In this interview, Mr Papagrigoriadis shares with the ESCP audience tips and tricks on current treatment of faecal incontinence.
Mr Savvas Papagrigoriadis is an experienced consultant colorectal and laparoscopic surgeon who has worked for over 20 years in Colorectal Surgery at King's College Hospital, London as Consultant Lead of Colorectal Surgery and Senior Lecturer. He is currently Director of Rectal and Pelvic Surgery at the Metropolitan Group of Hospitals in Athens, Greece. Mr Papagrigoriadis has an interest in pelvic floor disorders and treats patients with faecal incontinence, obstructive defecation syndrome and rectal prolapse.
Zoe Garoufalia (ZG): Mr. Papagrigoriadis thank you very much for agreeing to this interview. How many years are you involved in treatment of pelvic floor disorders and faecal incontinence (FI) in particular? How did you decide to specialise in this specific condition?
Savvas Papagrigoriadis (SP): I should thank you for the privilege of addressing your members and fellow colorectal specialists. I have practiced colorectal surgery for 35 years and my interest in pelvic floor disorders and faecal incontinence developed 25 years ago. I had the fortune to work in the same hospital and operating theatre with an internationally renowned pioneer Urogynaecologist, Professor Linda Cardozo, who had established a Pelvic Floor MDT at King’s College London since the 1990s. I was therefore exposed to a large volume of tertiary care pelvic floor patients with complex problems, many of which were of colorectal nature. I was able to see the amount of suffering caused by faecal incontinence and to appreciate the immense value of multi-disciplinary work.
ZG: We have the privilege of sharing your knowledge and experience that covers two different countries and cultures: UK and Greece. How common is FI in each country? Are the commonest causes for FI the same in both countries?
SP: FI is a very common problem, but the exact prevalence is hard to determine. The reason is that most patients suffer in silence. Discussing FI is a taboo and patients find it even hard to discuss it with their doctors and their family. When detailed symptoms questionnaires are administered it is found that up to 5% of the general public have suffered FI. It is estimated that an average 1.5% of the population may be sufferers however this figure is higher in subgroups such as the over 65s or institutionalised patients. Unfortunately, statistical figures on the prevalence of FI do not exist in Greece, but in my experience it is at least as common as in the UK and the cases are more neglected because of the cultural barriers and the lack of campaigns by the health service. In both countries the bulk of FI originates form obstetric injuries, but a variety of other conditions are also responsible.
ZG: Culture definitely plays a central role in reporting this condition. Do you think this affects statistics or type of treatment for FI in each country?
SP: You are right, FI is largely underreported. As most cases of FI come from obstetric complications, those may be perceived as a ‘women’s’ problem and thus only appropriate to discuss amongst women and gynaecologists. In both the UK and in Greece it is hard to find media references on FI. FI is a “conversation stopper” and a wall of silence surrounds sufferers.
Several Greek female patients have told me over the years that they considered incontinence as the inevitable price to pay for the gift of a child. Those perceptions and prejudices need an organised active approach to change. Doctors are not good in that role, other health professionals such as pelvic physiotherapists, specialist nurses and midwives need to be recruited. Pelvic floor physiotherapy, biofeedback, Kegel exercises, are accepted with greater ease in societies where women are comfortable to discuss their body and its functions. In societies with more introversive attitudes a ‘quick’ surgical procedure may be sought as the ideal solution, but this often leads to disappointment.
ZG: Now, let’s focus on Greece: is the care of patients with FI centralised? How accessible is information about this condition to the public? Where can one learn more about FI and possible treatment options?
SP: No, the care of FI is not centralised in Greece, centralisation of services is weak in the country because 50% of the specialist surgical services are provided by the private sector. There are historical reasons for that and the health system in any country is affected by history. The consequence is that although there is no shortage of specialists in FI and pelvic floor disorders, there is difficulty for the public to know where and how to seek help. The British style ‘patient pathways’ simply do not exist. On a brighter note, there is much flexibility in the system, meaning that once the information is available, referrals are easy to arrange and fast to implement and things move faster than in a centralised system.
ZG: Based on your experience, is a colorectal surgeon enough for treating patients with FI? Is there a need for multidisciplinary approach for this condition as well?
SP: The pelvis has three anatomical compartments and most pelvic pathologies involve more than one compartment. Many of the patients we see in colorectal clinics have a significant history of urogynaecological problems and vice versa. A multidisciplinary approach is necessary as good medical practice. We have however to remember that things take time to evolve: referral to a structured pelvic floor multidisciplinary team became mandatory in the UK only a decade ago even though Pelvic Floor MDT had existed in centres of excellence for more than 20 years.
Pelvic floor MDT is still not mandatory in Greece. Multi-disciplinary collaborations of specialists are however common and I have no doubt that a directive from the ESCP towards Pelvic Floor MDT in all countries would promote the implementation of MDT in Greece as well as everywhere else.
ZG: What are the techniques that a young colorectal surgeon should master in order to treat patients with FI?
SP: The first important aspect is the appropriate diagnostic approach. The obtainment of an accurate obstetric history and the clinical examination can often provide most of the valuable information. The role of endoanal ultrasound is crucial to establish the existence of any sphincter defects. Anorectal manometry – physiology is necessary, not only to determine the pressures but also to diagnose sensory dysfunction of the anorectum and dyssynergia.
The main surgical procedure which colorectal surgeons should be competent in is the overlapping anterior sphincter repair. Since in many cases the presence of rectal prolapse contributes to symptoms of faecal incontinence, familiarity with perineal and abdominal types of rectal prolapse repair is also mandatory.
The numbers of those operations are not very high in any given department. Therefore, it is necessary to concentrate the numbers by centralising the experience in specialist pelvic floor units and provide training in the form of a post-specialty fellowship.
ZG: Sacral neuromodulation (SNM) has been the mainstay for treating FI currently. What patients in your experience are eligible for SNM? Are there any contraindications? Do you take into account results of preoperative anal physiology testing or endorectal ultrasound before performing SNM?
SP: SNM is the treatment of choice when conservative treatments of FI have failed and surgical anal sphincter repair has either failed or is not a suitable option. Patients with combined faecal incontinence and urinary dysfunction are good candidates for SNM. There are indications that SNM may be useful in some cases of Low Anterior Resection Syndrome (LARS) which is seen increasingly nowadays as the consequence of sphincter preserving cancer surgery. Cases of spinal injury and cauda equina have also been reported to respond favourably.
Contraindications for SNM are rare and consist mainly of organic bowel disease, anorectal sepsis, cardiac pacemaker/ defibrillator, neurological/ psychiatric history.
Endoanal ultrasound and anorectal physiology are in my opinion always necessary because FI can be multifactorial. Many contributing pathologies may be missed when there is no full diagnostic workup.
ZG: Are there any other indications in colorectal surgery for SNM? If yes, are they approved in Greece?
SP: There are several studies that report a relatively satisfactory outcome of SNM in the treatment of severe intractable constipation. However, the overall evidence for the use in constipation is not definitive at this point.
There are also cases of severe chronic pelvic pain that are amenable to treatment with SNM. Some of those cases have a background of Cauda Equina Syndrome.
SNM should be applied or indications other than FI on an individualised patient basis and by review by a pelvic floor MDT.
In Greece patient candidates for SNM for FI have to be discussed by dedicated government bodies for authorization. Even though it is a cumbersome process the important thing is that funding is granted if the appropriate indications exist.
ZG: How can treatment of patients with FI improve? What in your opinion are the key steps for homogenising our practise worldwide and providing the best possible results in patients suffering from this disabling condition?
SP: The greatest improvement of female FI is prevention and early diagnosis of obstetric injuries. The involvement of midwives, obstetricians and pelvic physiotherapists is mandatory for that. When patients come to the colorectal surgeon it is late, hopefully not too late. Organised campaigning for education of the population by the ESCP and the national coloproctology societies as well as the governments is required, exactly as with most other public health issues.
Access of patients to SNM has to improve and the costs should come down now that it is becoming almost a first line treatment. This will require combined action by the professional bodies, the governments, and the manufacturers.
The best clinical results will come from formalisation of colorectal subspecialty training and collaboration in the formation of specialist pelvic floor units which provide SNM on the grounds of European guidelines. The role of ESCP will be invaluable in achieving that target.
ZG: Mr Papagrigoriadis thank you sincerely for your time and insights.