Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis.

BACKGROUND: Colonic stenting has failed to show an improvement in mortality rates in comparison with emergency surgery for acute large-bowel obstruction. However, it remains unclear which patients are more likely to benefit from this procedure. OBJECTIVE: The aim of this study is to identify factors that may be predictive of successful outcome of colonic stenting in acute large-bowel obstruction. DESIGN: All patients undergoing colonic stenting for acute large-bowel obstruction between 1999 and 2013 were studied. The demographics and characteristics of the obstructing lesion were analyzed. SETTINGS: This investigation was conducted at a district general hospital. PATIENTS: A total of 126 (76 men; median age, 76 y; range, 42-94 y) with acute large-bowel obstruction were included in the analysis. INTERVENTION: The insertion of a self-expanding metal stent was attempted for each patient to relieve the obstruction. MAIN OUTCOME MEASURES: The primary outcomes measured were technical success in the deployment of the stent, clinical decompression, and perforation rates. RESULTS: Technical deployment of the stent was accomplished in 108 of 126 (86%) patients; however, only 89 (70%) achieved clinical decompression. Successful deployment and clinical decompression was associated with colorectal cancer (p = 0.03), shorter strictures (p = 0.01), and wider angulation distal to the obstruction (p = 0.049). Perforation was associated with longer strictures (p = 0.03). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Colonic stenting in acute large-bowel obstruction is more likely to be successful in shorter, malignant strictures with less angulation distal to the obstruction. Longer benign strictures are less likely to be successful and may be associated with an increased risk of perforation.

Spontaneous mesenteric hematoma complicating an exacerbation of Crohn's disease: report of a case.

CASE PRESENTATION: Spontaneous mesenteric haematoma is a rare condition that occurs due to localized bleeding in the mesenteric vascular tree of a bowel segment in the absence of an identifiable cause. Here we report a case of spontaneous mesenteric haematoma during an inflammatory exacerbation of Crohn's disease. The patient underwent surgical management for small bowel obstruction secondary to Crohn's disease, however the concurrent presence of a spontaneous mesenteric haematoma in the mid-jejunal mesentery was successfully managed conservatively. CONCLUSION: This case identifies the first association of spontaneous mesenteric haematoma with an exacerbation of Crohn's disease and highlights the need to consider rare differential diagnoses such as SMH when performing radiological assessment of unexplained symptoms in inflammatory bowel disease patients.

Electrically stimulated gracilis neosphincter for end-stage fecal incontinence: the long-term outcome.

BACKGROUND: Electrically stimulated gracilis neosphincter is an established treatment for patients with end-stage fecal incontinence. Few data, however, describe its long-term efficacy. OBJECTIVE: This study aimed to assess the long-term functional outcome associated with this procedure. DESIGN: Patients who underwent gracilis neosphincter construction between1989 and 2001 were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiologic data were available for all patients. SETTINGS: This study was conducted at an academic colorectal unit in a tertiary center. PATIENTS: Sixty patients (median age, 42 years; 46 females) with fecal incontinence and a Williams continence score ≥5 were recruited to the study. The causes of incontinence included obstetric injury (n = 22), anal surgery (n = 17), atresia (n = 7), idiopathic incontinence (n = 6), anorectal excision (n = 4), and ileoanal pouch incontinence (n = 4). MAIN OUTCOME MEASURE: The primary outcomes measured were the Williams continence score and the proportion of patients with a Williams score ≤3 who avoided permanent stoma formation. RESULTS: Continence improved for the cohort postoperatively at 2 years (2(2-5); p < 0.001) but no significant difference was found between continence scores preoperatively and at 13 years (5(3-6); p = not significant). However, a sustained improvement at 13 years was noted for patients in the anal surgery (3(2-5);p < 0.001) and obstetric injury groups (4.5(3-6); p = 0.001). Twenty-six patients (43%) had a Williams score ≤3 and avoided permanent stoma after 13 years. Eighteen patients developed postoperative rectal evacuatory disorder; 10 of them required a conduit to facilitate colonic irrigation. Postoperative evacuatory disorder was more frequent in patients with a history of obstetric injury (p = 0.008). LIMITATIONS: This study was limited by the lack of bowel diaries and quality-of-life scores. CONCLUSION: Gracilis neosphincter is associated with clinically significant and sustained symptom improvement in patients with end-stage fecal incontinence secondary to obstetric injury or anal surgery. These data support the continued use of this procedure in highly selected patients.

Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease?

BACKGROUND: Rectal intussusception may be the initial abnormality of a progressive pelvic floor disorder culminating in external prolapse. The evidence, however, is unclear, and the pathophysiological mechanisms underlying this condition are unknown. OBJECTIVE: The aim of this study is to identify the relationship between age, symptom duration, anorectal physiology parameters, and type of intussusception/prolapse in order to appreciate the natural history of the condition. DESIGN: All female patients diagnosed proctographically with rectorectal/rectoanal intussusception or external prolapse between 1994 and 2007 were studied. Demographics, symptom duration, and anorectal physiology results were compared between these proctographic groups. Patients with repeat proctographic evaluation were also analyzed separately. SETTINGS: This investigation was conducted at a tertiary academic colorectal center. PATIENTS: A total of 1014 women (median age, 51; range, 16-96), including 32 who underwent repeat proctography, were analyzed. MAIN OUTCOME MEASURES: The primary outcomes measured were the differences in median age, symptom duration, and anorectal physiology parameters between the proctographic groups. RESULTS: The cohort exhibited a statistically significant difference (p = 0.0001) in the median age of the proctographic groups with older patients diagnosed with rectoanal rather than rectorectal intussusception, which was supported by uni- and multivariate modeling. Symptom duration was statistically different (p = 0.0002) between the rectorectal intussusception (60 months; range, 1-936) and external rectal prolapse patient groups (36 months; range, 2-732). Patients with external rectal prolapse had statistically lower anal resting (median, 41 versus 77 cmH2O) and squeeze pressures (median 40 versus 56 cmH2O) than patients with rectorectal intussusception. Within 2 years, 19.2% and 3.8% of patients with rectorectal intussusception on the initial proctogram demonstrated progression to rectoanal intussusception and external prolapse. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Rectal intussusception may be an initial abnormality leading to external prolapse, but this appears to happen infrequently. Long-term observational studies are required to fully understand its natural history.

Efficacy of sacral nerve stimulation for the treatment of fecal incontinence.

BACKGROUND: Sacral nerve stimulation has been shown to be an effective treatment for fecal incontinence and early studies reported success rates of 67% to 100%. However, "success" has been arbitrarily set at a 50% reduction in symptoms, and data are rarely reported with "intention to treat." OBJECTIVE: This study aimed to assess the true efficacy of sacral nerve stimulation for fecal incontinence compared with the published literature. DESIGN: This prospective 5-year study was conducted to assess 50 patients with fecal incontinence treated with sacral nerve stimulation. All analyses were performed on an intention-to-treat basis. SETTINGS: This study took place in a single tertiary referral colorectal department. PATIENTS: Fifty consecutive patients with fecal incontinence refractory to conservative management were included in the study. INTERVENTIONS: The interventions performed were temporary evaluation with or without permanent sacral nerve stimulation. MAIN OUTCOME MEASURES: : Primary outcome measures were 1) attainment of continence, 2) reduction in fecal incontinence episodes, 3) improvement in Cleveland Clinic Fecal Incontinence scores, and 4) improvement in the ability to defer defecation. RESULTS: Thirteen patients (26%) did not respond at the temporary evaluation stage or were dissatisfied with the result. Ten further patients (20%) did not achieve a 50% reduction in symptoms following permanent implantation. The median follow-up was 17 months (range, 2-55), at which time 27 patients (54%) experienced a 50% or more reduction in symptoms, including 13 (26%) who achieved apparent continence. Median fecal incontinence episodes per fortnight reduced from 14 (range, 0-53) to 2 (range, 0-20; P < .0001). Median Cleveland Clinic Fecal Incontinence scores reduced from 15 (range, 3-20) to 8 (range, 0-17; P < .0001). The ability to defer defecation improved significantly (P < .0001). These results compare favorably with the published literature. LIMITATIONS: Quality of life was not assessed. CONCLUSIONS: This study demonstrates that sacral nerve stimulation can be an effective treatment for patients with fecal incontinence; however, when analyzed by intention to treat, the symptoms of fecal incontinence continue in the majority (74%) of patients.

Percutaneous tibial nerve stimulation for the treatment of urge fecal incontinence.

PURPOSE: Percutaneous tibial nerve stimulation has been shown to be an effective treatment in patients with urinary disorders, but its benefit in fecal incontinence is uncertain. This study aimed to assess the efficacy of percutaneous tibial nerve stimulation in the treatment of urge fecal incontinence. METHODS: This prospective study, conducted over a 14-month period, assessed 31 patients with urge fecal incontinence treated with percutaneous tibial nerve stimulation. The outcomes measured were: 1) reduction in fecal incontinence episodes, 2) improvement in Cleveland Clinic incontinence scores, and 3) improvement in ability to defer defecation. All analysis was performed on an intention-to-treat basis. RESULTS: The median follow-up was 9 months (range, 3-14). Twenty-one (68%) patients improved following percutaneous tibial nerve stimulation and remain satisfied with the clinical response. Median fecal incontinence episodes per week declined from 4 (range, 0-30) to 0 (range, 0-27) (P < .0001). Median Cleveland Clinic incontinence scores declined from 13 (range, 5-20) to 7 (range, 0-20) (P < .0001). Ability to defer defecation was improved significantly (P < .0001). No morbidity was encountered for any patient. CONCLUSION: This preliminary study demonstrates that percutaneous tibial nerve stimulation is an effective and very well tolerated treatment for patients with urge fecal incontinence with particular improvement in reducing fecal urgency.

Efficacy of sacral nerve stimulation for fecal incontinence in patients with anal sphincter defects.

PURPOSE: Sacral nerve stimulation has traditionally been used to treat patients with fecal incontinence with intact anal sphincters. This rationale has been challenged, but it remains unknown if its efficacy is related to the extent of the sphincter injury. METHODS: This was a prospective study of 15 patients with sphincter defects (9 combined, 2 external only, and 4 internal only) undergoing sacral nerve stimulation for fecal incontinence. Endoanal ultrasound scans were reviewed and defects scored (0-16) with use of a system published by two independent observers. These were correlated with the following outcomes: 1) reduction in fecal incontinence episodes, 2) reduction in soiling, 3) improvement in Cleveland Clinic scores, and 4) improvement in ability to defer defecation. All patients were studied after temporary stimulation and again at three to six months after permanent implantation. RESULTS: Thirteen patients (87%) progressed to permanent stimulation. Median fecal incontinence episodes per two weeks decreased from 15 (range, 1-53) to 3 (range, 0-16; P = 0.01). Median soiling episodes were reduced from 10 (range, 1-14) to 6 (range, 0-14; P = 0.009). Median Cleveland Clinic scores decreased from 12 (range, 9-18) to 9 (range, 4-14; P = 0.0005). The ability to defer defecation was improved significantly (P = 0.05). There were no relationships between sphincter defect scores and outcome measures after sacral nerve stimulation (r = 0.001-0.10; P = 0.28-0.94). CONCLUSION: Sacral nerve stimulation is an effective treatment in patients with fecal incontinence who have anal sphincter defects, and outcome is not associated with severity of sphincter disruption.