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Biomedical subjects

C J Vaizey

Publications and source records attributed to C J Vaizey.

18 recordsLinked to original sources
PubMed2001

Internal anal sphincter augmentation for fecal incontinence using injectable silicone biomaterial.

PURPOSE: A disrupted or weak internal anal sphincter can lead to passive fecal incontinence. This muscle is not amenable to direct surgical repair. Previous preliminary attempts to restore functional continuity have included a cutaneous flap to fill an anal canal defect, and injection therapy using polytetrafluoroethylene, collagen, or autologous fat. Urologists have also used injections of collagen or silicone to enhance bladder neck function. This pilot study aimed to assess the efficacy of single or multiple injections of the silicone-based product Bioplastique for the symptoms of passive fecal incontinence caused by an anatomically disrupted or intact but weak internal anal sphincter. PATIENTS AND METHODS: Ten patients (6 females; median age, 64, range, 41-80 years) with passive incontinence secondary to a weak (n = 6) or disrupted (n = 4) internal anal sphincter were injected either circumferentially or at a single site, respectively. Patients were assessed before and six weeks after treatment by clinical assessment, two-week bowel diary card, anorectal physiologic testing, and endoanal ultrasound. Patients failing to show improvement after the first injection were offered a second injection six weeks after the first injection. Clinical assessment was further repeated at six months, and five patients had a further ultrasound examination. RESULTS: At six weeks, six of ten patients showed either marked improvement (n = 3) or complete cessation of leakage (n = 3). A further patient was greatly improved after a second injection. Three patients were not improved. At six months, two of the seven patients had maintained marked improvement, and one patient had maintained minor improvement; all of these three patients had circumferential multiple injections. Maximum resting and squeeze anal pressures did not differ significantly between before vs. six weeks after vs. six months after injection. At six weeks endoanal ultrasound (n = 9) confirmed the presence and correct position of the silicone in all but one patient who had experienced obvious external leakage of the product. At six months the silicone remained in the correct position in the five endosonographically assessed patients. Five of the initial patients experienced pain or minor ulceration at the injection site. CONCLUSIONS: Although clinically effective immediately after injection, the benefit of an injectable biomaterial was maintained in only a minority of patients. This occurred despite the continued presence of material in the correct anatomical site. Patients with diffuse weakness treated by circumferential injection seemed to be the most responsive, but further studies are required to clarify this.

Adult↗
PubMed2000

Reassessing artificial bowel sphincters.

The artificial sphincter has now been used for the treatment of patients with faecal incontinence since 1996. Presently, results in the UK do not match those reported from the rest of Europe, with infection caused by methicillin-resistant Staphylococcus aureus being the most common cause of failure.

Anal Canal↗
PubMed2000

Double-blind crossover study of sacral nerve stimulation for fecal incontinence.

PURPOSE: Patients with fecal incontinence not amenable to simple repair may have to undergo major reconstructive surgery or resort to a stoma. Sacral nerve stimulation is an alternative approach that may diminish incontinence by altering sphincter and rectal motor function. This study is the first double-blind trial examining the effectiveness of this therapy. METHODS: Two patients with passive fecal incontinence who had been implanted for nine months with a permanent sacral nerve stimulator and electrode were studied using fecal incontinence diaries, anorectal physiological tests, and quality-of-life assessments (SF-36 health survey). The trial period consisted of two two-week periods, with the stimulator turned on for two weeks and off for two weeks. The main investigator and the patients were blinded to the status of the stimulator. RESULTS: There was a dramatic difference between the number and severity of episodes of incontinence when the stimulator was turned on vs. turned off (Patient 1, 20 vs. 2 episodes; Patient 2, 4 vs. 0 episodes; off vs. on). There was an increase in squeeze pressure (Patient 1, 70 vs. 100 cm H2O; Patient 2, 60 vs. 90 cm H2O; off vs. on), with moderate increases in resting pressure and rectal threshold and urge volumes. Quality-of-life measurements showed a marked improvement prestimulation vs. nine months after permanent stimulation. CONCLUSIONS: There is a marked, unequivocal improvement in symptoms of fecal incontinence with sacral nerve stimulation shown in this double-blind crossover trial. Sacral nerve stimulation improves the quality of life in selected patients with fecal incontinence.

Aged↗
PubMed2000

Permanent sacral nerve stimulation for fecal incontinence.

OBJECTIVE: To characterize the longer-term therapeutic response of permanent sacral nerve stimulation for fecal incontinence and to delineate suitable indications and the mode of action. SUMMARY BACKGROUND DATA: A single report of permanent sacral nerve stimulation in three patients followed up for 6 months showed marked improvement in fecal continence. Acute evaluation has shown that the effect may be mediated by altered rectal and anal smooth muscle activity, and facilitation of external sphincter contraction. METHODS: Five women (age 41-68 years) with fecal incontinence for solid or liquid stool at least once per week were followed up for a median of 16 months after permanent implantation. All had passive incontinence, and three had urge incontinence. The cause was scleroderma in two, primary internal sphincter degeneration in one, diffuse weakness of both sphincters in one, and disruption of both sphincters in one. RESULTS: All patients had marked improvement. Urgency resolved in all three patients with this symptom. Passive soiling resolved completely in three and was reduced to minor episodes in two. Continence scores (scale 0-20) improved from a median of 16 before surgery to 2 after surgery. There were no early complications, and there have been no side effects. One patient required wound exploration at 6 months for local pain, and a lead replacement at 12 months for electrode displacement. The quality of life assessment improved in all patients. The resting pressure increased in four patients, but there was no consistent measured physiologic change that could account for the symptomatic improvement. CONCLUSIONS: In patients with sphincter degeneration and weakness, and possibly in those with sphincter disruption, sacral nerve stimulation markedly improves fecal incontinence.

Adult↗
PubMed2000

Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures.

Lateral sphincterotomy diminishes internal anal sphincter hypertonia and thereby reduces anal canal pressure. This improves anal mucosal blood flow and promotes the healing of anal fissures. However, sphincterotomy can be associated with long term disturbances of sphincter function. The optimal treatment for an anal fissure is to induce a temporary reduction of anal canal resting pressure to allow healing of the fissure without permanently disrupting normal sphincter function. Broader understanding of the intrinsic mechanisms controlling smooth muscle contraction has allowed pharmacological manipulation of anal sphincter tone. We performed an initial Medline literature search to identify all articles concerning "internal anal sphincter" and "anal fissures". This review is based on these articles and on additional publications obtained by manual cross referencing. Internal anal smooth muscle relaxation can be inhibited by stimulation of non-adrenergic non-cholinergic enteric neurones, parasympathetic muscarinic receptors, or sympathetic beta adrenoceptors, and by inhibition of calcium entry into the cell. Sphincter contraction depends on an increase in cytoplasmic calcium and is enhanced by sympathetic adrenergic stimulation. Currently, the most commonly used pharmacological agent in the treatment of anal fissures is topical glyceryl trinitrate, a nitric oxide donor. Alternative agents that exhibit a similar effect via membrane Ca2+ channels, muscarinic receptors, and alpha or beta adrenoceptors are also likely to have a therapeutic potential in treating anal fissures.

Anal Canal↗
PubMed2000

Prospective assessment of the clinical value of anorectal investigations.

BACKGROUND/AIM: Anorectal physiological testing and imaging have become part of routine colorectal and gastro-enterological practice, but their clinical value is controversial. We prospectively evaluated the new diagnostic information, impact on management and prognostic information provided by anorectal testing. METHODS: One hundred consecutive patients referred for testing were studied. The referring doctor's diagnosis, reason for referral, planned management and expectation of the value of investigations were recorded. Incontinent patients underwent anorectal physiological testing and endo-anal ultrasound. Patients with constipation underwent anorectal physiological testing and a study of whole-gut transit time to distinguish between slow and normal transit. Constipated patients over age 45, or those younger patients who digitated to assist defaecation, also underwent evacuation proctography to identify large rectoceles. RESULTS: Fifty-one patients had faecal incontinence. Of 12 patients with suspected anterior external anal sphincter obstetric damage, all of whom were planned for surgical repair, 3 were unsuitable for repair, 3 had a normal sphincter, 2 had a weak but structurally intact sphincter, and 1 had internal anal sphincter damage only. Of 6 patients with failed anterior repair, 3 had a defect suitable for repeat repair, 2 had intact repairs and good function, and 1 had extensive damage requiring reconstructive surgery. The tests also influenced management for incontinent patients after haemorrhoidectomy surgery (n = 5), after fistula surgery (n = 5), with congenital abnormalities (n = 3), after cerebrovascular accident (n = 1) and those with no presumptive diagnosis (n = 15). Of the 20 patients referred with constipation, demonstration of a recto-anal reflex in 1 patient with a megarectum excluded the need for full-thickness biopsy. A further patient with altered electrosensation went on to have a neurological lesion defined. Definition of slow transit in some patients did not immediately affect management. New information or a change in management was provided in patients referred for pre-operative assessment (n = 13). Information was gained in only 1 of 7 patients with solitary rectal ulcer and in none of the 8 patients with anal pain. CONCLUSION: Anorectal assessment provides important diagnostic and prognostic information and directly alters management in patients with benign anorectal disorders.

Adolescent↗
PubMed1999

Results of repeat anal sphincter repair.

BACKGROUND: Patients with a poor outcome from anterior sphincter repair may be candidates for dynamic graciloplasty, artificial bowel sphincter implantation or a secondary repair. This study examines the outcome of repeat overlap repairs in these patients. METHODS: Twenty-six of 235 patients undergoing a sphincter repair (median age 43 (range 23-63) years) underwent repeat repair from May 1994 to April 1997. Twenty-three patients were available for follow-up. Clinical evaluation included a satisfaction scale from 1 to 10, the patient's assessment of percentage improvement, ability to defer defaecation before and after operation, and Wexner continence scores before and after operation. Manometric studies were performed in 21 patients before and 17 patients after operation, and anal ultrasonography was undertaken in 17 patients before and 14 patients after operation. External sphincter defects were present on all preoperative scans. RESULTS: At a median follow-up of 20 (range 5-42) months, 15 patients felt that they were 50 per cent or more improved after operation. On the satisfaction scale of 1-10 the median score was 7 (range 1-10). There was a significant improvement in the Wexner continence score from 19 (range 17-20) before operation to 12 (range 1-20) after operation (P < 0.001). Ability to defer defaecation improved significantly from less than 5 min in all patients before operation to greater than 15 min in six patients after operation. Ultrasonography showed good overlap of the external sphincter muscle in eight of 14 patients. All patients who failed to improve showed a residual defect on ultrasonography. CONCLUSION: Repeat anterior repair produces a significant improvement in continence score and ability to defer defaecation in patients with obstetric sphincter damage. Clinical improvement correlates closely with an improvement in the appearance on endoanal ultrasonography.

Adult↗
PubMed1999

Prospective comparison of faecal incontinence grading systems.

BACKGROUND: Existing scales for assessing faecal incontinence have not been validated against clinical assessment, or with regard to reproducibility. They also fail to take into account faecal urgency, and the use of antidiarrhoeal medications. AIMS: To establish the validity, and sensitivity to change, of existing scales and a newly designed incontinence scale. METHODS: (1) Twenty three patients (21 females, median age 57 years) were prospectively evaluated by two independent clinical observers, using three established scales (Pescatori, Wexner, American Medical Systems), a newly devised scale which also includes details about urgency and antidiarrhoeal drugs, and by a 28 day diary. (2) A further 10 female patients were assessed by the same scales before and after surgery for faecal incontinence. RESULTS: (1) Assessments by two independent clinicians correlated well. All four scales and a diary card correlated highly and significantly with the clinical impression, with the new scale reaching the highest correlation (r=0.79, p<0.001). (2) All except one score changed significantly in response to surgical treatment; the new scale showed the greatest change, at the highest level of significance (p=0.004), and correlated best with the clinicians' assessment of change (r=0.94, p<0.001). CONCLUSIONS: Existing scales for the assessment of faecal incontinence correlate well with careful clinical impression of severity, and serve as useful and reproducible measures for comparison of patients and treatments. A newly devised scale has shown high clinical validity and utility.

Adult↗
PubMed1999

Effects of short term sacral nerve stimulation on anal and rectal function in patients with anal incontinence.

BACKGROUND: Some patients with faecal incontinence are not amenable to simple surgical sphincter repair, due to sphincter weakness in the absence of a structural defect. AIMS: To evaluate the efficacy and possible mode of action of short term stimulation of sacral nerves in patients with faecal incontinence and a structurally intact external anal sphincter. PATIENTS: Twelve patients with faecal incontinence for solid or liquid stool at least once per week. METHODS: A stimulating electrode was placed (percutaneously in 10 patients, operatively in two) into the S3 or S4 foramen. The electrode was left in situ for a minimum of one week with chronic stimulation. RESULTS: Evaluable results were obtained in nine patients, with early electrode displacement in the other three. Incontinence ceased in seven of nine patients and improved notably in one; one patient with previous imperforate anus and sacral agenesis had no symptomatic response. Stimulation seemed to enhance maximum squeeze pressure but did not alter resting pressure. The rectum became less sensitive to distension with no change in rectal compliance. Ambulatory studies showed a possible reduction in rectal contractile activity and diminished episodes of spontaneous anal relaxation. CONCLUSIONS: Short term sacral nerve stimulation notably decreases episodes of faecal incontinence. The effect may be mediated via facilitation of striated sphincter muscle function, and via neuromodulation of sacral reflexes which regulate rectal sensitivity and contractility, and anal motility.

Adult↗
PubMed1998

Clinical, physiological, and radiological study of a new purpose-designed artificial bowel sphincter.

BACKGROUND: Studies of the use of artificial urinary sphincters for faecal incontinence have led to refinement and adaptation of such sphincters to the anatomy of the anal region. We aimed to test this new device. METHODS: Six women, median age 53 (range 32-58) years, who were unsuitable for sphincter repair, had an artificial bowel sphincter implanted as a one-stage procedure without colostomy cover. Clinical assessment, physiological testing, and endosonography were done before and after the operation. Plain radiography, three-dimensional endosonography, and magnetic-resonance imaging were done after the operation, to define its anatomical location. RESULTS: Median follow-up was 10 (range 5-13) months and the device was functional in five patients. In one patient, the device was removed after ulceration through the skin. Of the patients with intact devices, Wexner incontinence scores improved from a median of 19 (18-20) of 20 before the operation, to 3 (0-6) of 20 after the operation. Median anal pressure at rest significantly increased from 60 (range 30-80) cm H2O to 110 (100-120) cm H2O. Functional anal-canal length varied after the operation from 3.3 cm to 3.8 cm. There was no significant change in the maximum tolerated volume of the rectum (140 [80-230] vs 100 [75-250] mL), or rectal compliance (2.9 [2.8-6.0] cm H2O/mL vs 3.5 [2.3-7.3] cm H2O/mL). All the imaging techniques accurately located the implant relative to the anal canal and pelvic floor in each patient. INTERPRETATION: The new artificial bowel sphincter provided a good functional result in five of the six patients, the surgical procedure was straightforward, and the maximum resting anal pressure rose without affecting rectal function. The ease of visualisation of such implants in situ should aid simple management of complications, should they arise.

Adult↗
PubMed1998

Recent advances in the surgical treatment of faecal incontinence.

BACKGROUND: Improved imaging and refined technology have led to a number of recent advances in the surgical treatment of faecal incontinence. METHODS: Original articles, identified using a computer database (Medline), and recently published abstracts of meetings were selected on the basis of greatest clinical relevance; these were reviewed. RESULTS: Ultrasonographic characterization has led to improved therapeutic strategies. Simple structural damage is readily identified and external sphincter repair results in a good outcome for a majority of patients. For more complex structural damage, or for the newly recognized primary internal sphincter degeneration, alternative treatment strategies are emerging. The electrically stimulated gracilis neosphincter and the artificial bowel sphincter offer good results. The latter may be a more simple operation. For structurally intact but weak sphincters, sacral nerve stimulation is a promising therapy. Other therapies, such as antegrade irrigation, may be helpful for patients with neurological disorders. CONCLUSION: Better imaging, refined classification and new operations are leading to improved surgical techniques for faecal incontinence.

Anus Diseases↗
PubMed1998

Solitary rectal ulcer syndrome.

BACKGROUND: Solitary rectal ulcer syndrome is a rare disorder characterized by erythema or ulceration of the rectal wall, associated with typical histological features, and disturbed defaecatory behaviour with the passage of blood and mucus. METHODS: This is a review based on a literature search using a computer database (Medline) and manual cross-referencing. RESULTS: The pathogenesis is likely to vary in different patients; it includes trauma from straining, direct digital trauma and possibly primary neuromuscular pathology. The histological findings of extension of the muscularis mucosa between crypts and muscularis propria disorganization on full-thickness specimens are characteristic. Biofeedback defaecation retraining, including habit training, can lead to symptom improvement and return to work in a majority of patients. Abdominal rectopexy offers long-term symptom improvement in approximately 50 per cent of patients. Rectal ulceration may persist after any treatment, even if symptoms improve. CONCLUSION: Behavioural therapy and carefully considered operations offer the best treatment results. Further work on psychological factors and neuromuscular and vascular pathology is required.

Humans↗
PubMed1997

Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence.

BACKGROUND: Faecal incontinence is usually attributed to pelvic-floor denervation of striated muscle or direct sphincter trauma. We have identified a cause of passive faecal incontinence related to degeneration of the internal anal sphincter smooth muscle, in the absence of denervation, structural damage, external-sphincter weakness, or sensory abnormalities. METHODS: Patients were included on the basis of: passive faecal incontinence, no urge faecal incontinence, low anal pressure whilst at rest, normal anal-squeeze pressure, endosonographically confirmed circumferentially intact internal and external anal sphincters, and normal pudendal nerve terminal nerve latencies. In a second analysis done to assess the proportion of patients with this disorder, we recorded the cause of incontinence in consecutive patients seen during a 6-month period. FINDINGS: 45 patients (35 women, median age 63 years, range 23-80 years) fulfilled the diagnostic criteria. Median duration of symptoms was 2 years (3 months to 20 years). Nine of the 35 women were nulliparous. The median resting anal pressure was 40 cm water (16-56 cm water, normal > 60 cm water). Endosonography revealed an internal sphincter that was thin and hyperechogenic, and had a poorly defined edge. The normal increase in the thickness of the internal anal sphincter with age was not seen. Anal-squeeze pressure, sensitivity, and pudendal nerve latencies were normal. In the second analysis the condition was identified in eight of 230 patients, representing 4% of new referrals. INTERPRETATION: Primary degeneration of the internal anal sphincter smooth muscle is a discrete clinical condition causing passive faecal incontinence.

Adult↗
PubMed1997

Invasive carcinoma in juvenile polyposis--report of a case in an African patient.

Since the 1980s it has been recognized that the polyps of juvenile polyposis have malignant potential. Since the introduction of colonoscopy this syndrome has been redefined and the hamartoma-adenoma-carcinoma sequence recognized. We believe this case is the first report of an invasive carcinoma associated with juvenile polyposis to be described in an African patient.

Adenocarcinoma, Mucinous↗
PubMed1997

Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback.

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is often resistant to medical and surgical treatment. AIM: To determine whether biofeedback retraining is a useful treatment for this condition. PATIENTS: Thirteen consecutive patients with SRUS (three men, median age 34 years, median duration of symptoms three years) underwent treatment. Previous surgical treatment had failed in five. METHODS: Patients were evaluated prospectively. Anorectal physiological studies were performed in 11 patients before treatment. A standardised questionnaire was used before and after treatment, and all but two patients were examined after treatment. RESULTS: Median follow up was nine months (range 3-22 months). After treatment four patients were asymptomatic, and four felt improved. Symptom improvement or elimination occurred in: need to strain (7/13 patients), digitation (7/11), laxative use (5/9). Time in the toilet (median 30 v 10 minutes, before v after treatment) and number of visits to toilet (6 v 3/day) were also improved. Three patients were able to maintain employment before treatment compared with eight after treatment. The solitary ulcer did not heal completely in any of the nine patients examined after treatment, but improved in four. Previous surgery, the macroscopic appearance of the ulcer, the presence of pelvic floor paradox, and other physiological parameters did not predict outcome. CONCLUSION: Biofeedback retraining is a useful treatment for this condition. Long term studies are now required.

Adult↗
PubMed1994

Trauma in pregnancy.

Trauma is a major cause of maternal death in pregnancy. The pregnant woman who has been involved in an episode leading to her arrival in an accident and emergency department presents with specific problems that often require specialist attention. The correct initial management of such patients should not be beyond the capabilities of an average trauma team and such management is clearly taught as part of the Advanced Trauma Life Support course now available in the UK. This review outlines the physiological changes associated with pregnancy that become important during resuscitation and definitive care. It discusses the presentation and management of specific problems, and the safety--or otherwise--of commonly administered drugs. Only the initial resuscitation of the patient is considered; specialist obstetric care is beyond the scope of the article.

Cardiovascular System↗