Lynne Bartlett

Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage

BACKGROUND The ligation of intersphincteric fistula tract (LIFT) is a relatively new surgical technique for treating complex anorectal fistulas. METHODS LIFT was compared with anorectal advancement flap management (ARAF) of complex anorectal fistulas requiring previous seton drainage. Crohns patients were excluded. Patients with no confirmed recurrent sepsis after 6 months were randomized to day surgery performance of LIFT (25; 17 male) or ARAF (14; 10 male) with removal of the seton. Outcome measures included recurrences, surgical time, complications, hospital readmissions, and fecal incontinence. RESULTS LIFT was 32.5 minutes shorter than ARAF (P < .001). Complications were similar, with no hospital readmissions. Return to normal activities was 1 week for LIFT patients, 2 weeks for ARAF patients (P = .016). At 19 months there were 3 recurrences (2 in the LIFT group). One ARAF patient had minor incontinence. CONCLUSIONS The LIFT procedure was simple, safe, shorter, and patients returned to work earlier. All patients had preliminary seton drainage, possibly contributing to the low recurrence rates.

PTQ™ anal implants for the treatment of faecal incontinence

In North Queensland demand for conservative faecal incontinence treatments outweighs supply. Injectable bulking agents offer a safe and effective treatment for patients with internal anal sphincter (IAS) dysfunction.

Biofeedback for Fecal Incontinence: A Randomized Study Comparing Exercise Regimens

BACKGROUND: Fecal incontinence affects up to 11% of Australian community-dwelling adults and 72% of nursing home residents. Biofeedback is a recommended conservative therapy when medication and pelvic floor exercises have failed to improve patient outcomes. OBJECTIVE: This study aimed to investigate the impact of a new exercise regimen on the severity of fecal incontinence and the quality of life of participants. DESIGN: This was a randomized clinical study. SETTINGS: This study was conducted at the Anorectal Physiology Clinic, Townsville Hospital, Queensland, Australia. PATIENTS: Seventy-two participants (19 male), with a mean age of 62.1 years, attended 5 clinic sessions: 4 weekly sessions followed by 4 weeks of home practice and a follow-up assessment session. A postal survey was conducted 2 years later. INTERVENTION: Thirty-seven patients (12 male) were randomly assigned to the standard clinical protocol (sustained submaximal anal and pelvic floor exercises) and 35 patients (7 male) were randomly assigned to the alternative group (rapid squeeze plus sustained submaximal exercises). MAIN OUTCOME MEASURES: The main outcomes were measured by use of the Cleveland Clinic Florida Fecal Incontinence score and the Fecal Incontinence Quality of Life Scale survey tool. RESULTS: No significant differences were found between the 2 exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality-of-life, or fecal incontinence severity measures. Sixty-nine participants completed treatment. The severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Eighty-six percent (59/69) of participants reported improved continence. Quality of life significantly improved for all participants (P < .001). Results were sustained 2 years later. Patients who practiced at least the prescribed number of exercises had better outcomes than those who practiced fewer exercises. LIMITATIONS: This study was limited because it involved a heterogeneous sample, it was based on subjective reporting of exercise performance, and loss to follow-up occurred because of the highly mobile population. CONCLUSIONS: Patients attending this biofeedback program attained significant improvement in the severity of their fecal incontinence and in their quality of life. Although introduction of rapid muscle squeezes had little impact on fecal incontinence severity or patient quality of life, patient exercise compliance at prescribed or greater levels did.

Reasons for non-disclosure of faecal incontinence: a comparison between two survey methods

PurposeWe explored reasons for discordance in disclosure of faecal incontinence (FI) between 2 measurement instruments: the Self Administered Faecal Incontinence Questionnaire (SAFIQ) and the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FI)MethodsPatients ≥18 years attending the urogynaecology (n=135) and colorectal (n=148) outpatient clinics at The Townsville Hospital, a referral centre serving regional North Queensland, Australia, were invited to complete the SAFIQ and answer questions from the CCF-FI asked by their treating doctor. Selected patients undertook semistructured interviews.Results262 patients completed both questionnaires. The prevalence of FI in this population was 25.6% (SAFIQ) and 29.9% (CCF-FI). 24% disclosed FI on both instruments, 3.1% on SAFIQ only and 6.1% on CCF-FI only. Major reasons for non-disclosure were: FI historical but not current; problem not considered as FI by patient; SAFIQ too long; condition embarrassing; doctor considered too busy; patient wanted to focus on primary reason for consultation; and doctor explained that a one-off bout of uncontrollable diarrhoea was not FI. Interviewees reported they would respond to FI questions initiated by their general practitioner (GP) during regular consultations, or in a generic questionnaire in the GP’s surgery.ConclusionsGPs could identify patients with FI by initiating discussions during routine consultations. Such patients could then be referred to colorectal surgeons for treatment. A more specific definition of FI, which excludes historical data and isolated instances of diarrhoea, is desirable. A measurement instrument suitable for population surveys should contain simple language and acknowledge issues of embarrassment.

Treatment of postsurgery bowel dysfunction: biofeedback therapy.

Following surgical procedures such as partial colectomy, total colectomy with ileorectal anastomosis, restorative proctocolectomy, or low anterior anastomosis, altered bowel habits and function may have adverse long-term effects on health-related quality of life. Symptoms of postsurgery bowel dysfunction include loose stools, frequent defecation, rectal urgency, fecal incontinence, and difficult or incomplete evacuation. The Anorectal Physiology Clinic at The Townsville Hospital, Queensland, Australia, offers a treatment program for postsurgery bowel dysfunction that combines behavioral strategies and pelvic floor muscle training using biofeedback techniques. The behavioral strategies include education, support and coping measures, and advice about diet, fluid intake, medication, and exercise discussed in a previous article. This article describes biofeedback-assisted pelvic floor muscle training, including techniques for relaxation and effective bowel evacuation, and exercises for pelvic floor muscle strengthening. Biofeedback is also used to modify rectal sensitivity and assist with anorectal coordination training, in order to alleviate stool frequency and urgency. We believe that behavioral strategies and pelvic floor muscle training are complementary components of the holistic treatment program.

Practical strategies for treating postsurgical bowel dysfunction.

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

Harmonic scalpel compared with conventional excisional haemorrhoidectomy: a meta-analysis of randomized controlled trials

BackgroundHaemorrhoidectomy is the most effective and definitive treatment for grade 3 or 4 haemorrhoids despite being associated with considerable pain. The aim of this study was to search the literature, which compares outcomes of harmonic scalpel haemorrhoidectomy and traditional surgical procedures, and conduct a quantitative meta-analysis of the randomized trials.MethodsRandomized controlled trials (RCTs) were identified from the major electronic databases using the keywords “harmonic scalpel haemorrhoidectomy” and “haemorrhoidectomy” and a quantitative meta-analysis conducted. The eight trials that met the inclusion criteria included 468 patients (233 in the harmonic scalpel group). Pain was the primary outcome measure, and other parameters assessed included duration of operation, length of hospital stay, time to return to work, and complications.ResultsSignificantly, more patients returned to work in the first post-operative week, and pain scores were an average of one unit lower following harmonic scalpel haemorrhoidectomy. Generally, the incidence of complications in the harmonic scalpel group was less than half that found in conventional haemorrhoidectomy. There was no significant difference between the groups as regards operating time or length of hospital stay. Recurrence was not reported in any of the studies.ConclusionsThe meta-analysis showed that harmonic scalpel haemorrhoidectomy is a safe and effective modality associated with less post-operative pain and a more rapid return to work than traditional surgery for haemorrhoids. Statistical heterogeneity was high; thus, it may be too early to place complete confidence in these results. Further RCTs are required.

Glyceryl trinitrate ointment did not reduce pain after stapled hemorrhoidectomy: a randomized controlled trial.

Medications, including topical 0.2% glyceryl trinitrate (GTN), can reduce anal spasm and pain after excisional hemorrhoidectomy. GTN after stapled hemorrhoidopexy was compared with routine postoperative management. Patients with symptomatic grade 3/4 hemorrhoids were recruited. After stapled hemorrhoidopexy, residual perianal skin tags were excised as appropriate. Those requiring double purse-string mucosectomy were excluded. Postoperative pain, pain duration, and complications were assessed. One hundred ten patients (74 men; mean age 50.6 years) were enrolled in the control group and 100 patients (57 men; mean age 49.8 years) in the GTN group. Maximum pain was higher in the GTN group (P  =  0.015). There were no differences between the two groups in residual perianal skin tags requiring excision, postoperative complications, recurrence rates, follow-up period, average pain, duration of pain, or satisfaction scores. Sixteen GTN patients were noncompliant due to side effects. None had persistent perianal skin tags. GTN did not reduce postoperative pain after stapled hemorrhoidectomy.

Supplementary home biofeedback improves quality of life in younger patients with fecal incontinence.

Background: Biofeedback is a scarce, resource-intensive clinical therapy. It is used to treat patients with bowel problems, including fecal incontinence (FI), who fail to respond to simple dietary advice, medication, or pelvic floor exercises. Populations are aging and younger cohorts use technology in managing their health, affording FI self-management opportunities. Aim: Does supplementary home-based biofeedback improve FI and quality of life (QOL)? Methods: Seventy-five incontinent participants (12 male), mean age 61.1 years, consented to participate. Thirty-nine patients (5 male) were randomized to the standard biofeedback protocol plus daily home use of a Peritron perineometer (intervention) and 36 patients (7 male) to the standard biofeedback protocol (control). On completion of the study each perineometer exercise session was rated for technique by 2 raters, blinded to the patient and order of sessions. Results: With the exception of Fecal Incontinence Quality of Life Scale lifestyle improvement (intervention—9.1% vs. controls—0.3%, P=0.026) and embarrassment improvement (intervention—50.0% vs. controls—18.3%, P=0.026), supplementary home biofeedback did not result in greater clinical improvement for the intervention group as a whole. However, on stratification around the mean age, continence and QOL of younger people in the intervention group were significantly better than those of their control counterparts. Graphed perineometer sessions demonstrated high compliance and improvement in exercise technique. Perineometers provided reassurance, motivation, and an exercise reminder ensuring that confidence was achieved quickly. Conclusions: Home biofeedback was acceptable and well tolerated by all users. Younger participants significantly benefited from using this technology.

Fecal Incontinence Reduces Quality of Life More Than You May Think

will be important for those studying the topic to clearly define FCCTX with respect to whether Amsterdam I or II is used and whether the absence of a gene defect, the presence of MSS, or both is required. We also appreciate the discussion regarding surgical options. It is important to note that these guidelines are developed based on systematic review of available evidence and not the consensus of expert opinion. Each method can give important guidance to the reader. However, to our knowledge, no study has been published examining either primary or tertiary prophylaxis. Accordingly, only secondary prophylaxis is included in this work, because there are insufficient data to provide guidance on primary or tertiary prophylaxis.