WHAT’S NEW IN SURGERY What’s New in Colon and Rectal Surgery

Field: Medicine (Health Sciences)

ANORECTAL CONDITIONS Fecal incontinence The societal impact of fecal incontinence is difficult to fully comprehend. The social stigmata and embarrassment associated with this condition prevents many people from ever seeking help from a physician. In a survey of more than 2,500 households, there was a 2.2% incidence of fecal incontinence. Johanson and Lafferty have previously shown that only 34% of incontinent patients have ever discussed this problem with their physician. As newer innovative treatments are developed, more and more people can be successfully treated. During 2002, several new options have emerged for these patients, ranging from relatively noninvasive outpatient methods to highly complex surgical procedures. For patients who are not surgical candidates, several treatments exist. The Procon incontinence device (Anatech, Inc LLC, Houston, TX) offers an interactive anal continence system. A small flexible catheter with a balloon and sensor electrode at the distal tip is inserted into the rectum. A silent vibrating signaling device is worn on the patient’s waist and signals the arrival of stool in the rectal vault. The second generation of this device is currently undergoing clinical trials. Seven patients who used the device in a recent trial noted an improvement in quality of life and fecal incontinence scores. Another nonoperative, but slightly more invasive technique involves injection of bulking agents under the anal mucosa to augment the internal anal sphincter. This technique is theoretically helpful in patients with passive incontinence who have failed medical therapy. Malouf and Vaizey injected bioplastique (Uroplasty Ltd, Geleen, The Netherlands) into 10 patients. Feasibility of this technique was demonstrated, but the initial improvement noted at 6 weeks deteriorated in all but two patients. Injection of carbon-coated beads (ACYST, Carbon Medical Technologies, Inc, St Paul, MN), into the submucosal space was more successful in the treatment of fecal incontinence. Weiss and colleagues reported this experience with 10 patients at Cleveland Clinic Florida. In a prospective, open-label trial, patients were injected with carbon-coated beads. All procedures were completed with local anesthesia in the outpatient setting. The independently validated Cleveland Clinic Florida Fecal Incontinence Score (CCFFIS; range 0 to 20) was 13 (range 7 to 15). Mean resting and squeeze pressures were 33 mmHg and 56 mmHg, respectively, and 80% of patients improved after ACYST injections. There was a 23% improvement in incontinence scores from a mean of 13 preprocedure to 10 at 3 months, and a 30% improvement in incontinence scores at 6 months (6 patients; score 9.3). One patient developed a complication of extravasation of the product into the perianal skin, which required enucleation in the office. ACYST injection is easy to perform, well tolerated, and can offer symptomatic improvement for patients with fecal incontinence. The use of radiofrequency energy in the anal canal (Secca procedure) is emerging as a new treatment for fecal incontinence. Takahashi and colleagues reported their results on the safety, feasibility, and efficacy of the Secca procedure. Ten patients underwent the procedure using local anesthesia and conscious sedation; one patient had bleeding that required intervention. The Received September 8, 2002; Accepted September 9, 2002. From the Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. Correspondence address: Steven D Wexner, MD, FACS, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331.