Artificial Options for the treatment of faecal incontinence M62 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 Sacral Neuromodulation

Patient Cable Ground Pad (+) Long Screener cable screener Foramen needle PNE TEST (Acute Phase) Materials

Sacral Nerve Stimulation (SNS) S 2 S 3 S 4 Percutaneous nerve evaluation (PNE) If 50% improvement, proceed to implantation of stimulator Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

SNS Results 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

SNS Results Malouf et al (2000) Permanent implantationn = 5 Median follow up 16 months Incontinence episodes BeforeAfter Range 2-58Range 0-8 Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

SNS Results Kenefick et al (2002) Permanent implantationn = 15 Median follow up 24 months Incontinence episodes BeforeAfter 110 Range 2-30Range 0-8 Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Endo-anal Ultrasonography Normal Anatomy (mid anal canal) IAS Female Male EAS

Artificial Bowel Sphincter (ABS) Results Lehur et al (2000) - 3-Centre Study n = 24 7 explanted17 remained Cuff rupturen = 4 Pump failuren = 1 Relocation of cuffn = 1 75% success Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

ABS Results Malouf et al, Lancet implants 12 removals Sepsisn = 7 Erosionn = 2 Poor wound healingn = 1 Rectal obstructionn = 1 Psychological problemn = 1 33% success at mean 20 months Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Gracilis Transposition without Stimulation Author Year n Excellent/ Fair Poor Good Corman Leguit Williams Not published Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Striated Muscle Fibres Type 1 Type 2 ActivityPhasic Tonic Contraction timeFast Slow Fusion frequency25Hz 10 Hz Fatigue resistanceLow High MetabolismAnaerobic Aerobic ATPase Ph 10.4High Low Ph 4.4Low High Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

ABS Results O’Brien et al 1999n = 13 3 explants10 successful Dodi et al 2000n = 8 2 explants6 successful Lehur et al 2000n = 16 4 explants10 of 11 successful Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Intramuscular Stimulation Multicentre Trial Madoff et al 1999 n = 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

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

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

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

All Neosphincter Patients NHS & NSCAG 107 cases 65 (60%) (40%) Feb 2002 Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Influence of CDU on morbidity

Academic Department of Surgery - Barts & The London School of Medicine & Dentistry Influence of CDU on functional outcome

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

Malone et al 1991

ACE Appendicostomy Ileocaecostomy Colonic conduit Caecostomy tube or button Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Results of combination of colonic conduit and ESGN for TAR 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

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

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 (mmHg) UR MR UR MR P (mmHg) P (mmHg) P (mmHg) 0 PRE-OP POST-OP Daytime Rectal Activity

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

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

MTV Pre-op1 yr Post-op ml P=0.002 Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Compliance Pre-op1 yr Post op ml/mmHg P=0.002 Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

Ability to defer defaecation Pre-op1 yr post-op Length of time for deferral of defaecation ( mins) P=0.005 Academic Department of Surgery - Barts & The London School of Medicine & Dentistry

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