Garg incontinence scores: New scoring system on the horizon to evaluate fecal incontinence. Will it make a difference?

The main aim of this opinion review is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023;29:4593–4603.The authors in the published article developed a new scoring system,Garg incon-tinence scores(GIS),for fecal incontinence(FI).FI is a chronic debilitating disease that has a severe negative impact on the quality of life of the patients.Rome IV criteria define FI as multiple episodes of solid or liquid stool passed into the clothes at least twice a month.The associated social stigmatization often leads to significant under-reporting of the condition,which further impairs management.An important point is that the complexity and vagueness of the disease make it difficult for the patients to properly define and report the magnitude of the problem to their physicians.Due to this,the management becomes even more difficult.This issue is resolved up to a considerable extent by a scoring ques-tionnaire.There were several scoring systems in use for the last three decades.The prominent of them were the Cleveland Clinic scoring system or the Wexner scoring system,St.Marks Hospital or Vaizey’s scores,and the FI severity index.However,there were several shortcomings in these scoring systems.In the opinion review,we tried to analyze the strength of GIS and compare it to the existing scoring systems.The main pitfalls in the existing scoring systems were that most of them gave equal weightage to different types of FI(solid,liquid,flatus,etc.),were not comprehensive,and took only the surgeon’s perception of FI into view.In GIS,almost all shortcomings of previous scoring systems had been addressed:different weights were assigned to different types of FI by a robust statistical methodology;the scoring system was made comprehensive by including all types of FI that were previously omitted(urge,stress and mucus FI)and gave priority to patients’rather than the physicians’perceptions while developing the scoring system.Due to this,GIS indeed looked like a paradigm shift in the evaluation of FI.However,it is too early to conclude this,as GIS needs to be validated for accuracy and simplicity in future studies.

Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study

BACKGROUND Fecal incontinence(FI)is an involuntary passage of fecal matter which can have a significant impact on a patient’s quality of life.Many modalities of treatment exist for FI.Sacral nerve stimulation is a well-established treatment for FI.Given the increased need of magnetic resonance imaging(MRI)for diagnostics,the In-terStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility.Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used.AIM To evaluate the efficacy,outcomes and complications of the MRI-compatible InterStim.METHODS Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport,University of Minnesota,Advocate Lutheran General Hospital,and University of Wisconsin-Madison was pooled and analyzed.Patient demographics,clinical features,surgical techniques,complications,and outcomes were analyzed.Strengthening the Reporting of Observational studies in Epidemiology(STROBE)cross-sectional reporting guidelines were used.RESULTS Seventy-three patients had the InterStim implanted.The mean age was 63.29±12.2 years.Fifty-seven(78.1%)patients were females and forty-two(57.5%)patients had diabetes.In addition to incontinence,overlapping symptoms included diarrhea(23.3%),fecal urgency(58.9%),and urinary incontinence(28.8%).Fifteen(20.5%)patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement.Thirty-two(43.8%)patients underwent rechargeable InterStim placement.Three(4.1%)patients needed removal of the implant.Migration of the external lead connection was observed in 7(9.6%)patients after the stage I procedure.The explanation for one patient was due to infection.Seven(9.6%)patients had other complications like nerve pain,hematoma,infection,lead fracture,and bleeding.The mean follow-up was 6.62±3.5 mo.Sixty-eight(93.2%)patients reported significant improvement of symptoms on follow-up evaluation.CONCLUSION This study shows promising results with significant symptom improvement,good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI.Further long-term follow-up and future studies with a larger patient population is recommended.

Sphincteroplasty for fecal incontinence in the era of sacral nerve modulation

The role of sphincteroplasty in the treatment of patients with fecal incontinence due to anal sphincter defects has been questioned because the success rate declines in the long-term.A new emerging treatment for fecal incontinence,sacral nerve stimulation,has been shown to be effective in these patients.However,the success rate of sphincteroplasty may depend of several patient-related and surgical-related factors and the outcome from sphincteroplasty has been evaluated differently(with qualitative data) from that after sacral nerve stimulation(quantitative data using scoring systems and quality of life).Furthermore,the data available so far on the longterm success rate after sacral nerve modulation do not differ substantially from those after sphincteroplasty.The actual data do not support the replacement of sphincteroplasty with sacral nerve stimulation in patients with fecal incontinence secondary to sphincter defects.

Fecal incontinence in men:Causes and clinical and manometric features

AIM:To determine the causes and characteristics of fecal incontinence in men and to compare these features with those presented by a group of women with the same problem.METHODS:We analyzed the medical history,clinical and manometric data from 119 men with fecal incontinence studied in our unit and compared these data with those obtained from 645 women studied for the same problem.Response to treatment was evaluated after 6 mo of follow-up.RESULTS:Fifteen percent of patients studied in our unit for fecal incontinence were male.Men took longer than women before asking for medical help.Anorectal surgery was the most common risk factor for men related to fecal incontinence.Chronic diarrhea was present in more than 40%of patients in both groups.Decreased resting and external anal sphincter pressures were more frequent in women.No significant differences existed between the sexes regarding rectal sensitivity and recto-anal inhibitory reflex.In 17.8%of men,all presenting soiling,manometric findings did not justify fecal incontinence.Response to treatment was good in both groups,as 80.4%of patients improved and fecal incontinence disappeared in 13.2%of them.CONCLUSION:In our series,it was common that men waited longer in seeking medical help for fecal incontinence.Ano-rectal surgery was the major cause of this problem.Chronic diarrhea was a predisposing factor in both sexes.Manometric differences between groups were limited to an increased frequency of hypotony of the external anal sphincter in women.Fecal incontinence was controllable in most patients.

Endoanal ultrasonography in fecal incontinence: Current and future perspectives

Fecal incontinence has a profound impact in a patient's life, impairing quality of life and carrying a substantial economic burden due to health costs. It is an underdiagnosed condition because many affected patients are reluctant to report it and also clinicians are usually not alert to it. Patient evaluation with a detailed clinical history and examination is very important to indicate the type of injury that is present. Endoanal ultrasonography is currently the gold standard for sphincter evaluation in fecal incontinence and is a simple, well-tolerated and non-expensive technique. Most studies revealed 100%sensitivity in identifying sphincter defect. It is better than endoanal magnetic resonance imaging for internal anal sphincter defects, equivalent for the diagnosis of external anal sphincter defects, but with a lower capacity for assessment of atrophy of this sphincter.The most common cause of fecal incontinence is anal sphincter injury related to obstetric trauma. Only a small percentage of women are diagnosed with sphincter tears immediately after vaginal delivery, but endoanal ultrasonography shows that one third of these women have occult sphincter defects. Furthermore, in patients submitted to primary repair of these tears, ultrasound revealed a high frequency of persistent sphincter defects after surgery. Three-dimensional endoanal ultrasonography is currently largely used and accepted for sphincter evaluation in fecal incontinence, improving diagnostic accuracy and our knowledge of physiologic and pathological sphincters alterations. Conversely,there is currently no evidence to support the use of elastography in fecal incontinence evaluation.

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential,full-thickness protrusion of the rectum through the anus.It is a rare condition,and only affects 0.5%of the general population.Multiple treatment modalities have been described,which have changed significantly over time.Particularly in the last decade,laparoscopic and robotic surgical approaches with different mobilization techniques,combined with medical therapies,have been widely implemented.Because patients have presented with a wide range of complaints(ranging from abdominal discomfort to incomplete bowel evacuation,mucus discharge,constipation,diarrhea,and fecal incontinence),understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure.It is crucial to assess these additional symptoms and their severities using preoperative scoring systems.Additionally,radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders.However,there is no consensus on or standardization of the optimal extent of dissection,type of procedure,and materials used for rectal fixation;this makes providing maximum benefits to patients with minimal complications difficult.Even recent publications and systematic reviews have not recommended the most appropriate treatment options.This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

Gender influence on defecographic abnormalities in patients with posterior pelvic floor disorders

AIM:To compare defecographic abnormalities in symptomatic men and women and to analyze differences between men and age-and symptom-matched women.METHODS:Sixty-six men(mean age:55.4 years,range:20-81 years) who complained of constipation and/or fecal incontinence and/or pelvic pain underwent defecography after intake of a barium meal.Radiographs were analyzed for the diagnosis of rectocele,enterocele,intussusception and perineal descent.They were compared with age-and symptom-matched women(n = 198) who underwent defecography during the same period.RESULTS:Normal defecography was observed in 22.7% of men vs 5.5% of women(P < 0.001).Defecography in men compared with women showed 4.5%vs 44.4%(P < 0.001) rectocele,and 10.6% vs 29.8%(P < 0.001) enterocele,respectively.No difference was observed for the diagnosis of intussusception(57.6% vs 44.9%).Perineal descent at rest was more frequent in women(P < 0.005).CONCLUSION:For the same complaint,diagnosis of defecographic abnormalities was different in men than in women:rectocele,enterocele and perineal descent at rest were observed less frequently in men than in women.

Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders

AIM To investigate compliance with transanal irrigation(TAI) one year after a training session and to identify predictive factors for compliance.METHODS The compliance of one hundred eight patients [87 women and 21 men; median age 55 years(range 18-83)] suffering from constipation or fecal incontinence(FI) was retrospectively assessed. The patients were trained in TAI over a four-year period at a single institution. They were classified as adopters if they continued using TAI for at least one year after beginning the treatment or as non-adopters if they stopped. Predictive factors of compliance with TAI were based on pretreatment assessments and trainingprogress. The outcomes of the entire cohort of patients who had been recruited for the TAI treatment were expressed in terms of intention-to-treat.RESULTS Forty-six of the 108(43%) trained patients continued to use TAI one year after their training session. The patients with FI had the best results, with 54.5% remaining compliant with TAI. Only one-third of the patients who complained of slow transit constipation or obstructed defecation syndrome continued TAI. There was an overall discontinuation rate of 57%. The most common reason for discontinuing TAI was the lack of efficacy(41%). However, 36% of the patients who discontinued TAI gave reasons independent of the efficacy of the treatment such as technical problems(catheter expulsion, rectal balloon bursting, instilled water leakage or retention, pain during irrigation, anal bleeding, anal fissure) while 23% said that there were too many constraints. Of the patients who reported discontinuing TAI, the only predictive factor was the progress of the training(OR = 4.9, 1.3-18.9, P = 0.02).CONCLUSION The progress of the training session was the only factor that predicted patient compliance with TAI.

Current applications of transperineal ultrasound in gastroenterology

Transperineal ultrasound is an inexpensive,safe and painless technique that dynamically and non-invasively evaluates the anorectal area.It has multiple indications,mainly in urology,gynaecology,surgery and gastroenterology,with increased use in the last decade.It is performed with conventional probes,positioned directly above the anus,and may capture images of the anal canal,rectum,puborectalis muscle(posterior compartment),vagina,uterus,(central compartment),urethra and urinary bladder(anterior compartment).Evacuatory disorders and pelvic floor dysfunction,like rectoceles,enteroceles,rectoanal intussusception,pelvic floor dyssynergy can be diagnosed using this technique.It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature,with images obtained at rest,straining and sustained squeezing.This technique is an accurate examination for detecting,classifying and following of perianal inflammatory disease.It can also be used to sonographically guide drainage of deep pelvic abscesses,mainly in patients who cannot undergo conventional drainage.Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence,postpartum and also following surgical repair of obstetric tears.There are also some studies referring to its role in anal stenosis,for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.

Coupling analysis of transcutaneous energy transfer coils with planar sandwich structure for a novel artificial anal sphincter

This paper presents a set of analytical expressions used to determine the coupling coefficient between primary and secondary Litz-wire planar coils used in a transcutaneous energy transfer(TET) system. A TET system has been designed to power a novel elastic scaling artificial anal sphincter system(ES-AASS) for treating severe fecal incontinence(FI), a condition that would benefit from an optimized TET. Expressions that describe the geometrical dimension dependence of self- and mutual inductances of planar coils on a ferrite substrate are provided. The effects of ferrite substrate conductivity, relative permeability, and geometrical dimensions are also considered. To verify these expressions, mutual coupling between planar coils is computed by 3D finite element analysis(FEA), and the proposed expressions show good agreement with numerical results. Different types of planar coils are fabricated with or without ferrite substrate. Measured results for each of the cases are compared with theoretical predictions and FEA solutions. The theoretical results and FEA results are in good agreement with the experimental data.