Selective sphincteroplasty of the papilla in cases at risk due to atypical anatomy

AIM： To analyze the indications, efficacy and safety of sphincteroplasty in our centre.METHODS： A retrospective study of sphincteroplasty in 53 cases of papilla at high risk was performed in 2004-2006. The procedure consisted of duodenoscopy with Olympus TJF 145 Videoduodenoscope, approach to the biliary tract using a catheter with a guidewire, and dilatation of the papilla with a dilatation balloon catheter using a syringe with a manometer for control of the filling pressure.RESULTS： The indications included intradiverticular papilla in 26 patients （49%）, stenosis of a previous sphincterotomy in 19 patients （35.8%）, small size of the papilla in 4 patients （7.5%）, Billroth R gastrectomy in 3 patients （5.6%）, and coagulopathy in one patient （1.9%）. The efficacy was 97.8%, with all the calculi extracted from the common bile duct in 84.4% of the patients, even though 21 of the patients （39.6%） had calculi with a diameter equal to or greater than 10 ram. Seven patients （13.2%） presented complications： haemorrhage in 1 patient （1.9%） and mild pancreatitis in 6 patients （11.3%）. The mean hospital stay in case of complications was of 3 ± 0.63 d.CONCLUSION： Sphincteroplasty is highly effective, with a compllcation rate similar to that of sphincterotomy, furthermore, the complications are of low clinical importance. The use of the 10 mm balloon makes it possible to extract calculi with a diameter of over 15 mm and to extract more than 3 calculi without increasing the rate of complications and reduces the need to resort to lithotripsy or rescue sphincterotomy.

Delorme's operation plus sphincteroplasty for complete rectal prolapse associated with traumatic fecal incontinence

Rectal prolapse associated with traumatic fecal incontinence is a rare clinical combination. This study was designed to assess Delorme＇s operation with sphincteroplasty as a surgical management of this combination in terms of recurrence and improvement of fecal incontinence. In this prospective study, we enrolled patients suffering from short, full-thickness rectal prolapse associated with traumatic fecal incontinence who had been admitted to Alexandria Main University Hospital during the period of May 2010-January 2013. Preoperative data including cause of trauma, duration of symptoms, results of anal manometry, and degree of fecal incontinence using Wexner score were collected from all patients. Delorme＇s procedure with overlap sphincteroplasty was done in all patients. Recurrence of prolapse and improvement of fecal incontinence were assessed after 1, 3, 6 and 12 months. The study included 13 patients aged （32±8.7） years, 9 females and 4 males. Cause of sphincteric injury included previous anal surgery in 7 patients and normal labor in 6 patients. Duration between sphinctefic injury and operation was （8.08±2.47） months. Preoperative Wexner＇s mean score was 16.07±3.4. Early postoperative complications included superficial wound infection （69.2%）, minor wound dehiscence （61.5%）, and postoperative bleeding （7.6%）. Recurrence was detected in 1 patient at 6 month follow-up. Wexner＇s score showed significant improvement for all patients after 6 months （4.00±2.04）. In conclusion, combination of Delorme＇s procedure and sphincteroplasty for treatment of patients with short complete rectal prolapse associated with traumatic fecal incontinence is a safe, effective surgical management with satisfactory results regarding anatomical and functional outcomes.

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.

Efficacy and safety of sphincterotomy with sphincteroplasty using large caliber balloons in the treatment of choledocholithiasis with extraction difficulties

Introduction: Endoscopic retrograde cholangiopan-creatography (ERCP) with endoscopic sphincterotomy (ES) is the most widely used technique for treating choledocholithiasis. In some cases, due to anomalies of the papilla or the presence of large or multiple calculi, additional maneuvers are needed to remove the stones. The present study investigates the efficacy and safety of ES with sphincteroplasty (SP) in the management of choledocholithiasis with extraction difficulties. Patients and Methods: A prospective study was made of 153 patients with choledocholithiasis subjected to ERCP. Fifty-two patients underwent ES with SP, while 101 were subjected only to ES. The two groups were compared in terms of age, gender, percentage cannulation, presence of papilla alterations, large or multiple stones, success in stone removal and complications (acute pancreatitis, bleeding and perforation). In the ES with SP group, we moreover recorded the diameters of the balloons employed (10-18 mm). Results: There were no significant differences between the groups in the stone extraction success rate (94.23% in the ES with SP group versus 97.03% in the ES group) or in the appearance of complications (3.8% in the ES with SP group versus 2.7% in the ES group). The presence of difficult papillae, and of multiple or large stones was significantly greater in the ES with SP group. The diameter of the balloon was not associated with the appearance of complications. Conclusion: Endoscopic sphincterotomy with sphincteroplasty is effective and safe in the treatment of choledocholithiasis with extraction difficulties.

Prior minimal endoscopic sphincterotomy to prevent pancreatitis related to endoscopic balloon sphincteroplasty

AIM To investigate the efficacy of prior minimal endoscopic sphincterotomy(EST) to prevent pancreatitis related to endoscopic balloon sphincteroplasty(EBS).METHODS After bile duct access was gained and cholangiogram confirmed the presence of stones < 8 mm in the common bile duct at endoscopic retrograde cholangiography, patients were subjected to minimal EST(up to one-third of the size the papilla) plus 8 mm EBS(ESTEBS group). The incidence of pancreatitis and the difference in serum amylase level after the procedure were examined and compared with those associated with 8-mm EBS alone in 32 patients of historical control(control group).RESULTS One hundred and five patients were included in the EST-EBS group, and complete stone removal was accomplished in all of them. The difference in serum amylase level after the procedure was- 25.0(217.9) IU/L in the EST-EBS group and this value was significantly lower than the 365.5(576.3) IU/L observed in the control group(P < 0.001). The incidence of post-procedure pancreatitis was 0%(0/105) in the EST-EBS group and 15.6%(5/32) in the control group(P < 0.001).CONCLUSION Prior minimal EST might be useful to prevent the elevation of serum amylase level and the occurrence of pancreatitis related to EBS.

Sphincteroplasty for anal incontinence

Sphincteroplasty(SP)is the operation most frequently performed in patients suffering from moderate-to-severe anal incontinence(AI)who do not respond to conservative treatment.Other costly surgeries,such as artificial bowel sphincter(ABS)and electro-stimulated graciloplasty,have been more or less abandoned due to their high morbidity rate.Minimally invasive procedures are widely used,such as sacral neuromodulation and injection of bulking agents,but both are costly and the latter may cure only mild incontinence.The early outcome of SP is usually good if the sphincters are not markedly denervated,but its effect diminishes over time.SP is more often performed for post-traumatic than for idiopathic AI.It may also be associated to the Altemeier procedure,aimed at reducing the recurrence rate of rectal prolapse,and may be useful when AI is due either to injury to the sphincter,or to a narrowed rectum following the procedure for prolapse and haemorrhoids(PPH)and stapled transanal rectal resection(STARR).The outcome of SP is likely to be improved with biological meshes and post-operative pelvic floor rehabilitation.SP is more effective in males than in multiparous women,whose sphincters are often denervated,and its post-operative morbidity is low.In conclusion,SP,being both low-cost and safe,remains a good option in the treatment of selected patients with AI.

Redo sphincteroplasty:are the results sustainable?

Objective:This study aimed to investigate the long-termoutcomes of patients who undergo redo sphincteroplasty(RS).Methods:Patients with fecal incontinence(FI)who underwent RS between November 1988 and December 2011 were retrospectively identified from a prospective database.A questionnaire and telephone survey assessed current Cleveland Clinic Fecal Incontinence Score(CCFFIS;best 0,worst 20)and Fecal Incontinence Quality of Life(FIQoL;best 4.1,worst 1)scale.Success was defined as no further continence surgery,no stoma and CCFFIS<9 at completion of follow-up.The Wilcoxon and Mann-Whitney U tests were used for comparing quantitative variables.Bivariate logistic regression analysis was done to identify predictive factors for success.Results:Fifty-six(66.7%)of 84 patients who underwent RS were available for evaluation at a median follow-up of 74(range:12-283)months.The mean CCFFIS decreased from 16.563.7 to 11.966.6(P<0.001)at last follow-up.Twelve patients(21.4%)underwent further continence surgery for failed sphincteroplasty,three(5.4%)of whom had a permanent stoma.Eighteen patients(32.1%)had a CCFFIS<9 at the completion of follow-up,and 16(28.6%)had long-term success.Twentyfour patients evaluated for FIQoL had a mean value of 2.6(range:1.0-4.1).Postoperative CCFFIS was correlated with FIQoL(Spearman’s correlation coefficient?0.854,P<0.001).Logistic regression analysis did not reveal any significant predictive variables for success of RS.Conclusion:Based on our criteria for success,the long-term success rate for RS over a median of 74 months is poor.

Fecal incontinence - Challenges and solutions

Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient&#x02019;s self-esteem and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.

Current management of fecal incontinence:Choosing amongst treatment options to optimize outcomes

The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life.Fecal incontinence is common,though it is often underreported by patients.In addition to standard treatment options,new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity.Non-operative treatments include dietary modifications,medications,and biofeedback therapy.Currently used surgical treatments include repair(sphincteroplasty),stimulation(sacral nerve stimulation or posterior tibial nerve stimulation),replacement(artificial bowel sphincter or muscle transposition)and diversion(stoma formation).Newer augmentation treatments such as radiofrequency energy delivery and injectable materials,are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence.In general,more invasive surgical treatments are now reserved for moderate to severe fecal incontinence.Functional and quality of life related outcomes,as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient.General indications,techniques,and outcomes profiles for the various treatments of fecal incontinence are discussed in detail.Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.