artificial options for the treatment of faecal incontinence m62 course 2004 norman s williams

Artificial Options for the treatment of faecal

incontinenceM62 Course

2004

Norman S Williams

Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

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

Patient Patient CableCable

Ground Pad Ground Pad (+)(+)

Long Screener Long Screener cablecable

screenerscreener

0 3- +

Foramen needleForamen needle

PNE TEST (Acute Phase)Materials

Sacral Nerve Stimulation(SNS)

S2 S3 S4

Percutaneous nerve evaluation (PNE)

If 50% improvement, proceed to

implantation of stimulator


SNSResults

Matzel et al (1995) n = 3

All improved

Vaizey et al (1999) n = 9

Success in 8 after one week PNE


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


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


Endo-anal Ultrasonography• Normal Anatomy (mid anal canal)

IAS

Female Male

EAS

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


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


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


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


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


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%


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


The RLH and NSCAG Funding

1997

• Funding for Supra-Regional Unit

• Assess end stage FI / APER

• Treat with ESGN


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


All Neosphincter PatientsNHS & NSCAG

107 cases

65 (60%) 1988 - 1997

42 (40%) 1997 - Feb 2002



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


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

• Better patient selection

• Multidisciplinary team /dedicated staff

• Purpose built equipment

• Greater experience

Possible Causes for Improvement


Malone et al 1991

ACE

• Appendicostomy

• Ileocaecostomy

• Colonic conduit

• Caecostomy tube or button


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%)


SEVERE RECTAL URGENCY


Upper Rectum

Rectum

Anal Canal

Prolonged Ambulatory Manometry

High amplitude contractions (> 60mmHg) : 5/hour

(70% associated with symptoms of urgency)

Caecum

Ileum

Small bowel mesentery

Ileum

GIA Stapler

Rectal Augmentation Operation

Anal canal

Rectum

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

Faecal Urgency

Rectal compliance

Rectal sensory

thresholds

High amplitude rectal pressure waves

Patient Selection


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


MTV

Pre-op 1 yr Post-op0

100

200

ml

P=0.002


Compliance

Pre-op 1 yr Post op0

10

20

ml/m

mH

g

P=0.002


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


Clinical Outcome of Rectal Augmentation

N=12 ( 11F:1M)

Minimum Follow up=12 months

10 patients satisfied


artificial options for the treatment of faecal incontinence m62 course 2004 norman s williams

Documents

sns results malouf et

abs results malouf et

sns results kenefick

sns results matzel et

abs results obrien et

sacral nerve stimulation

explants6 successful

improved vaizey et