[Treatment of injuries of the Chopart joint]. / Behandeling van letsels van het Chopart-gewricht.

BACKGROUND: Injuries to the Chopart joint of the tarsal foot are relatively rare, difficult to recognize and are associated with significant long term morbidity. CASE DESCRIPTION: A 16-year-old boy attended the emergency department after a forklift truck ran over his left foot. Physical examination and X-ray evaluation revealed a fracture of the Chopart joint with a navicular bone fracture and dislocation of the calcaneo-cuboidal joint. Operative open reduction and internal fixation was performed. One year after operative treatment, the patient was able to play sport without functional impairment. CONCLUSION: Adequate evaluation on initial presentation of the injury and additional investigations are imperative for the treatment of patients with Chopart joint injuries. Adequate operative reduction and fixation at an early stage will result in good functional recovery.

Sacral neuromodulation therapy: a promising treatment for adolescents with refractory functional constipation.

BACKGROUND: Sacral neuromodulation therapy has been successfully applied in adult patients with urinary and fecal incontinence and in adults with constipation not responding to intensive conservative treatment. No data, however, are available on sacral neuromodulation therapy as a treatment option in adolescents with refractory functional constipation. OBJECTIVES: This study aimed to describe the short-term results of sacral neuromodulation in adolescents with chronic functional constipation refractory to intensive conservative treatment. DESIGN: This is a retrospective review. SETTING: This study took place at the Department of Surgery, Maastricht University Medical Centre, The Netherlands. PATIENTS: Thirteen patients (all girls, age 10-18 years) with functional constipation according to the ROME III criteria not responding to intensive oral and rectal laxative treatment were assigned for sacral neuromodulation. MAIN OUTCOME MEASURES: When improvement of symptoms was observed during the testing phase, a permanent stimulator was implanted. Patients were prospectively followed up to at least 6 months after implantation of the permanent stimulator by interviews, bowel diaries, and Cleveland Clinic constipation score. Improvement was defined as spontaneous defecation ≥ 2 times a week. RESULTS: At presentation, none of the patients had spontaneous defecation or felt the urge to defecate. All patients had severe abdominal pain. Regular school absenteeism was present in 10 patients. After the testing phase, all but 2 patients had spontaneous defecation ≥ 2 times a week with a reduction in abdominal pain. After implantation, 11 (of 12) had a normal spontaneous defecation pattern of ≥ 2 times a week without medication, felt the urge to defecate, and perceived less abdominal pain without relapse of symptoms until 6 months after implantation. The average Cleveland Clinic constipation score decreased from 20.9 to 8.4. One lead revision and 2 pacemaker relocations were necessary. LIMITATIONS: This study is limited by its small sample size, single-institution bias, and retrospective nature. CONCLUSION: Sacral neuromodulation appears to be a promising new treatment option in adolescents with refractory functional constipation not responding to intensive conservative therapy. Larger randomized studies with long-term follow-up are required.

Rectal balloon training as add-on therapy to pelvic floor muscle training in adults with fecal incontinence: a randomized controlled trial.

AIMS: Fecal incontinence (FI) is embarrassing, resulting in poor quality of life. Rectal sensation may be more important than sphincter strength to relieve symptoms. A single-blind, randomized controlled trial among adults with FI compared the effectiveness of rectal balloon training (RBT) and pelvic floor muscle training (PFMT) versus PFMT alone. METHODS: We randomized 80 patients, recruited from the Maastricht University Medical Centre. Primary outcome was based on the Vaizey score. Secondary outcomes were the Fecal Incontinence Quality of Life Scale (FIQL), 9-point global perceived effect (GPE) score, anorectal manometry, rectal distension volumes, and thresholds of anorectal sensation. Analyses were by intention-to-treat. RESULTS: Forty patients were assigned to combined RBT with PFMT and 40 to PFMT alone. Adding RBT did not result in a significant improvement in the Vaizey score [mean difference: -1.19; 95% confidence interval (CI): -3.79 to 1.42; P = 0.37]. Secondary outcomes favoring RBT were: Lifestyle subscale of the FIQL (0.37; 95% CI: 0.02-0.73; P = 0.04), GPE (-1.01; 95% CI: -1.75 to -0.27; P = 0.008), maximum tolerable volume (49.35; 95% CI: 13.26-85.44; P = 0.009), and external anal sphincter fatigue (0.65; 95% CI: 0.26-1.04; P = 0.001). Overall, 50% of patients were considered improved according to the estimated minimally important change (Vaizey change ≥-5). CONCLUSIONS: RBT with PFMT was equally effective as PFMT alone. Secondary outcomes show beneficial effects of RBT on urgency control, GPE, and lifestyle adaptations. Characteristics of patients who benefit most from RBT remain to be confirmed.

Patient experience and satisfaction with sacral neuromodulation: results of a single-center sample survey.

PURPOSE: Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders. METHODS: After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007. RESULTS: A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%). CONCLUSIONS: This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns.

Sacral neuromodulation for the treatment of chronic functional anorectal pain: a single center experience.

INTRODUCTION: Treatment of functional anorectal pain disorders remains a challenge. The purpose of this study is to describe a single center experience with sacral neuromodulation for the treatment of chronic functional anorectal pain. METHODS: This is a retrospective study based on prospectively collected data of patients treated with sacral neuromodulation for functional anorectal pain from April 2005 to August 2008. Symptoms were analyzed using a visual analog scale pain score (0 to 10). A 7-point Likert scale was used to rate global perceived effect. All patients had a percutaneous nerve evaluation and subsequent test stimulation to assess sacral neuromodulation outcome prior to permanent implantation. Patients were eligible for permanent sacral neuromodulation in case of a pain score <3 during test stimulation and/or >50% decrease in the pain score compared to baseline. RESULTS: Nine patients (2 males) were included in this study. Mean age was 53.8 years (27.6 to 74.0). Four patients (1 male) had successful test stimulation and were eligible for permanent implantation. Median pain score decreased from 8.0 (6.0 to 9.0) to 1.0 (0 to 2.0). All patients experienced a lasting improvement during the follow-up till 24 months. Global perceived effect in successful patient was 1 (completely recovered) in one patient and 2 (much improved) in three patients. CONCLUSION: This study showed that sacral neuromodulation can be a successful treatment for functional anorectal pain not responding to other treatments. Improvement obtained during test stimulation is a good predictor (diagnostic) for sustained success of permanent sacral neuromodulation.

Effect of bowel transection and fecal passage deprivation on the enteric nervous system in neonatal rats.

INTRODUCTION: A temporary stoma is a relatively common procedure at the neonatal age for a number of disorders. At birth, the enteric nervous system (ENS) is not fully developed; temporary colostomy causes morphological changes in the ENS. We studied whether transection of bowel or deprivation of stool is responsible for these changes. Moreover, reversibility of the ENS changes after stoma closure was investigated. METHODS: Male Lewis rats aged 3 weeks were randomly divided into 3 groups. Group 1 (stoma group) received a stoma (t = 0), stoma closure 2 weeks later (t = 1), and were killed 2 weeks after stoma closure; group 2 (transection group) had a colon transection and immediate anastomosis (t = 0) and were killed 2 weeks afterward. Group 3 (sham group) had no operation. In all groups, the nerve/muscle fiber ratio (NMR) in the proximal and distal colon was assessed with full thickness biopsy specimens at operation or after killing. The NMR in the stoma, transection, and sham group at t = 1 were used to assess the effect of deprivation of passage of feces and transection itself on the development of the ENS of the colon. Results of the stoma group at t = 1 and t = 2 were compared to assess possible reversibility of ENS changes after stoma closure. RESULTS: There was a significantly higher NMR in the distal colon compared to the proximal colon in both the stoma and transection groups at t = 1 (2.0 +/- 0.38, P < .001 and 2.8 +/- 0.97, P < .001, respectively), whereas there was no significant difference in NMR ratio at t = 1 (1.1 +/- 0.18, P = .34) in group 3. In group 1, the NMR ratio increased further after stoma closure to 3.1 +/- 0.37, P < .001, at t = 2. CONCLUSION: Transection of the bowel rather than deprivation of fecal passage causes nerve fiber hypertrophy in the distal colon of neonatal rats. Restoration of bowel continuity does not result in recovery of these ENS changes.