The effects of sacral nerve stimulation on continence are temporarily maintained after turning the stimulator off.

Sacral nerve stimulation is an effective treatment for urinary and faecal incontinence even though its mechanism of action is uncertain. Central nervous system involvement by 'setting-up' neurological mechanisms appointed to control pelvic function has been hypothesized. The study aimed to evaluate whether the effects of long-term sacral nerve stimulation are memorized and therefore maintained after switching off the stimulator. METHOD: Patients having sacral nerve stimulation for faecal and/or urinary incontinence for at least 1 year had the stimulator turned off and the results monitored. Data recorded with the stimulator off were compared with post-implant data. If symptoms recurred the stimulator was switched back on. Nineteen patients entered the study. Fourteen had faecal and/or urinary incontinence and five had faecal incontinence alone. The symptoms were assessed by means of a bowel function diary and dedicated questionnaire. RESULTS: In 10 patients symptoms recurred at different intervals after a median off period of 3.4 months with a probability of symptom relapse of 55%. The Fecal Incontinence Quality of Life (FIQL) score did not show any significant difference in nine patients with the stimulator off for at least 1 year. No factors predictive of symptom recurrence were identified although an idiopathic aetiology, severity of disease and urinary incontinence had higher hazard ratios. During the off period, none of the scores and episodes of incontinence showed significant changes compared with the on period. CONCLUSION: The effects of sacral nerve stimulation on faecal and urinary incontinence were maintained in about half of patients after switching the stimulator off, but in some symptoms returned after different periods of time. The data shed new light on possible effects of sacral nerve stimulation on brain neuroplasticity in the control of continence

Safety and short term effectiveness of EEA stapler vs PPH stapler in the treatment of III degree haemorrhoids. Prospective randomised controlled trial.

Abstract Introduction:  Stapled hemorrhoidopexy has gained wide acceptance due to less postoperative pain although postoperative bleeding and prolapse recurrence are among the major drawbacks of this technique compared with the standard Milligan-Morgan hemorrhoidectomy. A new stapler device has been designed to overcome these side effects . Patients and Methods:  135 patients (71 males, mean age 42) with III degree haemorrhoids were randomly allotted to stapled haemorrhoidopexy with PPH(®) 01/03 stapler (Ethicon EndoSurgery) (63 patients) or with EEA(®) stapler (Covidien) (72 patients) in 4 referral colorectal centers. The number of haemostatic overstitches apposed on the stapled suture, the area of the resected mucosa (in cm(2) ), and any postoperative bleeding within 30-days were recorded. Results:  The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35,75 ± 17,51 vs 28,05 ± 10,23 cm(2) , p=0.002). The median number of haemostatic stitches apposed in the EEA group was significantly lower than in the PPH groups (median values 1, interquantile range 0-2, vs 3, interquantile range 2-5, p<0.0001). Intraoperative haemostasis was better in the EEA group compared both to PPH 01 and PPH 03 groups. Postoperative bleeding occurred only in 2 PPH patients. Discussion:  Data suggest that the EEA stapler has better haemostatic properties in comparison with PPH and allows resection of larger area of mucosal prolapsed with potential benefits over the recurrence rate of haemorrhoid prolapse

The Three Axial Perineal Evaluation (TAPE) score: a new scoring system for comprehensive evaluation of pelvic floor function.

Abstract AIM: Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. METHOD: A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. RESULTS: There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. CONCLUSION: The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management. Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland. KEYWORDS: Pelvic floor dysfunctions; obstructed defaecation syndrome; scoring systems Comment in Comment on 'The TAPE score'. [Colorectal Dis. 2014

Protection of intestinal anastomosis with biological glues: an experimental randomized controlled trial

Background: The aim of the study was to compare the degree of healing and air tightness of hand-sewn colonic anastomoses provided by different biological glues. Methods: Thirty colonic anastomoses were fashioned in ten rabbits, at 5, 10, 15 cm from the ileocecal valve, with 4/0 PDS running sutures. Each suture was randomized to treatment with fibrin sealant (Tissucol®), a synthetic glue (Coseal®), or nothing (control). After 15 days, the rabbits were killed and the anastomoses examined for their integrity and resistance to bursting. The van der Hamm scale was used to evaluate postoperative adhesions. A blind histological evaluation of the newly formed tissue was made (Ehrlich-Hunt scale). Results: Two rabbits developed an intraabdominal abscess, one in the control anastomosis group without glue. Postoperative adhesions were present in all animals. Median anastomosis bursting pressures were 0.9 atm in all three groups: Tissucol, Coseal, and control. Pressure values were 0.9, 1.0, and 0.9 atm in the three different proximodistal sites, respectively. A trend toward an increased resistance was observed in the glued anastomosis, although this was not significant. Lymphocyte infiltration, fibroblast activity, blood vessel density, and collagen deposition were lower in controls. Anastomoses treated with Tissucol had the highest lymphocyte infiltration level. The Coseal group developed the highest rates of fibroblast activity, collagen deposition, and blood vessel neogenesis. Conclusion: The use of biological glues did not result in a statistically significantly increased bursting resistance. Histological evaluation demonstrated more intense tissue neoformation in the glue groups, particularly in the Coseal group. The role of biological glues in decreasing the leakage rate of intestinal anastomoses is uncertain, and larger trials using different protective agents are warranted

Prevalence of constipation in a tertiary referral Italian Colorectal Unit.

Epidemiology data on constipation are not commonly available, particularly in Italy Here we review the prevalence and clinical features of constipated patients attending a tertiary referral Italian center. METHODS: Clinical data of patients attending our Coloproctology Unit in the last 15 years and complaining of constipation as the main clinical features were retrospectively analyzed. Rome-III criteria were adoptedto define constipation. RESULTS: 1041/11881 patients were affected by chronic constipation (8.8%), 376 had slow-transit constipation, 497 obstructed defecation and 168 both types of constipation. 76% of them were females. Patients distribution according to sex and age was Gaussian-like only in females. In the slow-transit group, constipation was idiopathic in 59.3% and secondary to other causes in 40.7% . In patients with anatomic obstructed defecation, rectocele and intussusceptions were the main findings, while pelvic floor dissynergia was the main finding in functional outlet obstruction, although more frequently all these components were associated. In 14.8% no apparent cause was identified. CONCLUSION: Constipation accounts for about 9% of patients attending a tertiary referral Colorectal Unit. Females were much more frequently affected in both types of constipation. Anatomic and functional defecatory disturbances are frequently associated, although in 15% no evident causes were identified