N. S. Williams

Development of an electrically stimulated neoanal sphincter

In early surgical attempts to create a neoanal sphincter for patients who are faecally incontinent, skeletal muscle (usually the gracilis) has been transposed around the anal canal. Despite modifications, such as intermittent electrical stimulation, this procedure is likely to fail because the fast-twitch gracilis muscle is incapable of prolonged contraction without fatigue. Long-term electrical stimulation to convert such a muscle to a slow-twitch, fatigue-resistant muscle, though practicable, has yielded inconsistent results. We describe further modifications of this technique. A neoanal sphincter was constructed with an electrically stimulated transposed gracilis muscle in 20 incontinent patients with a deficient anal sphincter, and as part of a reconstruction in 12 patients in whom the anorectum had been excised or was congenitally absent. A totally implanted stimulator was used to convert the muscle from a fast-twitch to a slow-twitch muscle. Other modifications included vascular delay 4-6 weeks before transposition of the muscle, stimulation of the main nerve to the gracilis rather than its peripheral branches, and intermittent higher frequency stimulation. 2-4 of these modifications gave significantly fewer failures than did 0-1. With the new technique, continence has been restored in patients whose only other treatment option was a permanent stoma.

Butyrate oxidation is impaired in the colonic mucosa of sufferers of quiescent ulcerative colitis.

The short chain fatty acids, acetate, propionate, and butyrate are produced by colonic bacterial fermentation of non-starch polysaccharides. Butyrate is the major fuel source for the colonic epithelium and there is evidence to suggest that its oxidation is impaired in ulcerative colitis. Triplicate biopsy specimens were taken at colonoscopy from five regions of the large bowel in 15 sufferers of ulcerative colitis. These patients all had mild or quiescent colitis as assessed by clinical condition, mucosal endoscopic and histological appearance. The rate of oxidation of glucose, glutamine, and butyrate through to carbon dioxide was compared with that in biopsy specimens from 28 patients who had no mucosal abnormality. Butyrate (272 (199-368)) was the preferred fuel source for the colitic mucosa followed by glutamine (33 (24-62)) then glucose (7.2 (5.3-15)) pmol/micrograms/hour; medians and 95% confidence intervals, p < 0.01. There was no regional difference in the rate of utilisation of these metabolites. In the group with colitis the rate of butyrate oxidation to carbon dioxide was significantly impaired compared with that in normal mucosa decreasing from 472 (351-637) pmol/micrograms/hour to 272 (199-368) pmol/micrograms/hour; median and 95% confidence intervals, p = 0.016. The rate of glucose and glutamine utilisation were not significantly different between normal and colitic mucosa. These data confirm that in quiescent ulcerative colitis there is an impairment of butyrate oxidation.

Rectal sensorimotor dysfunction in patients with urge faecal incontinence: evidence from prolonged manometric studies

Background and aims: Although external anal sphincter dysfunction is the major cause of urge faecal incontinence, approximately 50% of such patients have evidence of rectal hypersensitivity and report exaggerated stool frequency and urgency. The contribution of rectosigmoid contractile activity to the pathophysiology of this condition is unclear, and thus the relations between symptoms, rectal sensation, and rectosigmoid motor function were investigated. Methods: Fifty two consecutive patients with urge faecal incontinence, referred to a tertiary surgical centre, and 24 volunteers, underwent comprehensive anorectal physiological investigation, including prolonged rectosigmoid manometry. Patients were classified on the basis of balloon distension thresholds into those with rectal hypersensitivity (n = 27) and those with normal rectal sensation (n = 25). Automated quantitative analysis of overall rectosigmoid contractile activities and, specifically, high amplitude contractions and rectal motor complex activity was performed. Results: External anal sphincter dysfunction was similar in both patient groups. Overall, phasic activity and high amplitude contraction frequency were greater, and rectal motor complex variables significantly altered, in those with rectal hypersensitivity. Symptoms, more prevalent in the rectal hypersensitivity group, were also more often associated with rectosigmoid contractile events. For individuals, reduced compliance and increased rectal motor complex frequency were only observed in patients with rectal hypersensitivity. Conclusions: We have identified a subset of patients with urge faecal incontinence—namely, those with rectal hypersensitivity—who demonstrated increased symptoms, enhanced perception, reduced compliance, and exaggerated rectosigmoid motor activity. Comprehensive assessment of rectosigmoid sensorimotor function, in addition to evaluation of anal function, should be considered in the investigation of patients with urge faecal incontinence.

Continent colonic conduit for rectal evacuation in severe constipation

We describe a new operation for the treatment of rectal evacuatory disorders: a continent colonic conduit, incorporating an intussuscepted valve, was constructed from the sigmoid colon. Intubation of the conduit allowed irrigation and evacuation of the distal colon and rectum. Initially all 10 patients reported a reduction in time taken and the discomfort involved in completing evacuation. The number of stools passed per week increased in 9 out of 10 patients, from a median of 1.5 (range 0.25-7) to a median of 7 (range 3-7) postoperatively. Subsequently, 3 patients developed complications, 2 of whom required conversion to an ileostomy. Overall, the colonic conduit procedure was successful in treating the rectal evacuatory disorder in 7 patients, failed in 2, and 1 patient has a temporary defunctioning ileostomy. The procedure is a relatively simple surgical alternative for the treatment of a condition which is often resistant to conservative measures.

Clinical and physiological findings, and possible aetiological factors of rectal hyposensitivity†

Rectal hyposensitivity (RH) relates to insensitivity of the rectum on anorectal physiological investigation and appears common in functional bowel disorders. The clinical significance of this physiological abnormality is unclear.

EXternal Pelvic REctal SuSpension (Express procedure) for rectal intussusception, with and without rectocele repair†‡

The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients.

Evacuation proctography – should it be part of the assessment of all patients with faecal incontinence?

Introduction:  Evacuation Proctography (EP) is rarely incorporated into the assessment of patients with faecal incontinence (FI). Continence‐restoring surgery (e.g. sphincteroplasty, ESGN) may result in the worsening or unmasking of a pre‐existing rectal evacuatory disorder (RED), or precipitate a new‐onset RED. This study compared the incidence of RED, diagnosed on EP, between patients with FI, with or without symptoms of RED.

Rectal sensory dysfunction is prevalent in faecal incontinence

Introduction:  There has been increasing interest in the role of rectal sensitivity in continence, particularly as the advent of sacral nerve stimulation (SNS). Both rectal hypersensitivity (RHyper) and hyposensitivity (RHypo) have been described in patients with faecal incontinence (FI). We aimed to determine the prevalence of rectal sensory dysfunction according to the nature of FI.

Complications and functional outcome following artificial anal sphincter implantation (Br J Surg 2002; 89: 877-881).

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When should surgeons retire? (Br J Surg 2016: 103: 35–42)

When asked to comment on this excellent review my first response was ‘Why me?’. Perhaps the editor thought that as a senior member of the profession, and one who of late has transitioned from clinical practice into other areas, I might give a balanced view. For most surgeons reaching the twilight of their surgical career the thought of retirement can be challenging. A busy clinical practice has often failed to prepare for a life away from patients and the operating theatre, so there is a natural desire to prolong it as long as possible. There is little doubt from the evidence reviewed that ageing does