Antegrade colonic enema for faecal incontinence in adults: long-term results of 75 patients.

AIM: Faecal incontinence is a significant source of distress, and a permanent stoma is frequently offered to these patients. The antegrade colonic enema (ACE) procedure is an alternative approach to treat faecal incontinence. The long-term outcome remains unknown in adults with faecal incontinence. The aim of this study was to evaluate the long-term results of the ACE procedure for incontinence in adults and its impact upon quality of life. METHOD: All patients who underwent an ACE procedure between 1999 and 2009 were included. Clinical and demographic data and postoperative course were obtained from a review of medical records and databases. Each patient underwent a telephone interview. Quality of life was assessed using the GIQLI and SF36 scores, and faecal incontinence was evaluated using the Wexner score. RESULTS: Seventy-five patients (54 females; 72%) were included. An ileal neoappendicostomy was performed in 68 patients (90%). The mean hospital stay was 9 days (range 6-24 days). Early complications occurred in four patients and late surgical complications (after 3 months) were observed in 12 (16%) patients. At a median follow up of 48 months, 64 (91%) were still performing enemas, and treatment was judged to be successful in 55 (86%) of 64 patients. The Wexner score was 3.4 ± 2.4, showing a significant reduction when compared with the preoperative value (P < 0.0001). Quality of life scores were in the range of a control population. CONCLUSION: The ACE procedure is an effective long-term strategy in the treatment of faecal incontinence, with low and acceptable morbidity, and should be preferred before definitive colostomy.

Sacral nerve stimulation for faecal incontinence: response rate, satisfaction and the value of preoperative investigation in patient selection.

OBJECTIVE: Before undergoing sacral nerve stimulation (SNS) for faecal incontinence (FI), patients are investigated with morphologic, dynamic and electrophysiologic tests. The purpose of our study was to evaluate their value in the selection of patients who may benefit most from neuromodulation. METHOD: If temporary stimulation resulted in a good objective response, a permanent neuromodulator was implanted. Patients were reviewed at 3 months and then at 6 monthly intervals. Asked by telephone, patient's satisfaction was described as good, satisfactory or poor. RESULTS: Forty-five consecutive patients (41 females, median age 59 years) with FI (Wexner 16.1 +/- 2.9) underwent SNS. Temporary stimulation was successful in 32 (71)% patients. At a median follow-up of 33 months, the neuromodulator remained in place in 25 (55%) patients, two do whom switched it off, leaving 23 (51%) with a functioning neuromodulator. There was no statistically significant difference between the characteristics (including manometry, ultrasound and electrophysiology) of patients undergoing implantation (n = 32) or not (n = 13) and those with or without a functioning stimulator (n = 23: n = 13). In the 23 patients with a functioning stimulator the result was good in 12, satisfactory in five and poor in six. There was no statistically significant difference in the patient characteristics between those with a good result (n = 12) and the remainder (n = 32). CONCLUSION: The findings suggest that investigation for FI does not facilitate patient selection for SNS and cannot be used to predict outcome.

Impact of p53 expression and microsatellite instability on stage III colon cancer disease-free survival in patients treated by 5-fluorouracil and leucovorin with or without oxaliplatin.

BACKGROUND: The aim was to determine the values of p53 tumour expression and microsatellite instability (MSI) phenotype to predict benefit from adjuvant chemotherapy of colon cancer by 5-fluorouracil and leucovorin (FL) alone or with oxaliplatin (FOLFOX). PATIENTS AND METHODS: This retrospective study included 233 unselected patients with stage III colon cancer treated by FL (n = 124) or FOLFOX (n = 109). The impact of p53 expression and MSI on disease-free survival (DFS) was defined using univariate and multivariate analyses. A Cox proportional hazards model was specifically designed to evaluate the interaction between chemotherapy and these genetic alterations. RESULTS: In univariate analyses, addition of oxaliplatin significantly improved DFS provided that tumour overexpressed p53 [hazard ratio (HR) 0.39; 95% confidence interval (CI) 0.19-0.82; P = 0.01] or displayed MSI phenotype (HR 0.17; 95% CI 0.04-0.68; P = 0.01). In multivariate analyses, p53 was confirmed as an independent factor predictive of benefit from FOLFOX (P = 0.03), while the interaction of MSI with chemotherapy could not be determined in the absence of relapse in the MSI group treated with FOLFOX. CONCLUSION: Our observations indicate that MSI status and p53 expression may influence the impact of oxaliplatin on adjuvant treatment of stage III colon cancer patients.

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.

Outcome of antegrade continence enema procedures for faecal incontinence in adults.

BACKGROUND: Faecal incontinence has major consequences. Colostomy has been the mainstay of therapy when other options fail. Operations such as the Malone procedure have been proposed as an alternative. The aim of this study was to evaluate the outcomes and quality of life of patients having a Malone procedure for the treatment of faecal incontinence. METHODS: Charts of patients who had had a Malone procedure or equivalent between 1998 and 2004 were reviewed. The patients completed a Short Form (SF) 36 quality of life questionnaire. RESULTS: The study included 25 patients (17 female; median age 47 years). In seven, the appendix was used; an ileoneoappendicostomy was performed in the other 18. Three patients were lost to follow-up; the remaining 22 were followed for a median (range) of 21 (1-61) months. Five patients had a cutaneous stenosis; another had the appendicostomy removed and replaced by a colostomy. Four patients no longer used the stoma for irrigation. All other patients were completely clean except one, who reported occasional night-time seepage. The mean SF-36 showed a good physical recovery (43.9) but persisting psychological distress (36.0). CONCLUSION: The Malone procedure or equivalent achieves good results in the management of faecal incontinence, although psychological distress persists after surgery.

Treatment of postoperative peritonitis of small-bowel origin with continuous enteral nutrition and succus entericus reinfusion.

HYPOTHESIS: Proximal intestinal stomas established by the exteriorization of leaking anastomosis in the presence of peritonitis can be used to reinfuse succus entericus and provide adequate enteral nutrition. DESIGN: Retrospective analysis of prospectively gathered data from a cohort of consecutive patients admitted between January 1993 and December 1999 for postoperative peritonitis requiring laparotomy and the construction of one or more small-bowel stomas. SETTING: Tertiary referral center with a surgical intensive care unit experienced in the treatment of intra-abdominal sepsis and succus entericus reinfusion. PATIENTS: Twenty-one consecutive patients with postoperative peritonitis originating from a jejunal or ileal leak. We excluded patients with established enterocutaneous fistulae, abscesses amenable to percutaneous drainage or other conservative treatments, and postoperative peritonitis caused by ileocolic or ileorectal anastomosis. INTERVENTIONS: Early laparotomy with exteriorization of small-bowel leak(s), and continuous enteral nutrition (CEN) and succus entericus reinfusion (SER) via the distal portion of the stoma until gastrointestinal continuity was restored. MAIN OUTCOME MEASURES: Feasibility of CEN and SER with temporary, diverting small-bowel stomas and their associated postoperative morbidity and mortality rates. RESULTS: One patient died, and 14 experienced complications. For technical reasons, CEN and SER were discontinued early on in 7 patients. The mean duration of CEN and SER was 58 days and 61 days, respectively. Enteral feedings allowed the suppression of central venous access after a median of 28 days, with 82 days as a median time to restoration of intestinal continuity. CONCLUSIONS: Although the exteriorization of small-bowel leaks with CEN and SER is generally feasible and effective in the treatment of critically ill patients with peritonitis secondary to small-bowel leaks, it is associated with significant morbidity and mortality, in part relating to patients' underlying diseases.

Preoperative systemic 5-fluorouracil does not increase the risk of liver resection.

BACKGROUND/AIMS: The majority of patients who underwent surgery for colorectal liver metastases have been previously treated with 5-FU either as adjuvant chemotherapy or as a primary treatment. We have performed a retrospective study to assess whether this chemotherapy increases the risk of liver resection. METHODOLOGY: Mortality, morbidity and histology of the resected liver of two groups of patients having colorectal liver metastases who underwent major resection were studied. The first group included 17 patients who had received at least 2 courses of 5-FU chemotherapy within 3 months prior to liver resection. The second group included 18 patients who had received no chemotherapy and who were used as controls. RESULTS: Perioperative mortality was nil. Intraoperative blood loss during liver resection (1 +/- 2.5 vs. 1.2 +/- 2 units) was similar in the two groups. Changes of liver function tests on days 2 and 5 were similar in the two groups. Morbidity rate was similar in the two groups (29 vs. 22%) with a mean duration of postoperative hospital stay of 19 +/- 9 days in the 5-FU group and 16 +/- 6 days in the control group. Although 7 (41%) patients in the 5-FU group had an abnormal parenchyma consistency as compared to only 3 (17%) in the control group, the pathological findings within the resected specimen were not different. CONCLUSIONS: 5-FU based systemic chemotherapy does not increase the risk of liver resections.

[Pseudotumoral rectal endometriosis]. / Endométriose rectale pseudo-tumorale.

A case of rectal endometriosis, presenting in the form of acute obstruction, is described. The primary diagnosis was malignancy, but endometriosis was discovered at emergency operation. The diagnosis and management of rectal endometriosis are reviewed.