Sacral Nerve Stimulation for Fecal Incontinence: External Anal Sphincter Defect <Emphasis Type="Italic">vs</Emphasis>. Intact Anal Sphincter

Purpose  This prospective study was designed to assess the effectiveness of sacral nerve stimulation for fecal incontinence in patients with external anal sphincter defect and to evaluate its efficacy regarding presence and size of sphincter defect. Methods  Fifty-three consecutive patients who underwent sacral nerve stimulation for fecal incontinence were divided into two groups: external anal sphincter defect group (n = 21) vs. intact sphincter group (n = 32). Follow-up was performed at 3, 6, and 12 months with anorectal physiology, Wexner’s score, bowel diary, and quality of life questionnaires. Results  The external anal sphincter defect group (defect <90°:defect 90°–120° = 11:10) and intact sphincter group were comparable with regard to age (mean, 63 vs. 63.6) and sex. Incidence of internal anal sphincter defect and pudendal neuropathy was similar. All 53 patients benefited from sacral nerve stimulation. Weekly incontinent episodes decreased from 13.8 to 5 (P < 0.0001) for patients with external anal sphincter defects and from 6.7 to 2 (P = 0.001) for patients with intact sphincter at 12-month follow-up. Quality of life scores improved in both groups (P < 0.0125). There was no significant difference in improvement in functional outcomes after sacral nerve stimulation between patients with or without external anal sphincter defects. Clinical benefit of sacral nerve stimulation was similar among patients with external anal sphincter defects, irrespective of its size. Presence of pudendal neuropathy did not affect outcome of neurostimulation. Conclusions  Sacral nerve stimulation for fecal incontinence is as effective in patients with external anal sphincter defects as those with intact sphincter and the result is similar for defect size up to 120° of circumference. ^†Deceased.     

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.     

Sacral Nerve Stimulation in Fecal Incontinence: Are There Factors Associated with Success?

Purpose Sacral nerve stimulation has been used successfully in treating fecal incontinence. This study was designed to evaluate the proportion of patients with unsuccessful implantation despite positive test stimulation and to examine and compare factors associated with the success of the transitory and permanent sacral nerve stimulation. Methods A total of 61 patients (55 females; median age, 56 (range, 33–77) years) with refractory fecal incontinence underwent temporary stimulation. A 50 percent or greater improvement in the number of episodes of fecal incontinence or urgency was required to proceed to permanent implantation and was the criteria of success of permanent sacral nerve stimulation at the last follow-up visit in implanted patients. The factors compared between the success and the failure groups during temporary and permanent stimulation were patients’ age and gender, diagnosis and characteristics of fecal incontinence, previous surgery, quality of life scores, anorectal manometry, endoanal ultrasound, and electrophysiologic tests performed before stimulation. Results Temporary stimulation was successful in 35 patients (57.4 percent). A permanent neurostimulation device was implanted in 33 patients. Age was the only factor related to success of the temporary stimulation (P=0.03). After permanent implantation, 31 percent of patients did not attain screening phase results for the number of episodes of fecal incontinence or urgency. A neurologic disorder was more frequently the origin of fecal incontinence in the success group compared with others (P=0.03). The left bulbocavernosus reflex was more frequently delayed in the success group than in the others (P=0.03), and a prolonged or absent bulbocavernosus reflex was more frequent in the success group than in the failure group (P=0.03). Conclusions Patients with fecal incontinence from neurologic origins could be good candidates for sacral nerve stimulation. Presented at Digestive Disease Week, Los Angeles, California, May 20 to 25, 2006.     

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.     

Evaluation of the sacroanal motor pathway by magnetic and electric stimulation in patients with fecal incontinence

PURPOSE: The aim of this controlled study was to examine whether it was feasible to use magnetic stimulation as a new diagnostic tool to evaluate the motor function of the sacral roots and the pudendal nerves in patients with fecal incontinence. PATIENTS AND METHODS: Nineteen consecutive patients (17 females) with a median age of 67 (range, 36–78) years referred for fecal incontinence and 14 healthy volunteers (six females) with a median age of 42 (range, 23–69) years were examined. Latency times of the motor response of the external anal sphincter were measured after electric transrectal stimulation of the pudendal nerve and magnetic stimulation of the sacral roots. RESULTS: The success rates of pudendal nerve terminal motor latency and sacral root terminal motor latency measurements were 100 and 85 percent, respectively, in the control group and 94 and 81 percent, respectively, in the fecal incontinence group. Median left pudendal nerve terminal motor latency was 1.88 (range, 1.4–2.9) milliseconds in the control group and 2.3 (range, 1.8–4) milliseconds in the fecal incontinence group (P<0.006). Median right pudendal nerve terminal motor latency was 1.7 (range, 1.3–3.4) milliseconds in the control group and 2.5 (range, 1.7–6) milliseconds in the fecal incontinence group (P<0.003). Median left sacral root terminal motor latency was 3.3 (range, 2.1–6) milliseconds in the control group and 3.7 (range, 2.8–4.8) milliseconds in the fecal incontinence group (P<3 0.03). Median right sacral root terminal motor latency was 3 (range, 2.6–5.8) milliseconds in the control group and 3.9 (range, 2.5–7.2) milliseconds in the fecal incontinence group (P=0.15). CONCLUSIONS: Combined pudendal nerve terminal motor latency and sacral root terminal motor latency measurements may allow us to study both proximal and distal pudendal nerve motor function in patients with fecal incontinence. Values of sacral root terminal motor latency have to be interpreted cautiously because of the uncertainty about the exact site of magnetic stimulation and the limited magnetic field strength.     

Sacral nerve stimulation for treatment of fecal incontinence

PURPOSE: Many patients with fecal incontinence demonstrate a functional deficit of the internal anal sphincter or the external sphincter muscles without any apparent structural defects. Few patients are amenable to repair or substitution of the sphincter. However, sacral nerve stimulation appears to offer a valid treatment option for fecal incontinence. The objectives of this study were: to evaluate the efficacy of temporary stimulation of the sacral nerve roots (percutaneous nerve evaluation) in patients with functional fecal incontinence; to determine the mechanisms of possible improvement; and to evaluate if temporary stimulation could be reproduced and maintained by implanting a permanent neurostimulation system. METHODS: Twenty-three patients with fecal incontinence, 18 females and 5 males, median age of 54.9 years (range 28–71), underwent a percutaneous nerve evaluation test. Eleven patients (47.8 percent) also had urinary disorders: urge incontinence (4), stress incontinence (3), and retention (4). Associated disorders included perineal and rectal pain (1), spastic paraparesis (1), and syringomyelia (1). All patients underwent a preliminary evaluation using stationary anal manovolumetry, pudendal nerve terminal motor latency measurements, and anal ultrasound. A percutaneous electrode for the stimulation of the sacral nerve roots was positioned at the level of the third sacral foramen (S3) in 20 patients and S2 in 2 patients (1 patient missing). Stimulation parameters used were: pulse width 210µsec, frequency 25 Hz, and average amplitude of 2.8 V (range 1–6). The electrode was left in place for a minimum of 7 days. Five patients were successively implanted with a permanent sacral electrode with a stimulation frequency of 16 to 18 Hz and amplitude of 1.1–4.9 V. RESULTS: Seventeen of the 19 patients (89.4 percent) who completed the minimum percutaneous nerve evaluation period of 7 days (median 10.7 (range 7–30)), had a reduction of liquid or solid stool incontinence by more than 50 percent, and fourteen (73.6 percent) were completely continent for stool. The most important changes revealed by manovolumetry were an increase in resting pressure (P<0.001) and voluntary contraction (P=0.041), reduction of initial pressure for first sensation (P=0.049) and urge to defecate (P=0.002), and a reduction of the rectal volume for urge sensation (P=0.006). The percutaneous nerve evaluation results were reproduced at a median follow-up of 19.2 months (range 5 to 37) in the 5 patients who received a permanent implant. CONCLUSIONS: Temporary stimulation of the sacral roots (percutaneous nerve evaluation) can be of help in those patients with fecal incontinence, and the results are reproduced with permanent implantation. The positive effect on continence seems to be derived from not only the direct efferent stimulation on the pelvic floor and the striated sphincter muscle, but also from modulating afferent stimulation of the autonomous neural system, inhibition of the rectal detrusor, activation of the internal anal sphincter, and modulation of sacral reflexes that regulate rectal sensitivity and motility.     

Sacral Neuromodulation in Treatment of Fecal Incontinence Following Anterior Resection and Chemoradiation for Rectal Cancer

PURPOSE Fecal incontinence may occur in patients who have undergone anterior resection for rectal cancer without presenting sphincter lesions. Chemoradiation may contribute to disrupting continence mechanisms. Treatment is controversial. Assessment of fecal incontinence in patients who agreed to integrate treatment for rectal cancer and treatment with sacral neuromodulation are reported.METHODS Fecal incontinence following preoperative chemoradiation and anterior resection for rectal cancer was evaluated in four patients. A good response was observed during the percutaneous sacral nerve evaluation test, and so permanent implant of sacral neuromodulation system was performed. Reevaluation was performed at least two months after implant.RESULTS After device implantation, the mean fecal incontinence scores decreased, and the mean number of incontinence episodes dropped from 12.0 to 2.5 per week (P < 0.05). Permanent implant resulted in a significant improvement in fecal continence in three patients, and incontinence was slightly reduced in the fourth. Manometric parameters agreed with clinical results: maximum and mean resting tone and the squeeze pressure were normal in three patients and reduced in one. In these same three patients, neorectal sensation parameters increased when the preoperative value was normal or below normal and decreased when the preoperative value was higher than normal, whereas in one patient in whom extremely low values were recorded all of the parameters decreased significantly.CONCLUSIONS Fecal incontinence following anterior resection and neoadjuvant therapy should be carefully evaluated. If a suspected neurogenic pathogenesis is confirmed, sacral neuromodulation may be proposed. If the test results are positive, permanent implant is advisable. Failure of this approach does not exclude the use of other, more aggressive treatment.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

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.     

Overt Rectal Prolapse and Fecal Incontinence

PURPOSE  Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. METHODS  Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. RESULTS  The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). CONCLUSIONS  In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.     

Antegrade Continence Enema in the Treatment of Congenital Fecal Incontinence Beyond Childhood

Purpose  The role of antegrade continence enema for the treatment of congenital fecal incontinence in adult patients remains unclear. Materials  Twenty-seven patients, median age 19 (range, 17–43) years, with congenital fecal incontinence underwent surgery for antegrade continence enema and were prospectively followed up for functional outcome after a median of 25 (range, 3–117) months. Results  The diagnoses included myelodysplasia (n = 14), anorectal malformations (n = 6), and others (n = 7). Antegrade continence enema conduits included appendicostomy (n = 22) and cecal (n = 2), ileal (n = 2), and sigmoid (n = 1) tubes. Thirteen (48 percent) patients had complications. Eighteen (66 percent) patients became fully continent, six (23 percent) had minor, and three (11 percent) major soiling. Antegrade continence enema became unnecessary in three patients (11 percent). Treatment with antegrade continence enema failed in three cases. Of the 21 patients who continued with antegrade continence enema, 16 (76 percent) are fully continent, and bowel function and quality of life was improved in 15 (71 percent) and 13 (62 percent) patients, respectively. The scores of convenience (1 = easy, 5 = difficult) and overall satisfaction (1 = poor, 10 = excellent) were median 2 (range, 1–4) and 8 (range, 3–10). Conclusions  Despite numerous complications and occasional treatment failures, 90 percent of adult patients with congenital fecal incontinence benefited from antegrade continence enema. Reprints are not available     

Sacral neuromodulation in patients with fecal incontinence: a single-center study

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.Presented in part at the Tripartite Colorectal Meeting, Melbourne, Australia, October 27 to 30, 2002, and 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 can Improve Continence in Patients with Crohn’s Disease with Internal and External Anal Sphincter Disruption

Purpose  Sacral nerve stimulation is a technique commonly used for the treatment of idiopathic incontinence. This study was designed to assess the efficiency of sacral nerve stimulation as a means of treating fecal incontinence in patients with Crohn’s disease with disrupted internal and external anal sphincters. Methods  Five patients (3 women) with fecal incontinence suffering from Crohn’s disease-related anoperineal lesions were treated by applying three weeks of sacral nerve stimulation and then by permanent sacral nerve stimulation implantation. Endoanal ultrasonography showed that all of these patients had disrupted external and internal anal sphincters. Results  Continence was improved in all treated patients. The median follow-up time was 14 (range, 3–36) months. At the end of the follow-up period, the median Wexner’s score significantly improved from 15 to 6 and the median number of daily stools decreased from 7 to 2. The patients’ quality of life also increased significantly. Conclusions  Sacral nerve stimulation improves fecal continence in patients suffering from Crohn’s anoperineal lesions with internal and external anal sphincters disruption. Address of correspondence: Veronique Vitton, M.D., Service de gastroenterologie, H?pital Nord, Chemin des Bourrely, 13915 Marseille, Cedex 20, France. E-mail: veronique.vitton@mail.ap-hm.fr     

Cholestyramine—a useful adjunct for the treatment of patients with fecal incontinence

Aim/Background Cholestyramine may improve fecal incontinence, but its use has not been assessed. We report our experience with the use of cholestyramine in the treatment of fecal incontinence. Materials and methods Twenty-one patients (19 female, mean age 65 years) with fecal incontinence (≥1 episode/week) received cholestyramine along with biofeedback therapy (group A). Stool frequency, stool consistency (Bristol scale), number of incontinent episodes, satisfaction with bowel function (VAS), and anorectal physiology were assessed at 3 months and at 1 year after treatment. Data were compared with a matched group of 21 incontinent subjects (19 female, mean age 64 years) who received biofeedback alone (group B). Results At 3 months and at 1 year, group A patients showed decreased stool frequency (p < 0.01), stool consistency (p = 0.001), and number of incontinent episodes (p < 0.04). In contrast, stool frequency (p = 0.8) and stool consistency (0.23) were not different from baseline in group B subjects. In both groups, there was improvement in the satisfaction with bowel function (p < 0.05), anal sphincter pressures (p < 0.05) and ability to retain saline infusion (p < 0.05). Mean dose of cholestyramine used was 3.6 g; 13 subjects (62%) required dose titration, and 7 (33%) subjects reported minor side effects. Conclusion Cholestyramine is safe and useful adjunct for the treatment of diarrhea and fecal incontinence. Most patients require small doses, and dose titration is important. The improvement in stool characteristics favors a drug effect, over and above the benefits of biofeedback therapy. Portions of this work were presented at the 2006 American College of Gastroenterology Meeting, Las Vegas, Nevada and published as an abstract in Am J Gastroenterol 2006; 101 (Suppl):S210–S211.     

Effect of Second Vaginal Delivery on Anal Function in Patients at Risk of Occult Anal Sphincter Injury after First Forceps Delivery

Purpose  The study was designed to determine the effect of further vaginal delivery on anal sphincter function in women after apparently uncomplicated primiparous forceps delivery. Methods  Fifty-two secundigravid women whose first child was forceps-assisted were compared with a control group of 20 women who had undergone spontaneous first vaginal delivery. Both groups were studied antenatally and again at 12 weeks after second delivery using a standardized bowel function questionnaire, endoanal ultrasound, and anal manometry. The primary outcome was fecal incontinence score after second delivery. Results  Before second delivery, 20 of 52 (39 percent) of the forceps group and 3 of 20 (15 percent) control subjects (P = 0.103) reported minor alteration in fecal incontinence. Endoanal ultrasound was more frequently abnormal (38/52 (73 percent) vs. 6/20 (30 percent); P = 0.002), and median anal canal squeeze (71 vs. 104 mmHg; P = 0.004) and resting pressures (43 vs. 58 mmHg; P = 0.004) were lower in the forceps group. There was no difference in continence score between first and second delivery for the forceps group (P = 0.19) group or control subjects (P = 0.18). However, 10 of 38 (26 percent) women with an abnormal endoanal ultrasound after first forceps delivery developed new or worsening symptoms after second delivery. Conclusions  One-quarter of women with occult anal sphincter injury after first forceps delivery experienced some minor alteration in fecal continence after the second delivery. Presented at the 23^rd annual meeting of the Society for Maternal Fetal Medicine, San Francisco, California. Supported by the Irish Health Research Board.     

Dynamic Graciloplasty in Patients Born With an Anorectal Malformation

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.Presented at the meeting of the Nederlandse Vereniging Voor Gastro-Enterologie, Veldhoven, The Netherlands, October 2 to 3, 2003.     

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.     

Contribution of Posture to Anorectal Manometric Measurements: Are the Measurements in Left-Lateral Position Physiologic?

Purpose Anorectal manometry is commonly used to investigate fecal incontinence. Traditional practice dictates that measurements are performed with the patient in the left-lateral position however, episodes of fecal incontinence usually occur in the erect position. The influence of erect posture on anorectal manometry has not been studied. Methods We examined the contribution of posture to commonly measured variables during manometry by performing assessment in the left-lateral position and the erect posture. Maximum mean resting pressure, vector volumes, and resting pressure gradient were compared. Results Complete data were available for 172 patients. Median age was 55 (interquartile range, 44–65) years. Thirty-seven (22 percent) patients were continent, and 135 (78 percent) were incontinent. Both resting pressure and vector volume increased significantly in the erect position for both continent (P = 0.008 and 0.001, respectively) and incontinent (P = 0.001 for both) patients. A significant negative correlation was seen between severity of incontinence and resting pressure in the erect posture and amount of change in maximum mean resting pressure from left-lateral to erect posture (Spearman coefficients = −0.203, −0.211, and P = 0.013, 0.017, respectively) but not with maximum mean resting pressure in the left-lateral position (Spearman coefficient = −0.119; P = 0.164). Conclusions Our study shows significant increase in measurements of manometric variables in the erect position. The increase may be related to anal cushions, which have a significant role in this position. The measurements in erect posture are better correlated with severity of incontinence and may be a more physiologic method of performing anorectal manometry. Presented at the meeting of the Association of Coloproctology of Great Britain and Ireland, Birmingham, United Kingdom, June 28 to July 1, 2004.     

Sacral nerve stimulation for treatment of fecal incontinence: a novel approach for intractable fecal incontinence

PURPOSE: Many patients with fecal incontinence demonstrate a functional deficit of the internal anal sphincter or the external sphincter muscles without any apparent structural defects. Few patients are amenable to repair or substitution of the sphincter. However, sacral nerve stimulation appears to offer a valid treatment option for fecal incontinence. The objectives of this study were: to evaluate the efficacy of temporary stimulation of the sacral nerve roots (percutaneous nerve evaluation) in patients with functional fecal incontinence; to determine the mechanisms of possible improvement; and to evaluate if temporary stimulation could be reproduced and maintained by implanting a permanent neurostimulation system. METHODS: Twenty-three patients with fecal incontinence, 18 females and 5 males, median age of 54.9 years (range 28-71), underwent a percutaneous nerve evaluation test. Eleven patients (47.8 percent) also had urinary disorders: urge incontinence (4), stress incontinence (3), and retention (4). Associated disorders included perineal and rectal pain (1), spastic paraparesis (1), and syringomyelia (1). All patients underwent a preliminary evaluation using stationary anal manovolumetry, pudendal nerve terminal motor latency measurements, and anal ultrasound. A percutaneous electrode for the stimulation of the sacral nerve roots was positioned at the level of the third sacral foramen (S3) in 20 patients and S2 in 2 patients (1 patient missing). Stimulation parameters used were: pulse width 210 microsec, frequency 25 Hz, and average amplitude of 2.8 V (range 1-6). The electrode was left in place for a minimum of 7 days. Five patients were successively implanted with a permanent sacral electrode with a stimulation frequency of 16 to 18 Hz and amplitude of 1.1- 4.9 V. RESULTS: Seventeen of the 19 patients (89.4 percent) who completed the minimum percutaneous nerve evaluation period of 7 days (median 10.7 (range 7-30)), had a reduction of liquid or solid stool incontinence by more than 50 percent, and fourteen (73.6 percent) were completely continent for stool. The most important changes revealed by manovolumetry were an increase in resting pressure (P < 0.001) and voluntary contraction (P = 0.041), reduction of initial pressure for first sensation (P = 0.049) and urge to defecate (P = 0.002), and a reduction of the rectal volume for urge sensation (P = 0.006). The percutaneous nerve evaluation results were reproduced at a median follow-up of 19.2 months (range 5 to 37) in the 5 patients who received a permanent implant. CONCLUSIONS: Temporary stimulation of the sacral roots (percutaneous nerve evaluation) can be of help in those patients with fecal incontinence, and the results are reproduced with permanent implantation. The positive effect on continence seems to be derived from not only the direct efferent stimulation on the pelvic floor and the striated sphincter muscle, but also from modulating afferent stimulation of the autonomous neural system, inhibition of the rectal detrusor, activation of the internal anal sphincter, and modulation of sacral reflexes that regulate rectal sensitivity and motility.     

Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse

Purpose This study examines whether preoperative anal manometry and pudendal nerve terminal motor latency predict functional outcome after perineal proctectomy for rectal prolapse. Methods All adult patients treated by perineal proctectomy for rectal prolapse from 1995 to 2004 were identified (N = 106). Forty-five patients underwent anal manometry and pudendal nerve terminal motor latency testing before proctectomy and they form the basis for this study. Results Perineal proctectomy with levatoroplasty (anterior 88.9 percent; posterior 75.6 percent) was performed in all patients, with a mean resection length of 10.4 cm. Four patients (8.9 percent) developed recurrent prolapse during a 44-month mean follow-up. Preoperative resting and maximal squeeze pressures were 34.2 ± 18.3 and 60.4 ± 30.5 mmHg, respectively. Pudendal nerve terminal motor latency testing was prolonged or undetectable in 55.6 percent of patients. Grade 2 or 3 fecal incontinence was reported by 77.8 percent of patients before surgery, and one-third had obstructed defecation. The overall prevalence of incontinence (77.8 vs. 35.6 percent, P < 0.0001) and constipation (33.3 vs. 6.7 percent, P = 0.003) decreased significantly after proctectomy. Patients with preoperative squeeze pressures >60 mmHg (n = 19) had improved postoperative fecal continence relative to those with lower pressures (incontinence rate, 10 vs. 54 percent; P = 0.004), despite having similar degrees of preoperative incontinence. Abnormalities of pudendal nerve function and mean resting pressures were not predictive of postoperative incontinence. Conclusions Perineal proctectomy provides relief from rectal prolapse, with good intermediate term results. Preoperative anal manometry can predict fecal continence rates after proctectomy, because patients with maximal squeeze pressures >60 mmHg have significantly improved outcomes. Supported exclusively using institutional funding. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Rectal Hypersensitivity Worsens Stool Frequency, Urgency, and Lifestyle in Patients With Urge Fecal Incontinence

PURPOSE Rectal sensory mechanisms are important in the maintenance of fecal continence. Approximately 50 percent of patients with urge incontinence have lowered rectal sensory threshold volumes (rectal hypersensitivity) on balloon distention. Rectal hypersensitivity may underlie the heightened perception of rectal filling; however, its impact on fecal urgency and incontinence is unknown. This study was designed to investigate the impact of rectal hypersensitivity in patients with urge fecal incontinence.METHODS Prospective and retrospective audit review of all patients (n = 258) with an intact native rectum referred to a tertiary colorectal surgical center for physiologic investigation of urge fecal incontinence during a 7.5-year period. Patients with urge fecal incontinence who had undergone pelvic radiotherapy (n = 9) or rectal prolapse (n = 6) were excluded.RESULTS A total of 108 of 243 patients (44 percent) were found to have rectal hypersensitivity. The incidence of anal sphincter dysfunction was equal (90 percent) among those with or without rectal hypersensitivity. Patients with urge fecal incontinence and rectal hypersensitivity had increased stool frequency (P < 0.0001), reported greater use of pads (P = 0.003), and lifestyle restrictions (P = 0.0007) compared with those with normal rectal sensation, but had similar frequencies of incontinent episodes.CONCLUSIONS Urge fecal incontinence relates primarily to external anal sphincter dysfunction, but in patients with urge fecal incontinence, rectal hypersensitivity exacerbates fecal urgency, and this should be considered in the management and surgical decision in patients who present with fecal incontinence.Christopher L. H. Chan, F.R.C.S., is supported by a MRC Clinical Training Fellowship.