Effect of food additives on key bacterial taxa and the mucosa-associated microbiota in Crohn's disease. The ENIGMA study.

Food additives have been linked to the pro-inflammatory microbial dysbiosis associated with Crohn's disease (CD) but the underlying ecological dynamics are unknown. Here, we examine how selection of food additives affects the growth of multiple strains of a key beneficial bacterium (Faecalibacterium prausnitzii), axenic clinical isolates of proinflammatory bacteria from CD patients (Proteus, Morganella, and Klebsiella spp.), and the consortia of mucosa-associated microbiota recovered from multiple Crohn's disease patients. Bacterial growth of the axenic isolates was evaluated using a habitat-simulating medium supplemented with either sodium sulfite, aluminum silicate, carrageenan, carboxymethylcellulose, polysorbate 80, saccharin, sucralose, or aspartame, intended to approximate concentrations found in food. The microbial consortia recovered from post-operative CD patient mucosal biopsy samples were challenged with either carboxymethylcellulose and/or polysorbate 80, and the bacterial communities compared to unchallenged consortia by 16S rRNA gene amplicon profiling. Growth of all F. prausnitzii strains was arrested when either sodium sulfite or polysorbate 80 was added to cultures at baseline or mid-exponential phase of growth, and the inhibitory effects on the Gram-negative bacteria by sodium sulfite were conditional on oxygen availability. The effects from polysorbate 80, saccharin, carrageenan, and/or carboxymethylcellulose on these bacteria were strain-specific. In addition to their direct effects on bacterial growth, polysorbate 80 and/or carboxymethylcellulose can drive profound changes in the CD mucosa-associated microbiota via niche expansion of Proteus and/or Veillonellaceae - both implicated in early Crohn's disease recurrence. These studies on the interaction of food additives with the enteric microbiota provide a basis for dietary management in Crohn's disease.

Outcome of behavioural treatment for idiopathic chronic constipation.

BACKGROUND/AIM: Behavioural therapy is effective in patients with chronic intractable constipation despite standard treatment, but long-term results in unselected patients are unclear. This study investigates the effects of behavioural therapy on symptoms, subjective well-being, and the physical and mental quality of life. METHODS: Patients who had failed standard care for idiopathic chronic constipation underwent behavioural therapy in a specialist clinic. Symptom severity and quality of life were assessed before and after therapy using the 'Constipation Scoring System' and the Short-Form 36 questionnaire. The primary outcome was subjective perception of improvement. Secondary outcomes were symptoms of constipation and quality of life scores. RESULTS: Of 233 consecutive patients with self-reported constipation (median symptom duration 5-10 years, median age 44 years, females 86%), 180 (77%) completed treatment in a median of three (range 1-7) sessions. One hundred and sixty-five patients (71% of all referrals or 92% of those completing treatment) reported subjective improvement. Median bowel frequency improved from once every 2-7 days to 1-3 per day (P = 0.05). Pain and bloating improved in more than 80% of patients. The Short-Form 36 physical (P < 0.05) and mental (P < 0.05) composite scores improved significantly. Patients with a longer duration of symptoms were less likely to complete treatment. Digital evacuation prior to treatment was a predictor of poor outcome. CONCLUSION: Behavioural therapy is associated with significant improvement in symptoms of chronic constipation and quality of life. Non-drug therapies that successfully treat patients with functional gut disorders resistant to standard treatment are needed in the mainstream provision of care.

Improving the efficacy of sacral nerve stimulation for faecal incontinence by alteration of stimulation parameters.

BACKGROUND: Sacral nerve stimulation (SNS) is an effective treatment for faecal incontinence, but only standard stimulation parameters have been used. This study assessed the clinical impact of altering the parameters. METHODS: Twelve patients with partially improved faecal incontinence following SNS underwent acute testing to select optimal stimulation parameters; rectal compliance was used as a surrogate marker. Parameters tested were: stimulation off; frequency 14 (standard), 31 or 6.9 Hz; and pulse duration 210 (standard), 450 or 90 micros. Patients completed a 2-week bowel diary, St Mark's continence score (SMCS) and Rockwood faecal incontinence quality-of-life (FIQL) score before testing using standard settings, and after testing using optimized settings. RESULTS: Optimal settings, determined by greatest increase in rectal compliance, were shorter pulse width in five patients and higher frequency in seven. Optimized stimulation resulted in a decrease in mean episodes of incontinence from 2.3 to 1.2 per week (P = 0.031), soiling from 3.3 to 1.7 days per week (P = 0.016), faecal urgency from 31 to 18 per cent of all evacuations (P = 0.055) and SMCS from 12.3 to 8.7 (P = 0.008); the FIQL coping/behaviour score improved (P = 0.008). CONCLUSION: With a shorter pulse width and higher frequency, clinical efficacy in patients undergoing SNS for faecal incontinence can be improved.

Review article: new drug formulations, chemical entities and therapeutic approaches for the management of ulcerative colitis.

BACKGROUND: Treatment options for ulcerative colitis (UC) are expanding with the development of novel drug formulations and dosing regimens and new chemical entities. Although the goals of medical therapy for UC remain unchanged, that is to induce and to maintain remission, focus has also centred on improving patient compliance, modifying the natural course of disease and healing the mucosa. AIM: To examine novel formulations, new chemical entities and novel therapeutic approaches to the management of UC. METHODS: Searches for all studies related to UC treatment in Medline and abstracts from major national and international meetings published in the last 10 years. RESULTS: 5-Aminosalicylic acids (5-ASA) remain the standard first-line treatment for patients with mild to moderately active UC. New formulations with altered delivery, and new dosing regimens have demonstrated possible improvements in efficacy compared with historically available preparations and dosing patterns. Once-daily dosing, micropellet formulations,and high-dose tablets offer enhanced efficacy and improved compliance. 5-ASA is now recognized as a ligand for peroxisome proliferator activated receptor-gamma (PPAR-gamma) and it has a role as a chemo-preventive agent in long-standing UC. New colonic release corticosteroid formulations help to limit systemic toxicity; turmeric, tacrolimus and infliximab have shown promising results. New anti-inflammatory targeted therapies include an anti-CD3 antibody, selective integrin blockers, anti-IL-2 antibody and PPAR-gamma agonists. CONCLUSION: The evolution of novel oral 5-ASA formulations and dosage regimens,and recent development of new molecules have expanded the therapeutic armamentarium of UC.

Economic evaluation of sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence in patients who have failed conservative management. This study established the cost-effectiveness of treating patients with SNS compared with non-surgical treatment. METHODS: A decision analysis model was performed. Data from 70 patients were obtained from medical records, bowel habit diaries and Short Form 36 quality of life questionnaires. Direct medical and non-medical costs were ascertained using the 2005/2006 national tariff, national statistics, and medication, pad and device costs. Indirect non-medical costs were also estimated. RESULTS: Incontinence episodes were reduced from a median of 12 per fortnight at baseline to one per fortnight with SNS. Based on direct medical and non-medical costs, the incremental cost-effectiveness ratio (ICER) for SNS was pound25 070 per QALY gained. It cost pound1038 more per year to treat patients with SNS for a median reduction of 286 incontinence episodes, equating to pound3.63 per episode reduced. When indirect non-medical costs were included the ICER was reduced to pound12 959 per QALY gained. CONCLUSION: The ICER of pound25 070 is within the pound30 000 per QALY threshold recommended by the National Institute for Health and Clinical Excellence as an effective use of National Health Service resources with proper justification.

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: a 10-year cohort analysis.

OBJECTIVE: Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence. We aimed to identify specific factors that could predict the outcome of temporary and permanent stimulation. METHOD: A cohort analysis was performed to identify potential predictive factors in 81 patients who underwent temporary SNS at a single institution over a 10-year period (June 1996 to June 2006). Data were obtained from prospectively collected patient symptom diaries and quality of life questionnaires, operation reports, anorectal physiological studies, endoanal ultrasound images and radiology of lead placement. RESULTS: Clinical outcome of temporary screening was not affected by patient gender, age, body mass index, severity or length of symptoms. The need for a repeated temporary procedure was associated with subsequent failure during screening (P = 0.008). A low threshold to obtain a motor response during temporary lead insertion was associated with improved outcome (P = 0.048). Evidence of anal sphincter trauma was associated with a greater risk of failure (P = 0.040). However, there was no difference in medium-term outcome between patients with external anal sphincter (EAS) defects and patients with intact anal sphincter muscles. CONCLUSION: Variables have been identified that help to predict the outcome of SNS. The presence of an EAS defect should not preclude treatment.

Review article: biological drugs in Crohn's disease.

Biological drugs have opened new therapeutic horizons for treating Crohn's disease (CD), but have also brought with them issues related to immunogenicity, long-term efficacy, safety and cost. At present, inhibitors tumour necrosis factor and adhesion molecules are the most advanced in use and development. When treating luminal disease with infliximab, two-thirds of patients respond initially. The ACCENT 1 study demonstrated that 28% of initial responders are in remission for 1 year. Infliximab has also had a major impact on the management of Crohn's anorectal fistulas. The ACCENT 2 study demonstrated initial response in two-thirds of patients. One-fifth of all treated patients were healed at 1 year. Infliximab diminished the need for further surgery. Magnetic resonance imaging scanning allows the extent of deep healing to be assessed and may influence the duration of treatment. The Mayo Clinic experience in 500 patients demonstrated 6% serious adverse events related to infliximab. The TREAT registry will provide long-term safety data on a larger group of patients. Concurrent immunosuppressive drugs and pre-infusion steroids can decrease antibody formation to infliximab. Screening for tuberculosis (TB) diminishes the rate of TB activation. Biological drugs can offer great therapeutic benefit, but their use must be considered in context.

Effect of sacral neuromodulation for faecal incontinence on sexual activity.

INTRODUCTION: Faecal incontinence affects a percentage of the population and can have a significant effect on their ability to establish and maintain sexual relations. PATIENTS AND METHODS: Sixteen consecutive patients with permanent sacral neuromodulation (SNM) for faecal incontinence completed a 'Sex Life Questionnaire' at their follow up visit to ascertain whether there was any improvement in this aspect of their life. RESULTS: Nine of the sixteen patients was sexually active. These nine patients (median age 56 (35-61) years) had a significant reduction in faecal incontinence episodes per week from a median of 12 (1-55) to 1.5 (0-8.5) (P = 0.008). All nine patients reported that their sex life had been affected by feacal incontinence prior to SNM and seven had felt benefit from implantation. The median improvement in their sex life was 40% (1-100) and the percentage improvement was inversely correlated to age (r = -0.834, P = 0.005). CONCLUSION: SNM improves the quality of sexual activity in 78% of patients. More improvement seems to be gained the younger the patients.

Sacral nerve stimulation for faecal incontinence in patients with previous partial spinal injury including disc prolapse.

BACKGROUND: This study examined the use of sacral nerve stimulation (SNS) to treat faecal incontinence in patients with partial spinal injury. METHODS: Patients selected for SNS had experienced more than one episode of faecal incontinence per week to liquid or solid stool for more than 1 year and had failed maximal conservative treatment. All patients had an intact external anal sphincter. RESULTS: Temporary SNS was performed in 13 patients (median age 58.5 (range 39-73) years). The spinal insults were disc prolapse (six), trauma (four), spinal stenosis (one) or occurred during neurosurgery (two). Twelve patients (eight women and four men) had successful temporary stimulation and proceeded to permanent implantation. The median follow-up time was 12 (range 6-24) months. The mean(s.d.) number of episodes of incontinence decreased from 9.33(7.64) per week at baseline to 2.39(3.69) at last follow-up (P = 0.012). The number of days per week with incontinence and staining decreased significantly (both P < 0.001). Ability to defer defaecation improved from a median of not being able to defer (range 0-1 min) to being able to defer for 5-15 (range 0 to over 15) min (P = 0.022). CONCLUSION: SNS can benefit patients with faecal incontinence following partial spinal injury.

Systematic review of sacral nerve stimulation for faecal incontinence and constipation.

BACKGROUND AND METHOD: This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies). RESULTS: From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off. CONCLUSION: SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.

Sacral nerve stimulation for faecal incontinence in the UK.

BACKGROUND: Sacral nerve stimulation (SNS) is an effective therapy for faecal incontinence. Published studies derive largely from single centres and there is a need to determine the broader applicability of this procedure. METHODS: Prospective data were collected for all patients undergoing SNS in the UK. Records were reviewed to determine the outcome of treatment. RESULTS: In three UK centres 59 patients underwent peripheral nerve evaluation, with 46 (78 per cent) proceeding to permanent implantation. Of these 46 patients (40 women) all but two had improved continence at a median of 12 (range 1-72) months. Faecal incontinence improved from a median (range) of 7.5 (1-78) to 1 (0-39) episodes per week (P < 0.001). Urgency improved in all but five of 39 patients in whom ability to defer defaecation was determined, improving from a median of 1 (range 0-5) to 10 (range from 1 to more than 15) min (P < 0.001). Maximum anal squeeze pressure and sensory function to rectal distension changed significantly. Significant improvement occurred in general health (P = 0.024), mental health (P = 0.008), emotional role (P = 0.034), social function (P = 0.013) and vitality (P = 0.009) subscales of the Short Form 36 health survey questionnaire. There were no major complications. One implant was removed. CONCLUSION: SNS is a safe and effective treatment, in the medium to long term, for faecal incontinence when conservative treatment has failed.

Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow.

AIMS: The aim of the study was to determine if there is a permanent disorder of mucosal blood flow in patients with solitary rectal ulcer syndrome (SRUS) or a disorder related to autonomic gut innervation and physiological function that is reversible concomitant with successful treatment. Rectal mucosal blood flow was used as a validated measure of extrinsic autonomic nerve function. METHODS: Sixteen consecutive patients with SRUS (12 women; mean age 35 years) and 26 healthy controls (17 women; mean age 36 years) were studied. Laser Doppler mucosal flowmetry was performed before and after biofeedback treatment. Symptoms were documented before and after biofeedback treatment using a standardised prospectively applied questionnaire. RESULTS: Twelve of 16 patients (75%) reported subjective symptomatic improvement after treatment. Five of the 16 patients (31%) had sigmoidoscopic ulcer resolution. Pretreatment rectal mucosal blood flow was significantly lower in patients with SRUS compared with controls (163 (27) v 186 (14) flux units (FU) (mean (SD)); p<0.01). Biofeedback resulted in a significant improvement in rectal mucosal blood flow in subjects who felt subjectively better after biofeedback (p = 0.001), from 165 (30) FU to 190 (40) FU. CONCLUSION: Gut directed biofeedback is an effective behavioural treatment for the majority of patients with SRUS. Mucosal blood flow is reduced to a similar level seen in normal transit constipation, suggesting similar impaired extrinsic autonomic cholinergic nerve activity. Successful outcome following biofeedback is associated with increased rectal mucosal blood flow, suggesting that improved extrinsic innervation to the gut may be partially responsible for the response to treatment.

Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis.

BACKGROUND: Ten to 15% of patients with pouchitis experience refractory or recurrent disease. The aim of this study was to evaluate the effectiveness of a single daily high dose probiotic preparation (VSL#3) in maintaining antibiotic induced remission, and quality of life (QOL), for one year in such patients. METHODS: Patients with pouchitis at least twice in the previous year or requiring continuous antibiotics, associated with a pouchitis disease activity index (PDAI) > or =7 (0 = perfect; 18 = worst), in whom remission was induced by four weeks of combined metronidazole and ciprofloxacin, were randomised to receive VSL#3 6 g or placebo once daily for one year or until relapse. Symptomatic, endoscopic, and histological evaluations were made before, and two and 12 months after randomisation or at the time of relapse. Remission was defined as a clinical PDAI < or =2 and endoscopic PDAI < or =1. Relapse was defined as an increased clinical PDAI score > or =2 and increased endoscopic PDAI score > or =3. QOL was assessed using the inflammatory bowel disease questionnaire (IBDQ). RESULTS: Thirty six patients were randomised: 20 to VSL#3 and 16 to placebo. Remission was maintained at one year in 17 patients (85%) on VSL#3 and in one patient (6%) on placebo (p<0.0001). The IBDQ score remained high in the VSL#3 group (p = 0.3) but deteriorated in the placebo group (p = 0.0005). CONCLUSION: The once daily high dose probiotic VSL#3 is effective in maintaining antibiotic introduced remission for at least a year in patients with recurrent or refractory pouchitis. This is associated with a high level of quality of life.

Effect of sacral nerve stimulation on autonomic nerve function.

BACKGROUND: Sacral nerve stimulation has been used successfully to treat motility disorders of the bladder and bowel. The mechanism of action remains unknown. This study examined the effect of stimulation on rectal blood flow as a measure of autonomic nerve function. METHODS: Sixteen patients (15 women) of median age 59 (range 38-71) years were studied. All had undergone permanent electrode implantation for faecal incontinence, a median of 27 (range 2-62) months previously, with clinical benefit. Rectal laser Doppler flowmetry was performed at the level of chronic stimulation, without stimulation, and then at 0.1-V stepwise increments between zero and 1.0 V, and at 1-V increments to 5 V. RESULTS: There was a significant difference in the median flux between no stimulation and chronic stimulation: 545 (range 355-887) versus 869 (range 507-989) flux units (P = 0.001). Stepwise increments of 0.1 V, between zero and 1.0 V, caused a significant immediate rise in flux (P < 0.001). Further increments did not result in any further significant increase. CONCLUSION: Chronic sacral nerve stimulation has a significant effect on rectal blood flow and the autonomic innervation of the distal bowel. The response is rapidly reversible and varies in a dose-dependent manner up to a level of stimulation of 1.0 V.

Sacral nerve stimulation for faecal incontinence due to systemic sclerosis.

BACKGROUND: Faecal incontinence occurs in over one third of patients with systemic sclerosis. The aetiology is multifactorial. Conventional treatment is often unsuccessful. Sacral nerve stimulation is a new effective treatment for resistant faecal incontinence. AIMS: To evaluate sacral nerve stimulation in patients with systemic sclerosis. PATIENTS: Five women, median age 61 years (30-71), with scleroderma associated faecal incontinence were evaluated. All had failed maximal conventional treatment. Median number of preoperative weekly episodes of incontinence was 15 (7-25), median duration of incontinence was five years (5-9), and scleroderma 13 years (4-29). METHODS: All patients were screened with temporary stimulation. Those who benefited underwent permanent implantation. At baseline and after stimulation a bowel diary, the SF-36 quality of life assessment, endoanal ultrasound, and anorectal physiology were performed. RESULTS: Four patients were continent at a median follow up of 24 months (6-60). One patient failed temporary stimulation and was not permanently implanted. The weekly episodes of incontinence decreased from 15, 11, 23, and 7 to 0. Urgency resolved (median time to defer <1 minute (0-1) v 12.5 minutes (5-15)). Quality of life, especially social function, improved. Endoanal ultrasound showed an atrophic internal anal sphincter (median width 1.0 mm (0-1.6)). Anorectal physiology showed an increase in median resting pressure (37 pre v 65 cm H(2)O post) and squeeze pressure (89 v 105 cm H(2)O). Stimulation produced enhanced rectal sensitivity to distension. There were no major complications. CONCLUSIONS: Sacral nerve stimulation is a safe and effective treatment for resistant faecal incontinence secondary to scleroderma. The benefit is maintained in the medium term.

Prucalopride, a systemic enterokinetic, for the treatment of constipation.

BACKGROUND: Laxatives are frequently ineffective in treating constipation. An alternative therapeutic approach is to target serotonin-4 receptors, which are involved in initiating peristalsis. AIM: In a double-blind, placebo-controlled trial, to assess the efficacy and safety of a systemically active serotonin-4 agonist, prucalopride. METHODS: Seventy-four women with constipation were stratified into slow or normal transit groups, and each group was randomized to receive either placebo or 1 mg prucalopride daily for 4 weeks. A bowel function diary was maintained. Whole-gut and orocaecal transit, visceral sensitivity, quality of life and psychological state were assessed before and after treatment. RESULTS: Prucalopride, not placebo, increased spontaneous stool frequency (P=0.008) and reduced time to first stool (P < 0.001). Prucalopride reduced the number of retained markers in all patients compared to placebo (P=0.004). Prucalopride reduced the mean number of retained markers in slow transit (P=0.069), but did not alter the marker count in normal transit (P=0.86). Orocaecal transit was accelerated by prucalopride, not placebo (P=0.004). Prucalopride, notplacebo, increased rectal sensitivity to distension (urge volume, P=0.01) and electrical stimulation (P=0.001). Prucalopride significantly improved several domains of the Short Form Health Status Survey and the disease-specific quality of life. Adverse effects were similar for prucalopride and placebo. CONCLUSIONS: Prucalopride improves symptoms, upper gut transit and gut sensitivity in constipated patients with both slow and normal transit. It improves transit in patients with slow transit. These changes are associated with improved well-being.

Injectable silicone biomaterial for faecal incontinence due to internal anal sphincter dysfunction.

BACKGROUND: A weak or disrupted internal anal sphincter can cause passive faecal incontinence. Conservative measures may help some patients but there is no simple surgical solution for those who fail conservative treatment. A successful technique using trans-sphincteric injection of a bulking agent to augment the internal anal sphincter was developed in a previous pilot study. AIM: To determine the clinical results and underlying physiological effects of biomaterial injection. PATIENTS: Six patients (four males, median age 53 years (range 36-65)) with faecal incontinence to solid or liquid stool related to poor internal anal sphincter function, of varied aetiology, were recruited. METHODS: Silicone based biomaterial injections were performed, under local anaesthesia, with antibiotic cover. Three injections were placed circumferentially, trans-sphincterically, entering away from the anal margin and injecting at or just above the dentate line. Anorectal physiological studies, endoanal ultrasound, a bowel symptom diary, a validated incontinence score, and quality of life questionnaires were completed before treatment and on completion of follow up. RESULTS: At a median follow up of 18 months (range 15-19), five of six patients had marked symptom improvement. Faecal incontinence scores improved from a median of 14/24 (range 11-20) before to 8/24 (6-15) after injection. Short form-36 quality of life physical and social function scores improved from a median of 26/100 (5-33) to 79/100 (25-100) and from 10/100 (5-37) to 100/100 (50-100), respectively. There was a corresponding physiological increase in maximum anal resting and squeeze pressures. Ultrasound showed the Bioplastique to be retained in the correct position in the improved patients without migration. There were no complications. CONCLUSION: Trans-sphincteric injection of silicone biomaterial can provide a marked improvement in faecal incontinence related to a weak or disrupted internal anal sphincter. This is associated with improved sphincter function and quality of life.

Permanent sacral nerve stimulation for treatment of idiopathic constipation.

BACKGROUND: Constipation can usually be managed using conservative therapies. A proportion of patients require more intensive treatment. Surgery provides variable results. This paper describes an alternative approach, in which the neural control of the bowel and pelvic floor is modified, using permanent sacral nerve stimulation. METHODS: Four women (aged 27-36 years), underwent temporary and then permanent stimulation. All had idiopathic constipation, resistant to maximal therapy, with symptoms for 8-32 years. Clinical evaluation, bowel diary, Wexner constipation score, symptom analogue score, quality of life questionnaire and anorectal physiology were completed. RESULTS: There was a marked improvement in all patients with temporary, and in three with permanent, stimulation. Median follow-up was 8 (range 1-11) months. Bowel frequency increased from 1-6 to 6-28 evacuations per 3 weeks. Improvement occurred, at longest-follow-up, in median (range) evacuation score (4 (0-4) versus 1 (0-4)), time with abdominal pain (98 (95-100) versus 12 (0-100) per cent), time with bloating (100 (95-100) versus 12 (5-100) per cent), Wexner score (21 (20-22) versus 9 (1-20)), analogue score (22 (16-32) versus 80 (20-98)) and quality of life. Maximum anal resting and squeeze pressures increased. Rectal sensation was altered. Transit time normalized in one patient. CONCLUSION: Permanent sacral nerve stimulation can be used to treat patients with resistant idiopathic constipation.

Medium-term results of permanent sacral nerve stimulation for faecal incontinence.

BACKGROUND: Anal sphincter surgery for faecal incontinence is associated with significant morbidity and a variable outcome. Sacral nerve stimulation may provide a good functional outcome with minimal morbidity. This paper reports the experience in a single centre over 5 years. METHODS: Fifteen consecutive patients (14 women), median age 60 (range 37-71) years, underwent temporary, and subsequent permanent, stimulation. All had incontinence to solid or liquid stool; the aetiology was obstetric injury (seven patients), scleroderma (four), idiopathic (two), fistula surgery (one) and repaired rectal prolapse (one). Median duration of symptoms was 6 (range 2-15) years. Clinical evaluation, endoanal ultrasonography, bowel diary, quality of life questionnaire (Short Form (SF) 36) and anorectal physiological testing were performed before and after stimulation. RESULTS: Continence had improved in all patients at median follow-up of 24 (range 3-60) months. Eleven patients were fully continent. Episodes of faecal incontinence decreased from median (range) 11 (2-30) per week before stimulation to 0 (0-4) per week after permanent stimulation (P < 0.001). Urgency improved in all patients (median (range) ability to defer less than 1 (0-1) versus 8 (1-15) min; P = 0.01). 'Social function' and 'role-physical' subscales of the SF36 improved significantly. Mean resting pressure (35 versus 49 cmH2O with temporary stimulation; P < 0.05) and squeeze pressure increment (43 versus 69 cmH2O with permanent stimulation; P < 0.01) increased. Rectal sensitivity to initial distension changed (mean 47 versus 34 ml air; P < 0.05). There were no major complications. CONCLUSION: Sacral nerve stimulation is a safe and effective treatment for faecal incontinence when conventional treatment has failed. There is minimal morbidity. The benefit is maintained in the medium term.