Sacral nerve neuromodulation as primary treatment for faecal incontinence with disrupted anal sphincters: medium and long-term results

Introduction The standard treatment for faecal incontinence secondary to obstetric sphincterdamage is anal sphincter repair. However, the results of this procedure deteriorate withtime. Sacral nerve stimulation (SNS) has become an established therapy for faecal incontinencein patients with intact sphincter muscles, with good medium term results. We assess themedium and long-term results of SNS as first line treatment in patients with obstetric-relatedfaecal incontinence. Methods: All patients with obstetric-related faecal incontinence anddemonstrated external and internal sphincter disruption on anal endosonography wereincluded in the study. These patients would have normally undergone anterior anal sphincterrepair. Patients underwent temporary stimulation followed by assessment at 2 weeks. Permanentstimulator was then implanted in patients with significant improvement. Post implantationpatients were followed up 1, 3, 6, 12, 36, and 48 months. Demographic, clinical, operativeand anorectal physiology data was collected prospectively. Results: 20 consecutive womenwith a median age of 42 (35-62) years completed temporary screening and 19 went on topermanent implantation. Faecal incontinence improved in all patients from Wexner scoresof median 16 (10-20) preoperatively to median 5 (1-11) at 2 weeks. There was furtherimprovement in faecal incontinence with median Wexner scores of 3, 3.5, 4, 4, 3.5 & 3 at1,3,6,12,36 & 48 months respectively (p<0.0001). The remaining patient was followedup at 2 weeks post temporary SNS and demonstrated significant improvement in faecalincontinence (Wexner score 19 pre-procedure to 3 post-procedure), but was lost to followup thereafter. There was significant improvement in general and mental health, emotionalrole, social function and vitality in all patients. There were no major complications and noimplants were removed. Conclusion: This is the first study showing long-term results ofSNS for primary treatment of faecal incontinence with damaged anal sphincter. We haveshown that sacral nerve neuromodulation is a safe and effective minimally invasive first linetreatment for such patients. The improvement in faecal incontinence achieved in short termis sustained over a follow up of 4 years

Sacral nerve neuromodulation as primary treatment for faecal incontinence with disrupted anal sphincters: medium and long-term results

Introduction The standard treatment for faecal incontinence secondary to obstetric sphincterdamage is anal sphincter repair. However, the results of this procedure deteriorate withtime. Sacral nerve stimulation (SNS) has become an established therapy for faecal incontinencein patients with intact sphincter muscles, with good medium term results. We assess themedium and long-term results of SNS as first line treatment in patients with obstetric-relatedfaecal incontinence. Methods: All patients with obstetric-related faecal incontinence anddemonstrated external and internal sphincter disruption on anal endosonography wereincluded in the study. These patients would have normally undergone anterior anal sphincterrepair. Patients underwent temporary stimulation followed by assessment at 2 weeks. Permanentstimulator was then implanted in patients with significant improvement. Post implantationpatients were followed up 1, 3, 6, 12, 36, and 48 months. Demographic, clinical, operativeand anorectal physiology data was collected prospectively. Results: 20 consecutive womenwith a median age of 42 (35-62) years completed temporary screening and 19 went on topermanent implantation. Faecal incontinence improved in all patients from Wexner scoresof median 16 (10-20) preoperatively to median 5 (1-11) at 2 weeks. There was furtherimprovement in faecal incontinence with median Wexner scores of 3, 3.5, 4, 4, 3.5 & 3 at1,3,6,12,36 & 48 months respectively (p<0.0001). The remaining patient was followedup at 2 weeks post temporary SNS and demonstrated significant improvement in faecalincontinence (Wexner score 19 pre-procedure to 3 post-procedure), but was lost to followup thereafter. There was significant improvement in general and mental health, emotionalrole, social function and vitality in all patients. There were no major complications and noimplants were removed. Conclusion: This is the first study showing long-term results ofSNS for primary treatment of faecal incontinence with damaged anal sphincter. We haveshown that sacral nerve neuromodulation is a safe and effective minimally invasive first linetreatment for such patients. The improvement in faecal incontinence achieved in short termis sustained over a follow up of 4 years

Can artificial neural networks predict which patients need a colonoscopy?

Introduction: Artificial neural networks (ANN) are computer programs used to identify complex relations within data sets undetectable with conventional linear statistical analysis. One such complex problem is the prediction of need for lower gastrointestinal endoscopy in individual patients consulting for gastrointestinal symptoms. Routine predictions have low accuracy and result in large numbers of normal colonscopies with obvious implications, both logistic and economic. We aimed to develop a neural network algorithm which can predict the need for lower gastrointestinal endoscopy in patients attending the routine outpatient clinics. MethodsProspective clinical data of 200 patients undergoing elective colonoscopy were collected. The specifically developed questionnaire included 40 variables based on clinical features. Complete data sets of 50% of the series were used to train the ANN: remaining 50% used for internal validation. The primary output was a positive finding on the colonoscopy, including polyps, cancer, diverticular disease, or colitis. ResultsThe outcome and pathology reports of all patients were obtained and assessed. Clear correlation between actual data value and artificial neural network value were found (r=0.931; p=0.0001). The predictive accuracy of the neural network was 95% in the training group and was 89% (95% CI 84 to 96) in the validation set. This accuracy was significantly higher than the clinical accuracy (69%). ConclusionsArtificial neural networks are more accurate (89% correlation) than standard statistics (67%) when applied to the prediction in individual patients of the need for lower gastrointestinal endoscopy. The results obtained highlight their obvious usefulness, which could now be used in a prospective evaluation for application of the technique

Anal sphincter injury, fecal and urinary incontinence

Purpose: This study was designed to determine the long-term outcome of forceps delivery in terms of evidence of anal sphincter injury and the incidence of fecal and urinary incontinence. Methods: Women who delivered in 1964 were evaluated by using endoanal ultrasound, manometry, and a continence questionnaire. Women delivered by forceps were matched with the next normal delivery and elective cesarean delivery in the birth register. Results: The women's overall obstetric history was evaluated. Women who had ever had a forceps delivery (n=42) had a significantly higher incidence of sphincter rupture compared with women who had only unassisted vaginal deliveries (n=41) and elective cesarean sections (n=6) (44 vs. 22 vs. 0 percent; chi-squared 7.09; P=0.03). There was no significant difference in the incidence of significant fecal incontinence between the three groups (14 vs. 10 vs. 0 percent) or significant urinary incontinence (7 vs. 19 vs. 0 percent). Conclusion: Anal sphincter injury was associated with forceps delivery in the past; however, significant fecal and urinary incontinence was not

Randomized clinical trial of Entonox versus midazolam-fentanyl sedation for colonoscopy

BACKGROUND Intravenous sedation for colonoscopy is associated with cardiorespiratory complications and delayed recovery. The aim of this randomized clinical trial was to compare the efficacy of Entonox (50 per cent nitrous oxide and 50 per cent oxygen) and intravenous sedation using midazolam-fentanyl for colonoscopy. METHODS Some 131 patients undergoing elective colonoscopy were included. Patients completed a Hospital Anxiety and Depression questionnaire, letter cancellation tests and pain scores on a 100-mm visual analogue scale before, immediately after the procedure and at discharge. They also completed a satisfaction survey at discharge and 24 h after the procedure. RESULTS Sixty-five patients were randomized to receive Entonox and 66 to midazolam-fentanyl. Completion rates were similar (94 versus 92 per cent respectively; P = 0.513). Patients receiving Entonox had a shorter time to discharge. They reported significantly less pain (mean score 16.7 versus 40.1; P < 0.001), and showed better recovery of psychomotor function immediately after the procedure and at discharge. Patient satisfaction was higher among patients who received Entonox (median score 96 versus 89; P = 0.001). CONCLUSION Entonox provides better pain relief and faster recovery than midazolam-fentanyl and so is more effective for colonoscopy

A new method of assessing anal sphincter integrity using inverted vectormanometry

PURPOSE: Vectorgraphy as an integrated mapping of radial pressure profiles of the anal canal has been used to attempt identification of pressure-related defects with doubtful reliability since vectorgraphs bear no resemblance to endoanal ultrasound scans at similar levels in the anal canal. This study aimed to devise a technique to enable vectorgraphy to be more representative of sphincter function and integrity. METHODS: Vectormanometry was performed in 50 patients with anorectal disorders using an Arndorfer pneumohydraulic system. "Normal" three-dimensional manometric images of each 0.5 cm of the anal sphincter were computer-generated by plotting anal pi sures at rest and during squeeze radially around a central zero axis. The graphs were replotted with zero at the periphery and maximal anal pressure at the center. Both this ("inverted") and "normal" vectorgraphs were compared with endoanal ultrasound images at similar levels, assessing both internal and external anal sphincters. RESULTS: Standard vectormanometry produced excellent pictures of pressures throughout the anal canal; the anatomy however bore no resemblance to the pictures produced by endoanal ultrasound. The inverted vectographs showed a much better correlation with endoanal ultrasound at each 0.5-mm level of the anal canal, for both squeeze pressure graphs and external sphincter correlations and for resting pressure graphs and internal sphincter correlations. CONCLUSIONS: Accurate assessment of sphincter integrity is not possible when interpreting the vectormanometry graphs in the current format; however, inverted vectorgraphy gives good correlations with endoanal ultrasound and provides combined functional (pressure measurement) and anatomic (three-dimensional profile) information regarding the anal canal

Rectoanal reflex parameters in incontinence and constipation

PURPOSE: The transient relaxation of the internal anal sphincter in response to rectal distention is believed to play an important role in the continence mechanism. Most anorectal physiology laboratories merely report the rectoanal inhibitory reflex as being either present or absent. This study aimed to assess the parameters of the rectoanal inhibitory reflex in incontinent and constipated patients and healthy control subjects, in an attempt to analyze differences in internal anal sphincter function in these groups. We analyzed each response of the internal anal sphincter to rectal distention with progressively increasing volumes of air at a single site (proximal anal canal). METHODS: Fifty-five constipated and 99 incontinent patients and healthy control subjects underwent manometry. Various parameters of the rectoanal inhibitory reflex were analyzed, and percentage sphincter relaxation was calculated at each volume at which rectoanal inhibitory reflex occurred. RESULTS: There was no difference in the volume of rectal distention required to elicit sensation (P = 0.626) or the rectoanal inhibitory reflex (P = 0.371) in the three groups. There was a significant correlation between the volume required to elicit the rectoanal inhibitory reflex and that at which sensation was first felt only in the incontinent (P = 0.0001) group. Significantly greater sphincter relaxation was seen at each volume (P = 0.001) in the incontinent as compared with the constipated patients. With progressive rectoanal inhibitory reflex, consistently progressive increases in internal anal sphincter relaxation were found only in the incontinent group. This consistent relationship was not seen in the constipated patients or in healthy control subjects. CONCLUSIONS: Assessment of various parameters of the rectoanal inhibitory reflex yielded important information regarding the continence mechanism. Altered responses of the internal anal sphincter in anorectal disorders plays a role in the associated physiologic impairment. This may have significant clinical implications with regard to sphincter-saving resections

Sacral nerve stimulation for faecal incontinence

Faecal incontinence is a common problem. Conservative measures are effective in a significant proportion of patients. Failure of conservative management has until recently meant recourse to surgical intervention. Surgical treatment is often associated with disappointing results. Recently, sacral nerve stimulation (SNS) has been developed as a minimally invasive, effective technique for idiopathic and acquired faecal incontinence. The technique uses chronic low-level electrical stimulation of the sacral nerves, or neuromodulation, to produce a clinically beneficial effect on the distal colon and rectum, the pelvic floor and the anal sphincter complex. SNS is a 2-stage procedure: a diagnostic stage - temporary percutaneous nerve evaluation (PNE), and a therapeutic stage - permanent SNS. The predictive value of PNE is high, and the surgical trauma and morbidity of both procedures extremely low. The technique has been adapted from its original application in urinary dysfunction. It is almost impossible to produce level 1 evidence for this type of intervention; however, the results are superior to other interventions. Patient selection criteria are evolving, but there is a growing body of evidence that supports its use as first-line treatment for faecal incontinence in patients where conservative measures have failed