Microchip implants on the anterior sacral roots in patients with spinal trauma: does it improve bowel function?

[Analysis of anorectal manometry data in central and peripheral neurological deseases: Review of the literature]

INTRODUCTION

Peripheral or central neurological deseases are providers of anorectal disorders of variable clinical expression (constipation, dyschezia, faecal incontinence (FI)…). Anorectal manometry (ARM) participates in their exploration to determine the underlying mechanisms, guide and optimize treatments. The objective of this work was to determine if there is a pattern of ARM data in neurological populations.

MATERIALS ET METHODS

Literature review from PubMed, Cochrane and Google scholar databases, using the following keywords: parkinsonian disorders; parkinson's disease; multiple slcerosis; neurolog*; spinal cord injury; spina bifida occulta; stroke; pudendal; endometriosis; peripheral nervous system diseases. 196 articles were isolated and finally 45 retained after reading the title and the abstract.

RESULTS

Data comparison was difficult due to the heterogeneity of techniques and thresholds used. In central lesions, resting and squeeze anal pressures were often altered. The presence of FI or constipation, the sex and the lesion level were factors influencing these data (low if complete injury, women or EDSS>5.5). In case of peripheral lesion, it is the anal tone and the contraction that varied the symptomatology. The sensory thresholds were variable regardless of the impairment.

CONCLUSION

This review did not identify a data pattern of ARM in central and peripheral neurological deseases. Gradual standardization of techniques and protocols will allow better comparison of data.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Management of faecal incontinence and constipation in adults with central neurological diseases

BACKGROUND

People with central neurological disease or injury have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two symptoms, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. This is an update of a Cochrane review first published in 2001 and subsequently updated in 2003 and 2006. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease.

OBJECTIVES

To determine the effects of management strategies for faecal incontinence and constipation in people with a neurological disease or injury affecting the central nervous system.

SEARCH METHODS

We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials evaluating any type of conservative or surgical intervention for the management of faecal incontinence and constipation in people with central neurological disease or injury were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures.

MAIN RESULTS

Twenty trials involving 902 people were included. Oral medications There was evidence from individual small trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of cisapride and tegaserod in people with spinal cord injuries or Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review. Rectal stimulants One small trial in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB bisacodyl suppository.Physical interventions There was evidence from one small trial with 31 participants that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score).One small trial in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventions In one trial in stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral carbonated water (rather than tap water) improved constipation scores in people who had had a stroke.

AUTHORS' CONCLUSIONS

There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming laxative (psyllium), an isosmotic macrogol laxative, abdominal massage, electrical stimulation and an anticholinesterase-anticholinergic drug combination (neostigmine-glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to conservative management), oral carbonated (rather than tap) water and abdominal massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.

Management of faecal incontinence and constipation in adults with central neurological diseases

BACKGROUND

People with central neurological disease or injury have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two symptoms, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. This is an update of a Cochrane review first published in 2001 and subsequently updated in 2003 and 2006. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease.

OBJECTIVES

To determine the effects of management strategies for faecal incontinence and constipation in people with a neurological disease or injury affecting the central nervous system.

SEARCH METHODS

We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials evaluating any type of conservative or surgical intervention for the management of faecal incontinence and constipation in people with central neurological disease or injury were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures.

MAIN RESULTS

Twenty trials involving 902 people were included.Oral medicationsThere was evidence from individual small trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of cisapride and tegaserod in people with spinal cord injuries or Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review.Rectal stimulantsOne small trial in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB bisacodyl suppository.Physical interventionsThere was evidence from one small trial with 31 participants that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score).One small trial in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventionsIn one trial in stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral carbonated water (rather than tap water) improved constipation scores in people who had had a stroke.

AUTHORS' CONCLUSIONS

There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming laxative (psyllium), an isosmotic macrogol laxative, abdominal massage, electrical stimulation and an anticholinesterase-anticholinergic drug combination (neostigmine-glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to conservative management), oral carbonated (rather than tap) water and abdominal massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.

Assessment of patient-reported measures of bowel function before and after pelvic radiotherapy: an ancillary study of the North Central Cancer Treatment Group study N00CA

PURPOSE

The Bowel Function Questionnaire (BFQ) has been used in clinical trials to assess symptoms during and after pelvic radiotherapy (RT). This study evaluated the importance of symptoms in the BFQ from a patient perspective.

METHODS

Patients reported presence or absence of symptoms and rated importance of symptoms at baseline, 4 weeks after completion of pelvic RT, and 12 and 24 months after RT. The BFQ measured overall quality of life (QOL) and symptoms of nocturnal bowel movements, incontinence, clustering, need for protective clothing, inability to differentiate stool from gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency also was recorded. A content validity questionnaire (CVQ) was used to rate symptoms as "not very important," "moderately unimportant," "neutral," "moderately important," or "very important."

RESULTS

Most of the 125 participating patients rated all symptoms as moderately or very important. Generally, patients gave similar ratings for symptom importance at all study points, and ratings were independent of whether the patient experienced the symptom. Measures of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94 %), not having to wear protective clothing (90 %), and not having rectal bleeding (94 %). With the exception of need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (P < .01 for all).

CONCLUSIONS

The BFQ has excellent content validity. Patients rated most symptoms as moderately or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT.

[Intestinal alterations in patients with a medullary lesion]

Loss of bowel control is distressing for persons with a medullary lesion and affects their quality of life. The present study aims to provide an updated review of the topic. Impaired neural control of continence and defecation after a medullary lesion provokes bowel dysfunction, with a high prevalence of two main symptoms: fecal incontinence and constipation. The physiopathology of these disorders is correlated with the neurological characteristics of the lesion, and various physiopathologic patterns have been established that correlate with the clinical manifestations. Evaluation of bowel dysfunction in these patients is normally exclusively clinical and complementary examinations are rarely used, although they seem promising. Treatment is based on establishing a program of evacuation. However, despite correct application, the results can be unsatisfactory and consequently other therapeutic alternatives should be developed.

Neurogenic bowel management after spinal cord injury: a systematic review of the evidence

STUDY DESIGN

Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included.

OBJECTIVE

To systematically review the evidence for the management of neurogenic bowel in individuals with SCI.

SETTING

Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature.

METHODS

Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned.

RESULTS

A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications.

CONCLUSIONS

Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

Advances in study of severe acute pancreatitis and gastrointestinal dysmotility

Gastrointestinal dysmotility often occurs in patients with sever acute pancreatitis. This article reviews the effect of nerve, hormone, inflammatory factors and ischemia-reperfusion injury on gastrointestinal dysmotility. It elucidates that the gastrointestinal dysmotility is significanly relieved ater treatment of acute pancreatitis.

Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis

BACKGROUND

When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI.

METHODS

A decision analysis was created to compare the four surgical strategies using baseline analysis, one-way and two-way sensitivity analyses, 'worst scenario' and 'best scenario' sensitivity analyses, and probabilistic sensitivity analyses. Quality-adjusted life expectancy (QALE) was the primary outcome.

RESULTS

The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust.

CONCLUSION

The MACE procedure may provide the best long-term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available.

Sacral nerve stimulation induces pan-colonic propagating pressure waves and increases defecation frequency in patients with slow-transit constipation

OBJECTIVE

Colonic propagating sequences are important for normal colonic transit and defecation. The frequency of these motor patterns is reduced in slow-transit constipation. Sacral nerve stimulation (SNS) is a useful treatment for fecal and urinary incontinence. A high proportion of these patients have also reported altered bowel function. The effects of SNS on colonic propagating sequences in constipation are unknown. Our aims were to evaluate the effect of SNS on colonic pressure patterns and evaluate its therapeutic potential in severe constipation.

METHOD

In eight patients with scintigraphically confirmed slow-transit constipation, a manometry catheter (16 recording sites at 7.5 cm intervals) was positioned colonoscopically and the tip fixed in the caecum. Temporary electrodes (Medtronic) were implanted in the S2 and S3 sacral nerve foramina under general anaesthesia. In the fasted state, 14 Hz stimulation was administered and four sets of parameters (pulse width 300 or 400 micros; S2 and S3) were tested in four 2-h epochs, in random order, over 2 days. Patients were then discharged home with the sacral wires in situ and a 3-week trial stimulation commenced during which patients completed a daily stool diary.

RESULTS

When compared with basal activity, electrical stimulation to S3 significantly increased pan-colonic antegrade propagating sequence (PS) frequency (5.4 +/- 4.2 vs 11.3 +/- 6.6 PS/h; P=0.01). Stimulation at S2 significantly increased retrograde PSs (basal 2.6 +/- 1.8 vs SNS 5.6 +/- 4.8 PS/h; P=0.03). During the subsequent three-week trial (continuous stimulation), six of eight reported increased bowel frequency with a reduction in laxative usage.

CONCLUSION

These data demonstrate that SNS induces pan-colonic propagating pressure waves and therefore shows promise as a potential therapy for severe refractory constipation.

Management of faecal incontinence and constipation in adults with central neurological diseases

BACKGROUND

People with neurological disease have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two conditions, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical with a limited research base.

OBJECTIVES

To determine the effects of management strategies for faecal incontinence and constipation in people with neurological diseases affecting the central nervous system.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 26 January 2005), the Cochrane Central Register of Controlled Trials (Issue 2, 2005), MEDLINE (January 1966 to May 2005), EMBASE (January 1998 to May 2005) and all reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating any types of conservative or surgical measure for the management of faecal incontinence and constipation in people with neurological diseases were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials using a range of pre-specified outcome measures.

MAIN RESULTS

Ten trials were identified by the search strategy, most were small and of poor quality. Oral medications for constipation were the subject of four trials. Cisapride does not seem to have clinically useful effects in people with spinal cord injuries (three trials). Psyllium was associated with increased stool frequency in people with Parkinson's disease but did not alter colonic transit time (one trial). Prucalopride, an enterokinetic did not demonstrate obvious benefits in this patient group (one study). Some rectal preparations to initiate defaecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). There appears to be a benefit to patients in one-off educational interventions from nurses. The clinical significance of any of these results is difficult to interpret.

AUTHORS' CONCLUSIONS

There is still remarkably little research on this common and, to patients, very significant condition. It is not possible to draw any recommendation for bowel care in people with neurological diseases from the trials included in this review. Bowel management for these people must remain empirical until well-designed controlled trials with adequate numbers and clinically relevant outcome measures become available.

[Assessment of anorectal disorders with paraplegia]

INTRODUCTION

Functional anorectal disorders in paraplegia are frequent; few studies evaluate the effect of these disorders on quality of life.

OBJECTIVE

Assessment of the functional anorectal disorders in a homogeneous group of patients with total paraplegia in terms of quality of life.

METHODS

During a global follow-up consultation, patients answered questions on a systematic questionnaire about anorectal disorders and a specific quality-of-life autoquestionnaire about functional digestive disorders: Functional Digestive Disorders Quality of Life (FDDQL) questionnaire; score 0 to 100 (100 corresponding to no effect on quality of life).

RESULTS

Twenty-three patients with a mean age of 44.3 years who had been paraplegic for 10 years participated. Two had a colostomy because of bedsores. Fourteen underwent daily rectal examination, 10 with an evacuation aim; the time given to defecation was, on average, 36 minutes. One patient had clinical constipation. Twelve had had one or more episodes of incontinence. The mean global FDDQL score was 69.7. This score was not related to incontinence; only the "comfort" domain among the 8 domains was related to incontinence.

DISCUSSION

Anorectal disorders are frequent in paraplegia; the duration and the methods of defecation represent a great worry to patients. More than half of the patients already had faecal incontinence; the effect of even occasional incontinence on quality of life is significant. Since the FDDQL scale is not specific to patients with paraplegia, its interest should be checked on a greater number of patients. For certain patients, it is important not to dismiss more complex surgical treatment methods.

Sacral anterior root stimulated defecation in spinal cord injuries: An experimental study in canine model

AIM: To investigate whether there was a dominant sacral root for the motive function of rectum and anal sphincter, and to provide an experimental basis for sacral root electrically stimulated defecation in spinal cord injuries.

METHODS: Eleven spinal cord injured mongrel dogs were included in the study. After L4-L7 laminectomy, the bilateral L7-S3 roots were electrostimulated separately and rectal and sphincter pressure were recorded synchronously. Four animals were implanted electrodes on bilateral S2 roots.

RESULTS: For rectal motorial innervation, S2 was the most dominant (mean 15.2 kPa, 37.7% of total pressure), S1 (11.3 kPa, 27.6%) and S3 (10.9 kPa, 26.7%) contributed to a smaller part. For external anal sphincter, S3 (mean 17.2 kPa, 33.7%) was the most dominant, S2 (16.2 kPa, 31.6%) and S1 (14.3 kPa, 27.9%) contributed to a lesser but still a significant part. Above 85% L7 roots provided some functional contribution to rectum and anal sphincter. For both rectum and sphincter, the right sacral roots provided more contribution than the left roots. Postoperatively, the 4 dogs had electrically stimulated defecation and micturition under the control of the neuroprosthetic device.

CONCLUSION: S2 root is the most dominant contributor to rectal pressure in dogs. Stimulation of bilateral S2 with implanted electrodes contributes to good micturition and defecation in dogs.

Effect of stoma formation on bowel care and quality of life in patients with spinal cord injury

INTRODUCTION

Bowel management is a significant source of concern for patients with spinal cord injury (SCI) and may significantly alter quality of life. The effect of colostomy formation on both quality of life and time taken for bowel care is well recorded. We report our experience of intestinal stoma formation in SCI patients.

METHODS

Medical records from the spinal unit, operating theatres and stoma clinics were reviewed to identify SCI patients for whom a stoma had been formed. Patients were interviewed using a standard questionnaire. Average age at injury was 29 years (range 6-62 years). Mean time from injury to stoma formation was 17 years (range 0-36.25 years) and the mean period of poor bowel function prior to stoma was 8 years (range 1.5-25).

RESULTS

The average time spent on bowel care per week decreased from 10.3 h (range 3.5-45) prior to stoma formation to 1.9 h (range 0.5-7.75) afterwards (P<0.0001, paired t-test). In all, 18 patients felt that a stoma gave them greater independence and quality of life was described as much better by 25 patients. Complications occurred in 14 patients - eight described leakage of mucus and occasionally blood and pus per rectum, three developed parastomal hernias and three developed bowel obstruction.

CONCLUSION

Elective stoma formation is a safe and well-accepted treatment for the management of chronic gastrointestinal symptoms in patients with SCI.

Management of faecal incontinence and constipation in adults with central neurological diseases

BACKGROUND

People with neurological disease have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine dividing line between the two conditions, with any management intended to ameliorate, one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical with a limited research base.

OBJECTIVES

To determine the effects of management strategies for faecal incontinence and constipation in people with neurological diseases affecting the central nervous system.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Trials Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE and all reference lists of relevant articles. Date of the most recent searches: May 2000.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating any types of conservative, or surgical measure for the management of faecal incontinence and constipation in people with neurological diseases were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction have also been considered.

DATA COLLECTION AND ANALYSIS

All three reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials using a range of pre-specified outcome measures.

MAIN RESULTS

Only seven trials were identified by the search strategy and all were small and of poor quality. Oral medications for constipation were the subject of four trials. Cisapride does not seem to have clinically useful effects in people with spinal cord injuries (two trials). Psyllium was associated with increased stool frequency in people with Parkinson's disease but not altered colonic transit time (one trial). Some rectal preparations to initiate defecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). The clinical significance of any of these results is difficult to interpret.

REVIEWER'S CONCLUSIONS

It is not possible to draw any recommendation for bowel care in people with neurological diseases from the trials included in this review. Bowel management for these people must remain empirical until well-designed controlled trials with adequate numbers and clinically relevant outcome measures become available.

Dynamic graciloplasty for severe anal incontinence

BACKGROUND

The surgical options for the treatment of anal incontinence where standard procedures have failed include transposition of striated muscles, primarily gracilis and gluteus maximus, and implantation of artificial sphincters. Due to a high proportion of fatigue-prone fibres in striated muscles, the results of transposition without stimulation have been disappointing. This study presents the results of stimulated graciloplasty in 13 patients with severe anal incontinence in whom other surgical procedures had failed.

METHODS

The gracilis muscle was transposed around the anal canal according to a previously described technique. Eight weeks later the intramuscular electrodes were implanted into the gracilis at the site of the nerve entry and a neurostimulator was placed in a subcutaneous pocket in the abdominal wall. The patients were followed from 7 to 27 months.

RESULTS

Six patients obtained satisfactory continence and five showed marked improvement. Two patients were considered failures. Rectal evacuation problems occurred in three patients, in one so severe that the patient, in spite of satisfactory continence, considered the treatment a failure.

CONCLUSION

Dynamic graciloplasty is a viable option in carefully selected patients with severe anal incontinence where other methods have failed.

Neurogenic bowel dysfunction after spinal cord injury: clinical evaluation and rehabilitative management

Neurogenic bowel dysfunction (NBD) is one of many impairments that result from spinal cord injury (SCI). The experience of persons with SCI reveals that the risk and occurrence of fecal incontinence and difficulty with evacuation are particularly significant life-limiting problems. This review relates the anatomy and physiology of colon function to the specific pathophysiology that detracts from the quality of life of persons after SCI. There are two patterns of NBD after SCI: the upper motor neuron bowel, which results from a spinal cord lesion above the sacral level, and the lower motor neuron bowel, which results from a lesion to the sacral spinal cord, roots, or peripheral nerve innervation of the colon. Rehabilitation evaluation consists of a comprehensive history and examination to define impairments, disabilities, and handicaps pertinent to NBD. Rehabilitation goals include continence of stool, simple willful independent defecation, and prevention of gastrointestinal complications. Intervention consists of derivation and implementation of an individualized person-centered bowel program, which may include diet, oral/rectal medications, equipment, and scheduling of bowel care. Bowel care is a procedure devised to initiate defecation and accomplish fecal evacuation. Digital-rectal stimulation is a technique utilized during bowel care to open the anal sphincter and facilitate reflex peristalsis. Recent advances in rehabilitation practices, equipment, pharmacology, and surgery have offered patients new bowel program alternatives. Interdisciplinary development of solutions for problems of NBD are evolving rapidly.