Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence

INTRODUCTION

Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen.

METHODS

Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005-2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained.

RESULTS

Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery.

CONCLUSIONS

We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.

Randomized controlled trial of percutaneous versus transcutaneous posterior tibial nerve stimulation in faecal incontinence

BACKGROUND

Percutaneous, transcutaneous and sham transcutaneous posterior tibial nerve stimulation was compared in a prospective blinded randomized placebo-controlled trial.

METHODS

Patients who had failed conservative treatment for faecal incontinence were randomized to one of three groups: group 1, percutaneous; group 2, transcutaneous; group 3, sham transcutaneous. Patients in groups 1 and 2 received 30-min sessions of posterior tibial nerve stimulation twice weekly for 6 weeks. In group 3, transcutaneous electrodes were placed in position but no stimulation was delivered. Symptoms were measured at baseline and after 6 weeks using a bowel habit diary and St Mark's continence score. Response to treatment was defined as a reduction of at least 50 per cent in weekly episodes of faecal incontinence compared with baseline.

RESULTS

Thirty patients (28 women) were enrolled. Nine of 11 patients in group 1, five of 11 in group 2 and one of eight in group 3 had a reduction of at least 50 per cent in weekly episodes of faecal incontinence at the end of the 6-week study phase (P = 0·035). Patients undergoing percutaneous nerve stimulation had a greater reduction in the number of incontinence episodes and were able to defer defaecation for a longer interval than those undergoing transcutaneous and sham stimulation. These improvements were maintained over a 6-month follow-up period.

CONCLUSION

Posterior tibial nerve stimulation has short-term benefits in treating faecal incontinence. Percutaneous therapy appears to have superior efficacy to stimulation applied by the transcutaneous route.

REGISTRATION NUMBER

NCT00530933 (http://www.clinicaltrials.gov).

Sacral nerve stimulation in the elderly

AIM

Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years.

METHOD

Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively.

RESULTS

Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6).

CONCLUSION

SNS is an effective treatment for faecal incontinence in patients over 65 years.

A network approach to assessing cognition in disorders of consciousness

OBJECTIVE

Conventional assessments of consciousness rely on motor responses to indicate awareness. However, overt behaviors may be absent or ambiguous in patients with disorders of consciousness (DOC) resulting in underrating capacity for cognition. fMRI during a silent picture-naming task was evaluated as an indicator of command following when conventional methods are not sufficient.

METHODS

A total of 10 patients with and without conventional evidence of awareness, who met diagnostic criteria for the minimally conscious state (MCS) (n = 5), vegetative state (VS) (n = 3), emerged from MCS (EMCS) (n = 1), and locked-in syndrome (LIS) (n = 1), participated in this observational fMRI study.

RESULTS

The LIS and EMCS patients engaged a complete network of essential language-related regions during the object-naming task. The MCS and 2 of the VS patients demonstrated both complete and partial preservation of the object-naming system. Patients who engaged a complete network scored highest on the Coma Recovery Scale-Revised.

CONCLUSIONS

This study supports the view that fMRI during object naming can elicit brain activations in patients with DOC similar to those observed in healthy subjects during command following, and patients can be stratified by completeness of the engaged neural system. These results suggest that activity of the language network may serve as an indicator of high-level cognition and possibly volitional processes that cannot be discerned through conventional behavioral assessment alone.

Closure of Loop Ileostomies: Is Early Discharge Safe and Achievable?

A prospective audit of the complications associated with reversal of a loop ileostomy was carried out between March 2000 and March 2005. The complication rate, length of inpatient hospitalisation and re-admission rate were assessed in 100 patients, in a single clinical practice. The median (interquartile range) length of time between the primary procedure and closure was 133 days (120 – 270) days. Median length of inpatient stay was two days (one - three) days. The overall complication rate was 18 %. One patient had a post-operative leak leading to local abscess formation. This was drained surgically after initial failure with radiological drainage. A second patient had a late leak, three weeks after closure, leading to fistula formation. This patient required surgical resection of the anastomosis after failure of conservative management. Twelve patients were re-admitted with small bowel obstruction (12%), of whom 11 were managed conservatively, while one underwent further surgery. There was one post- operative death as a result of acute cardiac failure secondary to undiagnosed hypertensive cardiomyopathy.

Thus early discharge following closure of a loop ileostomy, can be achieved with an acceptably low serious complication rate.

Predictors of short-term outcome in brain-injured patients with disorders of consciousness

OBJECTIVES

To investigate predictors of recovery from the vegetative state (VS) and minimally conscious state (MCS) after brain injury as measured by the widely used Disability Rating Scale (DRS) and to explore differences in rate of recovery and predictors of recovery during inpatient rehabilitation in patients with non-traumatic (NTBI) and traumatic brain injury (TBI).

DESIGN

Longitudinal observational cohort design and retrospective comparison study, in which an initial DRS score was collected at the time of study enrollment. Weekly DRS scores were recorded until discharge from the rehabilitation center for both NTBI and TBI patients.

SETTING

Seven acute inpatient rehabilitation facilities in the United States and Europe with specialized programs for VS and MCS patients (the Consciousness Consortium).

PARTICIPANTS

One hundred sixty-nine patients with a non-traumatic (N=50) and a traumatic (N=119) brain injury who were in the VS or MCS states.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

DRS score at 13 weeks after injury; change in DRS score over 6 weeks post-admission; and time until commands were first followed (for patients who did not show command-following at or within 2 weeks of admission).

RESULTS

Both time between injury and enrollment and DRS score at enrollment were significant predictors of DRS score at week 13 post-injury but the main effect of etiology only approached significance. Etiology was however a significant predictor of the amount of recovery observed over the 6 weeks following enrollment. Time between injury and enrollment was also a good predictor of this outcome, but not DRS score at enrollment. For the time until commands were first followed, patients with better DRS scores at enrollment, and those with faster early rates of change recovered command following sooner than those with worse DRS scores or slower initial rates of change. The etiology was not a significant predictor for this last outcome. None of these predictive models explained sufficient variance to allow their use in individual clinical decision making.

CONCLUSIONS

Time post-injury and DRS score at enrollment are predictors of early recovery among patients with disorders of consciousness, depending on the outcome measure chosen. Etiology was also a significant predictor in some analyses, with traumatically injured patients recovering more than those with non-traumatic injuries. However, the hypothesized interaction between etiology and time post-injury did not reach significance in any of the analyses suggesting that, within the time frame studied, the decline in prognosis with the passage of time was similar in the two groups.

Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up: a new surgical procedure

BACKGROUND

Although laparoscopic repair of large, mostly paraesophageal hiatal hernias is widely applied, there is a great concern regarding the higher recurrence rate associated with this procedure. In order to reduce this high recurrence rate, several techniques have been developed, mostly applying a mesh prosthesis for hiatal reinforcement.

METHODS

We have recently introduced a new laparoscopic technique in which the hiatal closure is reinforced with the teres ligament. To date 26 patients have been entered into this ongoing prospective study. After the operation patients were called back on a regular basis for symptom evaluation and barium swallow. All 26 patients agreed to undergo barium swallow, with a mean follow-up of 35 months.

RESULTS

The mean operative time was 115 min. Perioperative morbidity was 11.5%, and conversion to an open procedure was performed in six cases. No mortality was registered. Anatomic recurrence, investigated by barium swallows was observed in four patients (15.3%). Of those four, only one (3.85%) had a symptomatic recurrent paraesophageal hernia; the other three had asymptomtic sliding hernias. In three of the four patients with anatomic recurrence, the diameter of the hiatal hernia was greater than 9 cm at the original operation, and the fourth patient underwent reoperation for recurrent hiatal hernia. No symptomatic recurrence was found in patients with diameter of hiatal hernia between 6 and 9 cm.

CONCLUSIONS

Laparoscopic reinforcement of the hiatal closure with the ligamentum teres is safe and effective treatment for large hiatal hernias. However, it appears that patients with extremely large hiatal hernias are at greater risk of recurrence, and therefore large hernias are not suitable for this new technique.

Behavioural improvements with thalamic stimulation after severe traumatic brain injury

Widespread loss of cerebral connectivity is assumed to underlie the failure of brain mechanisms that support communication and goal-directed behaviour following severe traumatic brain injury. Disorders of consciousness that persist for longer than 12 months after severe traumatic brain injury are generally considered to be immutable; no treatment has been shown to accelerate recovery or improve functional outcome in such cases. Recent studies have shown unexpected preservation of large-scale cerebral networks in patients in the minimally conscious state (MCS), a condition that is characterized by intermittent evidence of awareness of self or the environment. These findings indicate that there might be residual functional capacity in some patients that could be supported by therapeutic interventions. We hypothesize that further recovery in some patients in the MCS is limited by chronic underactivation of potentially recruitable large-scale networks. Here, in a 6-month double-blind alternating crossover study, we show that bilateral deep brain electrical stimulation (DBS) of the central thalamus modulates behavioural responsiveness in a patient who remained in MCS for 6 yr following traumatic brain injury before the intervention. The frequency of specific cognitively mediated behaviours (primary outcome measures) and functional limb control and oral feeding (secondary outcome measures) increased during periods in which DBS was on as compared with periods in which it was off. Logistic regression modelling shows a statistical linkage between the observed functional improvements and recent stimulation history. We interpret the DBS effects as compensating for a loss of arousal regulation that is normally controlled by the frontal lobe in the intact brain. These findings provide evidence that DBS can promote significant late functional recovery from severe traumatic brain injury. Our observations, years after the injury occurred, challenge the existing practice of early treatment discontinuation for patients with only inconsistent interactive behaviours and motivate further research to develop therapeutic interventions.

Evidence-based cognitive rehabilitation: recommendations for clinical practice

OBJECTIVE

To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke.

DATA SOURCES

A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled.

STUDY SELECTION

Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated.

DATA EXTRACTION

Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology.

DATA SYNTHESIS

Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options.

CONCLUSIONS

Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.

Does premorbid depression influence post-concussive symptoms and neuropsychological functioning?

We examined the contribution of premorbid affective disturbance to persistent post-concussive symptoms and neuropsychological functioning following a mild traumatic brain injury. No differences were observed on self-reported post-concussive symptoms, MMPI scales, or neuropsychological measures between two case-matched groups of patients with and without a history of pre-injury depression. Clinicians are urged to use caution in attributing post-concussive symptoms or neuropsychological deficits to the presence of a pre-existing affective disorder.

Neuropsychological rehabilitation of mild traumatic brain injury

A significant minority of patients who have sustained a mild traumatic brain injury (MTBI) may exhibit persistent disability. There have been few attempts to describe and evaluate the effectiveness of neurorehabilitation for these patients. We conducted a retrospective analysis of the results of a neuropsychological rehabilitation programme for 20 patients with MTBI. Based upon the ability to resume productive functioning after treatment, 10 patients were determined to exhibit a good outcome and 10 patients were considered to exhibit a poor outcome. Patients with good outcome exhibited significant pre-post-treatment improvements on both neuropsychological measures of cognitive functioning and self-reported post-concussive symptoms. Patients with poor outcome demonstrated little improvement in either area, and in some cases showed a decline in functioning. The results are consistent with the view that there may be significant variability in recovery and response to treatment after MTBI. There is a continued need to identify which patients may benefit from neurorehabilitation, develop specially tailored interventions, and conduct controlled, prospective studies in this area.