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Aim This study aimed to assess the cost-effectiveness of sacral neuromodulation ( SNM) compared with conservative treatment in children and adolescents with constipation refractory to conservative management. Method A Markov probabilistic model was used, comparing costs and effectiveness of SNM and conservative treatment in children and adolescents aged 10-18 years with constipation refractory to conservative management. Input for the model regarding transition probabilities, utilities and healthcare costs was based on data from a cohort of patients treated in our centre. This cohort consisted of 30 female patients (mean age 16 years) with functional constipation refractory to conservative management. The mean duration of laxative use in this group was 5.9 years. All patients had a test SNM, followed by a permanent SNM in 27/30. Median follow-up was 22.1 months (range 12.2-36.8). The model was run to simulate a follow-up period of 3 years. Results The mean cumulative costs for the SNM group and the conservative treatment group were €17 789 ( SD €2492) and €7574 ( SD €4332) per patient, respectively. The mean quality adjusted life years ( QALYs) in the SNM group was 1.74 ( SD 0.19), compared with 0.86 ( SD 0.14) in the conservatively managed group. The mean incremental cost-effectiveness ratio was €12 328 per QALY ( SD €4788). Sensitivity analysis showed that the outcomes were robust to a wide range of model assumptions. Conclusion Chronic constipation seriously affects the quality of life of children and adolescents. Preliminary evidence suggests that SNM can improve symptoms and quality of life at a reasonable cost. [ABSTRACT FROM AUTHOR]

Aim Surgical management of rectal prolapse varies considerably. Most surgeons are reluctant to use ventral mesh rectopexy in young women until they have completed their family. The aim of the present study was to review outcomes of pregnancy following laparoscopic ventral mesh rectopexy from a tertiary referral centre over a 10-year period (2006-2016) and to review the impact on pelvic floor symptoms. Method We undertook a retrospective review of a prospectively compiled database of patients who had undergone laparoscopic ventral rectopexy in a single centre over a 10-year period. Pelvic floor symptom scores (Vaizey for incontinence and Longo for obstructive defaecation) were collected at initial presentation (pre-intervention), post-intervention and after child birth. Results In all, 954 rectopexies were performed over this 10-year period. 225 (24%) patients were women and under 45 years of age (taken as an arbitrary cut-off for decreased likelihood of pregnancy). Eight (4%) of these patients became pregnant following rectopexy. The interval between rectopexy and delivery was 42 months (21-50). Six patients delivered live babies by elective lower segment caesarean section and two by spontaneous vaginal delivery. Six were first babies and two were second. No mesh related adverse outcome was reported. No difference in pelvic floor symptoms was demonstrated on comparison of post-rectopexy and post-delivery scores. Conclusion This study provides the first description in the English language literature of safe delivery by elective lower segment caesarean section or spontaneous vaginal delivery following laparoscopic ventral mesh rectopexy. No adverse impact on pelvic floor related quality of life was detected. [ABSTRACT FROM AUTHOR]

Aim Around one-third of patients with Crohn's disease are affected by Crohn's fistula-in-ano (p CD). It typically follows a chronic course and patients undergo long-term medical and surgical therapy. We set out to describe current surgical practice in the management of p CD in the UK. Method A survey of surgical management of pCD was designed by an expert group of colorectal surgeons and gastroenterologists. This assessed acute, elective, multidisciplinary and definitive surgical management. A pilot of the questionnaire was undertaken at the 2015 meeting of the Digestive Disease Federation. The survey was refined and distributed nationally through the trainee collaborative networks. Results National rollout obtained responses from 133 of 179 surgeons approached (response rate 74.3%). At first operation, 32% of surgeons would always consider drainage of sepsis and 31.1% would place a draining seton. At first elective operation, 66.6% would routinely insert of draining seton, and 84.4% would avoid cutting seton. An IBD multidisciplinary team was available to 87.6% of respondents, although only 25.1% routinely discussed pCD patients. Anti-tumour necrosis factor-alpha therapy was routinely considered by 64.2%, although 44.2% left medical management to gastroenterologists. Common definitive procedures were removal of the seton only (70.7%), fistulotomy (57.1%), advancement flap (38.9%), fistula plug (36.4%) and ligation of intersphincteric track ( LIFT) procedure (31.8%). Indications for diverting stoma or proctectomy were intractable sepsis, incontinence and poor quality of life. Conclusion This survey has demonstrated areas of common practice, but has also highlighted divergent practice including choices of definitive surgery and multimodal management. Practical guidelines are required to support colorectal surgeons in the UK. [ABSTRACT FROM AUTHOR]

Aim Our unit has recently shown that sacral nerve stimulation ( SNS) has a significantly positive short-term effect on selected patients with diarrhoea-predominant or mixed irritable bowel syndrome ( IBS). The aim of the present prospective study was to evaluate the medium-term efficacy of SNS for IBS to establish whether SNS could have a future role in the treatment of IBS. Method Patients with IBS who had previously been implanted with a permanent neurostimulator as part of a randomized, controlled, crossover study, were assessed for medium-term follow-up. The primary end-point was change in the IBS-specific symptom score (Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire) from baseline to 3-year follow-up. The secondary end-point was a change in the IBS-specific quality of life score (Irritable Bowel Syndrome-Impact Scale questionnaire) from baseline to 3-year follow-up. Results Of 26 patients, 20 were eligible for 3-year follow-up. The median IBS-specific symptom score was significantly lower at 3-year follow-up (30, range 13-71) than at baseline (62, 45-80) ( P = 0.0001). The effect was observed in all symptom clusters within the score. Also, the median IBS-specific quality of life score was significantly improved at 3-year follow-up (52, 26-169) compared with baseline (135, 82-180, P = 0.0002). The effect was observed in all domains of the score. As per the protocol, 75% of patients were judged therapeutic successes. Seventy per cent of patients had a more than 50% reduction in daily IBS symptoms. Conclusion At medium-term follow-up, SNS continues to be an effective treatment for highly selected patients with diarrhoea-predominant or mixed IBS. [ABSTRACT FROM AUTHOR]

Aim Chronic constipation can be aetiopathogenically classified into slow transit constipation ( STC), rectal evacuation difficulty ( RED) or a combination ( BOTH). Although the efficacy of percutaneous tibial nerve stimulation ( PTNS) in faecal incontinence has been well proved, a current literature search identifies only one study which assessed its effect on constipation. We aimed to evaluate the effectiveness of PTNS in patients with different causes of constipation. Method Thirty-four patients [30 women, median age 50 (20−79) years] with constipation who had previously failed maximal laxative and biofeedback therapy participated in the study. All patients underwent a baseline radio-opaque marker transit study and anorectal physiology examination. All had 12 sessions of PTNS of 30 min per session. A fall in the Wexner constipation score to ≤15 or by ≥5 points was taken as the primary outcome. Secondary outcomes included the results of pre- and post- PTNS transit and anorectal physiology studies. Results Eleven patients had STC, 14 had RED and nine had BOTH. A response was seen in four patients (1/11 STC, 2/14 RED and 1/9 BOTH). Comparing pre- and post- PTNS, there was no significant change in the mean Wexner score ( P = 0.10). There was no change in colonic transit time among the whole population ( P = 0.56) or among those with STC ( P = 0.47). There was no improvement in balloon expulsion in the whole group ( P = 0.73) or in patients with RED ( P = 0.69). Conclusion PTNS is of no benefit to patients with constipation, whatever aetiopathogenic mechanism is responsible for the symptoms. [ABSTRACT FROM AUTHOR]

Aim Overlapping anal sphincter repair (OASR) is used for treatment of faecal incontinence due to an external anal sphincter (EAS) defect; however, it is not the optimal treatment as its functional results tend to deteriorate significantly with time. The present study aimed to evaluate the effect of local injection of bone marrow aspirate concentrate (BMAC) on the outcome of OASR. Method We compared a prospective group of 20 patients with EAS defect who were managed with OASR and BMAC injection (group I) with a historical control group of an equal number of patients managed with OASR alone (group II). Patients were assessed preoperatively and during follow-up by the Wexner continence score and endoanal ultrasound. The primary end-points were the improvement of the continence level measured by the Wexner score and the residual EAS defect size measured by endoanal ultrasound. Results At the end of follow-up, group I had significantly lower mean postoperative Wexner score (5.4 ± 7.6 vs 10.6 ± 7.4; P = 0.03) and smaller EAS defect percentage (12.2 ± 17.5 vs 18.3 ± 18.9). These findings were statistically significant in patients with a small preoperative EAS defect equal to or less than one-third of the anal circumference. Patients with larger preoperative EAS did not show a significant improvement of the continence level after repair in either group. Conclusion Augmenting OASR with local injection of BMAC in patients with faecal incontinence caused by an EAS defect, particularly a smaller defect, can improve both functional and anatomical outcomes of OASR. [ABSTRACT FROM AUTHOR]

Aim This study evaluated continence, constipation and quality of life ( QOL) before and after laparoscopic ventral rectopexy ( LVR) Method Between February 2012 and July 2014, patients who underwent LVR for external rectal prolapse ( ERP) and/or rectoanal intussusception ( RAI) were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index ( FISI), the Constipation Scoring System ( CSS) and QOL instruments (Short-Form 36 Health Survey, Fecal Incontinence QOL scale, Patient Assessment of Constipation- QOL) were administered before and after operation. Psychiatric patients and those with dementia were excluded from the study. Defaecography was performed 6 months postoperatively. Results Fifty-nine patients were included in the study period and 44 (19 with ERP, 25 with RAI) completed the follow-up questionnaire and were reviewed after a median of 26 (range 12-42) months. There was no recurrent ERP. Postoperative defaecography showed new-onset RAI in 6 and persistent RAI in 1. One year after surgery, incontinence was improved in 30/39 patients (77%) and constipation in 19/32 (59%). The FISI scores reduced between preoperative status and 1 year after surgery [32 (13-61) vs 11 (0-33), P < 0.0001]. The CSS scores also reduced [preoperative 12 (5-18) vs 1 year 5 (1-12), P < 0.0001]. Compared with the preoperative scores, almost all of the scale scores on the three kinds of QOL instruments significantly improved over time. The presence of new-onset or persistent RAI did not have an adverse effect on the improvement of QOL. Conclusion LVR improves both generic and symptom-specific QOL with good functional results. [ABSTRACT FROM AUTHOR]

Aim A questionnaire completed by members of the ACPGBI in 1997 was a precursor to the PROSPER trial. It showed a significant variation in favoured practice for the surgical treatment of external rectal prolapse. We repeated the same questionnaire to assess how practice has changed since the completion of the trial and its publication. Method An online survey was circulated to all members of the ACPGBI with identical questions to those used in the original in 1997. Results Similar numbers of recipients responded (122/791 [15.4%] in 2014;153/600 [25.5%] in 1997). The median number of operations per surgeon per year was unchanged (6 [0-30] vs 6 [0-25]). The percentage of surgeons who favoured an abdominal approach in fit patients in 1997 rose significantly from 63.5% to 81.7% in 2014 ( P < 0.01). Delorme's remains the most popular perineal procedure (78.5% vs 93.3%), but the Altemeier procedure increased from 14.9% to 39.3%. Ventral rectopexy was the preferred abdominal approach in 2014 (48.6% vs 5.9% [ P < 0.01]), with 96.3% of these being performed laparoscopically. The number of surgeons carrying out posterior rectopexy decreased from 92.6% to 45.9% ( P < 0.01). Only 9.9% of surgeons still undertook resection rectopexy compared with 39.7% in 1997 ( P < 0.01). The numbers of surgeons favouring a perineal approach decreased (18.3% vs 36.5%) although the use of a perineal procedure in elderly or unfit patients was unchanged (38.5% vs 37.9%). Conclusion The surgical management of external rectal prolapse had changed. More surgeons favoured a laparoscopic abdominal approach in 2014 than in 1997 and the use of perineal approaches had decreased. Of these Delorme's operation remained the most popular but the incidence of the use of Altmeier's procedure had increased. [ABSTRACT FROM AUTHOR]

Aim The use of a loose seton for complex anal fistulae can cause perianal discomfort and reduced quality of life. The aim of this study was to assess the impact of the novel knot-free Comfort Drain on quality of life, perianal comfort and faecal continence compared to conventional loose setons. Method Forty-four patients treated for complex anal fistula at a single institution between July 2013 and September 2014 were included in the study. A matched-pair analysis was performed to compare patients with a knot-free Comfort Drain and controls who were managed by conventional knotted setons. The 12-item Short Form survey ( SF-12) questionnaire was used to assess quality of life. Additionally, patients reported perianal comfort and faecal incontinence using a Visual Analog Scale ( VAS) and the St Mark's Incontinence Score. Results The Comfort Drain was associated with improved quality of life with significant higher median physical ( P = 0.001) and mental ( P = 0.04) health scores compared with a conventional loose seton. According to the VAS, patients with a Comfort Drain in situ reported greater perianal comfort with significantly less burning sensation ( P < 0.001) and pruritus ( P < 0.001). Faecal continence was similar in each group. Conclusion The Comfort Drain offers improved perianal comfort and better quality of life compared with a conventional loose seton and therefore facilitates long-term therapy in patients with complex fistula-in-ano. [ABSTRACT FROM AUTHOR]

Background Pilonidal disease ( PD) is a common inflammatory disease of the gluteal fold, resulting in recurrent acute/chronic infection at the level of the natal cleft. In this study, endoscopic pilonidal sinus treatment ( EPSiT), a new endoscopic minimally invasive procedure, was evaluated for its effectiveness in treating PD. Methods Two hundred and fifty prospective patients with chronic PD were enrolled in a prospective multicentre study conducted at a secondary and tertiary colorectal surgery centre. The primary end-point of this study was wound healing, and the short-/long-term outcomes such as healing time, morbidity rate and recurrence rate were analysed. The secondary end-point of this study was quality of life (QoL). Results The complete wound healing rate was 94.8%, and the mean complete wound healing time was 26.7 ± 10.4 days. The incomplete healing rate (5.2%) was significantly related to the number of external openings ( P = 0.01). There was no difference in the failure rate when EPSiT was performed as the first-line treatment for PD or when it was used after unsuccessful procedures ( P = n.s.). Recurrence occurred in 12 cases (5%). The QoL significantly increased from preoperative levels 15 days after the EPSiT procedure (45.3 vs 7.9; P < 0.0001). Conclusions The EPSiT procedure is a safe and effective technique for treating PD. It provides better short- and long-term outcomes than various other techniques that are more invasive. EPSiT is a minimally invasive outpatient procedure, which is associated with a quick recovery and a good QoL outcome. [ABSTRACT FROM AUTHOR]

Aim Chronic constipation is difficult to treat when symptoms are intractable. Colonic propulsion may be altered by distal neuromodulation but this is conventionally delivered percutaneously. Transcutaneous tibial nerve stimulation is noninvasive and cheap: this study aimed to assess its efficacy in chronic constipation. Method Eighteen patients (median age 46 years, 12 female) with chronic constipation were recruited consecutively. Conservative and behavioural therapy had failed to improve symptoms in all 18. Thirty minutes of daily bilateral transcutaneous tibial nerve stimulation was administered by each patient at home for 6 weeks. The primary outcome measure was a change in the Patient Assessment of Constipation Quality of Life ( PAC-QoL) score. Change in Patient Assessment of Constipation Symptoms ( PAC- SYM), weekly bowel frequency and visual analogue scale ( VAS) score were also measured. Results Fifteen patients (12 female) completed the trial. The PAC-QoL score improved significantly with treatment [pretreatment, median 2.95, interquartile range ( IQR) 1.18; posttreatment, median 2.50, IQR 0.70; P = 0.047]. There was no change in PAC- SYM score (pretreatment, median 2.36, IQR 1.59; posttreatment, median 2.08, IQR 0.92; P = 0.53). Weekly stool frequency improved as did VAS score, but these did not reach statistical significance ( P = 0.229 and 0.161). The PAC-QoL and PAC- SYM scores both improved in four (26%) patients. Two patients reported complete cure. There were no adverse events reported. Conclusion Bilateral transcutaneous tibial nerve stimulation appears to be effective in a quarter of patients with chronic constipation. Carefully selected patients with less severe disease may benefit more. This requires further study. [ABSTRACT FROM AUTHOR]