An Interview with Professor Carlo Ratto on fecal incontinence.

Vittoria Bellato recently met Professor Carlo Ratto, an esteemed colorectal surgeon and researcher, to conduct this interview on fecal incontinence.VB CR

Professor Ratto is a leading expert in the field of colorectal surgery and has made significant contributions to the management of anorectal disorders, including fecal incontinence. He currently serves as the head of the Proctology and Pelvic Floor Surgery Unit at the Fatebenefratelli Gemelli Isola Hospital in Rome, Italy, and is a Professor of Surgery at the Catholic University, also in Rome. Professor Ratto has authored over 200 peer-reviewed publications and book chapters on a wide range of topics related to colorectal surgery, including sphincter-saving techniques in rectal cancer, anal fistula management, and surgical treatment of fecal incontinence. He has also served on numerous editorial boards and scientific committees for international journals and conferences and has received several awards for his research and clinical work.

In this interview, we will have had the opportunity to discuss Professor Ratto's insights and experiences in the diagnosis and treatment of fecal incontinence, as well as the latest advancements in this field.

Vittoria Bellato (VB): Although common in the Western societies, true incidence of FI remains unknown due to discrepancies in definitions used between different healthcare providers/countries. Moreover, many patients do not seek medical help, embarrassed by their condition. In most cases diagnostic criteria and workup are quite heterogeneous, making difficult to create classification and therefore guidelines. Regarding the workup to evaluate the anorectal function and integrity, which complementary exams do you usually ask for? Do you believe one size fits all? Or is your workup different on a case-by-case basis?

Carlo Ratto (CR): The first thing to ask is always a good medical history. In fact, fecal incontinence can derive from possible traumas, with childbirth being a common cause in women, but also from proctological surgical interventions and surgery involving the pelvis. The second fundamental thing is the objective examination, since, if done by an expert doctor in the field, it can identify alterations and direct a correct subsequent instrumental work-up.

On the latest regard, I usually ask for at least two tests: anorectal manometry and ultrasound. Anorectal manometry has the purpose of investigating the function of the sphincters in the various phases (rest and contraction) but also allows us to measure rectal sensitivity, which is often a key factor in the development of fecal incontinence but can be overlooked in diagnosis. Another important symptom to consider is the obstructed defecation, which has been linked to fecal incontinence in many patients.

Ultrasound is an essential exam because it allows us to distinguish between patients with and without sphincter lesions, which is an important factor in determining the best treatment options. In some cases, however, ultrasound alone is not enough, such as when we are faced with a patient with a sphincter lesion that occurred during childbirth but with symptoms of fecal incontinence only many years later. In such cases, we may need to perform additional tests and interpret the findings in a broader pathophysiological context.

For patients with a suspected neuropathic component, an electrophysiological study of the pelvic floor is necessary. For patients with obstructed defecation, a defecography should be added to the diagnostic workup. Overall, the diagnostic workup is like a puzzle where all the pieces must help in interpreting the clinical picture.

VB: I noticed that the possible benefit of first line treatment (for example pelvic floor muscle exercised +/- biofeedback) after surgical treatment is not frequently discussed in guidelines. Do you advocate the use of such treatment post-surgery?

CR: Biofeedback is typically recommended for patients with sphincter hypotonia in the absence of injury, as it can help to train the sphincter. Some even suggest pelvic floor rehabilitation before sphincteroplasty surgery. However, I personally do not recommend using biofeedback for patients with sphincter injury. This is because, conceptually, the contraction caused by biofeedback can move the two ends of the lesion even further apart, which can worsen the condition. Instead, I believe that biofeedback can be beneficial after a sphincteroplasty surgery, but only after a certain period of time, usually 6-8 weeks, to avoid compromising postoperative healing.

VB: Sacral neuromodulation (SNM) has been the mainstay for treating FI currently. What patients in your experience are eligible for SNM? Are there any contraindications?

CR: Sacral neuromodulation is a highly effective therapy that can achieve what surgery cannot. In my experience, incontinent patients with neuropathy are the most eligible for sacral neuromodulation therapy. However, neuropathy is a difficult condition to diagnose, which is why empirical testing is sometimes used to determine the efficacy of neuromodulation therapy in split sessions before implanting the devices definitively in those who have a positive response. Patients who have sphincteric lesions that occurred long ago, with added neuropathic components, may also benefit from this therapy. It is important to select patients carefully to avoid raising false expectations and wasting resources. As for contraindications, patients with cardiac pacemakers or other electronic devices should not undergo sacral neuromodulation, as it may interfere with these devices. Additionally, patients with bleeding disorders, infections, or who are pregnant are generally not considered good candidates for the procedure.

VB: You have invented and tested many surgical techniques and devices, Gatekeeper and Sphinkeeper just to name a few. The process of creating and patenting a surgical technique/device is not known to most. Could you share your story and experience with ESCP members?

CR: The invention and application of the "Gatekeeper" to fecal incontinence is an experience that I am absolutely proud of, as I tried to optimize the treatment of a specific type of patient with a minimally invasive method. The experience was also singular since the Gatekeeper was produced by a well-known company which, however, used it for a different indication. The intuition had been to use the same material, self-expanding prostheses, in the anal canal to reinforce its function. The company was then not interested in continuing its original application and, in fact, had decided to interrupt it also for fecal incontinence.

Luckily, it was then passed on to another company that currently produces it, with which I collaborated in the past to standardize and optimize the procedure. The use by many colleagues around the world has been a further satisfaction for me. The third satisfaction was to find a further optimization of the technique to broaden the indication. There is still a lot of work to be done, and those who will carry it forward are welcome!

VB: Many guidelines (more than 10 in the last 10 years) advocate that colorectal surgeon could possibly treat better obstetric anal sphincter injuries (OASIS) but frequently they do not have enough volume and experience. How long can you expect the learning curve to be for a colorectal surgeon that want to train in pelvic floor?

CR: Regarding the learning curve for a colorectal surgeon wanting to train in pelvic floor surgery, it is a process that requires a lot of dedication and practice. The time needed to become proficient varies depending on the surgeon's previous experience and the complexity of the cases they encounter. It is essential to attend specialized courses and workshops, participate in mentoring programs, and collaborate with experienced surgeons to gain the necessary knowledge and skills. Generally, it takes several years of practice and training to become proficient in pelvic floor surgery. However, the most important thing is to have a willingness to learn and a commitment to improving patient outcomes.

VB: Faecal incontinence, especially obstetric anal sphincter injuries (OASIS), demand a multidisciplinary approach, which would be in your opinion the best setting and how your unit is organized?

CR: In our unit, we have a multidisciplinary team composed of coloproctologists, gynecologists, physiotherapists, and psychologists. We work closely together to provide the best possible care to our patients with faecal incontinence. We also collaborate with other specialties, such as urologists and neurologists, when necessary. Our unit is organized in such a way that each patient is evaluated by a team of specialists and an individualized treatment plan is developed. This plan may include surgical or non-surgical interventions, such as pelvic floor muscle training or sacral neuromodulation. We also follow our patients closely post-treatment to ensure optimal outcomes.

VB: Many studied proved that OASIS repair could be done in delayed primary way, what is your experience regarding this topic and how your unit is organized to treat OASIS?

CR: The management of obstetric anal sphincter injuries (OASIS) is influenced by the expertise in the obstetrics and colorectal area and varies across different centers. Our colorectal team offers maximum availability to repair the lesion in agreement with the obstetricians. Delayed primary repair after a few hours postpartum allows for an organized approach. A thorough evaluation of the injury, including endoanal ultrasound in cases of doubtful physical examination, is necessary. Repair should follow precise and standardized steps, evaluating and repairing the vagina, rectum, internal and external sphincters if necessary. The postoperative period requires careful patient follow up to ensure that the outcome is successful. It is also important to consider the patient's future obstetric needs, particularly in cases where they wish to have subsequent births, as personalized indications are needed to determine the most suitable type of delivery.

VB: To improve strength of evidence, and thus strength of recommendations, more high quality randomized controlled trials should be performed which all should assess the same outcomes, facilitating comparison and evidence synthesis. Which is the next most needed trial on FI in your opinion?

CR: A single study cannot be sufficient to clarify the therapeutic algorithm for fecal incontinence. Instead, multiple studies are needed to investigate the role of a single treatment compared to an integration of treatments. While some types of treatments have demonstrated the best results, even the best treatments have a success rate of only 60-80%, meaning that the battle against incontinence is not yet won. A multidisciplinary approach, integrating several treatments, should be considered. The efficacy of these therapeutic combinations is an area that science should investigate. Future studies should assess the effectiveness of integrating certain treatments with physiotherapy or the use of one or more devices. This perspective also opens up the issue of costs, which can be prohibitively high and may prevent even the primary treatment from being carried out. Therefore, investigating the efficacy of therapeutic combinations can help optimize treatment for fecal incontinence.

VB: Any particular indication in case of FI in a LARS contex?

CR: It is important to note that fecal incontinence in the context of LARS is a complex issue and requires individualized treatment. Patients who undergo reconstruction after low rectal resection may have high expectations, but complications related to LARS can be frustrating and lead to a desire for a new colostomy. Treatment options for LARS-related fecal incontinence may include transanal irrigation or neuromodulation, depending on the specific needs and circumstances of the patient. Surgeons must carefully consider all factors and options when discussing treatment with a patient who has LARS.

VB: Do you have any messages to convey to the ESCP audience regarding diagnosis or treatment of patients with FI?

CR: The management of fecal incontinence requires a personalized approach to each patient, considering their unique circumstances and goals. As clinicians, we have a responsibility to prioritize the patient's quality of life and well-being in our diagnostic and therapeutic decision-making. It is essential to be transparent with patients about the realistic outcomes and potential risks of any treatment options, ensuring that they are informed and empowered to make the best decisions for their care. Professional honesty should be our guiding principle, emphasizing the importance of ethical practice and compassionate patient care. Overall, our message to the ESCP audience is to approach the diagnosis and treatment of fecal incontinence with sensitivity, compassion, and an individualized perspective.

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