Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study

BACKGROUND AND AIMS

This is the first double-blind multicenter study examining the effectiveness of sacral nerve stimulation in a significant number of fecally incontinent patients.

METHODS

A total of 34 consecutive patients (31 women), median age 57 years (range, 33-73 years), underwent sacral nerve stimulation for fecal incontinence. After implantation, 27 of 34 patients were randomized in a double-blind crossover design to stimulation ON or OFF for 1-month periods. While still blinded, the patients chose the period of stimulation (ON or OFF) that they had preferred. The mode of stimulation corresponding to the selected period was continued for 3 months (final period). Outcome measures were frequency of fecal incontinence and urgency episodes, delay in postponing defecation, score severity, feeling of improvement, preference for ON or OFF, quality of life, and manometric measurements.

RESULTS

In the crossover portion of the study, the self-reported frequency of fecal incontinence episodes was significantly reduced during the ON versus the OFF period (P = 0.03), and this symptomatic improvement was consistent: 1) with the patients feeling of greater improvement during the ON versus OFF period (P = 0.02); 2) with the significant preference of patients (P = 0.02) for the ON versus OFF period. In the final period of the study, the frequency of fecal incontinence episodes decreased significantly (P = 0.005) in patients with the stimulator ON. The ability to postpone defecation (P = 0.01), the score for symptom severity (P = 0.0004), and the quality of life (P < 0.05) as well as anal sphincter function significantly improved.

CONCLUSIONS

The significant improvement in FI during the ON versus OFF period indicated that the clinical benefit of sacral nerve stimulation was not due to placebo.

[Abdominal wound injuries: diagnosis and treatment. Report of 79 cases]

INTRODUCTION

- Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up.

PATIENTS AND METHODS

Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied.

RESULTS

Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications.

CONCLUSION

Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.

Entérocèle : facteurs de risque clinique et associations à d'autres troubles de la statique pelvienne (à partir de 544 défécographies)

OBJECTIVE

To study, by means of defecography, clinical risk factors of enterocele and association with others pelvic floor disorders.

PATIENTS AND METHODS

Five hundred and forty-four consecutive female patients were investigated by colpocystodefecography with contrast medium in the small bowel. One hundred and thirty-six women with enterocele were compared to 408 women without enterocele.

RESULTS

There were no significant differences in age, obstetrical history (parity, foetal macrosomia, instrumental extractions or perineal tear to delivery) between the two groups. More women with enteroceles had histories of hysterectomies (60% versus 24%) or cystopexies (29% versus 13%). Others pelvic floor disorders were associated in 91% of enterocele: rectocele (25%), cystocele (42%), uterine prolapse (28%), rectal intussusception (52%), rectal prolapse (4%) and abnormal perineal descent (30%). Stress urinary incontinence was significantly more frequent in women without enterocele.

DISCUSSION AND CONCLUSIONS

The study has demonstrated that previous hysterectomy and cystopexy increased the risk of enterocele formation and that enterocele and others pelvic floor disorders are often concomitant. Enterocele may have a pessary effect on urinary disorders. Results of colpocystodefecography reinforce the notion of pelvic floor local disease.

Frequency of anal incontinence and results of pelvic viscerography in 291 women with pelvic organ prolapse

OBJECTIVES

To determine the prevalence of anal incontinence in a population of 291 women with pelvic organ prolapse and evaluate the results of pelvic viscerogram in this situation.

MATERIALS AND METHODS

Each patient answered a standardized questionnaire on medical, obstetric and surgical past histories and answers were logged in a database. The viscerograms were performed by a single specialized radiologist.

RESULTS

All patients but one were parous. The prevalence of anal incontinence was 26.1%. Stress urinary incontinence and urge urinary incontinence were significantly associated with anal incontinence. No obstetric or surgical risk factor for anal incontinence was demonstrated. Viscerography demonstrated rectoceles (n=86, 29.1%), enteroceles (n=77, 26.5%), cystoceles (n=174, 59.8%), and intra-anal rectal prolapse (n=106, 36.4%). A significant association was found between intra-anal rectal prolapse and anal incontinence.

CONCLUSION

Anal incontinence is frequent in patients with pelvic organ prolapse, even more so in the presence of urinary incontinence, and should be investigated by pelvic viscerography. Pelvic floor dysfunction is frequently associated with enteroceles, rectoceles and rectal prolapse. Pelvic viscerograms should be systematically performed in the diagnostic work-up in patients with pelvic organ prolapse when surgical treatment is considered.

Contribution of magnetic resonance cholangiopancreatography to the management of patients with suspected common bile duct stones

OBJECTIVES

To evaluate the value of magnetic resonance cholangiography (MRC) as a systematic first-line investigation in the management of patients with suspected common bile duct stones.

METHODS

Ninety-nine consecutive patients with clinical suspicion of choledocolithiasis were prospectively explored by MRC. All MRCs were interpreted by two radiologists with knowledge of the patient's clinical condition and laboratory results. In case of discrepancy, a third opinion was obtained to reach consensus. The definitive diagnosis was established on the basis of endoscopic exploration of the common bile duct (n=40), clinical and biological follow-up at 6 Months (n=55) or other investigations (n=4). The clinician's level of confidence, management options implemented, and impact of management decisions were used to assess the contribution of MRC. The diagnostic accuracy of MRC for common bile duct stones was also determined.

RESULTS

At the observed level of confidence (85.9%), MRC identified a differential diagnosis in 7.1% of patients avoiding unnecessary endoscopic exploration in 59.6%. Systematic first-line MRC enabled appropriate management in 83.8% of patients. The sensitivity, specificity, and positive and negative predictive values of MRC for the diagnosis of common bile duct stones were 95.7%, 98.7%, 95.7% and 98.7%, respectively, with excellent inter-observer agreement (kappa=0.915).

CONCLUSION

Magnetic resonance cholangiography can be used to efficiently screen patients who may need further invasive exploration of the common bile duct. It specifically identifies patients requiring therapeutic ERCP.

Influence of rectal prolapse on the asymmetry of the anal sphincter in patients with anal incontinence

BACKGROUND

Anal sphincter defects have been shown to increase pressure asymmetry within the anal canal in patients with fecal incontinence. However, this correlation is far from perfect, and other factors may play a role. The goal of this study was to assess the impact of rectal prolapse on anal pressure asymmetry in patients with anal incontinence.

METHODS

44 patients, (42 women, mean age: 64 (11) years), complaining of anal incontinence, underwent anal vector manometry, endo-anal ultrasonography (to assess sphincter defects) and pelvic viscerogram (for the diagnosis of rectal prolapse). Resting and squeeze anal pressures, and anal asymmetry index at rest and during voluntary squeeze were determined by vector manometry.

RESULTS

Ultrasonography identified 19 anal sphincter defects; there were 9 cases of overt rectal prolapse, and 14 other cases revealed by pelvic viscerogram (recto-anal intussuception). Patients with rectal prolapse had a significantly higher anal sphincter asymmetry index at rest, whether patients with anal sphincter defects were included in the analysis or not (30 (3) % versus 20 (2) %, p < 0.005). Among patients without rectal prolapse, a higher anal sphincter asymmetry index during squeezing was found in patients with anal sphincter defects (27 (2) % versus 19 (2) %, p < 0.03).

CONCLUSIONS

In anal incontinent patients, anal asymmetry index may be increased in case of anal sphincter defect and/or rectal prolapse. In the absence of anal sphincter defect at ultrasonogaphy, an increased anal asymmetry index at rest may point to the presence of a rectal prolapse.

Fecal incontinence in females with a past history of vaginal delivery: significance of anal sphincter defects detected by ultrasound

PURPOSE

The aim of this study was to determine the significance of anal sphincter defects detected by ultrasonography, in a population of fecal incontinent parous females without previous anoperineal surgery.

METHODS

From 100 consecutive incontinent patients, 61 females with at least one previous vaginal delivery and no past anoperineal surgery were studied. The severity of fecal incontinence was assessed by the Cleveland Clinic questionnaire score. Lesions of the internal or external anal sphincters, and the radial size of these defects were assessed by ultrasonography. Anal vector manometry was performed to measure anal pressures at rest and during voluntary squeeze, and the anal asymmetry index.

RESULTS

Twenty-three had a normal sphincter (38 percent), and 38 (62 percent) had a defect detected by ultrasonography: 20 isolated defects of the external sphincter and 18 combined defects of the internal and external sphincters. Combined defects were significantly larger. The radial size of the defects was positively correlated with the severity of clinical symptoms. Anal pressure asymmetry index was significantly increased in the group with combined defects compared with the two other groups. An index of 25 percent or greater had a very high (100 percent) negative predictive value for the presence of a defect larger than 90 degrees.

CONCLUSIONS

This study confirms the high prevalence of anal sphincter defects detected by ultrasonography in a population of incontinent parous females without previous proctologic surgery. The clinical symptoms are related to the size of these defects. Anal vector manometry may be a useful tool to confirm the relation between echographic anal sphincter lesions and fecal incontinence.

[Three-luminal nasojejunal tube in digestive surgery: preliminary feasibility study]

STUDY AIM

The benefit of enteral nutrition is an established fact for severely burned or multiple injured patients with a reduction of septic morbidity. Enteral nutrition is now possible in upper gastrointestinal tract surgery with the development of nasojejunal triple lumen tube and we report a new application with an operative placement. The aim of the study was to evaluate the nasojejunal triple lumen tube in digestive surgery.

MATERIAL AND METHODS

From November 1999 to August 2001, a nasojejunal triple lumen tube was placed during surgery for high surgical risk patients (n = 17) or under radioscopic control for the treatment of post operative complications (n = 6).

RESULTS

The surgical placement was possible in all cases. The radioscopic placement failed in two cases, one of which being solved with endoscopic procedure. There was no morbidity during the tube placement. Four patients were excluded because of early post operative death (n = 3) or premature removal of the tube by the patient (n = 1). The enteral nutrition was early in 18 patients and its mean duration was 18.2 days (range 3-75). Technical problems occurred in 9 patients and the replacement of the tube was necessary in 8 cases.

CONCLUSION

The nasojejunal triple lumen tube is a feasible, safe and relatively well-tolerated procedure in upper gastrointestinal tract surgery.

[IMesenteric and mesocolic cystic lymphangiomas. Diagnostic and therapeutic management]

STUDY AIM

Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas.

MATERIAL AND METHODS

15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%).

RESULTS

Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection.

CONCLUSION

Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

[Anal incontinence: echographic and manometric study]

STUDY AIM

The goal of this study was to evaluate the clinical and functional consequences of anal sphincter echographic lesions in patients with fecal incontinence.

PATIENTS AND METHOD

From January 1997 to April 2001, 100 patients with fecal incontinence (90 women, 10 men) were prospectively explored by transanal ultrasound and vectormanometry. Internal and external sphincter defects, as well as their extension, were analyzed with regard to their clinical and functional expressions (resting and squeeze anal sphincter pressures, anal sphincter asymmetry index).

RESULTS

Among the 100 patients, 42 had no echographic lesions, 58 had a defect: 26 had an isolated defect (internal sphincter (n = 3), external sphincter (n = 23) and 32 had combined internal and external sphincter defects. Squeeze anal pressures were significantly lower in the group of patients with combined defects, compared to the group with isolated defect or without defect. Anal asymmetry index was higher in the group of patients with combined defects, compared to the other groups. There was a positive correlation between the radial extension of the defect and the importance of clinical complaints.

CONCLUSION

Echographic anal sphincter lesions are frequent in fecal incontinence and are clinically and functionally significant.

[Hepatic portal venous gas]

STUDY OBJECTIVE

Hepatic portal venous gas is a radiological symptom associated with a poor prognosis (75% to 90% mortality). The aim of this retrospective study was to report 7 cases observed over a 2-year period.

PATIENTS AND METHOD

From June 1997 to November 1999, hepatic portal venous gas was diagnosed in 6 patients by CT scan and in one patient by echosonography. It was not detected in any case by plain abdominal X-rays. Three patients had small bowel obstruction with necrosis, three had extensive superior mesenteric infarction and one had preperforative necrosis of the colon.

RESULTS

One patient with extensive intestinal infarction and a metastatic head and neck cancer was not operated. Two patients were operated, but the extensive mesenteric infarction was not amenable to surgical management. Three of the 7 patients died, while the other four patients survived after resection of the necrotic small intestine (n = 3) and left colectomy extended to the transverse colon (n = 1).

CONCLUSION

Hepatic portal venous gas was associated with intestinal necrosis in the seven cases of this series. The severity of portal venous gas is only correlated with the severity of the disease causing portal venous gas.

[Abdominopelvic ultrasonography in suspected acute appendicitis: prospective study in adults]

STUDY AIM

The aim of this prospective descriptive study was to evaluate the accuracy of abdomino-pelvic ultrasonography in suspected acute appendicitis in adults.

PATIENTS AND METHODS

From March to July 1998, 100 consecutive patients, 63 women, 37 men (mean age: 25 years), after examination by a visceral surgeon for suspected acute appendicitis, had an abdominal ultrasonography (US) examination with high frequency transducer (7.5 to 9 MHz). The US examination concerned appendice, periappendicular tissues and neighbouring organs. The US data were correlated with the histopathologic findings in operated on patients, and with the clinical and biological follow up in non operated patients.

RESULTS

Fourty-seven patients had acute appendicitis; 53 were operated on and 47 non operated. Analysis of US data revealed sensitivity 91.5%, specificity 94.3%, positive predictive value 93.5%, negative predictive value 94.3%, accuracy 93%; 75% of the other diagnosis were found by US.

CONCLUSION

Systematic abdominal ultrasonography in suspected acute appendicitis is recommended in adults.

Wound infection in open versus laparoscopic appendectomy. A meta-analysis

The authors performed a meta-analysis to determine whether open or laparoscopic appendectomy would reduce wound infection incidence in adult patients with acute appendicitis. The meta-analysis included nine of seven patients from eight randomized controlled trials. Data were analyzed using the fixed effect-model method of Mantel-Haenszel. Wound infection incidence was lower in the laparoscopic group.

[Solid pseudopapillary tumors of the pancreas. Pathology report of 13 cases]

OBJECTIVES

Solid pseudopapillary tumors of the pancreas are exceptional. The aims of our study were to reevaluate the mode of presentation of these tumors and to analyze the role of pathological examination in diagnostic assessment and prognostic evaluation.

PATIENTS

We report the clinical, radiological and pathological findings in a retrospective series of 13 patients in whom a diagnosis of solid pseudopapillary tumor of the pancreas was made between 1983 and 1997. There were 12 females (median age: 22.5 years) and one male, aged 73.

RESULTS

The tumor was discovered incidentally (3 cases) or because of nonspecific digestive symptoms (10 cases). Biological data were uninformative. The tumor was pancreatic in 12 cases and duodenal in 1. In all cases, imaging techniques showed an heterogeneous lesion with no or poor vascularization. A cystic component was identified in 4 cases. Surgical resection was performed in all cases. Pathological examination showed an encapsulated tumor in 8 cases, a non-encapsulated but well-limited lesion in 3 cases and an infiltrative tumor in 2 cases. At the time of diagnosis, multiple liver metastases were present in 1 case. Mean duration of follow-up was 24 months (range: 3-168). At last follow-up, all patients, including the patient with synchronous metastatic disease, were alive, without local recurrence.

CONCLUSION

Our study confirms that most cases of solid pseudopapillary tumors of the pancreas present with a suggestive clinical picture, including their occurrence in young women and their good prognosis after surgical resection. However, our results also underline the occurrence of cases presenting with unusual features, including old age, male sex, extra-pancreatic localization and malignant evolution. Histopathological examination is essential for the establishment of the diagnosis but morphological data are of little prognostic value.

[Rupture of the intra-abdominal spleen as a cause of hemothorax]

We report a case of a 17-year-old patient with an haemothorax related to an intra-abdominal spleen rupture. The nature of this haemothorax is unusual and the problem is how to obtain the etiology in this case. The spleen was in intra-abdominal position on all radiological examinations and was the source of bleeding. Therefore, laparotomy is the only convenient therapy.