Sacral Nerve Stimulation Can Be Successful in Patients With Ultrasound Evidence of External Anal Sphincter Disruption

PURPOSE This study was designed to determine whether patients with fecal incontinence and endoanal ultrasound evidence of anal sphincter disruption may be successfully treated by sacral nerve stimulation.METHODS Five consecutive females with incontinence to solids and endoanal ultrasound evidence of anal sphincter disruption were treated by a two-week trial of sacral nerve stimulation. If successful, patients then proceeded to permanent sacral nerve stimulation implantation.RESULTS Five patients, aged 34 to 56 years, were treated by temporary sacral nerve stimulation. Four had symptoms starting after childbirth. Two had previously had an anterior sphincter repair. After a two-week trial, three females reported full continence and an improvement in all aspects of their Rockwood fecal incontinence quality of life scores. These three females underwent permanent sacral nerve stimulation implantation. The remaining two patients reported no improvement and underwent dynamic graciloplasty or end colostomy respectively.CONCLUSIONS Sacral nerve stimulation may successfully restore bowel continence in some patients with endoanal ultrasound evidence of a defect in their external anal sphincter.     

Sacral Nerve Stimulation for Fecal Incontinence Related to Obstetric Anal Sphincter Damage

Purpose Sphincter repair is the standard treatment for fecal incontinence secondary to obstetric external anal sphincter damage; however, the results of this treatment deteriorate over time. Sacral nerve stimulation has become an established therapy for fecal incontinence in patients with intact sphincter muscles. This study investigated its efficacy as a treatment for patients with obstetric-related incontinence. Methods Fecally incontinent patients with external sphincter defects who would normally have undergone overlapping sphincter repair as a primary or repeat procedure were included. Eight consecutive women (median age, 46 (range, 35–67) years) completed temporary screening; all eventually had permanent implantation. Results Six of eight patients had improved continence at median follow-up of 26.5 (range, 6–40) months. Fecal incontinent episodes improved from 5.5 (range, 4.5–18) to 1.5 (range, 0–5.5) episodes per week (P = 0.0078). Urgency improved in five patients, with ability to defer defecation improving from a median of <1 (range, 0–5) minute to 1 to 5 (range, 1 to >15) minutes (P = 0.031, all 8 patients). There was no change in anal manometry or rectal sensation. There was significant improvement in lifestyle, coping/behavior, depression/self-perception, and embarrassment as measured by the American Society of Colon and Rectal Surgery fecal incontinence quality of life score. Conclusions Sacral nerve stimulation is potentially a safe and effective minimally invasive treatment for fecal incontinence in patients with de novo external anal sphincter defects or defects after unsuccessful previous external anal sphincter repair, although numbers remain small. Dr. Michael Kamm is a consultant to and received research support from Medtronic, however, study design, performance, analysis, and reporting have been conducted without the influence of Medtronic.     

Innovations in Fecal Incontinence: Sacral Nerve Stimulation

OBJECTIVE The aim of this study was to present an overview of sacral nerve stimulation in the treatment of fecal incontinence. We describe the evolution in technique, patient selection, and indications, and review results and complications.METHODS All articles on sacral nerve stimulation for fecal incontinence that were recovered on MEDLINE search were reviewed. With multiple articles from an institution, the most recent reports with the longest follow-up and largest cohort of patients were selected, unless information from earlier reports was relevant.RESULTS The technique of sacral stimulation is well established, carries little risk, and continues to be refined (e.g., a less invasive approach has been proposed). Patient selection is based on a two-stage diagnostic test stimulation (acute and subchronic), for which the predictive value is high. On this basis, permanent sacral nerve stimulation has proved effective in both single-center and multicenter trials in patients with a functional deficit but limited morphologic lesions or no morphologic lesions. The clinical benefit derives from multiple symptomatic improvements contributing to better bowel control and from substantially improved quality of life. The underlying mechanism of action remains undefined, but both somatic and autonomic function appears affected.CONCLUSION Sacral nerve stimulation offers a safe treatment mode in a patient population in whom conservative treatment has failed and traditional surgical approaches would have limited success. The high predictive value of the diagnostic approach offers a unique therapeutic advantage.Presented in part at the International Colorectal Disease Symposium, Fort Lauderdale, Florida, February 13 to 15, 2003.     

Sacral Nerve Stimulation in Fecal Incontinence

PURPOSE: The effect of sacral nerve stimulation was studied in 45 patients with fecal incontinence.METHODS: All patients were initially tested in general anesthesia. Sacral nerves 2, 3, and 4 were tested on both sides. If a perineal/perianal muscular response to sacral nerve stimulation could be obtained, electrodes were implanted for a three-week test-stimulation period. If sacral nerve stimulation resulted in at least a 50 percent reduction in incontinence episodes during the test period, a system for permanent sacral nerve stimulation was implanted.RESULTS: When tested in general anesthesia, 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period. Percutaneous electrodes were used in 34 patients, and 23 of these had at least a 50 percent reduction in incontinence episodes, whereas the electrodes dislocated in 7 patients and 4 had a poor response. Permanent electrodes with percutaneous extension electrodes were used primarily in 9 patients and after dislocation of percutaneous electrodes in an additional 6 patients; 14 of these had a good result. In the last patient, no clinical response to stimulation with the permanent electrode could be obtained. A permanent stimulation system was implanted in 37 patients. After a median of six (range, 0–36) months follow-up, five patients had the system explanted: three because the clinical response faded out, and two because of infection. Incontinence score (Wexner, 0–20) for the 37 patients with a permanent system for sacral nerve stimulation was reduced from median 16 (range, 9–20) before sacral nerve stimulation to median 6 (range, 0–20) at latest follow-up (P < 0.0001). There was no differences in effect of sacral nerve stimulation in patients with idiopathic incontinence (n = 19) compared with spinal etiology (n = 8) or obstetric cause of incontinence (n = 5). Sacral nerve stimulation did not influence anal pressures or rectal volume tolerability.CONCLUSIONS: Sacral nerve stimulation in fecal incontinence shows promising results. Patients with idiopathic, spinal etiology, or persisting incontinence after sphincter repair may benefit from this minimally invasive treatment.Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Reprints are not available.     

Sacral Nerve Stimulation for Fecal Incontinence Following Surgery for Rectal Prolapse Repair: A Multicenter Study

PURPOSE: A proportion of patients have fecal incontinence secondary to a full-thickness rectal prolapse that fails to resolve following prolapse repair. This multicenter, prospective study assessed the use of sacral nerve stimulation for this indication. METHODS: Patients had to have more than or equal to four days with fecal incontinence per 21-day period more than one year after surgery. They had to have failed conservative treatment and have an intact external anal sphincter. RESULTS: Four female patients aged 42, 54, 68, and 65 years met the inclusion criteria. Three of the four patients had had more than one operation for recurrent full-thickness rectal prolapse before sacral nerve stimulation, one of whom had undergone a further operation for recurrence following stimulation. One patient had undergone one operation for prolapse repair. The preoperative duration of symptoms was ten, eight, three, and nine years, respectively. Although patients had an intact external anal sphincter, one patient had a fragmented internal anal sphincter. The frequency of fecal incontinent episodes changed from 11, 24.7, 5, and 8 per week at baseline to 0, 1.5, 5.5, and 1 per week at latest follow-up. Ability to defer defecation was also improved in two of three patients who had this documented. Fecal incontinence-specific quality of life assessment showed an improvement in all four domains. CONCLUSION: Sacral nerve stimulation should be considered for patients with ongoing fecal incontinence following full-thickness rectal prolapse repair if they prove resistant to conservative treatment.     

Sacral Nerve Stimulation is more Effective than Optimal Medical Therapy for Severe Fecal Incontinence: A Randomized,Controlled Study

Purpose This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence. Methods Patients (aged 39–86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; n = 60) or best supportive therapy (control; n = 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal incontinence quality of life index. The follow-up duration was 12 months. Results The sacral nerve stimulation group was similar to the control group with regard to gender (F:M = 11:1 vs. 14:1) and age (mean, 63.9 vs. 63 years). The incidence of a defect of ≤ 120° of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved incontinent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 “successful” patients. There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group. Conclusions Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy. *Deceased. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Evolving Therapy for Fecal Incontinence

Background Fecal incontinence is common and can be socially debilitating. Nonoperative management of fecal incontinence includes dietary modification, antidiarrheal medication, and biofeedback. The traditional surgical approach is sphincteroplasty if there is a defect of the external sphincter. Innovative treatment modalities have included sacral nerve stimulation, injectable implants, dynamic graciloplasty, and artificial bowel sphincter. Discussion This review was designed to assess the various surgical options available for fecal incontinence and critically evaluate the evidence behind these procedures. The algorithm in the surgical treatment of fecal incontinence is shifting. Injectable therapy and sacral nerve stimulation are likely to be the mainstay in future treatment of moderate and severe fecal incontinence, respectively. Sphincteroplasty is limited to a small group of patients with isolated defect of the external sphincter. A stoma, although effective, can be avoided in most cases. ^aDeceased.     

Reliability of Electrophysiologic Anal Tests in Predicting the Outcome of Sacral Nerve Modulation for Fecal Incontinence

INTRODUCTION: Sacral nerve modulation has been demonstrated to be a new efficacious treatment for fecal incontinence. The effectiveness of the procedure is preliminarily tested by means of a peripheral nerve evaluation. Integrity of the sacral neural pathway is generally believed to be a necessary condition for a good response, but no data are available to confirm whether electrophysiologic anal tests are predictive of the clinical outcome of the peripheral nerve evaluation.METHODS: Eighty-two incontinent patients underwent the peripheral nerve evaluation after full evaluation of the anorectal physiology. Univariate analysis was performed, and the positive predictive value, sensitivity, and specificity were calculated for each of the tests.RESULTS: Forty-six patients had successful results to the peripheral nerve evaluation and were subjected to permanent implant of a sacral electrostimulator. Anal sphincter electromyography had been performed in 60 patients, whereas pudendal nerve terminal motor latency had been assessed in 68 and evoked sacral potentials in 29 patients. Anal electromyography was statistically related to the outcome of the peripheral nerve evaluation (P = 0.0004) with a positive predictive value of 81 percent, a sensitivity of 44 percent, and a specificity of 81 percent. Pudendal nerve terminal motor latency on the right side did not correlate with the outcome, but left pudendal nerve terminal motor latency was weakly correlated (P = 0.02), although both tests had a low positive predicting value and sensitivity vs. good specificity. Evoked sacral potentials did not correlate with the outcome and had a low positive predictive value, sensitivity, and specificity.CONCLUSIONS: Simple anal sphincter electromyography can predict the outcome of the peripheral nerve evaluation with good positive predictive value and specificity in patients with fecal incontinence. Other, more expensive, electrophysiologic anal tests do not add further prognostic information.Read at the meeting of The American Society of Colorectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Rectal Volume Tolerability and Anal Pressures in Patients With Fecal Incontinence Treated With Sacral Nerve Stimulation

Purpose Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation. Methods Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29–79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for “first sensation,” “desire to defecate,” and “maximal tolerable volume,” rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up. Results Median Wexner incontinence score decreased from 16 (range, 6–20) to 4 (range, 0–12; P < 0. 0001). Median “first sensation” increased from 43 (range, 16–230) ml to 62 (range, 4–186) ml (P = 0.1), median “desire to defecate” from 70 (range, 30–443) ml to 98 (range, 30–327) ml (P = 0.011), and median “maximal tolerable volume” from 130 (range, 68–667) ml to 166 (range, 74–578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0–109) cm H₂O to 38 (range, 0–111) cm H₂O (P = 0.045). No significant increase in maximum squeeze pressure was observed. Conclusions For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Experimental Models of Neuropathic Fecal Incontinence: An Animal Model of Childbirth Injury to the Pudendal Nerve and External Anal Sphincter

Purpose  Childbirth is the most common cause of fecal incontinence and damage to the pudendal nerve is a major component of childbirth injury. This study was designed to develop an acute animal model of injury to the innervation of the external anal sphincter. Methods  Forty-eight female virgin wistar rats were studied. Two models of neuropathic injury were developed. Bilateral inferior rectal nerve crush (Group A) acted as a positive control. Prolonged intrapelvic retrouterine balloon inflation (Group B) simulated the pelvic compressive forces of labor. Quantitative analysis of external anal sphincter muscle function was performed by using electromyography, external anal sphincter specific force production, and stereologic calculation of external anal sphincter mass. Results  Injury in both groups caused significant atrophy of the external anal sphincter (P = 0.002, ANOVA) and electromyographic evidence of reinnervation at one week. Specific force (mN force per mg mass) was not altered. External anal sphincter muscle mass recovered after four weeks in Group B. Conclusions  Balloon dilation within the boney pelvis results in denervation of the external anal sphincter and offers an experimental model of the effects of childbirth on the continence mechanism in humans. Supported by a grant from The Health Research Board, Ireland. Presented at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007, and was the winner of the Research Forum Prize.     

Biofeedback <Emphasis Type="Italic">vs</Emphasis>. Electrostimulation in the Treatment of Postdelivery Anal Incontinence: A Randomized,Clinical Trial

Purpose This study was designed to evaluate the effect of biofeedback and electrostimulation in a randomized, clinical trial for the treatment of patients with postdelivery anal incontinence. Methods Forty-nine females who sustained third-degree or fourth-degree perineal rupture with a mean age of 36 (range, 22–44) years were included in the study. The females were randomized to biofeedback or electrostimulation treatment. Forty females completed the study: 19 in the biofeedback and 21 in the electrostimulation group. Biofeedback or electrostimulation sessions were performed two times daily for eight weeks in each group. Wexner incontinence score, fecal incontinence quality of life scores, and reduced quality of life on visual analog scale were registred before and after treatment. Patients’ self-rating of treatment effect also was registered in both groups. The primary outcome measure was the Wexner incontinence score. Results There were no differences in treatment effect between groups. Comparing pretreatment status to posttreatment in each group showed no improvement in Wexner score, reduced quality of life, or any of the fecal incontinence quality of life scores. Patients’ self-rating of the treatment effect, however, showed a subjective improvement of symptoms both in the biofeedback and in the electrostimulation group (median, 7 vs. 5.) Conclusions This study shows that there was no difference in effect between biofeedback and electrostimulation. Neither biofeedback nor electrostimulation treatments improved Wexner incontinence score, reduced quality of life, or fecal incontinence quality of life scores. Both treatments resulted in improvement of patients’ subjective perception of incontinence control. Read at the meeting of the Norwegian Surgical Society, Oslo, Norway, October 24 to 28, 2005.     

A New Implantation Procedure of Artificial Sphincter for Anal Incontinence: The Transvaginal Approach

A destroyed or severely scarred anterior perineum predicts difficult healing and risk of perineal erosion and remains a contraindication for the implantation of an artificial anal sphincter via a perineal approach. This report describes the first implantations of an artificial anal sphincter via a transvaginal approach in female patients with anal incontinence. Between 2003 and 2005, the Acticon Neosphincter was implanted via a transvaginal approach in nine patients (average age, 43 (range, 25-73) years). These patients had severe fecal incontinence and failed previous therapies or were not amenable to lesser forms of therapy. A successful outcome was achieved in eight of nine patients (89 percent), and for these eight patients the artificial anal sphincter was activated. With a mean follow-up of 21.5 (range, 8-38) months, the mean Cleveland Clinic Score of incontinence decreased from 19 (range, 18-20) before the procedure to 8.6 (range, 2-14) at the last follow-up. None of the patients complained of dyspareunia; vaginal length was not a significant consideration, because this procedure does little to compromise this parameter. This approach is not without complications but its success rate is notable, especially when taking into account that these are patients not amenable to other therapies and only candidates to permanent colostomy.     

Atrophy and Defects Detection of the External Anal Sphincter: Comparison Between Three-Dimensional Anal Endosonography and Endoanal Magnetic Resonance Imaging

Purpose Using endoanal magnetic resonance imaging, atrophy of the external anal sphincter can be established. This aspect has not been thoroughly investigated using three-dimensional anal endosonography. The purpose of this study was to compare prospectively three-dimensional anal endosonography to magnetic resonance imaging in the detection of atrophy and defects of the external anal sphincter in patients with fecal incontinence. In addition, we compared both techniques for anal sphincter thickness and length measurements. Materials and Methods Patients with fecal incontinence underwent three-dimensional anal endosonography and magnetic resonance imaging. Images of both endoluminal techniques were evaluated for atrophy and defects of the external anal sphincter. External anal sphincter atrophy scoring with three-dimensional anal endosonography depended on the distinction of the external anal sphincter and its reflectivity. External anal sphincter atrophy scoring with magnetic resonance imaging depended on the amount of muscle and the presence of fat replacement. Atrophy score was defined as none, moderate, and severe. A defect was defined at anal endosonography by a hypoechogenic zone and at magnetic resonance imaging as a discontinuity of the sphincteric ring and/or scar tissue. Differences between three-dimensional anal endosonography and magnetic resonance imaging for the detection of external anal sphincter atrophy and defects were calculated. In addition, we compared external anal sphincter thickness and length measurements in three-dimensional anal endosonography and magnetic resonance imaging. Results Eighteen patients were included (median age, 58 years; range, 27–80; 15 women). Three-dimensional anal endosonography and magnetic resonance imaging did not significantly differ for the detection of external anal sphincter atrophy (P = 0.25) and defects (P = 0.38). Three-dimensional anal endosonography demonstrated atrophy in 16 patients, magnetic resonance imaging detected atrophy in 13 patients. Three-dimensional anal endosonography agreed with magnetic resonance imaging in 15 of 18 patients for the detection of external anal sphincter atrophy. Using the grading system, 8 of the 18 patients scored the same grade. Three-dimensional anal endosonography detected seven external anal sphincter defects and magnetic resonance imaging detected ten. Three-dimensional anal endosonography and magnetic resonance imaging agreed on the detection of external anal sphincter defects in 13 of 18 patients. Comparison between three-dimensional anal endosonography and magnetic resonance imaging for sphincter thickness and length measurements showed no statistically significant concordance and had no correlation with external anal sphincter atrophy. Conclusion This is the first study that shows that three-dimensional anal endosonography can be used for detecting external anal sphincter atrophy. Both endoanal techniques are comparable in detecting atrophy and defects of the external anal sphincter, although there is a substantial difference in grading of external anal sphincter atrophy. Correlation between three-dimensional anal endosonography and magnetic resonance imaging for thickness and length measurements is poor. Inconsistency between the two methods needs to be evaluated further. Supported in part by grant No. 945-01-013 from the Netherlands Organization for Health Research and Development. Presented in part at the United European Gastroenterology Week, Prague, Czech Republic, September 25 to 29, 2004. Reprints are not available.     

Randomized,Clinical Trial of Bowel Confinement <Emphasis Type="Italic">vs.</Emphasis> Laxative Use After Primary Repair of a Third-Degree Obstetric Anal Sphincter Tear

PURPOSE: Third-degree tears are generally managed by primary anal sphincter repair. Postoperatively, some physicians recommend laxative use, whereas others favor bowel confinement after anorectal reconstructive surgery. This randomized trial was designed to compare a laxative regimen with a constipating regimen in early postoperative management after primary obstetric anal sphincter repair. METHODS: A total of 105 females were randomized after primary repair of a third-degree tear to receive lactulose (laxative group) or codeine phosphate (constipated group) for three days postoperatively. Patients were reviewed at three days and at three months postpartum. Recorded outcome measures were symptomatic and functional outcome and early postoperative morbidity. RESULTS: Forty-nine patients were randomly assigned to the constipated group and 56 patients to the laxative group. The first postoperative bowel motion occurred at a median of four (mean, 4.5 (range, 1–9)) days in the constipated group and at two (mean, 2.5 (range, 1–7)) days in the laxative group (P < 0.001). Patients in the constipated group had a significantly more painful first evacuation compared with the laxative group (P < 0.001). The mean duration of hospital stay was 3.7 (range, 2–6) days in the constipated group and 3.05 days in the laxative group (range, 2–5; P = 0.001). Nine patients in the constipated group complained of troublesome postoperative constipation compared with three in the laxative group (P = 0.033). Continence scores, anal manometry, and endoanal ultrasound findings were similar in the two groups at three months postpartum. CONCLUSIONS: Patients in the laxative group had a significantly earlier and less painful bowel motion and earlier postnatal discharge. There was no difference in the symptomatic or functional outcome of repair between the two regimens. Presented at the meeting of the Society for Maternal-Fetal Medicine, San Francisco, California, February 2 to 7, 2003     

Direct Repair <Emphasis Type="Italic">vs.</Emphasis> Overlapping Sphincter Repair

PURPOSE: The aim of this study was to compare the results of two surgical techniques (direct end-to-end vs. overlapping) of delayed repair of a localized anterior defect of external anal sphincter after an obstetric trauma. METHODS: During a five-year period, 23 patients were randomly assigned to direct end-to-end repair (n = 12) or overlapping sphincter repair (n = 11), using 2-0 PDS sutures. Two patients from each group had an internal anal sphincter defect that also was repaired. All patients had a normal pudendal nerve terminal motor latency preoperatively. Evaluations included endoanal ultrasound, anorectal manometry, and neurophysiologic evaluation. Continence was assessed by the Cleveland Clinic Continence Score (0–20; 0, perfect continence; 20, complete incontinence). RESULTS: The two groups were comparable with regard to age (median, 45 years), past history of sphincter repair (n = 2), and posterior vaginal repair. There was no major morbidity. The wound-healing rate was identical between the two groups. However, of the patients undergoing overlapping repair, two had fecal impaction, and one had a urinary retention. Median preoperative continence score was 17 in both the direct-repair group (score, 8–20) and the overlap group (score, 7–20). At a median follow-up of 18 months, the improvement in continence was similar between the two surgical groups, with a median continence score of 3, respectively. In both surgical groups there was a significant and similar improvement in maximum squeeze pressure and in the functional anal canal length postoperatively (P < 0.05), but the mean resting pressure was relatively unchanged. In the overlap group, one patient developed a unilaterally prolonged pudendal nerve terminal motor latency that was persistent 22 months after surgery, and two patients had impaired fecal evacuation postoperatively. CONCLUSIONS: This randomized, controlled study suggests that the outcome is similar whether direct end-to-end or overlapping repair of a sphincter defect is performed. Overlapping repair might be associated with more difficulties with fecal evacuation and a prolonged pudendal nerve terminal motor latency postoperatively.     

Day-Case Stapled (Circular) <Emphasis Type="Italic">vs</Emphasis>. Diathermy Hemorrhoidectomy

PURPOSE: Stapled hemorrhoidectomy may be associated with less pain and faster recovery than conventional hemorrhoidectomy for prolapsing hemorrhoids. Therefore, the outcome of stapled hemorrhoidectomy was compared with that of diathermy hemorrhoidectomy in a randomized, controlled trial. METHODS: Sixty patients with third-degree hemorrhoids were randomly assigned to stapled hemorrhoidectomy (n = 30) or to diathermy hemorrhoidectomy in a day-case setting. Visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at six weeks and one year after surgery. RESULTS: Operation time was a median of 21 (range, 11–59) minutes in the stapled group vs. 22 (range, 14–40) minutes in the diathermy group. Day-case surgery was successful in 24 patients (80 percent) in the stapled group vs. 29 patients (97 percent) in the diathermy group. Average pain in the stapled group was significantly lower than in the diathermy group (median, 1.8 (0.1–4.8) vs. 4.3 (1.4–6.2), 95 percent confidence interval difference medians, 1.15–3.85, P = 0.0002, Mann-Whitney U test) as was the average pain expected by the patients (median –2.7 (–0.15–0.8) vs. 0.006 (–4.05–0.5) respectively, 95 percent confidence interval difference medians, 0.5–3.55, P = 0.0018, Mann-Whitney U test). Postoperative morbidity and time off work were not significantly different between the diathermy and stapled groups. Seven treatment failures in the stapled group and one in the diathermy group necessitated other treatments at a later date. Patient satisfaction scores in the stapled and diathermy group were similar. Symptoms attributed to difficult rectal evacuation decreased significantly after surgery. CONCLUSIONS: Stapled hemorrhoidectomy is a significantly less painful operation than diathermy hemorrhoidectomy, but does not seem to offer significant advantages in terms of hospital stay or symptom control in the long term. Hemorrhoidectomy may improve symptoms of difficult rectal evacuation.     

<Emphasis Type="Italic">Anisakis</Emphasis> spp. burden in <Emphasis Type="Italic">Trachurus trachurus</Emphasis>

Anisakis is a parasite of marine mammals that uses a great number of fish species as intermediate or paratenic hosts. It is common in commercially important marine fishes and its presence is of great concern for both human health and economic reasons. Horse mackerels (Trachurus trachurus) originated from the Northern Aegean Sea were examined for the presence of Anisakis spp. larvae. The prevalence of Anisakis spp. was found 98.8 %. The number of parasites was significantly related to the host’s length but was not related to the fish gender. The month of sampling affected the size of the fishes and consequently the number of parasites. The length of larvae was not related to the host’s length. The present study resulted in the design of a prediction model for the number of existing parasites in the fish by measuring only its Fixed Length.     

<Emphasis Type="Italic">T-</Emphasis>Scores and <Emphasis Type="Italic">Z</Emphasis>-Scores

Bone mineral density (BMD) can be measured by a variety of techniques at several skeletal sites. Once measured, the manufacturers’ software uses the BMD to calculate a T-score and/or Z-score. Both T-scores and Z-scores are derived by comparison to a reference population on a standard deviation scale. The recommended reference group for the T-score is a young gender-matched population at peak bone mass, while the Z-score should be derived from an age-matched reference population. T-scores and Z-scores are widely quoted in scientific publications on osteoporosis and BMD studies, and are the values used for DXA diagnostic criteria and current clinical guidelines for the management of osteoporosis. Errors in BMD measurement, differences in reference populations, and variations in calculation methods used, can all affect the actual T-score and Z-score value. Attempts to standardize these values have made considerable progress, but inconsistencies remain within and across BMD technologies. This can be a source of confusion for clinicians interpreting BMD results. A clear understanding of T-scores and Z-scores is essential for correct interpretation of BMD studies in clinical practice.     

Lower Recurrence Rate for Limberg <Emphasis Type="Italic">vs</Emphasis>. V-Y Flap for Pilonidal Sinus

Purpose Pilonidal sinus is a disease that does not have a standardized surgical treatment method. This study was designed to compare the outcomes of Limberg fasciocutaneous transposition and V-Y fasciocutaneous advancement flaps in the treatment of patients with pilonidal sinus. Methods A total of 111 patients (98 males; 88.3 percent; mean age, 27.1 years) who received reconstruction after pilonidal sinus excision in our clinics with Limberg flap (Group 1, n = 66, 59.5 percent) or V-Y flaps (Group 2, n = 45, 40.5 percent) between 1997 and 2004 were investigated retrospectively. Results No significant difference was detected between Groups 1 and 2 in terms of gender, history of infection or abscess, mean duration of operation, requirement for analgesics, wound-related complications, such as necrosis, seroma, and infection, and average time off work. Mean follow-up periods were 45.4 vs. 48.8 months in Group 1 and Group 2, respectively (P = 0.337). On the other hand, rate of recurrence was significantly lower in Group 1 (n = 1, 1.5 percent) compared with Group 2 (n = 5, 11.1 percent; P = 0.039). Conclusions We conclude that, if the defect is to be reconstructed with a flap in pilonidal sinus cases, reconstruction with Limberg flap should be preferred over reconstruction with V-Y flap because of its lower rate of recurrence.