Fecal Incontinence Is Associated With Mortality Among Older Adults With Complex Needs: An Observational Cohort Study.

OBJECTIVES: Fecal incontinence (FI) is a problem in growing older populations. Validating a suspected association between FI and mortality in community dwelling older adults could lead to improved planning for and management of the increasing complex older population. In a large cohort of New Zealand older adults, we assessed the prevalence of FI, urinary incontinence (UI), combined FI and UI, and their associations with mortality. METHODS: This study consisted of a retrospective analysis of international standardized geriatric assessment-home care (InterRAI-HC) data from community-dwelling adults aged 65 years or older, who met the criteria required for the InterRAI-HC, having complex needs and being under consideration for residential care. The prevalence of UI and FI was analyzed. Data were adjusted for demography and 25 confounding factors. Mortality was the primary outcome measure. RESULTS: The total cohort consisted of 41,932 older adults. Both UI and FI were associated with mortality (P<0.001), and risk of mortality increased with increased frequency of incontinence. In the adjusted model, FI remained significantly related to survival (P<0.001), whereas UI did not (P=0.31). Increased frequency of FI was associated with an increased likelihood of death (hazard ratio 1.28). CONCLUSIONS: This large national study is the first study to prove a statistically significant relationship between FI and mortality in a large, old and functionally impaired community. These findings will help improve the management of increasingly complex older populations.

Urinary incontinence as a marker of higher mortality in patients receiving home care services.

OBJECTIVE: To evaluate urinary incontinence (UI) as a predictor of nursing home admission, hospitalization or death in patients receiving home care services. SUBJECTS AND METHODS: A total of 699 community-dwelling participants receiving home care services in Geneva were evaluated in Autumn 2004 using the Minimal Data Set-Home Care, a validated instrument that includes grading of UI. Data on death, hospitalization and nursing home admission were collected up until June 2007. The impact of UI on time-dependent outcomes was analysed using survival analysis and multivariate regression Cox models to adjust for age, gender, body mass index, cardiac failure, cognitive impairment, delirium, depression, disability, alcohol and tobacco use, self-rated health, faecal incontinence and number of medications. RESULTS: We found that UI was present in 193 participants (27.8%). After adjustment for confounding factors, UI was associated with a longer length of hospital stay: +36.7 days, (95% confidence interval [CI]: 1.2-72.3) and a higher mortality rate (hazard ratio [HR] 1.6; 95% CI: 1.1-2.6). The HR for death was 1.5 (95% CI: 0.9-2.5) for participants complaining of one episode of urinary leakage per week at most, 2.0 (95% CI: 1.2-3.5) for those presenting with two or more episodes per week and 4.2 (95% CI: 2.3-7.7; P for trend: <0.001) for daily UI compared with participants without UI. Institutionalization (HR 1.1; 95% CI: 0.6-2.2) and hospitalization rates (HR 1.0; 95% CI: 0.7-1.3) were not different between patients with or without UI. CONCLUSION: In a cohort of patients receiving home care services, UI was a strong predictor of length of hospital stay and mortality, increasing with UI severity.

Hirschsprung's disease associated with Down syndrome: a meta-analysis of incidence, functional outcomes and mortality.

PURPOSE: Down syndrome (DS) is the most frequent chromosomal abnormality associated with Hirschsprung's disease (HD). It has often been suggested that this association results in poorer outcomes with regard to postoperative complications, continence and mortality. On the other hand, the results after surgical treatment of HD in patients with DS are reportedly similar to those in cases with HD alone. The objective of this study was to determine the incidence of DS in cohorts with HD, and to compare pre-/postoperative complications, functional outcome and mortality between cohorts with and without coexisting DS. METHODS: A systematic literature-based search for relevant cohorts was conducted using multiple online databases. The number of DS cases in HD cohorts was recorded and data on pre-/postoperative complications, functional outcome and mortality were extracted. Pooled odds ratios with 95% confidence intervals were calculated using meta-analysis methodology. RESULTS: Sixty-one articles met defined inclusion criteria, comprising data from 16,497 patients with HD. The overall incidence of DS among them was 7.32%. Vice versa, the incidence of HD in 29,418 patients with DS was 2.62%. There were no significant differences regarding the male-to-female ratio between cohorts with and without coexisting DS (4:1 vs. 3:1 respectively; P = 0.5376). The rate of additional comorbidities was significantly higher in HD associated with DS (P < 0.0001). Recto-sigmoid HD was in both cohorts the most common type of HD (P = 0.8231). Long-segment HD was significantly more frequent in HD with coexisting DS (P = 0.0267), while total colonic aganglionosis occurred significantly more often in HD without DS (P = 0.0003). There were no significant differences in preoperative constipation/obstruction (P = 0.5967), but the rate of preoperative enterocolitis was significantly higher in HD associated with DS (P = 0.0486). Postoperative complications such as recurrent enterocolitis (P = 0.0112) and soiling (P = 0.0002) were significantly more frequent in HD with coexisting DS. Although not statistically significant, fecal incontinence (P = 0.1014) and persistent constipation (P = 0.1670) occurred more often after surgical treatment of HD with DS. The mortality rate was significantly higher in HD associated with DS (P < 0.0001). CONCLUSIONS: The association of HD with DS is well-recognized with an incidence of 7.32%. A large number of patients with DS continue to have persistent bowel dysfunction after surgical treatment of HD. Our data provide strong evidence that the coexistence of HD and DS is associated with higher rates of pre-/postoperative enterocolitis, poorer functional outcomes and increased mortality.

Sacral nerve stimulation for fecal incontinence improves symptoms, quality of life and patients' satisfaction: results of a monocentric series of 119 patients.

PURPOSE: Sacral nerve stimulation (SNS) is validated as an efficient treatment for fecal incontinence (FI). However, long-term results are scarce in the literature. The goal of this study was to assess the impact of SNS on FI symptoms and quality of life, based on a retrospective analysis of prospectively collected data. METHODS: From 2001 to 2009, 119 patients (six men, mean age 61 years) underwent SNS testing for FI after an extensive diagnostic workup. Permanent implantation was realized when FI symptoms improved during testing, and follow-up visits were performed every 12 months thereafter. This follow-up evaluated morbidity and efficacy, based on clinical data and self-administered questionnaires including Jorge and Wexner FI score, urinary incontinence score (urinary distress inventory-6, UDI-6), gastrointestinal quality of life index (GIQLI), and auto-evaluation scale. RESULTS: A permanent stimulator was implanted after a positive test in 102 patients (91 %). Ten patients were explanted during follow-up (pain in one case and absence of efficacy in nine), and 29 had the stimulator and/or the electrode changed. The mean follow-up was 48 months (range 12-84): there was a significant improvement of FI score (9 ± 1 vs 14 ± 3, p < 0.0001), UDI-6 score (8 ± 4 vs 11 ± 5, p < 0.05), and GIQLI index (p < 0.002). The improvement was present at 12 months follow-up and remained stable. Eighty percent of patients were satisfied with the treatment at the last point of follow-up. None of the pretreatment variables were predictive of SNS efficacy. CONCLUSIONS: SNS improved FI and quality of life, and this efficacy remained over time. Although a complete disappearance of FI was rare, most patients were satisfied.

The association of fecal incontinence with institutionalization and mortality in older adults.

OBJECTIVES: Fecal incontinence is a growing problem in the aging population. Little is known about the association of fecal incontinence with institutionalization and mortality in community-dwelling older adults. The aim of this study was to determine the prevalence of fecal incontinence among older adults in Canada and whether it is associated with increased risk of institutionalization and mortality, independent of the effect of potential confounders. METHODS: This study consisted of a secondary analysis of data from 9,008 community-dwelling participants in the Canadian Study of Health and Aging, aged 65 years or older. The measures used in the study are age, gender, self-reported loss of bowel control, cognition, impairment in activities of daily living (ADL), and self-reported health. Outcomes were death or institutionalization over the 10 years of follow-up. RESULTS: Fecal incontinence was found in 354 (4%) of the 8,917 subjects. Those with incontinence were older, with a mean age of 75.5 years, compared with 72.9 years in the continent group (P<0.001). Fecal incontinence was more common among women (4.7%) than among men (3.0 %), and among people who were single at the time of the study (4.9%) compared with those who lived with partners (3.3%). The prevalence of fecal incontinence in the Canadian population aged 65 years and above at the time of data collection was estimated to be 4%. Although mortality was significantly higher among those with fecal incontinence, independent of age, sex, cognition, and functional independence (hazard ratio 1.19; 95% confidence interval (CI): 1.00-1.41; P=0.05), this association was not statistically significant after adjusting for self-reported health. Although individuals with fecal incontinence had higher odds of institutionalization independent of age and sex (odds ratio 1.79, 95% CI: 1.00-3.20, P=0.05), this association was not statistically significant after adjusting for cognition, ADL dependence, and self-reported health. CONCLUSIONS: Although fecal incontinence was associated with increased mortality and institutionalization, independent of age and gender, these associations were largely explained by other potential confounders such as poor self-assessed health, cognitive impairment, and ADL dependence.

Factors contributing to fecal incontinence in older people and outcome of routine management in home, hospital and nursing home settings.

OBJECTIVE: Fecal loading, cognitive impairment, loose stools, functional disability, comorbidity and anorectal incontinence are recognized as factors contributing to loss of fecal continence in older adults. The objective of this project was to assess the relative distribution of these factors in a variety of settings along with the outcome of usual management. METHODS: One hundred and twenty adults aged 65 years and over with fecal incontinence recruited by convenience sampling from four different settings were studied. They were either living at home or in a nursing home or receiving care on an acute or rehabilitation elderly care ward. A structured questionnaire was used to elicit which factors associated with fecal incontinence were present from subjects who had given written informed consent or for whom assent for inclusion in the study had been obtained. RESULTS: Fecal loading (Homes 6 [20%]; Acute care wards 17 [57%]; Rehabilitation wards 19 [63%]; Nursing homes 21 [70%]) and functional disability (Homes 5 [17%]; Acute care wards 25 [83%]; Rehabilitation wards 25 [83%]; Nursing homes 20 [67%]) were significantly more prevalent in the hospital and nursing home settings than in those living at home (P < 0.01). Loose stools were more prevalent in the hospital setting than in the other settings (Homes 11 [37%]; Acute care wards 20 [67%]; Rehabilitation wards 17 [57%]; Nursing homes 6 [20%]) (P < 0.01). Cognitive impairment was significantly more common in the nursing home than in the other settings (Nursing homes 26 [87%], Homes 5 [17%], Acute care wards 13 [43%], Rehabilitation wards 14 [47%]) (P < 0.01). Loose stools were the most prevalent factor present at baseline in 13 of the 19 (68%) subjects whose fecal incontinence had resolved at 3 months. CONCLUSION: The distribution of the factors contributing to fecal incontinence in older people living at home differs from those cared for in nursing home and hospital wards settings. These differences need to be borne in mind when assessing people in different settings. Management appears to result in a cure for those who are not significantly disabled with loose stools as a cause for their fecal incontinence, but this would need to be confirmed by further research.

Mortality in relation to urinary and faecal incontinence in elderly people living at home.

OBJECTIVE: To examine the relationship between incontinence and mortality in elderly people living at home. DESIGN: Of the randomly selected people aged 65 years and older living in Settsu city, Osaka in October 1992, 1405 were contacted and constituted the study cohort. Follow-up for 42 months was completed for 1318 (93.8%; 1129 alive, 189 dead). MEASURES: Data on general health status, history of health management, psychosocial conditions and urinary and faecal incontinence were collected by interview during home visits at the time of enrolment. RESULTS: From the Kaplan-Meier analysis, the estimated survival rates decreased with a decline in continence in both the 65-74 and 75 years and older age groups. From the Cox proportional hazards model, unadjusted hazard ratios of minor, moderate and severe incontinence for mortality, compared with continence, were 2.27, 2.96 and 5.94, respectively. Multivariate analysis yielded adjusted hazard ratios of minor, moderate and severe incontinence of 0.99, 1.17 and 1.91, respectively, leaving severe incontinence as the significant factor, when other indicators are controlled. CONCLUSIONS: Incontinence is related to mortality and severe incontinence represents an increased risk factor for mortality in elderly people living at home.

[Colonic pouch]. / Dickdarmpouch.

The tendency towards sphincter-preserving resection for distal rectal cancers has led to a revival of the technique of coloanal anastomosis (CAA) in recent years. In order to improve functional results, creation of a colonic J-pouch in conjunction with a coloanal anastomosis (CPA) was proposed. Two different operation techniques exist: i) Double-stapling with the anastomosis close to the dentate line and ii) intersphincteric resection with the anastomosis located immediately at the dentate line. A long rectal remnant after double-stapling leads to urgency in 15% of the patients due to stool retention in the atonic remnant. No propulsive motility patterns were recorded from the pouch which is emptied passively by upper colonic peristalsis. Therefore colonic pouches should be fashioned of descending colon and should not exceed a length of 6 cm in order to prevent stool fragmentation. Under these conditions the average stool frequency is reduced from 2-6/d after CAA to 1-3/d after CPA. This effect is maximal during the first postoperative months, but is still significant after 3 years. Colonic pouch construction also leads, due to better blood supply and prevention of pelvic hematomas, to a significant decrease of the anastomotic insufficiency rate from 10.0% after CAA to 5.4% after CPA. Therefore creation of a colonic J-pouch should be combined with coloanal reconstruction if the oncologic situation allows a sphincter-preserving procedure.

[Functional and oncological results of sphincter preserving rectal resection]. / Funktionelle und onkologische Resultate der sphinktererhaltenden Rektumresektion.

Most of the patients with a carcinoma of the middle and distal third of the rectum can now be operated on with a low anerior resection in consideration of all aspects of cancer surgery. Our experience with 59 resections with coloanal or low colorectal anastomosis was reviewed. The mean distance of the distal edge of the tumor to the L. anocutanea was 5.7 +/- 1.9 cm. Within the first 30 days the postoperative mortality rate was 3.4% (2/59). The most common postoperative complication was urinary retention, which affected 13.5%. The insufficiency rate of the anastomosis was 13.5%. Fecal continence was complete in 85% of the patients: we observed minor leaks in 6% and major leaks in 9%. Local recurrence occurred in 2 cases (3.8%), metastasis was noted in 6 cases (11.3%). Sphincter-preserving rectal resection is in our opinion an excellent treatment for low rectal cancer.

[Hemorrhoidectomy--a simple operation? Incontinence, stenosis, fistula, infection and fatalities]. / Die Hämorrhoidektomie--eine einfache Operation? Inkontinenz, Stenose, Fistel, Infektion und Todesfälle.

Hemorrhoidectomy is not a simple procedure. Hemorrhoids develop as hyperplastic formations of an important part of the anorectal organ of continence, i.e., the corpus cavernosum recti. This organ segment is analogous to tissue structures found in the tongue of certain birds which are used for hulling seeds. Well-meaning, complete resection of the corpus cavernosum will inevitably result in incontinence. Only operative techniques which resect exclusively those segments of the hemorrhoidal tissue adjacent to the muscle layer in the anal canal are adequate. These procedures will spare sufficient tissue of the corpus cavernosum to allow a safe segmental resection of this structure and at the same time permanently eradicate the hemorrhoids. In the present paper, the treatment of 53 patients with postoperative incontinence and of others with stenoses, fistulas and pelvic infections is discussed. Fatalities have never been reported in the literature following operative hemorrhoidectomy, however, have occurred after "banding" procedures and after injection therapy.

[Rectal cancer--results of continence-preserving resections]. / Rektumkarzinom--Ergebnisse kontinenzerhaltender Resektionen.

In a series of 586 patients with rectal carcinoma who underwent potentially curative resection between January 1977 and December 1990 postoperative complications, incidence of local recurrence and disease free survival are investigated. Of the 401 patients undergoing low anterior resection (LAR) and 89 patients with coloanal anastomosis (CAA) 389 anastomoses were fashioned with staples. The hospital mortality rate was 4.6%. Clinical anastomotic leakage occurred in 5.5% (handsewn 10.3% stapled 4.3% (p less than 0.05), anastomotic strictures in 7.5% and 2.4% (p less than 0.05). 20% of patients undergoing restaurative resection (RR) (handsewn 23%, stapled 20%) developed local recurrences compared with 21% for the group with abdominoperineal resection (APR). The corrected 5-year survival rate was 63% for RR respectively 55% for APR (p greater than 0.05). After CAA, incidence of local recurrence and survival rate for patients with carcinoma of the lower rectum was 11% respectively 63%. It is concluded that innovative advances like the development of circular stapling devices and the adoption of a more aggressive sphincter-saving policy like CAA cause not an increased risk of recurrent diseases and no decrease of the 5-year survival rate.

[Foundation, technique and results of short continence resection in rectal cancer]. / Begründung, Technik und Ergebnisse der knappen Kontinenzresektion beim Rektumkarzinom.

Ultra-short resections of the rectum have been recommended for rectal carcinomas extending to lower than eight cm from the dentate line in order to preserve anal continence. Resection of the main lymphatic pathways together with the adjacent lamellae is important for radical removal of all tumour cells. Valves in the rectal lymph vessels allow lymph fluids to drain only in a cranial direction. There are no lymph nodes behind the dorsal adjacent lamella. Thus, a distal margin of two cm from the tumour is sufficient to minimize the risk of recurrence. We recommend a transano-abdominal approach for very low rectal carcinomas. During the past years, we have operated on 241 patients with rectal carcinomas and found five-year-survival rates of 54 percent with rectum resections with colostomies, 67 percent with low anterior resections and 75% with ultra-short sphincter preserving resections.