Artificial options for the treatment of faecal incontinence
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Artificial Options for the treatment of faecal incontinence. M62 Course 2004 Norman S Williams. Academic Department of Surgery - Barts & The London School of Medicine & Dentistry. Sacral Neuromodulation. Peripheral Nerve Evaluation (PNE TEST)

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Artificial Options for the treatment of faecal incontinence

M62 Course

2004

Norman S Williams


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry


Sacral Neuromodulation

  • Peripheral Nerve Evaluation

  • (PNE TEST)

  • Acute Phase to test the functional relevance and integrity of each sacral spinal nerve to striated anal sphincter function

  • Subchronic Phase to assess the therapeutic potential of sacral spinal nerve stimulation in individual patients


PNE TEST (Acute Phase)

Materials

Long Screener cable

Ground Pad (+)

screener

Patient Cable

Foramen needle

03- +


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Sacral Nerve Stimulation

(SNS)

S2 S3 S4

Percutaneous nerve evaluation (PNE)

If 50% improvement, proceed to

implantation of stimulator


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

SNS

Results

Matzel et al (1995)n = 3

All improved

Vaizey et al (1999)n = 9

Success in 8 after one week PNE


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

SNS

Results

Malouf et al (2000)

Permanent implantationn = 5

Median follow up 16 months

Incontinence episodes

BeforeAfter

18.21.6

Range 2-58Range 0-8


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

SNS Results

Kenefick et al (2002)

Permanent implantationn = 15

Median follow up 24 months

Incontinence episodes

BeforeAfter

110

Range 2-30Range 0-8


Endo-anal Ultrasonography

  • Normal Anatomy (midanal canal)

EAS

IAS

Female

Male


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Artificial Bowel Sphincter (ABS)

Results

Lehur et al (2000) - 3-Centre Study

n = 24

7 explanted17 remained

Cuff rupturen = 4

Pump failuren = 1

Relocation of cuffn = 1

75% success


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

ABS

Results

Malouf et al, Lancet 2000

18 implants

12 removals

Sepsisn = 7

Erosionn = 2

Poor wound healingn = 1

Rectal obstructionn = 1

Psychological problemn = 1

33% success at mean 20 months


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Gracilis Transposition without Stimulation

Author Year n Excellent/ Fair Poor

Good

Corman 1985 14 7 4 3

Leguit 1985 10 7 2 1

Williams Not 9 0 1 8

published


Striated Muscle Fibres

Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Type 1 Type 2

ActivityPhasic Tonic

Contraction timeFast Slow

Fusion frequency25Hz 10 Hz

Fatigue resistanceLow High

MetabolismAnaerobic Aerobic

ATPase Ph 10.4High Low

Ph 4.4Low High


ABS

Results

Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

O’Brien et al 1999n = 13

3 explants10 successful

Dodi et al 2000n = 8

2 explants6 successful

Lehur et al 2000n = 16

4 explants10 of 11 successful


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Intramuscular Stimulation

Multicentre Trial

Madoff et al 1999

n = 139

85 of 128 patients (66%) – success

Aquired faecal incontinence 71%

Congenital faecal incontinence 50%

Total anorectal reconstruction 66%


Intramuscular Multicentre Trial

Complications

Madoff et al 1999

Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

n=28

Major wound complications 41(32)

Minor wound complications 37(29)

Pain 28(22)

Device/stimulation problems 14(11)

Tendon development 4(3)

Other 14(11)

Total 138


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

The RLH and NSCAG Funding

  • 1997

  • Funding for Supra-Regional Unit

  • Assess end stage FI / APER

  • Treat with ESGN


National Specialist Commissioning Advisory Group (NSCAG)

Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

  • Improve access to uncommon services

  • Prevent proliferation of centres - maintain

  • high levels of expertise

  • Financial support rare/expensive

  • treatments


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

All Neosphincter PatientsNHS & NSCAG

107 cases

65 (60%) 1988 - 1997

42 (40%) 1997 - Feb 2002


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Influence of CDU on morbidity


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Influence of CDU on functional outcome


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Possible Causes for Improvement

  • Better patient selection

  • Multidisciplinary team /dedicated

  • staff

  • Purpose built equipment

  • Greater experience


Malone et al 1991


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

ACE

  • Appendicostomy

  • Ileocaecostomy

  • Colonic conduit

  • Caecostomy tube or button


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Results of combination of colonic conduit and ESGN for TAR

  • 1994-1999 Follow up median 53 months (range 7-98)

  • n=16 patients

  • 8 (50%) success, 7 of whom continent for solids and liquids

  • End stoma fashioned in 6 (38%)


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

SEVERE RECTAL URGENCY


Prolonged Ambulatory Manometry

Upper Rectum

Rectum

Anal Canal

High amplitude contractions (> 60mmHg) : 5/hour

(70% associated with symptoms of urgency)


Small bowel mesentery

Caecum

Ileum


Rectal Augmentation Operation

GIA Stapler

Rectum

Ileum

Anal canal


UR

200

P (mmHg)

PRE-OP

0

200

MR

P (mmHg)

Daytime Rectal

Activity

0

UR

200

P (mmHg)

POST-OP

0

200

MR

P (mmHg)

0


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Patient Selection

Faecal Urgency

Rectal compliance

Rectal sensory thresholds

High amplitude rectal pressure waves


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

  • Rectal Augmentation

  • n=13

  • 12 patients have fully completed their

  • procedures

  • 7 = combined dynamic graciloplasty &

  • augmentation

  • 5 = rectal augmentation (alone)

  • 1 patient who had rectal augmentation

  • alone wishes to keep ileostomy permanently


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

MTV

200

100

ml

P=0.002

0

Pre-op

1 yr Post-op


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Compliance

20

ml/mmHg

10

P=0.002

0

Pre-op

1 yr Post op


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Ability to defer defaecation

20

deferral of defaecation

Length of time for

(mins)

10

P=0.005

0

Pre-op

1 yr post-op


Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Clinical Outcome of Rectal Augmentation

N=12 ( 11F:1M)

Minimum Follow up=12 months

10 patients satisfied


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