Evaluation of the role of cyanoacrylate glue in the management of fistula-in-ano

Background: Fistula in ano is a common problem in patients presenting to surgical OPD. Various procedures have been described for the treatment of anal fistula, including fistulectomy, fistulotomy and use of a cutting seton. Surgical treatment of anal fistula is associated with a significant risk of recurrence and faecal incontinence due to damage to anal sphincter. The introduction of cyanoacrylate glue to close fistula tracts using an occlusive material and with no risk of incontinence (as there is no sphincter damage). The study was designed to evaluate the role of cyanoacrylate glue in the management of fistula in ano.Methods: Here, 40 patients were enrolled in study as day cases. Patients were examined clinically and subjected to MRI pelvis where internal opening couldn’t be palpated on digital rectal examination (DRE). Fistula tract was mapped using fistula probe and washed with diluted hydrogen peroxide and normal saline. The excess granulation tissue at the external opening was curetted. The glue was then injected slowly into fistulous tract through 8 F infant feeding tube. Patients were further examined in the OPD until 6-months.Results: Here, 32 patients got healed after first instillation of glue with stoppage of discharge from the fistulous tract. The other 2 patients required second instillation of glue and showed no signs of discharge thereafter. While 6/40 continued to discharge even after instillation of glue.Conclusions: Cyanoacrylate glue can be offered as a sphincter sparing alternative to conventional procedure in patients with anal fistula.

Research progress of sacral neuromodulation procedure in the treatment of chronic constipation and fecal incontinence / 中华胃肠外科杂志

Sacral neuromodulation (SNM) procedure has become a new therapy to treat chronic constipation and fecal incontinence. The surgical procedure is easy and safe. It has a small incision compared with traditional surgery and is mainly used in patients whose traditional treatment was unsuccessful. Chronic constipation is one of the most common digestive symptoms. The quality of life in patients with severe constipation has decreased greatly. Although the incidence of fecal incontinence in China is not as high as that of constipation, it also seriously affects the life of the patients, resulting in a decline in the quality of life. Although the mechanism of SNM is uncertain, with more studies conducted, understanding has become more profound, and the curative effect has been recognized. SNM can improve the symptoms and the quality of life. Many studies have reported SNM treatment. Furthermore, some trials on SNM have been conducted. It is used after colorectal resections to promote symptoms of bowel dysfunction. However, few studies reported regarding SNM for constipation and fecal incontinence in China, and knowledge regarding SNM is limited. In this article, we will mainly discuss SNM in the treatment of chronic constipation and fecal incontinence, and its research progress on the mechanism and method, surgical procedure, effectiveness, complications, postoperative contraindications, and the population who need to pay attention, in order to provide reference for the treatment of SNM in China.

Health-seeking behaviour among patients with faecal incontinence in a Malaysian academic setting

Background: Faecal incontinence (FI) is not a commonpresenting complaint in Malaysia, and little has beenpublished on this topic. Since it is a treatable condition, agreater understanding of factors contributing to healthseekingbehaviour is needed in order to plan effectiveprovision of services.Methods: A survey of 1000 patients and accompanyingrelatives, visiting general surgical and obstetrics andgynaecology clinics for matters unrelated to FI, wasconducted at University Malaya Medical Centre betweenJanuary 2009 and February 2010. A follow-up regressionanalysis of the 83 patients who had FI, to identify factorsassociated with health-seeking behaviour, was performed.Variables identified through univariate analysis weresubjected to multivariate analysis to determineindependence. Reasons for not seeking treatment were alsoanalysed.Results: Only eight patients (9.6%) had sought medicaltreatment. On univariate analysis, the likelihood of seekingtreatment was significantly higher among patients who hadmore severe symptoms (OR 30.0, p=0.002), had incontinenceto liquid stool (OR 3.83, p=0.002) or when there was analteration to lifestyle (OR: 17.34; p<0.001). Nevertheless, theonly independently-associated variable was alteration inlifestyle. Common reasons given for not seeking treatmentwas that the condition did not affect patients’ daily activities(88.0%), “social taboo” (5.3%) and “other” reasons (6.7%).Conclusions: Lifestyle alteration is the main driver of healthseekingbehaviour in FI. However, the majority do not seektreatment. Greater public and physician-awareness on FIand available treatment options is needed.

The Role of Anorectal Physiology Tests in Ulcerative Colitis; Challenging 3 Cases.

Benign functional anorectal disorders such as faecal incontinence or constipation can be concomitant issues in inflammatory bowel disease (IBD) whether the main disease is under control or not and they lead to negative impact on patients’ quality of life. However, reports regarding these anorectal disorders and anorectal physiologic features in patients with IBD are rare and routine diagnostic tests and therapeutic options for these pelvic floor disorders reported by IBD patients are often underused. Anorectal physiology tests are important in patients with inflammatory bowel diseases, to better diagnose any symptomatic and concomitant anorectal functional disorders in order to avoid unnecessary medical or surgical therapies and to tailor the most suitable treatment modalities for the patients. Three challenging patients with ulcerative colitis (UC) under deep remission but having different defecatory and functional bowel problems are summarized here, under the guidance of specific anorectal physiology tests.

Does Patient Position Influence the Results of Three-dimension High Resolution Ano-rectal Manometry?.

Aims: Anorectal manometry is the current gold standard to explore anorectal functional disorders. Recently, three-dimensional high-resolution anorectal manometry (3DHRAM) was developed. However, although procedures are usually performed in the left lateral decubitus position, anorectal symptoms usually occur in the erect or in the sitting position. Our aim was to prospectively compare the values obtained with 3DHRAM in the left lateral decubitus position versus the erect position. Study Design and Setting: A monocentric prospective study was conducted at a tertiary referral center, in the Department of Gastroenterology, Hôpital Nord, Marseille, France. Study Duration: Study was conducted from June 2013 to March 2014. Methodology: All patients referred to our center for 3DHRAM and endoanal ultrasonography to explore faecal incontinence or constipation were eligible. The 3DHRAM was successively performed by the same operator in the left lateral decubitus and then in the erect position. For each patient, the body mass index, the values of the KESS score or of the Wexner score were systematically rated. Results: Forty patients were included in this prospective study (20 with constipation, 20 with faecal incontinence). The median anal resting pressure was the only significantly different parameter between the left lateral decubitus and the erect position, both in patients suffering from constipation or from faecal incontinence (p=0.02 and p<0.001 respectively). All pressures values, as well as anismus diagnosis, were well correlated between the two positions, except the high-pressure zone, the sensation threshold and the need to defecate. Conclusion: In this study, only the median anal resting pressure was significantly different between the two positions. The good correlation between anal pressures values obtained in the two positions allows achieving 3DHRAM in the left lateral decubitus.

Relación entre el grado de incontinencia fecal y el daño del esfínter anal externo / Relationship between faecal incontinence severity and external anal sphincter disruption

Introduction: Faecal incontinence (FI) represents an important psychological and social condition for an individual. There are several causes for FI, therefore its study and management is complex. Among different aetiologies, anatomical disruption of the external anal sphincter (EAS) as a consequence of anorrectal surgery or obstetric injury can be studied by endoanal ultrasound (EAUS). This study focus on anatomical assessment of sphincter muscle injury of EAS and its relationship with clinical presentation con FI. Objective: Compare anatomical and disruption of EAS features studied by 3D-EAUS between patients with FI, according to its severity. Methods: 3D-EAUS images were obtained from selected patients studied for FI between January 2008 and July 2010 at Clínica las Condes. Wexner Score (SW) was used to evaluate severity of FI, dividing patients into two categories: Mild FI (SW < 9) and Severe FI (SW ≥ 9). A single observer evaluated different morphological variables: width, length, percentage and angle of EAS disruption. Parametrical and non-parametrical analysis was used as appropriate. P-value < 0.05 was considered statistically significant. Results: From 31 female patients studied, mean SW was 11.7 +/- 0.8 points, range from 5 to 20 points. When dividing into two groups, 9 patients had mild FI and 22 had severe FI. Studied variables in EAUS 3D cubes: width, length, percentage and angle of EAS disruption, did not reach statistical significance between groups. Conclusion: No relationship was found between external anal sphincter anatomic injury variables studied and severity of faecal incontinence.

Introducción: La incontinencia fecal (IF) se refleja en una condición psicológica y social importante para el individuo. Las causas de IF son múltiples, siendo su estudio y manejo complejo. La disrupción anatómica del esfínter anal externo (EAE), secundaria, entre otras, a cirugía anorrectal o lesión obstétrica, es posible de ser estudiada por endosonografía anal (EAUS). El presente artículo se centra en el daño anatómico del EAE y su relación con la presentación clínica de la IF. Objetivo: Comparar las características anatómicas y daño del EAE objetivadas mediante endosonografía en 3 dimensiones (EAUS3D), entre los pacientes con IF según su severidad. Material y Método: Se obtuvo las EAUS3D realizadas en Clínica Las Condes por estudio de IF entre enero de 2008 y julio de 2010. Se utilizó el score de Wexner (SW) para separar la población en dos grupos, IF leve (SW < 9) e IF grave (SW ≥ 9). Un único observador evaluó las diferentes variables: grosor, longitud, porcentaje de defecto y ángulo de lesión del EAE. Se utilizó estadística paramétrica o no-paramétrica según corresponda. Se consideró significativo p < 0,05. Resultados: De un total de 31 pacientes femeninas estudiadas, el SW promedio fue de 11,7 +/- 0,8 con rango entre 5 y 20 puntos. Al separar según grupos, 9 pacientes tenían IF leve y 22 IF grave. De las variables estudiadas por EAUS3D: el promedio, grosor, longitud, porcentaje de defecto y el ángulo de lesión del EAE no lograron diferencia estadística entre los grupos. Conclusión: No existe una relación directa entre las variables estudiadas de daño anatómico del EAE y el grado de IF.

Biofeedback therapy combinell with electrical stimulation in the treatment of traumatic faecal incontinence / 中华物理医学与康复杂志

Objective To observe the effect of biofeedback therapy combined with electrical stimulation in patients with traumatic faecal incontinence.Methods Eishty-two patients with traumatic faecal incontinence were treated once daily with electric stimulation delivered via an intra-anal electrode.They also followed a biofeedback regimen including strengthening,sensory and coordination biofeedback.The whole progrtun consisted of 3 sessions of supervised treatment in hospital followed by 3 sessions of home therapy(10 days per session with an interval of 7days between the sessions).Clinical scores and anorectal function were assessed before and after the program.Results Before treatment,there were 9 patients with good clinical scores,and the general rate of fair and poor clinical scores Was 89%.After therapy,61 patients had good scores,and the general rate of fair and poor Was 26%.Anorectal squeeze pressure and sphincter electromyographic amplitude had improved significantly,the rectal sensory threshold Was decreased significantly,and 76%of the patients who had no external anal sphincter reflex recovered.At the two years follow-up,68% of the patients had maintained the clinical outcomes.Conclusion Biofeedback therapy in conjunction with electrical stimulation has significant therapeutic effects on patients with traumatic faecal incontinence.