Ann C. Lowry

Fecal incontinence quality of life scale

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index.

PURPOSE: The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS: The Fecal Incontinence Severity Index is based on a type × frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS: Surgeons and patients had very similar weightings for each of the type × frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS: Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.

Practice parameters for the treatment of sigmoid diverticulitis - Supporting documentation

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Faecal incontinence in adults

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.

Long-Term Results of Anterior Sphincteroplasty

PURPOSEThis study was designed to evaluate the outcome of anterior sphincteroplasty in a large series with ten-year follow-up.METHODSThe long-term results in 191 consecutive patients who were a median of ten years from sphincteroplasty were assessed. A questionnaire was administered to assess current bowel function, degree of incontinence, and quality of life as measured by the Fecal Incontinence Quality of Life Scale. Subjective assessment of early outcome was available for most patients at a median follow-up of three years.RESULTSDuring the follow-up period, three patients died and one developed severe dementia. Five patients required further surgery for incontinence and were considered failures. Of the remaining 182 patients, 130 (71 percent) returned a completed questionnaire. At ten years follow-up, 6 percent had no incontinence, 16 percent were incontinent of gas only, 19 percent had soiling only, and 57 percent were incontinent of solid stool. Results worsened significantly between the assessments at three and ten years. The only significant predictors of a poor outcome were older age and fecal incontinence at three years. Preoperative anorectal physiology studies did not predict outcome. Scores on the Fecal Incontinence Quality of Life Scale were lower in those with fecal incontinence, indicating a poorer disease-specific quality of life.CONCLUSIONSOnly 40 percent of patients maintain fecal continence long-term after sphincteroplasty. Older patients and patients with poorer short-term function are more likely to have fecal incontinence at ten years. Incontinence at ten years had a negative effect on quality of life. Further research is needed to develop techniques to improve long-term continence in these patients.

Open vs. closed sphincterotomy for chronic anal fissure - Long-term results

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1–6) years. RESULTS: Differences in persistence of symptoms (3.4 OISvs.5.3 percent CIS), recurrence of the fissure (10.9vs.11.7 percent CIS), and need for reoperation (3.4 percent OIStvs.4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3vs.236 percent;P0.062), soiling underclothing (26.7vs.16.1 percent;P< 0.001), and accidental bowel movements (11.8vs.3.1 percent;P< 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.

Complete rectal prolapse: evolution of management and results.

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.

Supplementation with dietary fiber improves fecal incontinence.

BackgroundHuman studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. ObjectiveTo compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. MethodsThirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. ResultsIn the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by non-significant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. ConclusionsSupplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.

Openvs. closed sphincterotomy for chronic anal fissure

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1–6) years. RESULTS: Differences in persistence of symptoms (3.4 OISvs.5.3 percent CIS), recurrence of the fissure (10.9vs.11.7 percent CIS), and need for reoperation (3.4 percent OIStvs.4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3vs.236 percent;P0.062), soiling underclothing (26.7vs.16.1 percent;P< 0.001), and accidental bowel movements (11.8vs.3.1 percent;P< 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.

Repair of simple rectovaginal fistulas. Influence of previous repairs.

The results of 81 endorectal flap advancements for simple rectovaginal fistulas are reported. Simple fistulas are defined as <2.5 cm in diameter, low or mid vaginal septum in location, and infectious or traumatic in origin. Essentially, the technique is advancement of a flap of mucosa, submucosa, and circular muscle over midline approximation of internal sphincter muscle. The mean patient age was 34 years old (range, 18 to 76 years). The causes were obstetrical injury (74 percent), perineal infection (10 percent), operative trauma (7 percent), and unknown (8 percent). Overall, the repair was successful in 83 percent of patients. Success correlated with the number of previous repairs,i.e., none: 88 percent success; one: 85 percent success; two: 55 percent success. There were 25 concomitant overlapping sphincteroplasty procedures. Only minor complications ensued, with no mortality. This repair is recommended for patients with no or one previous repair because of its lack of mortality, minimal morbidity, ease of concomitant sphincteroplasty, and avoidance of a colostomy. For patients with two or more earlier repairs, a muscle interposition should be considered.