B. Bittorf

Bilateral sacral spinal nerve stimulation for fecal incontinence after low anterior rectum resection

AbstractBackground and aims. The somatomotor innervation pattern has been shown to differ in patients undergoing percutaneous nerve evaluation for sacral nerve stimulation. In some patients bilateral stimulation might improve clinical outcome; however, only single-channel pulse generators have until now been available. We report a patient with fecal incontinence after surgery for rectal carcinoma in whom a dual-channel, individually programmable, pulse generator permitted implantation of neurostimulation electrodes bilaterally. Patients and methods. Intractable fecal incontinence developed in a 48-year-old man who underwent low anterior rectum resection, owing mainly to reduced internal anal sphincter function. The morphology of the anal sphincter was without defect. Based on the findings of unilateral and bilateral temporary sacral nerve stimulation the patient underwent placement of foramen electrodes on S4 bilaterally. Both electrodes were connected to a dual-channel impulse generator for permanent low-frequency stimulation. Results. The percentage of incontinent bowel movements decreased during unilateral test stimulation from 37% to 11%, during bilateral test stimulation to 4%, and with chronic bilateral stimulation to 0%. The Wexner continence score improved from 17 preoperatively to 2, and quality of life (ASCRS score) was notably enhanced. Anorectal manometry revealed improved striated anal sphincter function; the internal anal sphincter remained unaffected. Conclusion. Sacral nerve stimulation can effectively treat incontinence after rectal resection, and bilateral stimulation can improve the therapeutic effect.

Endoscopic light-induced autofluorescence spectroscopy for the diagnosis of colorectal cancer and adenoma.

To evaluate the new, bio-optical method of light-induced autofluorescence spectroscopy for the endoscopic in-vivo diagnosis of (pre)-cancerous lesions of the colorectum, 311 endogenous fluorescence spectra were obtained from normal, adenomatous and cancerous colorectal tissue in 11 patients with cancer, six patients with familial adenomatous polyposis, and six patients with multiple adenomatous polyps. A light source delivered either white or violet-blue light for excitation of tissue autofluorescence via a flexible endoscope. Endogenous fluorescence spectra emitted by the tissue were picked up with a fiberoptic probe and analysed with a spectrograph. Biopsies were taken for definitive classification of the spectra. Rectal cancer (n=11) as well as adenomas with severe dysplasia (n=19) showed specific differences between the emitted fluorescence spectra as compared with normal mucosa and hyperplastic polyps. Having applied a mathematical algorithm to the spectra, a sensitivity of 96% and a specificity of 93% were obtained for the diagnosis of rectal cancer. The equivalent values for the diagnosis of dysplastic ademomas were 98 and 89%, respectively. Light-induced autofluorescence spectroscopy is a new and promising bio-optical procedure for the endoscopic in-vivo diagnosis of colorectal cancer and dysplasia.

The influence of abdomino-peranal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence

Objective  The most extended form of rectal resection, representing the very last option for sphincter preservation is abdomino‐peranal intersphincteric resection for tumours of the lower third which otherwise would not be resectable with preservation of the sphincter by an abdominal approach alone.

Patients with familial adenomatous polyposis experience better bowel function and quality of life after ileorectal anastomosis than after ileoanal pouch.

Objective  To evaluate the quality of life with emphasis on bowel function in patients undergoing either total colectomy with ileorectal anastomosis (IRA) or restorative proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for familial adenomatous polyposis (FAP).

Rectal resection with low anastomosis: functional outcome.

Objective  Function after anterior, low anterior and intersphincteric resection for rectal cancer was studied.

Sacral nerve stimulation in the treatment of faecal incontinence

ZusammenfassungHintergrund. Die sakrale Spinalnervstimulation ist eine relativ neue Behandlungsmethode der Stuhlinkontinenz. Die Erfahrung eines Zentrums wird vorgestellt. Patienten und Methode. Bei 16 Patienten erfolgte aufgrund des klinischen Ergebnisses einer zeitlich limitierten Teststimulation die operative Implantation eines permanenten Schrittmachersystems.Aufgrund einer Funktionsminderung des morphologisch intakten analen Spinkterkomplexes litten alle Patienten unter Inkontinenz für flüssigen und festen Stuhl. Die Ätiologie variierte. Die mediane Dauer der Symptome war 8,5 Jahre (2–30).Vor und während der Stimulation erfolgte die Evaluation der klinischen Funktion mit standardisierten Fragebögen der Cleveland Clinic Incontinence Score und dem krankheitsspezifischen Lebensqualitätsindex (FIQL-ASCRS), die Messung der anorektalen Funktion mittels anorektaler Manometrie. Ergebnisse. Eine funktionelle Verbesserung konnte bei 94% der Patienten erzielt werden. Dauerhaft wurden bei einem medianen Follow-up von 32,5 Monaten 81% der Patienten erfolgreich behandelt.Der Anteil der inkontinenten Stuhlentleerungen sank von median 40% (5–100) vor Stimulation auf 0% (0–20) unter Stimulation (p=0.001).Der Cleveland Clinic Incontinence Score besserte sich von median 17 (11–20) auf 5 (0–15) (p=0.003).Der Lebensqualitätsindex zeigte eine deutliche Verbesserung sämtlicher Parameter. Der mittlere Willkürdruck war unter Stimulation von median 44 auf 75 mmHg (p=0.003), der maximale Willkürdruck von median 69 mmHg auf 97 mmHg (p=0.009) erhöht.Ruhedruck,Perzeptionsschwelle, Drangschwelle und maximal tolerables Volumen zeigten unter Stimulation keine signifikante Veränderung. Schlussfolgerung. Die sakrale Spinalnervstimulation ist eine auch auf Dauer effiziente Therapieoption mit limitierter Morbidität in der Behandlung der Stuhlinkontinenz. Sie ist indiziert,wenn konservative Maßnahmen versagen und konventionelle chirurgische Verfahren wenig Erfolg versprechend erscheinen.AbstractBackground. Sacral nerve stimulation is a recent development in the treatment of faecal incontinence.This paper reports the experiences of a single center on the use of this technique since its first application. Patients and Method. Based on the functional results of a temporary test stimulation phase, 16 patients underwent operative implantation of a permanent neurostimulation device. Due to a functional deficit of the morphologically intact anal sphincter, all patients suffered from incontinence for liquid and solid stool.The aetiology varied among the patients.The median duration of symptoms was 8.5 years (2–30). Clinical function was evaluated by standardized questionnaires, the Cleveland Clinic incontinence score and the disease specific quality of life instrument (FIQL-ASCRS) before and during stimulation.Anorectal physiology was tested by anorectal manometry. Results. Functional improvement was achieved in 94% of the patients.At a median follow-up of 32.5 months (3–99) treatment was successful in 81%.The percentage of incontinent bowel movements decreased from a median of 40% (5–100) before stimulation to 0% (0–20) with stimulation (P=0.001). The Cleveland Clinic incontinence score improved from a median of 17 (11–20) to 5 (0–15) (P=0.003).The quality of life index was improved in all categories.Mean squeeze pressure was increased form a median of 44 to 75 mmHg with stimulation (P=0.003) and maximal squeeze pressure from a median of 69 to 97 mmHg (P=0.009). Resting pressure, perception, urge threshold and maximum tolerable volume were not significantly changed. Conclusion. Sacral nerve stimulation is an effective treatment for faecal incontinence. Morbiditiy is low.Sacral nerve stimulation is indicated, if conservative treatment fails and more conventional surgical approaches are of limited success.

Sakralnervstimulation in der Behandlung der Stuhlinkontinenz

ZusammenfassungHintergrund. Die sakrale Spinalnervstimulation ist eine relativ neue Behandlungsmethode der Stuhlinkontinenz. Die Erfahrung eines Zentrums wird vorgestellt. Patienten und Methode. Bei 16 Patienten erfolgte aufgrund des klinischen Ergebnisses einer zeitlich limitierten Teststimulation die operative Implantation eines permanenten Schrittmachersystems.Aufgrund einer Funktionsminderung des morphologisch intakten analen Spinkterkomplexes litten alle Patienten unter Inkontinenz für flüssigen und festen Stuhl. Die Ätiologie variierte. Die mediane Dauer der Symptome war 8,5 Jahre (2–30).Vor und während der Stimulation erfolgte die Evaluation der klinischen Funktion mit standardisierten Fragebögen der Cleveland Clinic Incontinence Score und dem krankheitsspezifischen Lebensqualitätsindex (FIQL-ASCRS), die Messung der anorektalen Funktion mittels anorektaler Manometrie. Ergebnisse. Eine funktionelle Verbesserung konnte bei 94% der Patienten erzielt werden. Dauerhaft wurden bei einem medianen Follow-up von 32,5 Monaten 81% der Patienten erfolgreich behandelt.Der Anteil der inkontinenten Stuhlentleerungen sank von median 40% (5–100) vor Stimulation auf 0% (0–20) unter Stimulation (p=0.001).Der Cleveland Clinic Incontinence Score besserte sich von median 17 (11–20) auf 5 (0–15) (p=0.003).Der Lebensqualitätsindex zeigte eine deutliche Verbesserung sämtlicher Parameter. Der mittlere Willkürdruck war unter Stimulation von median 44 auf 75 mmHg (p=0.003), der maximale Willkürdruck von median 69 mmHg auf 97 mmHg (p=0.009) erhöht.Ruhedruck,Perzeptionsschwelle, Drangschwelle und maximal tolerables Volumen zeigten unter Stimulation keine signifikante Veränderung. Schlussfolgerung. Die sakrale Spinalnervstimulation ist eine auch auf Dauer effiziente Therapieoption mit limitierter Morbidität in der Behandlung der Stuhlinkontinenz. Sie ist indiziert,wenn konservative Maßnahmen versagen und konventionelle chirurgische Verfahren wenig Erfolg versprechend erscheinen.AbstractBackground. Sacral nerve stimulation is a recent development in the treatment of faecal incontinence.This paper reports the experiences of a single center on the use of this technique since its first application. Patients and Method. Based on the functional results of a temporary test stimulation phase, 16 patients underwent operative implantation of a permanent neurostimulation device. Due to a functional deficit of the morphologically intact anal sphincter, all patients suffered from incontinence for liquid and solid stool.The aetiology varied among the patients.The median duration of symptoms was 8.5 years (2–30). Clinical function was evaluated by standardized questionnaires, the Cleveland Clinic incontinence score and the disease specific quality of life instrument (FIQL-ASCRS) before and during stimulation.Anorectal physiology was tested by anorectal manometry. Results. Functional improvement was achieved in 94% of the patients.At a median follow-up of 32.5 months (3–99) treatment was successful in 81%.The percentage of incontinent bowel movements decreased from a median of 40% (5–100) before stimulation to 0% (0–20) with stimulation (P=0.001). The Cleveland Clinic incontinence score improved from a median of 17 (11–20) to 5 (0–15) (P=0.003).The quality of life index was improved in all categories.Mean squeeze pressure was increased form a median of 44 to 75 mmHg with stimulation (P=0.003) and maximal squeeze pressure from a median of 69 to 97 mmHg (P=0.009). Resting pressure, perception, urge threshold and maximum tolerable volume were not significantly changed. Conclusion. Sacral nerve stimulation is an effective treatment for faecal incontinence. Morbiditiy is low.Sacral nerve stimulation is indicated, if conservative treatment fails and more conventional surgical approaches are of limited success.

Primary signet-ring cell carcinoma of the colorectum

BackgroundObjective of the study was to investigate particular clinicopathological features of colorectal signet-ring cell carcinoma.MethodsThe data of 34 patients with primary colorectal signet-ring cell carcinoma were compared with those of 4,458 consecutive patients with primary non-signet-ring cell colorectal adenocarcinoma between 1978 and 1999. For outcome analysis patients, after curative resection of signet-ring cell cancer, were matched for age, gender, tumour site and stage with patients suffering from poorly differentiated non-signet-ring cell colorectal adenocarcinoma.ResultsSignet-ring cell carcinoma patients were significantly younger than patients with non-signet-ring cell colorectal adenocarcinoma (median age 60 years vs 64 years, P=0.033). The most common tumour sites were the rectum (47%) and the right hemicolon (29%). They presented with significantly more advanced tumour stages and a significantly higher frequency of distant metastases (44% vs 21%, P=0.002). The rate of curative resections was significantly lower (35% vs 79%, P<0.001). However, the prognosis after curative resection of signet-ring cell cancer was as poor as in poorly differentiated non-signet-ring cell colorectal adenocarcinoma of the same stage (5-year survival rate 46% vs 57%, p=0.935).ConclusionsColorectal signet-ring cell carcinoma is characterized by diagnosis in more advanced tumour stages resulting in lower rates of curative resection. Prognosis is as poor as in non-signet-ring cell colorectal cancer of low differentiation in the same stage.

Cerebral representation of the anorectum using functional magnetic resonance imaging

Anorectal continence depends not only on the organs of continence but also on cerebral control. There are relatively few data regarding cerebral processing of anorectal continence.

Survival after surgical treatment of cancer of the rectum

Background and aimsRectal carcinoma is one of the most prevalent tumour types. Prognostic factors are of special interest to estimate prognosis of the individual patient.Patients/methodsThe data of 1,067 consecutive patients with solitary invasive rectal carcinoma, resected between 1988 and 1999 at the Department of Surgery of the University of Erlangen, were analysed. Cancer-related survival rate was calculated by univariate and multivariate analysis with respect to all relevant proven and probable prognostic factors.ResultsThe R classification was found to be the parameter with the greatest influence on survival of patients with rectal carcinoma. Other tumour-related prognostic factors that influenced prognosis significantly were the anatomical extent, described by the TNM classification of the UICC, tumour grade and extramural venous invasion (EVI). In addition, the operating surgeon, a therapy-related factor, and the preoperative serum CEA level were found to influence prognosis.ConclusionTumour-related prognostic factors have the greatest influence on clinical decisions with regard to choice of a therapeutic concept. The increasing survival rates after treatment of rectal carcinoma have led to a focus on postoperative quality of life. Postoperative long-term global quality of life is similar to the preoperative level. Oncological outcome is still the most important factor, and tumour recurrence leads to a strong impairment of quality of life.