Derek J. Boyle

Percutaneous tibial nerve stimulation for the treatment of urge fecal incontinence.

PURPOSE: Percutaneous tibial nerve stimulation has been shown to be an effective treatment in patients with urinary disorders, but its benefit in fecal incontinence is uncertain. This study aimed to assess the efficacy of percutaneous tibial nerve stimulation in the treatment of urge fecal incontinence. METHODS: This prospective study, conducted over a 14-month period, assessed 31 patients with urge fecal incontinence treated with percutaneous tibial nerve stimulation. The outcomes measured were: 1) reduction in fecal incontinence episodes, 2) improvement in Cleveland Clinic incontinence scores, and 3) improvement in ability to defer defecation. All analysis was performed on an intention-to-treat basis. RESULTS: The median follow-up was 9 months (range, 3–14). Twenty-one (68%) patients improved following percutaneous tibial nerve stimulation and remain satisfied with the clinical response. Median fecal incontinence episodes per week declined from 4 (range, 0–30) to 0 (range, 0–27) (P < .0001). Median Cleveland Clinic incontinence scores declined from 13 (range, 5–20) to 7 (range, 0–20) (P < .0001). Ability to defer defecation was improved significantly (P < .0001). No morbidity was encountered for any patient. CONCLUSION: This preliminary study demonstrates that percutaneous tibial nerve stimulation is an effective and very well tolerated treatment for patients with urge fecal incontinence with particular improvement in reducing fecal urgency.

Efficacy of sacral nerve stimulation for fecal incontinence in patients with anal sphincter defects.

PURPOSE: Sacral nerve stimulation has traditionally been used to treat patients with fecal incontinence with intact anal sphincters. This rationale has been challenged, but it remains unknown if its efficacy is related to the extent of the sphincter injury. METHODS: This was a prospective study of 15 patients with sphincter defects (9 combined, 2 external only, and 4 internal only) undergoing sacral nerve stimulation for fecal incontinence. Endoanal ultrasound scans were reviewed and defects scored (0–16) with use of a system published by two independent observers. These were correlated with the following outcomes: 1) reduction in fecal incontinence episodes, 2) reduction in soiling, 3) improvement in Cleveland Clinic scores, and 4) improvement in ability to defer defecation. All patients were studied after temporary stimulation and again at three to six months after permanent implantation. RESULTS: Thirteen patients (87%) progressed to permanent stimulation. Median fecal incontinence episodes per two weeks decreased from 15 (range, 1–53) to 3 (range, 0–16; P = 0.01). Median soiling episodes were reduced from 10 (range, 1–14) to 6 (range, 0–14; P = 0.009). Median Cleveland Clinic scores decreased from 12 (range, 9–18) to 9 (range, 4–14; P = 0.0005). The ability to defer defecation was improved significantly (P = 0.05). There were no relationships between sphincter defect scores and outcome measures after sacral nerve stimulation (r2 = 0.001–0.10; P = 0.28–0.94). CONCLUSION: Sacral nerve stimulation is an effective treatment in patients with fecal incontinence who have anal sphincter defects, and outcome is not associated with severity of sphincter disruption.

Efficacy of sacral nerve stimulation for the treatment of fecal incontinence.

BACKGROUND: Sacral nerve stimulation has been shown to be an effective treatment for fecal incontinence and early studies reported success rates of 67% to 100%. However, “success” has been arbitrarily set at a 50% reduction in symptoms, and data are rarely reported with “intention to treat.” OBJECTIVE: This study aimed to assess the true efficacy of sacral nerve stimulation for fecal incontinence compared with the published literature. DESIGN: This prospective 5-year study was conducted to assess 50 patients with fecal incontinence treated with sacral nerve stimulation. All analyses were performed on an intention-to-treat basis. SETTINGS: This study took place in a single tertiary referral colorectal department. PATIENTS: Fifty consecutive patients with fecal incontinence refractory to conservative management were included in the study. INTERVENTIONS: The interventions performed were temporary evaluation with or without permanent sacral nerve stimulation. MAIN OUTCOME MEASURES: Primary outcome measures were 1) attainment of continence, 2) reduction in fecal incontinence episodes, 3) improvement in Cleveland Clinic Fecal Incontinence scores, and 4) improvement in the ability to defer defecation. RESULTS: Thirteen patients (26%) did not respond at the temporary evaluation stage or were dissatisfied with the result. Ten further patients (20%) did not achieve a 50% reduction in symptoms following permanent implantation. The median follow-up was 17 months (range, 2–55), at which time 27 patients (54%) experienced a 50% or more reduction in symptoms, including 13 (26%) who achieved apparent continence. Median fecal incontinence episodes per fortnight reduced from 14 (range, 0–53) to 2 (range, 0–20; P < .0001). Median Cleveland Clinic Fecal Incontinence scores reduced from 15 (range, 3–20) to 8 (range, 0–17; P < .0001). The ability to defer defecation improved significantly (P < .0001). These results compare favorably with the published literature. LIMITATIONS: Quality of life was not assessed. CONCLUSIONS: This study demonstrates that sacral nerve stimulation can be an effective treatment for patients with fecal incontinence; however, when analyzed by intention to treat, the symptoms of fecal incontinence continue in the majority (74%) of patients.

The effects of age and childbirth on anal sphincter function and morphology in 999 symptomatic female patients with colorectal dysfunction.

BACKGROUND AND OBJECTIVES: Conflicting data exist on the contributions of advancing age and childbirth on the structure and function of the anal sphincter. This study aimed to examine the relative contributions of age and childbirth in a large cohort of women referred for investigation of symptoms of colorectal dysfunction (fecal incontinence and constipation). SETTING: This study was conducted at a specialist surgical colorectal investigation unit in a university teaching hospital. PATIENTS: Retrospective analysis was performed on prospectively collected demographic, symptom profile, and physiologic data from 3686 female patients. Strict exclusion criteria were applied, leaving 999 patients for univariate, multivariate, and logistic statistical modeling. MAIN OUTCOME MEASURES: The effects of independent variables alone and in combination on anal sphincter pressures (resting and squeeze increment) and the presence of sphincter defects (internal and external) were expressed as regression coefficients and odds ratios. RESULTS: Median age was 42 years (range, 16–88), and parity was 2 (range, 0–11); 16% were nulliparous. Three hundred sixty patients had fecal incontinence, 352 had constipation, and 287 had combined symptoms. Anal resting tone decreased with age by 0.66 cm H2O per year, and by 4.3 cm H2O per birth, and was associated with both internal and external anal sphincter defects (p = 0.0001 for both). Squeeze increment pressures decreased by 0.3 cm H2O per year, and by 3.8 cm H2O per birth; decreased pressures were, however, only significantly associated with external anal sphincter defects (p = 0.0001) as a result of childbirth. Cesarean delivery was protective against both reduced anal pressures and sphincter defects. Pudendal nerve terminal motor latencies increased bilaterally with age and with vaginal delivery; the impact of both was greater on the left nerve. Rectal sensation was unaffected by age or parity. CONCLUSIONS: Aging predominantly affects anal resting pressures; childbirth, particularly instrumental delivery, is detrimental to the structure and function of the external sphincter.

Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis.

BACKGROUND: Colonic stenting has failed to show an improvement in mortality rates in comparison with emergency surgery for acute large-bowel obstruction. However, it remains unclear which patients are more likely to benefit from this procedure. OBJECTIVE: The aim of this study is to identify factors that may be predictive of successful outcome of colonic stenting in acute large-bowel obstruction. DESIGN: All patients undergoing colonic stenting for acute large-bowel obstruction between 1999 and 2013 were studied. The demographics and characteristics of the obstructing lesion were analyzed. SETTINGS: This investigation was conducted at a district general hospital. PATIENTS: A total of 126 (76 men; median age, 76 y; range, 42–94 y) with acute large-bowel obstruction were included in the analysis. INTERVENTION: The insertion of a self-expanding metal stent was attempted for each patient to relieve the obstruction. MAIN OUTCOME MEASURES: The primary outcomes measured were technical success in the deployment of the stent, clinical decompression, and perforation rates. RESULTS: Technical deployment of the stent was accomplished in 108 of 126 (86%) patients; however, only 89 (70%) achieved clinical decompression. Successful deployment and clinical decompression was associated with colorectal cancer (p = 0.03), shorter strictures (p = 0.01), and wider angulation distal to the obstruction (p = 0.049). Perforation was associated with longer strictures (p = 0.03) LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Colonic stenting in acute large-bowel obstruction is more likely to be successful in shorter, malignant strictures with less angulation distal to the obstruction. Longer benign strictures are less likely to be successful and may be associated with an increased risk of perforation.

Electrically stimulated gracilis neosphincter for end-stage fecal incontinence: the long-term outcome.

BACKGROUND: Electrically stimulated gracilis neosphincter is an established treatment for patients with end-stage fecal incontinence. Few data, however, describe its long-term efficacy. OBJECTIVE: This study aimed to assess the long-term functional outcome associated with this procedure. DESIGN: Patients who underwent gracilis neosphincter construction between1989 and 2001 were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiologic data were available for all patients. SETTINGS: This study was conducted at an academic colorectal unit in a tertiary center. PATIENTS: Sixty patients (median age, 42 years; 46 females) with fecal incontinence and a Williams continence score ≥5 were recruited to the study. The causes of incontinence included obstetric injury (n = 22), anal surgery (n = 17), atresia (n = 7), idiopathic incontinence (n = 6), anorectal excision (n = 4), and ileoanal pouch incontinence (n = 4). MAIN OUTCOME MEASURE: The primary outcomes measured were the Williams continence score and the proportion of patients with a Williams score ⩽3 who avoided permanent stoma formation. RESULTS: Continence improved for the cohort postoperatively at 2 years (2(2–5); p < 0.001) but no significant difference was found between continence scores preoperatively and at 13 years (5(3–6); p = not significant). However, a sustained improvement at 13 years was noted for patients in the anal surgery (3(2–5);p < 0.001) and obstetric injury groups (4.5(3–6); p = 0.001). Twenty-six patients (43%) had a Williams score ⩽3 and avoided permanent stoma after 13 years. Eighteen patients developed postoperative rectal evacuatory disorder; 10 of them required a conduit to facilitate colonic irrigation. Postoperative evacuatory disorder was more frequent in patients with a history of obstetric injury (p = 0.008). LIMITATIONS: This study was limited by the lack of bowel diaries and quality-of-life scores. CONCLUSION: Gracilis neosphincter is associated with clinically significant and sustained symptom improvement in patients with end-stage fecal incontinence secondary to obstetric injury or anal surgery. These data support the continued use of this procedure in highly selected patients.

Why are so Many Patients with Rectal Cancer Still Treated with Abdominoperineal Resection in America

To the Editor—Sphincter saving resection (SSR) for rectal cancer is associated with less long-term physical and psychologic morbidity than permanent stoma formation. While specialist colorectal centers have reported SSR rates of approximately 70 to 90 percent, a recent study has suggested the true incidence of SSR in America may be as low as 48 percent. Therefore, the aim of this population based study was to determine the current incidence of sphincter preservation for rectal cancer in England and Wales. Data were collected from the Department of Health Episode Statistics (HES) database which records all inpatient stays at National Health Service (NHS) hospitals in England and Wales. In keeping with the United States National Inpatient Sample Database, HES does not record tumor staging or survival data. HES procedure codes were used to identify which patients were admitted to NHS hospitals between April 2002 and April 2005 for rectal cancer resection. The primary outcome measure was defined as the proportion of patients who avoided abdominoperineal excision of the rectum (APR) and permanent stoma construction, with the effect of age and sex on stoma avoidance identified as secondary outcomes. There were 32,679 patients admitted to NHS hospitals for rectal cancer resection, with a mean age of 66.5 years and a male:female ratio of 1.4:1. SSR was performed in 26,210 patients (80.2 percent) while 6,469 (19.8 percent) underwent APR. The rate of SSR was lower in male patients (78.8 percent) when compared with female patients (82.1 percent) (paired t test: p=0.0086). However, age did not appear to affect SSR rates. Average inpatient stay was significantly lower in patients undergoing SSR (median 15.5 days) as compared with those undergoing APR (median 18.7 days) (paired t test: p=0.0012). This study suggests that the incidence of SSR across England and Wales is comparable with rates reported by specialist colorectal units. The 30 percent discrepancy between these findings and the apparent incidence in America may be because of a number of factors, such as the Department of Health encouraging that rectal cancer should be managed by high volume specialized surgeons in England and Wales. Further studies will be required to establish if the incidence of SSR in America is truly as low as 48 percent. However, if these rates are accurate, then the American surgical community will have little option but to consider adopting the English attitude that rectal cancer surgery is a specialty operation, which ‘should no longer be in the hands of every surgeon’.