[Anorectal disorders in patients with multiple sclerosis: Physiopathology, prevalence, impact, and management]

OBJECTIVE

Neurogenic bowel disorders (NBD) are frequently observed in patients with multiple sclerosis (MS); the prevalence of constipation is estimated to be 35-54 % and fecal incontinence between 29 and 51 % (LE 4). They contribute to the deterioration of patients' quality of life (LE 4). The aim of this article is to review the literature on the physiopathology, prevalence, impact, and management of bowel disorders in patients with MS in order to educate caregivers about their existence and thus help them to optimize therapeutic choices.

MATERIALS AND METHODS

A bibliographic search was conducted between 2000 and 2019 and 31 relevant scientific articles were selected. Relevant references were subsequently added, bringing the total to 50 articles. A level of scientific evidence (LE) was assigned to each article, except for literature reviews.

RESULTS

The origin of NBD is multifactorial and includes impairment of neurological pathways, polypharmacy, behavioural disorders, and loss of autonomy (LE 4). Patients with MS should be questioned about their bowel habits and, in cases of proven NBD, specific management options should be offered. The first step concerns the dietary and lifestyle rules associated with the use of laxatives, suppositories, and/or enemas (LE 4). In the event of failure, therapies such as abdominal massages (LE 1 and 2), biofeedback and transanal irrigation can be proposed (LE 4). Anterograde colonic irrigation may also be an option (LE 4). The efficacy of stimulating the posterior tibial nerve needs to be proven (LE 4). The implantation of a sacral neuromodulation device is, for the moment, difficult due to the impossibility of performing a spinal magnetic resonance imaging during follow-up. A stoma improves the quality of life of patients and should not be proposed too late.

CONCLUSION

Effective treatment of NBD improves the quality of life of patients and reduces the incidence of bladder disorders (LE 4).

The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence

BACKGROUND

The functional lumen imaging probe (EndoFLIP^® ) is a new technology that measures the distensibility of the anal canal represented by the anal distensibility index. The aims of this study were (i) to compare the anal distensibility index to anal pressure in a cohort of patients with fecal incontinence (FI) and (ii) to compare the diagnostic value of the EndoFLIP^® to that of high-resolution anorectal manometry (HRAM) in the same cohort of patients.

METHODS

Eighty-three consecutive patients with FI who underwent EndoFLIP^® and HRAM assessments were enrolled. The diagnostic value of the EndoFLIP^® was compared to that of HRAM and agreement between EndoFLIP^® and HRAM data was assessed.

KEY RESULTS

More than 70% of the patients diagnosed with anal deficiency at rest and/or during voluntary contractions by HRAM had the same diagnosis using the EndoFLIP^® . Two patients with higher distensibility indexes at rest had normal anal resting pressures. Sixteen patients with a normal EndoFLIP^® index (ie, normal distensibility index at rest and during voluntary contractions) had an abnormal HRAM result. Seven of these 16 patients (44%) had no sphincter lesion or neuropathic disorder that could explain an abnormal anal sphincter function.

CONCLUSIONS & INFERENCES

We demonstrated that the anal distensibility index and HRAM results are largely in agreement. We did, however, identify several discrepancies between the two techniques, indicating that they may be complementary.

Acute sacral nerve stimulation reduces visceral mechanosensitivity in a cross-organ sensitization model

BACKGROUND

Sacral nerve stimulation (SNS) is a surgical treatment of fecal and urinary incontinence that consists of inserting a stimulating electrode into one of the s3 or s4 sacral holes. In addition to the benefit of SNS in the treatment of incontinence, recent studies showed that SNS is effective in the treatment of irritable bowel syndrome as well as bladder pain syndrome. The aim of this study was to evaluate the effect of SNS on visceral mechanosensitivity in a cross-organ sensitization rat model.

METHODS

Hypersensitive model was obtained by instillation of acetic acid into the bladder of rats during 5 minutes, 30 minutes before the start of the experiments. Visceral sensitivity was assessed by monitoring the change in mean arterial pressure in response to graded isobaric colorectal distension series. To decipher the mechanisms underlying SNS effect, rats were administered intravenously either a nonselective opioid receptor antagonist (naloxone) or a nitric oxide synthesis antagonist (L-NAME). Neuronal activation in the dorsal horn of the sacral spinal cord was measured by counting c-fos immunoreactive cells in response to colorectal distension and NMS.

KEY RESULTS

Intravesical acetic acid instillation increased mean arterial pressure variation in response to colorectal distension when compared to saline group. SNS reduced the variation in arterial pressure. Colorectal distension induced a rise in c-fos immunoreactive cells in the dorsal horn of the spinal cord. This effect was reduced by SNS.

CONCLUSIONS & INFERENCES

SNS reduces visceral mechanosensitivity in a cross-organ sensitization model.

Do endoflip assessments of anal sphincter distensibility provide more information on patients with fecal incontinence than high-resolution anal manometry?

BACKGROUND

Anal manometry is the standard technique for evaluating anal sphincter function. However, the functional lumen imaging probe (EndoFLIP(®) ) can be used to measure sphincter distensibility during volume-controlled distensions. Our aims were (i) to assess anal distensibility in patients with fecal incontinence (FI) and in healthy subjects using the EndoFLIP(®) and (ii) to compare the results with anal pressures measured by 3D high-resolution manometry (3D-HRM) to determine whether the EndoFLIP(®) was more sensitive and specific for diagnosing FI than 3D-HRM.

METHODS

EndoFLIP(®) and 3D-HRM assessments of 34 female FI patients and 40 healthy female subjects were performed. Anal distensibility was measured as the median cross-sectional area at the narrowest point divided by the corresponding intra-bag pressure at rest and during peak voluntary contraction and was expressed in mm(2) /mmHg.

KEY RESULTS

A 40-mL anal distensibility index was selected for further comparisons as it provided the best discrimination between the FI patients and the healthy subjects. The index was significantly higher in the FI patients than in the healthy subjects at rest (p = 1.10(-4) ) and during voluntary contraction (p = 1.10(-4) ). The index at rest and during voluntary contraction appeared to be more appropriate than anal pressures for discriminating between FI patients and healthy subjects.

CONCLUSIONS & INFERENCES

The present study confirmed that FI is associated with an abnormally high distensibility index at rest and during voluntary contraction. The ability of the distensibility index to discriminate between FI patients and healthy subjects was significantly better than anal pressure.

Impact of deep brain stimulation on pharyngo-esophageal motility: a randomized cross-over study

BACKGROUND

Bilateral subthalamic nucleus (STN) stimulation is used to alleviate Parkinson's disease (PD) motor symptoms. Recently, it has been shown that this therapeutic also increased gut cholinergic contractions. We therefore investigated the effect of STN stimulation on esophageal motility in an interventional randomized study.

METHODS

Sixteen humans PD patients (4 women, 12 men; age: 62.4 ± 9.3-years old) who underwent STN stimulation for at least 6 months were randomly evaluated with either stimulator turned OFF then ON, or inversely. Esophageal high resolution manometry was performed at the end of each ON and OFF period, with a 5 min resting period followed by ten swallows of 5 mL.

KEY RESULTS

During the ON, an increase in the distal contractility index was found (OFF: 1750 ± 629 vs ON: 2171 ± 755 mmHg/cm/s; p = 0.03), with no difference in the distal front velocity. A decrease in the integrative relaxation pressure of the lower esophageal sphincter (LES) was noted (OFF: 11.1 ± 1.8 mmHg vs ON: 7.2 ± 1.8 mmHg; p < 0.05) in ON. The LES resting pressure remained unchanged during the two periods. This resulted in a decrease in the intrabolus pressure (p = 0.03). No difference was observed for the upper esophageal sphincter, nor the pharyngeal contraction amplitude and velocity.

CONCLUSIONS & INFERENCES

In conclusion, STN stimulation in PD patients increased esophageal body contractions and enhanced the LES opening. This suggests that the nigrostriatal-striatonigral loop is involved in the control of esophageal motility.

Acute sacral nerve stimulation reduces visceral mechanosensitivity in Rat through spinal opioid pathway

BACKGROUND

Sacral nerve stimulation (SNS) is an alternative surgical treatment of refractory urge incontinence and/or fecal incontinence. Despite its clinical efficacy, the mechanisms of action of SNS remain poorly understood. The aim of this experimental study was to evaluate the effect of SNS on visceral mechanosensitivity in rats.

METHODS

Anesthetized Sprague-Dawley rats were treated with SNS or sham stimulation. SNS was performed by implanting an electrode close to the sacral nerve root S1. Rats were administered either a non-selective opioid receptor antagonist (naloxone) or a nitric oxide synthase inhibitor (L-NAME). Colonic mechanosensitivity was evaluated using the variation of arterial blood pressure as a spino-bulbar reflex in response to graded isobaric colorectal distension (CRD). C-fos immunoreactive neurons were quantified in spinal and supraspinal sites. μ-opioid receptor (MOR) internalization was counted in the sacral spinal cord with sham or effective SNS in response to CRD.

KEY RESULTS

SNS reduced visceral mechanosensitivity in response to CRD. This effect was reversed by intrathecal and intraveinous naloxone administration. In both models, CRD induced increased c-fos immunoreactivity in the dorsal horn neurons of the sacral spinal cord and supraspinal areas. This increase was prevented by SNS. MOR internalization was significantly higher in stimulated group.

CONCLUSIONS & INFERENCES

SNS impacts on visceral mechanosensitivity by decreasing the spino-bulbar reflex in response to CRD. Spinal opioid receptors are likely involved in this effect.

Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation

BACKGROUND

Pyloric pressure and compliance have never been investigated in health nor gastroparesis.

AIM

We hypothesised that pyloric pressure and/or compliance may be altered in gastroparesis.

METHODS

Fasting pyloric pressure and compliance were investigated in 21 healthy volunteers (HV), 27 gastroparetic patients (GP) and 5 patients who had undergone oesophagectomy without pyloroplasty as positive controls. Under videofluoroscopic control, pyloric compliance and pressure were measured by the EndoFLIP technique. Gastric emptying half time (T1/2 ) using (13) C-octanoic acid breath test, as well as symptoms and quality of life (GIQLI score) were also monitored.

RESULTS

Mean fasting pyloric compliance was measured at 25.2 ± 2.4 mm²/mmHg in HV, and was lower both in GP (16.9 ± 2.1 mm²/mmHg; P < 0.05) and patients with oesophagectomy (10.9 ± 2.9 mm²/mmHg; P < 0.05). By contrast, fasting pyloric pressure was not different among groups. Fasting pyloric compliance and pressure correlated with T1/2 in GP (R = -0.43; P = 0.04). Fasting pyloric compliance, but not pressure, correlated with symptoms and GIQLI score. Pyloric dilation in 10 GP with low fasting pyloric compliance (<10 mm²/mmHg) increased compliance from 7.4 ± 0.4 to 20.1 ± 4.9 mm²/mmHg (P < 0.01) and improved the GIQLI score from 72.5 ± 5.5 to 89.3 ± 6.1 (P = 0.04).

CONCLUSION

This prospective study assessed pyloric compliance for the first time, and showed that fasting pyloric compliance is decreased in gastroparetic patients and is associated with T1/2 , symptoms and quality of life. This suggests that pyloric compliance may be a new relevant metric in gastroparetic patients, and may be useful to target patients for pyloric dilation or botulinum toxin injection.

Effect of transcranial magnetic stimulation on rectal sensitivity in irritable bowel syndrome: a randomized, placebo-controlled pilot study

AIM

Repetitive transcranial magnetic stimulation (rTMS) applied to the motor cortex can induce analgesic effects in patients with chronic pain syndromes through its effect on central pain-modulatory systems. Our aim was to evaluate the effect of rTMS on rectal sensitivity in irritable bowel syndrome (IBS) patients.

METHOD

In this randomized, sham-controlled, proof-of concept trial, 21 IBS patients (11 women and 10 men; mean age 44.0 ± 12.6 years) were randomized, using a double-blind crossover protocol, to active or sham rTMS for 5 days of treatment. The primary outcome was the increase in the pressure pain threshold after rTMS. Secondary outcomes were the changes in maximum tolerated rectal volume, rectal compliance and average pain intensity between baseline and the end of the treatments.

RESULTS

There were no statistically significant differences between active and sham rTMS in terms of an increase in the pressure pain threshold, maximum tolerated volume and rectal compliance at the end of the treatments compared with baseline. However, in the subgroup of patients with the most marked rectal hypersensitivity, the volume threshold was significantly improved by active, but not by sham, rTMS (P = 0.03). Patients experienced a significant improvement in pain regardless of the type of stimulation.

CONCLUSION

This pilot study failed to demonstrate any benefit of rTMS on our primary end-point. However, the effect of rTMS on rectal tolerated volume in the most hypersensitive patients was encouraging enough to plan more powered studies.

Evoked pressure curves from the external anal sphincter following transcranial magnetic stimulation in healthy volunteers and patients with faecal incontinence

AIM

The hypothesis was tested that evoked pressure curves (EPCs) after transcranial magnetic stimulation (TMS) would provide additional neuropathophysiological information on the descending pathways to the external anal sphincter (EAS) in patients with faecal incontinence (FI).

METHOD

Twenty-five healthy subjects and 69 patients with FI were investigated. TMS was applied to the vertex, and EPCs were recorded with a probe placed through the EAS. TMS was performed with the EAS at rest and during contraction (facilitated responses). At least three responses were recorded for each modality. Clinical data and anorectal manometric, electrophysiological perineal and transanal ultrasound recordings were compared with respect to the EPC results.

RESULTS

There was no statistically significant difference between the EPCs of healthy subjects and FI patients. Twenty-three per cent of the FI patients had abnormal EPC latencies, with significantly lower voluntary contraction amplitudes (P = 0.03) and significantly higher rectal sensation (P = 0.04) than the other group. We found no significant difference between FI patients with and without abnormal EPC latencies in terms of clinical characteristics and electrophysiological and endoanal ultrasound parameters. There was no difference in the identified causes of the FI between the two groups.

CONCLUSION

As abnormal EPC latencies were found in 23% of FI patients with no known central neurological disease, abnormal EPC latencies might reveal undetected lesions of descending pathways in patients with FI.

Can multichannel intraluminal pH-impedance monitoring be limited to 3 hours? Comparison between ambulatory 24-hour and post-prandial 3-hour recording

Esophageal multichannel intraluminal pH-impedance recording (MII) is now a valid technique for determining the acidic, liquid, gas or mixed nature of gastroesophageal reflux episodes. However, some recordings may stop prematurely due to technical reasons or poor patient tolerance of the probe. Therefore, we questioned whether analysis of post-prandial 3-hour recording could predict the results obtained in ambulatory 24-hour recording. Fifty patients with symptoms of gastroesophageal reflux disease were investigated. For each patient, post-prandial 3-hour MII was recorded after a test meal, then followed by ambulatory 21-hour MII. Correlation between the total number of liquid reflux events in the 3-hour and 24-hour recordings was elevated (R=0.71; P<0.001), with better correlation for acid (R=0.80; P<0.001) and weak acid reflux (R=0.56; P<0.001) than non-acid reflux (R=0.44; P<0.01). Sensitivity and specificity of 3-hour recording in detecting elevated liquid reflux over 24 hours (id>75reflux/24 h) were 49% and 100%, respectively, for 8 or less liquid/mixed reflux events per 3 hours, and 78% and 88%, respectively for 15 or more liquid/mixed reflux events per 3 hours. The sensitivity and specificity of symptom association probability (SAP) calculated over 3 hours were 56% and 91%, respectively. In conclusion, we identified relevant indicators on the 3-hour post-prandial recording likely to give accurate prediction of absence or presence of gastroesophageal reflux disease from 24-hour MII recording.

Influence of gastric emptying on gastro-esophageal reflux: a combined pH-impedance study

BACKGROUND

The involvement of delayed gastric emptying (GE) in the pathophysiology of gastro-esophageal reflux disease (GERD) remains debated and has been to date only assessed using esophageal pH-metry that only detects acidic reflux. We therefore investigated whether delay in GE could impact on liquid, mixed, and gas reflux detected using combined esophageal pH-impedance recording.

PATIENTS AND METHODS

Thirty consecutive patients were explored with GE and esophageal pH-impedance measurement in the workup of typical symptoms of GERD. Gastric emptying was assessed using the (13) C-octanoic acid breath test and an ambulatory esophageal pH-impedance recording was performed off proton pump inhibitors (PPIs) for 24 h.

KEY RESULTS

Gastric emptying was normal in 17 patients and delayed in 13 patients. Delay in GE increased the daily number of liquid/mixed reflux events detected by combined esophageal pH-impedance monitoring, but had no effect of esophageal acid exposure or gas reflux. This translated in increased number of postprandial reflux events, with a longer bolus clearance time and increased esophageal proximal extension. In patient with delayed GE, symptomatic reflux had a higher proximal extension and a longer bolus clearance time compared to symptomatic reflux events from patients with normal GE.

CONCLUSIONS & INFERENCES

Delay in GE increases daily and postprandial liquid/mixed reflux events. Reflux characteristics differently trigger symptoms in patients with normal and delayed GE, and may impact on the therapeutic strategy.

Transcutaneous electrical tibial nerve stimulation in the treatment of fecal incontinence: a randomized trial (CONSORT 1a)

OBJECTIVES

The objective of this study was to show that although transcutaneous electrical tibial nerve stimulation (TENS) is being increasingly used to treat fecal incontinence (FI), its efficacy has never been proved using controlled trials.

METHODS

In this randomized, double-blind, sham-controlled trial, 144 patients aged 30-82 years from nine centers were randomly assigned to receive either active or sham stimulations for 3 months. The primary end point was the response to treatment based on the number of incontinence and urgency episodes. Secondary end points were severity scores, quality of life scores, delay to postpone defecation, patient self-assessment of treatment efficacy, physician assessment of TENS efficacy, anorectal manometry, and adverse events.

RESULTS

No statistically significant difference was seen between active and sham TENS in terms of an improvement in the median number of FI/urgency episodes per week. Thirty-four patients (47%) who received the active TENS treatment exhibited a >30% decrease in the FI severity score compared with 19 patients (27%) who received the sham treatment (odds ratio 2.4, 95% confidence interval 1.1-5.1, P=0.02). No differences in delay to postpone defecation, patient self-assessment of treatment efficacy, or anorectal manometry were seen between the two groups. The evaluating physicians rated the active stimulations as more effective than the sham stimulations (P=0.01). One minor therapy-related adverse event was observed (1.5%) (see Supplementary Consort 1b).

CONCLUSIONS

We failed to demonstrate any benefit of TENS on our primary end-point.

Management of neurogenic bowel dysfunction

There are several modalities for treating neurogenic bowel dysfunction (NBD), including conservative treatments (diet, medications, biofeedback, transanal irrigation, massage, electrical stimulation, anal plug). When conservative treatments fail, clinicians can choose from a variety of therapeutic options, including colostomies, Malone anterograde continence enemas, sacral anterior root stimulator implantations, graciloplasties, and artificial bowel sphincters. We reviewed the various treatments for constipation and/or fecal incontinence in patients with NBD and propose over-reaching stepwise algorithms for the management of NBD. Our review included English language articles, randomized controlled studies, cohort studies, case-control studies, and retrospective studies (if necessary) that assessed the management of NBD. Our literature search identified 577 articles, of which 79 met our inclusion criteria. There is little evidence for the success of conservative but non-pharmacological treatments. There is strong evidence for the success of pharmacological interventions (i.e., prokinetic agents) in the treatment of chronic constipation. While surgical interventions may be considered, there is little evidence of their effectiveness. Bowel management programs for patients with neurologic diseases require a multi-faceted approach. While a range of medical and surgical treatments are available, there is little evidence for their effectiveness, with the exception of pharmacological interventions.

Effect of unilateral subthalamic deep brain stimulation on rat digestive motor activity

A significant proportion of patients with Parkinson's disease suffers from digestive symptoms. Bilateral deep brain stimulation of the subthalamic nucleus has become a reliable therapeutic option for parkinsonian patients, but its effects on digestive motility remain poorly investigated. The aim of our study was to assess whether subthalamic stimulation could induce changes in gastric, colonic, and rectal motility and modulate brain centers involved in gut motility.

METHODS

In anesthetized rats, unilateral subthalamic nucleus stereotactic implantation was performed while intra-gastric, -colonic, and -rectal pressures were recorded during the ON and OFF periods of the stimulation. c-Fos protein expression was quantified by immunostaining in the nucleus of the solitary tract, the dorsal motor nucleus of the vagus nerve, the locus coeruleus, and the Barrington's nucleus.

RESULTS

Compared to baseline, sham stimulation did not change phasic gastric, colonic or rectal motor activity. Unilateral subthalamic stimulation increased colonic phasic motility (P<0.05) compared to baseline and the OFF period with no change in gastric and rectal motility. Pre-treatment with atropine, or specific D1 and D2 receptors antagonists prevented the rise in colonic motor activity. An increase in c-Fos protein-positive cells within all the studied nuclei was observed in the stimulated group compared to the sham group.

CONCLUSIONS

Unilateral subthalamic stimulation impacts on gut motility in anesthetized rats with a significant increase in colonic motility probably via the modulation of several brain centers. These findings warrant further confirmation in parkinsonian rat models before being transposed to clinical conditions.

How sacral nerve stimulation works in patients with faecal incontinence

AIM

Sacral nerve stimulation (SNS) reduces incontinence episodes and improves the quality of life of patients treated for faecal incontinence. However, the exact mechanism of action of this technique remains unclear. The present article reviews the pertinent neuroanatomy and neurophysiology related to SNS and provides explanations for potential mechanisms of action.

METHOD

A systematic review of the literature was performed for studies of the potential mechanisms of action of SNS, using MEDLINE, PubMed, Embase and the Cochrane Library. Articles dealing with the technique, adverse events and economic evaluations of SNS, as well as literature reviews, were excluded, except for reviews dealing with the mechanisms of action of SNS. The following inclusion criteria were used to select articles: (i) articles in English, (ii) randomized, double-blinded, sham-controlled studies, and (iii) cohort studies. Case-control studies or retrospective studies were cited only when randomized or cohort studies could not be found.

RESULTS

We propose three hypotheses to explain the mechanism of action of SNS: (i) a somato-visceral reflex, (ii) a modulation of the perception of afferent information, and (iii) an increase in external anal sphincter activity.

CONCLUSION

The mechanism of action of SNS in patients with faecal incontinence almost certainly depends on the modulation of spinal and/or supraspinal afferent inputs. Further research on humans and animals will be required to gain a better understanding of the mechanisms of action of SNS.

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients

AIM

Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI.

METHOD

Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year.

RESULTS

The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome.

CONCLUSION

Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

The role of sacral neuromodulation in double incontinence

AIM

Urinary and faecal incontinence are common conditions that are frequently associated. When conservative treatments fail, sacral nerve modulation (SNM) is considered to be a first-line treatment for patients with urge urinary incontinence and for patients with faecal incontinence. This article aims to determine the effect of SNM on the treatment of double incontinence (i.e. urinary and faecal incontinence).

METHOD

We searched for relevant articles in MEDLINE, PubMed and Embase, and for reviews in the Cochrane database. Articles were restricted to the English language.

RESULTS

Only a few studies have studied the efficacy of SNM for double incontinence and in a limited number of patients. Between 30% and 100% of patients with double incontinence experience improvement in urinary and faecal incontinence at medium-term follow up.

CONCLUSION

Further prospective trials are needed to determine which patients with combined problems will benefit from SNM at a long-term follow up.

Conservative and behavioural management of constipation

This article deals with psychological contributions, such as stool withholding or responses to abuse experiences, to the aetiology of evacuation disorders (with a focus on dyssynergic defecation), and with education and behavioural approaches to treatment.

Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience

OBJECTIVE

Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS.

METHOD

Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence.

RESULTS

We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed.

CONCLUSION

We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Impact of swallowing and ventilation on oropharyngeal cortical representation

Our aim was to determine whether ventilation and swallowing tasks can modify oropharyngeal cortical motor organisation. Mylohyoid motor-evoked potentials (MEP) induced by non-focal (NF) and focal (F) magnetic stimulations were recorded in nine healthy volunteers four times, with 1 week between each recording. Baseline values were evaluated and their reproducibility was assessed 1 week later. Thereafter, the subjects were asked to perform swallowing and ventilation tasks in random order 15 min per day for 1 week. The NF MEP amplitudes after the swallowing and ventilation tasks increased after effortful swallows (p<0.001) and ventilation efforts (p<0.001). The F MEP amplitudes obtained after focal cortical stimulations increased after effortful swallows (p<0.01) and ventilation efforts (p<0.05). The cortical magnitude of the oropharyngeal muscle representation increased after swallowing practice (p<0.01). In conclusion, swallowing and ventilation tasks modified the motor cortex of oropharyngeal muscles and should be evaluated for use in rehabilitation strategies.

Gastric electrical stimulation modulates hypothalamic corticotropin-releasing factor-producing neurons during post-operative ileus in rat

High-frequency/low-energy gastric electrical stimulation (GES) is an efficient therapy to treat gastric emptying-related disorders but its mechanism of action remains poorly understood. We aimed to assess the effects of high-frequency/low-energy GES on corticotropin-releasing factor (CRF)-producing neurons in the paraventricular nucleus of the hypothalamus (PVN), which are involved in gastric ileus induced by laparotomy. Two electrodes were implanted in the rat gastric antrum during laparotomy, then stimulation (amplitude: 2 mA; pulse duration 330 micros; frequency: 2 Hz; 1 min ON/2 min OFF) or sham stimulation (control group) were applied. Using immunohistochemistry, the number of c-Fos protein-expressing neurons (c-Fos protein-immunoreactive cells, Fos-IR) was quantified in the PVN after 1 h of stimulation. The number of neurons expressing simultaneously c-Fos protein and CRF mRNA was measured by means of immunocytochemistry combined with in situ hybridization. Finally, c-Fos and CRF mRNA levels in the hypothalamus were determined by in situ hybridization or quantitative reverse transcriptase-polymerase chain reaction. Fos-IR in the PVN was significantly decreased 1 h after GES (P<0.05) but was not affected by sub-diaphragmatic vagotomy. The number of neurons containing c-Fos protein and CRF mRNA was lower in the GES group compared with the control group (P<0.05). In addition, c-Fos and CRF mRNA levels in the PVN were significantly decreased by GES (P<or=0.05). It is concluded that acute GES reduces the number of CRF-producing neurons and decreases CRF expression in the PVN during post-operative gastric ileus.

Results of 24-h manometric recording of colonic motor activity with endoluminal instillation of bisacodyl in patients with severe chronic slow transit constipation

The aims of this study were to assess the prevalence of manometric colonic abnormalities and to evaluate the motor effect of intraluminal bisacodyl in a cohort of refractory constipated patients. Twenty-four hour colonic motility recordings were performed in 40 patients referred for a severe intractable chronic constipation. At the end of each recording session the motor effects of the endoluminal instillation of 10 mg bisacodyl were assessed. These patients were compared with 20 healthy subjects. The number of high-amplitude propagating contractions (HAPC) was significantly decreased in patients with slow transit constipation (12 +/- 11.6 vs 1 +/- 8.6, P < 0.001). Based on manometric patterns four groups of patients were isolated. Ten patients had no spontaneous HAPC, no food-induced colonic motor response and significantly lower colonic activity in transverse colon (374 +/- 1220 vs 3249 +/- 3458, P < 0.05). Five patients had significantly increased sigmoid segmental motility (20298 +/- 6364 vs 88780 +/- 3643, P < 0.001) and eight patients had significantly lower number of HAPC without other manometric abnormalities while 17 patients had normal colonic motility recordings. Endoluminal bisacodyl was able to induce HAPCs in all groups of patients. Patients with severe slow transit refractory constipation represented a heterogeneous group and endoluminal bisacodyl was able to promote a propagated motor activity in a majority of patients even in those suspected of having an inert colon.

Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear

BACKGROUND

Disruption of the anal sphincter occurs in 0.6%-6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third-degree obstetric tear in order to compare the findings with the clinical outcome.

METHODS

Twenty-one women aged 27-41 (mean 31.5 years) who had undergone primary suture of a third-degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery.

RESULTS

Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P < 0.01). The presence of an external sphincter defect was associated with anal incontinence in 91.7%. Surgical repair was identified on endosonography in 88% continent women and in 25% incontinent women (P < 0.03). The combination of a visible surgical repair and absence of defect was highly associated with normal continence (91.7%). Squeezing pressures were higher in continent women (87 +/- 23 cm H2O) than in incontinent women (48 +/- 36 cm H2O; P = 0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome.

CONCLUSION

After primary repair of a third-degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.

ALES: cell lineage analysis and mapping of developmental events

MOTIVATION

Animals build their bodies by altering the fates of cells. The way in which they do so is reflected in the topology of cell lineages and the fates of terminal cells. Cell lineages should, therefore, contain information about the molecular events that determined them. Here we introduce new tools for visualizing, manipulating, and extracting the information contained in cell lineages. Our tools enable us to analyze very large cell lineages, where previously analyses have only been carried out on cell lineages no larger than a few dozen cells.

RESULTS

Ales (A Lineage Evaluation System) allows the display, evaluation and comparison of cell lineages with the aim of identifying molecular and cellular events underlying development. Ales introduces a series of algorithms that locate putative developmental events. The distribution of these predicted events can then be compared to gene expression patterns or other cellular characteristics. In addition, artificial lineages can be generated, or existing lineages modified, according to a range of models, in order to test hypotheses about lineage evolution.

AVAILABILITY

The program can run on any operating system with a compliant Java 2 environment. Ales is free for academic use and can be downloaded from http://mbi.dkfz-heidelberg.de/mbi/research/cellsim/ales.

Does water-perfused catheter overdiagnose anismus compared to balloon probe?

BACKGROUND

The purpose of this study was to compare the manometric assessment of straining effort as if to defecate and rectoanal inhibitory reflex obtained with a rectosphincteric balloon probe and with a water-perfused catheter in the same subject.

METHODS

Twelve healthy volunteers underwent two manometric assessments of anal sphincter function and electromyographic (EMG) surface recordings. one with a rectosphincteric balloon and one with a water-perfused catheter, 7 days apart in random order.

RESULTS

Increased EMG activity in the external anal sphincter in the midst of the rectoanal inhibitory reflex (P < 0.001) and during straining for defecation (P < 0.001) was more frequently observed with the perfused system than with the balloon probe. There was a discrepancy between the EMG activity of the external anal sphincter and the anal pressures during straining recorded with the perfused system. Duration of the reflex elicited by rectal distension with 10 and 20 ml of air was significantly greater with the rectosphincteric balloon than with the perfused catheter (P = 0.02 and P = 0.05, respectively).

CONCLUSION

Water instilled in the anal canal by the perfused system induces artifacts in EMG recording and active anal contractions. These artifacts and induced contractions could lead to an erroneous diagnosis of anismus, particularly if pelvic floor EMG is only taken into account for the diagnosis of anismus.

Treatment of enterocele by abdominal colporectosacropexy - efficacy on pelvic pressure

OBJECTIVE: Enterocele induces pelvic pressure, obstructed defaecation, lower abdominal pain and/or false urge to defaecate in patients. The aim of this study was to evaluate the efficacy of abdominal colporectosacropexy in these symptoms, especially on pelvic pressure. METHODS: Sixty-two consecutive women with enterocele were included. All patients were symptomatic because they had: pelvic pressure (n = 62), obstructed defaecation (n = 40), lower abdominal pain (n = 8) or faecal incontinence (n = 16). Defaecography confirmed enterocele in all patients. The surgical procedure was performed by the same surgeon and was an abdominal colporectosacropexy with a nonabsorbable Prolene(R) mesh. After surgery, clinical evaluation (62/62 patients) and a telephone questionnaire (56/62 patients) were performed, respectively, 3 months and 27 +/- 13 months after surgery. RESULTS: Defaecography showed rectal abnormalities associated with enterocele in 59/62 patients (rectocele, rectal prolapse). No recurrence of enterocele was observed 3 months after surgery, but 1 patient demonstrated recurrence 10 months after surgery. Pelvic pressure was less frequent after abdominal colporectosacropexy, than before surgery (P < 0.01): pelvic pressure totally disappeared in 41/56 patients, and partially in 10/56 patients. The number of patients with obstructed defaecation, lower abdominal pain, or faecal incontinence was not different before and 27 months after surgery. The number of patients with urinary incontinence was also not different before and after surgery (30 and 27 patients). CONCLUSIONS: This study of a large number of patients with enterocele shows that abdominal colporectosacropexy improves pelvic pressure in most patients and does not modify urinary status.

Testing life-history pleiotropy in Caenorhabditis elegans

Much life-history theory assumes that alleles segregating in natural populations pleiotropically affect life-history traits. This assumption, while plausible, has rarely been tested directly. Here we investigate the genetic relationship between two traits often suggested to be connected by pleiotropy: maternal body size and fertility. We carry out a quantitative trait locus (QTL) analysis on two isolates of the free-living nematode Caenorhabditis elegans, and identify two body size and three fertility QTLs. We find that one of the fertility QTLs colocalizes with the two body size QTLs on Chromosome IV. Further analysis, however, shows that these QTLs are genetically separable. Thus, none of the five body size or fertility QTLs identified here shows detectable pleiotropy for the assayed traits. The evolutionary origin of these QTLs, possible candidate loci, and the significance for life-history evolution are discussed.

Effect of sacral nerve stimulation in patients with fecal and urinary incontinence

PURPOSE

Preliminary studies have shown improvement in fecal incontinence in several patients who received temporary or permanent stimulation. The purpose of this study was to report our experience in sacral nerve stimulation in the treatment of fecal incontinence and to target patients who would benefit most from stimulation.

METHODS

Patients with fecal incontinence were studied clinically and manometrically before, during, and after temporary nerve stimulation. If temporary nerve stimulation was clinically successful, the patient was implanted and followed up for six months.

RESULTS

Nine patients (6 female) with a mean age of 50.7 +/- 12.3 years underwent temporary nerve stimulation. Temporary nerve stimulation was successful in eight patients, six of whom were implanted. Of the patients who could be evaluated, three of five had improved at the six-month follow-up visit, particularly in relation to the number of urgency episodes and delay in postponing defecation. All implanted patients had urinary symptoms. Urinary urgency was also improved by stimulation. During temporary nerve stimulation, the maximal squeeze pressure amplitude increased. After implantation, only the duration of maximal squeeze pressure seemed to improve.

CONCLUSION

Sacral nerve stimulation can be used in the management of fecal incontinence, particularly in cases of urge fecal incontinence associated with urinary urgency. This study seems to confirm the effect of sacral nerve stimulation on striated sphincter function.

Effects of polyethylene glycol 4000 on 24-h manometric recordings of left colonic motor activity

BACKGROUND

It has been shown that low doses of polyethylene glycol (PEG) 4000 are effective in the treatment of chronic constipation. The aim of this study was to describe the effects on colonic motility of oral PEG 4000 treatment and intraluminal instillation of PEG 4000.

METHODS

Left colonic and rectosigmoid manometric recordings were performed for 27 h in six constipated patients and in six healthy volunteers. At the end of the recording, bisacodyl and PEG 4000 were instilled into the lumen of the colon. To assess the effects of oral administration of PEG 4000 on colonic motility, manometric recordings were also performed in constipated patients after 4 weeks of treatment with PEG 4000.

RESULTS

All patients had significantly more stools during than before PEG treatment. There was no significant difference between the number and the characteristics of high-amplitude propagating contractions (HAPC) or the area under the curve (AUC) before or during treatment with PEG 4000. Intraluminal instillation of PEG induced HAPC in only one patient and in no controls.

CONCLUSION

This study shows that PEG 4000 has no effect on left colonic and rectosigmoid motor activity during oral treatment, despite its clinical effectiveness, or after local instillation.

A power law for cells

Darwin observed that multiple, lowly organized, rudimentary, or exaggerated structures show increased relative variability. However, the cellular basis for these laws has never been investigated. Some animals, such as the nematode Caenorhabditis elegans, are famous for having organs that possess the same number of cells in all individuals, a property known as eutely. But for most multicellular creatures, the extent of cell number variability is unknown. Here we estimate variability in organ cell number for a variety of animals, plants, slime moulds, and volvocine algae. We find that the mean and variance in cell number obey a power law with an exponent of 2, comparable to Taylor's law in ecological processes. Relative cell number variability, as measured by the coefficient of variation, differs widely across taxa and tissues, but is generally independent of mean cell number among homologous tissues of closely related species. We show that the power law for cell number variability can be explained by stochastic branching process models based on the properties of cell lineages. We also identify taxa in which the precision of developmental control appears to have evolved. We propose that the scale independence of relative cell number variability is maintained by natural selection.

[Evoked mechanical and electrical anal sphincter responses after cortical and lumbar magnetic stimulation]

In 13 healthy volunteers we recorded electrical and mechanical anal sphincter (AS) evoked responses. Electrical responses were obtained with surface electrodes, and mechanical responses by anal manometry; all responses were compared with those of anterior tibialis. Mechanical evoked responses' latency and amplitude were calculated. The mean total conduction time of the electrical responses was 26.07 ms at rest and 23.31 ms with mild contraction (p < 0.003). After lumbar magnetic stimulations, because of stimulation artefact, electrical responses couldn't be correctly measured. The mean central conduction time calculated with mechanical responses was 21.44 ms at rest and 18.81 ms with mild contraction (p < 0.003). The mean central conduction time to the anterior tibialis was shorter (14.38 ms; p < 0.003). Evoked mechanical responses', amplitudes were respectively 128.2 cm H2O (cortical stimulations at rest), 138.8 cm H2O (cortical stimulations with mild contraction) and 133.1 cm H2O (lumbar stimulations at rest) (NS). Evoked mechanical responses amplitudes were correlated with the AS maximal voluntary contraction amplitude (p < 10(-4)). Mechanical motor evoked responses after cortical and lumbar magnetic stimulations can be recorded and quantified. In anorectal disorders, this technique could be of major interest for the diagnosis of neurologic lesions versus behavioural problems.

Results of sphincteroplasty in 86 patients with anal incontinence

PURPOSE

This study was designed to analyze critically the short-term and long-term outcome of sphincteroplasty and to identify high-risk factors.

METHODS

Eighty-six patients with fecal incontinence associated with an ultrasound defect of the external anal sphincter were treated by anal sphincteroplasty. Clinical and physiologic assessment was made before surgery, and clinical evaluation was made three months and an average of 40 months after surgery.

RESULTS

The evaluation of 86 patients three months after surgery showed that 42 patients were totally continent (49 percent), 28 were incontinent for gas (33 percent), and 16 still had fecal incontinence (19 percent). Seventy-four patients (86 percent) were contacted 40 months after surgery. Twenty-one patients (28 percent) were totally continent, 17 were incontinent to gas (23 percent), and 36 were incontinent to feces (49 percent). Forty-six percent of patients felt they were clearly improved after surgery. Poor results were associated with an internal anal sphincter defect.

CONCLUSIONS

Our study suggests that in the long term, one-third of patients are totally continent after sphincteroplasty. One-half of patients are satisfied, but only if their incontinence to feces has totally disappeared. Results of sphincteroplasty deteriorate with time. One factor in poor prognosis is the presence of an associated defect of the internal anal sphincter.

Somatic polyploidization and cellular proliferation drive body size evolution in nematodes

Most of the hypodermis of a rhabditid nematode such as Caenorhabditis elegans is a single syncytium. The size of this syncytium (as measured by body size) has evolved repeatedly in the rhabditid nematodes. Two cellular mechanisms are important in the evolution of body size: changes in the numbers of cells that fuse with the syncytium, and the extent of its acellular growth. Thus nematodes differ from mammals and other invertebrates in which body size evolution is caused by changes in cell number alone. The evolution of acellular syncytial growth in nematodes is also associated with changes in the ploidy of hypodermal nuclei. These nuclei are polyploid as a consequence of iterative rounds of endoreduplication, and this endocycle has evolved repeatedly. The association between acellular growth and endoreduplication is also seen in C. elegans mutations that interrupt transforming growth factor-beta signaling and that result in dwarfism and deficiencies in hypodermal ploidy. The transforming growth factor-beta pathway is a candidate for being involved in nematode body size evolution.

Manometric assessment of an artificial bowel sphincter

BACKGROUND

This study investigated the relationship between functional clinical results after artificial bowel sphincter implantation and manometric assessment in 12 consecutive patients.

METHODS

A postoperative manometric study was performed in 12 patients, including measurement of resting and squeeze pressures, opening characteristics and pressure during straining. The relationship between postoperative findings, clinical outcome and preoperative manometric data was investigated. Anal pressure after rectal distension with a closed cuff was studied in seven patients. Results were expressed as mean(s.d.).

RESULTS

Continence for solid stool was achieved in all 12 patients. Five patients remained incontinent for gas. Anal resting pressure was 108(22) cmH2O; there was no difference between continent and incontinent patients. Rectal distension induced anal relaxation in six of seven patients. Total duration of cuff opening was 113(8) s with an amplitude of 60(22) per cent; residual pressure was correlated with the preoperative resting pressure. The total duration of the opening phase in patients with defaecation difficulties (47(24) (range 0-65) s) was shorter than that in patients without defaecation difficulties (178(78) (range 100-320) s) (P = 0.0022).

CONCLUSION

Postoperative defaecation difficulties after implantation of an artificial bowel sphincter are related to a short duration of opening of the cuff. The anal sphincter played a role in postoperative resting anal pressures and allowed relaxation even if the cuff was closed.

Prolonged stationary colonic motility recording in seven patients with severe constipation secondary to antidepressants

The aim of this study was to determine whether the colonic motor profile of seven patients with constipation secondary to antidepressants differed from the motility of seven patients with idiopathic constipation and seven healthy volunteers. All constipated patients had very severe constipation. Colonic manometric recordings were performed for 24 h. The number of high amplitude propagating contractions (HAPC) was lower in the two groups of constipated patients than in controls. No HAPC were observed in 5/7 patients with constipation secondary to antidepressants and in 1/7 patients with idiopathic constipation. The overall area under the curve (AUC) in the left colon was lower in the two constipated patient groups than in controls. AUC increased after a 1000-kcal standard meal given at noon in controls but not in the two groups of constipated patients. In conclusion, in patients with constipation secondary to antidepressants, the overall AUC was as poor as in patients with idiopathic constipation, and no colonic response to eating was observed. Moreover, the number of HAPC was more markedly decreased in patients with constipation secondary to antidepressants than in patients with idiopathic constipation.

The scale independence of evolution

In this paper, I argue that the ultimate causes of morphological, and hence developmental, evolution are scale independent. In other words, micro- and macroevolutionary patterns show fundamental similarities and therefore are most simply explained as being caused by the same kinds of evolutionary forces. I begin by examining the evolution of single lineages and argue that dynamics of adaptive evolution are the same for bacteria in test-tube evolution experiments and fossil lineages. Similarly, I argue that the essential features of adaptive radiations large and small can be attributed to conventional forces such as mutation and diversifying natural selection due to competition. I then address recent claims that the molecular features of metazoan development are the result of clade-level selection for evolvability, and suggest that these features can be more easily explained by conventional individual-level selection for the suppression of deleterious pleiotropic effects. Finally, I ask what must be known if we are to understand the ultimate causes of molecular and developmental diversity.

Prevalence of anal incontinence in 409 patients investigated for stress urinary incontinence

A clinical questionnaire concerning anorectal symptoms and urodynamic tests was used to investigate 409 women consulting for stress urinary incontinence. To compare urodynamic data, patients were divided into three groups of women who had either stress urinary incontinence associated with incontinence for formed and/or liquid stools or with gas incontinence, or isolated stress urinary incontinence. To take in account the patients'age for data interpretation, a Mantel-Haenszel test or covariate analysis was performed. Anal incontinence was reported in 114 (28%) of the 409 women investigated. The prevalence of incontinence for gas only, for liquid, or for solid stools was 18.3, 9.3, and 1%, respectively. The duration of gas incontinence was longer than that of fecal incontinence or stress urinary incontinence. Difficult defecation was more frequently observed in patients with double incontinence than in patients with only stress urinary incontinence, and the difference was significant between patients with gas incontinence and patients with stress urinary incontinence (53% versus 37%, P = 0. 03). There was no difference in the number of bowel movements per week among the three groups of patients. The number of vaginal deliveries was surprisingly lower in patients with fecal incontinence associated with urinary incontinence than in others. There was no urodynamic feature that could distinguish patients with urinary incontinence and patients with double incontinence. This study confirmed the close relationship between anal and stress urinary incontinence. Neurourol. Urodynam. 18:579-590, 1999.

Electrostimulation is not a clinically effective treatment of anal incontinence

OBJECTIVE

To evaluate the manometric and clinical efficacies of electrostimulation to treat anal incontinence.

PATIENTS AND METHODS

Thirty-three women suffering from anal incontinence self-administered anal electrostimulation twice daily for 15-min intervals for 4 months.

RESULTS

After 4 months, the incontinence score decreased from 10.4+/-0.5 to 7.1+/-0.8 (P<0.001) but all patients except two remained incontinent The decrease in the incontinence score was more marked in patients receiving medical treatment for an associated bowel disorder, than in patients treated by electrostimulation alone. Anal resting pressures and the amplitude of voluntary anal contractions did not increase after 4 months.

CONCLUSION

Electrostimulation decreased the incontinence score but all patients except two remained incontinent after 4 months, suggesting that electrostimulation is not a clinically effective treatment of anal incontinence.

Prevalence of anal sphincter defects revealed by sonography in 335 incontinent patients and 115 continent patients

OBJECTIVE

The aim of this study was to compare the prevalence of anal sphincter defects on anal sonography of incontinent and continent patients.

SUBJECTS AND METHODS

Four hundred sixty-eight consecutive subjects who underwent anal sonography were studied. The prevalence of anal sphincter defects was calculated in 335 incontinent patients, 115 continent patients, and 18 asymptomatic female volunteers. All subjects answered a questionnaire about childbirth and proctologic surgery.

RESULTS

The prevalence of anal sphincter defects revealed on sonography was 65% in the 335 incontinent patients. The prevalence of anal sphincter defects in incontinent patients was 88% in patients with a history of childbirth and proctologic surgery and 62% with childbirth alone. The prevalence of anal sphincter defects revealed on sonography was 43% in continent patients and 22% in asymptomatic volunteers. The prevalence of anal sphincter defects in continent patients with a history of childbirth and proctologic surgery was 92% and was 41% with childbirth alone. We found no difference in the prevalence of sphincter defects according to the age and sex of patients.

CONCLUSION

Anal sonography can be used to identify sphincter defects in approximately two thirds of incontinent patients. Prevalence is greater in patients with a history of proctologic surgery. Because of the presence of sphincter defects in continent patients and in asymptomatic volunteers, caution should be used in attributing incontinence to anal sphincter defects alone.

Octreotide in refractory functional epigastric pain with nutritional impairment--an open study

AIM

To test the therapeutic efficacy of octreotide administered subcutaneously for the relief of chronic refractory epigastric pain severe enough to provoke nutritional impairment.

SUBJECTS AND METHODS

Seventeen patients were enrolled in an open trial. Epigastric pain had lasted from 1 to 8 years (median: 5 years), following anti-reflux surgery in eight patients. Median weight loss was 10% (range 10-15). The initial dose of octreotide was 50 microgram b.d, adjusted during the follow-up visits which were scheduled for months 1, 3, 6, 8, 10, 12 and every 3 months. At each visit, overall symptomatic improvement, frequency and intensity of symptoms were checked on a 10-cm visual analogic scale.

RESULTS

At month 1, a progressive improvement of pain intensity was reported in 15 of the 17 patients, while octreotide was a therapeutic failure in two. In four out of 15, the daily dose of octreotide was increased to 100 microgram b.d. In these 15 patients, median follow-up was 7 months (3-27). The symptomatic benefit was maintained in each patient at month 3, with a median weight gain of 3.5 kg.2-5 An attempt to stop octreotide led to recurrence of symptoms in 2-3 days which were as intense as before the treatment. The 11 patients followed-up for at least 6 months reported persistent improvement of symptoms with octreotide and a median weight gain of 4 kg.3-7 Four patients were followed up for more 11-27 months: octreotide was withdrawn gradually in two who remained asymptomatic. Six of the 17 patients experienced minor side-effects, but none developed biliary sludge.

CONCLUSIONS

This open study suggests that octreotide could be a promising alternative treatment when all others fail in refractory chronic functional epigastric pain severe enough to limit food intake and to induce nutritional impairment. These results must be tested by a placebo-controlled study.

Pudendal neuropathy and severity of incontinence but not presence of an anal sphincter defect may determine the response to biofeedback therapy in fecal incontinence

PURPOSE

It has been suggested that the severity of fecal incontinence, the presence of pudendal neuropathy, or an external anal sphincter defect does not preclude clinical improvement with biofeedback therapy. A discrepancy, however, is frequently found between subjective improvement and objective results after biofeedback therapy. Our aim was to assess whether severity of fecal incontinence, presence of pudendal neuropathy, or an external anal sphincter defect could influence the results of manometric parameters after biofeedback therapy in patients with fecal incontinence.

METHODS

Biofeedback therapy was used to treat 27 patients with fecal incontinence (25 women; mean age, 53; range, 29-74 years), according to a strict protocol. Manometry, pudendal nerve terminal motor latency, and anal ultrasound were performed in all patients before biofeedback therapy. Manometric evaluation of external anal sphincter function was performed after the biofeedback sessions.

RESULTS

Eight of 27 patients had a good clinical response to biofeedback, but with no significant difference in their mean amplitude and duration of squeeze pressure before and after biofeedback. There was no relationship between the clinical results of biofeedback therapy and the initial severity of fecal incontinence, pudendal neuropathy, or external sphincter defect. Patients with severe incontinence (incontinence to solids) and pudendal neuropathy failed to improve the amplitude and duration of their maximum voluntary contraction after biofeedback therapy. Patients with mild fecal incontinence (incontinence to flatus, liquids, or both) (P<0.04), without pudendal neuropathy (P<0.02), or with (P<0.05) and without (P<0.05) external sphincter defect improved their external anal sphincter function after biofeedback therapy.

CONCLUSION

In patients with fecal incontinence, the severity of symptoms and pudendal neuropathy should be considered as two factors of poor prognosis of favorable manometric results after biofeedback therapy. Improvement, on the other hand, may be expected after biofeedback therapy despite an external anal sphincter defect.

Increased tone of the rectal wall in response to feeding persists in patients with cauda equina syndrome

The aim was to study fasting and postprandial rectal tone in patients with cauda equina injury. Electromechanical barostat measurement of rectal tone was made in 13 healthy volunteers and in five patients during a 10 min recording, while fasting and for 1 h after a 1000 kCal intake. A prompt decrease of rectal volume was observed in all control subjects and patients. The delay between the end of the meal and the onset of the rectal response was always less than 3 min in the five patients as well as in the control group. The rapidity of the rectal response to feeding observed in our five patients suggests that the rectal response was mediated via a neural or neurohumoral pathway despite severe injury of the sacral parasympathetic supply.

Pudendal neuralgia: CT-guided pudendal nerve block technique

Chronic anoperineal pain without any apparent etiology may be caused by compression of the pudendal nerve. This presentation illustrates the course of the pudendal nerve and the technique of computed tomography-guided infiltration of the nerve.

Results of pudendal nerve neurolysis-transposition in twelve patients suffering from pudendal neuralgia

PURPOSE

Pudendal neuralgia caused by nerve compression may be improved by surgical decompression of the pudendal nerve. This study was undertaken to determine if clinical symptoms, electrophysiological investigations, and the efficacy of preoperative pudendal nerve blocks could be used to predict the efficacy of surgery.

METHODS

Twelve consecutive patients complaining of anal pain, genital pain, or both, exacerbated in the sitting position and unsuccessfully treated by analgesic drugs before referral were studied. In these 12 patients decompression of the pudendal nerve was performed after unsuccessful CT-guided injection of corticosteroids in the pudendal nerve at the ischial spine or after pain relapse following successful injections. Nineteen nerves were decompressed by surgery, and the compressed area was located between the sacrospinal and sacrotuberal ligaments for 18 nerves.

RESULTS

Three months after surgery, four patients were totally relieved, and three were only partially improved. After 21 months of follow-up, three patients were cured, one was slightly improved, and eight remained in pain. In the three patients cured by surgery, pain completely disappeared for at least two weeks after a nerve block repeated twice before surgery, whereas pain relief was observed in only one of the nine other patients (P = 0.018). None of the three patients cured by surgery were being treated for depression, whereas six of the nine remaining patients were receiving antidepressants or were followed by a psychiatrist (P = 0.09). Results of surgery did not depend on other preoperative clinical or electrophysiological data.

CONCLUSIONS

This preliminary study suggests that complete disappearance of pain for at least two weeks after a nerve block repeated twice before surgery may be the best criterion to predict success. Based on this criterion, surgery would have been performed in four patients in this study, of whom three would have been cured.