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PURPOSE: Sacral nerve stimulation is one of many new surgical modalities for fecal incontinence. Short-term results from sacral nerve stimulation have been more encouraging than those from other modalities. The aim of this study was to report the outcome of percutaneous nerve evaluation tests and sacral nerve stimulation for the treatment of fecal incontinence from a single center covering a period of 6 years since the procedure was introduced. METHODS: All of the candidates for a percutaneous nerve evaluation test and sacral nerve stimulation seen at our anal physiology unit between March 2001 and March 2007 were included in the study. RESULTS: A total of 177 patients with fecal incontinence (160 females), median age 59.5 (range, 27-88) years, underwent a percutaneous nerve evaluation test. Of these patients, 142 (80%) had a positive test, including 21 of 25 (84%) patients who required a repeat percutaneous nerve evaluation test. Because of a functional failure, 16 patients underwent a revision of the permanent electrode, 7 of whom (44%) were satisfied with the functional result after the revision. Of 126 patients, 15 (12%) have undergone an explantation, with an infection rate of only 1.6%. Overall, after a median follow-up of 24 (range, 3-72) months, the median Wexner incontinence score decreased from 16 (range, 6-20) to 10 (range, 0-20) (P < .0001). In the 10 patients who underwent at least 6 years of treatment, the effect was sustained, as the median Wexner incontinence score decreased from 20 (range, 12-20) to 7 (range, 2-11) (P < .0001). CONCLUSION: Sacral nerve stimulation is a simple, safe, and minimally invasive technique with low morbidity and excellent results, which appear to be maintained for the first 6 years after the procedure. For patients who underwent the treatment, median Wexner incontinence score decreased significantly after a median follow-up of 24 (range, 3-72) months. Twelve percent were explanted. The infection rate was 1.6%.

Udgivelsesdato: 2009-Nov INTRODUCTION: Sacral nerve stimulation has become an established treatment for patients with fecal incontinence. However, the mechanism of its action remains obscure. We aim to assess whether sacral nerve stimulation improves patients' ability to retain rectal content. METHODS: Patients who had been treated successfully with sacral nerve stimulation underwent four retention tests during which the stimulator was turned either on or off. Both the patients and investigators were blinded to the status of the stimulator. The retention test results were assessed for interassessment agreement and for any differences between the on and off phases. Wexner scores, anorectal physiology tests, and patients' perceptions of stimulator settings were also recorded. RESULTS: Nineteen patients (16 women; mean age, 57.5 years) took part in the study. Retention tests showed moderate interassessment agreement (weighted Cohen's kappa index, 0.45). There were no sharp differences in retained volume between the stimulator's on and off phases (median 50 (range, 0-300) mL vs. 50 (range, 0-300) mL; P = 0.85). CONCLUSION: Sacral nerve stimulation does not alter patients' ability to retain rectal content. Further studies are needed to investigate the mechanism of sacral nerve stimulation.

Udgivelsesdato: 2009-Feb PURPOSE: This study evaluated long-term results of transanal irrigation for defecation disturbances. METHODS: Three hundred and forty-eight patients [248 women and 100 men; median age 52 years (range, 5-85)] suffering from constipation and fecal incontinence were introduced to transanal irrigation. Patients using transanal irrigation at follow-up received a mailed questionnaire describing bowel function and practical procedures. Results from patients not responding and patients no longer using transanal irrigation were drawn from hospital records and telephone interviews. Background variables were analysed using multivariate logistic regression. RESULTS: After a mean follow-up of 21 months (range, 1-116) 163 of 348 patients (47 percent) had a successful outcome from treatment with transanal irrigation. Success rates varied between patients with different underlying pathology: neurogenic bowel dysfunction, 67 of 107 (63 percent); anal insufficiency, 36 of 70 (51 percent); sequela to anorectal surgery, 14 of 48 (29 percent); idiopathic constipation, 27 of 79 (34 percent); and miscellaneous, 19 of 44 (43 percent). Factors correlating with positive outcome were neurogenic bowel dysfunction and anal insufficiency as underlying pathology, low rectal volume at urge to defecate, low maximal rectal capacity, and low anal squeeze pressure increment. Two nonfatal bowel perforations were found in approximately 110,000 irrigation procedures. CONCLUSIONS: Transanal irrigation is simple and safe for long-term treatment for defecation disturbances with greatest benefit in patients with neurogenic bowel dysfunction.

Udgivelsesdato: 2008-Oct PURPOSE: This retrospective study reviewed long-term results in a large group of adult patients treated with antegrade colonic enema and antegrade colonic enema combined with a colostomy. METHODS: Retrospective chart review identified 80 patients (64 females, mean age 51) surgically treated between 1993 and 2007 for fecal incontinence or constipation. Surgical treatments included 69 appendicostomies, 13 tapered ileum, 3 cecal tube, and 25 appendicostomy/neoappendicostomy combined with a colostomy. A 44-item questionnaire was mailed considering bowel regimen, complications, bowel function, social function, and quality of life. RESULTS: Sixty-nine patients were available for follow-up (mean follow-up, 75 months). Thirty patients (38 percent) had surgical complications. Forty-three patients (62 percent) were still performing antegrade continence enema and 8 patients (12 percent) no longer needed it. Accordingly, treatment was successful in 51 patients (74 percent). Twenty-seven patients (63 percent) had side effects. Evaluation of bowel function, social function, and quality of life all showed significant improvement. Antegrade continence enema was successful in patients with neurologic disabilities (67 percent), anorectal injury (53 percent), idiopathic fecal incontinence (50 percent), and idiopathic fecal constipation (42 percent). Antegrade continence enema was successful in patients with constipation, incontinence, and mixed symptoms. Results did not differ between appendicostomy, neoappendicostomy, and the combined appendicostomy/neoappendicostomy and colostomy. CONCLUSION: Long-term results were favorable in most patients treated with antegrade continence enema for fecal incontinence or constipation.

PURPOSE: Manometry and pressure-volume measurements are commonly used to study anorectal physiology. However, the methods are limited by several sources of error. Recently, a new impedance planimetric system has been introduced in a porcine model. It allows simultaneous determination of anorectal pressures and multiple rectal luminal cross-sectional areas. This study was designed to study normal human rectoanal motility by means of impedance planimetry with multiple rectal cross-sectional areas and rectal and anal pressure. METHODS: Twelve healthy volunteers (10 females), aged 24 to 53 years, were studied during one-hour fasting and one hour after a meal. Rectal cross-sectional areas were determined at five levels each 2 cm apart, as well as rectal and anal pressure. RESULTS: A number of rectoanal motility patterns were observed. A total of 25 episodes with very localized cyclic rectal contractions detected at only one of five channels were observed lasting two to four minutes with a median frequency of three per minute (range, 2-6). A total of 44 episodes of cyclic rectal contractions propagating over two or more channels were detected lasting 2 to 36 minutes. Most were associated with contractions of the anal canal. A significant increase in rectal contractile activity was observed after the meal (P < 0.05). Single rectal contractions were observed in 11 subjects, and the majority were located to one channel and lasted less than 40 seconds. In two subjects who felt a need to defecate during the experiment, the cross-sectional area at all channels showed strong cyclic contractile activity and the anal pressure increased by approximately 100 percent. CONCLUSIONS: The new rectal impedance planimetry system allows highly detailed description of rectoanal motility patterns. It has promise as a new method for description of rectoanal motility in further studies. Udgivelsesdato: 2007-Nov

Adjuvant radiotherapy in the treatment of rectal cancer has been shown to increase long-term morbidity causing severe anorectal dysfunction with physiologic changes whose interaction remains poorly understood. This study examines long-term anorectal morbidity from adjuvant postoperative radiotherapy. In a prospective study, patients with Dukes B or C rectal carcinoma were randomized to postoperative radiotherapy or no adjuvant treatment after anterior resection. The long-term effect of radiotherapy on anorectal function in a subset of surviving patients was assessed from a questionnaire on subjective symptoms and from physiology laboratory evaluation and flexible sigmoidoscopy. Twelve of 15 patients (80 percent) treated with radiotherapy had increased bowel frequency compared with 3 of the 13 patients (23 percent) who did not have radiation therapy (P = 0.003). The former group had loose or liquid stool more often (60 vs. 23 percent, P = 0.05), had fecal incontinence more often (60 vs. 8 percent, P = 0.004), and wore pad more often (47 vs. 0 percent, P = 0.004). They also experienced fecal urgency and were unable to differentiate stool from gas more often. Endoscopy revealed a pale and atrophied mucosa and telangiectasias in the irradiated patients. Anorectal physiology showed a reduced rectal capacity (146 vs. 215 ml, P = 0.03) and maximum squeeze pressure (59 vs. 93 cm H2O, P = 0.003) in the radiotherapy group. Impedance planimetry demonstrated a reduced rectal distensibility in these patients (P < 0.0001). Adjuvant postoperative radiotherapy after anterior resection causes severe long-term anorectal dysfunction, which is mainly the result of a weakened, less sensitive anal sphincter and an undistensible rectum with reduced capacity.

PURPOSE: This study aimed to evaluate the colorectal luminal transport obtained by retrograde colonic washout with a new scintigraphic technique. METHODS: Nineteen patients (5 with spinal cord lesion, 6 with idiopathic fecal incontinence, and 8 with idiopathic constipation) treated with retrograde colonic washout took indium-111–labeled polystyrene pellets to label the bowel contents. Technetium-99m-diethylene-triamine-pentaacetic acid was mixed with the irrigation fluid to assess its extent within the colorectum. Scintigraphy was performed before and after a standardized washout procedure. The colorectum was divided into four segments: the cecum and ascending colon, the transverse colon, the descending colon, and the rectosigmoid. Assuming ordered evacuation of the colorectum, the contribution of each colonic segment to the total evacuation was expressed in percent of the original segmental counts. The contributions of each segment were summed to reach a total defecation score (range, 0–400), and directional segmental transports were estimated. RESULTS: The defecation score in patients with idiopathic constipation (median, 59; range, 21–130) differed significantly (P < 0.05) from the scores in those with spinal cord lesions (median, 204; range, 108–323) and idiopathic fecal incontinence (median, 188; range, 155–234). Thus, patients with spinal cord lesion or idiopathic fecal incontinence were able to empty most of the rectosigmoid and most of the descending colon, but those with idiopathic constipation could only empty 59 percent of the rectosigmoid. The irrigation fluid on average reached a point just beyond the right colic flexure that correlated with the defecation score (r2 = 0.58, P < 0.001). CONCLUSION: The effect of retrograde colonic washout was significantly better in spinal cord lesion and idiopathic fecal incontinence than in idiopathic constipation, and its effect correlated with the extent to which the irrigation fluid had entered the colorectum.

INTRODUCTION: Compliance is defined as the change in volume or cross-sectional area divided by the change in pressure. Pressure-volume measurement during distention with a compliant balloon is the most commonly used method for computation of rectal compliance. However, intraindividual and interindividual variations are large, restricting the usefulness of the method. Other methods such as rectal distention by a large, noncompliant bag and rectal impedance planimetry for assessment of pressure-cross-sectional-area relations have been proposed as alternatives owing to the reduction of errors from elongation of the balloon within the rectal lumen. However,in vivo reproducibility of pressure-volume measurement during distention with a compliant balloon, pressure-volume measurement during rectal distention by a large, noncompliant bag, and rectal impedance planimetry have never been compared. PURPOSE: The aim of this study was to comparein vivo reproducibility of the above-mentioned methods and to study theirin vitro reproducibility and validity. METHODS: Ten healthy volunteers (six men) aged 21–59 years were randomized to either rectal pressure-volume measurement with a compliant balloon or rectal impedance planimetry. After a one-hour rest, the other procedure was performed. After two weeks, both procedures were again performed in the same order. During rectal impedance planimetry the volume of the bag used (maximum volume 450 ml; secured at both ends to the probe) was continuously registered, measuring pressure-volume relations during rectal distention by a large, noncompliant bag. Reproducibility was tested by comparing the difference divided by the mean for each method at eight pressure steps in the range from 5 to 40 cm H2O. Furthermore, thein vitro reproducibility and validity of the three methods were studied using polyvinyl chloride tubes with known cross-sectional areas. RESULTS:In vivo reproducibility for pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was significantly better than for pressure-volume measurement with a compliant balloon (P=0.005 andP=0.019, respectively). No statistically significant difference was found between pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry (P=0.20).In vitro reproducibility of pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was good, but some elongation occurred, reducing the validity of pressure-volume measurement with a large, noncompliant bag. Coiling and elongation of the balloon within the lumen were major sources of error for pressure-volume measurement with a compliant balloon. CONCLUSION:In vivo andin vitro reproducibility of methods used for measurement of rectal compliance can be improved by restricting the effects of elongation within the lumen either by using a large-volume, noncompliant bag or by rectal impedance planimetry. However, pressure-volume measurement will to some degree depend on the properties of the balloons or bags.