The effect of sacral nerve modulation on cerebral evoked potential latency in fecal incontinence and constipation.

OBJECTIVE: Influence of sacral nerve modulation (SNM) on cerebral somatosensory evoked potentials (SEP) was determined in patients with incontinence and constipation. BACKGROUND: Selection of patients with incontinence and constipation for SNM could be improved. METHODS: The latency (ms) of SEP induced by pudendal nerve stimulation was compared before (T0) and at 1 month during peripheral nerve evaluation (PNE) of SNM at frequencies of 21 Hz (T1) and 40 Hz (T2). The results were correlated with clinical outcome at 6 months. RESULTS: In 16 of 23 incontinent patients with clinical "success" from SNM (Wexner incontinence score ≤7), there was a significant difference between P40 latency at T0 and T2 (38.81 vs. 37.49 ms, P = 0.049). In the 7 with "failure," there was no change between T0 and T2. In 12 of 19 constipated patients with "success" (Wexner constipation score ≤15), there was no difference between T0 and T2 P40 latency (39.28 vs. 38.25 ms, P = 0.374). In the 7 with "failure," there was a significant fall in P40 latency (41.20 vs. 39.30 ms, P = 0.047) but not to the normal range. The T0 P40 latency in incontinent patients having "success" was significantly higher than in the normal range (P = 0.044). In constipated patients it was significantly higher than in the normal range in both those with "success" (P = 0.001) and "failure" (P = 0.022). CONCLUSIONS: Measurement of P40 latency of SEP at baseline and at 1 month of SNM at a frequency of 40 Hz may help to predict the outcome of SNM and thus influence the decision for permanent implantation for patients with incontinence and constipation.

Long-term outcome of Altemeier's procedure for rectal prolapse.

INTRODUCTION: Altemeier's procedure is infrequently applied in European countries and because of the small number of patients treated in each center, its long-term reliability is uncertain. METHODS: Medical records of 93 patients (median age, 77 years) undergoing perineal rectosigmoidectomy associated with levatorplasty in 72 patients (78 percent) were reviewed; 65 patients (70 percent) suffered from major fecal incontinence. RESULTS: There was no postoperative mortality. Eight (8.6 percent) major complications were observed (3 pelvic hematomas, 1 anastomotic dehiscence, 1 sigmoid perforation, 1 pararectal abscess, and 2 late anal strictures), and 13 (14 percent) minor complications. At a mean follow-up of 41 (range, 12-112) months the complete recurrence rate was 18 percent (17 patients); these patients were treated with a repeat Altemeier's procedure (6 patients), Delorme's operation (1 patient), Wells' rectopexy (1 patient), postanal repair (1 patient), anal bulking agents (2 patients), and sacral nerve stimulation (2 patients). Anal manometry significantly improved postoperatively. Incontinence improved postoperatively in 30 cases (28 percent), deteriorated in 2 patients, while 4 patients developed minor incontinence. CONCLUSIONS: Perineal rectosigmoidectomy for rectal prolapse is a relatively safe and effective treatment, in particular, for frail, older patients, with a low postoperative morbidity, but the recurrence rate is not negligible and restoration of continence is unpredictable.

Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain?

BACKGROUND: Chronic idiopathic anal pain is a common, benign symptom, the etiology of which remains unclear. Traditional treatments are often ineffective. This study investigated the efficacy of sacral nerve stimulation in treating chronic idiopathic anal pain. METHODS: Twelve patients (10 women and 2 men; mean age, 61.0 +/- 10.3 years; range, 48-82 years) implanted with a permanent device for sacral nerve stimulation were followed in the Italian Group for Sacral Neuromodulation (GINS) Registry. All patients had frequent chronic anal or perianal pain; 75 percent had previously undergone pelvic surgery. Pharmacologic and rehabilitative therapy had yielded poor results. Changes from baseline to last follow-up examination were evaluated for scores on a visual analog pain scale (0-10) and the Short-Form 36 (SF-36) health status questionnaire. Manometric measurements recorded at last follow-up were compared with preimplantation values. RESULTS: In one patient, the permanent device was removed because of technical failure. After a mean follow-up of 15 (range, 3-80) months, visual analog pain scores had significantly improved (from 8.2 +/- 1.7 to 2.2 +/- 1.3, P < 0.001). SF-36 physical component scores increased from 26.27 +/- 5.65 to 38.95 +/- 9.08, P < 0.02). Scores on the mental component showed improvement, although not significant. Postimplantation changes in manometric functional data were not significant, but sensitivity thresholds showed a considerable decrease. CONCLUSIONS: Long-term follow-up data showing improvements in scores on the visual analog pain scale and quality of life questionnaire indicate that, before adopting more aggressive surgical procedures, SNS should be considered for patients with chronic idiopathic anal pain in whom pharmacologic and biofeedback treatments have failed to produce effective results.

Long-term outcome of sacral nerve stimulation for fecal incontinence.

PURPOSE: Sacral nerve stimulation is a safe and effective procedure for fecal incontinence. We investigated whether its efficacy is maintained long term. PATIENTS AND METHODS: Sixty patients with fecal incontinence underwent permanent sacral nerve stimulation. Patients' data were prospectively recorded in the national registry of the Italian Group of sacral nerve stimulation. The severity of fecal incontinence was evaluated by the Wexner score, and data were collected in a bowel function diary. Quality of life was evaluated by the Italian version of the Medical Outcomes Survey Short Form (SF-36) questionnaire. RESULTS: Fifty-two patients were available for long-term follow-up lasting at least 5 years. Compared with baseline, the Wexner score decreased significantly after definitive implantation (from 15 +/- 4 to 5 +/- 5, P < 0.001). At least 50 percent improvement in continence was achieved in 74 percent of the patients, and at least 70 percent improvement (median value) was achieved in 50 percent. The mean number of solid/liquid incontinence episodes decreased significantly from 0.5 (+/-0.5) to 0.1 (+/-0.3) per day (P = 0.004). Quality of life improved in all domains. The overall mean improvement in SF-36 scores was 39.8 percent. Both mean resting and squeeze anal pressures increased significantly, and maximum volume tolerated decreased significantly. CONCLUSIONS: Sacral nerve stimulation maintains its efficacy long term, not only in regard to control of symptoms but also regarding quality of life.

Recurrent caecal volvulus in mesenterium commune. A case report.

We report a case of recurrent abdominal pain due to intermittent caecal volvulus arising in a patient with mesenterium commune. Colonic enema, abdominal CT scan and virtual colonography with three-dimensional colonic reconstruction were useful for detecting this rare abnormal intestinal fixation. Although right hemicolectomy was indicated, we performed a wide colonic resection from the terminal ileum to the distal sigmoid because the patient's short mesentery made it impossible to perform an ileum-transverse anastomosis. At six months follow-up, the patient was in good health and free of abdominal symptoms.