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Artificial Options for the treatment of faecal incontinence

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

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  1. Artificial Options for the treatment of faecal incontinence M62 Course 2004 Norman S Williams

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

  3. 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

  4. PNE TEST (Acute Phase) Materials Long Screener cable Ground Pad (+) screener Patient Cable Foramen needle 03- +

  5. 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

  6. 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

  7. 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

  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

  9. Endo-anal Ultrasonography • Normal Anatomy (midanal canal) EAS IAS Female Male

  10. 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

  11. 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

  12. 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

  13. Striated Muscle Fibres 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

  14. ABS 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

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

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

  17. 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%

  18. 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

  19. 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

  20. 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

  21. 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

  22. Academic Department of Surgery - Barts & The London School of Medicine & Dentistry Influence of CDU on morbidity

  23. Academic Department of Surgery - Barts & The London School of Medicine & Dentistry Influence of CDU on functional outcome

  24. 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

  25. Malone et al 1991

  26. Academic Department of Surgery - Barts & The London School of Medicine & Dentistry ACE • Appendicostomy • Ileocaecostomy • Colonic conduit • Caecostomy tube or button

  27. 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%)

  28. Academic Department of Surgery - Barts & The London School of Medicine & Dentistry SEVERE RECTAL URGENCY

  29. Prolonged Ambulatory Manometry Upper Rectum Rectum Anal Canal High amplitude contractions (> 60mmHg) : 5/hour (70% associated with symptoms of urgency)

  30. Small bowel mesentery Caecum Ileum

  31. Rectal Augmentation Operation GIA Stapler Rectum Ileum Anal canal

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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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