Long-term anorectal function in rectal cancer patients treated with chemoradiotherapy and endorectal brachytherapy.

AIM: The aim was to study anorectal function in long-term survivors after combined, curatively intended, chemoradiotherapy and endorectal brachytherapy for low rectal cancer. METHODS: This was a case-control design. We compared anorectal function by anal manometry, anal functional lumen imaging probe (EndoFLIP) and rectal bag distension in rectal cancer patients (RCPs) and healthy, normal subjects (NSs). Symptoms were assessed by the low anterior resection syndrome (LARS) and Wexner faecal incontinence scores. RESULTS: Thirteen RCPs (12 men, median age 68 years, range 52-92) after 60 Gy radiotherapy, 5 Gy endorectal brachytherapy and oral tegafur-uracil with complete clinical response (median time since treatment 2.8 years, range 2.2-5.6) were compared to 15 NSs (14 men, median age 64 years, range 47-75). RCPs had lower than normal anal resting pressure, 38.6 mmHg (range 8.8-67.7) versus 58.8 mmHg (25.7-105.2) (P < 0.003), and squeeze pressure, 117 mmHg (55.2-203) versus 188 mmHg (103-248) (P < 0.01). Squeeze-induced pressure increase recorded by EndoFLIP was also lower in RCPs (q > 7.56, P < 0.001) as was the anal canal resistance to increasing distension (q = 3.13, P < 0.05). No differences in median rectal volume at first sensation (72 [22-158] vs. 82 [36-190] ml, P = 0.4) or at urge to defaecate (107 [42-227] vs. 132 [59-334] ml, P = 0.2) were found. However, maximum tolerable rectal volume was lower in RCPs (145 [59-319] vs. 222 [106-447] ml, P < 0.02). The median (range) low anterior resection syndrome score was 27 (0-39) for RCPs and 7 (0-23) for NSs (P < 0.001), while the Wexner score was 0 (0-5) versus 0 (0-4) (P = 0.56). CONCLUSION: Radiotherapy combined with endorectal brachytherapy for rectal cancer causes long-term anorectal symptoms, impaired anal sphincter function and reduced rectal capacity.

Magnetic anal sphincter augmentation for the treatment of fecal incontinence: a preliminary report from a feasibility study.

BACKGROUND: Magnetic sphincter augmentation, a successful treatment of gastroesophageal reflux disease, has been applied to treat fecal incontinence. The purpose of this feasibility study was to understand the safety profile as well as the potential benefit of this new device when it is implanted in patients with fecal incontinence. METHODS: A magnetic anal sphincter device was surgically implanted in candidates with documented fecal incontinence of more than 2 episodes per week at 3 investigational centers in Europe and the United States following ethics/institutional review board approval. The magnetic anal sphincter device was placed around the anal canal via a single anterior incision. All data were collected prospectively. The primary outcome measure was the reduction of incontinent episodes based on a daily continence diary. RESULTS: To date 14 patients have been implanted with the device (all female; mean age, 62.8 y; range, 41-74 y) with a median follow-up of 6 months. There have been no intraoperative complications. Mean hospital stay was 3 days; range, 1 to 7 days. Adverse events were observed in 7 patients. Three patients are no longer implanted with a device; 2 devices were removed and one passed spontaneously following a separation at the suture connection. Five patients with 6-month follow-up demonstrated a mean reduction in the number of average weekly incontinence episodes from 7.2 to 0.7 (90.9%) and a mean reduction in Wexner Continence Score from 17.2 to 7.8 (54.7%). Compared with baseline, quality of life improved in all 4 domains of the fecal incontinence quality of life (FIQoL) scoring system. No patients have reported that their condition has worsened. Two patients at 1-year follow-up both reported perfect continence. CONCLUSION: This preliminary study describes the use of a new device to treat fecal incontinence. Compared with existing devices, implantation is simple and it requires no adjustments from the physician or patient once the device is implanted. Initial assessment with a small number of patients shows promising outcomes with a limited incidence of complications and good restoration of continence.

Scintigraphic assessment of retrograde colonic washout in fecal incontinence and constipation.

PURPOSE: This study aimed to evaluate the colorectal luminal transport obtained by retrograde colonic washout with a new scintigraphic technique. METHODS: Nineteen patients (5 with spinal cord lesion, 6 with idiopathic fecal incontinence, and 8 with idiopathic constipation) treated with retrograde colonic washout took indium-111-labeled polystyrene pellets to label the bowel contents. Technetium-99m-diethylene-triamine-pentaacetic acid was mixed with the irrigation fluid to assess its extent within the colorectum. Scintigraphy was performed before and after a standardized washout procedure. The colorectum was divided into four segments: the cecum and ascending colon, the transverse colon, the descending colon, and the rectosigmoid. Assuming ordered evacuation of the colorectum, the contribution of each colonic segment to the total evacuation was expressed in percent of the original segmental counts. The contributions of each segment were summed to reach a total defecation score (range, 0-400), and directional segmental transports were estimated. RESULTS: The defecation score in patients with idiopathic constipation (median, 59; range, 21-130) differed significantly (P < 0.05) from the scores in those with spinal cord lesions (median, 204; range, 108-323) and idiopathic fecal incontinence (median, 188; range, 155-234). Thus, patients with spinal cord lesion or idiopathic fecal incontinence were able to empty most of the rectosigmoid and most of the descending colon, but those with idiopathic constipation could only empty 59 percent of the rectosigmoid. The irrigation fluid on average reached a point just beyond the right colic flexure that correlated with the defecation score (r(2) = 0.58, P < 0.001). CONCLUSION: The effect of retrograde colonic washout was significantly better in spinal cord lesion and idiopathic fecal incontinence than in idiopathic constipation, and its effect correlated with the extent to which the irrigation fluid had entered the colorectum.