Radiofrequency energy delivery (Secca® procedure; Curon Medical) is a newer modality for treating fecal incontinence originally used for treating gastroesophageal reflux disease [1], benign prostatic hyperplasia [2], and joint-capsule laxity [3]. After being found a safe and effective means of strengthening tissues, its beneficial effects were first used within the anal canal in Mexico in 1999. Since then, demonstrated improvements have prompted further investigation, with promising results, for use within the anal canal. The radiofrequency generator produces heat by a high-frequency, alternating current that flows from two electrodes-active and dispersive-causing frictional movement of ions and tissue heating [4]. This procedure is not an option for obvious sphincter defects but can be used with a weak or thinned anal sphincter complex. Patients with a history of inflammatory bowel disease (IBD), extensive perianal disease, or chronic diarrhea should not be offered this treatment.

The exact mechanism of action is unknown, although the current hypothesis is that the temperature-controlled energy heats the tissue causing collagen contraction and initiates focal wound healing in the sphincter muscle, actually tightening the tissue [5]. Preliminary animal studies demonstrated small areas of fibrosis within the anal sphincter [6]. In a prospective follow-up study of ten women, Takahashi et al. [7] showed that symptomatic improvement persists for 2 years after delivery of radiofrequency energy to the anal canal. The patients answered questionnaires including the Cleveland Clinic Florida Fecal Incontinence (CCF-FI) scale, Fecal Incontinence Quality of Life (FIQOL) score, and the Short Form-36 (SF-36) at baseline and at 1,2,3,6,12, and 24 months after the procedure. At 24 months, the CCF-FI score improved from 13.8 to 7.3. The FIQOL score also improved significantly. There was no decrease in effect shown from 12 to 24 months postprocedure. Of note, manometric studies show a significant reduction in initial and maximal rectal volumes, although resting and squeeze pressures have not been demonstrated to change after treatment [7].

Patients who may be candidates for this treatment should have no definite sphincter defect, as overlapping sphincteroplasty is still the optimal treatment. Radiofrequency can still be used as an adjunct post sphincter repair. Patients who have IBD, chronic diarrhea, anal fissure, or abscesses should not undergo this treatment.

The procedure itself is simple to perform, requires minimal sedation, and can be performed in an ambulatory setting requiring no hospital admission. The patient is placed in the prone jackknife position with the buttocks taped apart. The handheld disposable anoscope (Fig. 1) is inserted into the anal canal 1 cm distal to the anal verge. The needle electrodes are deployed, and the radiofrequency energy is delivered deep within the muscle, while the mucosa and sub-mucosa are cooled by constant external irrigation. The needle electrodes contain sensors to prevent overheating and tissue desiccation. The energy is

Fig. 1. Handheld disposable anoscope is inserted into the anal canal 1 cm distal to the anal verge

deployed for 90 s to achieve a temperature of 85 °C. If the resistance or the mucosal tissue becomes too high, the energy being delivered to the tissue will be automatically discontinued. The main control unit (Fig. 2) displays the time elapsed, tissue and mucosal surface temperature, and the resistance of each electrode (Fig. 3). This procedure is carried out in 0.5-cm increments proximally along the distance of the internal sphincter and then repeated in each quadrant of the anal canal. By the end of the procedure, approximately 16-20 thermal lesions are created along the internal anal sphincter (Fig. 4).

Radiofrequency energy has proven to be an effective modality in treating fecal incontinence. In a multicenter study, Efron et al. [8] demonstrated a significant improvement in both CCF-FI and FIQOL scores. Fifty patients at five centers were enrolled. Initially and 6 months postprocedure, patients completed the CCF-FI score, the FIQOL score, the SF-36, and visual analog scale (VAS). At 6 months, the CCF-FI score improved from 14.5 to 11.1 (p<0.0001). FIQOL scores all improved significantly, although anal manometry and anal ultrasound showed no changes. Complications were minimal and included mucosal ulceration and delayed bleeding in one patient.

Radiofrequency energy delivery is minimally invasive requiring only sedation and can be performed on an outpatient basis. It is ideal as a preliminary step in a patient with multiple comorbidi-ties who may not be able to tolerate a lengthier procedure. Radiofrequency energy delivery has been shown to be a relatively safe treatment with minimal morbidity, including mucosal ulceration and bleeding [8]. It is a simple procedure that can be used alone or in conjunction with other modalities in the challenging, often difficult realm of treating fecal incontinence. The Secca procedure is approved by the US Federal Drug Administration for use in the United States. However, the Curon Company filed bankruptcy on November 15, 2006, and therefore this technology is not available at the time of publication of this chapter.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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