Artificial Options for the treatment of faecal incontinence

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Artificial Options for the treatment of faecal
incontinence

• M62 Course
• 2004
• Norman S Williams

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Sacral Neuromodulation

• 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

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PNE TEST (Acute Phase) Materials
Long Screener cable
Ground Pad ()
screener
Patient Cable
Foramen needle
0 3-
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Sacral Nerve Stimulation (SNS)
S2 S3 S4 Percutaneous nerve evaluation
(PNE) If 50 improvement, proceed to implantation
of stimulator
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SNS Results
Matzel et al (1995) n 3 All improved Vaizey
et al (1999) n 9 Success in 8 after one week
PNE
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SNS Results Malouf et al (2000)
Permanent implantation n 5 Median follow up 16
months Incontinence episodes Before After 18.2
1.6 Range 2-58 Range 0-8
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SNS Results Kenefick et al (2002)
Permanent implantation n 15 Median follow up 24
months Incontinence episodes Before After 11
0 Range 2-30 Range 0-8
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Endo-anal Ultrasonography

• Normal Anatomy (mid anal canal)

EAS
IAS
Female
Male
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Artificial Bowel Sphincter (ABS) Results Lehur et
al (2000) - 3-Centre Study n 24
7 explanted 17 remained Cuff rupture n
4 Pump failure n 1 Relocation of
cuff n 1 75 success
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ABS Results Malouf et al, Lancet 2000
18 implants 12 removals Sepsis n
7 Erosion n 2 Poor wound healing n
1 Rectal obstruction n 1 Psychological
problem n 1 33 success at mean 20 months
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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
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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
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ABS Results
OBrien et al 1999 n 13 3 explants 10
successful Dodi et al 2000 n 8 2 explants 6
successful Lehur et al 2000 n 16 4
explants 10 of 11 successful
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Intramuscular Stimulation Multicentre
Trial Madoff et al 1999
n 139 85 of 128 patients (66)
success Aquired faecal incontinence 71
Congenital faecal incontinence 50 Total
anorectal reconstruction 66
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Intramuscular Multicentre Trial
Complications Madoff et al 1999
n28 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
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The RLH and NSCAG Funding

• 1997
• Funding for Supra-Regional Unit
• Assess end stage FI / APER
• Treat with ESGN

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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

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All Neosphincter PatientsNHS NSCAG
107 cases 65 (60) 1988 - 1997 42 (40) 1997 -
Feb 2002
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Influence of CDU on morbidity
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Influence of CDU on functional outcome
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Possible Causes for Improvement

• Better patient selection
• Multidisciplinary team /dedicated
• staff
• Purpose built equipment
• Greater experience

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Malone et al 1991
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ACE

• Appendicostomy
• Ileocaecostomy
• Colonic conduit
• Caecostomy tube or button

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Results of combination of colonic conduit and
ESGN for TAR

• 1994-1999 Follow up median 53 months (range
  7-98)
• n16 patients
• 8 (50) success, 7 of whom continent for solids
  and liquids
• End stoma fashioned in 6 (38)

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SEVERE RECTAL URGENCY
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Prolonged Ambulatory Manometry
Upper Rectum
Rectum
Anal Canal
High amplitude contractions (gt 60mmHg) 5/hour
(70 associated with symptoms of urgency)
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Small bowel mesentery
Caecum
Ileum
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Rectal Augmentation Operation
GIA Stapler
Rectum
Ileum
Anal canal
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200
UR
P (mmHg)
PRE-OP
0
MR
200
P (mmHg)
Daytime Rectal Activity
0
UR
200
P (mmHg)
POST-OP
0
200
MR
P (mmHg)
0
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Patient Selection
Faecal Urgency
Rectal compliance
Rectal sensory thresholds
High amplitude rectal pressure waves
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• Rectal Augmentation
• n13
• 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

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MTV
200
100
ml
P0.002
0
Pre-op
1 yr Post-op
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Compliance
20
ml/mmHg
10
P0.002
0
Pre-op
1 yr Post op
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Ability to defer defaecation
20
deferral of defaecation
Length of time for
(mins)
10
P0.005
0
Pre-op
1 yr post-op
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Clinical Outcome of Rectal Augmentation

• N12 ( 11F1M)
• Minimum Follow up12 months
• 10 patients satisfied