International consensus definition of low anterior resection syndrome.

AIM: Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. METHOD: This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. RESULTS: Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSION: This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study.

AIM: Frailty is defined as a decrease in physiological reserve with increased risk of morbidity following significant physiological stressors. This study examines the predictive power of the five-item modified frailty index (5-mFI) in predicting outcomes in colorectal surgery patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database was queried from 2011 to 2016 to determine the predictive power of 5-mFI in patients who had colorectal surgery. RESULTS: Of 295 490 patients, 45.8% had a score of 0, 36.2% had a score of 1 and 18% had a score of ≥ 2. On univariate analysis, frailer patients had significantly greater incidences for overall morbidity, serious morbidity, mortality, prolonged length of hospital stay, discharge to a facility other than home, reoperation and unplanned readmission. These findings were consistent on multivariate analysis where the frailest patients had greater odds of postoperative overall morbidity (OR 1.39; 95% CI 1.35-1.43), serious morbidity (OR 1.39; 95% CI 1.33-1.45), mortality (OR 2.00; 95% CI 1.87-2.14), prolonged length of hospital stay (OR 1.24; 95% CI 1.20-1.27), discharge destination to a facility other than home (OR 2.80; 95% CI 2.70-2.90), reoperation (OR 1.17; 95% CI 1.11-1.23) and unplanned readmission (OR 1.31; 95% CI 1.26-1.36). Weighted kappa statistics showed strong agreement between the 5-mFI and 11-mFI (kappa = 0.987, P < 0.001). CONCLUSIONS: The 5-mFI is a valid and easy to use predictor of 30-day postoperative outcomes after colorectal surgery. This tool may guide the surgeon to proactively recognize frail patients to instigate interventions to optimize them preoperatively.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome.

AIM: Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. METHOD: A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed. RESULTS: Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001). CONCLUSION: Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Guía de la Sociedad Española de Infectología Pediátrica sobre tuberculosis en la embarazada y el recién nacido (I): epidemiología y diagnóstico. Tuberculosis congénita / Spanish Society for Pediatric Infectious Diseases guidelines on tuberculosis in pregnant women and neonates (i): Epidemiology and diagnosis. Congenital tuberculosis

El cribado de tuberculosis (TB) gestacional mediante la realización de la prueba de tuberculina (PT) se recomienda a las embarazadas con síntomas compatibles, contacto íntimo con TB bacilífera o riesgo de progresión a formas activas. Las nuevas técnicas de diagnóstico interferon gamma release assay (IGRA) están indicadas en gestantes sin factores de riesgo, con PT positiva y antecedente de vacunación BCG, y en inmunodeprimidas con sospecha clínica y PT negativa. El diagnóstico de enfermedad es difícil, ya que los síntomas pueden ser inespecíficos y hay más formas extrapulmonares, por el retraso en las exploraciones radiológicas y por la mayor tasa de anergia a la tuberculina. La TB neonatal puede adquirirse de forma intrauterina (TB congénita) o por vía respiratoria tras el parto (TB posnatal). La TB congénita es excepcional, no produce malformaciones fetales y, aunque puede estar presente en el nacimiento, suele iniciarse a partir de la segunda semana de vida. En ausencia de antecedentes familiares, la TB neonatal debe sospecharse en caso de neumonía con patrón miliar, hepatoesplenomegalia con lesiones focales o meningitis linfocitaria con hipoglucorraquia, especialmente si la madre procede de áreas de alta endemia de TB. La PT es habitualmente negativa y la sensibilidad de los IGRA es inferior a la de niños de más edad. Sin embargo, la baciloscopia y el cultivo de jugo gástrico tienen una rentabilidad superior, especialmente en la TB congénita. Las técnicas de diagnóstico molecular permiten un diagnóstico precoz y la detección de mutaciones de resistencia farmacológica. El riesgo de formas diseminadas y la mortalidad son elevados

Tuberculosis (TB) screening in pregnancy using tuberculin skin test (TST) is recommended in case of symptoms of TB disease, close contact with a patient with infectious TB, or high risk of developing active disease. The new interferon gamma release assay (IGRA) tests are recommended in BCG-vaccinated pregnant women with positive TST and no known risk factors for TB, and in those immunocompromised, with clinical suspicion of TB but negative TST. TB diagnosis is difficult due to the non-specific symptoms, the increased frequency of extrapulmonary disease, the delay in radiological examinations, and the high rate of tuberculin anergy. Neonatal TB can be acquired in utero (congenital TB), or through airborne transmission after delivery (postnatal TB). Congenital TB is extremely rare and does not cause fetal malformations. It may be evident at birth, although it usually presents after the second week of life. In newborns with no family history of TB, the disease should be considered in cases of miliary pneumonia, hepatosplenomegaly with focal lesions, or lymphocytic meningitis with hypoglycorrhachia, especially in those born to immigrants from high TB-burden countries. TST is usually negative, and IGRAs have lower sensitivity than in older children. However, the yield of acid-fast smear and culture is higher, mostly in congenital TB. Molecular diagnosis techniques enable early diagnosis and detection of drug resistance mutations. There is a substantial risk of disseminated disease and death

Guía de la Sociedad Española de Infectología Pediátrica sobre tuberculosis en la embarazada y el recién nacido (II): profilaxis y tratamiento / Spanish Society for Pediatric Infectious Diseases guidelines on tuberculosis in pregnant women and neonates (II): Prophylaxis and treatment

En la embarazada expuesta a tuberculosis (TB) no se recomienda profilaxis primaria con isoniazida salvo en gestantes inmunodeprimidas, con enfermedades crónicas o factores de riesgo obstétrico y antecedente de contacto íntimo mantenido con un enfermo bacilífero. En la infección tuberculosa latente (ITBL) se iniciará profilaxis con isoniazida si existe contacto reciente con TB o factores de riesgo de progresión a TB activa. En caso contrario, se retrasará hasta al menos 3 semanas después del parto. El tratamiento de la enfermedad tuberculosa es el mismo que fuera de la gestación. Los recién nacidos de madres con historia gestacional de TB diseminada o extrapulmonar, con TB activa en el parto o con contacto TB posnatal conocido, asintomáticos y con pruebas diagnósticas negativas, deben recibir profilaxis primaria con isoniazida durante al menos 12 semanas. Transcurrido ese tiempo se repiten los test diagnósticos, y si son negativos, se interrumpe la profilaxis. En la ITBL, se administrará isoniazida durante 9 meses. En la enfermedad tuberculosa, el tratamiento es el mismo que en el niño mayor pero mantenido al menos 9 meses. Se recomienda aislamiento respiratorio en la TB congénita y en la TB posnatal con baciloscopia positiva en jugo gástrico o aspirado bronquial. La separación madre-hijo solo está indicada en madres que han recibido tratamiento durante menos de 2 semanas, presentan baciloscopia positiva o tienen TB resistente. La lactancia materna no está contraindicada y en las situaciones de separación la madre puede extraerse la leche para que sea administrada en biberón al recién nacido

In pregnant women who have been exposed to tuberculosis (TB), primary isoniazid prophylaxis is only recommended in cases of immunosuppression, chronic medical conditions or obstetric risk factors, and close and sustained contact with a patient with infectious TB. Isoniazid prophylaxis for latent tuberculosis infection (LTBI) is recommended in women who have close contact with an infectious TB patient or have risk factors for progression to active disease. Otherwise, it should be delayed until at least three weeks after delivery. Treatment of TB disease during pregnancy is the same as for the general adult population. Infants born to mothers with disseminated or extrapulmonary TB in pregnancy, with active TB at delivery, or with postnatal exposure to TB, should undergo a complete diagnostic evaluation. Primary isoniazid prophylaxis for at least 12 weeks is recommended for those with negative diagnostic tests and no evidence of disease. Repeated negative diagnostic tests are mandatory before interrupting prophylaxis. Isoniazid for 9 months is recommended in LTBI. Treatment of neonatal TB disease is similar to that of older children, but should be maintained for at least 9 months. Respiratory isolation is recommended in congenital TB, and in postnatal TB with positive gastric or bronchial aspirate acid-fast smears. Separation of mother and infant is only necessary when the mother has received treatment for less than 2 weeks, is sputum smear-positive, or has drug-resistant TB. Breastfeeding is not contraindicated, and in case of mother-infant separation expressed breast milk feeding is recommended

[Spanish Society for Pediatric Infectious Diseases guidelines on tuberculosis in pregnant women and neonates (i): Epidemiology and diagnosis. Congenital tuberculosis]. / Guía de la Sociedad Española de Infectología Pediátrica sobre tuberculosis en la embarazada y el recién nacido (I): epidemiología y diagnóstico. Tuberculosis congénita.

Tuberculosis (TB) screening in pregnancy using tuberculin skin test (TST) is recommended in case of symptoms of TB disease, close contact with a patient with infectious TB, or high risk of developing active disease. The new interferon gamma release assay (IGRA) tests are recommended in BCG-vaccinated pregnant women with positive TST and no known risk factors for TB, and in those immunocompromised, with clinical suspicion of TB but negative TST. TB diagnosis is difficult due to the non-specific symptoms, the increased frequency of extrapulmonary disease, the delay in radiological examinations, and the high rate of tuberculin anergy. Neonatal TB can be acquired in utero (congenital TB), or through airborne transmission after delivery (postnatal TB). Congenital TB is extremely rare and does not cause fetal malformations. It may be evident at birth, although it usually presents after the second week of life. In newborns with no family history of TB, the disease should be considered in cases of miliary pneumonia, hepatosplenomegaly with focal lesions, or lymphocytic meningitis with hypoglycorrhachia, especially in those born to immigrants from high TB-burden countries. TST is usually negative, and IGRAs have lower sensitivity than in older children. However, the yield of acid-fast smear and culture is higher, mostly in congenital TB. Molecular diagnosis techniques enable early diagnosis and detection of drug resistance mutations. There is a substantial risk of disseminated disease and death.

[Spanish Society for Pediatric Infectious Diseases guidelines on tuberculosis in pregnant women and neonates (ii): Prophylaxis and treatment]. / Guía de la Sociedad Española de Infectología Pediátrica sobre tuberculosis en la embarazada y el recién nacido (ii): profilaxis y tratamiento.

In pregnant women who have been exposed to tuberculosis (TB), primary isoniazid prophylaxis is only recommended in cases of immunosuppression, chronic medical conditions or obstetric risk factors, and close and sustained contact with a patient with infectious TB. Isoniazid prophylaxis for latent tuberculosis infection (LTBI) is recommended in women who have close contact with an infectious TB patient or have risk factors for progression to active disease. Otherwise, it should be delayed until at least three weeks after delivery. Treatment of TB disease during pregnancy is the same as for the general adult population. Infants born to mothers with disseminated or extrapulmonary TB in pregnancy, with active TB at delivery, or with postnatal exposure to TB, should undergo a complete diagnostic evaluation. Primary isoniazid prophylaxis for at least 12 weeks is recommended for those with negative diagnostic tests and no evidence of disease. Repeated negative diagnostic tests are mandatory before interrupting prophylaxis. Isoniazid for 9 months is recommended in LTBI. Treatment of neonatal TB disease is similar to that of older children, but should be maintained for at least 9 months. Respiratory isolation is recommended in congenital TB, and in postnatal TB with positive gastric or bronchial aspirate acid-fast smears. Separation of mother and infant is only necessary when the mother has received treatment for less than 2 weeks, is sputum smear-positive, or has drug-resistant TB. Breastfeeding is not contraindicated, and in case of mother-infant separation expressed breast milk feeding is recommended.

Ileal pouch fistulas after restorative proctocolectomy: management and outcomes.

BACKGROUND: Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm. METHODS: Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011. RESULTS: Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month-20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn's disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2-108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy. CONCLUSIONS: Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.

Long-term efficacy of NASHA Dx injection therapy for treatment of fecal incontinence.

BACKGROUND: Injectable bulking treatment for fecal incontinence (FI) is intended to expand tissue in the anal canal and prevent fecal leakage. Use of injectable bulking agents is increasing because it can be performed in an outpatient setting and with low risk for morbidity. This study evaluated the long-term (36-month) clinical effectiveness and safety of injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA Dx) on FI symptoms. METHODS: In a prospective multicenter trial, 136 patients with FI received the NASHA Dx bulking agent. Treatment success defined as a reduction in number of FI episodes by 50% or more compared with baseline (Responder50 ). Change from baseline in Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL), and adverse events were also evaluated. KEY RESULTS: Successful decrease in symptoms was achieved in 52% of patients at 6 months and this was sustained at 12 months (57%) and 36 months (52%). Mean CCFIS decreased from 14 at baseline to 11 at 36 months (p < 0.001). Quality-of-life scores for all four domains improved significantly between baseline and 36 months of follow-up. Severe adverse events were rare and most adverse events were transient and pertained to minor bleeding and pain or discomfort. CONCLUSIONS & INFERENCES: Submucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years.

Guía de la Sociedad Española de Infectología Pediátrica para el diagnóstico y tratamiento de la toxoplasmosis congénita / The Spanish Society of Pediatric Infectious Diseases Guidelines for the diagnosis and treatment of congenital toxoplasmosis

La toxoplasmosis congénita es la consecuencia de la transmisión fetal por vía transplacentaria de Toxoplasma gondii tras la primoinfección materna. El riesgo de infección fetal es bajo en infecciones en el primer trimestre y va aumentando con la edad gestacional, mientras que la gravedad de la infección disminuye con esta. El diagnóstico de infección materna se realiza mediante la demostración de seroconversión o ante la presencia de IgM positiva con anticuerpos IgG de baja avidez. Las gestantes con infección demostrada deben recibir espiramicina para intentar evitar su transmisión al feto. El diagnóstico de infección fetal se realiza mediante reacción en cadena de la polimerasa (PCR) en líquido amniótico obtenido a partir de la semana 18 de gestación. Si esta prueba resulta positiva, debe iniciarse tratamiento a la embarazada con pirimetamina, sulfadiazina y ácido folínico. La mayoría de los niños infectados nacen asintomáticos pero hasta el 80% desarrolla secuelas visuales o neurológicas durante su infancia y adolescencia. El diagnóstico neonatal es complicado porque los anticuerpos IgM e IgA y la PCR en sangre y líquido cefalorraquídeo pueden ser falsamente negativos. En estos casos, el diagnóstico puede realizarse mediante la constatación de un ascenso significativo de los anticuerpos IgG o la persistencia de los mismos después del año de vida. El tratamiento neonatal con pirimetamina y sulfadiazina disminuye la posibilidad de secuelas a largo plazo. La toxoplasmosis congénita es una enfermedad prevenible mediante el cribado pregestacional y la adopción de medidas de profilaxis primaria en las gestantes seronegativas (AU)

Congenital toxoplasmosis is the result of transplacental fetal infection by Toxoplasma gondii after the primary maternal infection. The severity of the disease depends on the gestational age at transmission. First trimester infections are more severe, but less frequent, than third trimester infections. Acute maternal infection is diagnosed by seroconversion or by the detection of IgM antibodies and a low IgG avidity test. In these cases, spiramycin should be initiated to prevent transmission to the fetus. For identification of fetal infection, polymerase chain reaction (PCR) testing of amniotic fluid after 18 weeks gestation should be performed. If fetal infection is confirmed, the mothers should be treated with pyrimethamine, sulfadiazine and folinic acid. Most infants infected in utero are born with no obvious signs of toxoplasmosis, but up to 80% developed learning and visual disabilities later in life. Neonatal diagnosis with IgM/IgA antibodies or blood/cerebrospinal fluid PCR may be difficult because false-negative results frequently occur. In these cases diagnosis is possible by demonstrating a rise in IgG titers during follow-up or by the detection of antibodies beyond one year of age. Early treatment with pyrimethamine and sulfadiazine may improve the ophthalmologic and neurological outcome. Congenital toxoplasmosis is a preventable disease. Pre-pregnancy screening and appropriate counseling regarding prevention measures in seronegative women may prevent fetal infection (AU)

[The Spanish Society of Pediatric Infectious Diseases Guidelines for the diagnosis and treatment of congenital toxoplasmosis]. / Guía de la Sociedad Española de Infectología Pediátrica para el diagnóstico y tratamiento de la toxoplasmosis congénita.

Congenital toxoplasmosis is the result of transplacental fetal infection by Toxoplasma gondii after the primary maternal infection. The severity of the disease depends on the gestational age at transmission. First trimester infections are more severe, but less frequent, than third trimester infections. Acute maternal infection is diagnosed by seroconversion or by the detection of IgM antibodies and a low IgG avidity test. In these cases, spiramycin should be initiated to prevent transmission to the fetus. For identification of fetal infection, polymerase chain reaction (PCR) testing of amniotic fluid after 18 weeks gestation should be performed. If fetal infection is confirmed, the mothers should be treated with pyrimethamine, sulfadiazine and folinic acid. Most infants infected in utero are born with no obvious signs of toxoplasmosis, but up to 80% developed learning and visual disabilities later in life. Neonatal diagnosis with IgM/IgA antibodies or blood/cerebrospinal fluid PCR may be difficult because false-negative results frequently occur. In these cases diagnosis is possible by demonstrating a rise in IgG titers during follow-up or by the detection of antibodies beyond one year of age. Early treatment with pyrimethamine and sulfadiazine may improve the ophthalmologic and neurological outcome. Congenital toxoplasmosis is a preventable disease. Pre-pregnancy screening and appropriate counseling regarding prevention measures in seronegative women may prevent fetal infection.

Obesity and bariatric surgery: a systematic review of associations with defecatory dysfunction.

BACKGROUND: Obesity rates are rapidly growing in the developed world. While upper gastrointestinal disturbances and urinary incontinence are independently associated with obesity, the relationship between obesity and defecatory dysfunction is less well defined. OBJECTIVES: To summarize the literature on faecal incontinence, diarrhoea and constipation in obese patients and its effects of bariatric surgery. SEARCH STRATEGY: A Medline search was carried out on articles published from January 1966 to March 2010. SELECTION CRITERIA: Original articles on adult obese or morbidly obese patients were identified, including results following bariatric surgery that reported faecal incontinence, diarrhoea or constipation. Other forms of pelvic floor dysfunction were excluded. Main outcome measures included faecal incontinence, diarrhoea and constipation rates and their severity in obese patients and following bariatric surgery. RESULTS: Twenty studies reported defecatory outcomes in obese patients (n = 14) and after bariatric surgery (n = 6). While constipation rates were similar, the rates of faecal incontinence and diarrhoea were higher in obese patients compared with non-obese patients. The exact rates of these conditions, and the correlations between body mass index (BMI) and faecal incontinence, diarrhoea and constipation, were not clear. Faecal incontinence improved after Roux-en-Y gastric bypass in studies with preoperative data. The effects of bariatric surgery on diarrhoea were unclear. CONCLUSION: Few studies have assessed the correlations between obesity and defecatory function and the effect of bariatric surgery. Studies were often not well controlled and used non-uniform instruments to assess bowel function. Obesity appears to be correlated with higher rates of faecal incontinence and diarrhoea. The effects of bariatric surgery on these conditions are not well defined. Well-controlled studies correlating outcome with physiological pelvic floor function are needed.

State of the art: an integrated approach to pelvic floor ultrasonography.

Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available. In this review, pelvic floor ultrasonography, including two-dimensional (2D), three-dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor-urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome-is evaluated critically.

Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease.

AIM: Surgical repair of recto-vaginal fistula (RVF) in Crohn's disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. METHOD: A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. RESULTS: Fifty-one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. CONCLUSION: RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.

Faecal incontinence in men.

AIM: A few studies have specifically addressed faecal incontinence (FI) in men. We sought to describe patterns of male FI, assess treatment outcome and compare some aspects of FI between men and women, including quality of life. METHOD: Prospectively recorded data on 85 consecutive male patients evaluated for FI at our pelvic floor centre in 2004 and 2005 were reviewed and compared with a cohort of 408 female patients. Treatment outcome in men was assessed by questionnaire. RESULTS: The aetiology of FI could be determined in 61 (72%) men and was most commonly related to anal surgery (n = 23), prostate cancer therapy (n = 9) and spinal injury (n = 9). Eight patients had idiopathic soiling only. Mean age, Fecal Incontinence Severity Index (FISI) and quality of life scores were similar between men and women. Maximal mean resting pressure (MRP) and squeeze pressure (MSP) were on average higher in men than in women [MRP 56.9 (26.2) vs 40 (20.4) mmHg; P < 0.0001]; [MSP 98.1 (67.3) vs 39.4 (28.5) mmHg; P < 0.0001]. Sphincter defects involved the external sphincter less often in men (35 vs 70%, P = 0.004). Differences in faecal incontinence quality of life (FIQL) and SF-36 scores between men and women were minimal. After a median follow up of 2 years, complete resolution of symptoms was reported in 17% and improvement of symptoms in another 48% of men. CONCLUSION: Although physiological and anatomical features of FI differ between men and women, its severity and impact on quality of life are similar. External sphincter defects are less common in men; hence, direct sphincter repair is less frequently an option. Evaluation and treatment improves symptoms in more than half of male patients.

Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial.

OBJECTIVE: To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up. DESIGN: Randomised controlled trial. SETTING: University hospital in Sweden. POPULATION: A total of 165 women diagnosed with a third- to fourth-degree perineal tear. METHODS: The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up. MAIN OUTCOME MEASURES: Anal incontinence measured by the validated Pescatori incontinence score. RESULTS: A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces. CONCLUSION: Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.

Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients.

OBJECTIVE: The Fecal Incontinence Severity Index (FISI) is widely used in the assessment of patients with faecal incontinence, but the relationship between FISI and the measurements of quality of life, such as the Fecal Incontinence Quality of Life Scale (FIQL) and the Medical Outcomes Survey (SF-36) has not been evaluated previously. The aim of the present study was to evaluate the relationship between disease severity and quality of life in a large cohort of patients. METHOD: Five hundred and two consecutive patients (84.4% female, mean age 56 years) were evaluated for faecal incontinence between May 2004 and October 2005. Patients completed FISI, FIQL and SF-36 questionnaires. Pearson's coefficients were determined for the relationships between FISI and subscales of FIQL and SF-36. Quality of life scores were compared between groups of patients with different levels of incontinence severity (mild, moderate, severe) using Student's t-test. RESULTS: Sixty-eight per cent of patients were incontinent of solid stool, 62% of liquid stool, and 90% of gas or mucus. The average FISI score was 36 (0-61). Moderate correlations were found between FISI and all subscales in FIQL (negative 0.29 to 0.41; P < 0.0001). Weak correlations were found between FISI and the social functioning (-0.21) and mental health (-0.17) scales in SF-36 (P < 0.05). Scores on the FIQL differed significantly between mild, moderate and severe incontinence. CONCLUSION: FISI was only moderately correlated with a disease-specific quality of life measurement (FIQL). Even though this supports the common assumption that the quality of life in the patients with faecal incontinence worsens with an increase in disease severity, it also stresses the need of measuring both variables to determine the true impact of any treatment.