Intersphincteric anal lipofilling with micro-fragmented fat tissue for the treatment of faecal incontinence: preliminary results of three patients.

Faecal incontinence is a very debilitating problem. Many techniques have been proposed to treat this condition, with controversial results. Autologous transplant of fat tissue is an established procedure used for the repair of tissue damage, and recent studies revealed the potentiality of tissue regeneration by human adipose-derived stem cells. We treated this condition with the injection, in the intersphincteric anal groove, of lipoaspirate processed by an innovative technology (Lipogems). The aim of the study was to evaluate the efficacy of Lipogems injection for the treatment of faecal incontinence. In February 2014 we treated 3 patients with faecal incontinence. The surgical procedure required three phases: lipoaspiration, processing of lipoaspirate with the Lipogems system, and injection of the obtained product in the intersphincteric anal groove. An accurate proctological examination followed at 1 week, 1 month and 6 months after treatment. Each patient reported an improved Wexner incontinence score at 1 month after the procedure. We observed an increase of resting pressure (by at least 10 mm Hg) and thickness of the internal anal sphincter respectively at ano-rectal manometry and by ultrasound (US) evaluation at the sixth month of follow-up. Our preliminary results are encouraging, but multicentric studies with longer follow-up are needed to validate this novel technique for treatment of faecal incontinence.

Introduction

Faecal incontinence is a serious complaint with significant socio-economic implications: it often represents a significant limitation to daily activities, and patients become depressed due to this problem [1]. In different clinical conditions, different factors are recognized as causes of incontinence. In consequence, many different techniques, either conservative or invasive, have been proposed for the treatment, related to clinical stage: pelvic floor muscle training, biofeedback, sacral nerve stimulation, tibial nerve stimulation, sphincteroplasty, an anal plug or local devices, injection of bulking agents, and the Secca procedure [2]. Overall results are poor and often controversial.

Autologous transplant of adipose tissue is an established procedure used for repair of a variety of tissue damage. Recent biological studies have shown that the potentiality of tissue regeneration can be enhanced using adipose-derived stem cells (ADSCs) [3]. Stem cell frequency appears to be significantly higher in adipose tissue than in bone marrow [4]. The subcutaneous adipose tissue provides a clear advantage over other sources of stem cells, due to the ease with which adipose tissue can be accessed (under local anaesthesia and with minimum patient discomfort) as well as to the ease of isolating stem cells from the harvested tissue [5, 6].

Human adipose-derived stem cells (hADSCs) are usually localized in the stromal-vascular portion (SVp) of subcutaneous adipose tissue [7], which consists of a heterogeneous mesenchymal population of cells including adipose stromal and haematopoietic stem and progenitor cells, endothelial cells, erythrocytes, fibroblasts, lymphocytes, monocytes/macrophages, and pericytes [8]. Specifically, SVp of adipose tissue contains a multipotent cellular population with phenotypic and gene expression profiles similar to human mesenchymal stem cells (hMSCs) and pericytes [9].

Human mesenchymal stem cells are multi-potent, self-renewing cells with the capacity to differentiate, in vitro, into cells of mesenchymal origin, including osteoblasts, adipocytes, and chondrocytes, and give rise to bone, fat, cartilage, and muscle tissue in vivo [10]. Human mesenchymal stem cells have also the capacity of producing multiple trophic mediators that determine angiogenic, anti-apoptotic and anti-fibrotic responses [11].

In this study we treated 3 patients affected by faecal incontinence with the injection, in the intersphincteric anal groove, of fat tissue obtained by an innovative enzyme-free technology, named Lipogems.

Case reports

In February 2014 we treated three patients with faecal incontinence. Here we report the characteristics of the 3 cases.

Case 1

Female patient, aged 65 years, complaining of faecal incontinence for 6 years. She had a rectal prolapse and underwent a ventral rectopexy with prosthetic polypropylene mesh in 2011. Endo-anal US showed abnormality of pubo-rectal muscle and a reduced thickness of the internal sphincter; ano-rectal manometry revealed a diminished resting pressure of the internal anal sphincter.

Case 2

Female patient, aged 59 years, treated with sphincter overlapping for faecal incontinence in 2012. Nevertheless the operation did not improve this pathological condition. Endo-anal US detected hypotrophic fibres of the internal anal sphincter while ano-rectal manometry revealed a diminished resting pressure of the internal anal sphincter.

Case 3

Female patient, 73 years old, with faecal and urinary incontinence for about 5 years. The internal rectal mucosa was prolapsed, with a deep anterior rectocele and a severe bladder prolapse. Endo-anal US revealed homogeneous reduced thickness of the internal anal sphincter, and ano-rectal manometry evidenced an impaired response pressure of the external anal sphincter and a lower resting pressure of the internal anal sphincter.

Operative technique

A detailed informed consent form was signed by enrolled patients after a complete and comprehensive explanation of the experimental procedure by a member of the surgical staff. All patients were operated on by the same senior staff surgeon as a day surgery procedure under local anaesthesia. The surgical procedure consisted of three phases: 1) lipoaspiration, 2) processing of lipoaspirate, 3) injection of processed fat tissue into the intersphincteric anal groove. The presence of stainless steel marbles in the closed device is necessary to process lipoaspirate without enzymatic digestion.

The lower abdominal wall was infiltrated with adrenalin and lidocaine in a saline solution, in order to provide effective vasoconstriction and local anaesthesia. Lipoaspiration was performed with a syringe (10 cc) to harvest about 150 ml of fat tissue (usually needed for the Lipogems procedure) in less than 5 min (Photo 1).

Photo 1

Lipoaspiration

The second step was based on the novel Lipogems system. This innovative technology improves the classical Coleman lipofilling technique by providing micro-fragmented and transplantable clusters of lipoaspirate. The micro-fragmentation improve their post-transplant engraftment. This system consists of a single, disposable device that progressively reduces the clusters of adipose tissue in size while a saline solution washes away oil and blood residues, which flow into a waste bag, avoiding traumatic manipulation on the cells (Photo 2). The first cluster reduction was obtained by pushing the aspirated fat tissue from the syringe into the device and through the first size filter. Then we kept the device vertical with the first size reduction filter on top, and it was shaken to obtain micro-clusters and to emulsify oil residues. When the solution inside the device seemed clear and the lipoaspirate true yellow, the saline flow was stopped and the device was turned upside down. The second adipose cluster reduction was obtained by passing the floating adipose clusters through the second size reduction filter by pushing additional fluid from the lower opening of the device using a syringe. The final Lipogems product was collected into 10 cc syringes connected to the upper opening of the device.

Photo 2

Lipogems device

The last step consisted in the injection of Lipogems micro-fragmented fat tissue in the intersphincteric space, with patients in the lithotomic position and under local anaesthesia (Photo 3), obtained by infiltration of the ano-perineal area with adrenaline and lidocaine saline solution.

Photo 3

Anal lipofilling

Results

All patients underwent an accurate proctological examination 1 week, 1 month and 6 months after the surgical procedure.

End-points of the study were: pre- and post-operative evaluation of Wexner incontinence score, ano-rectal manometry and endo-anal US evaluation at follow-up examinations. All patients showed a clinical improvement with evidence of reduction of the Wexner incontinence score from 1 month after the procedure with a significantly improved quality of lifestyle 6 months after treatment in all cases. Pre-operative Wexner and post-operative faecal incontinence scores of these 3 patients are reported in Tables I–III.

Table I

Case 1

Type of incontinence	Never	Rarely	Sometimes	Usually	Always	Pre-op.	Post-op. 1 month	Post-op. 6 months
Solid	0	1	2	3	4	3	3	2
Liquid	0	1	2	3	4	3	2	2
Gas	0	1	2	3	4	3	2	2
Wear pad	0	1	2	3	4	3	2	1
Lifestyle altered	0	1	2	3	4	3	2	1

Table III

Case 3

Type of incontinence	Never	Rarely	Sometimes	Usually	Always	Pre-op.	Post-op. 1 month	Post-op. 6 months
Solid	0	1	2	3	4	2	2	2
Liquid	0	1	2	3	4	3	3	2
Gas	0	1	2	3	4	2	2	1
Wear pad	0	1	2	3	4	2	1	1
Lifestyle altered	0	1	2	3	4	2	2	1

All patients showed an increased resting pressure of the internal anal sphincter (at least 10 mm Hg) at ano-rectal manometry after 6 months (Table IV). Moreover, endo-anal US demonstrated increased thickness of the internal anal sphincter in all cases at the same time of follow-up.

Table IV

Ano-rectal manometry

Patients	Pre-op. resting pressure of IAS [mm Hg]	Resting pressure of IAS at 6th-month follow-up examination [mm Hg]
Case 1	51	62
Case 2	43	55
Case 3	62	72

IAS – Internal anal sphincter.

Regarding side effects, we observed only 1 case of subcutaneous lower abdominal haematoma that was spontaneously absorbed 2 months after the treatment.

Discussion

Even if the initial effect of the Lipogems product certainly depends on immediate bulking action of lipoaspirate injected into the intersphincteric space, the persistence of better anal continence probably can be explained by the capacity of human mesenchymal stem cells (hMSCs) to differentiate in muscle tissue [12]. In this paper, we have presented a simple, safe and effective day surgery procedure to treat faecal incontinence.

Classical fat tissue harvesting and injection techniques, such as Coleman lipofilling, may damage mature adipocytes more easily than in the case of immature stem cells: adipocytes that survive seems to be more fragile and less resistant to ischaemic damage due to revascularization following the transplant [13]. In contrast, human mesenchymal stem cells are more resistant to the trauma of both liposuction and implantation. This can be explained if we consider that immature cells require a minimal metabolic reserve and can survive longer with a minimal nutritional and oxygen amount compared to mature adipocytes [14].

Lipogems is a fat tissue derivative with the features of a minimally manipulated product that can be promptly injected in donors. Unlike the lipoaspirate that undergoes widely distributed modifications of the structure, the novel Lipogems product has a stromal/vascular portion (SVp) preserved, which is an important advantage allowing better and long-lasting clinical results in the recipient site. Digestive enzymes can reduce the cell glycocalyx, a carbohydrate-rich layer lining cell plasma membranes and the vascular endothelium which plays a role in the functioning of cells receptors, enhancing cell-to-cell adhesion, reducing membrane permeability and modulating inflammatory responses to cytokines. A deficiency of glycocalyx probably impairs adhesion properties of the cells and it is not adapt to modified extracellular environments and to respond to growth factors and angiogenic proteins. The Lipogems device avoids digestion of adipose tissue by enzymes, preserving the glycocalyx [15].

Ancestor endothelial and mesenchymal stem cells derived from adipose tissue not only could be useful in plastic and reconstructive surgery, but also may be interesting for treatment of other difficult diseases. In our opinion, proctological application and mainly the treatment of faecal incontinence can be included in this list, and this study revealed unexpected good results.

Conclusions

The current study concerns only the very early experience with this innovative approach. We are going to make our follow-up longer to collect more significant data, but there is no doubt that the preliminary results are encouraging. At present we are enrolling other patients to verify the effectiveness of this novel technique. Furthermore, multicentric studies are necessary to compare intersphincteric Lipogems injection with other available techniques for treatment of faecal incontinence.

Table II

Case 2

Type of incontinence	Never	Rarely	Sometimes	Usually	Always	Pre-op.	Post-op. 1 month	Post-op. 6 months
Solid	0	1	2	3	4	3	2	2
Liquid	0	1	2	3	4	4	3	2
Gas	0	1	2	3	4	4	3	3
Wear pad	0	1	2	3	4	3	3	2
Lifestyle altered	0	1	2	3	4	4	3	2