322.40; and 3979.14, respectively. Surgical procedures offered by the Brazilian Public Health system were surveyed in SIGTAP (Management System of SUS Procedures) and had compensation values ranging from R$ 372.54 to R$ 457.67. According to the SIGTAP, the price of a single physiotherapy procedure for incontinence control purposes is R$ 4.67; the recommended are 20 sessions per week. CONCLUSIONS: We observed that the average spending estimation patients using diapers and auxiliary inputs for the care and treatment of incontinence is high, reaching R $ 2255.78 per year. The diaper use will be necessary in case of fecal incontinence and conditional in the case of urinary incontinence (UI). UI, use diaper will depend on the type and severity of incontinence, physical and functional condition of the person and were used treatment options (reeducation, controlled fluid intake, physical therapy, occupational therapy, medication and surgery). According to the evidence raised by this PTC, there seems to be an underspend of drug therapy, physical therapy and surgical procedures and overuse of adult diapers, which can, in case of unnecessary use, contribute to maintain or establish incontinence. Anyway SUS does not dispense drugs recommended for UI and auxiliary products to the treatment; moreover the value of the subsidy provided to patients is insufficient to cover the costs of the incontinences, in situations where the use of the diaper is properly recommended. (AU)

TECNOLOGÍA: Pañales geriátricos y entradas auxiliares. INDICACIÓN: Incontinencia urinaria y fecal. CARACTERIZACIÓN DEL TECNOLOGÍA: Pañal geriátrica es un producto de higiene íntima utilizado por adultos, especialmente los ancianos, que no tienen (o han perdido) el control de sus necesidades fisiológicas. Productos auxiliares son preparaciones utilizadas para la prevención y / o tratamiento de los problemas derivados del uso de los pañales. PREGUNTA: ¿Cuáles son las indicaciones para el uso de los pañales geriátricos y de los productos auxiliares, que son las alternativas terapéuticas para estos productos y cuál es el costo estimado de su uso crónico en comparación con las alternativas terapéuticas disponibles en el Sistema Único de Salud (SUS ­ Sistema Único de Saúde)? MÉTODOS: Las indicaciones de uso de pañales para adultos, así como otras alternativas para el control / tratamiento de la incontinencia se encontraron en la búsqueda de la literatura científica y directrices nacionales e internacionales de tratamiento. Los precios de pañales se buscaron en el Banco de los Precios en Salud de Brasil, para tener una idea del actual gasto público en pañales para adultos. Además, los precios de pañales fueron encuestados en 57 sitios electrónicos de las farmacias y droguerías, así como los sitios de compra en grupo y el Servicio de Atención al Consumidor (SAC) de los fabricantes. Los tipos y precios de productos auxiliares fueron encuestados en tres grandes redes de farmacias privadas, en el que uno se encuentra sólo en el Estado de Minas Gerais. Además, a fin de contemplar aquellos principales productos demandados en los tribunales, los productos auxiliares se buscaran en sitio electrónico JusBrasil. RESULTADOS: El gasto del SUS con procedimientos quirúrgicos y de terapia física es mucho menos que la propia subvención dada a la compra de pañales en el programa "Aqui tem Farmácia Popular" y por lo tanto se debe recomendar más veces, dependiendo de la condición de incontinencia individual. En este estudio, se constató la necesidad de la utilización de productos de barrera y humectantes en la prevención y cuidado de la dermatitis y úlceras asociadas con la condición de pañales, destacando la necesidad de mayor esfuerzo financiero por el SUS en garantizar el acceso a cremas, ungüentos y lociones (preventivo y / o curativo), que, por la análisis hecha aquí, son bastante costosos para el paciente. De acuerdo con los datos recogidos, los valores estimados anuales de gastos individuales con pañales para adultos fueron de R$ 1.674,04 ± 722,89; R$ 1827,81 ± 1179,24; R$ 1.439,31 ± 724,88; y R$ 1.123,72 ± 521,21, respectivamente, para los pañales extra grandes, grandes, medianas y pequeños. Productos considerados auxiliares son cremas, lociones, ungüentos, aceites y pastas, con propiedades oclusivas, hidratante y de restauración de la piel afectada por la utilización del pañal. El gasto estimado medio anual con productos auxiliares fue de R$ 2.255,78 ± 3.096,36. Se consideraron alternativas terapéuticas la terapia con medicamentos, fisioterapia y procedimientos quirúrgicos, de acuerdo con la literatura y las guías nacionales y extranjeras para la incontinencia. Los principales fármacos son oxibutinina, tolterodina, darifenacina y la toxina botulínica, que mostraron coste estimado medio anual de R$ 988,20; R$ 4,355.05; R$ 4,322.40; y R$ 3.979,14, respectivamente. Los procedimientos quirúrgicos ofrecidos por el Sistema Único de Salud fueron buscados en SIGTAP (tabla de Procedimientos del SUS) y tenían valores de compensación que van desde R$ 372,54 a R $ 457,67. Según el SIGTAP, el precio de la sesión de fisioterapia para el control de la incontinencia es de R $ 4,67; son recomendadas 20 sesiones por semana. CONSIDERACIONES FINALES: Se observó que el gasto promedio estimado de los pacientes utilizando pañales y productos auxiliares para el cuidado y tratamiento de la incontinencia es alta, alcanzando R $ 2.255,78 por año. El uso del pañal será necesario en el caso de la incontinencia fecal y condicional en el caso de la incontinencia urinaria (UI). En la UI, el uso de pañales dependerá del tipo y la gravedad de la incontinencia y de la condición física y funcional de la persona y se fueron utilizadas opciones de tratamiento (reeducación, la ingestión controlada de líquidos, fisioterapia, terapia ocupacional, medicamentos y cirugía). De acuerdo con las evidencias de este PTC, parece que hay una infrautilización del tratamiento farmacológico, fisioterapia y los procedimientos quirúrgicos y el uso excesivo de pañales para adultos, que pueden, en caso de uso innecesario, contribuir a mantener o establecer la incontinencia. De todos modos SUS no dispensa fármacos recomendados para UI y productos auxiliares para el tratamiento, además el valor del subsidio económico prestado a los pacientes es insuficiente para cubrir los costos de las incontinencias, en situaciones donde se recomienda adecuadamente el uso del pañal.(AU)

Assessment and in vitro experiment of artificial anal sphincter system based on rebuilding the rectal sensation function.

In this paper, a novel artificial anal sphincter (AAS) system based on rebuilding the rectal sensation function is proposed to treat human fecal incontinence. The executive mechanism of the traditional AAS system was redesigned and integrated for a simpler structure and better durability. The novel executive mechanism uses a sandwich structure to simulate the basic function of the natural human anal sphincter. To rebuild the lost rectal sensation function caused by fecal incontinence, we propose a novel method for rebuilding the rectal sensation function based on an Optimal Wavelet Packet Basis (OWPB) using the Davies-Bouldin (DB) index and a support vector machine (SVM). OWPB using a DB index is used for feature vector extraction, while a SVM is adopted for pattern recognition.Furthermore, an in vitro experiment with the AAS system based on rectal sensation function rebuilding was carried out. Experimental results indicate that the novel executive mechanism can simulate the basic function of the natural human anal sphincter, and the proposed method is quite effective for rebuilding rectal sensation in patients.

Safety assessment of myogenic stem cell transplantation and resulting tumor formation.

OBJECTIVES: To assess for stem cell migration to liver and lung after transplantation in injured rat anal sphincters. To evaluate histological findings of unanticipated ectopic foci of growth. METHODS: This is a prospective study involving 33 female virginal Sprague-Dawley rats. Anal sphincters were transected and repaired under sterile technique. Animals received injections of 5.0 × 10 myogenic stem cells (24 rats) or sham control (9 rats) and were killed on day 30. Liver and lung samples were obtained. Upon encountering abnormal foci of growth, further staining protocols were employed. Enzyme-linked immunosorbent assay studies evaluated stem cell media for in vitro growth factor secretion. RESULTS: No evidence of cell migration to liver or lung was found at the time of euthanasia in any study animal. Ectopic foci of growth were noted in 2 transplant rats. Further histological evaluations of these growths were consistent with benign tumors: no nuclear abnormalities and no evidence of proliferation at day 30. Enzyme-linked immunosorbent assay studies demonstrated positive secretion of vascular endothelial growth factor and insulin growth factor into the media of cultured rat myogenic stem cells. CONCLUSIONS: Whereas distant migration was not encountered in the liver or lung, 2 transplanted rats developed abnormal foci of growth, that is, tumors, from the external anal sphincter-raising further safety questions. Additional evaluation of these foci seemed benign. Possible explanations include cell trapping, stem cell overgrowth, and/or paracrine factors. The lack of cell migration supports that future investigation of safety parameters could focus locally.

New developments in colorectal surgery.

PURPOSE OF REVIEW: The field of colorectal surgery continues to move forward as technical innovations emerge and as surgeons ask critical questions. The results of subsequent investigations often lead to changes in practice. This review examines recent publications that describe these practice changes. RECENT FINDINGS: We identified and reviewed recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery. SUMMARY: New technologies and practice innovations will continue to enhance patient outcomes. Multiinstitutional studies, randomized when able, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices in colorectal surgery.

Unexpected results of a nationwide, treatment-independent assessment of fecal incontinence in patients with anorectal anomalies.

PURPOSE: To determine the anorectal function in patients with anorectal malformations (ARM) in order to facilitate patient counseling and follow-up. METHODS: Data were collected by the German network for urorectal malformations (CURE-Net) according to the International Krickenbeck consensus. Questionnaires on bowel function and a defecation protocol were completed by the families/patients. The clinical findings were assessed from the patients' clinical records. RESULTS: Two hundred and ninety-seven patients with ARM were assessed, 175 patients gave complete data on continence, 52 of them were excluded due to mental retardation, age, and earlier type of pullthrough. Complete continence was found in 27 %, perineal fistula in 40 %, rectourethral/vesical in 10 %, vestibular in 24 %, cloaca in 0 %. Krickenbeck grade 1 soiling: 42 %, grade 2 and 3: 31 %. Forty-nine percent of the incontinent patients practiced bowel management, reaching continence in 19 %. The statement of constipation (67 %) was validated with the last clinical findings, showing coprostasis in 46 %, "Not suffering constipation" was confirmed in 61 % and falsified in 29 %. CONCLUSION: ARM patients in Germany, as assessed by independent researchers, show a high rate of fecal incontinence and insufficiently treated constipation. Parents should be counseled accordingly and motivated to engage in consequent follow-up. Intensified efforts in the conservative treatment of constipation and fecal incontinence are crucial to improvement.

In vitro and in vivo assessment of an intelligent artificial anal sphincter in rabbits.

Artificial sphincters have been developed for patients with fecal incontinence, but finding a way to make such sphincters more "intelligent" remains a problem. We assessed the function of a novel intelligent artificial anal sphincter (IAAS) in vitro and in vivo in rabbits. After the prosthesis was activated, rabbits were continent of feces during 81.4% of the activation time. The fecal detection unit provided 100% correct signals on stool in vitro and 65.7% in vivo. The results indicated that the IAAS could efficiently maintain continence and detect stool; however, the IAAS is still in the preliminary experimental stage and more work is needed to improve the system.

[Reconstruction of anal sphincters following fecal incontinence and assessment of functional results]. / Rekonstrukce análních sveracu pro fekální inkontinenci a hodnocení funkcních výsledku.

The aim of the study was to assess functional results of surgical sphincter reconstructions for anal incontinence. From August 1999 to January 2007, 52 patients (females 50, males 2), 45 y.o.a. on average (24-69), underwent secondary anal sphincters reconstructions for fecal incontinence, resulting from birth injuries, event. in combination with sphincter weakening in pudendal neurophathy, or for post-anorectal surgery incontinence. Duration of the incontinence symptoms prior to the surgery was 2 months to 19 years. The overlap technique in combination with anterior levatorplasty was used in most subjects (n = 31). In 12 subjects, anterior sphincters and levators plication was performed. Four patients underwent overlap reconstructions only and five patients underwent complete sphincter reconstructions. Protective colostomy was performed in six patients. Six patients underwent additional postoperative biofeedback. Endoanal ultrasound was performed in all patients prior to their procedures. Terminal motor latency examination of the pudendal nerve was indicated in all patients with sphincter dysfunction without localized defects. Anal manometry was recorded prior and post-operatively. Incontinence was assessed using the St. Mark's incontinence score (0-13). The patients assessed the reconstruction results based on the Likert scale. The reconstruction was successfull in 46 patients (88.5 %), full continence was recovered in 20 (38.5 %) patients and improvement of incontinence was recorded in 26 (50 %) subjects. In six subjects (11.5 %), the reconstruction failed. The mean incontinence score reduction following the procedure was from 11.8 to 2.4. The short-term sphincter reconstruction results were successful in the majority of the subjects, the long-term results will be assessed in another study.

Long-term results of antegrade colonic enema in adult patients: assessment of functional results.

PURPOSE: This retrospective study reviewed long-term results in a large group of adult patients treated with antegrade colonic enema and antegrade colonic enema combined with a colostomy. METHODS: Retrospective chart review identified 80 patients (64 females, mean age 51) surgically treated between 1993 and 2007 for fecal incontinence or constipation. Surgical treatments included 69 appendicostomies, 13 tapered ileum, 3 cecal tube, and 25 appendicostomy/neoappendicostomy combined with a colostomy. A 44-item questionnaire was mailed considering bowel regimen, complications, bowel function, social function, and quality of life. RESULTS: Sixty-nine patients were available for follow-up (mean follow-up, 75 months). Thirty patients (38 percent) had surgical complications. Forty-three patients (62 percent) were still performing antegrade continence enema and 8 patients (12 percent) no longer needed it. Accordingly, treatment was successful in 51 patients (74 percent). Twenty-seven patients (63 percent) had side effects. Evaluation of bowel function, social function, and quality of life all showed significant improvement. Antegrade continence enema was successful in patients with neurologic disabilities (67 percent), anorectal injury (53 percent), idiopathic fecal incontinence (50 percent), and idiopathic fecal constipation (42 percent). Antegrade continence enema was successful in patients with constipation, incontinence, and mixed symptoms. Results did not differ between appendicostomy, neoappendicostomy, and the combined appendicostomy/neoappendicostomy and colostomy. CONCLUSION: Long-term results were favorable in most patients treated with antegrade continence enema for fecal incontinence or constipation.

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury.

OBJECTIVE: Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed. METHOD: Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n = 103; delayed, n = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes--probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon. RESULTS: Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated 2750 pounds, giving an ICER of 487 pounds per QALY. DS produced a gain of 3.73 QALYs for a cost of 2667 pounds, giving an ICER of 719 pounds per QALY. Both procedures fell below the 10,000 pounds per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark. CONCLUSION: If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.

Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects.

OBJECTIVE: To determine if there is a correlation between the sonographic extent of anal sphincter defects revealed by three-dimensional endoanal sonography (EAUS) and the degree of anal incontinence following primary repair of obstetric sphincter tears. METHODS: This was a follow-up study of women who had suffered anal sphincter tearing during vaginal delivery at Aalesund Hospital between January 2002 and July 2004. Incontinence was assessed by St Mark's score. The anal canal was assessed with three-dimensional endoanal sonography (EAUS). Sphincter defects were classified according to the Starck score and our new EAUS defect score. The EAUS images were interpreted by an observer blinded to other patient data. RESULTS: Sixty-one women were included in this study. Incontinence was reported by 32 (52%) women at a median of 21 (range, 9-35) months after delivery. Three-dimensional EAUS datasets were obtained in 55 women. There was a significant correlation between St Mark's score and our EAUS defect score (P = 0.034), and correlation approached but did not reach significance between St Mark's score and the Starck score (P = 0.053). There was a strong correlation between our EAUS defect score and the Starck score (P < 0.001). CONCLUSIONS: There is a positive correlation between the extent of sphincter defects and the degree of anal incontinence following primary repair of obstetric sphincter tears. Our findings highlight the importance of adequate reconstruction of the anal sphincters during primary repair.

Surgical strategies for faecal incontinence--a decision analysis between dynamic graciloplasty, artificial bowel sphincter and end stoma.

BACKGROUND: Artificial bowel sphincter (ABS) and dynamic graciloplasty (DG) are surgical treatments for faecal incontinence (FI). FI may affect quality of life (QOL) so severely that patients are often willing to consider a permanent end stoma (ES). It is unclear which is the more cost-effective strategy. METHOD: Probability estimates for patients with FI were obtained from published data (ABS, n = 319; DG, n = 301), supplemented by expert opinion. The primary outcome was quality-adjusted life years (QALYs) gained from each strategy. Factors considered were the risk of failure of the primary and redo operation and the consequent risk of permanent stoma. Results were assessed as incremental cost-effectiveness ratio (ICER). RESULTS: Over the 5-year time horizon, ES gave a QALY gain of 3.45 for 16,280 pounds sterling, giving an ICER of 4719 pounds sterling/QALY. ABS produced a gain of 4.38 QALYs for 23,569 pounds sterling, giving an ICER of 5387 pounds sterling/QALY. DG produced a gain of 4.00 QALYs for 25,035 pounds sterling, giving an ICER of 6257 pounds sterling/QALY. With the willingness-to-pay threshold set at 30,000 pounds sterling/QALY, ES was the most cost-effective intervention. The ABS was most cost-effective after 10 years. CONCLUSION: All three procedures were found to be cost-effective. The ES was most cost-effective over 5 years, while the ABS was most cost-effective in excess of 10. DG maybe considered as an alternative in specialist centres.

National trends and costs of surgical treatment for female fecal incontinence.

OBJECTIVE: The objective of the study was to describe national trends, hospital charges, and costs of inpatient surgical treatment for female fecal incontinence in the United States. STUDY DESIGN: We used the Nationwide Inpatient Sample from 1998 to 2003 to identify women who underwent surgery for fecal incontinence using International Classification of Diseases, ninth revision-CM coding. We examined national trends in procedures, patient demographics, outcomes, hospital charges, and costs. Multiple linear regression was used to identify variables associated with increased costs. RESULTS: A total of 21,547 women underwent inpatient surgery for fecal incontinence during the study period. This number has remained stable, with 3423 procedures in 1998 and 3509 procedures in 2003. The overall risk of complications was 15.4% and the risk of death was 0.02%, which remained stable during the study period. Total charges increased from $34 million in 1998 to $57.5 million in 2003, translating to a total cost of $24.5 million in 2003. Variables associated with increased costs included number of procedures per admission, length of stay, patient age, and race (P < .05). CONCLUSION: The number of women undergoing surgical treatment for fecal incontinence is stable but has a significant economic impact on the health care system.

Anal endosonography is useful for postoperative assessment of anorectal malformations.

AIM: This study aimed to develop and evaluate a scoring system for anal endosonography to assess anal canal structures after repair of anorectal malformations (ARM). METHODS: Forty patients with ARM aged 16 years (range, 1-22 years) and 20 controls aged 17 years (range, 0.5-20 years) were examined. Anal function was assessed clinically and by anal canal manometry. The anal canal structures were imaged by anal endosonography using a 7.5-MHz transducer. A scoring system was developed to assess the anal sphincters as visualized on the endosonographic images. RESULTS: Continence was significantly correlated to anal canal pressures. The estimated extent of muscle defect (measured in quadrants) and the number of disruptions in the internal and external anal sphincters correlated significantly to the rest and squeeze pressures, respectively. Thus, patients (>4 years) with squeeze pressure of less than 80 cm H2O were characterized by more than 1 disruption in the external anal sphincter ring and 2 or more quadrants with scar tissue. CONCLUSION: The extent of scar tissue and the number of disruptions in the anal sphincters correlate with anal canal pressures and continence after ARM repair. Anal endosonography may be used to study the results after different surgical techniques and for prognosis on continence in patients with ARM.