Long-term results of sacral neuromodulation for the treatment of anorectal diseases.

INTRODUCTION: Sacral neuromodulation (SNM) aims to improve anorectal function in patients with disorders of anal continence and rectal emptying. The mechanism of action of SNM is not well known, and its indications are still under evaluation. We report the functional results and morbidity of a prospective cohort treated between 2002 and 2019. RESULTS: A total of 284 patients (of 423 tested) had implantation of a SNM. Five patients (1.8%) were lost to follow-up. Among those who had implantation, the indications for SNM were anal incontinence (n=376), refractory constipation (n=17), anterior resection syndrome (n=13), solitary rectal ulcer syndrome (n=7), and chronic inflammatory bowel disease (IBD) (n=10). The morbidity rate was 2.7% (Dindo-Clavien>2), 33 patients (11%) required explantation for infection (n=5), pain (n=2), inefficacy (n=24) or other reasons (rectal cancer) (n=3). It was necessary to change the stimulator in 68 patients (24%) during the follow-up period. Regarding the group of patients with anal incontinence, functional results showed improvement of the incontinence score in 40% and of quality of life in 25% after a mean follow-up of 55months. CONCLUSION: SNM constitutes a mini-invasive treatment associated with low morbidity. Its' efficacy in anal incontinence makes it a priority approach. Other indications are still under evaluation; while results are promising, they are highly variable.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Innovative appliance for colostomy patients: an interventional prospective pilot study.

BACKGROUND: The control of body waste emptying is a constant research topic in stoma care. The aim of this pilot study was to assess the efficacy and safety of an innovative colostomy appliance. METHODS: An interventional prospective non-comparative pilot study was conducted in seven French centers. The study device is a new type of two-piece appliance including a base plate and a "capsule cap" (CC) composed of a capsule cover and a folded collecting bag. The device gently seals the stoma to provide stoma output control. When the bowel movement pressure increases the patient may control the deployment of the folded bag and collect stools. Patients with left-sided colostomy all using a flat appliance, were enrolled in a 2-week trial. Outcome measures were type of CC removal and peristomal fecal leaks while wearing the device. RESULTS: Of 30 patients (females 66.7%), with left-sided colostomy (permanent 76.7%), 23 (76.7%) completed the 2-week trial. A total of 472 CC changes were analyzed. EFFICACY: of 404 (85.5%) CC changes reported in diaries, 302 (74.8%) were linked with stool and/or gas. In 244 (60.3%) changes, the patient controlled stoma bag deployment and it occurred with bowel emptying 301 (74.5%) times. No leaks around the appliance were observed in 400 (85.3%) changes. SAFETY: no serious adverse event occurred. Peristomal skin was not modified during the trial. CONCLUSIONS: In the short term this new device has provided an increased control over bowel emptying at no risk in half of the trial population suggesting that an alternative approach to bag wearing is achievable.

Wound closure with Karydakis flap is decreasing the perioperative costs after pilonidal sinus excision as compared to lay-open approach.

PURPOSE: To assess the impact of a simple flap closing procedure by Karydakis flap (KF) after pilonidal sinus excision on the costs and healing time as compared to routine lay-open technique. METHOD: Out of 44 consecutive patients operated on for pilonidal excision (November 2013-March 2015), 17 had a Karydakis flap and 27 a lay-open procedure. For each patient, the length of stay, the operating time (OT), the time needed for complete healing and postoperative care resources were recorded. The global costs included OT, nursing care quantity, and modalities until complete scar healing. RESULTS: One reoperation in the lay-open group was necessary during the follow-up (8±5months). No recurrence occurred. Postoperative morbidity was similar in both groups. Results showed that KF global cost was inferior as compared to lay-open technique (941±178€ vs. 1601±399€; P=0.0001), KF healed faster (32±17 vs. 59±22days; P=0.0001), whereas OT was longer in KF group (16±7 vs. 25±4min; P=0.001). CONCLUSION: KF allows a faster healing time and a 41% lower cost than lay-open technique. Preferential use of KF rather than lay-open procedure could allow a significant health cost saving.

Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence.

BACKGROUND: The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT. METHODS: Patients aged over 18 years with FI were included in a multicentre, single-blinded RCT. The primary endpoint was reduction in the median or mean number of FI episodes per week. Secondary endpoints were changes in measures of FI severity, and disease-specific and generic quality of life. Outcomes were compared between PTNS and sham stimulation after 9 weeks of treatment. RESULTS: A higher proportion of patients in the PTNS (13 of 29) than in the sham (6 of 30) group showed a reduction of at least 50 per cent in the median number of FI episodes/week (incidence rate ratio (IRR) 2·40, 95 per cent c.i. 1·10 to 5·24; P = 0·028), but not in the mean number of episodes/week (10 of 29 versus 8 of 30; IRR 1·42, 0·69 to 2·92; P = 0·347). The absolute median number of FI episodes per week decreased in the PTNS but not in the sham group (IRR 0·66, 0·44 to 0·98; P = 0·041), as did the mean number (IRR 0·65 (0·45 to 0·97); P = 0·034). Scores on the Cleveland Clinic Florida faecal incontinence scale decreased significantly in both groups, but more steeply in the PTNS group (mean difference -1·3, 95 per cent c.i. -2·6 to 0·0; P = 0·049). The aggregated mental component score of Short Form 36 improved in the PTNS but not in the sham group (mean difference 5·1, 0·5 to 9·6; P = 0·028). CONCLUSION: PTNS may offer a small advantage in the clinical management of FI that is insufficiently responsive to conservative treatment. The key challenge will be to identify patients who may benefit most from this minimally invasive surgical procedure. Registration number: NCT00974909 (http://www.clinicaltrials.gov).

Randomized clinical trial of sacral nerve stimulation for refractory constipation.

BACKGROUND: Open studies have reported favourable results for sacral nerve stimulation in the treatment of refractory constipation. Here, its efficacy was assessed in a double-blind crossover RCT. METHODS: Patients with at least two of the following criteria were included: fewer than three bowel movements per week; straining to evacuate on more than 25 per cent of attempts; or sensation of incomplete evacuation on more than 25 per cent of occasions. Response to therapy was defined as at least three bowel movements per week and/or more than 50 per cent improvement in symptoms. Responders to an initial 3-week peripheral nerve evaluation were offered permanent implantation of a pulse generator and were assigned randomly in a crossover design to two 8-week intervals of active or sham stimulation. At the end of the two trial periods, the patients received active stimulation until the final evaluation at 1 year. RESULTS: Thirty-six patients (34 women; mean(s.d.) age 45(14) years) underwent peripheral nerve evaluation. Twenty responded and received a permanent stimulator. A positive response was observed in 12 of 20 and 11 of 20 patients after active and sham stimulation periods respectively (P = 0·746). Pain related to the device occurred in five patients and wound infection or haematoma in three, leading to definitive removal of the pulse generator in two patients. At 1 year, 11 of the 20 patients with an implanted device continued to respond. Stimulation had no significant effect on colonic transit time. CONCLUSION: These results do not support the recommendation of permanent implantation of a pulse generator in patients with refractory constipation who initially responded to temporary nerve stimulation. Registration number: NCT01629303 (http://www.clinicaltrials.gov).

Internal rectal prolapse: Definition, assessment and management in 2016.

Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.

Carcinoma arising in enteric diversion or rectal neobladder for bladder exstrophy.

Bladder exstrophy is a rare malformation. Ureteral diversion, such as ureterosigmoidostomy or a neorectal bladder, has been described. When the patients reach adulthood, cancer may arise in these reconstructions. Our aim was to perform a systematic review (all languages) of the published literature on neoplasia after urinary diversion and suggested management in cases of cancer. PubMed and Cochrane library were searched for relevant articles published within the last 20 years. All identified articles were reviewed for inclusion. Carcinoma occurring in the bladder and unreconstructed exstrophy were excluded. Out of 47 articles found, 12 matched our search criteria. The outcomes of 23 patients (including 2 from the authors' institution) were reported. Twenty-two patients with adenocarcinoma and 1 with carcinoid tumour were identified. Median age at urinary diversion was 3 (range 1-13) years. There were 20 ureterosigmoidostomies and 2 neorectal bladders. Cancer was diagnosed subsequently at a median of 31 (range 5-55) years after urinary diversion still in place (n = 18) or 21 years (range 1-30) after incomplete excision of ureteric stump when re-diverted (n = 5). The long-term outcomes of 15 patients were available. Ten died due to colorectal adenocarcinoma, and 5 were disease-free at 3 years. Patients with enteric diversion for bladder exstrophy, including those with subsequent reconstruction, are at risk of adenocarcinoma during adulthood. It is important to provide adequate surveillance. If lesions suggestive of carcinoma are seen, complete excision of the receptive bowel and urinary diversion are mandatory.

Current surgical treatment of obstructed defecation among selected European opinion leaders in pelvic floor surgery.

BACKGROUND: The aim of this study was to perform a survey on the surgical management of obstructed defecation (OD) across advocated selected coloproctological experts across Europe. METHODS: Surgeons from 42 centers of coloproctology in Europe were asked to complete a questionnaire, including seven questions about their past and present operative treatment strategy for patients with OD. RESULTS: The questionnaire was completed by 32 experts of pelvic floor surgery in 13 European countries. All but one indicated that they consider surgical treatment for OD. Seventy-four percent of these have been using transanal stapled rectal resection (STARR) and 96 % transabdominal rectopexy. While only 65 %, who have begun performing STARR are still using transanal resection, the technique is still being used by all surgeons performing abdominal procedures. Rectopexy only, STARR only, or both approaches are offered by 52, 3, and 45 % of surgeons, respectively. CONCLUSIONS: The use of STARR in the treatment of OD is decreasing among European opinion leaders in the field of pelvic floor surgery, while the application of transabdominal procedures continues.

Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons.

BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

Surgical approaches to fecal incontinence in the adult.

Surgical treatment of anal incontinence is indicated only for patients who have failed medical treatment. Sphincterorraphy is suitable in case of external sphincter rupture. In the last decade, sacral nerve stimulation has proven to be a scientifically validated solution when no sphincter lesion has been identified and more recently has also been proposed as an alternative in cases of limited sphincter defect. Anal reconstruction using artificial sphincters is still under evaluation in the literature, while indications for dynamic graciloplasty are decreasing due to its complexity and high morbidity. Less risky techniques involving intra-sphincteric injections are being developed, with encouraging preliminary results that need to be confirmed especially in the medium- and long-term. Antegrade colonic enemas instilled via cecostomy (Malone) can be an alternative to permanent stoma in patients who are well instructed in the techniques of colonic lavage. Stomal diversion is a solution of last resort.

The magnetic anal sphincter in faecal incontinence: is initial success sustained over time?

AIM: In the short term, implantation of a magnetic anal sphincter (MAS) is a safe and effective treatment for faecal incontinence (FI). In this paper we show that the initial results stand the test of time and patient satisfaction remains high in the medium term. METHOD: Data on 23 women [median age 64 (35-78) years] implanted with a MAS device between December 2008 and September 2012 were reviewed from a prospective database. Assessment was based on significant improvement of incontinence scores - the Cleveland Clinic Florida Incontinence Severity (CCF-IS) score, Faecal Incontinence Quality of Life (FIQoL) score - and patient satisfaction at 6, 12, 24 and 36 months after surgery. RESULTS: The device was removed in two patients owing to complications. Median follow-up was 17.6 months. The median preoperative CCF-IS score was 15.2 and fell to 6.9, 7.7, 7.8 and 5.3 at 6, 12, 24 and 36 months, respectively. The median FIQoL score significantly (P < 0.001) improved from 1.97 preoperatively to 3.19, 3.11, 2.92 and 2.93, respectively, at the same time periods. The concordance of the CCF-IS and FIQoL scores was 91%. Sixteen of the 23 patients were satisfied but only 14 would have recommended the MAS to someone else. Lack of improvement was the main reason for dissatisfaction. CONCLUSION: Good initial results tend to remain stable over time and about two-thirds of patients are satisfied after MAS implantation.

Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation?

AIM: Function, morbidity and recurrence of symptoms after robotic-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for pelvic floor disorders (PFDs) were compared. METHOD: Forty-four patients operated on for PFD with RVMR were compared with 74 of 144 patients who had had LVMR performed between 2008 and 2011. The groups were matched for age, body mass index, American Society of Anesthesiologists status and previous hysterectomy. The same surgical technique and type of mesh were used. Early postoperative morbidity and function [obstructed defaecation syndrome (ODS), incontinence scores (CCF) and sexual activity] were compared. RESULTS: Operation time was longer in RVMR compared with LVMR (191 ± 26 vs 163 ± 39 min; P = 0.0002). RVMR showed less blood loss (8 ± 34 vs 42 ± 88 ml; P = 0.012) and fewer early complications (2% vs 11%; P = 0.019). ODS and CCF scores improved in both groups. Patients after RVMR reported a better improvement in digitation, straining and satisfaction after defaecation. There was a statistically significant difference in the postoperative ODS score in favour of RVMR (P = 0.004). Sexually active patients in both groups reported a similar improvement. There was no difference in early recurrence (P = 0.692). CONCLUSION: Although not a randomized comparison, this study shows that ventral mesh rectopexy performed by the robot was followed by better function then LVMR.

Sexual function and laparoscopic ventral rectopexy for complex rectocoele.

AIM: Laparoscopic ventral rectopexy (LVR) has recently been shown to be feasible, safe and efficient in restoring anatomy and improving rectal emptying in female patients presenting with a posterior pelvic floor prolapse. However, little is known about the sexual function of these patients. This study aimed to assess sexual activity in a group of patients referred for complex rectocoele and the consequences on sexual comfort of their treatment after LVR. METHOD: We prospectively assessed 41 consecutive patients who underwent LVR (either laparoscopic or robotic-assisted) for symptomatic complex rectocoele from January 2009 to January 2010. We first identified sexually active patients in the cohort using a nonvalidated simplified questionnaire. The Brief Index Sexual Functioning for Women (BISF-W) questionnaire was used postoperatively to assess the impact of LVR on sexual function. Acceptability of the assessment of sexuality was also tested. The postoperative outcome of the sexually active patients was compared with data obtained from the French general population. RESULTS: Among 38 patients in whom a successful LVR had been performed (three conversions), 22 (57.9%) were sexually active preoperatively and 18 (47.4%) were sexually active postoperatively at a mean of 7±4.2months of follow-up (P=0.44). No de novo dyspareunia was reported. At baseline, 13 patients experienced dyspareunia compared with six after LVR (P=0.02). A significant improvement in dyspareunia was observed (seven patients vs two patients; P=0.03). 19 (86%) of the 22 patients responded to the BISF-W questionnaire. The mean composite score was 26.7±8.2, with 63.2% of patients estimating sexual activity as important or very important. Compared with a reference population, sexual comfort was similar in LVR patients (32.2±12.6 vs 26.7±8.2; P=0.14). CONCLUSION: Assessment of sexual function is accepted by the majority of patients suffering from pelvic floor disorders. In addition to the benefit on anatomical restoration and bowel function, LVR improves sexual function and dyspareunia in patients operated on for complex rectocoele.

An unusual case of rectal prolapse.

We report the case of a 73-year-old female who presented with rectal prolapse due to a sigmoid lipoma. This is a rare benign tumor that can result in mechanical complications; it should be resected for this reason. Transanal resection is a feasible approach.

[Double spinofixation laparoscopic versus laparoscopic robot-assisted: Morbidity, anatomical and functional short-term results]. / Double promontofixation laparoscopique versus laparoscopique robot-assistée : morbidité, résultats anatomiques et fonctionnels à court terme.

OBJECTIVE: The purpose of our study was to compare the morbidity and the short-term anatomical and functional outcome of the double promontofixation according to the surgical access laparoscopic versus laparoscopic robot-assisted. METHODS: Forty-six patients were operated for anterior and posterior promontofixation with two mesh between March 2008 and February 2010, 19 were robot-assisted (PR) and 27 laparoscopic (PL). All the patients were contacted again by telephone to answer a questionnaire estimating the functional results. RESULTS: Both groups (PR vs PL) were comparable in terms of age, score ASA and of surgical histories. There was no difference in terms of hospital stay nor per- and postoperative complications. The mean operating time was significantly more important in the group PR (P=0.049). With a mean follow-up of 10,7±7,8 months (PL) versus 8,8±5,9 months (PR), the anatomical result was good without recurrence in 93,5% of the cases. The rate of recurrence was similar in both groups with three patients who had a cystocele grade 2, two in the group PR and one in the group PL (P=0.411). The urinary and sexual functional results were comparable between both groups with an improvement of the rate of dyspareunia and dysuria. However we observed more postoperative constipation in the group PR (10/19 vs 6/27, P=0.033). CONCLUSION: The robot-assisted laparoscopic promontofixation is a reproducible technique with a morbidity and anatomical and functional results comparable to the laparoscopic way.