The second symposium on day two of ESCP’s Virtually Vilnius focused exclusively on the complex topic of faecal incontinence. Charles Knowles (UK), Chair of ESCP's Research Committee and Professor of Surgery at Barts and The London School of Medicine and Dentistry, hosted a range of expert speakers from across Europe who presented insightful and thought-provoking research.
First up, Yasuko Maeda (UK) presented a core subject update for the EBSQ Coloproctology Examination on faecal incontinence which outlined the key areas to consider when studying. This included the classification, assessment, and initial management of faecal incontinence - from dietary modification to medication and continence products - as well as surgical options to consider, such as injectable bulking agent, sphincter repair, SNS/SNM and stoma formation. Yasuko also referred to useful guidelines on PubMed for those currently studying.
Different approaches and concepts on the management and treatment of faecal incontinence were then discussed. Julie Cornish (UK) then kicked off with a presentation on ‘Preoperative work-up: how to interpret the results’ and explained why history is one of the most crucial aspects when it comes to the work-ups. She said: "It is vital to take the time to understand the specifics of how it is affecting patients. An examination of the anal region as well as blood and faecal investigations should be conducted."
Emma Carrington (Ireland), followed Julie with a presentation on ‘Anal Pathophysiology: beyond the sphincter’ which looked specifically at the pathophysiology of faecal incontinence, which is widely considered to be a complex process.
Emma discussed how symptoms have a significant impact on social functioning and quality of life of patients, particularly as they are chronic in nature. Treatment options are rather poor as surgeons can often fail to tailor treatment plans to the underlying physiological problem.
As incontinence is multifactorial, physiological testing often demonstrates abnormalities in the function of multiple facets of the anorectal unit. Despite this, emphasis can be placed on rehabilitation/repair of anal sphincter abnormalities and other aspects of continence can be overlooked.
“Traditionally anal sphincter integrity was thought to have primacy, however this is not necessarily the case” she said. Research shows that aberrant rectal sensitivity may lead to an abnormal call to stool and that pudendal neuropathy is associated with abnormal function, and is especially common in patients with faecal incontinence. Constipation can also overlap with symptoms and such incomplete evacuation can lead to passive leakage.
Emma believes testing should be comprehensive - typically starting with three complimentary investigations - high resolution anorectal manometry, a rectal sensory test and balloon expulsion test.
Carlo Ratto (Italy) was up next with a presentation on 'Traumatic sphincter injury: repair now or later?'
Carlo explained that traumatic sphincteric injuries can occur due to delivery, iatrogenic trauma, blunt or penetrating trauma and cause morbidity and mortality.
“Sphincter repair has been performed in OASIS for many decades, by both obstetricians and surgeons. This technique seems still indispensable, at least when an early operation is necessary” he said. The best outcome can be obtained when expert hands manage both the diagnosis and the surgical procedure, and when obstetricians are called to prevent the perineal damages and to identify a sphincter lesion as soon as possible when it occurs so that it can be correctly repaired immediately. Collaboration with coloproctologists in a 'perineal clinic' is the key to offer the best management for the patient in these circumstances.
Paul-Antoine Lehur (France), the fourth speaker, then appeared on screen to present ‘Minimally invasive and novel surgical therapies.’
Paul shared updates on current faecal incontinence management pathways, specifically around the way the patient is informed and approached, compassionately and realistically, about the treatment options for his/her condition. This is in line with the current recommendation “First do not harm” that prevails today when treating functional bowel disorders.
Paul also mentioned the limited help of anorectal investigations in assessing the severity of faecal incontinence and predicting success of the therapy across plugs/enemas, neuromodulation, PTNS, TNT and injectables (bulking agents such as the SphinKeeper) and artificial sphincters.
A lively panel discussion followed shortly after, hosted by Klaus Matzel (Germany) and Ines Rubio Perez (Spain). The different approaches and concepts presented on the management and treatment of faecal incontinence – from sophisticated diagnostics to conservative treatments – were discussed in further detail.
Klaus Matzel then presented a standardised trainee video which outlined a step-by-step process of sacral nerve modulation. Ayhan Kuzu (Turkey) also provided a detailed standardised trainee video on Extended Colectomy Right Open.
Closing the session, Emilie Duchalais (France) shared an abstract presentation on ‘Magnetic Anal Sphincter (MAS) versus Sacral Neuromodulation (SNM) in the Treatment of Severe Fecal Incontinence: Final Clinical Results of the MOS STIC Randomized Controlled Trial.’
Emilie shared the results of the MOS STIC trial (interventional multicentre open non inferiority RCT) which looked at 71 patients across 11 centres with severe faecal incontinence (more than one leak per-week). Emilie explained that the study failed to demonstrate the non-inferiority of MAS compared to SNM and noted a significantly higher morbidity rate in the MAS group.
Charles Knowles (UK) then hosted a Q&A session which gave viewers the chance to engage with the speakers and ask their burning questions about the varying treatments of faecal incontinence presented.
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