Pyloric valve transposition as substitute for a colostomy in humans: a preliminary report

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Composite Antropyloric Valve and Gluteus Maximus Muscle Wrap for Neoanal Reconstruction: Initial Results

BACKGROUND

Severe fecal incontinence has a significant negative impact on patient well-being. Current surgical methods of total anorectal reconstruction to substitute a colostomy have suboptimal results. A composite graft using antropyloric valve transposition and gracilis wrap has been described with good outcomes. However, this procedure requires extensive training of patients. Gluteus maximus, an accessory muscle for continence, may be better suited for this purpose.

OBJECTIVE

The purpose of this study was to evaluate the outcomes of composite antropylorus-gluteus graft for intractable fecal incontinence.

DESIGN

Patients underwent a 3-stage procedure: antropyloric transposition with diversion stoma followed by gluteus wrap. Stoma was closed after ensuring the anatomic and functional integrity of the graft.

SETTINGS

This study was conducted at a single tertiary care institution.

PATIENTS

Patients who were on permanent colostomy for intractable incontinence or would have had one after abdominoperineal resection were included.

MAIN OUTCOME MEASURES

Endoultrasonography, MRI, loopogram, saline holding test, anal manometry, St. Mark's fecal incontinence score, and personal interviews were used for measurement.

RESULTS

Eleven patients underwent the procedure with a median follow-up of 16 months (range, 13-34 mo). Digital rectal examination revealed a resting tone with a distinct squeeze provided by the composite graft. Radiological imaging confirmed healthy grafts. There was a significant improvement in mean anal manometry values (resting pressure: preoperative = 10.25 mm Hg vs postoperative = 20.45 mm Hg; squeeze pressure: preoperative = 22.63 mm Hg vs postoperative = 105.18 mm Hg) and mean incontinence score postprocedure (preoperative = 22.8 vs postoperative = 8.6). On personal interview, majority of the patients were continent and expressed satisfaction with the procedure.

LIMITATIONS

The study was limited by its small sample size with no control group.

CONCLUSIONS

Composite graft in patients with intractable fecal incontinence can serve as a viable novel method for total anorectal reconstruction. However, it should only be recommended for a highly select group of individuals in a surveillance setting. Its long-term outcomes remain to be determined as well as its risk versus benefit.

Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review

Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.

Faecal incontinence: Current knowledges and perspectives

Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools.

Novel treatment options for fecal incontinence

Fecal incontinence (FI) is a devastating condition affecting a substantial portion of the population. The etiologies of FI are wide ranging, as are the treatment options. When conservative measures fail, often surgical intervention is required. As in any area where a wide range of treatment options exist, there is no one perfect solution. Fortunately, novel treatment options for FI are becoming available, namely, posterior tibial nerve stimulation, magnetic anal sphincter, stem cell transplant, pyloric transplantation, and acupuncture.

Initial management and outcome of modern battlefield anal trauma

BACKGROUND

Despite the potential for morbidity and permanent lifestyle alteration, few reports exist examining traumatic injury to the anal canal, particularly among modern-day combatants.

OBJECTIVE

The aim of this study was to document the incidence, initial surgical management, and long-term outcomes of wartime anal trauma.

DESIGN

This study is a retrospective review.

DATA SOURCES

Data were compiled from multiple electronic medical record systems, including the Department of Defense Trauma Registry, the Patient Administration Systems and Biostatistics Activity, and the Armed Forces Health Longitudinal Tracking Application.

SETTINGS

Combatants were treated at military treatment facilities with surgical capability during the wars in Iraq and Afghanistan, 2003 through early 2011.

PATIENTS

All US and coalition combatants sustaining trauma to the anal canal or sphincter musculature were included.

MAIN OUTCOME MEASURES

The quantification of incidence, the evaluation of initial treatment approach, and the determination of clinical and surgical factors correlating with restoration or preservation of GI tract continuity were the primary outcomes measured.

RESULTS

Anal trauma occurred in 46 combatants, predominantly from blast injury (76.1%). Most (36, 78.2%) underwent fecal diversion. Concurrent severe systemic or intra-abdominal injuries correlated with colostomy creation. Acute anoplasty was attempted in 11 patients (23.7%) but did not influence eventual colostomy reversal. Among 33 US personnel, the permanent colostomy rate was 30.3%. Concurrent injury to the abdomen strongly predicted long-term colostomy (p = 0.009), along with hypogastric arterial ligation (p = 0.05) and pelvic fracture (p = 0.06).

LIMITATIONS

This study was limited by the potential underdiagnosis of anal injury and the restricted follow-up of non-US personnel.

CONCLUSIONS

Other injuries besides anal trauma typically have guided the decision for fecal diversion, and acute anal repair has rarely been indicated. The majority of patients with anal trauma regained normal GI continuity, although certain pelvic injuries increased the likelihood of permanent colostomy.

Perineal antropylorus transposition for end-stage fecal incontinence in humans: initial outcomes

BACKGROUND

Technical feasibility of perineal antropyloric valve transposition to reconstruct a severely damaged incontinent anal sphincter or to replace an excised anorectal sphincter has been reported previously.

OBJECTIVE

This study aimed to document the follow-up results of patients who underwent successful perineal antropyloric valve transposition for end-stage fecal incontinence.

SETTING

This study was conducted at a single tertiary care institution.

PATIENTS

Seventeen patients underwent the procedure. Eight patients had replacement (group 1) and 9 patients had augmentation (group 2) of the anal sphincter. Two patients in group 1 with early graft-related complications were excluded from further analysis, because they had the grafts excised.

MAIN OUTCOME MEASURES

The primary outcome measures were anatomical integrity and functional status of the graft in the perineum, fecal incontinence scores, and quality-of-life scores (SF-36) over a median follow-up of 18 months.

RESULTS

The transposed grafts had a definite tone on digital examination, were well visualized on perineal MRI, showed high-velocity vascular inflow on Doppler ultrasound study, and good vascularity on celiac CT angiography. Anal manometry showed a significant (p = 0.03) rise in the postoperative resting neosphincter pressures with good retention of barium proximal to pyloric valve on distal loopogram. The postoperative St Mark incontinence score improved in both groups and was significantly better in group 2 than in group 1. There was significant improvement in postoperative physical and mental component scores in both groups with higher scores in group 2 than in group 1 on follow-up.

LIMITATIONS

A longer follow-up with a larger sample size is required.

CONCLUSIONS

Antropyloric valve transposition can be used effectively for a selected group of patients with end-stage fecal incontinence. Patients undergoing anal sphincter augmentation have better outcomes in comparison with those having an excised sensate anorectum.

Feasibility of neurovascular antropylorus perineal transposition with pudendal nerve anastomosis following anorectal excision: a cadaveric study for neoanal reconstruction

Purpose

Perineal transposition of the antropyloric valve following an anorectal excision as a substitute for a permanent colostomy has recently been reported in humans. However, the problem of neural control still remains in these patients. Our aim herein was to study the anatomical feasibility of an anastomosis between the pudendal nerve branches (inferior rectal nerve) innervating the external anal sphincter and the anterior vagal branches of the perineally-transposed antropyloric segment in cadavers.

Methods

The antropyloric segment, along with its carefully dissected branch of the anterior vagus, was mobilized based on the left gastroepiploic pedicle in six fresh human cadavers. The antropyloric valve was then transposed in the perineum after the pudendal nerve branches had been dissected out, and an approximation of these two nerves was performed to ascertain the technical feasibility of their neural anastomosis.

Results

The anterior vagus innervating the antropylorus could be harvested in all cadavers below the hepatic division of the main vagus trunk. The inferior rectal nerve or its branches were found consistently around the 3 or the 9 o'clock position in the ischioanal fossa. An anatomical tension-free approximation of the anterior vagus branch (of the transposed antropyloric segment) to the inferior rectal nerve in the perineum was feasible in all the cadavers studied.

Conclusion

An inferior rectal nerve anastomosis with the anterior vagal branch of the perineally-transposed antropyloric segment can be achieved anatomically. This preliminary step can be the basis for future animal studies and subsequent clinical application of the procedure for possible neural control of the transposed antropyloric segment in the perineum.

Physiological and functional evaluation of the transposed human pylorus as a distal sphincter

Background/Aims

Studies evaluating the human pylorus as a sphincter are scanty and contradictory. Recently, we have shown technical feasibility of transposing the human pylorus for end-stage fecal incontinence. This unique cohort of patients provided us an opportunity to study the sphincter properties of the pylorus in its ectopic position.

Methods

Antro-pylorus transposition on end sigmoid colostomies (n = 3) and in the perineum (n = 15) was performed for various indications. Antro-pylorus was assessed functionally (digital examination, high resolution spatiotemporal manometry, barium retention studies and colonoscopy) and by imaging (doppler ultrasound, MRI and CT angiography) in its ectopic position.

Results

The median resting pressure of pylorus on colostomy was 30 mmHg (range 28-38). In benign group, median resting pressure in perineum was 12.5 mmHg (range 6-44) that increased to 21.5 mmHg (range 12-29) (P = 0.481) and 31 mmHg (range 16-77) (P = 0.034) on first and second follow-up, respectively. In malignant group, median post-operative pressures were 20 mmHg (range 14-36) and 21 mmHg (range 18-44) on first and second follow-up, respectively. A definite tone and gripping sensation were felt in all the patients on digital examination. On distal loopogram, performed through the diverting colostomies, barium was retained proximal to the neo-pyloric valve. Both perineal ultrasound and MRI showed viable transposed graft. CT angiography and color doppler studies confirmed vascular flow in the transposed position.

Conclusions

The human pyloric valve can function as a tonic sphincter when removed from the gastroduodenal continuity.

Advanced technologies in trauma critical care management

Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care.