Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres.

AIM: The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013. METHOD: This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded. RESULTS: A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05). CONCLUSION: The paradigm of surgical intervention for FI has changed with increasing use of SNM.

Improved longevity and efficacy of sacral nerve stimulation by simple adjustments at follow-up.

AIM: Sacral nerve stimulation (SNS) for faecal incontinence (FI) at subsensory amplitudes as low as 50% of the sensory threshold has been found to be effective at 3 months' follow-up. Furthermore, alternative pacemaker settings may improve functional outcome in patients with suboptimal treatment efficacy. In this work we aim to explore if sub-sensory stimulation as low as 50% of sensory threshold is effective at 1-year follow-up. We also aimed to investigate if 31 Hz (frequency) or 90 µs (pulse width) stimulation improved treatment efficacy in dissatisfied patients. METHOD: All patients in whom the stimulation was effective in controlling FI (satisfied group) were encouraged to have the stimulation amplitude reduced. Those in whom the device was less effective (dissatisfied group) were offered alternative frequency settings or pulse width (31 Hz or 90 µs). Patients were follow-up after 12 months and evaluated by a visual analogue scale (VAS) for patient satisfaction, the Cleveland Clinic Continence Score (CCCS), Rockwood Faecal Incontinence Quality of Life Scale (QoL) and a bowel habit diary. RESULTS: Two hundred and nineteen patients were contacted, with a response rate of 71% (n = 155). Those who were successfully contacted comprised 110 (71%) patients classed as satisfied and 45 (29%) as dissatisfied. Seventy-five (68%) of the satisfied patients agreed to have their stimulation amplitude reduced. At 1-year follow-up the median amplitude had reduced from 1.5 V [interquartile range (IQR) 0.85-2.0 V] to 0.75 V (IQR 0.45-1.4 V) (P-value < 0.001) representing an overall reduction of 39% (6.6-62.5%). There were no significant differences in VAS, CCCS or QoL despite subsensory stimulation at 1-year follow-up. In 28% of the dissatisfied patients alternative pacemaker settings improved VAS to satisfactory levels. CONCLUSION: Subsensory stimulation is as effective as stimulation at or above the sensory threshold. High-frequency stimulation (31 Hz) can improve functional outcome in patients with loss of efficacy.

Three-year follow-up of sacral nerve stimulation for patients with diarrhoea-predominant and mixed irritable bowel syndrome.

AIM: Our unit has recently shown that sacral nerve stimulation (SNS) has a significantly positive short-term effect on selected patients with diarrhoea-predominant or mixed irritable bowel syndrome (IBS). The aim of the present prospective study was to evaluate the medium-term efficacy of SNS for IBS to establish whether SNS could have a future role in the treatment of IBS. METHOD: Patients with IBS who had previously been implanted with a permanent neurostimulator as part of a randomized, controlled, crossover study, were assessed for medium-term follow-up. The primary end-point was change in the IBS-specific symptom score (Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire) from baseline to 3-year follow-up. The secondary end-point was a change in the IBS-specific quality of life score (Irritable Bowel Syndrome-Impact Scale questionnaire) from baseline to 3-year follow-up. RESULTS: Of 26 patients, 20 were eligible for 3-year follow-up. The median IBS-specific symptom score was significantly lower at 3-year follow-up (30, range 13-71) than at baseline (62, 45-80) (P = 0.0001). The effect was observed in all symptom clusters within the score. Also, the median IBS-specific quality of life score was significantly improved at 3-year follow-up (52, 26-169) compared with baseline (135, 82-180, P = 0.0002). The effect was observed in all domains of the score. As per the protocol, 75% of patients were judged therapeutic successes. Seventy per cent of patients had a more than 50% reduction in daily IBS symptoms. CONCLUSION: At medium-term follow-up, SNS continues to be an effective treatment for highly selected patients with diarrhoea-predominant or mixed IBS.

Is the efficacy of sacral nerve stimulation for faecal incontinence dependent on the number of active electrode poles achieved during permanent lead insertion?

AIM: Sacral nerve stimulation (SNS) is effective for faecal incontinence (FI). Little is known about the relationship between the implantation technique and the functional outcome. This study aimed to explore the relationship between the numbers of active electrode poles (AEP) achieved during permanent lead placement and subsequent function, therapeutic amplitude and the need for extra appointments between scheduled follow-up visits. METHOD: One hundred and eighty-six patients with FI who underwent permanent implantation between May 2009 and March 2015 with a tined (barbed) lead (3093/3080, Medtronic) using the straight stylet were registered on the European two-centre SNS prospective database (SNSPD). Correlation between the number of AEP, function, stimulation amplitude and the need for extra visits was analysed. RESULTS: The numbers of patients having an intra-operative motor response on stimulation of one, two, three and four poles were 18 (9.7%), 75 (40.3%), 61 (32.8%) and 32 (17.2%). The Wexner incontinence score was significantly reduced from 15 (±2.8) at baseline to 9.2 (±4.8) at the latest follow-up after a mean 878 ± 561 days (SD; P < 0.001). No correlation was found between the number of AEP and the functional outcome (P > 0.05). Patients with four-AEP had a reduced therapeutic amplitude up to 289 (±146) days of follow-up (P < 0.03). The number of AEP did not influence the need for extra follow-up visits (P < 0.223). CONCLUSION: The functional outcome and number of extra visits after SNS for FI did not depend on the number of AEP achieved. The therapeutic amplitude was reduced during the first postoperative year if four AEP were achieved during lead placement.

Bilateral compared with unilateral sacral nerve stimulation for faecal incontinence: results of a randomized, single-blinded crossover study.

AIM: This randomized single-blinded crossover study aimed to investigate whether bilateral sacral nerve stimulation (SNS) is more efficient than unilateral stimulation for faecal incontinence (FI). METHOD: Patients with FI who responded during a unilateral test stimulation, with a minimum improvement of 50% were eligible. Twenty-seven patients who were accepted to enter the trial were bilaterally implanted with two permanent leads and pacemakers. Patients were randomized into three periods of 4 weeks' stimulation including unilateral right, unilateral left and bilateral stimulation. Symptoms scores and bowel habit diaries were collected at baseline and in each study period. A 1-week washout was introduced between each study period. RESULTS: Twenty-seven (25 female) patients with a median age of 63 (36-84) years were bilaterally implanted from May 2009 to June 2012. The median number of episodes of FI per 3 weeks significantly decreased from 17 (3-54) at baseline to 2 (0-20) during stimulation on the right side, 2 (0-42) during stimulation on the left side and 1 (0-25) during bilateral stimulation. The Wexner incontinence score improved significantly from a median of 16 (10-20) at baseline to 9 (0-14) with right-side stimulation, 10 (0-15) with left-side stimulation and 9 (0-14) with bilateral stimulation. The differences between unilateral right or unilateral left and bilateral stimulation were non-significant, for FI episodes (P = 0.3) or for Wexner incontinence score (P = 0.9). CONCLUSION: Bilateral SNS therapy for FI is not superior to standard unilateral stimulation in the short term. Equal functional results can be obtained regardless of the side of implantation.

Lack of effect of sacral nerve stimulation for incontinence in patients with systemic sclerosis.

AIM: Systemic sclerosis (SSc) is a multisystem disorder of unknown aetiology leading to the deposition of excessive connective tissue in the skin, blood vessels and internal organs. Gastrointestinal involvement occurs in 90% of cases and the prevalence of faecal incontinence (FI) is 38%. This study comprises the largest case series assessing the efficacy of sacral nerve stimulation (SNS) treatment for incontinence in this patient group. METHOD: A retrospective analysis on prospectively collected data was performed on all SSc patients from our two centres who had undergone SNS for FI. RESULTS: Ten female patients of mean age of 54 (37-72) years had temporary SNS performed. The mean duration of FI was 13 (2-25) years. All had passive FI. Each patient had preprocedure anorectal physiology and endoanal ultrasound examinations documenting internal sphincter atrophy/fragmentation or reduced anal resting pressure. Overall there was no statistically significant difference (P = 0.57) in the total Wexner incontinence scores before (mean 15.1 ± 2.6 SD) and during temporary SNS procedures (mean 13.1 ± 3.6 SD). Two patients with a significant improvement went on to have permanent SNS with only one achieving a favourable outcome at 1 year. CONCLUSION: This study showed that SNS failed to reduce episodes of leakage in nine out of 10 patients with systemic sclerosis affected with incontinence.

Nurse-led clinics can manage faecal incontinence effectively: results from a tertiary referral centre.

AIM: In May 2010, a specialist nurse-initiated assessment and treatment algorithm for faecal incontinence (FI) was introduced at the department of Anal Physiology, Aarhus University Hospital, Denmark. This study aimed to evaluate the effectiveness of and patient satisfaction with the program. METHOD: A medical file audit was preformed on patients evaluated and treated for FI and discharged after September 2010. Patients were invited to participate in a structured telephone interview. This study aimed to enrol 100 patients. Patients were asked if they were satisfied with their current level of continence status (yes/no), and a numerical satisfaction score and Wexner score were recorded. These results were compared to baseline and at time of discharge. RESULTS: One-hundred patients completed the telephone interview; 73 of these patients were satisfied after a median of 420 (range: 114-586) days following discharge from the program. A median of one outpatient consultation followed by one telephone follow-up was required before the patients were discharged. The Wexner score was significantly reduced by 3.9 (±4.4) (P < 0.001) points among the satisfied and non-significantly reduced by 0.52 (± 3.3) (P = 0.42) points among the dissatisfied patients at follow-up compared to baseline. The satisfied and dissatisfied patients at follow-up did not differ in baseline characteristics including Wexner score. CONCLUSIONS: FI can successively be evaluated and conservatively managed by specialist nurses, and these nurses achived high satisfaction rates among their patients. The concept of specialist nurse-led clinics will reduce waiting lists, and descrease the number of patients needing to be evaluated by a surgeon.

Sacral nerve stimulation changes rectal sensitivity and biomechanical properties in patients with irritable bowel syndrome.

BACKGROUND: Sacral nerve stimulation (SNS) has been demonstrated to alleviate symptoms and improve quality of life in selected patients with irritable bowel syndrome (IBS). The mechanisms of action, however, remain unknown. The aim of the study was to evaluate the effects of SNS on rectal sensitivity and biomechanical properties in patients with IBS. METHODS: Twenty patients with diarrhea-predominant (n = 11) or mixed (n = 9) IBS were treated with SNS in a controlled, randomized crossover trial. They were randomized to either 1 month of SNS (ON) or placebo (OFF) with the opposite setting for the next month. Sensory and biomechanical parameters were assessed by multimodal rectal stimulation at the end of each period. IBS-specific symptoms were evaluated at baseline and at the end of each treatment period. KEY RESULTS: Cold stimuli were better tolerated in the ON period (19.9 °C[± 0.6]) compared to the OFF period (21.8 °C[± 0.6]; p = 0.03). Significantly lower cross-sectional areas were needed to elicit sensory responses in the ON period (1545 mm(2) [± 95]) compared to the OFF period (1869 mm(2) [± 92]; p = 0.015). The association between reduced sensory threshold and improvement of constipation was of borderline significance (p = 0.05). Wall stiffness was significantly lower in the ON period (192 mmHg[± 10]) compared to the OFF period (234 mmHg[± 10]; p = 0.004). Reduced wall stiffness was significantly associated with improved overall GSRS-IBS symptom score (p = 0.01). Reduced sensory threshold to stretch (p = 0.02) and reduced wall stiffness (p < 0.001) were predictors of the GSRS-IBS symptom score. CONCLUSIONS & INFERENCES: SNS for diarrhea-predominant and mixed IBS relaxes the rectal wall, while making it more sensitive to stretch and less sensitive to cold. Reduced wall stiffness and increased sensitivity to stretch are associated with improved GSRS-IBS symptom score.

Randomized double-blind crossover study of alternative stimulator settings in sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation is an established treatment for faecal incontinence. Nearly half of all patients experience loss of efficacy at some point. Standard reprogramming restores efficacy for some, but not all, patients. This study aimed to determine whether alternative stimulator settings would increase treatment efficacy. METHODS: Patients with sustained loss of efficacy were recruited from two international specialist centres. A number of alternative stimulation parameters were tested using a double-blind randomized crossover study design. Stimulation settings tested were pulse frequencies of 6.9 and 31 Hz, and pulse widths of 90 and 330 µs, compared with one standard setting of 14 Hz/210 µs. Treatment efficacy was evaluated using a disease-specific quality-of-life score (Fecal Incontinence Quality of Life Scale, FIQLS) and a bowel habit diary completed before randomization, during the study period and after 3 months of follow-up with one preferred setting. RESULTS: Fifteen patients were analysed. With one preferred setting, three of four subdomains in the FIQLS improved significantly. The mean(s.d.) total number of incontinence episodes dropped from 11.7(10.8) to 4.8(4.5) per 3 weeks (P = 0.011) and improvements were maintained after 3 months of follow-up. Optimal pacemaker settings were individual, but a trend towards highest patient satisfaction and improved treatment outcome was evident for high-frequency stimulation (31 Hz/210 µs), which was preferred by eight of the 15 patients. CONCLUSION: Patients experiencing loss of efficacy can experience improvement if alternative pacemaker settings are tested. High-frequency stimulation (31 Hz/210 µs) was preferred by more than half of the patients, and improved treatment outcome was sustained at 3 months.

Functional results and patient satisfaction with sacral nerve stimulation for idiopathic faecal incontinence.

AIM: Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence (FI) when conservative modalities have failed to restore continence. This two-centre study aimed to document functional outcome and its relationship to patient satisfaction. METHOD: Patients treated with SNS for idiopathic FI in Aarhus (Denmark) and Maastricht (The Netherlands) were included. At the most recent follow-up appointment, 127 patients (80%) were identified as receiving active SNS therapy. A questionnaire considering bowel habits, quality of life, and self-reported satisfaction and a 3-week bowel-habit diary were mailed to these patients, and 85% responded. RESULTS: Patient satisfaction was clearly related to the number of FI episodes. Patients experiencing full continence were all satisfied, and although the satisfaction rate decreased as the number of FI episodes increased, 46% of the patients with more FI episodes at follow-up than at baseline were still satisfied. Per-protocol analysis resulted in a satisfaction rate of 57.3%. In total, 74.7% of the patients receiving active SNS therapy reported a reduction of ≥ 50% in FI episodes, 10.3% of whom were dissatisfied after a median of 46 months of follow-up. CONCLUSION: There is a clear relationship between patient satisfaction and improved continence. A total of 57.3% of the patients offered SNS therapy were satisfied at follow-up. However, 46% of the patients with more FI episodes at follow-up than at baseline were also satisfied. Therefore, functional outcome of SNS therapy cannot be based only on bowel-habit diaries and bowel scores.

Suboptimal outcome following sacral nerve stimulation for faecal incontinence.

BACKGROUND: The aim of the study was to identify the incidence of suboptimal therapeutic responses and adverse events associated with sacral nerve stimulation (SNS) for faecal incontinence, and to determine their influence on treatment outcome. METHODS: Prospectively collected data from 176 patients who underwent SNS were reviewed retrospectively. Patient variables and reportable events were analysed by binary regression to identify the predictors of treatment outcome. RESULTS: Overall, 592 reportable events were recorded from 150 patients (85·2 per cent) at a median of 11 (interquartile range (i.q.r.) 4-26) months. Loss of efficacy (212 events, 87 patients), lack of efficacy (186 events, 68 patients) and pain/discomfort (126 events, 67 patients) accounted for 88·5 per cent of reportable events. Loss of efficacy (odds ratio (OR) 2·52, 95 per cent confidence interval 1·33 to 4·79; P = 0·007), lack of efficacy (OR 2·80, 1·46 to 5·36; P = 0·002) and pain in the leg (OR 4·07, 1·34 to 12·33; P = 0·013) were predictors of unfavourable outcome in the medium to long term. At a median follow-up of 33 (i.q.r. 20-52) months, 31 patients (17·6 per cent) had explantation of the device or discontinued treatment. CONCLUSION: Suboptimal therapeutic responses and adverse events are not uncommon when SNS is employed for faecal incontinence. They have a negative impact on treatment outcome.

Predictors of the outcome of percutaneous nerve evaluation for faecal incontinence.

BACKGROUND: The aim was to identify patient-related and operative factors that might predict the outcome of percutaneous nerve evaluation (PNE). METHODS: Demographic data (age, sex, body mass index), primary cause of incontinence, number and type of incontinence episodes, results of endoanal ultrasonography and manometry, and operative factors from 244 patients who underwent PNE for faecal incontinence were reviewed. Each factor was assessed according to the outcome, and explored by univariable and multivariable analysis to identify predictors. RESULTS: Some 191 patients (78.3 per cent) had a successful PNE. A low amplitude of sensory threshold during PNE (odds ratio (OR) 0.69 (95 per cent confidence interval 0.59 to 0.81); P < 0.001) and lead placement anterior to the sacral cortex (OR 9.06 (4.70 to 17.45); P < 0.001) were positive predictive factors for successful outcome of PNE. Neither a defect nor an abnormality of either the external (OR 0.88 (0.39 to 1.97); P = 0.749) or internal (OR 0.62 (0.27 to 1.42); P = 0.255) anal sphincter was a negative predictive factor. Demographic variables, number of incontinence episodes and the motor response threshold did not predict outcome. CONCLUSION: No preoperative predictor of PNE outcome could be identified. Predictors were limited to operative lead placement and sensory response during PNE.

Anorectal function after long-term transanal colonic irrigation.

AIM: The increased use of transanal colonic irrigation (TAI) warrants study of its effects on anorectal function after long term use. METHOD: Anorectal physiology tests were performed in 12 patients with chronic idiopathic constipation (CC) and 10 with idiopathic faecal incontinence (FI) [median 55 years (range 21-70)] before and after a median 68 (range 32-113) months use of TAI. RESULTS: In CC median, urge rectal volume increased from 121 (70-264) to 268 ml (69-484) (P = 0.05) whereas rectal compliance, volume at first sensation, maximum tolerable rectal volume, anal sensory level, median anal resting and squeeze pressures were unaltered. In FI median, urge volume increased from 125 (range 50-221) to 158 ml (range 97-287) (P = 0.033) and maximum tolerable volume increased from 156 (80-321) to 253 ml (162-332) (P = 0.047). Median anal resting pressure decreased from 48 (29-100) to 32 cmH(2) O (12-79) (P = 0.011) and anal squeeze pressure decreased from 69 (30-107) to 38 cmH(2) O (30-70) (P = 0.017). Rectal compliance, volume at first sensation and anal sensory level were unaltered. CONCLUSIONS: As rectal compliance was unaltered, it is likely that the increased rectal tolerable volume is explained by patients adapting to irrigation rather than by changes in the property of the mechanical rectal wall. As anal sphincter function was deteriorated only in FI, we suggest that this is because of the natural history of FI rather than any effect of long term TAI.

Rectal motility after sacral nerve stimulation for faecal incontinence.

Sacral nerve stimulation (SNS) is effective against faecal incontinence, but the mode of action is obscure. The aim of this study was to describe the effects of SNS on fasting and postprandial rectal motility. Sixteen patients, 14 women age 33-73 (mean 58), with faecal incontinence of various aetiologies were examined. Before and during SNS, rectal cross-sectional area (CSA) and ano-rectal pressures were determined with impedance planimetry and manometry for 1 h during fast and 1 h postprandially. Neither in the fasting state nor postprandially did SNS affect the number of single rectal contractions, total time with cyclic rectal contractions, the number of aborally and orally propagating contractions, the number of anal sampling reflexes or rectal wall tension during contractions. Postprandial changes in rectal tone were significantly reduced during SNS (P < 0.02). Before SNS, median rectal CSA was 2999 mm(2) (range: 1481-3822) during fast and 2697 mm(2) (range: 1227-3310) postprandially (P < 0.01). During SNS, median rectal CSA was 2990 mm(2) (1823-3678) during fast and 2547 mm(2) (1831-3468) postprandially (P = 0.22). SNS for faecal incontinence does not affect phasic rectal motility but it impairs postprandial changes in rectal tone.

Long-term outcome and safety of transanal colonic irrigation for neurogenic bowel dysfunction.

STUDY DESIGN: Long-term follow-up study. OBJECTIVES: Short-term results find transanal colonic irrigation (TAI) favourable in the treatment of neurogenic bowel dysfunction (NBD). Therefore, long-term results need to be described. SETTING: Department of Surgery P, Aarhus University Hospital, Denmark. METHODS: Between 1994 and 2007, 211 (115 female) patients with NBD (age: 7-81 years (median 49)) were introduced to TAI. One hundred and seventy-three patients had spinal cord injury and 38 had other neurological disorders. Data were obtained from hospital records and a mailed questionnaire. Treatment was considered successful in patients still using TAI, patients who had used TAI until they died and patients whose symptoms had resolved while using TAI. RESULTS: Successful outcome was achieved in 98 (46%) patients after a mean follow-up of 19 months (range 1-114 months). A Kaplan-Meier plot showed a dropout of 20% in the first 3 months. After 3 years, the rate of success was 35% and remained almost unchanged afterwards. A regression analysis showed male gender (odds ratio (OR) 2.1), mixed symptoms (OR 2.9) and prolonged colorectal transit time (OR 2.4) to be significantly associated with successful outcome. One non-lethal bowel perforation occurred in approximately 50,000 irrigations (0.002%), whereas minor side effects were observed in 48%. CONCLUSION: After a mean follow-up of 19 months, 46% was successfully treated. The rate of success was 35% after 3 years and remained almost unchanged afterwards. TAI is safe and can be introduced to most patients suffering from NBD.

Long-term results of antegrade colonic enema in adult patients: assessment of functional results.

PURPOSE: This retrospective study reviewed long-term results in a large group of adult patients treated with antegrade colonic enema and antegrade colonic enema combined with a colostomy. METHODS: Retrospective chart review identified 80 patients (64 females, mean age 51) surgically treated between 1993 and 2007 for fecal incontinence or constipation. Surgical treatments included 69 appendicostomies, 13 tapered ileum, 3 cecal tube, and 25 appendicostomy/neoappendicostomy combined with a colostomy. A 44-item questionnaire was mailed considering bowel regimen, complications, bowel function, social function, and quality of life. RESULTS: Sixty-nine patients were available for follow-up (mean follow-up, 75 months). Thirty patients (38 percent) had surgical complications. Forty-three patients (62 percent) were still performing antegrade continence enema and 8 patients (12 percent) no longer needed it. Accordingly, treatment was successful in 51 patients (74 percent). Twenty-seven patients (63 percent) had side effects. Evaluation of bowel function, social function, and quality of life all showed significant improvement. Antegrade continence enema was successful in patients with neurologic disabilities (67 percent), anorectal injury (53 percent), idiopathic fecal incontinence (50 percent), and idiopathic fecal constipation (42 percent). Antegrade continence enema was successful in patients with constipation, incontinence, and mixed symptoms. Results did not differ between appendicostomy, neoappendicostomy, and the combined appendicostomy/neoappendicostomy and colostomy. CONCLUSION: Long-term results were favorable in most patients treated with antegrade continence enema for fecal incontinence or constipation.

Sacral nerve stimulation for faecal incontinence alters colorectal transport.

BACKGROUND: Sacral nerve stimulation reduces the frequency of defaecation in patients with faecal incontinence. The aim of this study was to examine the mechanism behind the reduced number of bowel movements in incontinent patients treated with sacral nerve stimulation. METHODS: The study included 20 patients with faecal incontinence and a positive percutaneous nerve evaluation test: 19 women and one man, with a median age of 63 (range 28-78) years. Colorectal scintigraphy was performed to assess colorectal emptying at defaecation before and after implantation. Segmental colorectal transit times were determined using radio-opaque markers. RESULTS: The median frequency of defaecation per 3 weeks decreased from 56 (range 19-136) to 26 (range 12-78) (P < 0.002). At defaecation, antegrade transport from the ascending colon decreased from a median score of 8 (range 0-23) to 0 (range 0-11) per cent (P = 0.001), while retrograde transport from the descending colon increased from a median score of 0 (range 0-14) to 2 (range 0-30) per cent (P = 0.039). The median defaecation score was unchanged. There was a non-significant increase in median total gastrointestinal transit time from 2.5 (range 0.9-6.2) to 3.3 (range 0.8-6.2) days (P = 0.079). CONCLUSION: Sacral nerve stimulation reduces antegrade transport from the ascending colon and increases retrograde transport from the descending colon at defaecation. This may prolong colonic transit time and increase the storage capacity of the colon.

Neurogenic colorectal dysfunction - use of new antegrade and retrograde colonic wash-out methods.

OBJECTIVES: To evaluate results of the Enema Continence Catheter (ECC) and the Malone Antegrade Continence Enema (MACE) applied in patients with severe neurogenic colorectal dysfunction. METHODS: The ECC was offered to 21 patients (mean age 39.9, range 7 - 72 years). The MACE was used in eight patients (mean age 32.8 years, range 15 - 66 years). All patients still using the ECC or the MACE at follow-up were interviewed. Results from patients not available for follow-up were drawn from hospital records. RESULTS: Overall success with the ECC was found in 12 of 21 patients (57%). In patients with faecal incontinence, the ECC was successful in eight out of eleven patients (73%), while four out of ten patients (40%) with constipation were successfully treated. Overall success with the MACE was found in seven out of eight patients (87%). Successful treatment with the ECC or the MACE was followed by significant improvement in quality of life. CONCLUSION: The ECC is a simple therapeutic method in severe neurogenic colorectal dysfunction. If the ECC fails the MACE, as a minor and reversible operation, is a suitable alternative to more extensive procedures.