Sandra García-Osogobio

Radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence.

AbstractPURPOSE: In this prospective study we investigated the feasibility, safety, and efficacy of radio-frequency energy delivery deep to the mucosa of the anal canal for the treatment of fecal incontinence. METHODS: We studied ten patients with fecal incontinence of varying causes. All patients underwent anoscopy, anorectal manometry, endorectal ultrasound, and pudendal nerve terminal motor latency testing at baseline and six months. The Cleveland Clinic Florida scale for fecal incontinence (Wexner, 0–20), fecal incontinence-related quality of life score, and Short Form 36 were administered at baseline, 1, 2, 3, 6, and 12 months. Using conscious sedation and local anesthesia, we delivered temperature-controlled radio-frequency energy via an anoscopic device with multiple needle electrodes to create thermal lesions deep to the mucosa of the anal canal. RESULTS: Ten females (age, 55.9 ± 9.2 years; range, 44–74) were enrolled and treated. Median discomfort by visual analog scale (0–10) was 3.8 during and 0.9 two hours after the procedure. Bleeding occurred in four patients (14–21 days after procedure), spontaneous resolution (n = 3) and anoscopic suture ligation (n = 1). At 12 months, the median Wexner score improved from 13.5 to 5 (P < 0.001), with 80 percent of patients considered responders. All parameters in the fecal incontinence-related quality of life were improved (lifestyle (from 2.3 to 3.4), coping (from 1.4 to 2.7), depression (from 2.2 to 3.5), and embarrassment (from 1.3 to 2.8); P < 0.05 for all parameters). Protective pad use was eliminated in five of the seven baseline users. At six months, there was a significant reduction in both initial and maximum tolerable rectal distention volumes. Anoscopy was normal at six months. CONCLUSION: Radio-frequency energy delivery to the anal canal for treatment of fecal incontinence is a new modality that, in this study group, safely improved Wexner and fecal incontinence-related quality of life scores, eliminated protective pad use in most patients, and improved patient quality of life.

SECCA® Procedure for the Treatment of Fecal Incontinence: Results of Five-Year Follow-Up

PurposeThis study evaluated the long-term (5-year) durability of radiofrequency energy delivery for fecal incontinence.MethodsThis was an extension of the follow-up from our original prospective study in which patients who suffered from fecal incontinence were treated with the SECCA® system for radiofrequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0–20), fecal incontinence-related quality of life score, and Medical Outcomes Study Short-Form 36 were administered to five years. Differences between baseline and follow-up were analyzed by using paired t-test.ResultsA total of 19 patients were treated and followed for five years, including 18 females (aged 57.1 (range, 44–77) years). The mean duration for fecal incontinence was 7.1 (range, 1–21) years. At five-year follow-up, the mean fecal incontinence score had improved from 14.37 to 8.26 (P < 0.00025) with 16 patients (84.2 percent) demonstrating >50 percent improvement. All fecal incontinence-related quality of life scores improved, including lifestyle (2.43 to 3.15; P < 0.00075), coping (1.73 to 2.6; P < 0.00083), depression (2.24 to 3.15; P < 0.0002), and embarrassment (1.56 to 2.51; P < 0.0003). The social function component of the Short-Form 36 improved from 38.3 to 60 (P < 0.05). There was a trend toward improvement in the mental component summary of the Short-Form 36 from 38.1 to 48.14. There were no long-term complications.ConclusionsSignificant and sustained improvements in fecal incontinence symptoms and quality of life are seen at five years after treatment with the SECCA® system. This treatment should be considered for patients suffering from fecal incontinence not amenable to surgery and who have failed conservative management.

Toxic pseudomembranous colitis in a patient with ulcerative colitis.

UNLABELLED Toxic colitis is a severe disease that may be caused by several inflammatory and/or infectious diseases. Ulcerative colitis is one of the most frequent causes of toxic colitis in the United States. Toxic megacolon complicating Clostridium difficile colitis is a rare occurrence with significant morbidity and mortality. CASE REPORT A 52-year-old male presented with rectal bleeding and tenesmus. He had been treated for amebiasis with metronidazole, and had improved. Two weeks later, symptoms recurred, and he was referred to our hospital. A sigmoidoscopy and biopsies demonstrated mucosal ulcerative colitis. He underwent treatment with systemic prednisone, mesalamine, and hydrocortisone enemas with adequate response. He was asymptomatic for 2 months, but later presented with a tender abdomen and rectal bleeding. Plain abdominal and thorax films showed colonic distention and free intraperitoneal air. Emergency laparotomy was performed, and an inflamed and distended colon, with free inflammatory liquid in the peritoneum, was found. A total abdominal colectomy with temporary ileostomy and Hartmanns pouch was performed. The histopathology analysis demonstrated a Clostridium difficile pseudomembranous colitis. CONCLUSION The presence of toxic megacolon due to Clostridium difficile in patients with ulcerative colitis is a rare complication that may be suspected in patients with initial relapse who are on antibiotics.

Diagnostic yield and therapeutic impact of rectal retroflexion: a prospective, single-blind study conducted in three centers.

Background/Aims No clear data have been established and validated regarding whether rectal retroflexion has an important and therapeutic impact. The aim of the present study was to evaluate the diagnostic yield and therapeutic impact of rectal retroflexion compared with straight view examination. Methods A prospective single-blind study was conducted. Consecutive patients evaluated between October 2011 and April 2012 were included. Results A total of 934 patients (542 women, 58%) were included. The mean age was 57.4±14.8 years. Retroflexion was successful in 917 patients (98.2%). Distinct lesions in the anorectal area were detected in 32 patients (3.4%), of which 10 (1%) were identified only on retroflex view and 22 (2.4%) on both straight and retroflex views. Of the 32 identified lesions, 16 (50%) were polyps, nine (28.1%) were angiodysplasias, six (18.8%) were ulcers, and one (3.1%) was a flat lesion. All 10 patients (1%) in whom lesions were detected only by rectal retroflexion showed a therapeutic impact. Conclusions Rectal retroflexion has minimal diagnostic yield and therapeutic impact. However, its low rate of major complications and the possibility of detecting lesions undetectable by straight viewing justify its use.

Effect of Ulcerative Colitis in the Bursting Strength of Colonic Anastomoses in Rats

Inflammatory bowel disease may have a deleterious effect on bowel healing, but its difficult to demonstrate in clinical practice because of the association of multiple factors. An experiment was conducted in rats. They were divided in two groups: group I, a model of acetic acid induced-colitis, and group II, the control group. Both groups underwent a rectal resection and primary anastomosis. On postoperative day 7, the bursting strength of the anastomosis was evaluated. There were 44 rats in group I and 38 in group II. In 91% of group I rats there were histopathological changes compatible with inflammatory bowel disease (IBD). Mean bursting was significantly reduced in rats with acetic acid-induced IBD (142.18 ± 18.22 mm Hg in group I, and 208.85 ± 14.8 mm Hg in group II; p < .05). These results suggest a deleterious effect of IBD on bowel healing.