Artificial Options for the treatment of faecal incontinenceM62 Course2004Norman S Williams

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 CableGround Pad (+)Long Screener cablescreener0 3 - +Foramen needlePNE TEST (Acute Phase)Materials

Sacral Nerve Stimulation(SNS)S2 S3 S4Percutaneous nerve evaluation (PNE)If 50% improvement, proceed toimplantation of stimulator

SNSResults

Matzel et al (1995)n = 3All improved

Vaizey et al (1999)n = 9Success in 8 after one week PNE

SNSResultsMalouf et al (2000)Permanent implantationn = 5Median follow up 16 monthsIncontinence episodesBeforeAfter18.21.6Range 2-58Range 0-8

SNS ResultsKenefick et al (2002)Permanent implantationn = 15Median follow up 24 monthsIncontinence episodesBeforeAfter110Range 2-30Range 0-8

Endo-anal UltrasonographyNormal Anatomy (mid anal canal)IASFemaleMaleEAS

Artificial Bowel Sphincter (ABS)ResultsLehur et al (2000) - 3-Centre Study

n = 247 explanted17 remainedCuff rupturen = 4Pump failuren = 1Relocation of cuffn = 175% success

ABS ResultsMalouf et al, Lancet 200018 implants12 removalsSepsisn = 7Erosionn = 2Poor wound healingn = 1Rectal obstructionn = 1Psychological problemn = 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 FibresType 1 Type 2ActivityPhasic TonicContraction timeFast SlowFusion frequency25Hz 10 HzFatigue resistanceLow HighMetabolismAnaerobic AerobicATPase Ph 10.4High Low Ph 4.4Low High

ABSResultsOBrien et al 1999n = 133 explants10 successful

Dodi et al 2000n = 82 explants6 successful

Lehur et al 2000n = 164 explants10 of 11 successful

Intramuscular StimulationMulticentre TrialMadoff et al 1999n = 139 85 of 128 patients (66%) successAquired faecal incontinence 71% Congenital faecal incontinence 50% Total anorectal reconstruction 66%

Intramuscular Multicentre Trial ComplicationsMadoff et al 1999 n=28Major 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 Funding1997 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 Patients NHS & NSCAG107 cases 65 (60%) 1988 - 199742 (40%) 1997 - Feb 2002

Influence of CDU on morbidity

Influence of CDU on functional outcome

Better patient selection Multidisciplinary team /dedicated staff Purpose built equipment Greater experiencePossible Causes for Improvement

Malone et al 1991

ACEAppendicostomyIleocaecostomyColonic conduitCaecostomy tube or button

Results of combination of colonic conduit and ESGN for TAR1994-1999 Follow up median 53 months (range 7-98)n=16 patients8 (50%) success, 7 of whom continent for solids and liquidsEnd stoma fashioned in 6 (38%)

SEVERE RECTAL URGENCY

Upper RectumRectumAnal CanalProlonged Ambulatory ManometryHigh amplitude contractions (> 60mmHg) : 5/hour (70% associated with symptoms of urgency)

CaecumIleumSmall bowel mesentery

IleumGIA StaplerRectal Augmentation OperationAnal canalRectum

200P (mmHg)URMRURMR0200P (mmHg)0200P (mmHg)0200P (mmHg)0PRE-OPPOST-OPDaytime RectalActivity

Faecal UrgencyRectal complianceRectal sensory thresholdsHigh amplitude rectal pressure wavesPatient 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

MTVPre-op1 yr Post-op0100200mlP=0.002

CompliancePre-op1 yr Post op01020ml/mmHgP=0.002

Ability to defer defaecationPre-op1 yr post-op01020Length of time fordeferral of defaecation(mins)P=0.005

Clinical Outcome of Rectal Augmentation N=12 ( 11F:1M) Minimum Follow up=12 months

10 patients satisfied

The aetiology of faecal urgency is unclear but plausible mechanisms can be hypothesised and these include..