Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients.

AIM: Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI. METHOD: Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year. RESULTS: The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome. CONCLUSION: Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience.

OBJECTIVE: Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS. METHOD: Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence. RESULTS: We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed. CONCLUSION: We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Long-term healing of Crohn's anal fistulas with fibrin glue injection.

BACKGROUND: Injecting fibrin glue has proved to be an effective means of treating anal fistulas (AF). There has been some debate, however, as to whether this technique should be used on the AF often involved in Crohn's disease (CD). AIM: To assess the effectiveness of injecting heterologous fibrin glue as a means of treating AF refractory to immunosuppressive treatment in patients with CD. METHODS: Fourteen CD patients (five men and nine women, average age 42 years) presenting with refractory AFs were included in this study. Heterologous fibrin glue was injected into the fistula tract under general anaesthesia under continuous endosonographic monitoring using a 7.5-MHz blind linear probe. The patients were followed up clinically and ultrasonographically for 3 months after the procedure, and then at regular intervals. RESULTS: Three months after the fibrin glue injection, the fistulas had completely dried up in 10 patients (71%), the leakage had decreased in one patient (7%), and no improvement was observed in the other three patients (21%). Endosonographic findings showed that the fistula tract had completely disappeared in two cases (14%). The fistula tract was found to be non-permeable in eight cases (57%), and no change in the fistula was observed in four patients (29%). At the end of the follow-up period [average 23.4 months (12-26 months)], the leakage had completely dried up in eight of the 14 patients (57%). No side effects were observed. CONCLUSION: Nearly 2 years after the use of a heterologous fibrin glue to treat an AF, over half of the patients with CD showed clinical signs of remission. Because it is easy to use and harmless as well as being effective, this method provides a good alternative to classical methods of surgical treatment.

Effects of alverine citrate on cat intestinal mechanoreceptor responses to chemical and mechanical stimuli.

BACKGROUND: Alverine citrate is commonly used in the treatment of painful affections of the colon. AIM: To determine whether alverine citrate acts on the vagal sensory endings. METHODS: Unitary recordings were performed at the level of the vagal fibres in the nodose ganglion of anaesthetized cats using extracellular glass microelectrodes, and the patterns of response to chemical and mechanical stimuli applied to identified vagal intestinal mechanoreceptors were studied. RESULTS: The intestinal mechanoreceptors located at the endings of type C vagal fibres responded mainly to mechanical stimuli (distension and contraction), but also responded to chemical substances (cholecystokinin and substance P). The most conspicuous effect of alverine (2 mg/kg) was that it significantly inhibited the pattern of vagal activity produced in response to either cholecystokinin (5-10 microg/kg), substance P (5-10 microg/kg) or phenylbiguanide (5-10 microg/kg), a 5-HT3 receptor agonist. On the other hand, the unitary vagal response to the mechanical distension was slightly enhanced by alverine, as was any spontaneous activity present. CONCLUSIONS: Based on the present data, alverine citrate can be said to decrease the sensitivity of the intestinal mechanoreceptors, which is consistent with its previously established anti-spasmodic effects.

Evidence for supraspinal nervous control of external anal sphincter motility in the cat.

The aim of this study was to investigate the role of noradrenergic descending nervous pathways in external anal sphincter motility. For this purpose, the effects of intravenously injected adrenoceptor antagonist and agonist on the tonic electrical activity of this sphincter were studied in anesthetized cats. The effects of stimulating the region of the locus coeruleus and the effects of intravenous, intracerebroventricular and intrathecal injection of the above drugs on the electromyographic responses of this muscle to pudendal nerve stimulation were also investigated. The tonic sphincteric activity and the reflex response triggered by electrically stimulating pudendal afferent nerve fibers were inhibited by alpha1-adrenoceptor antagonist nicergoline and enhanced by alpha1-adrenoceptor agonist phenylephrine. Stimulation of the locus coeruleus area either inhibited or enhanced the reflex responses. Intracerebroventricular and intrathecal injection of the alpha2-adrenoceptor agonists, morphine and leu-enkephalin decreased the amplitude of these reflex responses. All the effects of opioids were blocked by naloxone and by spinalization performed at the cervical and lumbar levels. The direct response elicited by stimulating the sphincteric motor axons was not affected either by these drugs or by the brainstem stimulation. These results suggests the existence of a pontine neuronal network controlling the motility of the external anal sphincter via noradrenergic and opioid neurons.

Bilateral bronchial anastomosis in double lung and heart-lung transplantations.

During heart-lung or double lung transplantation, the airway anastomosis is usually made at the tracheal level. Healing of this anastomosis is one source of postoperative complications especially after double lung transplantation (DLT). In this series of 10 patients with cystic fibrosis undergoing DLT, the tracheas of donor and recipient were anastomosed with omental wrapping in 2 cases while the two main stem bronchi were joined without omental wrapping in 8. Endoscopy disclosed no sign of ischaemia in the patients with bilateral bronchial anastomoses. Three patients died on day 20, 21 and 35, respectively, after DLT. Two of these patients (one with a tracheal and the other with bronchial anastomoses) showed no complication at the level of the suture line. The third patient (with bronchial suture) suffered dehiscence of both anastomoses which was attributed to a misdosage of corticosteroids. Of the 6 patients alive after bronchial anastomosis, 3 recovered uneventfully and 3 who had required prolonged postoperative mechanical ventilation developed bronchomalacia. Bronchomalacia was treated by laser resection and stenting. Dehiscence did not occur in any of these six cases. This technique was based on the findings of 12 fresh cadaver dissections showing that collaterals between the bronchial arteries and the pulmonary arteries and veins extend up to the origin of the main stem bronchus. Bronchial suture without omental wrap may be used for double lung and heart-lung transplantation instead of tracheal suture.

The value of histological study by surface analysis of preserved and injected pancreatic grafts: a prospective controlled study in dogs.

To evaluate the effects of pancreas preservation and pancreatic duct obliteration on the endocrine pancreas, three groups of dogs were used: a control group (six) in which histologic analysis of normal pancreas was performed and two randomized groups (seven) from which the caudal pancreas was auto-transplanted, injected with fibrin glue and removed on the 28th day. In Group A, each graft was flushed out with Euro-Collins' solution and immediately transplanted. In Group B, each graft was preserved 24 hours in a preservation solution and transplanted. Islet surface ratios on the sections and mean islet surfaces were greater in the control group than in Group A (p = 0.011 and 0.023) and no different between control group and Group B (p = 0.334 and 0.099). This surface analysis study suggests that the mode of management of grafts in itself explains the alteration of endocrine pancreas and that obliteration of the pancreatic ducts has little influence on this alteration.

[Laparoscopic replacement of the abdominal aorta. Experimental study in the pig]. / Remplacement laparoscopique de l'aorte abdominale. Etude expérimentale chez le porc.

BACKGROUND: Progress in abdominal laparoscopy led us to study end-to-end anastomoses performed laparoscopically. METHOD: An experimental protocol in 10 castrated male pigs weighing 74-95 kg was approved by the ethics committee. After conventional anesthesia, each animal was positioned in lateral decubitus and a retropneumoperitoneum was created. CO2 inflation was maintained at 14 mmHg for insertion of 3 trocars, 5 to 10 mm width. The entire infrarenal aorta was dissected and resected with insertion of a 6 mm dacron prosthesis. Postoperative arteriography was performed in all cases. The animal was sacrificed for direct examination. RESULTS: One animal died during anesthesia induction and the entire protocol was conducted in 9 animals. Mean operative time was 397 min (305-535 min) including a mean 123 min (65-150) for aortic dissection, 82 min (30-155) for proximal anastomosis and 70 min (45-105) for distal anastomosis. Total blood loss varied from 100 to 450 cc (mean 252 cc). Mean difference between pre- and postoperative hematocrits was 4% (0-6%). Among the 18 aortic anastomoses performed, arteriography showed one with moderate leakage and one anastomotic thrombus. Stenosis > 50% was found in 4 cases and < 50% in 4 cases. Analysis of the different operative parameters showed a learning curve with decreasing operative time and improved quality of the anastomoses. CONCLUSION: This study demonstrates the feasibility of aortic reconstruction via retroperitoneal laparoscopy in the animal. This procedure could be introduced in man.

Staging of rectal cancer: a prospective study of digital examination and endosonography before and after preoperative radiotherapy.

Between January 1988 and January 1992, 34 patients with rectal cancer were evaluated both by clinical examination and endosonography before and after pre-operative radiotherapy. Two criteria were correlated with histologic findings: confinement to the rectal wall or spread beyond, the presence of mesorectal lymph node involvement. The 32 patients who underwent endosonography before radiotherapy were staged as: uT2: 4, uT3: 26, uT4: 2 cases. Fifteen days after irradiation, endosonography showed tumour regression in all cases; uT stage was different in 15 patients, uN stage in 4 cases. Comparison of the pre-operative local invasion beyond the rectal wall with postoperative histopathy revealed a correlation with: digital examination after radiotherapy in 20 of the 31 patients with palpable tumours; endosonography before irradiation in 18 of the 32 staged tumours; endosonography after irradiation in 25 of the 32 staged tumours. The presence of mesorectal lymph node involvement determined by histologic examination was correlated with the results of endosonography after radiotherapy for 22 of the 32 staged tumours. Endosonography provides a good assessment of the tumour stage before irradiation. Since radiotherapy alters endosonographic staging of rectal cancer, this staging should be included in survival studies.