Ghislain Devroede

Segmental colonic transit time

Mean segmental transit time of radiopaque markers through the right colon, left colon and rectosigmoid areas of adults and children has been calculated from their distribution on consecutive plain films of the abdomen. Overall mean transit does not differ significantly in the large bowel between adults and children. However, there are regional differences within the colon in relation to age. Mean transit time in the right colon is 13.8 hours in adults and 7.7 in children (p<0.01). Corresponding values in the left colon are 14.1 and 8.7 hours (p<0.02) and, in the rectum, 11 and 12.4 hours (p=NS). The percentage of the mean total large bowel transit time spent in the right colon, left colon and rectosigmoid area are respectively for adults and children 33±4 and 28±3 per cent (p=NS); 39±4 and 32±4 per cent (p=NS); and 28±4 and 41±4 per cent (p<0.05), indicating a relative stagnation in the rectosigmoid area of children. These physiologic differences may have implications in diseased states.

Sacral nerve stimulation for fecal incontinence: Results of a 120-patient prospective multicenter study

Background:Sacral nerve stimulation has been approved for use in treating urinary incontinence in the United States since 1997, and in Europe for both urinary and fecal incontinence (FI) since 1994. The purpose of this study was to determine the safety and efficacy of sacral nerve stimulation in a large population under the rigors of Food and Drug Administration-approved investigational protocol. Methods:Candidates for SNS who provided informed consent were enrolled in this Institutional Review Board-approved multicentered prospective trial. Patients showing ≥50% improvement during test stimulation received chronic implantation of the InterStim Therapy (Medtronic; Minneapolis, MN). The primary efficacy objective was to demonstrate that ≥50% of subjects would achieve therapeutic success, defined as ≥50% reduction of incontinent episodes per week at 12 months compared with baseline. Results:A total of 133 patients underwent test stimulation with a 90% success rate, and 120 (110 females) of a mean age of 60.5 years and a mean duration of FI of 6.8 years received chronic implantation. Mean follow-up was 28 (range, 2.2–69.5) months. At 12 months, 83% of subjects achieved therapeutic success (95% confidence interval: 74%–90%; P < 0.0001), and 41% achieved 100% continence. Therapeutic success was 85% at 24 months. Incontinent episodes decreased from a mean of 9.4 per week at baseline to 1.9 at 12 months and 2.9 at 2 years. There were no reported unanticipated adverse device effects associated with InterStim Therapy. Conclusion:Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with FI.

What is the meaning of colorectal transit time measurement

This study was done to understand the different available methods used to calculate colorectal transit times. A single abdominal radiograph is taken following six successive daily ingestions of the same number of identical radiopaque markers. This method correlates well (P< 0.001) with that using a single ingestion of markers with daily x-ray films until total expulsion. In techniques used to measure colorectal transit time with multiple ingestion of markers, the number of days of ingestion depends on the kinetics of marker defecation. This was found to differ markedly in various groups of control subjects and constipated patients (P< 0.001) and can be used to obtain reliable data, even in subjects with severe constipation. When they ingest 20 markers, constipated patients are found to retain eight or more markers three days after ingestion, and taking a plain film of the abdomen on that day is sufficient to make a diagnosis of constipation. Transit time studies are reproducible from month to month in patients with an irritable bowel syndrome. Control subjects who claim that their bowel habits are not modified by stress have shorter transit times, similar in both sexes, than those who say they are (P<0.001). This may explain why a large percentage of constipated patients have been found by most authors to have “normal” colorectal transit times. The choice of control subjects is thus a key element in studies of functional bowel motor disorders. Stool frequency and consistency, in health, correlate only to rectosigmoid transit time.

Constipation with colonic inertia. A manifestation of systemic disease

Transit of radiopaque markers was delayed in the ascending colon of 51 females and 3 males treated for severe idiopathic constipation. Onset of symptoms was between age 10 and 20 in more than half of the patients. Eighteen percent had previously undergone unnecessary laparotomy for large bowel pseudoobstruction. Stool frequency ranged from 1 stool every three days to 1 every 2 months. Twenty-six percent suffered from fecal incontinence. In addition, 30% had orthostatic hypotension and 15% galactorrhea of idiopathic origin. Patients had a higher than normal anal pressure (P<0.001). They all had a rectoanal inhibitory reflex, but it was abnormal in 76%. In the upper esophageal sphincter, resting pressure was higher (P<0.02), and coordination poorer (P<0.05) than in normal control subjects. Incidence of spontaneous tertiary contractions in the body of the esophagus was greater than normal (P<0.03). In the lower esophageal sphincter, resting pressure was lower (P=0.001) and gastroesophageal gradient weaker (P=0.05). Closing pressure of the sphincter was lower (P<0.001) and coordination less adequate (P<0.02). After subcutaneous injection of 0.035 mg/kg bethanechol, urinary bladder intraluminal pressure increased by over 15 cm H2O in 31% of patients but never did in controls, and average maximal pressure was greater (P<0.025). Time taken to reach peak pressure was shorter (P<0.01). This study provides evidence that patients who suffer from constipation with colonic inertia also have abnormal function in other hollow viscera. The high incidence of extraintestinal symptoms provides further suggestion of the existence of one or more underlying systemic diseases.

Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence

BACKGROUND: Limited data have been published regarding the long-term results of sacral nerve stimulation, or sacral neuromodulation, for severe fecal incontinence. OBJECTIVES: The aim was to assess the outcome of sacral nerve stimulation with the use of precise tools and data collection, focusing on the long-term durability of the therapy. Five-year data were analyzed. DESIGN: Patients entered in a multicenter, prospective study for fecal incontinence were followed at 3, 6, and 12 months and annually after device implantation. PATIENTS: Patients with chronic fecal incontinence in whom conservative treatments had failed or who were not candidates for more conservative treatments were selected. INTERVENTIONS: Patients with ≥50% improvement over baseline in fecal incontinence episodes per week during a 14-day test stimulation period received sacral nerve stimulation therapy. MAIN OUTCOME MEASURES: Patients were assessed with a 14-day bowel diary and Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index questionnaires. Therapeutic success was defined as ≥50% improvement over baseline in fecal incontinence episodes per week. All adverse events were collected. RESULTS: A total of 120 patients (110 women; mean age, 60.5 years) underwent implantation. Seventy-six of these patients (63%) were followed a minimum of 5 years (maximum, longer than 8 years) and are the basis for this report. Fecal incontinence episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89% (n = 64/72) having ≥50% improvement (p < 0.0001) and 36% (n = 26/72) having complete continence. Fecal Incontinence Quality of Life scores also significantly improved for all 4 scales between baseline and 5 years (n = 70; p < 0.0001). Twenty-seven of the 76 (35.5%) patients required a device revision, replacement, or explant. CONCLUSIONS: The therapeutic effect and improved quality of life for fecal incontinence is maintained 5 years after sacral nerve stimulation implantation and beyond. Device revision, replacement, or explant rate was acceptable, but future efforts should be aimed at improvement.

Long-Term efficacy and safety of sacral nerve stimulation for fecal incontinence

BACKGROUND AND OBJECTIVE: Sacral nerve stimulation is effective in the treatment of urinary incontinence and is currently under Food and Drug Administration review in the United States for fecal incontinence. Previous reports have focused primarily on short-term results of sacral nerve stimulation for fecal incontinence. The present study reports the long-term effectiveness and safety of sacral nerve stimulation for fecal incontinence in a large prospective multicenter study. DESIGN AND METHODS: Patients with fecal incontinent episodes more than twice per week were offered participation in this multicentered prospective trial. Patients showing ≥50% improvement during test stimulation were offered chronic implantation of the InterStim Therapy system (Medtronic; Minneapolis, MN). The aims of the current report were to provide 3-year follow-up data on patients from that study who underwent sacral nerve stimulation and were monitored under the rigors of an Food and Drug Administration-approved investigational protocol. RESULTS: One hundred thirty-three patients underwent test stimulation with a 90% success rate, of whom 120 (110 females) with a mean age of 60.5 years and a mean duration of fecal incontinence of 7 years received chronic implantation. Mean length of follow-up was 3.1 (range, 0.2–6.1) years, with 83 patients completing all or part of the 3-year follow-up assessment. At 3 years follow-up, 86% of patients (P < .0001) reported ≥50% reduction in the number of incontinent episodes per week compared with baseline and the number of incontinent episodes per week decreased from a mean of 9.4 at baseline to 1.7. Perfect continence was achieved in 40% of subjects. The therapy also improved the fecal incontinence severity index. Sacral nerve stimulation had a positive impact on the quality of life, as evidenced by significant improvements in all 4 scales of the Fecal Incontinence Quality of Life instrument at 12, 24, and 36 months of follow-up. The most common device- or therapy-related adverse events through the mean 36 months of follow-up included implant site pain (28%), paresthesia (15%), change in the sensation of stimulation (12%), and infection (10%). There were no reported unanticipated adverse device effects associated with sacral nerve stimulation therapy. CONCLUSIONS: Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with fecal incontinence. These data support long-term safety and effectiveness to 36 months.

Anismus as a marker of sexual abuse: Consequences of abuse on anorectal motility

Anorectal manometry was performed in 40 women, who consulted for functional disorders of the lower gastrointestinal tract and had been sexually abused. Anismus, defined as a rise in anal pressure during straining, was observed in 39 of 40 abused women, but in only six of 20 healthy control women (P<0.0001). Other parameters of anorectal manometry were compared with those observed in another control group composed of 31 nonabused women but with anismus, as well as the group of healthy controls. A decreased amplitude of anal voluntary contraction and an increased threshold volume in perception of rectal distension were observed in both abused and nonabused patients. A decreased amplitude of rectoanal inhibitory reflex, little rise in rectal pressure upon straining, frequent absence of initial contraction during rectal distension, and increased resting pressure at the lower part of the anal canal were observed in abused but not in nonabused patients, suggesting that these abnormalities, in association with anismus, suggest a pattern of motor activity in the anal canal that could be indicative of sexual abuse.

Functional importance of extrinsic parasympathetic innervation to the distal colon and rectum in man.

Abstract A patient with multiple sclerosis had a bladder incontinence due to hyperactivity of the detrusor muscle. She underwent resection of the nervi erigentes in an attempt to relieve this symptom. After the procedure, she immediately lost rectal sensation and the ability to defecate. Fluoroscopic examination of the colon after perfusion with diluted barium revealed motility of the right colon, but little progression of the substance towards the left colon. Transit time through the large intestine of 20 radio-opaque markers introduced by mouth was markedly slower in the patient than in 9 healthy control subjects. In particular, the distribution of the markers in the large intestine, as determined on daily plain films of the abdomen, revealed that, in the patient, the markers were retained longer in the right colon, appeared later, and were retained longer in the left colon, and none was excreted within 8 days. The distal colon and rectum were bypassed by a Soave type of procedure, anastomosing the right part of the transverse colon to the dentate line. At laparotomy, the left colon and left half of the transverse colon were strikingly dilated and did not show any sign of haustration. After the procedure, the transit time of radio-opaque markers returned to normal. Pathological examination revealed thickening of the muscularis mucosae in the specimen as compared with control colons resected for unobstructed carcinomas. In addition, there was neuronal loss, decrease in size of the remaining neurons, and marked focal Schwann cell hyperplasia. It is concluded that the nervi erigentes have ramifications to the left colon and left half of the transverse colon in man, and that this parasympathetic extrinsic innervation to the distal large intestine plays an important role in the maintenance of normal defecation.

Idiopathic constipation by colonic dysfunction. Relationship with personality and anxiety.

The personality of two groups of constipated women (by delayed colonic transit or by colonic inertia) was compared to that of two control groups of arthritic patients (rheumatoid or degenerative disease) with the Minnesota Multiphasic Personality Inventory (MMPI). All subjects suffered from chronic pain. Constipated women were found to have significantly higher scores on the hypochondria, hysteria, control, and low back pain scales and a lower score on the masculinity—femininity scale. Discriminant analysis permitted us to sort out constipated from arthritic patients in 83% of the cases, on the basis of only the personality data. In women with constipation by delayed colonic transit, multiple regression analysis demonstrated a close link (r=0.90;P<0.001 between transit time in the ascending colon and levels of anxiety. It is concluded that women with constipation of colonic origin have a different pattern of personality than arthritic women and that severe constipation may play the role of a defense mechanism, where psychophysiologic responses to life stresses replace normal emotional reactions.

Comparative Esophageal and Anorectal Motility in Scleroderma

Esophageal and anorectal pressures were recorded in 26 patients (4 men and 22 women) with scleroderma. Eleven patients suffered from a localized form of the disease and 15 from progressive systemic sclerosis. The latter only had marked functional abnormalities in esophageal and anorectal motility. Mean resting pressure at the lower esophageal sphincter of patients with progressive system sclerosis and controls was, respectively, 6 +/- 2 and 25 +/- 1 mmHg (p less than 0.001); mean closing pressure was 5 +/- 5 and 48 +/- 3 mmHg (p less than 0.001); coordination of opening the lower esophageal sphincter with the oncoming contraction in the distal esophagus was 0% and 68% +/- 5% (p less than 0.001); and relaxation (fall of the lower esophageal sphincter pressure to resting levels in the stomach) was 18% +/- 12% and 98% +/- 1% (p less than 0.001). The rectoanal inhibitory reflex was of lesser amplitude than normal in 74% of patients with progressive system sclerosis and was absent in 13%. Quantitative analysis demonstrated a significant reduction in response to rectal distention with 20 or more ml of air (p less than 0.001). There was a correlation between the amplitude of the lower esophageal sphincter relaxation and the amplitude of the rectoanal inhibitory reflex in response to rectal distention with 30-50 ml of air (p less than 0.05 to p less than 0.025). Our data show that in systemic sclerosis, anorectal motility is as frequently abnormal as esophageal motility.