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AimThis 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.MethodA Markov probabilistic model was used, comparing costs and effectiveness of SNM and conservative treatment in children and adolescents aged 10-18years 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 16years) with functional constipation refractory to conservative management. The mean duration of laxative use in this group was 5.9years. All patients had a test SNM, followed by a permanent SNM in 27/30. Median follow-up was 22.1months (range 12.2-36.8). The model was run to simulate a follow-up period of 3years.ResultsThe mean cumulative costs for the SNM group and the conservative treatment group were Euro17789 (SD Euro2492) and Euro7574 (SD Euro4332) 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 Euro12328 per QALY (SD Euro4788). Sensitivity analysis showed that the outcomes were robust to a wide range of model assumptions.ConclusionChronic 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.

Purpose Functional constipation in children and adolescents is a common and invalidating condition. In a minority of patients, symptoms persist despite optimal conservative therapy. The aim of this study was to evaluate whether the short-term effects of sacral neuromodulation (SNM) in children and adolescents with constipation are sustained over prolonged period of time. Methods Patients aged 10–20 years, with refractory constipation, fulfilling the Rome III criteria, were included in our study. If SNM test treatment showed >50 % improvement in defecation frequency, a permanent stimulator was implanted. Primary outcome measure was defecation frequency during 3 weeks. Secondary endpoints were abdominal pain and Wexner score. To assess sustainability of treatment effect, a survival analysis was performed. Cross-sectional quality of life was assessed using the EQ-5D VAS score. Results Thirty girls, mean age 16 (range 10–20), were included. The mean defecation frequency increased from 5.9 (SD 6.5) in 21 days at baseline to 17.4 (SD 11.6) after 3 weeks of test treatment (p

PURPOSE: Sacral neuromodulation (SNM) is an established treatment for fecal incontinence (FI). A recent study from our group found that the relationship between patient satisfaction and clinical outcome is complex and does not match the traditional used success criteria. Therefore, the ability to predict patient satisfaction must be given priority. The aim of the present study is to identify baseline factors predictive of patient satisfaction, with SNM, for idiopathic FI.METHODS: We analyzed data from patients treated with SNM for idiopathic FI in Aarhus, Denmark, and Maastricht, The Netherlands. A questionnaire considering self-reported satisfaction was mailed to these patients and compared to baseline characteristics. Logistic regression was used to determine the predictive value of baseline demographic and diagnostic variables.RESULTS: In total, 131 patients were included in the analysis. Patient satisfaction with the current treatment result was reported in 75 patients. Fifty-six patients were dissatisfied with SNM treatment, after median 46 months (range 11-122) with permanent implantation. Pudendal nerve terminal motor latency (PNTML) was the solely identified predictor for long-term patient satisfaction. A subgroup univariate-logistic regression analysis showed that PNTML ≤ 2.3 ms at the side of lead implantation was a statistically significant predictor for patient satisfaction (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.01-5.24, p = 0.048).CONCLUSION: Baseline PNTML measurement may be predictive of long-term satisfaction with SNM therapy for idiopathic FI. Further studies are needed to confirm this result.

Aims: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. Materials & methods: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. Results: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. Conclusion: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.

INTRODUCTION AND HYPOTHESIS: This study aims to assess the responsiveness and interpretability of the Vaizey score, Wexner score, and the Fecal Incontinence Quality of Life Scale (FIQL) for use in the evaluation of patients with fecal incontinence (FI). METHODS: Eighty patients with FI with a mean age of 59.3 (SD +/- 11.9) were enrolled in a randomized controlled trial. The patient-reported outcomes were tested for internal and external responsiveness, longitudinal construct validity, and interpretability. RESULTS: All total scores proved to have both adequate to excellent responsiveness and longitudinal construct validity, and changes were in agreement with subjective improvement. Due to variability in minimally important change estimates (Vaizey score -5 to -3, Wexner score -3 to -2, FIQL 1.1 to 1.2), they should be used as indicators. All patient-reported outcomes showed psychometric or practical limitations. CONCLUSIONS: The instruments available to date to evaluate severity and quality of life in FI do not yet attain the highest levels of psychometric soundness. As the focus of patients may differ from that of physicians, it is recommended that several measures should be included for evaluation. So far, there are suggestions that the Wexner score is most suitable for severity assessment and the FIQL for evaluating quality of life.

Background The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT. Methods Patients aged over 18 years with FI were included in a multicentre, single-blinded RCT. The primary endpoint was reduction in the median or mean number of FI episodes per week. Secondary endpoints were changes in measures of FI severity, and disease-specific and generic quality of life. Outcomes were compared between PTNS and sham stimulation after 9 weeks of treatment. Results A higher proportion of patients in the PTNS (13 of 29) than in the sham (6 of 30) group showed a reduction of at least 50 per cent in the median number of FI episodes/week (incidence rate ratio (IRR) 2·40, 95 per cent c.i. 1·10 to 5·24; P = 0·028), but not in the mean number of episodes/week (10 of 29 versus 8 of 30; IRR 1·42, 0·69 to 2·92; P = 0·347). The absolute median number of FI episodes per week decreased in the PTNS but not in the sham group (IRR 0·66, 0·44 to 0·98; P = 0·041), as did the mean number (IRR 0·65 (0·45 to 0·97); P = 0·034). Scores on the Cleveland Clinic Florida faecal incontinence scale decreased significantly in both groups, but more steeply in the PTNS group (mean difference –1·3, 95 per cent c.i. –2·6 to 0·0; P = 0·049). The aggregated mental component score of Short Form 36 improved in the PTNS but not in the sham group (mean difference 5·1, 0·5 to 9·6; P = 0·028). Conclusion PTNS may offer a small advantage in the clinical management of FI that is insufficiently responsive to conservative treatment. The key challenge will be to identify patients who may benefit most from this minimally invasive surgical procedure. Registration number: NCT00974909 (http://www.clinicaltrials.gov).

Aim Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost-effectiveness. This study aimed to analyse this and the quality-adjusted life-years (QALYs) associated with two different treatment algorithms. The first (SNM−) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms. Method A Markov model was developed. A hypothetical cohort of patients was run through both strategies of the model. A mailed EuroQoL-5D questionnaire was used to determine health-related quality of life. Costs were reproduced from the Maastricht University Medical Centre prospective faecal incontinence database. The time scale of the analysis was 5 years. Results The former treatment protocol cost €22 651 per patient and the latter, after the introduction of SNM, cost €16 473 per patient. The former treatment protocol resulted in a success rate of 0.59 after 5 years, whereas with the introduction of SNM this was 0.82. Adhering to the former treatment protocol yielded 4.14 QALYs and implementing the latter produced 4.21 QALYs. Conclusion The study demonstrated that introducing SNM in the surgical management algorithm for faecal incontinence was both more effective and less costly than DGP or ABS without SNM. This justifies adequate funding for SNM for patients with faecal incontinence.

Aim: The aim of this study was to evaluate prospectively transvaginal posterior colporrhaphy (TPC), combined with laparoscopic ventral mesh rectopexy (LVR), in patients with a symptomatic isolated rectocele. Method: Patients with these complaints underwent dynamic and static MRI. All consecutive patients with a grade III (4 or more cm) rectocele and without internal/external rectal prolapse, enterocele and external sphincter damage were operated on. The patients completed the Obstructed Defecation (ODS) Score system and the Cleveland clinic incontinence (CCIS) score. All tests were repeated after treatment. Dynamic disorders of the pelvic floor detected by MRI were recorded. Results: In 27 patients (median age 67 (46-73) years, TPC combined with LVR was feasible. Complications were limited to port site infection in two patients. Sexual discomfort due to prolapse diminished in six (75%) patients and in one (4%) de novo dyspareunia developed after treatment. The median follow up was 12 (10-18) months. The median CCIS was 12 (10-16) before treatment and 8 (7-10) after (p

AIM: This study is a prospective evaluation of patients with passive faecal incontinence and patients with soiling treated by elastomer implants and rectal irrigation. PATIENTS AND METHODS: Patients with passive faecal incontinence after birth trauma resulting from a defect of the internal sphincter and patients with soiling after previous anal surgery were included. All patients underwent endo-anal ultrasound, magnetic resonance imaging, and anal manometry. The patients with passive faecal incontinence were initially treated by anal sphincter exercises and biofeedback therapy during half a year. The patients completed incontinence scores, a quality of life questionnaire, and a 2-week diary card. RESULTS: The elastomer group consisted of 30 males and 45 females with a mean age of 53 years (25-77). The rectal irrigation group consisted of 32 males and 43 females with a mean age of 50 years (25-74). At 6 months follow-up, 30 patients with soiling of the rectal irrigation group and only nine patients of the elastomer group were completely cured (p = 0.02). Only three patients with passive faecal incontinence were cured in the rectal irrigation group and none in the elastomer group. Three distal migrations of elastomer implants required removal at follow-up. CONCLUSIONS: After patients had performed anal sphincter exercises, no clear improvement of passive faecal incontinence was obtained by elastomer implants or rectal irrigation. However, rectal irrigation is far more effective than elastomer implants in patients with soiling.

Aim Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence (FI) when conservative modalities have failed to restore continence. This two-centre study aimed to document functional outcome and its relationship to patient satisfaction. Method Patients treated with SNS for idiopathic FI in Aarhus (Denmark) and Maastricht (The Netherlands) were included. At the most recent follow-up appointment, 127 patients (80%) were identified as receiving active SNS therapy. A questionnaire considering bowel habits, quality of life, and self-reported satisfaction and a 3-week bowel-habit diary were mailed to these patients, and 85% responded. Results Patient satisfaction was clearly related to the number of FI episodes. Patients experiencing full continence were all satisfied, and although the satisfaction rate decreased as the number of FI episodes increased, 46% of the patients with more FI episodes at follow-up than at baseline were still satisfied. Per-protocol analysis resulted in a satisfaction rate of 57.3%. In total, 74.7% of the patients receiving active SNS therapy reported a reduction of ≥ 50% in FI episodes, 10.3% of whom were dissatisfied after a median of 46 months of follow-up. Conclusion There is a clear relationship between patient satisfaction and improved continence. A total of 57.3% of the patients offered SNS therapy were satisfied at follow-up. However, 46% of the patients with more FI episodes at follow-up than at baseline were also satisfied. Therefore, functional outcome of SNS therapy cannot be based only on bowel-habit diaries and bowel scores.

Aim: Sacral nerve modulation is a well accepted method for the treatment of defaecation disorders and voiding dysfunction. Results of sacral nerve modulation in patients with spinal cord lesions are not well assessed, but preliminary results look poor. Therefore, the purpose of this study was to assess the effectiveness of sacral nerve modulation for defaecation disorders and voiding dysfunction in patients with spina bifida. Method: Consecutive patients with spina bifida suffering from a myelomeningocele and combined faecal and urinary functional disorders that were eligible for peripheral nerve evaluation were studied. A permanent sacral nerve modulation implantation was performed after successful peripheral nerve evaluation (PNE). Results: Ten patients (four females) were included in this study with a median age of 26.4 (range 11.1-41.0) years. In two the PNE was not possible. The median faecal incontinence days (6.0 vs. 3.5) and episodes (8.5 vs. 3.5) per 21 days decreased significantly during the 3 week period of PNE (p=0.033). Only 3/10 (30%) patients had a more than 50% improvement and proceeded to a permanent sacral nerve modulation implantation. In one patient it was not possible to perform the permanent implant. Conclusions: Preliminary results of sacral nerve modulation in a subgroup of spina bifida patients with combined faecal and urinary functional disorders look promising, but long-term results in larger patient groups need to be studied.

Objectives: To determine whether sacral neuromodulation (SNM) for urinary symptoms or fecal incontinence gives improvement of female sexual function and whether improvement is due to physiological or psychological factors. Methods: Between 2002 and 2008, 8 patients had an array of questionnaires before and after SNM implantation. The questionnaires were: the Questionnaire for Screening for Sexual Dysfunctions, the Golombok Rust Inventory of Sexual Satisfaction, the Symptom Checklist-90, the Maudsley Marital Questionnaire and the McGill-Mah Orgasm Questionnaire. Three of these 8 patients underwent vaginal plethysmography before and after implantation. Results: No statistically significant changes were found, although there seems to be a trend toward improvement in orgasm scores. In plethysmography all 3 patients showed increased vaginal pulse amplitude with the stimulator turned on with both erotic and non-erotic stimuli. Conclusions: This study does not show a clear effect of SNM on sexual function, although there seems to be an improvement in orgasm scores. The lack of response on psychological questionnaires and the increase in vaginal pulse amplitude after SNM implantation indicate that there might be a physiological response.

Aims Fecal incontinence (FI) is embarrassing, resulting in poor quality of life. Rectal sensation may be more important than sphincter strength to relieve symptoms. A single-blind, randomized controlled trial among adults with FI compared the effectiveness of rectal balloon training (RBT) and pelvic floor muscle training (PFMT) versus PFMT alone. Methods We randomized 80 patients, recruited from the Maastricht University Medical Centre. Primary outcome was based on the Vaizey score. Secondary outcomes were the Fecal Incontinence Quality of Life Scale (FIQL), 9-point global perceived effect (GPE) score, anorectal manometry, rectal distension volumes, and thresholds of anorectal sensation. Analyses were by intention-to-treat. Results Forty patients were assigned to combined RBT with PFMT and 40 to PFMT alone. Adding RBT did not result in a significant improvement in the Vaizey score [mean difference: −1.19; 95% confidence interval (CI): −3.79 to 1.42; P = 0.37]. Secondary outcomes favoring RBT were: Lifestyle subscale of the FIQL (0.37; 95% CI: 0.02–0.73; P = 0.04), GPE (−1.01; 95% CI: −1.75 to −0.27; P = 0.008), maximum tolerable volume (49.35; 95% CI: 13.26–85.44; P = 0.009), and external anal sphincter fatigue (0.65; 95% CI: 0.26–1.04; P = 0.001). Overall, 50% of patients were considered improved according to the estimated minimally important change (Vaizey change ≥−5). Conclusions RBT with PFMT was equally effective as PFMT alone. Secondary outcomes show beneficial effects of RBT on urgency control, GPE, and lifestyle adaptations. Characteristics of patients who benefit most from RBT remain to be confirmed. Neurourol. Urodynam. 31:132–138, 2012. © 2011 Wiley Periodicals, Inc.

Aim Since 1994 sacral neuromodulation (SNM) has increasingly been used for the treatment of faecal incontinence, but no long-term data in a large group of patients have so far been published. We report long-term outcome and quality of life in the first 50 patients treated by permanent SNM for faecal incontinence. Method We began to use SNM in 2000. Data from the first 50 patients with faecal incontinence who underwent permanent SNM are presented. Efficacy was assessed using a bowel diary and the Quality of Life score was assessed by the Faecal Incontinence Quality of Life questionnaire (FIQOL) and the standard short form health survey questionnaire (SF-36). Results Over a median follow up of 7.1 (5.6–8.7) years, forty-two (84%) patients had an improvement in continence of over 50%. Median incontinent episodes and days of incontinence per week decreased significantly during follow up (P

Aim This review article aims to provide a brief update on the current data on and position of sacral neuromodulation (SNM) in the specialized management of refractory idiopathic constipation. Method Published evidence from PubMed and our own unpublished data on SNM treatment for refractory idiopathic constipation were used for this evaluation. Results Seven studies were found in PubMed that covered this topic. The main focus was on the most recently published multicentre nonrandomized European trial. Summary data from our unpublished study on constipation in children are also included. Conclusions The use of SNM in the treatment of idiopathic constipation is still in its early phase and while the available efficacy and safety data are limited, they show promising results. As there are few alternatives for this difficult patient group, it is worth offering a percutaneous nerve evaluation (PNE) test, which is known to be a good predictor of postimplant treatment success.

Aim The aim of this study was to explore autologous platelet-rich plasma as an adjunct to the staged mucosal advancement flap in the treatment of perianal fistulae. Method Between February 2006 and May 2007, 10 patients with fistula tracts transversing from the middle-third or upper part of the anal sphincter were treated for at least 3 months with noncutting setons prior to definitive closure by autologous platelet-rich plasma as an adjunct to a mucosal advancement flap. Five patients smoked tobacco. Results The study group consisted of six women and four men with a median age of 44 (range 30–75) years and a median follow up of 26 (range 17–32) months. One (10%) patient had a recurrent fistula. No new continence disorders developed after definitive treatment in both groups. Conclusion Platelet-rich plasma as an adjunct to a staged mucosal advancement flap for the treatment of perianal cryptoglandular fistulae is a promising treatment modality and seems to establish a high healing rate.

Aim Percutaneous tibial nerve stimulation (PTNS) is a minimal invasive treatment that can be performed in the outpatient clinic. This is a pilot study to investigate PTNS in the treatment of faecal incontinence. Method Percutaneous tibial nerve stimulation was performed by insertion of a needle electrode near the posterior tibial nerve. Patients were treated twice a week. Evaluation of faecal incontinence and quality of life was performed at baseline, 6 weeks, 3 months, 6 months and 1 year. Quality of life was estimated using SF-36 and FIQL questionnaires. Results A total of 22 patients were included. The mean age was 60.4 ± 11.7 years. After 6 weeks, 18 continued the treatment; 13 patients had a > 50% decrease in incontinence episodes. Overall incontinence episodes fell from 19.6 ± 21.0 at baseline to 9.9 ± 15.5 (P = 0.082) at 6 weeks and to 3.6 ± 4.8 (P = 0.029) at 1 year. Postponement time and quality of life increased significantly during follow up. Conclusion Percutaneous tibial nerve stimulation is simple and can be used in the outpatient setting. Good results can be obtained and sustained during maintenance treatment.

Objectives Sacral Nerve Modulation is a minimally invasive technique for the treatment of faecal incontinence. This study investigates the results of sacral nerve modulation after negative outcome of a standardized pelvic floor rehabilitation program for the treatment of faecal incontinence. Patients and methods A prospective cohort study was performed between December 2001 and August 2007. Consecutive patients who visited the outpatient department for faecal incontinence were included in a multicentre study and treated with standardized pelvic floor rehabilitation. Those with an unsuccessful result who were eligible for sacral nerve modulation were included in the present study. Failures at test stimulation or sacral nerve modulation received another treatment. Clinical outcome, Vaizey scores and quality of life (EQ-5D and HAQL) were assessed during follow-up in patients with sacral nerve modulation and in patients with other treatments. Adverse events were documented. Results Thirty-five patients (mean age 59.7 years; 31 females) were included. Twenty-one had a successful test stimulation and 19 patients proceeded to a sacral nerve modulation implant. Incontinence episodes per week decreased significantly from 11.1+/-11.7 to 1.9+/-2.6 during test stimulation (p

Background. Conflicting results are reported about the contribution of maternal, obstetric and fetal characteristics to postpartum fecal incontinence (FI), which is hampering prevention and management of FI. Objective. To perform a systematic review identifying delivery-related etiological factors for postpartum FI. Search strategy. Literature searches of PubMed, EMBASE, CINAHL, DocOnline and reference lists from 1980 up to 2009 were conducted. Selection criteria. Prospective cohort studies evaluating maternal, obstetric or fetal risk factors for postpartum FI, with a follow-up period of at least three months, were assessed. We reviewed full reports in English, German or Dutch, with anal incontinence (AI), FI, flatus incontinence, soiling, urgency and FI severity scores as reported outcomes. Data collection and analysis. Data on study characteristics, methodological quality and outcome were extracted from 31 studies according to a standardized protocol. Clinical and methodological sources of heterogeneity permitted only a qualitative analysis. Main results. A third- or fourth-degree sphincter rupture was the only etiological factor strongly (AI) or moderately (flatus incontinence) associated with postpartum FI. No association with other postulated risk factors was found, for example, birth weight or instrumental delivery. The potential co-existence of different risk factors impedes the interpretation of the influence of a single delivery-related risk factor. Conclusions. This systematic review, including only longitudinal studies and recognizing the importance of separating results for different outcomes, identifies that a third- or fourth-degree sphincter rupture is the only factor that is strongly (AI) or moderately (flatus incontinence) associated with postpartum FI.

blacksquare, square, filled Abstract Introduction: Treatment of functional anorectal pain disorders remains a challenge. The purpose of this study is to describe a single center experience with sacral neuromodulation for the treatment of chronic functional anorectal pain. Methods: This is a retrospective study based on prospectively collected data of patients treated with sacral neuromodulation for functional anorectal pain from April 2005 to August 2008. Symptoms were analyzed using a visual analog scale pain score (0 to 10). A 7-point Likert scale was used to rate global perceived effect. All patients had a percutaneous nerve evaluation and subsequent test stimulation to assess sacral neuromodulation outcome prior to permanent implantation. Patients were eligible for permanent sacral neuromodulation in case of a pain score 50% decrease in the pain score compared to baseline. Results: Nine patients (2 males) were included in this study. Mean age was 53.8 years (27.6 to 74.0). Four patients (1 male) had successful test stimulation and were eligible for permanent implantation. Median pain score decreased from 8.0 (6.0 to 9.0) to 1.0 (0 to 2.0). All patients experienced a lasting improvement during the follow-up till 24 months. Global perceived effect in successful patient was 1 (completely recovered) in one patient and 2 (much improved) in three patients. Conclusion: This study showed that sacral neuromodulation can be a successful treatment for functional anorectal pain not responding to other treatments. Improvement obtained during test stimulation is a good predictor (diagnostic) for sustained success of permanent sacral neuromodulation. blacksquare, square, filled.

Aim After implantation of a sacral nerve modulation (SNM) device for faecal incontinence (FI), patients are subjected to a rigid follow-up schedule. If symptoms recur, it may be necessary to reprogramme the stimulation parameters of the device. The aims of this study was to assess the need for reprogramming in patients with an SNM implant for FI. Method All patients who received a permanent SNM implant for FI from January 2000 to February 2008 were included in this study. Patients were subjected to a rigid follow-up schedule at 1, 3, 6 and 12 months, and yearly thereafter. Stimulator settings of the SNM device and changes made at every visit were collected and added to the database, and the number of patients in whom the stimulation parameter settings needed reprogramming was determined. Results A total of 155 patients (11 men) were analysed. The mean age (± standard deviation) of the patients was 57.7 ± 11.9 years. Median follow-up was 28.1 (range: 1.0–93.6) months. The mean voltage increased significantly from 1.8 V at 1 month to 2.0 V at 3 months. Thirty-nine (25.2%) patients required no reprogramming of their SNM implant during any of their follow-up visits; however, 51 (32.9%) patients required reprogramming at 1–25% of their visits, 42 (27.1%) patients at 26–50% of their visits, 14 (9.0%) patients at 51–75% of their visits and nine (5.8%) patients at 76–100% of their visits. Conclusion Physicians and patients need to be aware of the fact that reprogramming of the SNM stimulator needs to be carried out at least once during follow-up in the majority of patients. Trained physicians or specialist nurses are imperative to ensure effective follow-up and appropriate SNM reprogramming.

PURPOSE: A major advantage of sacral nerve modulation in the treatment of fecal incontinence is the ability to determine the likely treatment outcome before implantation by means of a percutaneous nerve evaluation and a test stimulation period. This study evaluated the predictive value of both sensory and motor responses during percutaneous nerve evaluation for determining the outcome of subchronic test stimulation and permanent stimulation. METHODS: All percutaneous nerve evaluation procedures performed between 2000 and 2007 were analyzed. Two hundred eight procedures (194 females; mean age, 56.7 years) were included in this study. Correct needle placement was confirmed by typical S-3 sensory and/or motor responses. The sensory and motor responses during the procedure were analyzed in relation to the outcomes of the test stimulation and permanent stimulation. RESULTS: In all, 72.6% of patients had a successful subchronic test stimulation. A total of 13.9% had no motor response. There was no significant difference in outcome between the group with only sensory responses and the group with both sensory and motor responses (P = 0.89; odds ratio, 1.01; 95% confidence interval, 0.42-2.43). Correlation with permanent implantation showed no significant difference between both groups in outcome (P = 0.53; odds ratio, 0.48; 95% confidence interval, 0.17-1.41). CONCLUSION: Positive motor responses during percutaneous nerve evaluation are highly predictive of a successful outcome of subchronic test stimulation and permanent sacral nerve modulation. Sensory responses also have the same predictive value. For this reason, percutaneous nerve evaluation preferably should be performed in awake patients under local anesthesia to avoid missing those who may benefit from permanent stimulation but who do not have a motor response during the procedure.

BACKGROUND AND AIMS: This study aims to evaluate the therapeutic effect of retrograde colonic irrigation in patients with faecal incontinence after a low anterior resection for a rectal carcinoma. MATERIALS AND METHODS: Patients with a previous low anterior resection, who were selected for treatment with retrograde colonic irrigation for faecal incontinence between 2005 and 2008, were included in the study. The data from the patients were gathered by chart research and an interview by phone. RESULTS: Thirty patients were included in the study. Three patients died and one patient was not able to answer questions due to a cognitive disorder. The data of the remaining 26 patients were analysed. Five patients had already stopped with the retrograde colonic irrigation treatment due to side effects. Twelve of the 21 patients (57.46%) who still performed RCI became completely (pseudo)continent, three patients (14.2%) were incontinent for flatus and six patients (29.4%) were still incontinent for liquid stool. Five patients stopped with the retrograde colonic irrigation treatment due to side-effects. CONCLUSION: Retrograde colonic irrigation is an effective method to treat patients with faecal incontinence after a low anterior resection for rectal carcinoma. Retrograde colonic irrigation is not invasive and has only mild side effects.

PURPOSE: This study was designed to evaluate recurrence and functional outcome of three surgical techniques for rectopexy: open (OR), laparoscopic (LR), and robot-assisted (RR). A case-control study was performed to study recurrence after the three operative techniques used for rectal procidentia. The secondary aim of this study was to examine the differences in functional results between the three techniques. MATERIALS AND METHODS: All consecutive patients who underwent a rectopexy between January 2000 and September 2006 enrolled in this study. Peri-operative data were collected from patient records and functional outcome was assessed by telephonic questionnaire. RESULTS: Eighty-two patients (71 females, mean age 56.4 years) underwent a rectopexy for rectal procidentia. Nine patients (11%) had a recurrence; one (2%) after OR, four (27%) after LR, and four (20%) after RR. RR showed significantly higher recurrence rates when controlled for age and follow-up time compared to OR, (p = 0.027), while LR showed near-significant higher rates (p = 0.059). Functional results improved in all three operation types, without a difference between them. CONCLUSIONS: LR and RR are adequate procedures but have a higher risk of recurrence. A RCT is needed assessing the definitive role of (robotic assistance in) laparoscopic surgery in rectopexy.

BACKGROUND AND AIMS: Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). MATERIALS AND METHODS: Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed. RESULTS: Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8-106.3) months. The Williams score improved significantly after placement of the ABS (p < 0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p = 0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p = 0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted. CONCLUSION: The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.

Fecal incontinence (fi) is a major healthcare problem that is particularly embarrassing and affects about 2 to 24% of the adult population. Apart from being a social burden to the patient, fi is also a major economic burden. Several diagnostic measures are available to assess the nature and severity of fi, although guidance for conservative or surgical therapy is not always obvious. Conservative treatment consists of dietary and pharmacological treatment, bowel management, use of products and appliances and physiotherapeutic interventions. Physiotherapy is often tried before surgical treatment because it is safe and inexpensive; it is also possible to employ other treatments after its use. Promising results of physiotherapy in fi have been published, although its effectiveness should be further elucidated. Surgical treatment aims at correcting the anal sphincters and pelvic floor, using encirclement procedures and sacral nerve stimulation. When the outcomes of both conservative and surgical treatment are unsatisfactory, colostomy is the only remaining solution.

Background Retrograde colonic irrigation is a possible treatment for defaecation disorders when conservative treatment or surgery has failed. The aim of this prospective study was to investigate its effectiveness. Methods Patients were divided into three groups: those with faecal incontinence (A), constipation (B) or both (C). The Biotrol® Irrimatic pump or the irrigation bag was used for colonic irrigation. Patients completed a questionnaire at baseline and after 3, 6 and 12 months, as well as a Short Form 36 health survey and an American Society of Colon and Rectal Surgery quality of life questionnaire at baseline and after 6 months. Results The study included 39 patients (26 women; mean age 58·0 years). In group A, 11 of 18 patients were pseudocontinent for faeces at 3 months (P < 0·001). Parks' incontinence scores decreased for all patients in this group at 3 months (P < 0·001), 6 months (P = 0·036) and 1 year (P = 0·005). In group B, three of ten patients reported a major improvement. The mean score for the feeling of incomplete evacuation decreased at 3 months (P = 0·007), 6 months (P = 0·013) and 1 year (P = 0·036). In group C, six of ten patients became pseudocontinent for faeces (P = 0·009) and three reported improvement in constipation. The overall quality of life scores improved (P = 0·012). Conclusion Retrograde colonic irrigation is an undervalued but effective alternative treatment for intractable defaecation disorders.

Objective Sacral nerve modulation (SNM) for the treatment of faecal incontinence was originally performed in patients with an intact anal sphincter or after repair of a sphincter defect. There is evidence that SNM can be performed in patients with faecal incontinence and an anal sphincter defect. Method Two groups of patients were analysed retrospectively to determine whether SNM is as effective in patients with faecal incontinence associated with an anal sphincter defect as in those with a morphologically intact anal sphincter following anal repair (AR). Patients in group A had had an AR resulting in an intact anal sphincter ring. Group B included patients with a sphincter defect which was not primarily repaired. Both groups underwent SNM. All patients had undergone a test stimulation percutaneous nerve evaluation (PNE) followed by a subchronic test over 3 weeks. If the PNE was successful, a permanent SNM electrode was implanted. Follow-up visits for the successfully permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter. Results Group A consisted of 20 (19 women) patients. Eighteen (90%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33% of the anal circumference. Fourteen (70%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. In both groups, the mean number of incontinence episodes decreased significantly with SNM (test vs baseline: P = 0.0001, P = 0.0002). There was no significant difference in resting and squeeze pressures during SNM in group A, but in group B squeeze pressure had increased significantly at 24 months. Comparison of patient characteristics and outcome between groups A and B revealed no statistical differences. Conclusion A morphologically intact anal sphincter is not a prerequisite for success in the treatment of faecal incontinence with SNM. An anal sphincter defect of

To evaluate the frequency and spectrum of lesions of different pelvic floor muscles at endoanal MRI in women with severe faecal incontinence and to study their relation with incontinence severity and manometric findings. In 105 women MRI examinations were evaluated for internal anal sphincter (IAS), external anal sphincter (EAS), puborectal muscle (PM) and levator ani (LA) lesions. The relative contribution of lesions to differences in incontinence severity and manometric findings was studied. IAS (n = 59) and EAS (n = 61) defects were more common than PM (n = 23) and LA (n = 26) defects. PM and LA defects presented mainly with IAS and/or EAS defects (isolated n = 2 and n = 3). EAS atrophy (n = 73) was more common than IAS (n = 19), PM (n = 16) and LA (n = 9) atrophy and presented mainly isolated. PM and LA atrophy presented primarily with EAS atrophy (isolated n = 3 and n = 1). Patients with IAS and EAS lesions had a lower resting and squeeze pressure, respectively; no other associations were found. PM and LA lesions are relatively common in patients with severe faecal incontinence, but the majority of lesions are found in women who also have IAS and/or EAS lesions. Only an association between anal sphincter lesions and manometry was observed.

AB - BACKGROUND AND AIMS: Dynamic graciloplasty (DGP) improves anal continence and quality of life for most patients. However, in some patients, DGP fails and fecal incontinence is unsolved or only partially improved. Constipation is also a significant problem after DGP, occurring in 13-90%. Colonic irrigation can be considered as an additional or salvage treatment for defecation disorders after unsuccessful or partially successful DGP. In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP is investigated. MATERIALS AND METHODS: Patients with defecation disorders after DGP visiting the outpatient clinic of the University Hospital Maastricht were selected for colonic irrigation as additional therapy or salvage therapy in the period between January 1999 and June 2003. The Biotrol(R) Irrimatic pump or the irrigation bag was used for colonic irrigation. Relevant physical and medical history was collected. The patients were asked to fill out a detailed questionnaire about colonic irrigation. RESULTS: Forty-six patients were included in the study with a mean age of 59.3 +/- 12.4 years (80% female). On average, the patients started the irrigation 21.39 +/- 38.77 months after the DGP. Eight patients started irrigation before the DGP. Fifty-two percent of the patients used the irrigation as additional therapy for fecal incontinence, 24% for constipation, and 24% for both. Irrigation was usually performed in the morning. The mean frequency of irrigation was 0.90 +/- 0.40 times per day. The mean amount of water used for the irrigation was 2.27 +/- 1.75 l with a mean duration of 39 +/- 23 min. Four patients performed antegrade irrigation through a colostomy or appendicostomy, with good results. Overall, 81% of the patients were satisfied with the irrigation. Thirty-seven percent of the patients with fecal incontinence reached (pseudo-)continence, and in 30% of the patients, the constipation completely resolved. Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation, abdominal cramps, and distended abdomen. Seven (16%) patients stopped the rectal irrigation. CONCLUSION: Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP

Purpose: Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies. Methods: A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings. Results: Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (p < 0.001). A Vaizey score reduction of ≥ 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; p = 0.04) and maximal tolerated volume (+11 ml; p = 0.01) improved from baseline. Resting pressure (p = 0.22), sensory threshold (p = 0.52), and urge sensation (p = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups. Conclusions: Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

Objective Faecal incontinence (FI) is a socially devastating problem. Sacral nerve modulation (SNM) has proven its place in the treatment of patients with FI. In this study, the first 100 definitive SNM implants in a single centre have been evaluated prospectively. Method Patients treated between March 2000 and May 2005 were included. Faecal incontinence was defined as at least one episode of involuntary faecal loss per week confirmed by a 3-week bowel habit diary. Patients were eligible for implantation of a permanent SNM when showing at least a 50% reduction in incontinence episodes or days during ambulatory test stimulation. Preoperative workup consisted of an X-defaecography, pudendal nerve terminal motor latency measurement, endo-anal ultrasound and anal manometry. The follow-up visits for the permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter. The bowel habit diary and anal manometry were repeated postoperatively during the follow-up visits. Results A total of 134 patients were included and received a subchronic test stimulation. One hundred patients (74.6%) had a positive test stimulation and received a definitive SNM implantation. The permanent implantation group consisted of 89 women and 11 men. The mean age was 55 years (range 26–75). The mean follow-up was 25.5 months (range 2.5–63.2). The mean number of incontinence episodes decreased significantly during the test stimulation (baseline, 31.3; test, 4.4; P

OBJECTIVE: External anal sphincter atrophy seen at endoanal MRI may predict poor outcome of surgical anal sphincter repair for an external anal sphincter defect. The purposes of this study were to compare external phased-array MRI to endoanal MRI for depicting external anal sphincter atrophy in patients with fecal incontinence and to evaluate observer reproducibility in detecting external anal sphincter atrophy with these techniques. SUBJECTS AND METHODS: Thirty patients with fecal incontinence (23 women, seven men; mean age, 58.7 years; age range, 37-78 years) underwent both endoanal and external phased-array MRI. Images were evaluated for external anal sphincter atrophy by three radiologists. Measures of differences and agreement between both MRI techniques and of interobserver and intraobserver agreement of both techniques were calculated. RESULTS: The MRI techniques did not significantly differ in their ability to depict external anal sphincter atrophy (p = 0.63) with good agreement (kappa = 0.72). Interobserver agreement was moderate (kappa = 0.53-0.56) for endoanal MRI and moderate to good (kappa = 0.55-0.8) for external phased-array MRI. Intraobserver agreement was moderate to very good (kappa = 0.57-0.86) for endoanal MRI and fair to very good (kappa = 0.31-0.86) for external phased-array MRI. CONCLUSION: External phased-array MRI is comparable to endoanal MRI in depicting external anal sphincter atrophy and, thereby, in selecting patients for anal sphincter repair. Because results among interpreters varied considerably depending on the experience level, both techniques can be recommended in the diagnostic workup of fecal incontinence only if sufficient experience is available.

PURPOSE: To prospectively compare external phased-array magnetic resonance (MR) imaging with endoanal MR imaging in depicting external and internal anal sphincter defects in patients with fecal incontinence and to prospectively evaluate observer reproducibility in the detection of external and internal anal sphincter defects with both MR imaging techniques. MATERIALS AND METHODS: The medical ethics committees of both participating hospitals approved the study, and informed consent was obtained. Thirty patients (23 women, seven men; mean age, 58.7 years; range, 37-78 years) with fecal incontinence underwent MR imaging with both endoanal and external phased-array coils. MR images were evaluated by three radiologists with different levels of experience for external and internal anal sphincter defects. Measures of inter- and intraobserver agreement of both MR imaging techniques and of differences between both imaging techniques were calculated. RESULTS: Both MR imaging techniques did not significantly differ in the depiction of external (P > .99) and internal (P > .99) anal sphincter defects. The techniques corresponded in 25 (83%) of 30 patients for the depiction of external anal sphincter defects and in 28 (93%) of 30 patients for the depiction of internal anal sphincter defects. Interobserver agreement was moderate to good for endoanal MR imaging and poor to fair for external phased-array MR imaging. Intraobserver agreement ranged from fair to very good for both imaging techniques. CONCLUSION: External phased-array MR imaging is comparable to endoanal MR imaging in the depiction of clinically relevant anal sphincter defects. Because of the weak interobserver agreement, both MR imaging techniques can be recommended in the diagnostic work-up of fecal incontinence only if sufficient experience is available.

Background Sacral neuromodulation (SNM) is a new treatment for faecal incontinence. At present the exact underlying mechanism is still unclear. Modulation of the sacral reflex arcs might have an effect on rectal sensitivity, wall tension and compliance. Methods Fifteen consecutive patients with faecal incontinence who qualified for SNM underwent barostat measurements before and during neuromodulation. An ‘infinitely’ compliant plastic bag with a volume of 600 ml was placed in the rectum and connected to a computer-controlled barostat system. An isobaric phasic distension protocol was used. Patients were asked to report rectal filling sensations: first sensation (FS), earliest urge to defaecate (EUD) and an irresistible, painful urge to defaecate (maximum tolerated volume; MTV). Rectal wall tension and compliance were calculated. Results During isobaric phasic distension each patient experienced all rectal filling sensations at the time of stimulation. Median volume thresholds decreased significantly during stimulation, from 98·1 to 44·2 ml for FS (P = 0·003), from 132·3 to 82·8 ml for EUD (P = 0·001) and from 205·8 to 162·8 ml for MTV (P = 0·002). Pressure thresholds tended to be lower for all filling sensations, but only that to evoke MTV was reduced significantly by stimulation (37·3 versus 30·3 mmHg; P = 0·005). Median rectal wall tension for all filling sensations decreased significantly with stimulation. There was no significant difference between compliance before and during stimulation. Conclusion SNM affects rectal sensory perception, but further research is required to clarify the mechanism.

PURPOSE: This study was designed to assess the healing rate of complex perianal fistulas in Crohn's disease after a multistep strategy, including induction treatment with Infliximab in case of active proctitis, followed by definitive surgery. METHODS: From 2000 to 2003, all consecutive patients with complex fistulas and Crohn's disease underwent pretreatment with noncutting setons and, in case of severe recurrent fistulas or abscesses, a diverting stoma. Infliximab was added in cases of active proctitis. After definitive surgical treatment, patients were examined. RESULTS: Seventeen patients were included (median age, 34 (range, 22-58) years). Seven patients were treated by surgery only, and in ten patients Infliximab was added. After a median follow-up of 19 (range, 8-40) months, fistula healing was observed in 17 patients (100 percent). One patient of the Infliximab group developed a recurrent fistula (10 percent) after 24 months, and in one patient (10 percent) soiling occurred. Two patients of the surgical group developed a recurrent fistula (29 percent) and soiling occurred in two patients (29 percent). CONCLUSIONS: A multistep strategy followed by definitive surgery for the treatment of complex perianal fistulas in patients with Crohn's disease is a promising treatment modality. The preliminary results of this study suggest that Infliximab treatment has a beneficial additive effect in the multistep treatment followed by definitive surgery of complex anal fistulas and active proctitis in Crohn's disease.

Background This study examined the use of sacral nerve stimulation (SNS) to treat faecal incontinence in patients with partial spinal injury. Methods Patients selected for SNS had experienced more than one episode of faecal incontinence per week to liquid or solid stool for more than 1 year and had failed maximal conservative treatment. All patients had an intact external anal sphincter. Results Temporary SNS was performed in 13 patients (median age 58·5 (range 39–73) years). The spinal insults were disc prolapse (six), trauma (four), spinal stenosis (one) or occurred during neurosurgery (two). Twelve patients (eight women and four men) had successful temporary stimulation and proceeded to permanent implantation. The median follow-up time was 12 (range 6–24) months. The mean(s.d.) number of episodes of incontinence decreased from 9·33(7·64) per week at baseline to 2·39(3·69) at last follow-up (P = 0·012). The number of days per week with incontinence and staining decreased significantly (both P < 0·001). Ability to defer defaecation improved from a median of not being able to defer (range 0–1 min) to being able to defer for 5–15 (range 0 to over 15) min (P = 0·022). Conclusion SNS can benefit patients with faecal incontinence following partial spinal injury.

Background The aim of the study was to determine the therapeutic stimulation threshold in patients with successful sacral nerve modulation for faecal incontinence. Methods Patients who had undergone successful permanent sacral nerve modulator implantation and had been followed up for a minimum of 3 months were included. The sensitivity threshold and motor threshold were determined and correlated with therapeutic response. Patients went home with the stimulator set at 0·6 V below the sensitivity threshold. Each week the voltage was increased by 0·2 V until the sensitivity threshold was reached. The effects on anorectal physiology and continence were recorded. Results Eight patients (seven women) with a median age of 58·5 years were included. The median follow-up was 6·3 months. The median sensibility threshold volume of rectal sensation was 50 ml, the median urge threshold volume was 140 ml and the median maximum tolerated rectal volume 240 ml. The median number of incontinence episodes and days per week affected by incontinence decreased from 5·0 and 3·8 before operation to 0·7 and 0·7 respectively after follow-up for 3 months. At anorectal manometry the median resting and stimulation anal canal pressures were 57 and 85 mmHg respectively, and remained constant over time. The therapeutic response threshold was significantly lower than the sensitivity threshold (median 1·6 versus 1·7 V; P = 0·042). The median motor threshold was 2·1 V, significantly higher than the sensitivity threshold (P = 0·009). The stimulation threshold for suboptimal therapeutic response was 1·4 V. In five of the eight patients the therapeutic response threshold was the same as the sensitivity threshold. Conclusion Sacral nerve modulation can produce a therapeutic effect below the sensitivity threshold. A lower stimulation voltage increases the lifespan of the pulse generator.

Dynamic graciloplasty in patients born with an anorectal malformation.Koch SM, Uludag O, Rongen MJ, Baeten CG, van Gemert W.Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.PURPOSE: The aim of this study was to compare long-term results for patients born with an anorectal malformation and fecal incontinence treated with a dynamic graciloplasty with those for the total group of patients undergoing dynamic graciloplasty. METHODS: Consecutive patients with fecal incontinence after surgical treatment of anorectal malformation and treated with dynamic graciloplasty were included in this study. Preoperative assessment was performed. Postoperative follow-up consisted of anorectal manometry and registration of defecation frequency, continence scores, and postponement time of defecation. RESULTS: Twenty-eight patients with a median age of 25.5 years were included in the study. The median follow-up was 4 years. A high anorectal malformation was present in 89.3 percent of patients. Conventional graciloplasty had been previously performed in 36 percent. All patients were incontinent for stools. Median frequency of defecation was four times/day. Median postponement time of defecation was 0 minutes. Rectoanal inhibition reflex was present in 17 percent of patients. Median preoperative sensory threshold during balloon distention was 30 ml and median maximum urge threshold was 165 ml. Satisfactory continence was reached in 35 percent of patients, however, 7.1 percent of patients gained this continence score by additional bowel irrigation. Twenty-nine percent of patients were incontinent for loose stool, 36 percent were incontinent for formed stool. Satisfactory continence was achieved in only 18 percent of patients with a high anorectal malformation, compared with 100 percent in patients with a low anorectal malformation. In the total group of patients with dynamic graciloplasty, satisfactory continence was obtained in 76 percent. The sensitivity threshold in patients with a successful dynamic graciloplasty was lower than that in patients with a failing dynamic graciloplasty (45 vs. 24 ml, P = 0,06). When we compare median preoperative rectal sensitivity threshold in our study group with that in the total patient group with dynamic graciloplasty, statistical difference was established (P = 0.008). Postponement time (0 to 20 minutes) and anal squeeze pressure (81 to 120 mmHg) increased significantly after surgery. Patients with an anorectal malformation had significantly lower resting and stimulation pressure than that of the total group of patients, but the difference between resting and stimulation pressure in both groups was not significantly different (P = 0.33). The difference between resting and stimulation pressure was not significantly different between anorectal malformation patients with a failing dynamic graciloplasty and patients with a successful dynamic graciloplasty. Complications were noted in 57 percent of patients. Explantation of the dynamic graciloplasty was necessary in 32 percent of patients, mainly because of infection of the implant. CONCLUSIONS: Results of dynamic graciloplasty for fecal incontinence are reasonable for this specific group of patients with limited treatment options. Despite functional dynamic graciloplasty, the results are worse than those for the total group of patients with dynamic graciloplasty. Rectal sensitivity and type of malformation are prognostic factors for outcome and can be used to select patients for treatment with dynamic graciloplasty, thereby improving treatment outcome.

Sacral neuromodulation in patients with fecal incontinence: a single-center study.Uludag O, Koch SM, van Gemert WG, Dejong CH, Baeten CG.Department of Colorectal Surgery, University Hospital Maastricht, Maastricht, The Netherlands.PURPOSE: Fecal incontinence is a psychologically devastating and socially incapacitating condition. Conventional treatment is likely to improve continence in many patients; however, there remains a group with persisting symptoms who are not amenable for a simple surgical repair. We evaluated the effect of sacral neuromodulation in patients with structurally intact sphincters after failure of conventional treatment. METHODS: Patients aged 18 to 75 years were evaluated. Incontinence was defined as involuntary loss of stool at least once per week, which was objectified by completion of a three-week bowel-habits diary during ambulatory electrode stimulation at the S3 or S4 foramen. Patients were qualified for permanent stimulation when showing a reduction of at least 50 percent in incontinence episodes or days. RESULTS: Seventy-five patients (66 females; mean age, 52 (range, 26-75) years) were treated. Three patients had partial spinal cord injury, two patients a previous low-anterior resection, and nine patients had a previous sphincter repair. Evaluation after trial screening showed that 62 patients (83 percent) had improved continence. Median incontinence episodes per week decreased from 7.5 to 0.67 (P < 0.01), median incontinence days per week from 4 to 0.5 (P < 0.01). The symptomatic response stayed unchanged after implantation of a permanent electrode and pacemaker in 50 patients. After a median follow-up of 12 months, this effect could be sustained in 48 patients. Anal manometry during stimulation showed no increase of sphincter pressures. CONCLUSIONS: Sacral neuromodulation is a feasible treatment option for fecal incontinence in patients with structurally intact sphincters.

Sacral spinal nerve stimulation for faecal incontinence: multicentre study.Matzel KE, Kamm MA, Stosser M, Baeten CG, Christiansen J, Madoff R, Mellgren A, Nicholls RJ, Rius J, Rosen H.Department of General Surgery, University Hospital Erlangen, Erlangen, Germany. Klaus.Matzel@chir.imed.uni-erlangen.deBACKGROUND: In patients with faecal incontinence in whom conservative treatment fails, options are limited for those with a functionally deficient but morphologically intact sphincter. We investigated the effect of sacral nerve stimulation on continence and quality of life. METHODS: In this multicentre prospective trial, 37 patients underwent a test stimulation period, followed by implantation of a neurostimulator for chronic stimulation in 34. Effect on continence was assessed by daily bowel-habit diaries over a 3-week period and on quality of life by the disease-specific American Society of Colon and Rectal Surgeons (ASCRS) questionnaire and the standard short form health survey questionnaire (SF-36). Every patient served as his or her own control. FINDINGS: Frequency of incontinent episodes per week fell (mean 16.4 vs 3.1 and 2.0 at 12 and 24 months; p

[Anal sphincter replacement][Article in German]Baeten CG.Department of Surgery, Academic Hospital, Maastricht, Netherlands. c.baeten@surgery.azm.nlPresently, deep rectal carcinoma is usually treated by deep anterior rectal resection and colonal anastomosis. Abdominoperineal resection is needed only for the very few patients whose tumors infiltrate the pelvic base or sphincter musculature. This means the loss of normal anal function and thus of normal defecation. Many patients find the idea of a stoma unacceptable. In our experience, the construction of a functional neoanus after abdominoperineal rectal resection is a suitable option for patients in good general health and who are highly motivated.

Long-term follow-up of dynamic graciloplasty for fecal incontinence.Rongen MJ, Uludag O, El Naggar K, Geerdes BP, Konsten J, Baeten CG.Department of Surgery, University Hospital Maastricht, the Netherlands.PURPOSE: Graciloplasty has been used as a treatment for end-stage fecal incontinence since 1946. Electric stimulation with an implantable pulse generator has existed for 15 years. The gracilis muscle is wrapped around the anal canal and stimulated by intramuscular electrodes connected with an implantable pulse generator. Initial reports have been promising, but long-term results have not been presented to date. METHODS: Data of 200 consecutive patients with a follow-up of at least two years were analyzed in a prospective manner from 1986 until 1999. RESULTS: The overall success rate was 72 percent. In patients with fecal incontinence caused by trauma, the rate was 82 percent. Once continent, patients remained continent after a median follow-up of 261 (standard deviation, 132) weeks. Median survival of the implantable pulse generator until battery expiration was 405 weeks. Disturbed evacuation remained a problem in 16 percent of all patients. Complications were frequent but treatable. CONCLUSION: Dynamic graciloplasty is a good, cost-effective treatment for fecal incontinence with results lasting for a median of more than five years.

Since the 1990s, one of the methods used for treating fecal incontinence due to internal anal sphincter defects has been the injection of bulking agents. The aim of this paper is to report two cases of local giant cell foreign body reaction after injection of PTQ(TM) in humans. To the best of the authors' knowledge, this is the first report of an adverse immune response to silicone injection in humans.

Second-line treatment for faecal incontinence.Baeten CG, Uludag O.Dept. of Surgery, Academic Hospital Maastricht, The Netherlands.BACKGROUND: In the treatment of faecal incontinence, more than 30% of patients experience continuation of their problem. We discuss new therapeutic procedures for dealing with faecal incontinence. METHODS: Discussion of authors' own work in relation to the literature. RESULTS: First-line care includes diets, constipating drugs, biofeedback therapy, anal repair and operations for prolapse and fistulas. For the failures of these first-line treatments there is hope with second-line therapies. Creation of a neosphincter is possible with a dynamic graciloplasty (DGP) or an artificial bowel sphincter (ABS). A DGP is a conventional graciloplasty with the addition of implanted electrodes and a stimulator that transforms the muscle into an automatic contracting sphincter. ABS comprises an inflatable cuff around the anus that is filled from a pressure-regulating balloon. The cuff can be emptied with an implanted pump. CONCLUSIONS: DGP and ABS give good results in 56%-88% of cases. For patients with an anatomical intact but nonfunctioning sphincter there is a new treatment: sacral nerve stimulation. This gives continence in a high percentage of cases, but experience is rather limited. Second-line treatment for faecal incontinence is successful and should be considered in cases where initial therapies fail.

BACKGROUND: A rectovaginal fistula (RVF) is a debilitating condition that is difficult to treat. Many available techniques are invasive and involve extensive surgery. A local procedure with good closure rates would be preferable as a first step in the treatment of RVF. The aim of this study was the development of a local technique for the closure of RVF with good closure rates to prevent the use of more invasive procedures. METHODS: This was a pilot study. Patients with RVF who had undergone multiple operations in the pelvic area, local radiotherapy, chemotherapy or had been diagnosed with Crohn's disease were included in the study. All had a history of surgery for RVF. A cross-linked collagen matrix biomesh was placed in the rectovaginal septum using a transperineal or a transvaginal approach. The main outcome measure in this study was the closure rate reported as absence of the fistula at 1 year. RESULTS: Twelve patients were included in the study. Absence of fistula at 1 year was 0.64 (95 % confidence interval 0.30-0.85). Three patients (25.0 %) developed a recurrence, two were reoperated on with a gracilis flap transposition, and one was treated with laparoscopic ligation. In one patient (8.3 %), the fistula failed to close within 3 months after the mesh placement. CONCLUSIONS: Our technique shows promising results. A local and simple technique with acceptable closure and morbidity rates, like our local repair with biomesh, would be ideal as a first step in treating RVFs. Long-term results are needed.

A surgical site infection (SSI) is a serious and costly complication with the highest rates being reported after gastrointestinal surgery. The objective of this cross sectional study was to assess the incidence and risk factors of SSI after gastrointestinal surgery during and after hospitalization, and to evaluate the effect of the VMS (Dutch: “VeiligheidsManagementSysteem”) safety programme on the SSI rate. We assessed the SSI rate from July 2008 until December 2011, according to the criteria of the Centres for Disease Control and Prevention (CDC), before and after implementation of the VMS safety programme which includes a bundle of four interventions. We differentiated between the SSI rate during and after hospitalization and between superficial, deep and organ/ space infections. The incidence of SSI in relation to the wound class, risk factors for SSI, and the compliance with the programme were assessed. Data were obtained during a thirty-day follow-up period after surgery. Surveillance after discharge significantly increased the overall SSI rate. Age higher than fifty years and contaminated or dirty wounds were risk factors for SSIs. Despite increased compliance with the safety programme, no significant decrease in SSI rate was found after implementation. The Dutch VMS safety programme did not show a significant effect on the decrease in incidence of SSI. Surveillance during and after hospitalization is essential for a reliable assessment of the SSI rate.

Measurement of anal sphincter muscles: endoanal US, endoanal MR imaging, or phased-array MR imaging? A study with healthy volunteers.Beets-Tan RG, Morren GL, Beets GL, Kessels AG, el Naggar K, Lemaire E, Baeten CG, van Engelshoven JM.Department of Radiology, University Hospital of Maastricht, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands. rbe@rdia.azm.nlPURPOSE: To compare endoanal ultrasonography (US), endoanal magnetic resonance (MR) imaging, and phased-array MR imaging for anal sphincter muscle measurement. MATERIALS AND METHODS: Sixty healthy volunteers underwent 1.5-T phased-array MR, endoanal MR, and endoanal US examinations. Sphincter muscle thicknesses were measured. Measurement reliability was analyzed, and correlations among the imaging methods were calculated. Multivariate analysis was performed to assess the influence of age, weight, height, sex, parity, and obstetric trauma on sphincter dimensions. RESULTS: Both MR methods had good reliability for measurements of all sphincter components, whereas endoanal US was reliable for internal sphincter measurement only. There was little correlation between the techniques, except between the two MR techniques, with a strong correlation for total sphincter and perineal body thickness. The internal sphincter thickened significantly (P =.002) with age at endoanal US and endoanal MR imaging but not at phased-array MR imaging. There were small sex-based differences in sphincter muscle measurements at phased-array MR imaging only. CONCLUSION: Endoanal US enables reliable measurement of only internal sphincter thickness, whereas both MR imaging methods enable reliable measurement of all sphincter components. Sphincter measurement with phased-array MR imaging is as reliable as that with endoanal MR imaging