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Neurogastroenterology and Motility Sep 2022Diagnosing anal incontinence (AI) based on manometry results is challenging due to the variation of the normal values and overlap between patients with and without AI.... (Review)
Review
BACKGROUND
Diagnosing anal incontinence (AI) based on manometry results is challenging due to the variation of the normal values and overlap between patients with and without AI. This study aimed to perform a systematic review on the difference in sphincter fatigability between patients with and without AI.
METHODS
MEDLINE, EMBASE, SCOPUS, and Google Scholar were searched. Studies were included if they included adult patients and assessed anal sphincter fatigability between using manometry. The effect size was estimated as the standardized mean difference (SMD) with 95% confidence intervals. A random-effects model was used.
RESULTS
The database searches identified 125 unique articles, and five additional articles were identified from the reference list of articles. One hundred thirteen were excluded through title and abstract review. Nine articles were included in the final analysis. There was no statistically significant difference in the resting pressure between the two groups. Patients with AI had significantly lower squeeze pressure. There was no statistically significant difference between the groups in the fatigue rate. The FRI was significantly lower in patients with AI (SMD 1.636, p = 0.001). Approximately a third of the patients in one study were able to maintain a contraction for 20s without reducing pressure. There was significant heterogeneity in the studies. The data available were inadequate for more robust calculations.
CONCLUSIONS
Sphincter fatigability, measured by the Fatigability Rate Index, has good discriminating power for anal incontinence. A standardized protocol needs to be followed by future researchers. Graphical Abstract The analysis used six studies with 413 patients to compare Fatigue Rate Index between patients with AI and controls. All studies reported a lower FRI in patients with incontinence and the FRI was significantly lower in patients with AI (standardized mean difference [SMD] 1.636, p= 0.001). Conflicting results were reported on the correlation between FRI and AI symptom scores.
Topics: Adult; Anal Canal; Fatigue; Fecal Incontinence; Humans; Manometry
PubMed: 35246890
DOI: 10.1111/nmo.14342 -
Techniques in Coloproctology Aug 2017Anal fissure has a very large number of treatment options. The choice is difficult. In an effort to assist in that, choice presented here is a systematic review and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anal fissure has a very large number of treatment options. The choice is difficult. In an effort to assist in that, choice presented here is a systematic review and meta-analysis of all published treatments for anal fissure that have been studied in randomized controlled trials.
METHODS
Randomized trials were sought in the Cochrane Controlled Trials Register, Medline, EMBASE and the trials registry sites clinicaltrials.gov and who/int/ictrp/search/en. Abstracts were screened, full-text studies chosen, and finally eligible studies selected and abstracted. The review was then divided into those studies that compared two or more surgical procedures and those that had at least one arm that was non-surgical. Studies were further categorized by the specific interventions and comparisons. The outcome assessed was treatment failure. Negative effects of treatment assessed were headache and anal incontinence. Risk of bias was assessed for each study, and the strength of the evidence of each comparison was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.
RESULTS
One hundred and forty-eight eligible trials were found and assessed, 31 in the surgical group and 117 in the non-surgical group. There were 14 different operations described in the surgical group and 29 different non-surgical treatments in the non-surgical group along with partial lateral internal sphincterotomy (LIS). There were 61 different comparisons. Of these, 47 were reported in 2 or fewer studies, usually with quite small patient samples. The largest single comparison was glyceryl trinitrate (GTN) versus control with 19 studies. GTN was more effective than control in sustained cure (OR 0.68; 95% CI 0.63-0.77), but the quality of evidence was very poor because of severe heterogeneity, and risk of bias due to inadequate clinical follow-up. The only comparison to have a GRADE quality of evidence of high was a subgroup analysis of LIS versus any medical therapy (OR 0.12; CI 0.07-0.21). Most of the other studies were downgraded in GRADE due to imprecision.
CONCLUSIONS
LIS is superior to non-surgical therapies in achieving sustained cure of fissure. Calcium channel blockers were more effective than GTN and with less risk of headache, but with only a low quality of evidence. Anal incontinence, once thought to be a frequent risk with LIS, was found in various subgroups in this review to have a risk between 3.4 and 4.4%. Among the surgical studies, manual anal stretch performed worse than LIS in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open LIS and closed LIS appear to be equally efficacious, with a moderate GRADE quality of evidence. All other GRADE evaluations of procedures were low to very low due mostly to imprecision.
Topics: Anal Canal; Calcium Channel Blockers; Fecal Incontinence; Fissure in Ano; Humans; Nitroglycerin; Randomized Controlled Trials as Topic; Sphincterotomy; Vasodilator Agents
PubMed: 28795245
DOI: 10.1007/s10151-017-1664-2 -
Techniques in Coloproctology Jun 2017Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to... (Review)
Review
Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.
Topics: Adult; Anal Canal; Chronic Disease; Crohn Disease; Cytokines; Epithelial-Mesenchymal Transition; Female; Gastrointestinal Microbiome; Humans; Male; Middle Aged; Rectal Fistula
PubMed: 28620877
DOI: 10.1007/s10151-017-1645-5 -
Ultrasound in Obstetrics & Gynecology :... Oct 2023The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective.
METHODS
We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool.
RESULTS
A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias.
CONCLUSION
Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Anal Canal; Retrospective Studies; Prospective Studies; Delivery, Obstetric; Episiotomy; Anus Diseases; Perineum; Risk Factors; Obstetric Labor Complications
PubMed: 37329513
DOI: 10.1002/uog.26292 -
Techniques in Coloproctology Dec 2023A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly...
BACKGROUND
A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques.
METHODS
A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed.
RESULTS
Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically.
CONCLUSIONS
To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.
Topics: Humans; Anal Canal; Low Anterior Resection Syndrome; Postoperative Complications; Quality of Life; Rectal Neoplasms; Robotic Surgical Procedures
PubMed: 38091118
DOI: 10.1007/s10151-023-02872-5 -
Surgery Jul 2022There are multiple treatments for anal fissures. These range from medical treatment to surgical procedures, such as sphincterotomy. The aim of this study was to compare... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There are multiple treatments for anal fissures. These range from medical treatment to surgical procedures, such as sphincterotomy. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for anal fissure.
METHODS
Randomized controlled trials were identified by means of a PRISMA-compliant systematic review using the Medline, EMBASE, and CENTRAL databases. Inclusion criteria were randomized controlled trials comparing treatments for anal fissure. A Bayesian network meta-analysis was performed using BUGSnet package in R. Outcomes of interest were healing (6-8-, 10-16-, and >16-week follow-up), symptom recurrence, pain (measured on a visual analog scale), and fecal or flatus incontinence. PROPSERO Registration: CRD42021229615.
RESULTS
Sixty-nine randomized controlled trials were included in the analysis. Lateral sphincterotomy remains the treatment with the highest odds of healing compared to botulinum toxin and medical therapy at all follow-up time points. There was no significant difference in healing between botulinum toxin and medical therapy at any time point. Advancement flap showed similar effectiveness compared to lateral sphincterotomy. Medical treatment and botulinum toxin had the highest pain scores at follow-up. Sphincterotomy had the highest odds of fecal and flatus incontinence.
CONCLUSION
Lateral sphincterotomy had the highest rates of healing and should be considered as the definitive treatment after failed initial therapy with botulinum toxin or medical treatment. Botulinum toxin was equally effective compared to medical treatment. Advancement flap shows similar effectiveness compared to lateral sphincterotomy, but more studies are needed to evaluate its efficacy.
Topics: Anal Canal; Bayes Theorem; Botulinum Toxins; Chronic Disease; Fissure in Ano; Flatulence; Humans; Network Meta-Analysis; Pain; Treatment Outcome
PubMed: 34998619
DOI: 10.1016/j.surg.2021.11.030 -
Journal of Midwifery & Women's Health 2015The aim of this study was to systematically review current evidence for the relationship between obstetric anal sphincter injury (ie, episiotomy and third- or... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The aim of this study was to systematically review current evidence for the relationship between obstetric anal sphincter injury (ie, episiotomy and third- or fourth-degree perineal lacerations) and anal incontinence in parous women.
METHODS
PubMed, Ovid (MEDLINE), Cochrane Trials, and Cumulative Index to Nursing and Allied Health Literature were searched. Studies eligible for review assessed the relationship between episiotomy and/or third- or fourth-degree perineal laceration and anal incontinence. Two reviewers independently searched for studies for review and used the Meta-Analysis of Observational Studies in Epidemiology guidelines. Quality of individual studies was appraised using the Downs and Black criteria. Pooled effect sizes were estimated for the relationships between episiotomy and third- or fourth-degree perineal laceration with anal incontinence using random effects meta-analysis models. Heterogeneity of each model was assessed using Cochran Q and I(2) statistics.
RESULTS
Of 578 articles, 19 studies (7 prospective cohort studies, 6 retrospective studies, one case-control study, and 5 population-based cross-sectional studies) met inclusion/exclusion criteria for the systematic review. Of the 19 studies, 3 examined episiotomy, 7 examined third- or fourth-degree perineal laceration, and 9 studies examined both risk factors for anal incontinence. Eight studies (N = 2929 women) examining the relationship between episiotomy and anal incontinence and 12 studies (N = 2288 women) examining the relationship between third- or fourth-degree perineal laceration and anal incontinence met criteria for inclusion in the meta-analyses. Pooled odds ratios (ORs) demonstrated a significant association between perineal trauma (episiotomy [OR, 1.74; 95% confidence interval [CI], 1.28-2.38; Q = 8.9; P < .26; I(2) = 21.4] and third- or fourth-degree perineal laceration (OR, 2.66; 95% CI, 1.77-3.98; Q = 27.9; P = .002; I2 = 64.1) and anal incontinence.
DISCUSSION
Both episiotomy and third- or fourth-degree perineal laceration are significantly associated with anal incontinence after vaginal birth. The evidence provided in this systematic review and meta-analysis highlights the importance of reducing perineal trauma during vaginal births in order to ameliorate anal incontinence in parous women.
Topics: Anal Canal; Episiotomy; Fecal Incontinence; Female; Humans; Lacerations; Obstetric Labor Complications; Perineum; Pregnancy
PubMed: 25712278
DOI: 10.1111/jmwh.12283 -
Injury Jun 2017Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian... (Review)
Review
INTRODUCTION
Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting.
METHODS
A systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma.
RESULTS
Seven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies.
CONCLUSION
There remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.
Topics: Algorithms; Anal Canal; Clinical Protocols; Digestive System Surgical Procedures; Drainage; Emergency Medicine; Fecal Incontinence; Humans; Peritoneal Lavage; Practice Guidelines as Topic; Proctoscopy; Rectum; Wounds, Penetrating
PubMed: 28292518
DOI: 10.1016/j.injury.2017.03.002 -
Colorectal Disease : the Official... May 2022Manometry is the best established technique to assess anorectal function in faecal incontinence. By systematic review, pooled prevalences of anal... (Meta-Analysis)
Meta-Analysis Review
Systematic review and meta-analysis of anal motor and rectal sensory dysfunction in male and female patients undergoing anorectal manometry for symptoms of faecal incontinence.
AIM
Manometry is the best established technique to assess anorectal function in faecal incontinence. By systematic review, pooled prevalences of anal hypotonia/hypocontractility and rectal hypersensitivity/hyposensitivity in male and female patients were determined in controlled studies using anorectal manometry.
METHODS
Searches of MEDLINE and Embase were completed. Screening, data extraction and bias assessment were performed by two reviewers. Meta-analysis was performed based on a random effects model with heterogeneity evaluated by I .
RESULTS
Of 2116 identified records, only 13 studies (2981 faecal incontinence patients; 1028 controls) met the inclusion criteria. Anal tone was evaluated in 10 studies and contractility in 11; rectal sensitivity in five. Only three studies had low risk of bias. Pooled prevalence of anal hypotonia was 44% (95% CI 32-56, I = 96.35%) in women and 27% (95% CI 14-40, I = 94.12%) in men. The pooled prevalence of anal hypocontractility was 69% (95% CI 57-81; I = 98.17%) in women and 36% (95% CI 18-53; I = 96.77%) in men. Pooled prevalence of rectal hypersensitivity was 10% (95% CI 4-15; I = 80.09%) in women and 4% (95% CI 1-7; I = 51.25%) in men, whereas hyposensitivity had a pooled prevalence of 7% (95% CI 5-9; I = 0.00%) in women compared to 19% (95% CI 15-23; I = 0.00%) in men.
CONCLUSIONS
The number of appropriately controlled studies of anorectal manometry is small with fewer still at low risk of bias. Results were subject to gender differences, wide confidence intervals and high heterogeneity indicating the need for international collective effort to harmonize practice and reporting to improve certainty of diagnosis.
Topics: Anal Canal; Fecal Incontinence; Female; Humans; Male; Manometry; Muscle Hypotonia; Rectum
PubMed: 35023242
DOI: 10.1111/codi.16047 -
Clinical Oncology (Royal College of... Aug 2014Squamous cell cancer of the anal canal is a rare tumour for which there remains uncertainty regarding optimal therapy. A systematic review was conducted to summarise the... (Review)
Review
Squamous cell cancer of the anal canal is a rare tumour for which there remains uncertainty regarding optimal therapy. A systematic review was conducted to summarise the evidence examining concurrent chemotherapy and radiotherapy or different chemotherapy regimens in combination with radiotherapy. MEDLINE, EMBASE and conference proceedings were searched for relevant randomised controlled trials. Outcomes of interest were colostomy rate, local failure, overall survival, disease-free survival, adverse effects and quality of life. Six randomised controlled trials were identified. Two trials reported lower colostomy and local failure rates for concurrent 5-fluorouracil (5-FU) plus mitomycin C (MMC) and radiotherapy compared with radiotherapy alone. The omission of MMC from this regimen resulted in higher colostomy and local failure rates and lower disease-free survival. Induction chemotherapy followed by concurrent 5-FU plus cisplatin and radiotherapy resulted in a higher colostomy rate than concurrent 5-FU plus MMC and radiotherapy. Haematological toxicity rates were lower in patients who received radiotherapy with 5-FU alone or 5-FU plus cisplatin compared with 5-FU plus MMC. No benefit was seen for the addition of induction or maintenance chemotherapy to concurrent chemoradiotherapy. The available evidence continues to support the use of radiotherapy with concurrent 5-FU and MMC as standard treatment for cancer of the anal canal to decrease colostomy and local failure rates.
Topics: Anus Neoplasms; Chemoradiotherapy; Humans; Neoplasms, Squamous Cell
PubMed: 24721444
DOI: 10.1016/j.clon.2014.03.005