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Concept: Fecal incontinence

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Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure.

Concepts: Medical terms, Fecal incontinence, Anal fissure, Lateral internal sphincterotomy

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AIM: An evaluation was performed of the one-year outcome of open haemorrhoidectomy (Milligan-Morgan alone or with posterior mucosal anoplasty [Leopold Bellan procedure]). METHOD: A prospective, multicentre, observational study included all patients having a planned haemorrhoidectomy from January 2007 of June 2008. Data were collected before surgery, at three months and one year after surgery. Patients assessed their anal symptoms and quality of life (SF-36). RESULTS: 633 patients (median age 48 years, 56.5% female) underwent haemorrhoidectomy including Milligan-Morgan alone (n=231, 36.5%) or the Leopold Bellan procedure (posterior mucosal anoplasty) for resection of a fourth haemorrhoid (n=345, 54.5%), anal fissure (n=56, 8.9%) or low anal fistula (n=1, 0.16%). Median healing time was 6 weeks. Early complications included urinary retention (n=3), bleeding (n=11), local infection (n=7) and faecal impaction (n=9). At one year, main complications included skin tags (n=2) and anal stenosis (n=23). There were three recurrences requiring a second haemorrhoidectomy. On a visual analogue scale, anal pain at one year had fallen from a median of 5.5/10 before treatment to 0.1/10 (p<0.001), anal discomfort from 5.5/10 to 0.1/10 (p<0.001) and the KESS constipation score from 9/45 to 6/45 (p<0.001). The median Wexner score for anal incontinence was unchanged (2/20). De novo anal incontinence (Wexner >5) affected 8.5% of patients at one year, but preoperative incontinence disappeared in 16.7% of patients with this symptom. All physical and mental domains of quality of life significantly improved and 88% of patients were satisfied or very satisfied. CONCLUSION: Complications of open haemorrhoidectomy were infrequent. Anal continence was not altered. Comfort and well-being were significantly improved at one year after surgery. Patient satisfaction was high despite residual anal symptoms. © 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.

Concepts: Surgery, Gastroenterology, Dietary fiber, Fecal incontinence, Hemorrhoid, Anal fissure, Lateral internal sphincterotomy, Proctology

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PURPOSE: To clarify health-related quality of life (HRQOL) by self-evaluation after restorative proctocolectomy with ileal J-pouch anal anastomosis (IPAA) in children with ulcerative colitis, a questionnaire using the Pediatric Quality of Life Inventory™ 4.0 (PedsQL) was administered. METHODS: The PedsQL was administered to 13 consecutive children (mean age 14.5 years) who underwent IPAA between 2005 and 2010 in our hospital and age-matched healthy controls. The mean duration after IPAA was 2.5 years (range 0.08-6 years) at the time of this study. Healthy children completed the same questionnaire by retrospective imaging during the past 1 month by the PedsQL evaluation policy. RESULTS: Patients' total score and each functioning score after IPAA reached the same levels as those in healthy controls. Soiling, pouchitis occurrence, and bowel movements had no significant relationship to the PedsQL total score and each functioning score. CONCLUSIONS: Interference of physical activity, emotional status, and social life caused by refractory ulcerative colitis (UC) worsens patients' HRQOL. IPAA could resolve these problems in children with UC and result in an HRQOL comparable with that in healthy children.

Concepts: Evaluation, Digestive system, Ulcerative colitis, Colon, Dietary fiber, Fecal incontinence, Ileo-anal pouch, Pouchitis

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BACKGROUND: It was the aim of this prospective study to analyze both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for complex fistulas in Crohn’s disease. METHODS: All patients with perianal Crohn’s disease suffering from complex fistulas who underwent definitive surgery using VAAFT combined with advancement flap repair were prospectively enrolled in the study. Only complex fistulas with concurrent stable disease and without any evidence of severe inflammatory activity or perianal sepsis were treated using the VAAFT technique. Patients with Crohn’s proctitis or prior proctectomy were not candidates for the procedure. VAAFT was performed by using the VAAFT equipment (Karl Storz, Tuttlingen, Germany). Key steps included visualization of the fistula tract and/or side tracts using the fistuloscope and correct localization of the internal fistula opening under direct vision with irrigation. Diagnostic fistuloscopy was followed by advancement flap repair. In addition to feasibility, primary end points included detection of side tracts, success and continence status (assessed by the Cleveland Clinic Incontinence Score). Success was defined as closure of both internal and external openings, absence of drainage without further intervention and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6 and 9 months postoperatively. RESULTS: Within a 3-month observation period (September to November 2011), VAAFT was attempted in 13 patients with Crohn’s associated complex fistulas. The completion rate was 85 % (11/13). In these 11 patients (median age 34 years, 64 % females), complex fistulas were transsphincteric (8), suprasphincteric (2) and recto-vaginal (1). Forty-six percent (5/11) had concomitant therapy with biologic drugs. In 36 % (4/11), VAAFT was performed with fecal diversion. Median duration of surgery was 22 (range 18-42) minutes. Using VAAFT, additional side tracts not detected preoperatively could be identified in 64 % (7/11). No morbidity occurred. After a mean follow-up of 9 months, the success rate was 82 % (9/11). No deterioration of continence was documented (Cleveland Clinic Incontinence Score 2.4 vs. 1.6, p > 0.05). CONCLUSION: Preliminary results of the addition of the VAAFT technique to advancement flap repair in Crohn’s fistulas demonstrate that this leads to a high identification rate of occult side tracts with encouraging short-term healing rates. Moreover, a completion rate of 85 % seems promising.

Concepts: Ulcerative colitis, Crohn's disease, Fistula, Fecal incontinence, Anal fistula, Abscess, Cleveland, Cleveland Clinic

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Introduction. Longo’s technique (or PPH technique) is well known worldwide. Meta-analysis suggests that the failure due to persistence or recurrence is close to 7.7%. One of the reasons for the recurrence is the treatment of the advanced hemorrhoidal prolapse with a single stapling device, which is not enough to resect the appropriate amount of prolapse. Materials and methods. We describe the application of “Double PPH Technique” (D-PPH) to treat large hemorrhoidal prolapses. We performed a multicentric, prospective, and nonrandomized trial from July 2008 to July 2009, wherein 2 groups of patients with prolapse and hemorrhoids were treated with a single PPH or a D-PPH. Results were compared. The primary outcome was evaluation of safety and efficacy of the D-PPH procedure in selected patients with large hemorrhoidal prolapse. Results. In all, 281 consecutive patients suffering from hemorrhoidal prolapse underwent surgery, of whom 74 were assigned intraoperatively to D-PPH, whereas 207 underwent single PPH. Postoperative complications were 5% in both groups (P = .32), in particular: postoperative major bleeding 3.0% in PPH versus 4.1% D-PPH (P = .59); pain 37.9 % PPH versus 27.3% D-PPH (mean visual analog scale [VAS] = 2.5 vs 2.9, respectively; P = .72); and fecal urgency 2.1% PPH versus 5.7% D-PPH (P = .8). Persistence of hemorrhoidal prolapse at 12-month follow-up was 3.7% in the PPH group versus 5.9% in the D-PPH group (P = .5). Conclusions. Our data support the hypothesis that an accurate intraoperative patient selection for single (PPH) or double (D-PPH) stapled technique will lower in a significant way the incidence of recurrence after Longo’s procedure for hemorrhoidal prolapse.

Concepts: 2008, Bleeding, Visual analogue scale, Fecal incontinence, Staple, Prolapse, Hemorrhoid

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Anorectal manometry (ARCM) provides valuable information in children with chronic constipation and fecal incontinence but may not be tolerated in the awake child. This study aimed to evaluate the effect of ketamine anesthesia on the assessment of anorectal function by manometry and to evaluate defecation dynamics and anal sphincter resting pressure in the context of pathophysiology of chronic functional (idiopathic) constipation and soiling in children.

Concepts: Constipation, Opioid, Feces, Programming language, Fecal incontinence, Defecation, Hemorrhoid, Anus

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The aim of this study was to assess the prevalence and associations between anal intercourse and fecal incontinence.

Concepts: Fecal incontinence, Anal sex

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People suffering from neurogenic bowel dysfunction (NBD) and an ineffective bowel regimen often suffer from fecal incontinence (FI) and related symptoms, which have a huge impact on their quality of life. In these situations, transanal irrigation (TAI) has been shown to reduce these symptoms and improve quality of life.

Concepts: Life, Gastroenterology, Pain, Suffering, Fecal incontinence, Defecation

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Crohn’s disease (CD) is a chronic idiopathic inflammatory intestinal disorder associated with fecal dysbiosis. Fecal microbial transplant (FMT) is a potential therapeutic option for individuals with CD based on the hypothesis that changing the fecal dysbiosis could promote less intestinal inflammation.

Concepts: Medicine, Ulcerative colitis, Gastroenterology, Small intestine, Inflammatory bowel disease, Fecal incontinence, Malabsorption, Abscess

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Monitoring mucosal inflammation is crucial to prevent complications and disease progression in Crohn’s disease (CD). Endoscopy is the current standard, but is invasive. Clinical activity scores and non-invasive biochemical markers do not correlate well with mucosal inflammation. Microbial perturbations have been associated with disease activity in CD. Therefore, we aimed to investigate its potential use to differentiate CD patients in remission from those with an exacerbation. From 71 CD patients repeated fecal samples were collected, resulting in 97 active disease and 97 remission samples based on a combination of biochemical and clinical parameters. The microbiota composition was assessed by pyrosequencing of the 16S rRNA V1-V3 region. Random Forest analysis was used to find the most discriminatory panel of operational taxonomic units (OTUs) between active and remission samples. An independent internal validation set was used to validate the model. A combination of 50 OTUs was able to correctly predict 73% of remission and 79% of active samples with an AUC of 0.82 (sensitivity: 0.79, specificity: 0.73). This study demonstrates that fecal microbial profiles can be used to differentiate between active and remission CD and underline the potential of the fecal microbiota as a non-invasive tool to monitor disease activity in CD.

Concepts: Archaea, Ribosomal RNA, 16S ribosomal RNA, 30S, Colonoscopy, Inflammatory bowel disease, Fecal incontinence, Abscess