Cesare Stabilini

Ezio Gianetta

Francesca Mandolfino

Marco Frascio

Maria Santino Bruno

Mikaela Imperatore

Rosario Fornaro

Serena Perotti

Tommaso Testa

FRASCIO, MARCO

FORNARO, ROSARIO

STABILINI, CESARE

GIANETTA, EZIO

Archivio istituzionale della ricerca - Università di Genova

 UNITÀ E VALORE DELLA CHIRURGIA ITALIANA 1° CONGRESSO NAZIONALE ROMA, 23-27 SETTEMBRE 2012   TRATTAMENTO CON RADIOFREQUENZA DELL’INCONTINENZA FECALE.   Mikaela Imperatore, Marco Frascio, Rosario Fornaro, Tommaso Testa, Cesare Stabilini, Francesca Mandolfino, Serena Perotti, Maria Santino Bruno, Ezio Gianetta.   Background Pathophysiology of fecal incontinence (FI) is complex and multifactoral. Contemporary diagnostic tools reveals structural or functional parameters poorly related to FI symptoms. Among institutionalized persons the prevalence of fecal incontinence (FI) has been reported as high as 45% (1) There is no single treatment which could address disorders of muscles, nerves, bowel and coordination. In fact current methods of treatment are ineffective, characterized by a high complication rate and in general poorly accepted by patients. Substantial number of FI patients are dissatisfied with medical therapy but not willing undergo or not eligible for major surgery.  Treatment options  Medical therapy  Biofeedback  Surgery  Bulking injections  Sacral nerve stimulation  Surgical interventions  Radiofrequency (SECCA procedure)  Radiofrequency: mechanism of action Several less invasive approaches to the treatment of fecal incontinence have been developed in recent years. One of these is the application to the internal anal sphincter of radiofrequency (RF) energy. The hypothesis that this may be an effective alternative originated from its benefit in a variety of other conditions, such as gastroesophageal reflux disease (GERD), benign prostatic hypertrophy (BPH), and obstructive sleep apnea.1–4 In theory, RF-induced injury to the internal anal sphincter should, ideally, cause collagen deposition and fibrosis with the potential for tightening of the affected area. RF energy has been used for electrosurgical techniques (cutting and coagulation) since the 1920s.  Material and methods  Our experience is based on a prospective, single center, observational study. We enrolled 4 female pts, the average age 68 years (from 59 to 77), the mean duration of FI 21,5 months (from 12 to 31). In all cases the FI had an idiopatic etiology.  All the patients completed a protocol of preoperative evaluation:  Clinical efficacy  FIQL   Anorectal Physiological   Anorectal manometry:   ▪ BAP, SAP, HPZL   ▪ RAIR, RSCC  Anorectal Imaging   Trans-Anal Ultrasonograph Patients were treated in Lloyd-Davis position in general anesthesia  RF impulse generator SECCA and single-use handpiece deliver radiofrequency energy to the anal tissues at each of 5 levels at left, right, anterior and posterior wall of anal canal.  Results Clinical  No intra o postoperative complications (early or late)  Jorge – Wexner 0  Jorge – Wexner 1  Jorge – Wexner 3  Jorge – Wexner 6 Anorectal manometry Basal Anal Pressure Squeeze Anal Pressure Rectal compliance Endoanal ultrasound  Discussion and conclusion From this experience, we can concluded that  Secca® appeared safe and effective FI treatment, it reduces the frequency and severity of FI symptoms, and improves patient’s quality of life. Clinical evaluations have so shown good therapeutic effects which have been related to the improvement of sphincter function and restored anorectal sensitivity and recto-anal coordination but the real mechanism of action has only been hypotized.  In particular four actions have been imagined:  1. improvement in anorectal sensation and coordination through C and A delta afferent fibers neuromodulation 2. collagen remodelling 3. smooth muscle remodelling 4. modulation of interstitial Cajal cells function Our team has standardized an experimental protocol on porcine model to clarify SECCA action on anorectal tissues.  This protocol includes the SECCA procedure performance and a subsequent histological and immunochemical analysis of internal anal sphincter and the nearby soft tissues. Several studies present in literature seem to confirm these conclusions. A pilot trial in Mexico on 10 patients demonstrated a significant improvement in Cleveland Clinic Florida Fecal Incontinence Scores (CCF-FIS) from a pre-treatment score of 13.5 to 12-month post-treatment score of 3.8. Those patients continued to have significantly improved continence with an average CCF-FIS of 7.3 at 24-month follow up.  A multi-center, institutional review board-approved, open label, prospective trial that evaluated the efficacy and safety of the SECCA procedure has been completed in the United States (U.S.). Five centers prospectively enrolled 50 patients with greater than or equal to 3 months of weekly fecal incontinence who also had failed either medical or surgical interventions.  Patients underwent anoscopy, anorectal manometry, endoanal ultrasound, and pudendal nerve terminal motor latency (PNTML) at 0 and 6 months. The CCF-FIS scale, fecal incontinence-related quality of life score (FIQL), and SF-36 were administered at 0, 3, and 6 months. At 6 months, the mean CCF-FI score improved significantly (14.5 to 11.1, p<0.0001). All FIQL parameters improved: lifestyle (2.5 to 3.1, p=0.0001), coping (1.9 to 2.3, p=0.005), depression (2.8 to 3.1, p=0.0008), embarrassment (1.9 to 2.5, p<0.0001). Sixty-percent (n=30) of the patients improved after therapy, with 70% resolution of their symptoms. The SF-36 mental composite score (45.3 to 48.3, p=0.06) and social function sub-score (64.0 to 77.3, p=0.003) improved.   References Felt-Bersma rJ, szojda MM, Mulder cJ, Temperature- controlled radiofrequency energy (seccA) to the anal canal for the treatment of faecal incontinence offers moderate improvement, Eur J Gastroenterol Hepatol, 2007;19(7):575–80. Kim DW, Yoon hM, Park Js, et al., radiofrequency energy delivery to the anal canal: is it a promising new approach to the treatment of fecal incontinence?, Am J Surg, 2009;197(1):14–8. Ruiz D, Pinto r, hull T, et al., Does the radiofrequency Procedure for fecal incontinence improve Quality of life and incontinence at 1-Year follow-up?, Dis Colon Rectum, 2010;53(7):1041–6. Lefebure B, Tuech J, Bridoux V, et al., Temperature- controlled radio frequency energy delivery (secca® procedure) for the treatment of fecal incontinence: results of a prospective study, Int J Colorectal Dis, 2008;23:993–7. Parisien c, corman M, The secca Procedure for the Treatment of fecal incontinence: Definitive Therapy or short-Term solution, Clin Colon Rectal Surg, 2005;18(1):42–5. Walega P, Jasko K, Kenig J, et al., radiofrequency waves in the treatment of faecal incontinence. Preliminary report, Proktologia, 2009;10(2):134–43.   

Italian

Trattamento con radiofrequenza dell’incontinenza fecale.

Trattamento con radiofrequenza dell\u2019incontinenza fecale.

Trattamento con radiofrequenza dell\u2019incontinenza fecale.

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Archivio istituzionale della ricerca - Università di Genova