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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Sacral Neuromodulation of Medicine & Dentistry

  • 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) of Medicine & Dentistry

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 implantation n = 5

Median follow up 16 months

Incontinence episodes

Before After

18.2 1.6

Range 2-58 Range 0-8


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

SNS Results

Kenefick et al (2002)

Permanent implantation n = 15

Median follow up 24 months

Incontinence episodes

Before After

11 0

Range 2-30 Range 0-8


Endo-anal Ultrasonography of Medicine & Dentistry

  • 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 explanted 17 remained

Cuff rupture n = 4

Pump failure n = 1

Relocation of cuff n = 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

Sepsis n = 7

Erosion n = 2

Poor wound healing n = 1

Rectal obstruction n = 1

Psychological problem n = 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 of Medicine & Dentistry

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

Type 1 Type 2

Activity Phasic Tonic

Contraction time Fast Slow

Fusion frequency 25Hz 10 Hz

Fatigue resistance Low High

Metabolism Anaerobic Aerobic

ATPase Ph 10.4 High Low

Ph 4.4 Low High


ABS of Medicine & Dentistry

Results

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

O’Brien et al 1999 n = 13

3 explants 10 successful

Dodi et al 2000n = 8

2 explants 6 successful

Lehur et al 2000 n = 16

4 explants 10 of 11 successful




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 of Medicine & Dentistry

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) of Medicine & Dentistry

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
Malone et al 1991 of Medicine & Dentistry


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

ACE

  • Appendicostomy

  • Ileocaecostomy

  • Colonic conduit

  • Caecostomy tube or button


Results of combination of colonic conduit and esgn for tar

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 of Medicine & Dentistry

Upper Rectum

Rectum

Anal Canal

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

(70% associated with symptoms of urgency)


Small bowel mesentery of Medicine & Dentistry

Caecum

Ileum


Rectal Augmentation Operation of Medicine & Dentistry

GIA Stapler

Rectum

Ileum

Anal canal


UR of Medicine & Dentistry

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


Clinical outcome of rectal augmentation

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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