artificial options for the treatment of faecal incontinence m62 course 2004 norman s williams
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Artificial Options for the treatment of faecal
incontinenceM62 Course
2004
Norman S Williams
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Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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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
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
Sacral Neuromodulation
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Patient Patient CableCable
Ground Pad Ground Pad (+)(+)
Long Screener Long Screener cablecable
screenerscreener
0 3- +
Foramen needleForamen needle
PNE TEST (Acute Phase)Materials
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Sacral Nerve Stimulation(SNS)
S2 S3 S4
Percutaneous nerve evaluation (PNE)
If 50% improvement, proceed to
implantation of stimulator
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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SNSResults
Matzel et al (1995) n = 3
All improved
Vaizey et al (1999) n = 9
Success in 8 after one week PNE
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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SNSResults
Malouf et al (2000)
Permanent implantation n = 5
Median follow up 16 months
Incontinence episodesBefore After
18.2 1.6Range 2-58 Range 0-8
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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SNS Results
Kenefick et al (2002)
Permanent implantation n = 15
Median follow up 24 months
Incontinence episodesBefore After
11 0Range 2-30 Range 0-8
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Endo-anal Ultrasonography• Normal Anatomy (mid anal canal)
IAS
Female Male
EAS
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Artificial Bowel Sphincter (ABS)
ResultsLehur et al (2000) - 3-Centre Study
n = 24
7 explanted 17 remainedCuff rupture n = 4Pump failure n = 1Relocation of cuff n = 1
75% success
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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ABS Results
Malouf et al, Lancet 2000
18 implants
12 removalsSepsis n = 7Erosion n = 2Poor wound healing n = 1Rectal obstruction n = 1Psychological problem n = 1
33% success at mean 20 months
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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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
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Striated Muscle Fibres
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
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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ABS
Results
O’Brien et al 1999 n = 133 explants 10 successful
Dodi et al 2000 n = 82 explants 6 successful
Lehur et al 2000 n = 164 explants 10 of 11 successful
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Intramuscular Stimulation
Multicentre TrialMadoff et al 1999
n = 139
85 of 128 patients (66%) – success
Aquired faecal incontinence 71%
Congenital faecal incontinence 50%
Total anorectal reconstruction 66%
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Intramuscular Multicentre Trial
Complications
Madoff et al 1999
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
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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The RLH and NSCAG Funding
1997
• Funding for Supra-Regional Unit
• Assess end stage FI / APER
• Treat with ESGN
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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National Specialist Commissioning Advisory Group (NSCAG)
• Improve access to uncommon services
• Prevent proliferation of centres - maintain
high levels of expertise
• Financial support rare/expensive
treatments
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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All Neosphincter PatientsNHS & NSCAG
107 cases
65 (60%) 1988 - 1997
42 (40%) 1997 - Feb 2002
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
Influence of CDU on morbidity
32.3* 32.335.4
9.1*
18.1
43.2
0
5
10
15
20
25
30
35
40
45
1988-97 1997-2002
SepsisTechnicalPhysiological
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Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
Influence of CDU on functional outcome
45*49.2**
71.7*
19.5**
0
10
20
30
40
50
60
70
80
1988-97 1997-2002
Continent tosolid and liquid
Stoma
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• Better patient selection
• Multidisciplinary team /dedicated staff
• Purpose built equipment
• Greater experience
Possible Causes for Improvement
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Malone et al 1991
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ACE
• Appendicostomy
• Ileocaecostomy
• Colonic conduit
• Caecostomy tube or button
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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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%)
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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SEVERE RECTAL URGENCY
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Upper Rectum
Rectum
Anal Canal
Prolonged Ambulatory Manometry
High amplitude contractions (> 60mmHg) : 5/hour
(70% associated with symptoms of urgency)
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Caecum
Ileum
Small bowel mesentery
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Ileum
GIA Stapler
Rectal Augmentation Operation
Anal canal
Rectum
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200
P (
mm
Hg)
UR
MR
UR
MR
0200
P (
mm
Hg)
0
200
P (
mm
Hg)
0200
P (
mm
Hg)
0
PRE-OP
POST-OP
Day
tim
e R
ecta
lA
ctiv
ity
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Faecal Urgency
Rectal compliance
Rectal sensory
thresholds
High amplitude rectal pressure waves
Patient Selection
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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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
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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MTV
Pre-op 1 yr Post-op0
100
200
ml
P=0.002
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Compliance
Pre-op 1 yr Post op0
10
20
ml/m
mH
g
P=0.002
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Ability to defer defaecation
Pre-op 1 yr post-op0
10
20
Len
gth
of
tim
e fo
rd
efer
ral
of
def
aeca
tio
n(m
ins)
P=0.005
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry
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Clinical Outcome of Rectal Augmentation
N=12 ( 11F:1M)
Minimum Follow up=12 months
10 patients satisfied
Academic Department of Surgery - Barts & The London School of Medicine & Dentistry