RESUMEN
PURPOSE: Functional constipation in children and adolescents is a common and invalidating condition. In a minority of patients, symptoms persist despite optimal conservative therapy. The aim of this study was to evaluate whether the short-term effects of sacral neuromodulation (SNM) in children and adolescents with constipation are sustained over prolonged period of time. METHODS: Patients aged 10-20 years, with refractory constipation, fulfilling the Rome III criteria, were included in our study. If SNM test treatment showed >50 % improvement in defecation frequency, a permanent stimulator was implanted. Primary outcome measure was defecation frequency during 3 weeks. Secondary endpoints were abdominal pain and Wexner score. To assess sustainability of treatment effect, a survival analysis was performed. Cross-sectional quality of life was assessed using the EQ-5D VAS score. RESULTS: Thirty girls, mean age 16 (range 10-20), were included. The mean defecation frequency increased from 5.9 (SD 6.5) in 21 days at baseline to 17.4 (SD 11.6) after 3 weeks of test treatment (p < 0.001). During test treatment, abdominal pain and Wexner score decreased from 3.6 to 1.5 and 18.6 to 8.5 (p < 0.001), respectively. Improvement of symptoms sustained during a median follow-up of 22.1 months (12.2-36.8) in 42.9 % of patients. On a scale from 0 to 100, quality of life was 7 points lower than the norm score (mean 70 vs. 77). CONCLUSION: SNM is a therapeutic option for children with chronic constipation not responding to intensive oral and/or laxative therapy, providing benefits that appear to be sustained over prolonged period of time.
Asunto(s)
Tratamiento Conservador , Estreñimiento/fisiopatología , Estreñimiento/terapia , Sacro/fisiopatología , Adolescente , Niño , Enfermedad Crónica , Defecación , Terapia por Estimulación Eléctrica , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Recurrencia , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Laparoscopic surgery might be beneficial for the patient, but it imposes increased physical and mental strain on the surgeon. Robot-assisted laparoscopic surgery addresses some of the laparoscopic drawbacks and may potentially reduce mental strain. This could reduce the risk of surgeon's fatigue, mishaps and strain-induced illnesses, which may eventually improve the safety of laparoscopic surgical procedures. METHODS: To test this hypothesis, a randomized study was performed, comparing both heart rate and heart rate variability (HRV) of the surgeon as a measure of total and mental strain, respectively, during conventional and robot-assisted laparoscopic cholecystectomy. RESULTS: Both heart rate and HRV (the low-frequency band/high-frequency band ratio) were significantly decreased when using robotic assistance. CONCLUSIONS: These data suggest the use of the daVinci® Surgical System leads to less physical and mental strain of the surgeon during surgery. However, assessing mental strain by means of HRV is cumbersome since there is no clear cutoff point or scale for maximum tolerated strain levels and its related effects on surgeon's health.
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Colecistectomía Laparoscópica/métodos , Electrocardiografía , Frecuencia Cardíaca/fisiología , Procedimientos Quirúrgicos Robotizados/métodos , Cirujanos/psicología , Adulto , Análisis de Varianza , Colecistectomía Laparoscópica/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Enfermedades Profesionales/diagnóstico , Estudios Prospectivos , Procedimientos Quirúrgicos Robotizados/psicología , Estadísticas no Paramétricas , Estrés PsicológicoRESUMEN
AIM: To give an overview of the microbiology of blood and wound samples from surgical site infections (SSIs) after gastrointestinal surgery, as well as the antimicrobial susceptibility of the microorganisms involved, and to discuss the appropriateness of the prophylactic antibiotics administered. MATERIALS & METHODS: During a 3.5-year study period, wound swabs and blood samples of patients with an SSI were taken in the first 48 h after surgery until 30 days thereafter. RESULTS: Most pathogens were isolated from wound swabs. Escherichia coli (25%) and Pseudomonas aeruginosa (10%) were the most frequently found microorganisms. Both microorganisms showed a slight tendency towards a decrease in susceptibility for the tested antibiotics, although after correction, this was not significant. CONCLUSION: The comparison between wound swabs taken in the first 48 h after a surgical procedure and swabs in the 30 days thereafter provides important information concerning the microbiology of SSIs and the development of antibiotic resistance of the causative agents over time.
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Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Enfermedades Gastrointestinales/complicaciones , Enfermedades Gastrointestinales/cirugía , Complicaciones Posoperatorias , Infección de la Herida Quirúrgica/microbiología , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Técnicas de Tipificación Micológica , Países Bajos , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Factores de TiempoRESUMEN
PURPOSE: Sacral neuromodulation (SNM) is an established treatment for fecal incontinence (FI). A recent study from our group found that the relationship between patient satisfaction and clinical outcome is complex and does not match the traditional used success criteria. Therefore, the ability to predict patient satisfaction must be given priority. The aim of the present study is to identify baseline factors predictive of patient satisfaction, with SNM, for idiopathic FI. METHODS: We analyzed data from patients treated with SNM for idiopathic FI in Aarhus, Denmark, and Maastricht, The Netherlands. A questionnaire considering self-reported satisfaction was mailed to these patients and compared to baseline characteristics. Logistic regression was used to determine the predictive value of baseline demographic and diagnostic variables. RESULTS: In total, 131 patients were included in the analysis. Patient satisfaction with the current treatment result was reported in 75 patients. Fifty-six patients were dissatisfied with SNM treatment, after median 46 months (range 11-122) with permanent implantation. Pudendal nerve terminal motor latency (PNTML) was the solely identified predictor for long-term patient satisfaction. A subgroup univariate-logistic regression analysis showed that PNTML ≤ 2.3 ms at the side of lead implantation was a statistically significant predictor for patient satisfaction (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.01-5.24, p = 0.048). CONCLUSION: Baseline PNTML measurement may be predictive of long-term satisfaction with SNM therapy for idiopathic FI. Further studies are needed to confirm this result.
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Terapia por Estimulación Eléctrica/métodos , Incontinencia Fecal/terapia , Satisfacción del Paciente , Adulto , Anciano , Anciano de 80 o más Años , Canal Anal/fisiopatología , Incontinencia Fecal/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nervio Pudendo/fisiología , Nervio Pudendo/fisiopatología , Tiempo de Reacción , Estudios Retrospectivos , Sacro/fisiopatología , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: The long-term closure rate of high perianal fistulas after surgical treatment remains disappointing. OBJECTIVE: The goal of this study was to improve the long-term closure rate of high cryptoglandular perianal fistulas combining mucosal advancement flap with platelet-rich plasma. DESIGN: This study was retrospective in design. SETTING: This study was conducted at 2 secondary and 1 tertiary referral hospitals. PATIENTS: Patients presenting with high cryptoglandular perianal fistulas involving the middle/upper third of the anal sphincter complex were included. INTERVENTIONS: A staged surgical treatment was performed; After seton placement, a mucosal advancement flap was combined with platelet-rich plasma. MAIN OUTCOME MEASURES: Recurrence was the main outcome. Incontinence was the secondary outcome. RESULTS: We operated on 25 patients between 2006 and 2012. Thirteen (52%) patients had previous fistula surgery. The median follow-up period was 27 months. One patient (4.0%) was lost to follow-up after 4 months. Freedom from recurrence at 2 years was 0.83 (95% CI, 0.62-0.93). Two of the 4 patients with a recurrence (8%) had a repeated treatment and healed. One patient (4.0%) refused another treatment, but agreed to stay in follow-up. One patient (4.0%) requested a colostomy, resulting in closure of the fistula. Complications occurred in 1 patient (4.0%). Incontinence numbers were low with a median Vaizey score of 3.0 out of a maximum of 24. LIMITATIONS: The study was limited by its retrospective design, lack of preoperative incontinence data, selection bias, and phone interview follow-up. CONCLUSION: The long-term outcome results of patients with primary and recurrent high cryptoglandular perianal fistulas treated with a seton followed by mucosal advancement flap and platelet-rich plasma show low recurrence, complication, and incontinence rates. Therefore, this technique seems to be a valid option as treatment. Larger and preferably randomized controlled studies are needed to further explore this surgical technique.
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Plasma Rico en Plaquetas , Fístula Rectal/cirugía , Colgajos Quirúrgicos , Adulto , Anciano , Incontinencia Fecal/prevención & control , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Fístula Rectal/patología , Estudios Retrospectivos , Prevención Secundaria , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de Heridas , Adulto JovenRESUMEN
BACKGROUND: Robot-assisted laparoscopy has been used in a wide variety of surgical fields; however, the financial costs involved are high and convincing proof of superiority in terms of quality of life, cost effectiveness and survival is often lacking. Possibly, there might be small benefits for the patient or for the surgeon's health that might warrant the use of robotics in limited fields of surgery. METHODS: We performed a critical appraisal of the literature, searching for scientific evidence supporting the use of robotics in daily laparoscopic surgery. RESULTS: Convincing evidence supporting the use of robotics is lacking. CONCLUSION: In an era of worldwide economic crisis, it is about time to start a critical discussion as to whether we should drastically limit, or even abandon, the use of robot-assisted laparoscopic surgery and focus on more cost-effective strategies of healthcare improvement. We suggest the use of robotics should be limited to well-powered, randomized clinical trials in a limited field of research.
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Laparoscopía/estadística & datos numéricos , Robótica/estadística & datos numéricos , Costos y Análisis de Costo , Humanos , Laparoscopía/economía , Robótica/economíaRESUMEN
AIMS: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. MATERIALS & METHODS: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. RESULTS: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. CONCLUSION: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.
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Infección Hospitalaria/epidemiología , Pseudomonas aeruginosa/fisiología , Staphylococcus aureus/fisiología , Infección de la Herida Quirúrgica/epidemiología , Enfermedades Vasculares/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Estudios Transversales , Monitoreo Epidemiológico , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Pseudomonas aeruginosa/genética , Pseudomonas aeruginosa/aislamiento & purificación , Factores de Riesgo , Staphylococcus aureus/genética , Staphylococcus aureus/aislamiento & purificación , Infección de la Herida Quirúrgica/microbiología , Infección de la Herida Quirúrgica/prevención & control , Adulto JovenRESUMEN
BACKGROUND: Sacral neuromodulation therapy has been successfully applied in adult patients with urinary and fecal incontinence and in adults with constipation not responding to intensive conservative treatment. No data, however, are available on sacral neuromodulation therapy as a treatment option in adolescents with refractory functional constipation. OBJECTIVES: This study aimed to describe the short-term results of sacral neuromodulation in adolescents with chronic functional constipation refractory to intensive conservative treatment. DESIGN: This is a retrospective review. SETTING: This study took place at the Department of Surgery, Maastricht University Medical Centre, The Netherlands. PATIENTS: Thirteen patients (all girls, age 10-18 years) with functional constipation according to the ROME III criteria not responding to intensive oral and rectal laxative treatment were assigned for sacral neuromodulation. MAIN OUTCOME MEASURES: When improvement of symptoms was observed during the testing phase, a permanent stimulator was implanted. Patients were prospectively followed up to at least 6 months after implantation of the permanent stimulator by interviews, bowel diaries, and Cleveland Clinic constipation score. Improvement was defined as spontaneous defecation ≥ 2 times a week. RESULTS: At presentation, none of the patients had spontaneous defecation or felt the urge to defecate. All patients had severe abdominal pain. Regular school absenteeism was present in 10 patients. After the testing phase, all but 2 patients had spontaneous defecation ≥ 2 times a week with a reduction in abdominal pain. After implantation, 11 (of 12) had a normal spontaneous defecation pattern of ≥ 2 times a week without medication, felt the urge to defecate, and perceived less abdominal pain without relapse of symptoms until 6 months after implantation. The average Cleveland Clinic constipation score decreased from 20.9 to 8.4. One lead revision and 2 pacemaker relocations were necessary. LIMITATIONS: This study is limited by its small sample size, single-institution bias, and retrospective nature. CONCLUSION: Sacral neuromodulation appears to be a promising new treatment option in adolescents with refractory functional constipation not responding to intensive conservative therapy. Larger randomized studies with long-term follow-up are required.
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Estreñimiento/terapia , Terapia por Estimulación Eléctrica , Neuroestimuladores Implantables , Adolescente , Canal Anal/fisiopatología , Niño , Estreñimiento/fisiopatología , Defecación , Terapia por Estimulación Eléctrica/efectos adversos , Femenino , Tránsito Gastrointestinal , Humanos , ManometríaRESUMEN
AIMS: It is unclear which patients with fecal incontinence (FI) are likely to benefit from physiotherapy treatment, which is relevant for medical decision making and patient counseling. This study aimed to identify patient characteristics predicting a favorable outcome of physiotherapy. METHODS: Eighty patients with FI, with a mean age of 59.3 (SD ± 11.9), were recruited at the Maastricht University Medical Centre and enrolled in a randomized controlled trial, which assessed the effect of adding rectal balloon training to pelvic floor muscle training. Treatment groups were combined for prediction modeling. Candidate predictors were obtained from demographics, medical history, physical examination, baseline tests, questionnaires, and physiotherapy diagnostics. Favorable outcome was defined as a combination of: (i) Vaizey score reduction ≥ 5 points, and (ii) "slightly" to "very much improved" on the nine-point global perceived effect score. Predictors were identified by univariable and multivariable logistic regression analysis. RESULTS: Thirty-seven patients (46.3%) had a favorable outcome. Multivariable analysis showed that longer time since FI onset appeared to be associated with an unfavorable outcome (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.47-1.00; P = 0.05), whereas the use of constipating medication (OR, 3.79; CI, 0.99-14.51; P = 0.05), any obstetric factor (OR, 2.15; CI, 0.94-4.89; P = 0.07), and experiencing minor embarrassment (OR, 2.12; CI, 1.10-4.09; P = 0.03) predicted a favorable outcome. CONCLUSIONS: The small subset of identified predictors for a favorable outcome may be relevant in patient counseling and targeting physiotherapy treatment more efficiently, especially as they are available early in the diagnostic process.
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Defecación , Incontinencia Fecal/terapia , Diafragma Pélvico/fisiopatología , Modalidades de Fisioterapia , Recto/fisiopatología , Adulto , Anciano , Incontinencia Fecal/diagnóstico , Incontinencia Fecal/fisiopatología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Países Bajos , Oportunidad Relativa , Selección de Paciente , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: Fecal incontinence (FI) is embarrassing, resulting in poor quality of life. Rectal sensation may be more important than sphincter strength to relieve symptoms. A single-blind, randomized controlled trial among adults with FI compared the effectiveness of rectal balloon training (RBT) and pelvic floor muscle training (PFMT) versus PFMT alone. METHODS: We randomized 80 patients, recruited from the Maastricht University Medical Centre. Primary outcome was based on the Vaizey score. Secondary outcomes were the Fecal Incontinence Quality of Life Scale (FIQL), 9-point global perceived effect (GPE) score, anorectal manometry, rectal distension volumes, and thresholds of anorectal sensation. Analyses were by intention-to-treat. RESULTS: Forty patients were assigned to combined RBT with PFMT and 40 to PFMT alone. Adding RBT did not result in a significant improvement in the Vaizey score [mean difference: -1.19; 95% confidence interval (CI): -3.79 to 1.42; P = 0.37]. Secondary outcomes favoring RBT were: Lifestyle subscale of the FIQL (0.37; 95% CI: 0.02-0.73; P = 0.04), GPE (-1.01; 95% CI: -1.75 to -0.27; P = 0.008), maximum tolerable volume (49.35; 95% CI: 13.26-85.44; P = 0.009), and external anal sphincter fatigue (0.65; 95% CI: 0.26-1.04; P = 0.001). Overall, 50% of patients were considered improved according to the estimated minimally important change (Vaizey change ≥-5). CONCLUSIONS: RBT with PFMT was equally effective as PFMT alone. Secondary outcomes show beneficial effects of RBT on urgency control, GPE, and lifestyle adaptations. Characteristics of patients who benefit most from RBT remain to be confirmed.
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Cateterismo/métodos , Ejercicio Físico/fisiología , Incontinencia Fecal/terapia , Músculo Esquelético/fisiología , Diafragma Pélvico/fisiología , Modalidades de Fisioterapia , Entrenamiento de Fuerza/métodos , Anciano , Incontinencia Fecal/fisiopatología , Femenino , Humanos , Estilo de Vida , Masculino , Persona de Mediana Edad , Contracción Muscular/fisiología , Evaluación de Resultado en la Atención de Salud , Calidad de Vida , Estudios Retrospectivos , Método Simple Ciego , Resultado del TratamientoRESUMEN
AIM: The aim of this study is to prospectively evaluate 40 patients with a high rectovaginal fistula treated by a laparoscopic fistula division and closure, followed by an omentoplasty. PATIENTS AND METHODS: Forty patients with a rectovaginal fistula, between the middle third of the rectum and the posterior vaginal fornix, resulting from different causes (IBD, iatrogenic and birth trauma) were treated by a laparoscopic excision of the fistula and insertion of an omentoplasty in the rectovaginal septum. The patients completed the gastrointestinal quality of life index questionnaire (GIQLI) and the Cleveland Clinic incontinence score (CCIS). All tests were performed at regular intervals after treatment. RESULTS: In 38 (95%) patients with a median age of 53 years (range 33-72), the surgical procedure was feasible. In two patients, the fistula was closed without an omentoplasty, and a diverting stoma was performed. The median follow-up was 28 months (range 10-35). Two patients (5%) developed a recurrent fistula. In one patient, the interposed omentum became necrotic and was successfully treated laparoscopically. In another patient, an abscess developed, which needed drainage procedures. The mean CCIS was 9 (range 7-10) before treatment and 10 (range 7-13) after treatment (p = 0.5 Wilcoxon). The median GIQLI score was 85 (range 34-129) before treatment and 120 (range75-142) after treatment (p = 0.0001, Wilcoxon). CONCLUSIONS: Laparoscopic fistula excision combined with omentoplasty is a good treatment modality with a high healing rate for high rectovaginal fistulas and an acceptable complication rate.
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Laparoscopía , Epiplón/cirugía , Procedimientos de Cirugía Plástica , Fístula Rectovaginal/cirugía , Adulto , Anciano , Femenino , Humanos , Laparoscopía/efectos adversos , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Calidad de Vida , Procedimientos de Cirugía Plástica/efectos adversos , Encuestas y Cuestionarios , Resultado del Tratamiento , Incontinencia UrinariaRESUMEN
Faecal incontinence should primarily be managed in a conservative way, and if this is not sufficient different options for minimally invasive surgery should be considered. Dietary regimens, fibers, constipating agents, enemas, biofeedback and colonic irrigation may be tried as first-line therapy. Posterior tibial nerve stimulation and injections of bulging agents can be offered, but the evidence is still not convincing. Sacral nerve stimulation is a well documented treatment for faecal incontinence. Magnetic anal sphincter implantation should be considered only in highly selected patients.
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Incontinencia Fecal/terapia , Canal Anal/cirugía , Apéndice/cirugía , Biorretroalimentación Psicológica , Fibras de la Dieta/administración & dosificación , Terapia por Estimulación Eléctrica/métodos , Incontinencia Fecal/dietoterapia , Incontinencia Fecal/cirugía , Humanos , Magnetoterapia/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Sacro/lesiones , Nervio Tibial/fisiopatología , Estimulación Eléctrica Transcutánea del Nervio/métodosRESUMEN
PURPOSE: Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders. METHODS: After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007. RESULTS: A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%). CONCLUSIONS: This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns.
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Enfermedades Funcionales del Colon/terapia , Terapia por Estimulación Eléctrica , Satisfacción del Paciente , Análisis de Varianza , Enfermedades Funcionales del Colon/fisiopatología , Estreñimiento/fisiopatología , Estreñimiento/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/fisiopatología , Manejo del Dolor , Calidad de Vida , Enfermedades del Recto/fisiopatología , Enfermedades del Recto/terapia , Análisis de Regresión , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: Traditional surgical procedures for intractable idiopathic constipation are associated with a variable outcome and substantial morbidity. The symptomatic response, physiological effect and effect on quality of life of sacral nerve stimulation (SNS) were evaluated in patients with constipation (slow transit and normal transit with impaired evacuation). METHODS: In a prospective study at five European sites patients who failed conservative treatment underwent 21 days test stimulation. Patients with >50% improvement in symptoms underwent permanent neurostimulator implantation. Primary end points were increased defecation frequency, decreased straining and decreased sensation of incomplete evacuation. RESULTS: 62 patients (55 female, median age 40 years) underwent test stimulation, of whom 45 (73%) proceeded to chronic stimulation. 39 (87%) of these 45 patients achieved treatment success. After a median 28 (range 1-55) months follow-up, defecation frequency increased from 2.3 to 6.6 evacuations per week (p<0.001). Days per week with evacuation increased from 2.3 to 4.8 (p<0.001). There was a decrease in time spent toileting (10.5 to 5.7 min, p=0.001), straining (75-46% of successful evacuations, p<0.001), perception of incomplete evacuation (71.5-46% of successful evacuations, p<0.001) and subjective rating of abdominal pain and bloating (p<0.001). Cleveland Clinic constipation score (0=no to 30=severe constipation) decreased from 18 to 10 (p<0.001). Visual analogue scale (VAS) score (0=severe to 100=no symptoms) increased from 8 to 66 (p<0.001). Patients with slow and normal transit benefited. Quality of life significantly improved. Colonic transit normalised in half of those with baseline slow transit (p=0.014). CONCLUSION: SNS is effective in the treatment of idiopathic slow and normal transit constipation resistant to conservative treatment. Clinical Trial Number NCT00200005.
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Estreñimiento/terapia , Terapia por Estimulación Eléctrica/métodos , Plexo Lumbosacro/fisiopatología , Adolescente , Adulto , Anciano , Enfermedad Crónica , Estreñimiento/fisiopatología , Defecación/fisiología , Terapia por Estimulación Eléctrica/efectos adversos , Electrodos Implantados , Métodos Epidemiológicos , Femenino , Tránsito Gastrointestinal/fisiología , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Conflicting results are reported about the contribution of maternal, obstetric and fetal characteristics to postpartum fecal incontinence (FI), which is hampering prevention and management of FI. OBJECTIVE: To perform a systematic review identifying delivery-related etiological factors for postpartum FI. Search strategy. Literature searches of PubMed, EMBASE, CINAHL, DocOnline and reference lists from 1980 up to 2009 were conducted. Selection criteria. Prospective cohort studies evaluating maternal, obstetric or fetal risk factors for postpartum FI, with a follow-up period of at least three months, were assessed. We reviewed full reports in English, German or Dutch, with anal incontinence (AI), FI, flatus incontinence, soiling, urgency and FI severity scores as reported outcomes. Data collection and analysis. Data on study characteristics, methodological quality and outcome were extracted from 31 studies according to a standardized protocol. Clinical and methodological sources of heterogeneity permitted only a qualitative analysis. MAIN RESULTS: A third- or fourth-degree sphincter rupture was the only etiological factor strongly (AI) or moderately (flatus incontinence) associated with postpartum FI. No association with other postulated risk factors was found, for example, birth weight or instrumental delivery. The potential co-existence of different risk factors impedes the interpretation of the influence of a single delivery-related risk factor. CONCLUSIONS: This systematic review, including only longitudinal studies and recognizing the importance of separating results for different outcomes, identifies that a third- or fourth-degree sphincter rupture is the only factor that is strongly (AI) or moderately (flatus incontinence) associated with postpartum FI.
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Canal Anal/lesiones , Parto Obstétrico/efectos adversos , Incontinencia Fecal/etiología , Periodo Posparto , Trastornos Puerperales/etiología , Femenino , Flatulencia , Humanos , Embarazo , Factores de Riesgo , Rotura/etiologíaRESUMEN
AIM: To determine the psychometric properties of the total Vaizey score and its individual items. METHODS: The study was conducted as part of a prospective cohort study assessing the outcome of pelvic floor rehabilitation in patients with fecal incontinence. RESULTS: One hundred ninety-four patients were analyzed, 53 of whom provided data on the global perceived effect (GPE) score. Pelvic floor rehabilitation resulted in a significant reduction of the total Vaizey score and most individual items. The total Vaizey scores changed in agreement with the GPE scores. The total Vaizey score was responsive, but some individual items yielded inconsistent results for three different measures. The test-retest reliability was adequate or excellent for six individual items and the total Vaizey score. The internal consistency was low for the total Vaizey score at baseline, in contrast to the follow-up and change scores. The estimates for the minimally important change (MIC) and smallest detectable change yielded moderately consistent results. An MIC of -5 points seemed preferable and yielded the lowest misclassification rate. CONCLUSIONS: More research is required to confirm conclusions on the psychometric properties of the total Vaizey score and its individual items, and to justify its use in research and routine clinical practice.
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Terapia por Ejercicio , Incontinencia Fecal/rehabilitación , Encuestas y Cuestionarios , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diafragma Pélvico , Estudios Prospectivos , PsicometríaRESUMEN
INTRODUCTION: Treatment of functional anorectal pain disorders remains a challenge. The purpose of this study is to describe a single center experience with sacral neuromodulation for the treatment of chronic functional anorectal pain. METHODS: This is a retrospective study based on prospectively collected data of patients treated with sacral neuromodulation for functional anorectal pain from April 2005 to August 2008. Symptoms were analyzed using a visual analog scale pain score (0 to 10). A 7-point Likert scale was used to rate global perceived effect. All patients had a percutaneous nerve evaluation and subsequent test stimulation to assess sacral neuromodulation outcome prior to permanent implantation. Patients were eligible for permanent sacral neuromodulation in case of a pain score <3 during test stimulation and/or >50% decrease in the pain score compared to baseline. RESULTS: Nine patients (2 males) were included in this study. Mean age was 53.8 years (27.6 to 74.0). Four patients (1 male) had successful test stimulation and were eligible for permanent implantation. Median pain score decreased from 8.0 (6.0 to 9.0) to 1.0 (0 to 2.0). All patients experienced a lasting improvement during the follow-up till 24 months. Global perceived effect in successful patient was 1 (completely recovered) in one patient and 2 (much improved) in three patients. CONCLUSION: This study showed that sacral neuromodulation can be a successful treatment for functional anorectal pain not responding to other treatments. Improvement obtained during test stimulation is a good predictor (diagnostic) for sustained success of permanent sacral neuromodulation.
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Enfermedades del Ano/terapia , Terapia por Estimulación Eléctrica/métodos , Plexo Lumbosacro/cirugía , Dolor Pélvico/terapia , Enfermedades del Recto/terapia , Raíces Nerviosas Espinales/cirugía , Adulto , Anciano , Enfermedades del Ano/fisiopatología , Terapia por Estimulación Eléctrica/instrumentación , Electrodos Implantados/normas , Electrodos Implantados/estadística & datos numéricos , Femenino , Humanos , Plexo Lumbosacro/anatomía & histología , Plexo Lumbosacro/fisiología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/métodos , Dimensión del Dolor/métodos , Dolor Pélvico/fisiopatología , Enfermedades del Recto/fisiopatología , Estudios Retrospectivos , Autoestimulación/fisiología , Raíces Nerviosas Espinales/anatomía & histología , Raíces Nerviosas Espinales/fisiología , Resultado del TratamientoRESUMEN
PURPOSE: Angiogenesis, as measured by degree of microvessel density, has been associated with tumor progression in many tumor types but does not always correlate with clinical outcome. In 1999, aggressive tumor cells were shown to form blood-conducting tubes not lined by endothelial cells, and this phenomenon was termed vasculogenic mimicry. We investigated angiogenesis and the presence of vasculogenic mimicry in colorectal carcinoma in relation to tumor stage, patient survival, and genetic indicators of tumor cell plasticity. METHODS: Paraffin-embedded tissue samples were examined from a study of 117 patients with colorectal carcinoma with a 12-year follow-up. Immunohistochemical analysis was used to measure microvessel density and proliferating endothelial cells and to detect vasculogenic mimicry (scored by 3 independent observers). Cell cultures from 7 colon cell lines, real-time polymerase chain reaction (PCR) on cell lines, frozen tissue material from 4 colorectal cancer patients with and 4 without vasculogenic mimicry, and fresh colorectal cancer tissue from 2 patients were used to investigate the relationship between vasculogenic mimicry and tumor cell plasticity. RESULTS: Microvessel density was not a prognostic marker in our patients. We found vasculogenic mimicry in 23 (19.7%) of 117 colorectal tumor samples. Cell culture experiments and real-time PCR on human colorectal carcinoma material showed evidence for vasculogenic mimicry with overexpression of EPHA2 and LAMC2, known to be important for the tube-forming capacity of melanoma tumor cells. The presence of vasculogenic mimicry was associated with significantly shortened survival, both overall (P < 0.0001) and within intermediate cancer stages (Dukes B, P = 0.0277; Dukes C, P < 0.0001). CONCLUSIONS: Vasculogenic mimicry can occur in colorectal carcinoma and appears to be comparable to vasculogenic mimicry described in other tumors. Moreover, vasculogenic mimicry in colorectal carcinoma may be a strong independent prognostic marker for survival.
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Adenocarcinoma/irrigación sanguínea , Adenocarcinoma/patología , Neoplasias Colorrectales/irrigación sanguínea , Neoplasias Colorrectales/patología , Neovascularización Patológica/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Colorrectales/genética , Femenino , Expresión Génica , Humanos , Laminina/genética , Masculino , Microvasos/patología , Persona de Mediana Edad , Neovascularización Patológica/patología , Pronóstico , Receptor EphA2/genética , Células Tumorales CultivadasRESUMEN
PURPOSE: This study was designed to evaluate recurrence and functional outcome of three surgical techniques for rectopexy: open (OR), laparoscopic (LR), and robot-assisted (RR). A case-control study was performed to study recurrence after the three operative techniques used for rectal procidentia. The secondary aim of this study was to examine the differences in functional results between the three techniques. MATERIALS AND METHODS: All consecutive patients who underwent a rectopexy between January 2000 and September 2006 enrolled in this study. Peri-operative data were collected from patient records and functional outcome was assessed by telephonic questionnaire. RESULTS: Eighty-two patients (71 females, mean age 56.4 years) underwent a rectopexy for rectal procidentia. Nine patients (11%) had a recurrence; one (2%) after OR, four (27%) after LR, and four (20%) after RR. RR showed significantly higher recurrence rates when controlled for age and follow-up time compared to OR, (p = 0.027), while LR showed near-significant higher rates (p = 0.059). Functional results improved in all three operation types, without a difference between them. CONCLUSIONS: LR and RR are adequate procedures but have a higher risk of recurrence. A RCT is needed assessing the definitive role of (robotic assistance in) laparoscopic surgery in rectopexy.
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Laparoscopía , Prolapso Rectal/prevención & control , Prolapso Rectal/cirugía , Recto/cirugía , Robótica , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Cuidados Preoperatorios , Prolapso Rectal/fisiopatología , Recurrencia , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: A temporary stoma is a relatively common procedure at the neonatal age for a number of disorders. At birth, the enteric nervous system (ENS) is not fully developed; temporary colostomy causes morphological changes in the ENS. We studied whether transection of bowel or deprivation of stool is responsible for these changes. Moreover, reversibility of the ENS changes after stoma closure was investigated. METHODS: Male Lewis rats aged 3 weeks were randomly divided into 3 groups. Group 1 (stoma group) received a stoma (t = 0), stoma closure 2 weeks later (t = 1), and were killed 2 weeks after stoma closure; group 2 (transection group) had a colon transection and immediate anastomosis (t = 0) and were killed 2 weeks afterward. Group 3 (sham group) had no operation. In all groups, the nerve/muscle fiber ratio (NMR) in the proximal and distal colon was assessed with full thickness biopsy specimens at operation or after killing. The NMR in the stoma, transection, and sham group at t = 1 were used to assess the effect of deprivation of passage of feces and transection itself on the development of the ENS of the colon. Results of the stoma group at t = 1 and t = 2 were compared to assess possible reversibility of ENS changes after stoma closure. RESULTS: There was a significantly higher NMR in the distal colon compared to the proximal colon in both the stoma and transection groups at t = 1 (2.0 +/- 0.38, P < .001 and 2.8 +/- 0.97, P < .001, respectively), whereas there was no significant difference in NMR ratio at t = 1 (1.1 +/- 0.18, P = .34) in group 3. In group 1, the NMR ratio increased further after stoma closure to 3.1 +/- 0.37, P < .001, at t = 2. CONCLUSION: Transection of the bowel rather than deprivation of fecal passage causes nerve fiber hypertrophy in the distal colon of neonatal rats. Restoration of bowel continuity does not result in recovery of these ENS changes.