[Italian translation and prospective validation of fecal incontinence quality of life (FIQL) index]. / Traduzione e validazione prospettica della versione italiana del Fecal Incontinence Quality Of Life (FIQL) index.

The evaluation of any functional disease affecting quality of life requires a purpose-designed quality-of-life index for clinical trials as well as for evaluating the outcomes of treatments. The fecal incontinence quality of life index (FIQL) was developed at Minnesota University (USA) for patients with faecal incontinence but could not be used for Italian patients without appropriate cultural and linguistic adaptation. Therefore this index was translated into italian and prospectively validated on a new series of 73 incontinent patients and 8 healthy controls in order to provide Italian coloproctologists with a useful tool for clinical research. The italian version or the FIQL index met all the statistical criteria of reliability, reproducibility, specificity and convergency required and therefore can be used with confidence in clinical trials on such patients.

Sacral neuromodulation in treatment of fecal incontinence following anterior resection and chemoradiation for rectal cancer.

PURPOSE: Fecal incontinence may occur in patients who have undergone anterior resection for rectal cancer without presenting sphincter lesions. Chemoradiation may contribute to disrupting continence mechanisms. Treatment is controversial. Assessment of fecal incontinence in patients who agreed to integrate treatment for rectal cancer and treatment with sacral neuromodulation are reported. METHODS: Fecal incontinence following preoperative chemoradiation and anterior resection for rectal cancer was evaluated in four patients. A good response was observed during the percutaneous sacral nerve evaluation test, and so permanent implant of sacral neuromodulation system was performed. Reevaluation was performed at least two months after implant. RESULTS: After device implantation, the mean fecal incontinence scores decreased, and the mean number of incontinence episodes dropped from 12.0 to 2.5 per week (P < 0.05). Permanent implant resulted in a significant improvement in fecal continence in three patients, and incontinence was slightly reduced in the fourth. Manometric parameters agreed with clinical results: maximum and mean resting tone and the squeeze pressure were normal in three patients and reduced in one. In these same three patients, neorectal sensation parameters increased when the preoperative value was normal or below normal and decreased when the preoperative value was higher than normal, whereas in one patient in whom extremely low values were recorded all of the parameters decreased significantly. CONCLUSIONS: Fecal incontinence following anterior resection and neoadjuvant therapy should be carefully evaluated. If a suspected neurogenic pathogenesis is confirmed, sacral neuromodulation may be proposed. If the test results are positive, permanent implant is advisable. Failure of this approach does not exclude the use of other, more aggressive treatment.

Reliability of electrophysiologic anal tests in predicting the outcome of sacral nerve modulation for fecal incontinence.

INTRODUCTION: Sacral nerve modulation has been demonstrated to be a new efficacious treatment for fecal incontinence. The effectiveness of the procedure is preliminarily tested by means of a peripheral nerve evaluation. Integrity of the sacral neural pathway is generally believed to be a necessary condition for a good response, but no data are available to confirm whether electrophysiologic anal tests are predictive of the clinical outcome of the peripheral nerve evaluation. METHODS: Eighty-two incontinent patients underwent the peripheral nerve evaluation after full evaluation of the anorectal physiology. Univariate analysis was performed, and the positive predictive value, sensitivity, and specificity were calculated for each of the tests. RESULTS: Forty-six patients had successful results to the peripheral nerve evaluation and were subjected to permanent implant of a sacral electrostimulator. Anal sphincter electromyography had been performed in 60 patients, whereas pudendal nerve terminal motor latency had been assessed in 68 and evoked sacral potentials in 29 patients. Anal electromyography was statistically related to the outcome of the peripheral nerve evaluation ( P = 0.0004) with a positive predictive value of 81 percent, a sensitivity of 44 percent, and a specificity of 81 percent. Pudendal nerve terminal motor latency on the right side did not correlate with the outcome, but left pudendal nerve terminal motor latency was weakly correlated ( P = 0.02), although both tests had a low positive predicting value and sensitivity vs. good specificity. Evoked sacral potentials did not correlate with the outcome and had a low positive predictive value, sensitivity, and specificity. CONCLUSIONS: Simple anal sphincter electromyography can predict the outcome of the peripheral nerve evaluation with good positive predictive value and specificity in patients with fecal incontinence. Other, more expensive, electrophysiologic anal tests do not add further prognostic information.

Permanent sacral nerve modulation for fecal incontinence and associated urinary disturbances.

BACKGROUND AND AIMS: Sacral nerve modulation (SNM) using an implantable pulse generator is gaining increasing acceptance in the treatment of several functional disturbances of the urinary and intestinal tract. This new therapeutic approach offers new possibilities in the treatment of fecal incontinence (FI) by means of its possible effects on anorectal physiology. PATIENTS AND METHODS: Fourteen patients with FI, six of whom had associated urinary disturbances, underwent permanent SNM after successful peripheral nerve evaluation tests. All had a clinical evaluation including FI grading systems (American Medical systems, AMS; Continence Grading System, CGS) and quality of life questionnaires (Fecal Incontinence Quality of Life, FIQL), and anorectal physiology tests performed before and during electrostimulation. Two patients had a lead displacement which was repositioned. Median follow-up was 14 months (range 6-48 months). RESULTS: AMS scores decreased significantly from 101 to 67 after 24 months CGS scores from 15 to 2 after 2 months. The median number of episodes of major incontinence per 2 weeks decreased from 14 to 1 after 24 months. FIQL scores improved significantly in the nine patients tested from an overall score of 1.59 to 3.3, with improvement in all areas of the FIQL. Four of the six patients with associated urinary disturbances had a significant improvement in their symptoms. Anal resting and squeezing tone did not change significantly, nor did rectal volumetry, compliance, rectoanal inhibitory reflex, or length of the anal high-pressure zone, while 24-h rectal manometry showed inhibition of the spontaneous rectal motility complexes after meal and on awakening in the only two patients undergoing this investigation. CONCLUSION: Although the mechanism of action of SMN is still unclear and requires further investigations, clinical results are very encouraging, confirming the role of this new and safe procedure in the treatment of FI and associated urinary disturbances.

Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique.

PURPOSE: The aim of this study was to present a new technique for treatment of disabling rectocele when associated with internal mucosal prolapse or hemorrhoids using a 33-mm circular stapler. METHODS: Eight female patients complaining of obstructed defecation because of distention rectocele associated with internal mucosal prolapse or hemorrhoids and perineal descent entered the study. The rectovaginal septum was opened by diathermy up to the end of the rectal wall weakness. The perineal wound and the anus were held open by a self-retractor. Using a transparent anoscope (PPH 01 system), 2 mucosal pursestrings were prepared 5 and 8 to 9 cm distant from the dentate line. Posteriorly, only the submucosa was included in the pursestring; anteriorly, it included the rectal wall, which was kept separate from the vaginal wall. A transanal 33-mm circular stapler was then used to close the rectocele and treat the mucosal prolapse. Before closing the perineum a levatorplasty was fashioned. RESULTS: One patient had a vaginal tear during dissection of the septum, which healed spontaneously in one month. No other complications were recorded. Postoperative defecography showed correction of the rectocele and the posterior rectal prolapse in all patients. In two of them, a small lateral diverticulum could be seen, although this was asymptomatic. After a median follow-up of 12 months, all had significantly improved defecation (chronic constipation score dropped from 14.3 to 5, P < 0.04). CONCLUSION: Combined perineal and endorectal stapler repair of rectocele may be a useful new surgical tool for correcting distention rectocele associated with mucosal prolapse or hemorrhoids and perineal descent in selected patients. A longer follow-up on a larger number of patients is needed to confirm these preliminary results.