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The use of PTQ anal bulking injections

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2 The use of PTQ anal bulking injections
Kirsty Cattle Pelvic floor clinical fellow

3 Introduction to treatment of faecal incontinence
Heterogenous condition, multiple treatments available, often disappointing results Conservative: Alteration of stool consistency, physiotherapy, biofeedback Surgical: Anterior sphincter repair, postanal repair, stimulated graciloplasty, artificial bowel sphincter Sacral nerve stimulation, anal bulking injections

4 images Authors: Journal: Professor Yik-Hong Ho:
Head of surgery, school of Medicine, James Cook University, Townsville, Queensland, Australia Journal: British Journal of Surgery: Impact factor 4.921

5 Introduction & aim Problem: Aim:
Serving a large rural area, long waiting list for biofeedback, only one colorectal surgeon Aim: to document the outcomes, in the short and medium term, from a large case series of patients with faecal incontinence and IAS dysfunction who received PTQ implants over a 4-year interval

6 Methods Identification of patients Surgical method
IAS defects or dysfunction, either alone or in combination Those unfit for surgery or opted for PTQ Surgical method Assessment of results Anorectal physiology, standard symptom assessment tools, QoL At baseline and 6 weeks Statistical method No statement of how they determine what IAS dysfunction is, although in results section they do discuss EAUS appearances (mottling, thinning < 1mm, atrophy not defined) Also include those without IAS dysfunction who opted for PTQ injections or unsuitable for other surgical approaches: Pragmatic approach, in their setting, but not rigorous scientific technique. Appropriate surgical technique, perhaps clouded by learning curve. Standard data collection: anorectal physiology & EAUS, a commonly used symptom score, quality of life assessment, and assessment of satisfaction with procedure. Statistical tests used are for non-parametric data. CART analysis?

7 Results 74 patients 28 (14.5 – 42) months follow up
At 6 weeks follow up: 70 (95%) improved, 42 (57%) cured At December 2008 follow up: 40 of the 42 “cured” patients remain fully continent Further 12 now “cured”

8 Satisfaction with procedure
Symptom scores & QoL Both improved at 6 weeks and Dec 2008 Satisfaction with procedure Improve with time in those achieving complete continence High, but do not improve in those with remaining incontinence

9 Anal manometry Significant rise in resting pressure, more so in those achieving continence EAUS Implants not intact in 10 of 70 patients Further 2 had late migration of implants Re-implantation of PTQ in those whose implants were not intact, but no documentation of symptoms at 6 weeks, apparently poorer results in those requiring repeat implantation, but no stats ?insufficient numbers. No description of PTQ implant appearance on EAUS.

10 Complications Required antidiarrhoeal medication (n=2)
Constipation (n=1) Infection (n=1) Anal irritation or discomfort (n=3) Superficial mucosal ulceration (n=1) But antidiarrhoeal medication is a treatment for FI.

11 Risk factors predictive of poor outcome:
Pudendal neuropathy Previous sphincter repair Previous or subsequent biofeedback therapy Migrated implants on EAUS Female sex Most of these factors are indicative of FI that is difficult to treat – by definition, patients will only be referred for biofeedback if PTQ has not worked. Similarly, if sphincter repair has been ineffective, how can you expect simple anal canal injections to be effective? Pudendal neuropathy associated with poorer outcomes following sphincter repair, therefore probably a reflection of more complex/severe pelvic floor injury. Similarly female sex – whole pelvic floor trauma, rather than isolated anal sphincter injury seen in men post haemorrhoidectomy, Lord’s stretch, etc.

12 Discussion Comparison with other studies of PTQ:
They claim better results and longer follow up Improved anal manometry Rate of implant migration: Improved during study period Study design Cost implications Alternatives

13 Conclusion Effective Safe Careful patient selection
Meticulous surgical technique

14 Critique Poor scientific technique, but pragmatic approach in their setting Surprising improvement in continence scores

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