Preliminary Study on the Echo-Assisted Intersphincteric Autologous Microfragmented Adipose Tissue Injection to Control Fecal Incontinence in Children Operated for Anorectal Malformations

Abstract

Aim of the study: To assess the efficacy of a novel technique (echo-assisted intersphincteric autologous microfragmented adipose tissue injection, also called “anal-lipofilling”) in the management of non-responsive fecal incontinence in children born with anorectal malformations (ARMs). Methods: Following ethical committee approval (CHPED-MAR-18-02), anal-lipofilling was proposed to patients with fecal incontinence not responsive to medications or bowel management (bowel enema and/or transanal irrigation automatic systems), then a prospective study was conducted. Anal-lipofilling consisted of three phases: lipoaspiration from the abdominal wall, processing of the lipoaspirate with a Lipogems system and intersphincteric injection of the processed fat tissue via endosonographic assistance. A questionnaire based on Krickenbeck’s scale (KS) was administered to the patients to evaluate the clinical outcome. Main Results: Four male patients (three recto-urethral fistula, and one recto-perineal fistula) underwent the anal-lipofilling procedure at a mean age of 13.0 ± 4.2 yrs. There were no complications during or after the procedure. From an initial assessment of the patients there was an improvement in the bowel function at a median follow up of 6 months, with better scores at KS (100% Soiling grade three pre-treatment vs. 75% grade one post-treatment). Conclusions: Even if our Study is preliminary, echo-assisted anal-lipofilling could be considered as a feasible and safe alternative technique in the management of the fecal incontinence in non-responding ARMs patients. More studies are still necessary to support the validity of the implant of autologous adipose tissue in the anal sphincter as a therapy for fecal incontinence in children born with ARMs.

Role of Autologous Fat Grafting in the Conservative Treatment of Fecal Incontinence in Children

“…Previous studies in adults [ 7 , 8 , 9 ] and our first study in a pediatric population [ 10 ] showed that, when used to treat fecal incontinence, the injected fat, in addition to its regenerative potential, acts as a bulky agent increasing the resting pressure, as verified with anorectal manometry, and thickens the anal sphincter, as documented by anal endo-sonography.…”

Diagnosis and management of fecal incontinence in children and adolescents

“…In another study, Parente et al performed an EUS-assisted autologous intersphincteric injection of autologous microfragmented adipose tissue in four patients with FI following surgery for anorectal malformation. A significant improvement in bowel function FI scores were found ( 41 ). Meanwhile, the EUS performance needs a specific rectal 360° probe and cooperation between doctors and patients.…”

“…SRS is generally recommended for sphincter defects, but not for neurologic incontinence. The injection of bulking agents around the anal canal can effectively reduce the frequency of involuntary FI and relieve symptoms, and can therefore be used in the treatment of sphincter-associated FI ( 41 , 81 , 82 ). Although increasing evidence shows the potential of SRS in FI, a few studies were performed in children.…”

Microfragmented adipose tissue is associated with improved ex vivo performance linked to HOXB7 and b-FGF expression

“…Several evidences report a significant positive clinical outcome such us in plastic surgery in the treatment of ulcers, burns, scars, soft tissue augmentation [ 5 , 7 – 9 ]. The application of AT-MSC was not confined to plastic surgery but was also extended to cardiac, rheumatoid, gastro-intestinal and musco-skeletal fields, etc [ 10 – 12 ]. For this reason, different enzymatic and mechanical procedures have been established for processing AT to isolate cells that can be locally implanted [ 13 , 14 ].…”