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  • Fecal incontinence  (7)
  • Springer  (7)
  • Nature Publishing Group (NPG)
  • Blackwell Science Pty
  • Macmillian Magazines Ltd.
Collection
Publisher
  • Springer  (7)
  • Nature Publishing Group (NPG)
  • Blackwell Science Pty
  • Macmillian Magazines Ltd.
Years
  • 1
    ISSN: 1530-0358
    Keywords: Fecal incontinence ; Anal incontinence ; Artificial anal sphincter ; Surgical technique
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract PURPOSE: This study was undertaken to evaluate the use of a fully implanted artificial anal sphincter for management of severe fecal incontinence. METHODS: An artificial anal sphincter was implanted in 12 patients who failed conventional management for severe fecal incontinence. Careful patient follow-up was recorded during a mean 58-month follow-up. Patients underwent preoperative and postoperative manometric assessment. Functional and patient satisfaction evaluations were obtained by mailed questionnaire. RESULTS: Three infections and three mechanical complications occurred in four patients (33 percent). A successful outcome was achieved in nine patients (75 percent). Postoperative manometric studies documented establishment of an elevated high-pressure zone compared with preoperative resting pressures. Seven patients returned a detailed functional assessment and patient satisfaction questionnaire at a mean of 40 months postsphincter activation. All seven patients reported continence to solid stool. Two patients had some problems with control of liquid stool, and three had occasional incontinence to flatus. Six of the seven patients rated their bowel control as good to excellent. All seven respondents were satisfied with their functional improvement. CONCLUSIONS: Early experience with an artificial anal sphincter has demonstrated that continence can be restored with acceptable morbidity in patients with severe fecal incontinence.
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  • 2
    ISSN: 1530-0358
    Keywords: Sphincter injury ; Sphincter disruption ; Delivery ; Fecal incontinence ; Endoanal ultrasound ; Manometry ; Pudendal latency
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract PURPOSE: Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States. METHODS: Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients. RESULTS: Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P〈0.05), and manometric results were reduced. Three of these seven patients had a third-degree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section. CONCLUSIONS: The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.
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  • 3
    ISSN: 1530-0358
    Keywords: Fecal incontinence ; Sphincter replacement ; Neosphincter ; Artificial anal sphincter
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract PURPOSE: Anal sphincter replacement offers a new treatment option for patients with severe refractory fecal incontinence or for those who require abdominoperineal resection for localized malignancy. The purpose of this study was to review the current status of anal sphincter replacement, formulate a consensus statement regarding its current use, and outline suggestions for future development. METHODS: Four areas of interests were selected: indications for sphincter replacement, continence scoring and quality of life, choice of therapy, and dissemination of new technology. A questionnaire regarding these issues was developed and circulated to working party members; its results served as the basis for this consensus document. RESULTS: Both electrically stimulated skeletal muscle neosphincter and artificial anal sphincter are options for patients with end-stage fecal incontinence. Electrically stimulated skeletal muscle neosphincter is also appropriate for reconstruction after surgical excision of the anorectum in selected cases. Avoidance of complications requires strict attention to sterile technique, prophylactic antibiotics, and deep venous thrombus prophylaxis. A standardized scoring system is proposed that evaluates both continence and evacuation. Quality of life is a critical endpoint for assessing sphincter replacement, and use of The American Society of Colon and Rectal Surgeons incontinence-specific quality-of-life instrument is recommended. As the efficacy of sphincter replacement becomes proven, dissemination of the technique should occur in a controlled manner to ensure adequate surgeon training, minimization of complications, and optimization of results. CONCLUSIONS: Sphincter replacement by electrically stimulated skeletal muscle neosphincter and artificial anal sphincter provide a continent option for patients with end-stage fecal incontinence and those requiring abdominoperineal resection. The guidelines offered in this document are intended to facilitate the controlled and safe development and acceptance of these new techniques.
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  • 4
    ISSN: 1530-0358
    Keywords: Rectovaginal fistula ; Obstetric injuries ; Fecal incontinence ; Preoperative assessment ; Endoanal ultrasound ; Anal manometry ; Endorectal advancement flap ; Sphincteroplasty ; Levatoroplasty
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defect on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preoperative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry studies. Follow-up was by mailed questionnaire in 36 patients (69 percent) and by telephone interview in 12 (23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18–70) years, and median follow-up was 15 (range, 0.5–123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before surgery. There were 27 endorectal advancement flaps and 35 sphincteroplasties (28 with and 8 without levatoroplasty). RESULTS: Success rates were 41 percent with endorectal advancement flaps and 80 percent with sphincteroplasties (96 percent success with and 33 percent without levatoroplasty;P=0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function(P=not significant). For sphincteroplasties, success rates were 73vs. 84 percent for normal and abnormal sphincter function, respectively (P=not significant). Results were better after sphincteroplastiesvs. endorectal advancement flaps in patients with sphincter defects identified by endoanal ultrasound (88vs. 33 percent;P=not significant) and by manometry (86vs. 33 percent;P = not significant). Poor results correlated with prior surgery in patients undergoing endorectal advancement flaps (45 percentvs. 25 percent;P = not significant) but not sphincteroplasties (80vs. 75 percent;P = not significant). CONCLUSIONS: All patients with rectovaginal fistula should undergo preoperative evaluation for occult sphincter defects by endoanal ultrasound or anal manometry or both procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of previous repairs. Patients with clinical or anatomic sphincter defects should be treated by sphincteroplasty with levatoroplasty.
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  • 5
    ISSN: 1530-0358
    Keywords: Transanal ultrasonography ; Accuracy ; Reliability ; Anal sphincter injury ; Fecal incontinence
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract INTRODUCTION: Although transanal ultrasound has rapidly become the test of choice for the diagnosis of anal sphincter injury, the accuracy and reliability of this technique are unknown. This study evaluates the accuracy and reliability of transanal ultrasound for anterior (obstetric-related) anal sphincter injury. METHODS: Sixty-two women underwent transanal ultrasound with hard-copy images obtained at 0.5-cm intervals from the anal verge to 2.5 cm into the anal canal. All transanal ultrasound procedures were also recorded on videotape. Two experienced ultrasonographers blinded as to the patients' clinical history and examination independently reviewed the images and videotape recordings for the presence or absence of anal sphincter injury. RESULTS: The accuracy of transanal ultrasound in 22 incontinent women with known anal sphincter injury was 100 percent. The accuracy of transanal ultrasound in 20 nulliparous women with intact anal sphincters was only 35 percent but improved to 50 percent after the “real time” videotape was reviewed (P=0.16) and further improved to 85 percent when interpretation was limited to the distal 1.5 cm of the anal canal (P=0.004). In these nulliparous women, intact internal sphincters were more accurately predicted than intact external sphincters (95vs. 85 percent;P=0.24). Measurement agreement between the two ultrasonographers was 68 percent (fair; kappa, 0.26) but significantly improved to 78 percent (moderate; kappa, 0.48;P=0.0001) when interpretation was limited to the distal 1.5 cm of the anal canal. Overall clinical agreement (final scan interpretation) was good (81 percent agreement; kappa, 0.61). Agreement was better for the internal sphincter (74 percent; fair; kappa, 0.36) than the external sphincter (61 percent; poor; kappa, 0.17;P=0.0002). CONCLUSIONS: Although transanal ultrasound can accurately identify anterior anal sphincter injury when present, transanal ultrasound falsely identifies sphincter injury in at least 5 to 25 percent of normal anal sphincters. Only fair agreement in the interpretation of transanal ultrasound exists between experienced ultrasonographers. Both the accuracy and reliability of transanal ultrasound are significantly improved by limiting transanal ultrasound to the distal 1.5 cm of the anal canal.
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  • 6
    ISSN: 1530-0358
    Keywords: Rectal prolapse ; Recurrence ; Abdominal rectopexy ; Perineal rectosigmoidectomy ; Fecal incontinence ; Constipation ; Patient satisfaction
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Optional treatment for complete rectal prolapse remains controversial. PURPOSE: We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. METHODS: We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64; range, 12–231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). RESULTS: Median age of patients was 64 (11–100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineal rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61vs. 30 percent,P=0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomyvs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8vs. 5 days,P=0.001). Perineal procedures, however, had a higher recurrence rate (16vs. 5 percent,P=0.002). Functional improvement was not significantly different, and most patients were satisfied with treatment and outcome. CONCLUSIONS: We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate.
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  • 7
    ISSN: 1530-0358
    Keywords: Anal incontinence ; Fecal incontinence ; Cost analysis ; Costs ; Charges ; Delivery ; Obstetric complication ; Endoanal ultrasound ; Manometry ; Pudendal latency
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract INTRODUCTION: Anal incontinence is eight times more frequent in females than in males because of injuries sustained at childbirth. The aim of the present study was to determine the long-term costs associated with anal incontinence related to obstetric injuries. METHODS: Sixty-three patients with anal incontinence caused by obstetric sphincter injuries answered questionnaires regarding previous treatments, symptoms, and use of protective products. Of the patients, 31 were treated surgically, 11 with biofeedback, 6 with a combination of surgery and biofeedback, and 15 conservatively. Treatments and their respective costs were obtained from patient records, patient questionnaires, billing database, and Health Care Financing Administration's 1996 inpatient database. Costs were expressed in 1996 dollars. RESULTS: The mean incontinence score changed from 26 at evaluation to 16 at follow-up (P〈0.001). The average cost per patient was $17,166. Evaluation and follow-up charges totaled $65,412, and physiologic assessment accounted for 64 percent of these costs. Treatment charges totaled $559,341, and physician charges accounted for 18 percent of these charges. CONCLUSIONS: Fecal incontinence after childbirth results in substantial economic costs, and treatment is not always successful. New treatment modalities, such as artificial bowel sphincter or dynamic graciloplasty, should be assessed to determine their cost-effectiveness.
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