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.

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.

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.

The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes.

BACKGROUND: Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown. OBJECTIVE: This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease. DESIGN: This is a prospective, observational study. SETTINGS: Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center. INTERVENTION: All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit. MAIN OUTCOME MEASURES: The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate. RESULTS: A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score. LIMITATIONS: This study was limited by the small cohort size and unclear patient adherence to medical management. CONCLUSIONS: Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.

Increased Long-term Dietary Fiber Intake Is Associated With a Decreased Risk of Fecal Incontinence in Older Women.

BACKGROUND & AIMS: Fiber supplements are frequently used as treatment for fecal incontinence (FI), but little is known about the role of dietary fiber in the prevention of FI. METHODS: We performed a prospective study to examine the association between long-term dietary fiber intake and risk of FI in 58,330 older women (mean age, 73 years) in the Nurses' Health Study who were free of FI in 2008. Energy-adjusted long-term dietary fiber intake was determined using food frequency questionnaires starting in 1984 and updated through 2006. We defined incident FI as at least 1 liquid or solid FI episode per month during the past year during 4 years of follow-up using self-administered biennial questionnaires. We used Cox proportional hazards models to calculate multivariable-adjusted hazard ratios and 95% CIs for FI according to fiber intake, adjusting for potential confounding factors. RESULTS: During 193,655 person-years of follow-up, we documented 7,056 incident cases of FI. Compared with women in the lowest quintile of fiber intake (13.5 g/day), women in the highest quintile (25 g/day) had an 18% decrease in risk of FI (multivariable hazard ratio, 0.82; 95% CI, 0.76-0.89). This decrease appeared to be greatest for risk of liquid stool FI, which was 31% lower in women with the highest intake of fiber compared with women with the lowest intake (multivariable hazard ratio, 0.69; 95% CI, 0.62-0.75). Risk of FI was not significantly associated with fiber source. CONCLUSIONS: In an analysis of data from almost 60,000 older women in the Nurses' Health Study, we found higher long-term intake of dietary fiber was associated with decreased risk of FI. Further studies are needed to determine the mechanisms that mediate this association.

Antegrade Enema After Total Mesorectal Excision for Rectal Cancer: The Last Chance to Avoid Definitive Colostomy for Refractory Low Anterior Resection Syndrome and Fecal Incontinence.

BACKGROUND: Total mesorectal excision and preoperative radiotherapy in mid and low rectal cancer allow us to achieve very good oncological results. However, major and refractory low anterior resection syndrome and fecal incontinence alter the quality of life of patients with a long expected life span. OBJECTIVE: We assessed the functional results of patients treated by antegrade enema for refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision. DESIGN: This is a prospective monocentric study from 2012 to 2016. PATIENTS: Patients who underwent percutaneous endoscopic cecostomy for refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision were prospectively analyzed. MAIN OUTCOME MEASURES: We assessed the morbidity of the procedure and compared low anterior resection syndrome score, Wexner score, and Gastrointestinal Quality of Life Index before and after the use of antegrade enema. RESULTS: Of 25 patients treated by antegrade enema over the study period, 6 (24%) had a low anterior resection, 18 (72%) had a coloanal anastomosis, and 1 (4%) had a perineal colostomy. Postoperatively, the rate of local abscess was 8%, all treated by antibiotics. Low anterior resection syndrome score (33 vs 4, p < 0.001), Wexner score (16 vs 4, p <0.001), and Gastrointestinal Quality of Life Index (73 vs 104, p < 0.001) were all significantly improved after antegrade enema. The 2 main symptoms reported by patients were sweating (28%) and local pain (36%). At the end of the follow-up, 16% (n = 4) catheters were removed, and the rate of definitive colostomy was 12% (n = 3). LIMITATIONS: The main limitations of this study are the monocentric features and the sample size. CONCLUSION: Antegrade enema for major and refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision appears to be a promising treatment to avoid definitive colostomy. See Video Abstract at http://links.lww.com/DCR/A608.

Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial.

AIM: The study aimed to evaluate the effectiveness of antenatal perineal massage (APM) in reducing perineal trauma and post-partum morbidities. METHODS: A randomized controlled trial of 108 primigravidae at the University of Nigeria Teaching Hospital, Enugu, Nigeria, was conducted from January 2013 to May 2014. The intervention group received APM, while the control group did not receive APM. RESULTS: Women who received APM were significantly more likely to have an intact perineum after childbirth [27/53 (50.9%) vs 16/55 (29.1%); RR: 1.75; 95% CI: 1.07-2.86; P = 0.02]. The incidence of episiotomy was lower in the intervention group [20/53 (37.7%) vs 32/55 (58.2%); RR: 0.65; 95% CI: 0.43-0.98; P = 0.03; NNT = 5]. Women who received APM were significantly less likely to develop flatus incontinence [4/53 (8.3%) vs 13/55 (26.0%); RR: 0.32; 95% CI: 0.11-0.91; P = 0.03]. However, the incidences of premature rupture of membranes, preterm labor and birth asphyxia were similar between the two groups (P > 0.05). CONCLUSION: APM reduces the incidence of episiotomy and increases the incidence of women with an intact perineum after vaginal delivery. It also reduces the risk of flatus incontinence after childbirth without increased maternal or neonatal complications. Women should therefore be counseled on the likely benefits of APM and the information provided during antenatal care. Obstetricians should consider the technique as routine prenatal care for nulliparous women so as to reduce the incidence of perineal trauma during vaginal birth.

Episiotomy: What angle do you cut to the midline?

OBJECTIVE: Although episiotomies are the commonest obstetric procedure performed the technique of performing one varies amongst obstetricians and midwives. The angle of episiotomy to the midline in particular has been shown to influence the risk of developing obstetric anal sphincter injuries (OASIS). In order to identify the differences in technique and to identify targets for training we undertook a practice survey of episiotomies to analyse the differences in technique between grades of obstetricians and midwives. STUDY DESIGN: A prospective practice survey of staff working on delivery suite in a tertiary referral unit with 9000 deliveries/year was conducted between 01/10/2014 to 01/03/2015. Each participant was provided with a pictoral representation of a perineum and a pair of standard episiotomy scissors and asked to perform an episiotomy as per their usual practice. The profession and grade of each participant was recorded along with information regarding the incision including the angle to the midline, length of incision and lateral starting distance from the midline. One way ANOVA (unrelated) was used to perform statistical analysis using IBM SPSS v23. RESULTS: 101 staff members participated in the practice survey including 63 midwives, 9 junior trainees, 15 senior trainees and 14 consultants. The mean angle of incision to the midline of episiotomies was 47°, 51°, 66° and 77° for midwives, junior trainees, senior trainees and consultants respectively. The mean angle of incision performed by midwives was significantly different to senior trainees (p>0.01) and consultants (p<0.01). 45% of all episiotomies undertaken by midwives were done at an angle <45° to the midline, compared to 7% by senior trainees and none by consultants. CONCLUSIONS: This study identified clear deficiencies in the performance of episiotomies amongst obstetric trainees and midwives. Both midwives and obstetric trainees need to improve their technique if episiotomies are going to influence the incidence of OASIS and, more importantly the development of faecal incontinence. These results should be used to inform future training programmes to reduce the risks of OASIS.

Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

BACKGROUND: The role of fecal diversion with pelvic anastomosis during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is not well defined. METHODS: A retrospective review of patients who underwent CRS and HIPEC between 2009 and 2016 was performed to identify those with a pelvic anastomosis (colorectal, ileorectal, or coloanal anastomosis). RESULTS: The study identified 73 patients who underwent CRS and HIPEC at three different institutions between July 2009 and June of 2016. Of these patients, 32 (44%) underwent a primary anastomosis with a diverting ileostomy, whereas 41 (56%) underwent a primary anastomosis without fecal diversion. The anastomotic leak rate for the no-diversion group was 22% compared with 0% for the group with a diverting ileostomy (p < 0.01). The 90-day mortality rate for the no-diversion group was 7.1%. The hospital stay was 14.1 ± 8.0 days in the diversion group compared with 17.9 ± 12.5 days in the no-diversion group (p = 0.12). Of those patients with a diverting ileostomy, 68% (n = 22) had their bowel continuity restored, 18% of which required a laparotomy for reversal. Postoperative complications occurred for 50% of those who required a laparotomy and for 44% of those who did not require a laparotomy (p = 0.84). CONCLUSION: Diverting ileostomies in patients with a pelvic anastomosis undergoing CRS and HIPEC are associated with a significantly reduced anastomotic leak rate. Reversal of the diverting ileostomy in this patient population required a laparotomy in 18% of the cases and had an associated morbidity rate of 50%.

Low energy manual anal stretch: an approach in the treatment of chronic anal fissure.

BACKGROUND: Anal fissure is a tear in the epitelial lining of the anal canal. This is a very common anorectal disorder, but the choice of treatment is unclear. Sphincterotomy is effective but it is affected by a high risk of fecal incontinence. Manual anal stretch is aN efficacious, economic and safe maneuver. The aim of this prospective study was to assess the safety and effectiveness of anal stretch in resolving chronic anal fissures. METHODS: Twenty-five patients with a clinical diagnosis of chronic anal fissure were submitted to anal stretch. All patients were submitted to anal stretch, after clinical evaluation. All patients were studied at basal time, and at 7 days, 3, 6 and 12 months after the treatment. RESULTS: At 3 months and 6 months after the anal stretch, 88% and 94% of patients showed a resolution of anal fissures and only 12% have relapsed at 12 months, without complications, such as faecal incontinence. CONCLUSIONS: The anal stretch appears to induce better resolution of chronic anal fissure with a very low risk of fecal incontinence.

[Faecal incontinence - serious medical and social issue]. / Fekální inkontinence - závazný medicínský a spolecenský problém.

Faecal incontinence presents gastrointestinal disorder with high prevalence (more than 2% of population) and serious impact on the quality of life. General practitioners, gastroenterologists and colorectal surgeons play the principal role in screening, diagnostics and providing health care to patients who suffer from faecal incontinence. Insufficient knowledge about faecal incontinence and minimal training aimed at its diagnostics and therapy lead to the low quality of provided health care.Authors offer comprehensive up-to-date review focused on faecal incontinence - its definition, prevalence, seriousness, consequences, pathophysiology, diagnostics and management. Detailed anatomical and physiological assessment of each patient is fundamental in determining correct cause of faecal incontinence and consequent selection of the most appropriate therapeutic modality.Broad spectrum of available therapeutic options comprises conservative management (lifestyle modification, diet, medications, and absorbent tools), biofeedback and surgical interventions (sphincter augmentation, sphincter reconstruction, sacral nerve stimulation, sphincter substitution and stools diversion). Application of the most appropriate treatment can lead in majority of patients to significant improvement in faecal incontinence and quality of life. Early diagnosis prevents possible complications, which would possibly deteriorate patients quality of life.

The Effect of Biofeedback Therapy on Anorectal Function After the Reversal of Temporary Stoma When Administered During the Temporary Stoma Period in Rectal Cancer Patients With Sphincter-Saving Surgery: The Interim Report of a Prospective Randomized Controlled Trial.

We evaluated the effect of biofeedback therapy (BFT) on anorectal function after stoma closure when administered during the interval of temporary stoma after sphincter-preserving surgery for rectal cancer.Impaired anorectal function is common after lower anterior resections, though no specific treatment options are currently available to prevent this adverse outcome.Fifty-six patients who underwent neoadjuvant chemoradiation therapy after sphincter-preserving surgery with temporary stoma were randomized into 2 groups: group 1 (received BFT during the temporary stoma period) and group 2 (did not receive BFT). To evaluate anorectal function, anorectal manometry was performed in all patients and subjective symptoms were evaluated using the Cleveland Clinic Incontinence Score. The present study is a report at 6 months after rectal resection.Forty-seven patients, including 21 in group 1 and 26 in group 2, were evaluated by anorectal manometry. Twelve patients (57.1%) in group 1 and 13 patients (50%) in group 2 were scored above 9 points of Cleveland Clinic Incontinence Score, which is the reference value for fecal incontinence (P = 0.770). With time, there was a significant difference (P = 0.002) in the change of mean resting pressure according to time sequence between the BFT and control groups.BFT during the temporary stoma interval had no effect on preventing anorectal dysfunction after temporary stoma reversal at 6 months after rectal resection. However, BFT might be helpful for maintaining resting anal sphincter tone (NCT01661829).

[Postpartum pelvic floor muscle training and abdominal rehabilitation: Guidelines]. / Rééducation périnéale et abdominale dans le post-partum: recommandations.

OBJECTIVE: Provide guidelines for clinical practice concerning postpartum rehabilitation. METHODS: Systematically review of the literature concerning postpartum pelvic floor muscle training and abdominal rehabilitation. RESULTS: Pelvic-floor rehabilitation using pelvic floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. At least 3 guided sessions with a therapist is recommended, associated with pelvic floor muscle exercises at home. This postpartum rehabilitation improves short-term urinary incontinence (1 year) but not long-term (6-12 years). Early pelvic-floor rehabilitation (within 2 months following childbirth) is not recommended (grade C). Postpartum pelvic-floor rehabilitation in women presenting with anal incontinence, is associated with a lower prevalence of anal incontinence symptoms in short-term (1 year) (EL3) but not long-term (6 and 12) (EL3). Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C) but results are not maintained in medium or long term. No randomized trials have evaluated the pelvic-floor rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long term. It is therefore not recommended (expert consensus). Rehabilitation supervised by a therapist (physiotherapist or midwife) is not associated with better results than simple advice for voluntary contraction of the pelvic floor muscles to prevent/correct, in short term (6 months), a persistent prolapse 6 weeks postpartum (EL2), whether or not with a levator ani avulsion (EL3). Postpartum pelvic-floor rehabilitation is not associated with a decrease in the prevalence of dyspareunia at 1-year follow-up (EL3). Postpartum pelvic-floor rehabilitation guided by a therapist is therefore not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). No randomized trials have evaluated the effect of pelvic floor muscle training after an episode of postpartum urinary retention or bladder outlet obstruction symptoms, or for the primary prevention of anal incontinence following third-degree anal sphincter tear or in patients presenting with anal incontinence after third-degree anal sphincter tear. The electrostimulation devices used alone were not assessed in this postpartum context (regardless of symptoms); therefore, isolated pelvic floor electrostimulation is not recommended (expert consensus). CONCLUSION: Pelvic floor muscle therapy is recommended for persistent postpartum urinary (grade A) or anal (grade C) incontinence (3 months after delivery).

Utilizing Cerebral Perfusion Scan and Diffusion-tensor MR Imaging to Evaluate the Effect of Hyperbaric Oxygen Therapy in Carbon Monoxide-induced Delayed Neuropsychiatric Seqeulae- A Case Report and Literature Review.

PURPOSE: Detection of regional cerebral blood flow (rCBF) and/or brain magnetic resonance imaging (MRI) has been used to investigate functional defect of brain caused by carbon monoxide (CO) poisoning. In this report, we attempted to demonstrate the correlation of changes in brain singlephoton emission computed tomography (SPECT) and diffusion-tensor MR image (DTI) with functional improvement of severe delayed neuropsychiatric sequelae (DNS) after CO intoxication during the treatment of hyperbaric oxygen therapy (HBOT). CASE REPORT: The patient had normal activities of daily life after he recovered from acute CO poisoning. One month later, he presented symptoms of declined cognitive functioning, aphasia, apraxia, dysphagia, muscle rigidity, urine and fecal incontinence. After one course of HBOT, these symptoms improved significantly and the patient could regain most of his previous functioning. The patient's improvement was evidenced by increased rCBF in Brodmann areas 7, 8, 11 and 40, as well as higher mean fractional anisotropy (FA) value of DTI. CONCLUSION: Although the efficacy of HBOT in DNS patients is still needed to be evaluated in large clinical study, these data suggest that HBOT may be the choice to improve DNS efficiently and shorten the duration of suffering with favorable outcome.

Dutch evidence statement for pelvic physical therapy in patients with anal incontinence.

INTRODUCTION AND HYPOTHESIS: To promote agreement among and support the quality of pelvic physiotherapists' skills and clinical reasoning in The Netherlands, an Evidence Statement Anal Incontinence (AI) was developed based on the practice-driven problem definitions outlined. We present a summary of the current state of knowledge and formulate recommendations for a methodical assessment and treatment for patients with AI, and place the evidence in a broader perspective of current developments. METHODS: Electronic literature searches were conducted in relevant databases with regard to prevalence, incidence, costs, etiological and prognostic factors, predictors of response to therapy, prevention, assessment, and treatment. The recommendations have been formulated on the basis of scientific evidence and where no evidence was available, recommendations were consensus-based. RESULTS: The evidence statement incorporates a practice statement with corresponding notes that clarify the recommendations, and accompanying flowcharts, describing the steps and recommendations with regard to the diagnostic and therapeutic process. The diagnostic process consists of history-taking and physical examination supported by measurement instruments. For each problem category for patients with AI, a certain treatment plan can be distinguished dependent on the presence of pelvic floor dysfunction, awareness of loss of stools, comorbidity, neurological problems, adequate anorectal sensation, and (in)voluntary control. Available evidence and expert opinion support the use of education, pelvic floor muscle training, biofeedback, and electrostimulation in selected patients. CONCLUSIONS: The evidence statement reflects the current state of knowledge for a methodical and systematic physical therapeutic assessment and treatment for patients with AI.

Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third-degree tears (EBAPT Trial).

OBJECTIVE: To compare early home biofeedback physiotherapy with pelvic floor exercises (PFEs) for the initial management of women sustaining a primary third-degree tear. DESIGN: Single centre, randomised trial. SETTING: National Maternity Hospital, Dublin, Ireland. POPULATION: A total of 120 women sustaining a primary third-degree tear. METHODS: Women were randomised in a one to three ratio: 30 to early postpartum home biofeedback physiotherapy and 90 to PFEs. MAIN OUTCOME MEASURES: Differences in anorectal manometry results, Cleveland Clinic continence scores and Rockwood faecal incontinence quality of life scale scores after 3 months of postpartum treatment. RESULTS: The mean anal resting pressure was 39 ± 13 mmHg in the early biofeedback physiotherapy group and 43 ± 17 mmHg in the PFE group. The mean anal squeeze pressure was 64 ± 17 mmHg in the biofeedback group and 62 ± 23 mmHg in the PFE group. There was no significant difference in anal resting and squeeze pressure values between the groups (P = 0.123 and P = 0.68, respectively). There were no differences in symptom score and quality of life measurements between the groups. CONCLUSIONS: This study demonstrates no added value in using early home biofeedback physiotherapy in the management of women sustaining third-degree tears. Poor compliance may have contributed because women found it difficult to designate time to using biofeedback.

Mechanical bowel preparation for elective colorectal surgery.

BACKGROUND: The presence of bowel contents during colorectal surgery has been related to anastomotic leakage, but the belief that mechanical bowel preparation (MBP) is an efficient agent against leakage and infectious complications is based on observational data and expert opinions only.An enema before the rectal surgery to clean the rectum and facilitate the manipulation for the mechanical anastomosis is used for many surgeons. This is analysed separately OBJECTIVES: To determine the security and effectiveness of MBP on morbidity and mortality in colorectal surgery. SEARCH STRATEGY: Publications describing trials of MBP before elective colorectal surgery were sought through searches of MEDLINE, EMBASE, LILACS, IBECS and The Cochrane Library; by handsearching relevant medical journals and conference proceedings, and through personal communication with colleagues.Searches were performed December 1, 2010. SELECTION CRITERIA: Randomised controlled trials (RCTs) including participants submitted for elective colorectal surgery. Eligible interventions included any type of MBP compared with no MBP. Primary outcomes included anastomosis leakage - both rectal and colonic - and combined figures. Secondary outcomes included mortality, peritonitis, reoperation, wound infection, extra-abdominal complications, and overall surgical site infections. DATA COLLECTION AND ANALYSIS: Data were independently extracted and checked. The methodological quality of each trial was assessed. Details of randomisation, blinding, type of analysis, and number lost to follow up were recorded. For analysis, the Peto-Odds Ratio (OR) was used as the default (no statistical heterogeneity was observed). MAIN RESULTS: At this update six trials and a new comparison (Mechanical bowel preparation versus enema) were added. Altogether eighteen trials were analysed, with 5805 participants; 2906 allocated to MBP (Group A), and 2899 to no preparation (Group B), before elective colorectal surgery.For the comparison Mechanical Bowel Preparation Versus No Mechanical Bowel Preparation results were:1. Anastomotic leakage for low anterior resection: 8.8% (38/431) of Group A, compared with 10.3% (43/415) of Group B; Peto OR 0.88 [0.55, 1.40].2. Anastomotic leakage for colonic surgery: 3.0% (47/1559) of Group A, compared with 3.5% (56/1588) of Group B; Peto OR 0.85 [0.58, 1.26].3. Overall anastomotic leakage: 4.4% (101/2275) of Group A, compared with 4.5% (103/2258) of Group B; Peto OR 0.99 [0.74, 1.31].4. Wound infection: 9.6% (223/2305) of Group A, compared with 8.5% (196/2290) of Group B; Peto OR 1.16 [0.95, 1.42].Sensitivity analyses did not produce any differences in overall results.For the comparison Mechanical Bowel Preparation (A) Versus Rectal Enema (B) results were:1. Anastomotic leakage after rectal surgery: 7.4% (8/107) of Group A, compared with 7.9% (7/88) of Group B; Peto OR 0.93 [0.34, 2.52].2. Anastomotic leakage after colonic surgery: 4.0% (11/269) of Group A, compared with 2.0% (6/299) of Group B; Peto OR 2.15 [0.79, 5.84].3. Overall anastomotic leakage: 4.4% (27/601) of Group A, compared with 3.4% (21/609) of Group B; Peto OR 1.32 [0.74, 2.36].4. Wound infection: 9.9% (60/601) of Group A, compared with 8.0% (49/609) of Group B; Peto OR 1.26 [0.85, 1.88]. AUTHORS' CONCLUSIONS: Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found. Further research on patients submitted for elective rectal surgery, below the peritoneal verge, in whom bowel continuity is restored, and studies with patients submitted to laparoscopic surgeries are still warranted.

Estrategia para disminuir la incidencia de patología grave del periné durante el parto / Strategy to reduce severe perineal tears during delivery

Antecedentes La importancia de los desgarros graves del periné durante el parto radica en que son un factor de riesgo para la incontinencia anal. Decidimos establecer una estrategia para disminuir la incidencia de éstos. Material y método La estrategia fue la siguiente: 1) ofertar otras técnicas de analgesia además de la epidural; 2) no aconsejar pujar hasta no tener sensación de pujo; 3) ofertar los pujos e incluso el parto en posición vertical; 4) basarnos en las definiciones del Colegio Americano de Obstetras y Ginecólogos para indicar un parto instrumental; 5) usar como primer instrumento la ventosa, y 6) uso restrictivo de la episiotomía. Resultados Hubo una disminución significativa en la tasa de desgarros graves (1,56–0,84%).Conclusiones Con una estrategia consensuada ente matronas y ginecólogos es posible disminuir de forma significativa la incidencia de desgarros graves del periné, lo que se ha conseguido sin modificar la tasa de cesáreas (AU)

Background Severe (third- or fourth-grade) perineal tears during delivery lies in their ability can produce fecal incontinence. We decided to establish a strategy to reduce the incidence of severe tears during delivery. Material and methods The strategy was as follows: 1) pain relief options other than epidural were offered; 2) active pushing was delayed until there was maternal urge; 3) upright positions for pushing and delivery were offered; 4) the indication for instrumental delivery was based on the American College of Obstetricians and Gynecologists’ definitions for instrumental delivery, 5) ventouse extraction was used as the instrument of choice, and 6) the use of episiotomy was restricted. Results The rate of severe tears significantly decreased (1.56%–0.84%).Conclusions A strategy agreed between midwives and gynecologists can significantly reduce the incidence of severe perineal tears. This reduction was achieved without changing the rate of cesarean sections (AU)