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Aim: Low anterior resection syndrome (LARS) can affect up to 70% of all patients with rectal cancer. In the last two decades, sacral nerve stimulation (SNS) has emerged as an effective treatment for faecal incontinence. There is some encouraging literature on the use of SNS in patients with LARS. The purpose of this review is to provide an up to date review on the utility of SNS on LARS., Method: A literature search was conducted using the MEDLINE, Embase and PubMed databases (January 1981-March 2019). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses., Results: Ten studies met the inclusion criteria and were included in this study. All studies used the Cleveland Clinic Incontinence Score (CCIS), whereas the low anterior resection syndrome score (LARS score) was used in three studies. Overall median improvement in the scoring system was 67.0% (range 35.5%-88.2%) after SNS implantation. There was a significant reduction in CCIS after SNS implantation (mean difference 11.23, 95% confidence interval 9.38-13.07, Z = 11.90, P < 0.00001). The LARS score was also significantly reduced after using SNS in patients with LARS (mean difference 17.87, 95% confidence interval 10.15-25.59, Z = 4.54, P < 0.00001)., Conclusion: Use of SNS may provide symptomatic benefits for patients with LARS refractory to medical therapy. However, the current level of evidence remains limited. A large multicentre study of SNS for LARS using the validated LARS score is warranted. In addition, the cost-effectiveness of SNS for patients with LARS needs further exploration., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Aim: Biofeedback is an established, effective and non-invasive treatment for faecal incontinence (FI). The aim was to compare the effectiveness of four different biofeedback treatment regimes., Method: This was a randomized control trial of patients with FI, stratified into two groups (metropolitan and rural) and then randomized into two subgroups (groups 1 and 2 within metropolitan, groups 3 and 4 within rural) with varying face-to-face and telephone biofeedback components. All patients received standardized counselling and education, dietary modification and the use of anti-diarrhoeal medications. Group 1 received four monthly face-to-face biofeedback treatments, groups 2 and 3 received one face-to-face biofeedback followed by telephone biofeedback and group 4 received a one-off face-to-face biofeedback treatment. Primary outcomes were patient-assessed severity of FI and quality of life as assessed by the 36-item Short Form Health Survey and direct questioning of objectives. Secondary outcomes included St Mark's incontinence score, anxiety, depression and anorectal physiology measures (resting, squeeze pressures; isotonic, isometric fatigue times)., Results: Between 2006 and 2012, 351 patients were recruited. One patient died leaving 350 for analysis. 332 (95%) were women. Mean age was 60 (SD = 14). All groups had significant improvements in FI, quality of life, incontinence score and mental status (P < 0.001 each). There were no differences in improvements in FI between groups although patient satisfaction was less with reduced face-to-face contact. There were modest improvements in isotonic and isometric fatigue times suggesting improved sphincter endurance (both P < 0.001)., Conclusion: Biofeedback is effective for FI. Although face-to-face and telephone biofeedback is not necessary to improve FI, it is important for patient satisfaction., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Aim: To explore the relationship between such a construct and an existing continence score., Methods: A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed., Results: Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP ( P = 0.0002), ACL ( P = 0.0006) and pudendal neuropathy ( P < 0.0001). The association between APS and CCCS was significant ( P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%., Conclusion: This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores., Competing Interests: Conflict-of-interest statement: None of them has received fees for serving as a speaker, or been a consultant and/or an advisory board member for any organization(s). None has received research funding for this project. None owns stocks and/or shares relevant to this research. None owns any patents

Purpose: Fecal incontinence in systemic sclerosis can occur secondary to fibrous replacement of the internal sphincter or ischemic myopathy of internal anal sphincter from vasculitis. Both lead to morphologic changes of the internal anal sphincter on endoanal ultrasound. This study documents the morphologic changes that can occur., Methods: A retrospective study of consecutive patients with systemic sclerosis and fecal incontinence was performed. Endoanal ultrasound was performed by using a 10 MHz Bruel and Kjaer endoprobe. Internal anal sphincter thickness and echogenecity were assessed at mid anal canal using prospectively collected images. Sphincter thicknesses were measured at 3, 6, 9, and 12 o'clock positions and averaged. Sphincter quality was assessed as homogeneous or heterogeneous and hyperechoic or hypoechoic by an experienced colorectal surgeon. Sphincter thickness was compared with sex- and age-matched controls by using Wilcoxon's signed-rank test., Results: There were 11 patients (all women). Two distinct morphologic changes were observed where patients had a thickened, homogeneous, and hypoechoic internal anal sphincter, or a thinned, difficult to discern, and hyperechoic internal anal sphincter. Average sphincter thickness was 1.6 (range, 0.8-4) mm, which was significantly different from control subjects (P = 0.028)., Conclusions: Available literature suggest that internal anal sphincter in systemic sclerosis is invariably thinned and hyperechoic. This series suggests that two distinct morphologic changes are possible.