Kheng-Seong Ng

Fecal Incontinence: Community Prevalence and Associated Factors--A Systematic Review.

BACKGROUND: Fecal incontinence is a chronic and debilitating condition with significant health burden. Despite its clinical relevance, the prevalence of fecal incontinence remains inconsistently described. OBJECTIVE: This study aimed to systematically review the literature regarding the prevalence of and factors associated with fecal incontinence among community-dwelling adults. DATA SOURCES: A search of the PubMed, Embase, and Cochrane databases was performed. STUDY SELECTION: Studies that reported the prevalence of fecal incontinence and/or associated factors in a community-based (ie, unselected) adult population were included. Two independent assessors reviewed eligible articles. MAIN OUTCOME MEASURES: Relevant data were extracted from each study and presented in descriptive form. The main outcome measures included the prevalence of fecal incontinence (adjusted and/or unadjusted), stratified for age and sex if reported; factors associated (and not associated) with fecal incontinence; and study quality, assessed using predefined criteria. RESULTS: Of 3523 citations identified, 38 studies were included for review. The reported median prevalence of fecal incontinence was 7.7% (range, 2.0%–20.7%). Fecal incontinence equally affected both men (median, 8.1%; range, 2.3%–16.1%) and women (median, 8.9%; range, 2.0%–20.7%) and increased with age (15–34 years, 5.7%; >90 years, 15.9%). The study populations and diagnostic criteria used were heterogeneous, precluding any meaningful pooling of prevalence estimates. Study quality assessment revealed 6 high-quality studies, of which only 3 were performed in a representative sample. The median prevalence of fecal incontinence was higher in these studies at 11.2% (range, 8.3%–13.2%). The factors most commonly reported to be associated with fecal incontinence included increasing age, diarrhea, and urinary incontinence. LIMITATIONS: Heterogeneity of studies precluded meaningful pooling or meta-analysis of data. CONCLUSIONS: Fecal incontinence is a prevalent condition of equal sex distribution, affecting ≈1 in 8 community adults, and has identifiable associated factors. The paucity of high-quality prevalence studies emphasizes the need for future population-based studies that use standardized diagnostic criteria for fecal incontinence.

Prevalence of functional bowel disorders and faecal incontinence: an Australian primary care survey

Interest in functional bowel disorders (FBDs) and faecal incontinence (FI) has increased amongst coloproctologists. The study aimed to assess the prevalence of FBDs and FI (including its severity) among Australian primary healthcare seekers using objective criteria.

Electrophysiological Characterization of Human Rectal Afferents

This study confirms the existence of extrinsic nerves supplying the human rectum for the first time and demonstrates differences in the sensory innervation between the rectum and colon with rectal afferents being more mechanically and chemically sensitive than colonic afferents. As sensitization of gut afferent pathways appears important in the development of chronic pain in patients with functional bowel disorders, this in vitro model will allow evaluation of potential therapeutic agents on human visceral afferents.

Are we entering a needlescopic era

1. Makary MA, Mukherjee A, Sexton JB et al. Operating room briefings and wrong-site surgery. J. Am. Coll. Surg. 2007; 204: 236–43. 2. Makary MA, Sexton JB, Freischlag JA et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J. Am. Coll. Surg. 2006; 202: 746–52. 3. Gawande A. The Checklist Manifesto. London: Profile Books, 2011. 4. Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays. Ann. Surg. 2010; 252: 477–85. 5. Nundy S, Mukherjee A, Sexton JB et al. Impact of perioperative briefings on operating room delays: a preliminary report. Arch. Surg. 2008; 143: 1068–72.

Quantification and neurochemical coding of the myenteric plexus in humans: No regional variation between the distal colon and rectum

It remains unclear whether regional variation exists in the human enteric nervous system (ENS) ie, whether intrinsic innervation varies along the gut. Recent classification of gastrointestinal neuropathies has highlighted inadequacies in the quantification of the human ENS. This study used paired wholemounts to accurately quantify and neurochemically code the hindgut myenteric plexus, comparing human distal colon and rectum.

Brain responses to mechanical rectal stimuli in patients with faecal incontinence: an fMRI study

Continence is dependent on anorectal–brain interactions. Consequently, aberrations of the brain–gut axis may be important in the pathophysiology of faecal incontinence (FI) in certain patients. The aim of this study was to assess the feasibility of recording brain responses to rectal mechanical stimulation in patients with FI using functional magnetic resonance imaging (fMRI).

Postoperative lower gastrointestinal haemorrhage following bowel resection.

A 67‐year‐old woman underwent an open right hemicolectomy for a malignant polyp. A stapled functional end‐to‐end anastomosis was fashioned using a TLC 75 linear stapler (Ethicon, Somerville, NJ, USA). She had been on long‐term dual antiplatelet therapy for an extensive cardiac history, including ischaemic heart disease with two coronary bare‐metal stents inserted 6 months prior. The antiplatelet agents were withheld prior to surgery and recommenced on day 6 postoperatively according to advice, just prior to hospital discharge. Two weeks after discharge, she re‐presented to the hospital with large volume secondary lower gastrointestinal haemorrhage characterized by painless fresh bleeding per rectum. On physical examination, she was conscious but appeared pale and unwell. She was haemodynamically unstable, with a heart rate of 110 beats per minute and a blood pressure of 92/50 mmHg. Examination of the gastrointestinal system revealed that her abdomen was soft and non‐tender, but there was frank bleeding per rectum with clotted bright red blood. Laboratory investigations revealed a haemoglobin level of 89 g/L (compared with 132 g/L on discharge). All other parameters measured were within normal limits, including a normal arterial blood gas analysis. A computed tomography angiogram was performed, which demonstrated active contrast extravasation (arterial phase) adjacent to the ileocolic anastomosis (Fig. 1). The management of this patient presented a clinical dilemma. The options considered included operative, endoscopic and radiological intervention. Given her unstable clinical condition, there was an obvious need for prompt arrest of haemorrhage. As the bleeding source was proximal in the colon, endoscopic intervention was considered undesirable. Repeat surgical intervention was deferred in preference to potentially less morbid radiological intervention given her medical co‐morbidities and rapid access to interventional radiology in our institution. The patient was consented regarding potential ischaemia and possible compromise of the anastomosis following embolization. Formal angiography confirmed that the offending vessel was a branch of the middle colic artery. This vessel was ‘superselectively’ catheterized and successfully embolized with 5 mL of polyvinyl alcohol particles. A post‐embolization contrast run demonstrated successful embolization of the feeder vessel with no further extravasation of contrast. In the immediate post‐procedure period, there were no further episodes of lower gastrointestinal bleeding. After a short hospital stay, the patient was discharged home. There was no clinical evidence of anastomotic compromise. She continues to remain well at 12 months review. Anastomotic bleeding is a recognized complication following colonic resection. While the majority of patients respond to conservative management with supportive therapy, a proportion continue to bleed at a significant rate, posing a challenging clinical problem. As in our case, patients with anastomotic bleeding are often elderly with multiple co‐morbidities and on antiplatelet and/or anticoagulant therapy, further complicating management decisions. When supportive therapy proves inadequate, treatment options include endoscopic and surgical interventions (including reoperation with or without stoma formation). Angiographic embolization is increasingly regarded as a primary treatment modality for other aetiologies of acute lower gastrointestinal haemorrhage. However, its use to arrest bleeding from vessels supplying an anastomosis has been traditionally regarded as counterintuitive for fear of compromising the blood flow to the anastomosis with potential for ischaemia and subsequent dehiscence. Apprehension regarding the use of angiographic embolization for the management of anastomotic bleeding is based on results from early experiences, in which high rates (up to 20% in some series) of colonic infarction following embolization were documented.

An unusual cause of large bowel obstruction.

A 75-year-old man was referred for assessment of lower gastrointestinal symptoms. He reported a 12-month history of increasing difficulties with rectal emptying, associated with abdominal bloating and discomfort. He denied any anorectal bleeding and stated that his appetite was unchanged and his weight stable. Past medical history included coronary artery bypass grafting 13 years previously and a trans-abdominal laparoscopic repair of a left inguinal hernia 6 years ago. His daily medications were amlodipine 10 mg, clopidogrel 75 mg, simvastatin 10 mg and ramipril 5 mg. On examination his vital signs were normal. There was no pallor, jaundice or lymphadenopathy. Abdominal examination was unremarkable with no masses or organomegaly. Digital rectal examination was also normal. Routine blood investigations showed no abnormality. A colonoscopy revealed the abnormality shown in Fig. 1a. Colonoscopy revealed the presence of endoluminal mesh obstructing the sigmoid colon, such that it was not possible to advance the scope proximal to this. Due to the quantity of mesh visible within the bowel lumen and its likely full-thickness penetration of the bowel wall, it was considered unsafe to attempt endoscopic removal. Inguinal hernias are extremely common and surgical repair is recommended to relieve local discomfort and pain and reduce the occurrence of complications. Today this usually involves the placement of a synthetic mesh and laparoscopic repair has become popular, involving either a trans-abdominal or an extra-peritoneal approach. It is recommended that bilateral and recurrent inguinal hernias be repaired laparoscopically [1]. However, mesh migration with or without erosion into surrounding intra-abdominal viscera has complicated this technique [2–4]. This patient’s case demonstrates migration of the mesh placed at previous laparoscopic trans-abdominal repair of a left inguinal hernia with subsequent erosion into the sigmoid colon presenting with subacute large bowel obstruction. Some authors have reported endoscopic management of this condition with removal of the mesh at colonoscopy [5]. However, this patient underwent surgical management following appropriate counselling and preoperative assessment. At laparotomy, the sigmoid colon was densely adherent to the deep ring of the inguinal canal and the hernia mesh had eroded

Uncommon site for a common lesion

Perianal basal cell carcinomas (BCCs) are rare. While BCCs constitute around 75% of non-melanoma skin cancers in sun-exposed skin in Australia, fewer than 200 cases of BCC on perianal or genital skin have been reported in the English literature. The majority of these carcinomas have been reported in men aged 65–75 years; around one-third of cases displayed either synchronous or metachronous BCCs at other skin sites. An 80-year-old man presented with a lump on his perianal region, which he reported to be slowly growing over a 2-year period. He could not recall any precipitating event and denied any associated symptoms of pain or itchiness. He did not notice any discharge or bleeding from the lesion. He denied the presence of any lower gastrointestinal or anal symptoms, specifically, pain or bleeding associated with defecation or change in bowel habit. He denied previous episodes of perianal sepsis and there was no relevant personal or family history of neoplasia or inflammatory bowel disease. Similarly, the remainder of his past medical history was unremarkable. General examination and examination of the abdominal system revealed no abnormalities. Specifically, there were no abdominal masses, organomegaly or palpable inguinal lymphadenopathy. Upon inspection of the perianal region, there was a raised circular nodular lesion of approximately 2 cm in diameter located 5 cm from the anal margin in the 3 o’clock position with a well-defined edge. The central area of the lesion appeared slightly ulcerated with slough and a small patch of necrosis evident (see Fig. 1). There were no other notable skin lesions detected elsewhere. Following primary local excision of the perianal lesion, a diagnosis of a perianal BCC was made on histopathological examination which was invading to the mid-dermis and which had been completely excised (Fig. 2). Clinically, perianal BCCs present as slow-growing lesions with average size at presentation being <2 cm in diameter. Their appearance is similar to those found in other areas of the body and may range from erythematous papules to nodules and ulcers. They tend to be superficial and mobile. It is notable, however, in this case that the typical rolled, pearly edge was not obvious upon inspection. Perianal BCCs were previously regarded as more aggressive than other cutaneous BCCs. However, this is likely attributable to historically poor histological distinction between BCCs and the more aggressive basaloid carcinomas, which have a worse prognosis. It is now thought that they have little invasive or metastatic potential and their prognosis is very similar to their counterparts on sun-exposed skin. In two separate series, 5-year survival rates have been reported to be 100%. Perianal BCCs can easily be misdiagnosed as non-specific inflammatory or infectious skin conditions, resulting in delayed and/or incorrect treatment. They should be carefully distinguished from other causes of chronic perianal dermatosis such as anal intraepithelial neoplasia or extramammary Paget’s disease. Furthermore, there is usually a delay in seeking medical attention due to the location of the lesion. Appropriate management thus relies on a strong index of suspicion. Formal diagnosis requires biopsy and histopathological examination. Specific treatment depends on size and location of the lesion. While lesions <2 cm in diameter can be adequately treated by wide local excision with adequate margins and primary closure, larger lesions may require reconstructive skin grafting or Mohs micrographic surgery for tissue preservation. Mohs micrographic surgery