Sacral neuromodulation in the treatment of severe anal incontinence. Forty consecutive cases treated in one institution.

INTRODUCTION: Sacral neuromodulation is a recognized therapeutic option in severe anal incontinence from neurogenic origins, when medical treatment has failed. METHODS: We report the results of this procedure applied in 40 consecutive patients operated on by a single surgeon from August 2001 to June 2004. Mean duration of incontinence was 5 years. There were 33 women and 7 men of mean age 59 (range 29-89). All patients had had medical treatment, 26 had had physiotherapy and 9 had been previously operated on for that problem. Neuromodulation consisted in a temporary electrical stimulation test followed by implantation of a stimulator in case of efficacy. RESULTS: Twenty nine patients had a positive test and were implanted. Ten had a negative test and one is waiting for implantation. From the 29 patients, 23 had uneventful postoperative course. Incontinence score varied from 17 before neuromodulation to 6 after in the 24 patients who were improved. Mean resting pressure, mean maximum squeeze pressure and mean duration of squeeze pressure did not change from pre to postoperative period. CONCLUSION: Sacral neuromodulation is a safe and efficacious procedure in properly selected anal incontinent patients. However, we observed no correlation between clinical and manometric data.

Protocol for the treatment of malignant inoperable bowel obstruction: a prospective study of 80 cases at Grenoble University Hospital Center.

A prospective protocol for treatment of malignant inoperable bowel obstruction was implemented at Grenoble University Hospital Center for 4 years. All 80 episodes of obstruction resulted from peritoneal carcinomatosis and none could expect another treatment cure. The protocol comprised three successive stages. Stage I included treatment for 5 days with a corticosteroid, antiemetic, anticholinergic, and analgesic. Stage II provided a somatostatin analogue if vomiting persisted. After 3 days, Stage III provided a venting gastrostomy. Obstruction relief with symptom control was obtained by medical treatment in 29 cases and symptom control occurred alone in an additional 32 cases. Ten patients were relieved by venting gastrostomy. Symptom control without permanent nasogastric tube (NGT) placement occurred in 72 episodes (90%). Eight patients with refractory vomiting were obliged to continue the NGT until death. Fifty-eight obstruction episodes (73%) were controlled in 10 days or less. Median time before gastrostomy was 17 days. Median survival was 31 days. This series suggests that a staged protocol for the treatment of inoperable malignant bowel obstruction is highly effective in relieving symptoms. A subgroup experiences relief of obstruction using this approach.

Percutaneous video-assisted necrosectomy for infected pancreatic necrosis.

AIMS OF THE STUDY: Percutaneous drainage of infected pancreatic necrosis is not always efficient and morbidity is high with open necrosectomy techniques. Minimally-invasive procedures have been developed to reduce this morbidity. We report our early experience with percutaneous video-assisted necrosectomy. METHODS: Among 61 patients with acute pancreatitis treated between January 2001 and February 2003, seven developed infected pancreatic necrosis. Six of these seven patients underwent percutaneous video-assisted necrosectomy after failure of radio-guided percutaneous drainage. RESULTS: One to four sessions of percutaneous video-assisted necrosectomy were required. There was no death. Sepsis control was achieved in all patients. One patient developed postoperative peritonitis due to intraoperative contamination of the peritoneal cavity. Eighteen months after the last necrosectomy, one patient developed a pseudocyst which was successfully cured by percutaneous drainage. One patient developed diabetes mellitus. CONCLUSION: Early experience in six patients has shown that percutaneous video-assisted necrosectomy is feasible, safe and efficient, in accordance with reports in the literature. Further evaluation is necessary.