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