Bryan Parry

The Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review of the Literature

PURPOSE:Reported prevalence estimates for fecal incontinence among community-dwelling adults vary widely. A systematic review was undertaken to investigate the studied prevalence of fecal incontinence in the community and explore the heterogeneity of study designs and sources of bias that may explain variability in estimates.METHODS:A predetermined search strategy was used to locate all studies published that reported the prevalence of fecal incontinence in a community-based sample of adults. Data were extracted onto a proforma for sampling frame and method, sample size, response rate, definition of fecal incontinence used, data-collection method, and prevalence rates. Included studies were critically appraised for possible sources of selection bias, information bias, and imprecision.RESULTS:A total of 16 studies met the inclusion criteria. These could be grouped into definitions of incontinence that included or excluded incontinence of flatus. The estimated prevalence of anal incontinence (including flatus incontinence) varied from 2 to 24 percent, and the estimated prevalence of fecal incontinence (excluding flatus incontinence) varied from 0.4 to 18 percent. Only three studies were found to have a study design that minimized significant sources of bias, and only one of these used a validated instrument for data collection. The prevalence estimate of fecal incontinence from these studies was 11 to 15 percent. No pooling of estimates was undertaken because there was wide variation in study design.CONCLUSIONS:A consensus definition of fecal incontinence is needed that accounts for alterations in quality of life. Further cross-sectional studies are required that minimize bias in their design and use validated self-administered questionnaires.

ANASTOMOTIC LEAKAGE AFTER LOWER GASTROINTESTINAL ANASTOMOSIS: MEN ARE AT A HIGHER RISK

Background:  Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis.

Metachronous colorectal cancer risk for mismatch repair gene mutation carriers: the advantage of more extensive colon surgery

Background Surgical management of colon cancer for patients with Lynch syndrome who carry a mismatch repair (MMR) gene mutation is controversial. The decision to remove more or less of the colon involves the consideration of a relatively high risk of metachronous colorectal cancer (CRC) with the impact of more extensive surgery. Objective To estimate and compare the risks of metachronous CRC for patients with Lynch syndrome undergoing either segmental or extensive (subtotal or total) resection for first colon cancer. Design Risk of metachronous CRC was estimated for 382 MMR gene mutation carriers (172 MLH1, 167 MSH2, 23 MSH6 and 20 PMS2) from the Colon Cancer Family Registry, who had surgery for their first colon cancer, using retrospective cohort analysis. Age-dependent cumulative risks of metachronous CRC were calculated using the Kaplan–Meier method. Risk factors for metachronous CRC were assessed by a Cox proportional hazards regression. Results None of 50 subjects who had extensive colectomy was diagnosed with metachronous CRC (incidence rate 0.0; 95% CI 0.0 to 7.2 per 1000 person-years). Of 332 subjects who had segmental resections, 74 (22%) were diagnosed with metachronous CRC (incidence rate 23.6; 95% CI 18.8 to 29.7 per 1000 person-years). For those who had segmental resections, incidence was statistically higher than for those who had extensive surgery (P <0.001). Cumulative risk of metachronous CRC was 16% (95% CI 10% to 25%) at 10 years, 41% (95% CI 30% to 52%) at 20 years and 62% (95% CI 50% to 77%) at 30 years after segmental colectomy. Risk of metachronous CRC reduced by 31% (95% CI 12% to 46%; p=0.002) for every 10 cm of bowel removed. Conclusions Patients with Lynch syndrome with first colon cancer treated with more extensive colonic resection have a lower risk of metachronous CRC than those receiving less extensive surgery. This finding will better inform decision-making about the extent of primary surgical resection.

Meta-analysis of oral water-soluble contrast agent in the management of adhesive small bowel obstruction.

Adhesions are the leading cause of small bowel obstruction. Identification of patients who require surgery is difficult. This review analyses the role of Gastrografin® as a diagnostic and therapeutic agent in the management of adhesive small bowel obstruction.

Prioritizing patients for elective surgery: a systematic review

Background:  Priority scoring tools are mooted as means for dealing with burgeoning elective surgical waiting lists. There is ongoing development work in New Zealand, Canada and the UK. This emerging international perspective is invaluable in determining the application of these tools and addressing any pitfalls.

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery

Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double‐blind randomized trial.

Cusum analysis of trends in operative selection and conversion rates for laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) requires a high degree of technical ability, spatial resolution and dexterity. Assessing trainees and competent operators is an important aspect of quality assurance in patient care. Most institutions quote mean conversion rate as a method of comparing operators’ performance. The purpose of the present study was to use the technique of cumulative sum (cusum) analysis to determine whether a learning curve phenomenon exists in operators performing LC.

Long-term outcome of postanal repair in the treatment of faecal incontinence

Background:  Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence.

Correlation between gross anatomical topography, sectional sheet plastination, microscopic anatomy and endoanal sonography of the anal sphincter complex in human males

This study elucidates the structure of the anal sphincter complex (ASC) and correlates the individual layers, namely the external anal sphincter (EAS), conjoint longitudinal muscle (CLM) and internal anal sphincter (IAS), with their ultrasonographic images. Eighteen male cadavers, with an average age of 72 years (range 62–82 years), were used in this study. Multiple methods were used including gross dissection, coronal and axial sheet plastination, different histological staining techniques and endoanal sonography. The EAS was a continuous layer but with different relations, an upper part (corresponding to the deep and superficial parts in the traditional description) and a lower (subcutaneous) part that was located distal to the IAS, and was the only muscle encircling the anal orifice below the IAS. The CLM was a fibro‐fatty‐muscular layer occupying the intersphincteric space and was continuous superiorly with the longitudinal muscle layer of the rectum. In its middle and lower parts it consisted of collagen and elastic fibres with fatty tissue filling the spaces between the fibrous septa. The IAS was a markedly thickened extension of the terminal circular smooth muscle layer of the rectum and it terminated proximal to the lower part of the EAS. On endoanal sonography, the EAS appeared as an irregular hyperechoic band; CLM was poorly represented by a thin irregular hyperechoic line and IAS was represented by a hypoechoic band. Data on the measurements of the thickness of the ASC layers are presented and vary between dissection and sonographic imaging. The layers of the ASC were precisely identified in situ, in sections, in isolated dissected specimens and the same structures were correlated with their sonographic appearance. The results of the measurements of ASC components in this study on male cadavers were variable, suggesting that these should be used with caution in diagnostic and management settings.

Design and Validation of a Comprehensive Fecal Incontinence Questionnaire

PurposeFecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise.MethodsPatients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion.ResultsThe questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35–1).ConclusionsThis questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.