Outcomes of Sacral Nerve Stimulation For Faecal Incontinence in Northern Ireland.

BACKGROUND: Sacral nerve root stimulation (SNS) is an effective and developing therapy for faecal incontinence, a debilitating condition that can result in social and personal incapacitation. OBJECTIVES: The objectives of this study are to assess the morbidity of the procedure, improvement in the incontinence scores and Quality of Life (QoL) following SNS. MATERIALS AND METHODS: Patients were identified from the Northern Ireland regional SNS service from 2006 to 2012. Numbers of patients who had temporary placement and permanent placement were collated. Pre and postoperative assessment of severity of incontinence and QoL was performed using Cleveland Clinic Incontinence Score (CCIS) and Short Form-36 (SF-36) respectively. Statistical analysis was undertaken using Wilcoxon signed rank test. Morbidity was assessed by retrospective review of patient records. RESULTS: Seventy-five patients were considered for trial of a temporary SNS. Sixty-one proceeded to insertion of a temporary SNS and, of these, 40 elected to have a permanent SNS. There was a significant reduction in the pre-SNS and post-SNS Cleveland Clinic Incontinence Scores from median of 14 to 9 respectively (p=0.008). There was a significant improvement in Role Physical (p=0.017), General Health (p=0.02), Vitality (p=0.043), Social Functioning (p=0.004), Role Emotional (p=0.007), Mental Health (p=0.013) and Mental Health Summary (p=0.003). However, this is not reflected in the bodily pain and physical functional domains. CONCLUSION: Permanent sacral nerve stimulation is effective and results in significant improvement of faecal incontinence scores and quality of life.

Intrahepatic delivery of feeds caused by a displaced percutaneous radiological gastrostomy catheter.

Percutaneous radiological gastrostomy (PRG) is a safe and accepted method of providing enteral nutrition in those with inadequate oral intake. We report a case of PRG that required laparotomy for intrahepatic displacement of a catheter that had been placed inadvertently through the liver under fluoroscopic guidance. Additional ultrasound or CT guidance may help to define a safe tract to avoid liver or colonic injury. Although transhepatic placement is reported to be well tolerated, this case raises concerns of additional morbidity associated with intrahepatic displacement.

The house advancement anoplasty for treatment of anal disorders.

OBJECTIVES: Anal advancement flaps treat a variety of anal disorders. In recent years the "House" advancement flap has been used with good success, the term referring to the shape of the flap used. It is simple with few shortcomings. We reviewed a single centre's experience of this procedure. METHODS: All patients who underwent a house advancement flap between 1996 and 2001 were identified. The case notes were examined and data collected on indication for surgery, complications, follow-up and outcome. RESULTS: Thirteen consecutive patients were identified, mean age of 44 years. Indications for surgery were chronic anal fissure, fistulous disease and post surgical deformity or stenosis of the anal canal. Median follow-up was 37 months (25-84). In 9 patients the flaps healed within 4 weeks. In the remaining 4 patients the flaps healed by secondary intention over a median of 14 weeks (8-20). Postoperative complications occurred in 5 patients (3 donor site separation and 2 flap retraction). Two patients developed recurrence of their original disorder. Eleven patients have relief of pre-operative symptoms with fully healed flaps. CONCLUSION: This procedure is simple, easy to construct and robust. It can be performed for a variety of anal disorders with satisfactory results and few complications and should be in every Coloproctologist's armamentarium.

Long-term results of polyp clearance by intraoperative enteroscopy in the Peutz-Jeghers syndrome.

PURPOSE: Enteroscopy during laparotomy for Peutz-Jeghers syndrome was introduced in our unit in 1987. Its aim is to achieve more complete polyp clearance and thereby reduce the number of subsequent laparotomies for small intestinal polyps. METHODS: All patients with Peutz-Jeghers syndrome who had undergone intraoperative enteroscopy since its introduction into our unit in 1987 were identified. The numbers of polyps identified by palpation and transillumination and by enteroscopy were recorded. The timing of, indications for, and findings of all subsequent laparotomies were analyzed and compared with data from our unit before the introduction of intraoperative enteroscopy. RESULTS: Twenty-five patients (14 females) were studied. Enteroscopy identified 350 (median 12, range 0-35) polyps not detected by palpation and transillumination. All impalpable polyps were removed endoscopically by snare or biopsy. The median follow-up was 53 (interquartile range, 13-133) months. Six patients have had an additional laparotomy (1 urgent relaparotomy for small-bowel perforation after endoscopic polypectomy, 4 polypectomies, and 1 adhesion obstruction). No patient has required operative polypectomy within 4 years of polyp clearance by intraoperative enteroscopy, compared with registry data of 4 (17 percent) of 23 patients who had more than 1 laparotomy within 1 year. CONCLUSION: Intraoperative enteroscopy for Peutz-Jeghers syndrome improves polyp clearance without the need for additional enterotomies and may help to reduce the frequency of laparotomies.

Effect of folate supplementation on mucosal cell proliferation in high risk patients for colon cancer.

AIMS: Intracellular folate deficiency has been implicated in colonic carcinogenesis in epidemiological studies and animal and human cancer models. Our aim was to determine the effect of folate supplementation on patients with recurrent adenomatous polyps using rectal mucosal cell proliferation as a biomarker. PATIENTS AND METHODS: Eleven patients with recurrent adenomatous polyps of the colon were randomised into a treatment group (n=6) receiving a dietary supplement of 2 mg folic acid per day for three months and a control group (n=5) receiving a placebo. Rectal biopsies where taken at 10 cm from the anal verge prior to supplementation and repeated at four, 12, and 18 weeks from the start of the supplementation. Each biopsy was immediately incubated in culture medium enriched with bromodeoxyuridine (BrdU). The S phase cells which incorporated BrdU into their DNA were identified following immunohistochemical staining. Twenty five orientated crypts were identified for each time point and the number and position of BrdU positive and BrdU negative cells were counted. BrdU labelling indices (LIs) were calculated for the entire crypt and for each of five equal compartments running consequently from the base to the luminal surface. RESULTS: The LI of the treatment group (9.1 (6.7, 12.3)) and the control group (9.3 (7.8, 10.3)) were comparable at the start. Over the duration of the supplementation period, LI in the control group did not alter significantly (9.3 (7.8, 10.3) v 9.6 (8.9, 10.4)). However, LI of the folate treated group was lowered after 12 weeks of supplementation (9.1 (6.7, 12.3) v 7.4 (5.3, 9.6)). Analysis of the LI for compartments within the crypt showed that the most significant drop in number of proliferating cells was in the upper most regions of the crypt. CONCLUSION: These data indicate that (a) folate supplementation decreases colonic mucosal cell proliferation in a high risk group for colon cancer and (b) the most significant reduction takes place at the luminal aspect of the crypt.

Colonic malignancy arising in colitis - a single unit experience.

OBJECTIVES: Colorectal malignancy complicating inflammatory bowel disease constitutes 1% of all colorectal malignancies. Although its overall numbers are low it represents the greatest cause of colitis related mortality in these patients. This paper describes the management of 24 patients presenting to a single unit over a period of 10 years. METHODS: The names of patients were collected prospectively when they presented with malignancy. Clinical details were collected by retrospective review of charts. RESULTS: In all, 24 patients with 27 malignancies were identified. The median age of presentation with malignancy was 56 years. Most patients were treated with proctocolectomy. Other patients were treated with segmental colectomy. In these patients the surgical procedure was dictated by the stage of the cancer, the age and comorbid state of the patient and the severity of ongoing colitis. CONCLUSIONS: Malignancy arising in colitis will constitute only a small part of a colorectal practice. The optimum method for detecting early, and potentially curable, disease has not been defined. Surgery should be tailored to the individual needs of the patient.

Hartmann procedure revisited.

OBJECTIVE: To assess the complications and results of Hartmann's procedure and secondary restoration of continuity for left-sided colonic disease. DESIGN: Retrospective study. SETTING: University hospitals, Northern Ireland. SUBJECTS: 72 Patients who required a Hartmann's procedure over a 13 year period (1985-1998). INTERVENTION: Of these 45 (63%) were done as emergencies and 27 (38%) as elective procedures. The indications for an emergency procedure were obstruction and perforation. MAIN OUTCOME MEASURES: Mortality, morbidity, reversal of stoma rate. RESULTS: The overall postoperative mortality was 7/72 (10%), with no significant difference between the emergency (4/45, 9%) and the elective (3/27, 11%) groups. Postoperative complications occurred in 31 patients (43%), and 8 developed wound infections (11%). Of the 43 surviving patients who where deemed suitable for re-establishment of continuity, 30 (70%) have had it done. There were no postoperative deaths or anastomotic dehiscences after the restoration of continuity. CONCLUSION: Hartmann's procedure remains a safe and suitable option in patients with left sided colonic emergencies.