2 The use of PTQ anal bulking injections Kirsty CattlePelvic floor clinical fellow
3 Introduction to treatment of faecal incontinence Heterogenous condition, multiple treatments available, often disappointing resultsConservative:Alteration of stool consistency, physiotherapy, biofeedbackSurgical:Anterior sphincter repair, postanal repair, stimulated graciloplasty, artificial bowel sphincterSacral nerve stimulation, anal bulking injections
4 images Authors: Journal: Professor Yik-Hong Ho: Head of surgery, school of Medicine, James Cook University, Townsville, Queensland, AustraliaJournal: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 surgeonAim: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 combinationThose unfit for surgery or opted for PTQSurgical methodAssessment of resultsAnorectal physiology, standard symptom assessment tools, QoLAt baseline and 6 weeksStatistical methodNo 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%) curedAt December 2008 follow up:40 of the 42 “cured” patients remain fully continentFurther 12 now “cured”
8 Satisfaction with procedure Symptom scores & QoLBoth improved at 6 weeks and Dec 2008Satisfaction with procedureImprove with time in those achieving complete continenceHigh, but do not improve in those with remaining incontinence
9 Anal manometrySignificant rise in resting pressure, more so in those achieving continenceEAUSImplants not intact in 10 of 70 patientsFurther 2 had late migration of implantsRe-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 neuropathyPrevious sphincter repairPrevious or subsequent biofeedback therapyMigrated implants on EAUSFemale sexMost 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 upImproved anal manometryRate of implant migration:Improved during study periodStudy designCost implicationsAlternatives