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Background Anal sphincter defects are a major cause of fecal incontinence causing negative effects on daily life, social interactions, and mental health. Because human adipose-derived stromal/stem cells (hADSCs) are easier and safer to access, secrete high levels of growth factor, and have the potential to differentiate into muscle cells, we investigated the ability of hADSCs to improve anal sphincter incontinence. Methods The present randomized double-blind clinical trial was performed on patients with sphincter defects. They were categorized into a cell group ( n  = 9) and a control group ( n  = 9). Either 6 × 10 6 hADSCs per 3 ml suspended in phosphate buffer saline (treatment) or 3 ml phosphate buffer saline (placebo) was injected. Two months after surgery, the Wexner score, endorectal sonography, and electromyography (EMG) results were recorded. Results Comparing Wexner scores in the cell group and the control group showed no significant difference. In our EMG and endorectal sonography analysis using ImageJ/Fiji 1.46 software, the ratio of the area occupied by the muscle to total area of the lesion showed a 7.91% increase in the cell group compared with the control group. Conclusion The results of the current study show that injection of hADSCs during repair surgery for fecal incontinence may cause replacement of fibrous tissue, which acts as a mechanical support to muscle tissue with contractile function. This is a key point in treatment of fecal incontinence especially in the long term and may be a major step forward. Trial registration Iranian Registry of Clinical Trials IRCT2016022826316N2 . Retrospectively registered 7 May 2016.

Background Defecatory disorders are very common complications after left hemicolectomy and anterior rectal resection. These disorders seem related primarily to colonic denervation after the resection. To evaluate the real benefits of inferior mesenteric artery (IMA) preservation via laparoscopic left hemicolectomy performed for diverticular disease in terms of reduced colonic denervation and improved postoperative intestinal functions, a randomized, single-blinded (patients) controlled clinical trial was conducted. Methods From January 2004 to January 2010, patients with symptomatic diverticular disease and a surgical indication were enrolled in the study and randomly assigned to two treatment groups. The first group underwent laparoscopic left hemicolectomy, which preserved the IMA by sectioning the sigmoid arteries one by one near the colonic wall, In the second group, the IMA was sectioned immediately below the origin of left colic artery. Defecation disorders were assessed by anorectal manometry and by three questionnaires to evaluate constipation, incontinence, and quality of life 6 months after the intervention. Results A total of 107 patients were included in the study. The 54 patients with preserved IMA showed a statistically lower incidence of defecation disorders such as fragmented evacuations, alternating bowel function, constipation, and minor incontinence, as well as less lifestyle alteration than the 53 patients with the IMA sectioned just below the left colic artery. Conclusions This study confirmed that preservation of the IMA should be recommended to reduce the incidence of defecatory disorders after left hemicolectomy for benign disease.

Purpose The aim of this study was to compare the clinical effect of graciloplasty using two different gracilis encircled loops for the treatment of fecal incontinence after anoplasty for imperforate anus. Methods From January 2009 to January 2012, 38 patients were treated by graciloplasty. The patients were randomly divided into two groups, one group consisting of 18 cases underwent the “γ-loop” and the other group consisting of 20 cases underwent the “υ-loop.” All patients underwent postoperative defecation training and regular follow-up. All patients were evaluated via Wexner score and anal manometry (including anal resting pressure, anal maximal squeeze pressure, duration of anal squeeze, and rectal maximum tolerable volume) before and after graciloplasty. In addition, it was assessed whether the patients had difficulty defecating while squatting after surgery. Results The surgeries on the 38 patients were accomplished successfully. There were no differences in postoperative complications between the two groups ( P  > 0.05). The Wexner score and anal manometry parameters of the two groups were gradually improved after operation. The generalized estimating equation results of the Wexner score indicated that the difference of measurement time was statistically significant ( P  < 0.05) but the difference of measurement group was not statistically significant ( P  > 0.05). The results of anal manometry parameters using repeated measures ANOVA indicated that differences between different time points were statistically significant (all P  < 0.05) but differences between different surgery groups were not statistically significant (all P  > 0.05). Regarding the postoperative defecating difficulties while squatting, the probability of occurrence in the “γ-loop” group was significantly higher than that in the “υ-loop” group. The difference between the two groups was statistically significant ( P  < 0.05). Conclusions Graciloplasty with different gracilis loops can improve anal function in patients. However, “υ-loop” can significantly improve difficulties in defecating while squatting.

Purpose Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. Methods Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. Results Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n  = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n  = 102 patients). Conclusions There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Introduction Obesity is associated with pelvic floor disorders (PFD). Sleeve gastrectomy (SG) is one of the most effective weight loss methods. Although SG has been found to improve urinary incontinence (UI) and overactive bladder (OAB), its impact on fecal incontinence (FI) remains controversial. Materials and Methods This prospective, randomized study involved 60 female patients with severe obesity who were randomly assigned to two groups: the SG group and the diet group. The SG group underwent SG, while the diet group received a low-calorie, low-lipid diet for 6 months. The patients’ condition was assessed before and after the study using three questionnaires: the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), the Overactive Bladder 8-Question Awareness Tool (OAB-V8), and the Wexner Score (CCIS). Results After 6 months, the SG group had a significantly higher percentage of total weight loss (%TWL) compared to the diet group ( p <0.01). Both groups showed a decrease in the ICIQ-FLUTS, OAB-V8, and CCIS scores ( p <0.05). UI, OAB, and FI improved significantly in the SG group ( p <0.05), but no improvement was observed in the diet group ( p >0.05). The correlation between %TWL and PFD was statistically significant but weak, with the strongest correlation between %TWL and ICIQ-FLUTS score and the weakest correlation between %TWL and CCIS score ( p <0.05). Conclusions We recommend bariatric surgery for the treatment of PFD. However, given the weak correlation between %TWL and PFD after SG, further research should explore factors other than %TWL that are effective in recovery, particularly in relation to FI. Graphical abstract

Although most children with Hirschsprung disease ultimately achieve functional and comfortable stooling, some will experience a variety of problems after pull-through surgery. The most common problems include soiling, obstructive symptoms, enterocolitis, and failure to thrive. The purpose of this guideline is to present a rational approach to the management of postoperative soiling in children with Hirschsprung disease. The American Pediatric Surgical Association Hirschsprung Disease Interest Group engaged in a literature review and group discussions. Expert consensus was then used to summarize the current state of knowledge regarding causes, methods of diagnosis, and treatment approaches to children with soiling symptoms following pull-through for Hirschsprung disease. Causes of soiling after pull-through are broadly categorized as abnormalities in sensation, abnormalities in sphincter control, and “pseudo-incontinence.” A stepwise algorithm for the diagnosis and management of soiling after a pull-through for Hirschsprung disease is presented; it is our hope that this rational approach will facilitate treatment and optimize outcomes.

Background Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients. Methods The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies. Results Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8–48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81–85%, I 2  = 37.9%), 16% (95% CI 14–18%, I 2  = 4.8%), 11% (95% CI 7–15%, I 2  = 72.1%), respectively. The postoperative Jorge–Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9–1.27, I 2  = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1–99.6%, I 2  = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96–3.35, I 2  = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher  compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger’s tests showed no evidence of publication bias. Conclusions According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.

Purpose Magnetic anal sphincter (MAS) augmentation is a novel surgical option for the treatment of fecal incontinence. Current clinical evidence is conflicting. The purpose of this meta-analysis was to report the safety profile, potential benefits, and the functional efficacy of this device. Methods The study followed the PRISMA guidelines. Literature databases (Medline, Scopus, Web of Science, CENTRAL) were screened for eligible articles. The primary endpoint was the pooled effect of MAS in the Cleveland Clinic Incontinence Score (CCIS) score. Quality evaluation was based on the ROBINS-I and Risk of Bias 2 tool. Results Overall, 8 studies with 205 patients were included. MAS resulted in a significant reduction of CCIS values ( p  = 0.019), and improvement only in the embarrassment domain of FIQoL scores ( p  = 0.034). The overall morbidity rate was 61.8%. Postoperative adverse events included MAS explantation in 12%, infection in 5.1%, pain in 10% and obstructed defecation in 5.8% of patients. Conclusion The application of MAS in patients with fecal incontinence results in the improvement of some clinical parameters with a notable morbidity rate. Due to several study limitations, further, high-quality RCTs are required to delineate the efficacy and safety of MAS.

Introduction and Hypothesis Knowledge regarding rates of improvement of fecal incontinence (FI) after repair of posterior compartment prolapse is limited. We aimed to estimate the rate of resolution or improvement of fecal incontinence postoperatively following transvaginal posterior compartment repair. Methods This was a retrospective cohort study including patients with diagnosis of fecal incontinence who underwent transvaginal posterior repair at a single academic institution between 1/2016 and 1/2022. Patients who underwent concomitant anal sphincteroplasty served as controls. The primary outcome was resolution of FI symptoms within 6-weeks postoperatively. Secondary outcomes included improvement of FI symptoms and preoperative anorectal manometry characteristics. Univariate and bivariate analysis were performed to describe and compare outcomes between groups with multivariable regression performed to address potential confounders. Results Of 179 patients included, 91 had posterior repair alone, while 88 had concomitant anal sphincteroplasty. Demographic and clinical characteristics were similar between groups. Overall, 143 (80%) patients did not report any FI symptoms at their 6-week postoperative visit. An additional 28 (16%) reported improvement in FI symptoms. Among patients who underwent posterior repair alone, 76 (84%) had resolution of their FI compared to 67 (76%) in patients with concomitant anal sphincteroplasty ( P  = 0.6); 71 patients underwent anorectal manometry preoperatively. There were no significant differences in mean average resting pressures or mean maximum squeeze pressures between groups. Conclusions Posterior compartment repair resulted in resolution or improvement of fecal incontinence symptoms within 6-weeks postoperatively. The mechanism for FI symptoms in women with rectoceles may be independent of the anal sphincter complex.

BackgroundPosterior sagittal anorectoplasty and laparoscopic-assisted anorectal pull-through are preferred for anorectal malformation (ARM) today, while careful pull-through procedures with sacroperineal approach yield excellent outcomes. This study focuses on a pull-through procedure emphasizing continence mechanism preservation and compares outcomes with historical studies with various procedures.MethodsBowel function of patients with intermediate ARM followed up for over 10 years post-surgically was assessed. Data collected included ARM type with the Krickenbeck classification, comorbidities, complications, post-surgical examinations, follow-up, and bowel function at the latest clinic visit. The literature review collected original articles including more than 10 post-anorectoplasty cases which were followed for over 10 years.ResultsEleven cases were identified, with a median age at anorectoplasty and follow-up length of 6.9 months and 14.4 years. Two fistula recurrences required surgical treatment. Long-term incontinence and constipation were observed in 9% and 45% of the cohort, respectively. Good rectal angulation and a positive rectoanal inhibitory reflex were confirmed in most cases examined. A literature review identified eight studies with various outcome-measuring instruments.ConclusionOutcomes of the introduced pull-through procedure were favorable, while the literature review highlights the variation in outcomes of various anorectoplasty.Evidence LevelLevel IV.