ArticleLiterature Review

Etiology and management of fecal incontinence

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Abstract

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives- The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.

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... Two independent reviewers (E.D. and D.P.) screened the titles and abstracts of all identified articles for relevance. Any discrepancies were resolved through discussion or consultation with a third reviewer (G.H. 15 Wexner score, 16 Low Anterior Resection Syndrome (LARS) 17 and Gastrointestinal Quality of Life Index (GIQLI). 18 The Knowles-Eccersley-Scott Symptom questionnaire (KESS) was used to diagnose constipation, which is composed of 11 individual items with a maximum of 39 points. ...
... The score 0 corresponds to continence and 20 represents anal incontinence. 16 LARS Score was originally designed to assess quality of life following low anterior resection for rectal cancer and includes 5 questions regarding bowel function, consequently dividing patients into three groups: no LARS with 0-20 points, minor LARS: 21-29 and major LARS: 30-42. 17 This tool was shown to be also useful in evaluating patients after radical colorectal surgery for DE. ...
... 21 This checklist includes 27 criteria, widely covering areas reporting quality, external and internal validity, and power. Downs and Black score ranges were given quality levels as: excellent (26)(27)(28); good (20)(21)(22)(23)(24)(25); fair (15)(16)(17)(18)(19); and poor (<14) ( Table 1). Conflicts regarding study quality were resolved by the authors. ...
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Introduction Patients who have undergone colorectal surgery for symptomatic deep endometriosis may still encounter persistent or worsening digestive complaints. The aim of the present work was to analyze gastrointestinal function outcomes after radical and conservative colorectal surgery to further elucidate the effect of surgery on postoperative bowel function. Material and Methods PubMed, EMBASE, Web of Science, Clinical Trials.gov and the Cochrane Database databases were searched from January 1, 2010 until April 1, 2024. The quality of included studies was assessed by the Downs and Black quality checklist. Studies including patients with colorectal endometriosis who either underwent segmental resection (SR) or conservative approaches and reported data on bowel function were included. Results From the initial pool of 55 studies, 14 reported patient reported outcome measures eligible to be pooled in the meta‐analysis. Conservative surgery was less associated with constipation and increased number of daily stool (>3/day) when compared to SR (p = 0.02 and p = 0,0004, respectively). No difference was found in the occurrence of gas and stool incontinence (p = 0.72), postsurgical defecation pain (p = 0.44) and time to defer defecation (≤ 15 min; p = 0.64). Patients in the conservative surgery group reported higher postoperative Gastrointestinal Quality of Life Index (GIQLI) when compared to SR (p = 0.01). However, when comparing changes between pre‐ and postsurgical patient reported outcome measures within the respective groups, rather than evaluating postsurgical outcomes alone, none of the intervention groups showed significant changes between pre‐ and postsurgical GIQLI, Knowles Eccersley Scott Symptom Score(KESS) and Wexner scores (p = 0.28, p = 0.94 and p = 0.78, respectively). Conclusions Segmental resection seems to be associated with higher rates of post‐operative constipation and lower GIQLI scores when compared to conservative surgery. However, when comparing the change of gastrointestinal function symptoms reflected by changes of gastrointestinal function parameters from pre‐ to postoperative rather than focusing on purely postoperative parameters alone, no significant difference of these parameters was observed between surgical techniques.
... The secondary objectives were the rate of wound healing (defined as epithelialization or scar formation), the need for stoma and proctectomy, and long-term outcomes related to fecal incontinence and quality of life. Quality of life was assessed using self-reported questionnaires, including the Wexner Fecal Incontinence Score and the RAND Short Form-36 (RAND SF-36) [12,13]. ...
... The exclusion criteria were inflammatory bowel disease, rectovaginal fistulas, low anal fistulas, and fistulas treated solely with seton-sutures or other surgical procedures. Eligible patients were invited to participate in an online survey assessing functional outcomes through self-reported questionnaires, including the RAND SF-36 for quality of life [12] and the Wexner fecal incontinence score [13]. ...
... A significant difference was observed between patients with primary healing and those requiring reoperation (P = 0.0003). Patients with primary healing had a median Wexner score of 2 (range: 0-17), while those who underwent reoperation had a median score of 12 (range: [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. ...
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Background Surgical repair for high anal fistulas is challenging and can be associated with impaired functional outcomes. This study evaluated the long-term results of transsphincteric fistulectomy with primary sphincter repair for high anal fistulas in terms of recurrence, wound healing, fecal incontinence, and quality of life. Method This retrospective cohort study included patients who underwent surgical repair for high anal fistulas between 2006 and 2015. Data were collected by reviewing patients’ electronic hospital records, including demographic characteristics, medical conditions, surgical findings, performed procedures, and follow-up data until the last recorded visit. Functional outcomes were assessed using self-reported online questionnaires for quality of life (RAND SF-36) and fecal incontinence (Wexner score). Results Fifty-five patients were included. Primary healing was achieved in 42 (76%) patients, while 13 (24%) experienced recurrence. Following reoperations for recurrence, an additional 12 patients achieved healing, resulting in an overall healing rate of 98%. The median Wexner score was significantly higher in reoperated patients, and the median scores across all eight parameters of the RAND SF-36 were lower. None of the patients required proctectomy, and two ended with permanent stomas. Conclusion Surgery for high anal fistulas is associated with a high success rate, but reoperations for recurrence are linked to considerable impairment in functional outcomes.
... Valores médios mais baixos foram obtidos para força, resistência e número de contrações sustentadas e rápidas no grupo exposto à episiotomia, comparado ao grupo controle. A episiotomia aumentou as chances de: IU (OR= 15,2; IC95%= 8,4), alteração na qualidade de vida relacionada à IU (OR= 15,9; IC95%= 8,0), incontinência fecal (OR= 18,5; IC95%= 6,(4)(5)7) e constipação intestinal (OR= 10,8; IC95%= 4,(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24),2) em adolescentes primíparas, comparado ao grupo controle. ...
... A pontuação final do instrumento é obtida multiplicando-se a frequência e a quantidade de perda urinária. Assim, a IU pode ser classificada como leve (1-2), moderada (3)(4)(5)(6), grave (8)(9) ou muito grave (12). 11 A Escala de Jorge e Wexner 12 foi usada para avaliar o grau de IF em adolescentes que relataram perda involuntária de fezes e/ou flatos. ...
... Entre os fatores que podem explicar a maior prevalência de constipação em mulheres estão os danos causados aos músculos do assoalho pélvico e suas inervações, resultantes do parto e de cirurgias ginecológicas, além dos prolapsos genitais. 12 Especificamente em relação ao parto, o trabalho de parto prolongado, episiotomia, cesariana e o uso de enema e analgésicos no parto são fatores que aumentam o risco de constipação. ...
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Resumo Objetivos: avaliar a associação da episiotomia na função do assoalho pélvico e na ocorrência de incontinência urinária e fecal em adolescentes primíparas. Métodos: foi realizado um estudo transversal, com adolescentes primíparas de dez a 19 anos, de sete e 48 meses pré coleta de dados. As participantes preencheram um formulário contendo seus dados pessoais e ao Questionário da Consulta Internacional sobre Incontinência Urinária (IU) Short Form, Índice de Gravidade da Incontinência e à Escala de Incontinência de Jorge & Wexner. Resultados: os valores médios foram estatisticamente significativos para as variáveis analisadas. Valores médios mais baixos foram obtidos para força, resistência e número de contrações sustentadas e rápidas no grupo exposto à episiotomia, comparado ao grupo controle. A episiotomia aumentou as chances de: IU (OR= 15,2; IC95%= 8,1-28,4), alteração na qualidade de vida relacionada à IU (OR= 15,9; IC95%= 8,5-30,0), incontinência fecal (OR= 18,5; IC95%= 6,4 -5,7) e constipação intestinal (OR= 10,8; IC95%= 4,8-24,2) em adolescentes primíparas, comparado ao grupo controle. Conclusões: a episiotomia pode influenciar negativamente a função do assoalho pélvico e a contenção urinária e fecal. Os profissionais que atuam na atenção à saúde materna devem estar atentos e refletir sobre as práticas obstétricas no parto de adolescentes.
... The instrument's final score is obtained by multiplying urinary loss frequency and amount. Thus, UI can be classified as slight (1-2), moderate (3)(4)(5)(6), severe (8)(9), or very severe (12). 11 The Jorge and Wexner 12 Incontinence Scale was used to assess the degree of FI in adolescents who reported involuntary loss of feces and/or flatus. ...
... The instrument consists of a simple scale composed of five questions whose answers can be: 0 -never, 1 -rarely, 2 -sometimes, 3 -usually, 4 -always. The final score ranges from 0 to 20, and FI can be classified as slight (0-7), moderate (8)(9)(10)(11)(12)(13), or severe (14)(15)(16)(17)(18)(19)(20). 12 Constipation was assessed based on the Rome IV criteria; type of FI presented, categorized as: flatus incontinence, liquid fecal incontinence, solid fecal incontinence, passive fecal incontinence, and fecal incontinence during intercourse, according to ICS recommendations; 3 irritative urinary symptoms, classified as: urinary frequency (number of spontaneous urinations greater than or equal to 8 while the volunteer is awake), urinary urgency (a difficult-to-control, strong urge to urinate) and nocturia (need to wake up one or more times to urinate while sleeping), according to ICS recommendations. ...
... The final score ranges from 0 to 20, and FI can be classified as slight (0-7), moderate (8)(9)(10)(11)(12)(13), or severe (14)(15)(16)(17)(18)(19)(20). 12 Constipation was assessed based on the Rome IV criteria; type of FI presented, categorized as: flatus incontinence, liquid fecal incontinence, solid fecal incontinence, passive fecal incontinence, and fecal incontinence during intercourse, according to ICS recommendations; 3 irritative urinary symptoms, classified as: urinary frequency (number of spontaneous urinations greater than or equal to 8 while the volunteer is awake), urinary urgency (a difficult-to-control, strong urge to urinate) and nocturia (need to wake up one or more times to urinate while sleeping), according to ICS recommendations. 3 Pelvic floor evaluation was carried out by: measurement of the vulvovaginal opening (distance between the large lips in the vulvar region), classified as: fully closed (0 centimeter), discrete opening (0.1 -0.5 cm) and accentuated opening (over 0.5 cm); 13 palpation of the perineal body and external anal sphincter, assessed by digital pressure and classified as: normal, hypotonia, or hypertonia; assessment of the presence of voluntary pelvic floor muscle contraction and use of accessory muscles, assessed by bidigital palpation; and assessment of perineal muscle function using the PERFECT scheme. ...
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Objectives: to evaluate the association of episiotomy with pelvic floor function and the occurrence of urinary and fecal incontinence in primiparous adolescents. Methods: a cross-sectional study was conducted with primiparous adolescents aged ten to 19 years, seven and 48 months before data collection. Participants completed a form containing their personal data and the International Consultation on Urinary Incontinence (UI) Short Form, Incontinence Severity Index and the Jorge & Wexner Incontinence Scale. Results: the mean values were statistically significant for the variables analyzed. Lower mean values were obtained for strength, endurance and number of sustained and rapid contractions in the group exposed to episiotomy, compared to the control group. Episiotomy increased the odds of: UI (OR= 15.2; CI95%= 8.1-28.4), UI-related changes in quality of life (OR= 15.9; CI95%= 8.5-30.0), fecal incontinence (OR= 18.5; CI95%= 6.4-5.7) and constipation (OR= 10.8; CI95%= 4.8-24.2) in primiparous adolescents, compared to the control group. Conclusions: episiotomy can negatively influence pelvic floor function and urinary and fecal retention. Professionals working in maternal health care should be aware of and reflect on obstetric practices during childbirth in adolescents.
... Up to 80% of the patients can develop secondary digestive symptoms to these types of resections [1][2][3], which are defined as LARS syndrome that impairs quality of life over a variable period or is sometimes permanent, requiring conversion to definitive colostomy [2,3]. For this reason, anterior resection syndrome (LARS) began to be studied and acknowledged by surgeons and oncologists; thus, patients must be informed about the possibility of its appearance after curative surgical intervention, and treatment should be instituted as early as possible [4][5][6]. ...
... According to the consensus definition, the patient must exhibit at least one of the following symptoms: variable or unpredictable bowel function, altered stool consistency, increased stool frequency, pain during defecation, evacuation difficulties, urgency, incontinence, or involuntary leakage. Additionally, these symptoms must result in at least one of the following consequences: toilet dependency, constant concern about bowel function, unsatisfactory bowel function, strategies or compromises related to defecation, impact on mental and emotional wellbeing, effect on daily social activities, impact on social relationships, or interference with social roles and responsibilities [1][2][3][4][5][6][7]. Factors such as obesity, diabetes, type of surgery, and the length of the preserved rectum may influence the appearance of LARS symptoms [1,2]. ...
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Objectives: The aim of the study was to assess the diagnosis and evolution of low anterior rectal resection syndrome (LARS) in patients admitted to a tertiary surgical center in Romania. Materials and Methods: From 120 patients initially included in the analysis, after applying the exclusion criteria, we selected 102 patients diagnosed and operated on for neoplasm of the upper, middle, and lower rectum for which resection and excision (partial or total) of mesorectum was associated. All the patients we treated in the general surgery department of the County Emergency Hospital of Craiova within a time frame of 5 years (1 October 2017–1 September 2022), and all experienced at least one symptom associated with LARS. The group included 68 men and 34 women aged between 35 and 88, who were followed-up for at least 2 years. Patients with progression of neoplastic disease, with advanced neurological disease, and those who died less than 2 years after surgery were excluded. Results: The overall incidence varied by gender, site of the tumor (requiring a certain type of surgery), and anastomotic complications, and it was directly proportional to the time interval between resection and restoration of continuity of digestion. Conclusions: Obesity, size of the remaining rectum, total excision of the mesorectum, anastomotic complications, and prolonged ileostomy time are cofactors in the etiology of LARS. The LARS score decreased in most patients during the 2-year follow-up, although there were a small number of patients in whom the decrease was insignificant. The persistence of major LARS at 6 months after surgery may predict the need for a definitive colostomy.
... The Wexner Scale for Fecal Incontinence consists of 5 items that assess incontinence to solids or liquids, presence of gas, lifestyle changes, and the need to wear a pad. Each item is scored from 0 (never) to 4 (daily), and a score other than 0 is considered positive, with a total score ranging from 0 to 20 [24,25]. The Wexner Constipation Score System evaluates 8 factors: frequency of bowel movements, painful evacuation attempts, incomplete evacuation, abdominal pain, minutes required for each attempt, assistance with evacuation, unsuccessful evacuation attempts per 24 h, and duration of constipation. ...
... It ranges from 0 (no constipation problems) to 30 (worst problem possible) [26]. For this study, we will divide the scores into severity classes: mild (1-5), moderate (6-10), severe (11)(12)(13)(14)(15), and very severe symptoms (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). ...
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Objective To assess the prevalence and the characteristics of pelvic floor dysfunction (PFD) in women with endometriosis. Methods This is a methodological paper that describes the ‘Endometriosis and Pelvic Floor Dysfunction’ (EndoPFD) multicenter study protocol. It involves three sites: the University Hospital of Pisa, the San Raffaele Hospital of Milan and the Vanvitelli University Hospital of Naples. Women are recruited through web links and are asked whether they want to participate to the clinical evaluation or only to the web survey. The web survey gathers personal history, endometriosis history and symptoms, and performs a subjective evaluation of PFD through questionnaires: Urinary Distress Inventory 6, Colorectal-Anal Distress Inventory 8, Wexner Scale for Fecal Incontinence, Wexner Constipation Scoring System, and Female Sexual Function Index. Those interested in the clinical evaluation will add to the questionnaires the following exams: gynecological and proctological exam, pelvic ultrasound, urodynamic test, and anorectal manometry. Preliminary results Recruitment for the web survey was completed. A total of 1,149 women signed the electronic consent, 329 were excluded due to inclusion/exclusion criteria; hence, 525 completed all the questionnaires (response rate of 64.02%). Recruitment for the clinical evaluation is ongoing. Discussion This study protocol offers the possibility to define the prevalence of PFD in endometriosis patients with a subjective and an objective assessment of signs and symptoms. This may pave the way for changing the approach to patients with endometriosis. Moreover, it demonstrates the validity of the method used (online survey and recruitment) to reach a high number of patients.
... Various scales are used to evaluate fecal incontinence, one of which is the WS (also known as the Cleveland Clinic Incontinence Score). 60 We assessed incontinence using the WS. In this criterion, data such as whether incontinence is solid, liquid, or gas and its frequency, pad usage, and lifestyle changes are evaluated. ...
... In this criterion, data such as whether incontinence is solid, liquid, or gas and its frequency, pad usage, and lifestyle changes are evaluated. 60,61 Fecal incontinence score ranges from 0 to 20, with 0 being perfect continence and 20 being complete incontinence. In our study, the median WS was 3.5, and complete incontinence was not observed in any patient. ...
Article
Background Rectal eversion (RE) is a natural orifice specimen extraction (NOSE) method that allows anus-sparing resection in very low rectal tumors. This study aims to share the long-term results of RE in laparoscopic rectal resection performed with double stapling anastomosis. Materials and Methods A single-center retrospective cohort study was conducted for patients who underwent laparoscopic low anterior resection with RE. Age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, type of surgery, distance of the tumor to the dentate line, specimen extraction site, cancer stage, preoperative chemoradiotherapy, postoperative complications, and postoperative clinical follow-up findings were recorded. Incontinence was assessed using the Wexner score (WS). Low anterior resection syndrome (LARS) is determined by the LARS score. A 7-point Likert scale was used to evaluate the satisfaction of the patients. Results A total of 17 patients underwent resection by RE for rectal tumors. Of the 11 patients included in the study, 4 were female and 7 were male. The mean age was 66.09±15.04 years. The mean follow-up was 64.18±16.83 months. The mean tumor diameter was 3.1 cm (range: 0.9 to 7.2 cm). The mean distance of the tumor from the dentate line was 2.7 cm (range: 1.2 to 5.6 cm). No anastomotic leak was observed in any patient. One patient had an anastomotic stenosis and was treated with balloon dilatation. The median LARS score was 16 (range 0 to 32) and 64% of the patients had no LARS. Two patients had minor LARS and 2 patients had major LARS. The median Wexner score was 3.5 (range 0 to 14). The median Likert scale was 7 (range 5 to 7). It was found that 55% of the patients were extremely satisfied, 18% were satisfied, and 27% were slightly satisfied with their surgery. There were no dissatisfied patients. Conclusion RE is a safe NOSE technique in laparoscopic double stapling anastomosis for rectal resection. There is a high level of long-term patient satisfaction with anus-sparing procedures via RE, even in the presence of various symptoms.
... Anal incontinence was defined as the involuntary passage of stool (liquid or solid) or flatus, and it was assessed using the Wexner scoring system [12] ( Table 1). ...
... Regarding fecal incontinence, 14% of the PIS group showed a degree of mild incontinence in the 3-month follow-up period; nine patients had a Wexner score of 4 (two events of liquid stool soiling in the followup period) and five patients with a score of 2 (minor incontinence to flatus), which Wexner classifies as minor incontinence [12], whereas the rest were fully continent. This is consistent with the rates documented in literature as mentioned before. ...
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Background and Study aims Chronic anal fissures (CAF) are common and associated with reduced quality of life. Partial posterior internal sphincterotomy (PPIS) is frequently carried out and involves partial division of the internal anal sphincter. It carries a risk of anal incontinence, which can be as high as 14%. Anal advancement flap (AAF) combined with fissurectomy has emerged as an alternative, 'sphincter-preserving' procedure. Fissurectomy involves excision of the underlying fissure, effectively converting a chronic fissure to an acute one, whereas AAF involves the transfer of well-vascularized, healthy tissue onto the fissure base. The objective of this study was to compare the conventional PPIS and the AAF, using a V-Y advancement flap, regarding healing, anal continence, operative time, postoperative pain, and postoperative bleeding. Patients and methods Our study included 200 consecutive patients who presented at Kasr Al-Ainy colorectal outpatient clinic with CAF, who were randomized and divided into two groups. Group A underwent V-Y advancement flap, whereas group B underwent PPIS. Patients were followed up in the outpatient clinic at 1 week, 6 weeks, and 3 months postoperatively. Results The current study shows group A had lower healing rate (82%) compared with group B (96%). However, there were no recorded cases of anal incontinence postoperatively in group A compared with 14% in group B. Operative time was much less in group B. There were no significant differences regarding postoperative bleeding or pain. Conclusion We recommend the AAF for the surgical management of patients with CAF who are at high risk of developing anal incontinence. Further studies with bigger sample sizes are required to properly assess the rate of healing of the AAF compared with PIS.
... FI was confirmed in these patients through physical examination and Wexner score assessment. 25 The presence of an EAS defect was further verified using both 2D and 3D endorectal ultrasound with a 360-degree probe (BK Pro Focus type 2202; GE Health-Care). The patients were randomly assigned to one of two groups, each comprising 15 individuals: Group A, the control group, underwent sphincteroplasty, and Group B, the laser group, received both sphincteroplasty and laser therapy. ...
... To evaluate muscle function and the severity of FI, the Wexner score of patients was recorded at three time points: immediately after sphincteroplasty, and then three and six months post-surgery. This assessment, based on patient history and the Wexner table, 25 was conducted by another colorectal surgeon. The scores range from 0 to 20, where a score of zero indicates complete control of defecation, and a score of 20 signifies complete FI. ...
... Patients' characteristics extracted from the prospectively maintained institutional database for the 2012 study included age, sex, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, past history of hysterectomy, previous surgery for RP whatever the technique and approach, psychiatric disease including past anorexia nervosa, history of chronic constipation and/or obstructive defaecation syndrome (ODS) [22], faecal incontinence defined as a Jorge and Wexner score > 5 [23], onset of the prolapse defined as < 1 year, ≥ 1 but < 5 years and ≥ 5 years, conversion to laparotomy, and associated cystopexy and/or colpopexy and/or other procedure. ...
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Laparoscopic ventral mesh rectopexy (LVR) has gained increasing acceptance for the treatment of patients with a full-thickness rectal prolapse (RP), but literature on follow-up of at least 10 years is scarce. We studied recurrence rate, long-term functional results and quality of life in patients who had LVR for RP more than 12 years ago. The study population consisted of patients who could be contacted among the 175 who had undergone LVR for RP and whose short- and medium-term outcomes were published in 2012. We studied the long-term recurrence rate (Kaplan-Meier), functional outcome (Wexner and ODS scores), quality of life (EuroQol) and satisfaction of the patient through clinical examination(s), specific scores and questionnaires. Of the 175 patients, 14 patients had exclusion criteria, 57 had died, and 42 were lost to follow-up, leaving 62 patients for analysis. Seventeen patients presented with a recurrence (10.5%) at the 10-year follow-up. The only statistically significant risk factor for recurrence was recurrent RP (HR = 11.5 (2.54–52.2), P = 0.002). The median faecal incontinence score was 4 (0–10) and significantly worse in patients who had a recurrence [12 (7–13) vs 3 (0–9); P = 0.016]. The median obstructive defaecation score was 6 (3–12). The median quality of life score was 7 (6–8). Most patients who presented with a recurrence said they would undergo the operation again and recommended it, as would patients with no recurrence. LVR for RP is a safe and efficient technique with sustainable long-term results that shows long-term efficacy at > 10 years after the operation.
... 6 Preoperative variables included the following patient characteristics: sex; presence of concomitant vaginal prolapse and urinary incontinence; prior pelvic floor surgery; prior rectal prolapse repair with a specific description of the type(s) of prior repair(s); and information regarding patient symptoms of fecal incontinence (as measured by a surgeon-collected Wexner Cleveland Clinic Incontinence Score) and obstructed defecation (as measured by a surgeondocumented Altomare Obstructed Defecation Symptom Score). 7,8 Intraoperative variables included critical technical aspects of the procedures, such as approach (robotic, laparoscopic, open, and perineal), fixation technique (posterior suture, ventral mesh), addition of concomitant gynecologic procedures such as colpopexy, posterior repair, or colpocleisis. Postoperative variables were collected during the first 3 to 6 months after surgery and included a list of self-reported complications; patient hospital length of stay; patient symptoms of fecal incontinence (as measured by a surgeon-collected Wexner Cleveland Clinic Incontinence Score); and obstructed defecation (as measured by a surgeon-documented Altomarer Obstructed Defecation Score). ...
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BACKGROUND: Surgical treatment of recurrent rectal prolapse is associated with unique technical challenges, partially determined by the surgical approach used for the index operation. Success rates are variable, and data to determine the best approach in patients with recurring prolapse are lacking.
... Preoperative data collection included patient characteristics: sex, presence of concomitant vaginal prolapse and urinary incontinence, previous pelvic floor surgery, previous rectal prolapse repair, and information about the patient symptoms of fecal incontinence (as measured by a surgeon-collected Wexner Cleveland Clinic Incontinence Score) and obstructed defecation (as measured by a surgeon-documented Altomare Obstructed Defecation Score). 11,12 Intraoperative data included critical technical aspects of the procedures, such as approach (robotic, laparoscopic, open, perineal), fixation technique (posterior suture, ventral mesh), addition of concomitant gynecological procedures, or the addition of colpopexy or other procedures leading to resuspension of the middle compartment. Postoperative data collection included data collection on complications, length of stay, readmissions, and functional outcomes. ...
... Eligible patients from both the intervention (TAI) and control (conservative) groups were requested to answer four questionnaires (same as in the original study) [8]. Three questionnaires were sent regarding bowel function; the LARS score questionnaire [6,14], Cleveland Clinic Florida Fecal Incontinence Score (CCFFIS) [15] and fourstudy specific questions regarding bowel function ( [16,17]. ...
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Purpose The aim of the study was to explore long-term experiences of transanal irrigation (TAI) in patients with major low anterior resection syndrome (LARS). Methods The study included a qualitative and quantitative analysis of patients who developed major LARS after rectal cancer surgery between 2016 and 2019 and have undergone treatment with TAI. The patients received questionnaires. Mean scores were calculated with time-to-deterioration. Individual semi-structured interviews were performed and analyzed, according to Graneheim and Lundman with patients who performed TAI regularly for more than one year. Results In total 28 out of 39 patients responded to the questionnaires and 16 patients participated in the interviews. At mean 6-years follow-up, a 9.4 points difference in mean LARS score was obtained, (21.2 vs. 30.7) indicating less LARS symptoms in favor of the TAI treatment. Patients in the TAI group used less loperamide compared to the control group (36% vs. 79%). The use of bulky agents was similar. The interview text rendered into three main categories: regaining control in everyday life, need for structure and planning and becoming familiar with the procedure. Conclusions Treatment with TAI showed the potential to improve the quality of life of patients with major LARS. The improvements in their general well-being were valued over adjustments and time spent on TAI. Implications for cancer survivors Bowel dysfunction remains after 6-years with lower LARS scores favoring the TAI treatment. In the absence of a definitive treatment, survivors of rectal cancer coping with LARS have shown appreciation of the TAI treatment.
... However, no diagnostic criteria or definitions have been established for a long time due to the diversity and complexity of LARS symptoms. Consequently, the definition of LARS varies among articles and reports, with some using the Cleveland Clinic Incontinence Score (CCIS [Wexner score]), St. Marks' Fecal Incontinence Grading Score, Rockwood Fecal Incontinence Severity Index, or Kirwan classification, and others evaluating individual symptoms, such as stool frequency, defecation urgency, and the distinction between stool and gas [2][3][4][5]. Therefore, evaluation by systematic review or meta-analysis is difficult, and the incidence of LARS has not been clearly demonstrated [6]. ...
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Defecation disorders following rectal resection have long been overlooked as an inevitable surgical complication due to the lack of established diagnostic criteria or definitions. However, these disorders have been recently termed low anterior resection syndrome (LARS), which is a defecation disorder that occurs following rectal resection and impairs the patient's quality of life (QOL). The LARS score developed by Emmertsen et al., which is a patient-reported outcome measure to evaluate the severity of bowel dysfunction following rectal surgery by scoring the major symptoms of LARS, facilitates the diagnosis and assessment of LARS and enables international comparison and validation through the use of validated scores generated according to the international standards. Based on comparisons with other evaluation instruments, the use of the LARS score is strongly recommended internationally for LARS screening in patients following rectal resection. Recent findings have indicated that multiple pathophysiological changes, including reservoir function and evacuation of the neorectum, anal sphincter function, negative impact of a diverting stoma, autonomic denervation, and radiotherapy, are involved in the etiology of LARS. Due to the lack of established treatments and prevention of LARS, a suggested treatment chart for patients with LARS was presented in the Management Guidelines for Low Anterior Resection Syndrome (MANUEL) project. Future surgical treatment should focus not only on the radical cure of cancer and safety of treatment but also on the maintenance and improvement of QOL, with particular attention to the preservation of function. Particularly for rectal cancer, surgeons must formulate treatment plans that consider the prevention and treatment of LARS. Fullsize Image
... Clinical examination revealed a severe anoperineal lesion, and anoscopy identified an anterior ano-vaginal fistulous tract. At the time of the first evaluation, the patient's Cleveland Clinic Incontinence Score (CCIS) was 15 [6]. We used the Fecal Incontinence Quality of Life (FIQoL) questionnaire to assess the impact of the patient's condition on her everyday activities (Table 1) [7]. ...
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Background and Clinical Significance: Recto-vaginal fistulae (RVF) and fecal incontinence (FI) pose significant challenges for colorectal surgeons. Various therapeutic options have been proposed for each condition over time. Despite its procedural complexity and the risk of complications, graciloplasty remains a viable therapeutic option for both conditions, with favorable long-term results. To our knowledge, this is the first report of a case where the need to treat both conditions concurrently arose. Case Presentation: We report the case of a 54-year-old woman with severe FI and repeatedly operated on recurrent recto-vaginal fistula. The patient underwent graciloplasty to provide healthy tissue with an adequate vascular supply to both enhance the healing process of the fistula and reshape the anal canal with a circular muscular structure. Following the procedure, the patient experienced prompt symptom resolution and good clinical and functional recovery at a 1-year follow-up evaluation. Conclusions: This case report highlights the safety and effectiveness of an overlooked procedure for the treatment of large sphincter defects and concurrent recto-vaginal or recto-vaginal tears.
... However, there is a lack of high-level evidence on dose constraints to the anal region without any existing relevant prediction models of toxicity. In this study, using the Jorge & Wexner scale [6], we aimed to evaluate the relationship between RT parameters and dose constraints to the LFI incidence in a large singleinstitution cohort. ...
Article
Background Radiation‐induced late fecal incontinence (LFI) is one of the most quality‐of‐life impairing symptoms in prostate cancer. We aimed to assess the impact of radiotherapy (RT) technique and dose‐volume effects on LFI using a robust score. Methods We identified 409 patients who underwent curative intent using standard fractionated radiation therapy, 190 of them were finally included and analyzed. The severity of LFI was assessed using the Jorge & Wexner score. Results With a median follow‐up of 55 months (range 15–96) months, LFI crude rate was 11.5%. In the multivariate analyses, image‐guided radiotherapy (IGRT), rectal maximum dose (Dmax) and anal canal minimum dose (Dmin) were significantly associated with LFI risk. The use of IGRT was associated with lower risk of LFI ( p = 0.02); higher rectum Dmax (≥ 68.4 Gy; p = 0.02) and anal canal Dmin (≥ 6.4 Gy; p = 0.04) were associated with increased risk. Conclusion Our results suggest a significant impact of the total dose delivered to the anorectal volumes and the use of IGRT to spare organs at risk during radiation delivery.
... Preoperative evaluation followed the same standard protocol and included a thorough history, complete laboratory workup, psychological counseling, counseling by a dietician and Wexner score [10]. MRI Defecography was done to all patients to assess rectal prolapse, associated urogenital prolapse, and pelvic floor (Levator) hiatus. ...
Article
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Background and aims Rectal prolapse (RP) is a debilitating condition and can cause symptoms of fecal incontinence, obstructed defecation, incomplete evacuation of the rectum, and pain. In recent years, there has been increasing evidence that prolapse development is strongly associated with pelvic hiatus (GH) size (normal 4.5 +/- 0.7). Multiple surgical studies have suggested that an enlarged pelvic hiatus may be associated with prolapse recurrence. The main aim of this study is to assess the role of combining levatorplasty -with different rectal prolapse surgeries- on recurrence rate and improvement of symptoms in patients that were treated for rectal prolapse with wide pelvic hiatus. Patients and methods Our study is a combined retrospective and prospective cohort study which included sixty patients with rectal prolapse with wide pelvic hiatus, they were divided into two groups (each group thirty patients). One group underwent rectal prolapse repair, the other group underwent rectal prolapse repair with levatorplasty. Results Levatorplasty group showed improvement in Wexner score, recurrence rate in comparison to the other group. Both groups showed similar results in postoperative pain and dyspareunia. Conclusion Rectal prolapse repair combined with levatorplasty in patients complaining of rectal prolapse with wide pelvic hiatus have better outcome mainly in decreasing recurrence rate.
... For assessing gastrointestinal function, we analysed recorded clinical notes of fecal incontinence during patients' follow-up. This involved documenting bowel movement frequency, recording episodes of fecal or gas incontinence, and either utilising the LARS score [16] or other defecatory function assessment scales, such as St. Mark's incontinence score [17] or Wexner Continence score [18]. ...
Article
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Background Patients with rectal cancer often experience adverse effects on urinary, sexual, and digestive functions. Despite recognised impacts and available treatments, they are not fully integrated into follow-up protocols, thereby hindering appropriate interventions. The aim of the study was to discern the activities conducted in our routine clinical practice outside of clinical trials. Methods This multicentre, retrospective cohort study included consecutive patients undergoing rectal cancer surgery between January 2016 and January 2020 at six tertiary Spanish hospitals. Results A total of 787 patients were included. Two years post surgery, gastrointestinal evaluation was performed in 86% of patients. However, bowel movements per day were only recorded in 242 patients (46.4%), and the values of the Low Anterior Resection Syndrome (LARS) questionnaire were recorded in 106 patients (20.3%); 146 patients received a diagnosis of fecal incontinence (28.2%), while 124 patients were diagnosed with low anterior resection syndrome (23.8%). Urogenital evaluation was recorded in 21.1% of patients. Thirty-seven patients (5.1%) were detected to have urinary dysfunction, while 40 patients (5.5%) were detected to have sexual dysfunction. A total of 320 patients (43.9%) had their quality of life evaluated 2 years after surgery, and only 0.8% completed the Quality of Life questionnaire. Medication was the most used treatment for sequelae (26.9%) followed by referral to other specialists (15.1%). Conclusions There is a significant deficit in clinical follow-ups regarding the functional assessment of patients undergoing rectal cancer surgery. It is crucial to implement a postoperative functional follow-up protocol and to utilize technologies such as Patient-Reported Outcome Measures (PROMs) to enhance the evaluation and treatment of these sequelae, thereby ensuring an improved quality of life for patients.
... In addition to general QoL assessment tools, specific instruments are available to evaluate key aspects of patient well-being. The Wexner score, also known as the Cleveland Clinic Fecal Incontinence Score (CCFIS) is widely used to measure the severity of fecal incontinence [22], while the International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI) assess male and female sexual function, respectively [23,24]. ...
Article
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Rectal cancer is one of the most common carcinomas and a leading cause of cancer-related mortality. Although significant advancements have been made in the treatment of rectal cancer, the deterioration of quality of life (QoL) remains a challenging issue. Various tools have been developed to assess QoL, including the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) scale, the QLQ-C30 and QLQ-CR29 by the European Organization for Research and Treatment of Cancer (EORTC), and the 36-Item Short Form Health Survey (SF-36). Factors such as the lower location of the tumor, radiation therapy, chemoradiotherapy, and chemotherapy are associated with a decline in QoL. Furthermore, anastomotic leakage following rectal cancer resection is an important risk factor affecting QoL. With the development of novel treatment approaches, including neoadjuvant therapies such as chemoradiotherapy and total neoadjuvant therapy, the rate of clinical complete remission has increased, leading to the emergence of organ-preserving strategies. Both local excision and the “watch-and-wait” approach following neoadjuvant therapy improved functional outcomes and QoL. Efforts to improve QoL after rectal cancer surgery are ongoing in surgical techniques for rectal cancer. Since QoL is determined by a complex interplay of factors, including the patient's physical condition, surgical techniques, and psychological and social elements, a comprehensive approach is necessary to understand and enhance it. This review aims to describe the methods for measuring QoL in rectal cancer patients after surgery, the key risk factors involved, and various strategies and efforts to improve QoL outcomes.
... Patients' characteristics extracted from the prospectively maintained institutional database for the 2012 study included age, sex, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, past history of hysterectomy, previous surgery for RP whatever the technique and approach, psychiatric disease including past anorexia nervosa, history of chronic constipation and/or obstructive defaecation syndrome (ODS), 22 faecal incontinence de ned as a Jorge and Wexner score > 5, 23 onset of the prolapse de ned as < 1 year, ≥ 1 but < 5 years, and ≥ 5 years, conversion to laparotomy, and associated cystopexy and/or colpopexy and/or other procedure. ...
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Background Laparoscopic ventral mesh rectopexy (LVR) has gained increasing acceptance for the treatment of patients with a full-thickness rectal prolapse (RP), but the literature on follow-up of at least ten years is scarce. We studied recurrence rate, long-term functional results, and quality of life in patients who had LVR for RP more than twelve years ago. Method The study population consisted of patients who could be contacted among the 175 who had undergone LVR for RP and whose short and medium-term outcomes were published in 2012. We studied the long-term recurrence rate (Kaplan-Meier), functional outcome (Wexner and ODS scores), quality of life (EuroQol), and satisfaction of the patient through clinical examination(s), specific scores, and questionnaires. Results Of the 175 patients, 14 patients had exclusion criteria, 57 had died, and 42 were lost to follow-up, leaving 62 patients for analysis. Seventeen patients presented with a recurrence (10.5%) at the 10-year follow up. The only statistically significant risk factor for recurrence was recurrent RP (HR = 11.5 (2.54–52.2), p = 0.002). The median faecal incontinence score was 4 (0–10) and significantly worse in patients who had a recurrence (12 (7–13) vs 3 (0–9); P = 0.016). The median obstructive defaecation score was 6 (3–12). The median quality of life score was 7 (6–8). Most patients who presented with a recurrence said they would undergo the operation again and recommended it, as would patients with no recurrence. Conclusion LVR for RP is a safe and efficient technique with sustainable long-term results that shows long-term efficacy at more than 10 years after the operation.
... The Wexner Score ranges from 0-20, where 0 is perfect continence and 20 is complete incontinence (Table 1). 20 Complications were also classified and detailed by using the Clavien-Dindo system. 21 ...
Article
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Introduction: Anal fissures (AFs) are a prevalent pathology. Although internal lateral sphincterotomy is still the gold-standard surgery for treating chronic AFs, this procedure is associated with a considerable risk of anal incontinence. This study describes an alternative and minimally invasive technique for treating AFs using photobiomodulation and a high-power diode laser-fissure treatment (LFT) and highlights initial results pertaining to pain. Methods: This retrospective study focused on 38 patients treated with LFT on an outpatient basis at three different hospitals in different states of Brazil (Santa Catarina, Paraná, and São Paulo). The objective was to evaluate the effects of LFT treatment on AF patient pain following the procedure. The Friedman test was used to identify the effects of LFT treatment over time (D0, D7, D15, D30, and D60) on postoperative pain intensity using the visual analogue scale (VAS). Complications and incontinence rates were also analyzed. Results: Roughly two-thirds of the patients (66%; n=25) were male. The median age of the cohort was 49. Constipation was described by 32% of the patients, 13% were smokers, and 21% had recently used opioids. In 92% of the cases, the AF was localized posteriorly. Skin tags were present in 27% of the cases, and 26% had recently undergone a previous orificial surgery. A significant reduction in pain was observed over time in the intensity of postoperative pain measured by the VAS. Prior to surgery (D0), the patients’ mean VAS score was 4.1; it progressively decreased to 0.1 on the 60th postoperative day (P<0.05). There was no significant change in fecal continence at the end of the 60-day follow-up period. Minor complications occurred in 7.9% of the patients (2.6% hemorrhoidal thrombosis, 2.6% skin tag, and 2.6% "failure"). Conclusion: Our results suggest that treating AFs with laser therapy results in a significant reduction in pain intensity over time without interfering with anal continence.
... Anorectal function was assessed in 12 of the 20 included studies with the Wexner score (WS) being the reported outcome in all [18, 27-29, 31-36, 42, 44]. The WS is a validated patient-reported faecal incontinence symptom severity measure with scores ranging from 0, indicating no symptoms, to 20 indicating severe symptoms of faecal incontinence [45]. One study reported the LARS score [42]. ...
Article
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Purpose Anorectal and urogenital dysfunctions are common after rectal surgery and have a significant impact on quality of life. Intraoperative pelvic autonomic nerve monitoring (pIONM) has been proposed as a tool to identify patients at risk of these functional sequelae. This systematic review aims to evaluate the diagnostic accuracy of pIONM in detecting anorectal and urogenital dysfunction following rectal surgery. Methods A systematic review of articles published since 1990 was conducted using MEDLINE, Embase, CINAHL, Google Scholar, Scopus, and Web of Science. Studies describing pIONM for rectal surgery and reporting anorectal or urogenital functional outcomes were included. The risk of bias was assessed using the QUADS-2 tool. The diagnostic accuracy of pIONM was established with pooled sensitivity and specificity alongside summary receiver-operating characteristic curves. Results Twenty studies including 686 patients undergoing pIONM were identified, with seven of these studies including a control group. There was heterogeneity in the pIONM technique and reported outcome measures used. Results from five studies indicate pIONM may be able to predict postoperative anorectal (sensitivity 1.00 [95% CI 0.03–1.00], specificity 0.98 [0.91–0.99]) and urinary (sensitivity 1.00 [95% CI 0.03–1.00], specificity 0.99 [0.92–0.99]) dysfunction. Conclusions This review identifies the diagnostic accuracy of pIONM in detecting postoperative anorectal and urogenital dysfunction following rectal surgery. Further research is necessary before pIONM can be routinely used in clinical practice. PROSPERO Registration Details CRD42022313934.
... Foi validada para a população portuguesa do Brasil em 2014 e é uma escala de fácil e rápido preenchimento (Meinberg, 2014). No que respeita as propriedades psicométricas, o instrumento apresenta: boa consistência interna, com o valor de Alpha de Cronbach de 0,932, elevada confiabilidade e bons valores de reprodutibilidade (p= 0,354) ( Jorge & Wexner, 1993). Esta escala apresenta 5 itens: 3 relativos à consistência (sólido, líquido e gases), 1 relativo ao uso de absorventes e outro diz respeito à alteração do estilo de vida. ...
Article
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Metodologia: estudo de caso com uma participante de 64 anos, professora, autónoma, com diagnóstico de IF devido a sequela de cirurgia a prolapso retal. Realizou-se um programa de Treino dos Músculos do Pavimento Pélvico (TMPP), de uma sessão/semana, durante 16 semanas, supervisionado por Biofeedback anorretal. Cada sessão demorou 45 minutos, dos quais 20 minutos para TMPP e o restante para o exame físico, terapia manual, massagem e ensinos/registos da doente: diário de sintomas, supervisão da gestão da alimentação, treino intestinal, técnicas/posturas de defecação e suporte emocional. Na primeira sessão (T0) e na última (T1), foi ainda efetuado a anamnese, Índice de Wexner, Bristol Stool Form Scale (BSFS) e Fecal Incontinence Quality of Life (FIQL). Os resultados evidenciaram ganhos na força dos MPP, que evoluíram de grau 2 para 4 na escala de Oxford modificada; na qualidade de vida (QdV), ausência de perdas fecais, as fezes passaram de consistência tipo 2 para 4 na BSFS. Conclusão: o programa de reabilitação uropélvica, mostrou-se eficaz na reeducação dos MPP e melhorou significativamente a QdV da participante.
... Patients were randomized into two groups, a study group (SG) and a control group (CG), via computer. Patients were evaluated for incontinence before the first operation using the Wexner fecal incontinence score (WIS) [7]. ...
... The CCF-FI is one of the most used scoring systems globally to help patients assess severity with their doctors. By using the scoring system, we tried to get a universal view of all aspects of fecal incontinence, and the overall impact on the incontinence was assessed by evaluating the 14 total CCF-FI score. ...
Article
Background: Sphincter-saving procedures for anal fistula have been seldom assessed compared to conventional procedures. This study addressed this research need gap with respect to outcomes, incontinence, and recurrence rate. The prospective, compar Methodology: ative, single-center study included patients with history of fistula-in-ano between the age group of 18–60 years of coming to surgical OPD or ward. All patients were subjected to the usual standardized pre-operative and post-operative protocol. The assessment of Cleveland Clinic Florida Fecal incontinence score (CCF-FI) and pain visual analogue score (VAS) was done to evaluate patient outcomes post-surgery. 100 fistula-in-ano cases were Results: enrolled and randomized in conventionalsurgery group and the sphincter-saving-surgery groups (50 patients each). Baseline patient characteristics were comparable (p>0.05). Most patients in both, the conventional fistulectomy group (64%) and sphincter saving group (62%) were having trans-sphincteric type of anal fistula. At all time-points, the mean CCF-FI scores for gas, use of pad for stools, lifestyle alteration, as well as the total CCF-FI scores were comparable between study groups (p>0.05). Mean pain VAS score was significantly lower in the sphincter saving group at 2-weeks and 4-weeks post-surgery (p<0.05) versus conventional fistulectomy group. 1 patient in conventional fistulectomy group and 3 patients in sphincter-saving group experienced recurrence. Based on fecal incontinence Conclusion: status, no difference in outcomes was noted between the conventional and sphincter-saving surgery groups. However, the postoperative pain was noted to be significantly lower in the sphincter saving surgery group. Recurrence rates were low and comparable between both surgery groups.
... В научных трудах всего мира можно найти огромное количество опросников и шкал, оценивающих качество жизни как в целом, так и в отношении отдельно взятых аспектов повседневной жизни. Так, например, в колоректальной хирургии и хирургическом лечении травматического анального недержания (АН) для планирования лечения и оценки его эффективности в международной практике наиболее часто применяются такие инструменты, как Wexner Incontinence Score (Cleveland Clinic Fecal Incontinence Severity Score), PISQ-12 и Fecal incontinence quality of life scale (FIQL) [1][2][3]. ...
Article
Aim . To evaluate the effectiveness of the cultural and linguistic adaptation of the Fecal Incontinence Quality of Life Scale (FIQOL) for the Russian-speaking population. Methods : A cultural and linguistic adaptation of the FIQL questionnaire was performed in accordance with international guidelines. This process included several key steps: professional translation of the questionnaire, back translation, and critical discussion within an interdisciplinary council comprising translators, linguists, psychologists, doctors, and patients. Preliminary testing and reliability assessment were also conducted. The results of the preliminary testing are presented in this article. A total of 26 patients who had undergone surgical treatment for anal incontinence (sphincterolevatoroplasty) between 2016 and 2022 participated in the preliminary testing phase. Results . The result of the cultural adaptation is the Russian language version of the Fecal Incontinence Quality of Life Scale (FIQOL), which has undergone all the aforementioned stages with corrections and comments in the order of the council of doctor-translator-psychologist-patient. The average time elapsed from the moment of surgery to the survey was 32 months (SD = 20). The average overall score of the questionnaire was 3.2 (SD = 0.62), the average score on the ‘Lifestyle’ scale was 3.3 (SD = 0.74), the average score on the ‘Behaviour, daily worries’ scale was 3.2 (SD = 0.65), the average score on the ‘Depression and self-perception scale was 3.4 (SD = 0.91) and the average score on the ‘Shame’ scale was 3.2 (SD = 0.71). The assessment of the reliability of the questionnaire, as shown by the alpha-Kronbach coefficient, was 0.94, which corresponds to the assessment of ‘very good reliability’. Conclusion . The presented data show that the Russian version of the Fecal Incontinence Quality of Life Scale (FIQOL) is adapted for use by Russian-speaking patients and specialists, is reliable, and can be used as a primary tool for assessing the quality of life of patients with anal incontinence.
... Hartmann's procedure), frequency of relaparotomies, interventional drainage, completion of intended adjuvant chemotherapy, frequency of an ostomy at 6 months after index surgery, mean length of bearing an ostomy, overall length of postoperative hospital stay and survival. Furthermore, the postoperative anorectal function was assessed by the Wexner score at 6 months after surgery and quality of life was assessed by the EORTC QLQ-C30 and CR29 at 3 and 6 months postoperatively [17][18][19]. More detailed information about the outcome parameters can be found in the previously published protocol [13]. ...
Article
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Purpose The objective of the current pilot trial was to evaluate whether ghost ileostomy is a safe alternative to the current standard of care in terms of a conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision (LAR/TME) for rectal cancer. Methods This randomized controlled pilot trial included patients undergoing LAR/TME, randomly assigning them to ghost ileostomy or conventional loop ileostomy intraoperatively. Follow-up spanned 6 months, evaluating the following endpoints: comprehensive complication index (CCI), postoperative morbidity, transformation of ghost ileostomy, presence of ostomy at 6 months, Wexner score, and quality of life (EORTC QLQ-C30 & CR29). Exploratory statistical analysis based on the intention-to-treat principle was conducted. Results Recruiting 30 patients from May 2018 to September 2022, the trial was prematurely stopped due to slow recruitment. The mean CCI was comparable between groups at any point of time (at 6 months: 30.7 vs. 29.7, p = 0.889). There was no mortality and no need for creation of a terminal ostomy. Anastomotic leakage rates were similar in ghost ileostomy and loop ileostomy groups (p > 0.99). The ghost ileostomy was converted into a conventional loop ileostomy in 6 of 15 (40.0%) patients. Neither postoperative function, nor the overall quality of life showed significant differences. Conclusion Ghost ileostomy appears as a viable and safe option for selectively deciding ileostomy creation in LAR/TME for rectal cancer. However, challenges in patient selection, excluding those at high risk for anastomotic leakage, limit widespread application and call for optimization in future research. Trial-registration German Clinical Trials Register (https://drks.de/): DRKS00013997; date of registration: April 9th 2018.
... During follow-up, any sign and/or symptom of perianal disease was recorded and the Perianal Disease Activity Index (PDAI) and CDAI were collected. The patients' continence was evaluated through the Wexner score [22]. Possible adverse events such as hemorrhage, eczema and perianal pain were also assessed during the follow-up appointments. ...
Article
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Objectives: Crohn's perianal fistula represents a challenging condition to treat. Sphincters-preserving surgical techniques are increasingly being adopted as repeated surgical procedures may lead to various degrees of incontinence. This prospective study aims to assess the long-term efficacy of collagen paste application in patients with simple and complex Crohn's perianal fistulas. Methods: Patients with Crohn's perianal fistula (simple or complex) and inactive luminal disease were enrolled. The fistula tract was treated by curettage and injection of acellular, porcine dermal collagen paste between 2019 and 2021. The primary endpoint was the clinical healing of the fistula at 12 and 24 months, defined as the absence of suppuration on clinical examination. The trial was preregistered on a public repository (ClinicalTrials.gov; NCT03776825). Results: Fourteen patients were included in the study, ten patients (71%) had complex perianal fistula. All patients underwent previous fistula operations. Nine patients (64%) reached complete clinical remission at 12 months, two patients (14%) had a clinical recurrence six months after surgery, and three patients (21%) at 12 months follow-up. Three relapsed patients presented postoperative abscesses. Twelve patients (86%) were followed up at 24 months, no further clinical recurrences or complications were observed and the complete healing rate was 58%. No continence disturbances were recorded after collagen paste injection. Conclusions: The results suggest that collagen paste injection may represent a safe and effective option for Crohn's perianal fistulas, worth further investigation in larger trials. Fullsize Image
Article
Patients with pelvic organ prolapse (POP) often have simultaneous defecation disorders in the form of obstructive defecation syndrome (ODS) or anal incontinence. The underlying causes include functional pelvic floor dyssynergia, spasms of the pelvic floor muscles and anatomical changes such as rectocele, enterocele, rectal intussusception and external rectal prolapse. Although conservative and surgical treatment of POP alone often leads to an improvement in bowel function, these symptoms can persist or worsen postoperatively. Therefore, in patients with combined symptoms, interdisciplinary diagnostics and treatment planning are advisable in order to provide a multimodal treatment concept consisting of interprofessional conservative strategies and joint surgical planning adapted to the existing disorders.
Chapter
In this chapter, we focus on the various digestive symptoms that may, alone or in combination with each other, contribute to significant clinical problems and alterations in the quality of life of patients with gut PD. Our emphasis highlights what triggers these symptoms and what needs to be done about them.
Article
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Purpose This study aimed to determine the optimal natural orifice specimen extraction (NOSE) method for robotic-assisted mid-rectal cancer resection in women. Methods This retrospective propensity score-matched (PSM) study was to analyze the clinical data prospectively collected from female rectal cancer patients who underwent either robotic-assisted transvaginal specimen extraction (RATV) or robotic-assisted transanal specimen extraction (RATA) at our center between June 2016 and December 2022. The main outcome measures were urinary, anal, and sexual function. Disease-free survival (DFS), and overall survival (OS) were also included . Results Anal function, assessed by the Wexner score, was better in the RATV group than in the RATA group (P = 0.034). Additionally, pre-menopausal women in RATV group exhibited superior anal function over those in RATA group (P = 0.031). There was no statistically significant difference in urinary function between the groups for both pre-menopausal and peri-menopausal patients (P = 0.711, P = 0.106). No difference was observed in sexual function between the two groups (P = 0.351); however, pre-menopausal patients in RATA group had better sexual function than those in RATV group (P = 0.045). Univariate logistic regression analysis showed surgical procedure was not a significant factor for the occurrence of sexual dysfunction. There were no significant difference in DFS (P = 0.845)and OS (P = 0.642) between the two groups. Conclusion Though the postoperative efficacy of the RATA and RATV was equivalent on urinary and sexual function, RATV is an optimal natural orifice specimen extraction for robotic middle rectal cancer resection in women based on anal function.
Chapter
Transanal total mesorectal excision (taTME) constitutes a novel approach for the radical removal of the rectum. The procedure was designed to take advantage of the natural orifice surgery concept; it allows for the bottom-up dissection of the rectum through the insertion of either a flexible or rigid transanal platform. Historically, removal of the rectum represents a technical challenge due to the anatomical constraints posed by the rigid pelvis. The procedure gathered great interest from surgeons across the world; this ultimately met significant scrutiny after the publication of a local moratorium from Norway. The procedure is done by either a sequential or a synchronous approach with single or dual teams, respectively. Surgeons can use specifically designed equipment or adapt laparoscopic instruments for this procedure. Standardization of the procedure for the learning and safe implementation of the procedure have not been agreed upon. Despite having mastered the technique, the authors recognize that taTME has the potential for devastating and otherwise infrequent complications; therefore extreme caution is recommended if a decision is made to embark in the implementation of taTME. We present our perspective and experience on this complex intervention.
Article
Background and aim High complex anal fistula is a clinical challenge for proctologists and a nightmare for patients. Although the sphincter-sparing approach seems an ideal surgical intervention, there remains room for improvement in treatment efficacy. Herein, we introduce an enhanced sphincter-sparing approach, namely the fistula occlusion with the internal sphincter flap (FOISF), for treating high complex anal fistulas. Methods This study evaluated 15 patients with high complex anal fistulas who underwent FOISF between October 2021 and December 2022 in the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou, P. R. China). Data on success rates, anal function, and various surgical characteristics were subjected to rigorous analysis. Results All patients underwent the FOISF procedure, with a median operation time of 53 min. Fourteen patients achieved primary intention healing, while one patient healed by second intention. No recurrence was observed over a follow-up period of 14–30 months. All patients exhibited satisfactory anal continence, with no statistically significant difference observed between preoperative and postoperative Wexner scores (P = 0.331). A significant improvement in the quality of life was observed when compared with the preoperative assessment (P < 0.001). Conclusion The preliminary results of the FOISF procedure present an effective approach to treat high complex anal fistula.
Article
Unsuccessful first-line conservative treatments for managing fecal incontinence (FI) lead to considering predominantly invasive options, posing challenges in terms of cost and patient acceptance of benefit/risk ratio. Recent data from a prospective randomized study have highlighted intramural rectal botulinum toxin (BoNT/A) injection as a promising minimally invasive alternative for urge FI, demonstrating efficacy at 3 months but lacking long-term evidence. This study aimed to evaluate the sustained efficacy and injection frequency of intramural rectal BoNT/A injection in the treatment of urge FI. This retrospective monocentric study enrolled all patients who underwent intramural rectal BoNT/A injection for urge FI after failed conservative therapy or sacral neuromodulation (SNM). Injections were administered during sigmoidoscopy, delivering 200 U of BoNT/A at 10 circumferentially distributed sites. Treatment effectiveness was assessed using the Cleveland clinic incontinence score (CCS) and a visual analog scale (VAS) to measure the severity of discomfort related to episodes of fecal urgency, with reinjection performed upon symptom recurrence. In total, 41 patients (34 females) were included, with a median follow-up of 24.9 (range 3.2–70.3) months. Overall, 11 patients had previously failed sacral nerve stimulation. Significant reductions were observed in the CCS (median 11 versus 7, p = 0.001) and VAS symptoms (median 4, range 0–5 versus median 2, range 0–5, p = 0.001). In total, 22 patients (53%) experienced a reduction in the CCS by over 50%. The median interval between intramural rectal BoNT/A injections was 9.8 months (range 5.3–47.9 months). This study provides the first evidence of the sustained efficacy of intramural rectal BoNT/A injection for urge FI. Further investigations are warranted to refine patient selection and reinjection criteria, evaluate socioeconomic impacts, and compare rectal BoNT/A injection with other therapeutic modalities.
Article
Objectives This scoping-review sought to summarize the current knowledge on the epidemiology, pathogenesis, clinical presentation, and the investigations that may help characterize faecal incontinence (FI) in patients with systemic sclerosis (SSc). Methods The planned scoping review was based on the methodological framework proposed by Arksey & O’Malley.Two databases were screened: PubMed (Medline), (webofSciences), data extraction was performed using a predefined template. Results 454 abstracts were screened and 61 articles were finally included, comprising 32 original articles. The prevalence of FI was 0,4% to 77% in original articles that did not use FI among the mandatory inclusion criteria. Internal anal sphincter was reported as more impacted than external sphincter and vasculopathy of arterioles and extra-cellular matrix deposition with fibrous replacement of the internal sphincter were the key underlaying pathogenic events. The most represented PRO in original articles was the Wexner FI score (22% of original articles) followed by the UCLA SCTC-GIT 2.0 (16% of original articles). Although there is no validated diagnostic approach for FI in SSc, 47% of original articles used anorectal manometry to assess rectal physiology in SSc patients. Conservative measures to treat either liquid or hard stool including anti-diarrheal medications and dietary adjustments were the first step of proposed FI management in included narrative reviews and guidelines. Conclusion This is the first scoping review exploring FI in SSc. We propose a new research agenda which may help improve treatment strategies and foster research focusing on a neglected manifestation of SSc.
Article
Rectal prolapse often affects women but may also affect men. This systematic review aimed to provide outcomes of surgery for complete rectal prolapse reported in studies with a predominantly male population. This PRISMA-compliant systematic literature review searched PubMed and Scopus between January 2000 and February 2024; Google Scholar was queried for studies reporting outcomes of complete rectal prolapse surgery in predominately (> 90%) male populations. Main outcome measures were recurrence, complications, operative time, and bowel function. Eight studies (452 patients; median age 45.6 years) were included; 80.5% of patients underwent abdominal procedures whereas 19.5% underwent perineal procedures. The prevalence of recurrence was 11.2% after ventral mesh rectopexy (VMR), 0.8% after posterior mesh rectopexy (PMR), 0 after resection rectopexy, and 19.3% after perineal procedures. The prevalence of complications was 13.9% after VMR, 13.1% after PMR, 43.3% after resection rectopexy, and 17.4% after perineal procedures. The most improvement in constipation was noted after resection rectopexy (83.3–100%) and in fecal incontinence (FI) was noted after posterior mesh rectopexy (86.4–90%). Abdominal procedures had lower rates of recurrence (6% vs. 19.3%, RR 0.50, 95% CI 0.21–1.18, p = 0.113), similar complication rates (14.3% vs. 13.6%, RR 0.41, 95% CI 0.06–2.9, p = 0.374), and longer operative times (116 ± 47.2 vs. 74.2 ± 23.6 min, p < 0.001). Treatment of rectal prolapse in male patients undergoing abdominal procedures was associated with longer operative times, lower recurrence rates, and similar complications to perineal procedures. PMR and resection rectopexy had the lowest recurrence. The most improvement in FI and constipation was noted after PMR and resection rectopexy, respectively.
Article
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The innervation of the puborectalis and external anal sphincter muscles was studied in 32 patients with idiopathic (neurogenic) faecal incontinence, 12 of whom also had complete rectal prolapse, using transcutaneous spinal stimulation, transrectal pudendal nerve stimulation, single fibre EMG, anorectal manometry, and measurement of perineal descent. Fourteen normal subjects served as controls. Significant increases in the spinal motor latencies from L1 to the puborectalis and external anal sphincter muscles were shown in all 32 incontinent patients (p less than 0.01). The single fibre (EMG) fibre density was increased in the puborectalis muscle in 60% and in the external anal sphincter in 75% of patients. An increased pudendal nerve terminal motor latency was found in 68% of patients; 69% had an abnormal degree of perineal descent and all had reduced anal canal contraction pressures. These data show that the different innervations of the puborectalis and external anal sphincter muscles are both damaged in patients with anorectal incontinence.
Article
Loss of control of the anal sphincter may result from distant lesions, chiefly involving the central nervous system and resulting in paralysis, or from local injuries to the muscle itself or to the nerves entering it. Of the second group of cases perhaps a majority are due to surgical operations, often undertaken with clear knowledge that incontinence may result, but nevertheless necessary. The condition is most distressing. It is frequently associated with a greater or less degree of prolapse of the rectal mucosa. Incontinence may be partial or complete. Often with a high degree of incontinence and marked prolapse the patient not only is unfitted for any form of social life, but is so uncomfortable physically as to be actually bedridden. A number of methods have been described for the treatment of anal incontinence. I have tried most of them, from simple suture of the remnants of the damaged muscle
Article
Manometric testing was performed on three groups of subjects: 14 patients complaining of fecal incontinence, 14 age- and sex-matched continent patients, and 14 sex-matched younger normal controls. The younger group displayed significantly stronger contractions of the external anal sphincter and puborectalis than the two patient groups, which did not differ. No differences were found in the relaxation of the internal and sphincter. The incontinent group required a significantly larger stimulus in order to detect rectal distension compared to either the continent patients or the younger normals. An additional group of unmatched normals and incontinent patients demonstrated significant differences in their ability to retain rectally infused saline. The patients leaked sooner and retained less; however, the performance of the normals was considerably reduced from that reported in previous studies. The aging process seems to result in weakening of the striated muscles of the anal canal, although fecal incontinence need not occur. The afferent limb of the anorectal sensorimotor mechanism does not necessarily deteriorate with aging. A lower threshold for sensation of rectal distension among continent individuals apparently helps them to avoid incontinent episodes, even though maximum contractile pressures in their anal canal are no different from a comparable group of incontinent individuals.
Article
The contribution of the resting anal canal pressure (RAP) and the maximal squeeze pressure (MSP) to the problem of fecal incontinence was assessed by comparing 143 incontinent patients to a control population of 157 healthy subjects. These parameters were determined using a multilumen continuously perfused catheter and a mechanized rapid pull-through technique. In 10 male volunteers both RAP and MSP were determined using catheters that varied from 3 mm to 18 mm in diameter. In the control population, the RAP was significantly lower in females 40 years of age and over as compared to males. MSP values were significantly lower in females at virtually all ages. In women, parity did not correlate with RAP (coefficient = -0.099, P greater than 0.05) and MSP (coefficient = -0.123, P greater than 0.05) and any decrease in pressures was related to aging. Aging in women was associated with a consistent reduction in RAP (coefficient = -0.614, P less than 0.00005) and MSP (coefficient = -0.372, P = 0.0006). In males, there was a similar but less impressive age-related reduction for the RAP (coefficient = -0.333, P = 0.006) but not for the MSP (coefficient = -0.196, P greater than 0.05). Nine percent of the volunteer population were essentially unable to increase the RAP with maximal squeeze efforts. A linear increase in anal pressures was recorded as catheter diameter increased from 3 to 12 mm. Normative data for the RAP and MSP (mean +/- 2 SD) were constructed for each sex on a decade basis and showed a wide range of pressures for each age grouping. In the group with fecal incontinence (FI) 39% of females and 44% of males fell within the "normal" range for both the RAP and MSP. For all patients with FI, 41% and 17% had impairment of one or both parameters, respectively. It is concluded that: aging affects the RAP in both sexes but to a greater degree in women. The MSP is related to aging in women only; child bearing has no effect upon these parameters; clinical problems of bowel control can occur when sphincter pressure measurements are within the low "normal" range; and recording instrument diameter consistently affects RAP and MSP.
Article
The frequency of urgency and fecal soiling in the population and among people with irritable bowel syndrome (IBS), and the association of these symptoms with health care seeking is unknown. Among 1128 students and hospital employees that we surveyed, urgency was reported in 14.4%, fecal soiling in 5.3%, and diarrhea in 9.0%. Most persons with fecal soiling did not report urgency or diarrhea. Although bowel dysfunction compatible with IBS was present in 20% (227), only 29% of this group (65) had seen a physician for bowel complaints. People with bowel dysfunction were more likely to be women, to take laxatives, and to have rectal urgency. Fecal soiling was more likely among those with bowel dysfunction who had been to the doctor, and included almost half of the men in this group. There was no difference in the frequency of diarrhea reported among those with bowel dysfunction regardless of whether they had been to the doctor. These data suggest fecal soiling may influence people with bowel dysfunction to go to the doctor. Physiological studies are needed to determine if anal sphincter dysfunction is a component of IBS.