Biomedical subjects

M J Rongen

Publications and source records attributed to M J Rongen.

8 recordsLinked to original sources

PubMed2001

Dynamic graciloplasty for fecal incontinence.

Fecal incontinence is a socially incapacitating condition with associated high treatment costs. The most common cause of fecal incontinence is trauma during childbirth followed by surgical interventions. After unsuccessful conventional treatment, muscle transposition is the next treatment option. Two local muscles are used for this purpose: the gluteus and the gracilis muscles. With both muscles, long-term muscle contractions are difficult to maintain due to muscle fatigue. The gracilis muscle, however, is technically much easier to transfer and most activities of daily living and even sports are still possible. Experimental studies have shown that electrical stimulation of skeletal muscles can transform fatigue-prone muscles into fatigue-resistant muscles. In 1986, we started to perform graciloplasty procedures with intramuscular electrodes connected to an electrical stimulator. To date, 200 patients have been treated in our institution using dynamic graciloplasty. All patients had severe incontinence without control of liquid or solid feces, most of them had previously received unsuccessful treatment using other techniques. The mean age was 48 years, the average time that patients had been incontinent was 12.4 years, and the cause of incontinence were trauma (n = 99), congenital (n = 28), pudendopathy (n = 58), and low motor neurological lesions (n = 15). Of these patients, 76% were considered to have successful outcomes. Patients whose cause of incontinence was trauma or pudendopathy tended to respond better to this treatment than patients with anal atresia.

Adolescent↗

PubMed2001

Comparison of epineural or intramuscular nerve electrodes for stimulated graciloplasty.

OBJECTIVE: Two different techniques have been developed to stimulate the gracilis muscle when it is used in anal neosphincter reconstruction. These are direct neural stimulation and intramuscular electrode stimulation. The aim of this study was to compare these techniques. METHODS: Comparison was made of gracilis anal neosphincter reconstruction using neural stimulation (Royal London Hospital in the United Kingdom) with the intramuscular muscular method (University Hospital Maastricht in the Netherlands). The United Kingdom data were obtained from a retrospective database, whereas the Netherlands data were gathered prospectively. RESULTS: A successful outcome was achieved in 46 of 81 patients (57 percent) in London and 148 of 200 cases (74 percent) in the Maastricht study (chi-squared = 7.2; P < 0.01). There was no significant difference between the two techniques in voltage required for stimulation of the neosphincter muscle during a ten-year period. Reoperative surgery for electrode failure or dislocation was required in 21 (26 percent) patients in the London study, whereas only four (2.7 percent) of the Maastricht cases required such procedures (chi-squared = 37.8; P < 0.05). The high electrode plate failure rate in the London study was related to the source of manufacture. CONCLUSIONS: Both neural and intramuscular nerve techniques provide effective long-term stimulation of the gracilis anal neosphincter.

Adolescent↗

PubMed2001

Cecal access for antegrade colon enemas in medically refractory slow-transit constipation: a prospective study.

PURPOSE: The current surgical treatment for therapy-resistant slow-transit constipation consists of either subtotal colectomy or ileostomy. This prospective study was performed to examine the creation of an access enabling antegrade enemas of the colon as an alternative to these interventions. Development of symptoms associated with constipation was also a study subject. METHODS: Twelve patients with a median defecation frequency of once a week were evaluated preoperatively, using marker-transit studies, defecography, manometry, and colonoscopy. All patients subsequently received an enema access, placed in the lower right abdomen. The appendix (available in seven cases) was laparoscopically fixed to the abdominal wall and served as a stoma, a procedure that required a conversion in one case. In five previously appendectomized cases, the terminal part of the ileum was transected, the distal side fixed to the abdominal wall to serve as a stoma, and the proximal side anastomosed to the ascending colon. Quality-of-life-assessment was included. This consisted of Nottingham Health Profile, State Trait Anxiety Inventory, and Zung tests, as well as disease specific questions. Besides perioperative and out-patient evaluations, patients were asked about and scored on constipation associated symptoms. RESULTS: Twelve patients (8 female) with a mean age of 43 (17-66) years were treated. Using various enema regimes, frequency of defecation (median one daily) without major complications was established. In four cases, a subtotal colectomy was required in the long run. Two of these four patients needed an ileostomy after for persisting symptoms. State Trait Anxiety Inventory and Zung results improved, as did several associated symptoms. Overall, constipation scores dropped from a median of 21.5 to 5.5. CONCLUSION: Cecal access for antegrade colon enemas in medical therapy-resistant slow-transit constipation is a minimally invasive procedure with promising results. In case of failure, further surgery is not compromised by this procedure.

Adolescent↗

PubMed2001

One-step vs two-step procedure in dynamic graciloplasty.

OBJECTIVE: Dynamic graciloplasty, a proven treatment for end-stage faecal incontinence, requires transposition of the gracilis muscle around the anal canal and implantation of a pulse generator and intramuscular electrodes. In view of the risk of infection around the implanted material the implantation was initially not performed in combination with the perineal procedure but 6 weeks later. Sparing the patients an extra operation, however, might be justified if morbidity is not increased. This study aimed to compare the combined single-stage with the two-stage procedures. PATIENTS AND METHODS: Two groups of 13 patients were admitted to this prospective, matched control study according to waiting list ranking. They were matched for age, gender and aetiology. Group I had transposition and transplantation combined, group II underwent these procedures separately with a 6-week interval. Continence, manometry, stimulation parameters, quality of life results and adverse events were recorded. RESULTS: After a mean 521-day follow up infection rates were comparable in both groups, as were continence rates, morbidity, anal manometry, stimulation parameters and quality of life. CONCLUSION: Outcome, morbidity and quality of life seem to be comparable. A single procedure avoids the need for an extra admission and operation, so the one-stage approach should be the standard procedure in dynamic graciloplasty.

Clinical Trial↗

PubMed1999

Secondary coloperineal pull-through and double dynamic graciloplasty after Miles resection--feasible, but with a high morbidity.

PURPOSE: Until recently, patients who underwent abdominoperineal resections had to cope with a colostomy for the rest of their lives. For some of these patients this colostomy was a terrible burden, physically and mentally. Publications about abdominoperineal pull-through and double dynamic graciloplasty immediately after a Miles resection showed good results. The purpose of this study was to investigate the procedure as a secondary approach after abdominoperineal resections. METHODS: In this study seven patients were evaluated. All had had an abdominoperineal resection and proved to have unbearable problems with their stoma. All had a secondary pull-through and double dynamic graciloplasty, a mean of 8.5 (range, 1.1-34.8) years after the Miles resection. RESULTS: In five patients continence was regained; two were reversed to colostomy because of several complications. Patients who had a successful outcome also suffered from numerous complications, with a total mean hospital stay of 73.8 (range, 27-167) days, a mean of 3.1 (range, 1-6) additional operations, and 1.8 (range, 0-4) readmissions. CONCLUSION: Secondary anorectal reconstruction after abdominoperineal resection is a feasible option, but with a high morbidity. Because of this the procedure was stopped at the beginning of 1997.

Colon↗

PubMed1997

Total anorectal reconstruction with a double dynamic graciloplasty after abdominoperineal reconstruction for low rectal cancer.

PURPOSE: Total anorectal reconstruction with a double dynamic graciloplasty was performed after abdominoperineal reconstruction (APR) for low rectal cancer. In four patients an additional pouch was constructed to improve neorectal motility and capacity. The aim of this study was to evaluate the results in the first 20 patients and to report on the preliminary results of patients with an additional pouch. METHODS: Twenty patients with a mean age of 52 (range, 25-71) years and a rectal tumor at a mean of 3 (range, 0-5) cm from the anal verge were treated. In 14 patients the Miles resection, colon pull-through, and construction of a neosphincter were performed in one session. Six patients had the double graciloplasty at an average of 4.1 (range, 1.1-8.8) years after APR. In four patients a pouch was constructed with an isolated segment of distal ileum. RESULTS: After a mean follow-up of 24 (range, 1-60) months after APR, none of the patients developed local recurrence, whereas four patients developed distant metastasis. Fifteen of 20 patients were available for evaluation, and 5 patients were still in training. Of these 15 patients, 8 patients were continent (53 percent), 2 patients were incontinent, and in 5 patients the perineal stoma was converted to an abdominal stoma. Failures were attributable to necrosis of the colon stump (n = 2) and incontinence (n = 3). At 26 weeks mean resting pressure was 44 (standard deviation (SD), 28) mmHg, and mean pressure during stimulation was 90 (SD, 46) mmHg at a mean of 3.5 (SD, 1.2) volts at 52 weeks. Mean defecation frequency was three times per day (range, 1-5). Of the eight patients who were continent, six used daily enemas. Mean time to postpone defecation was 11 (range, 0-30) minutes. CONCLUSION: In experienced hands, the double dynamic graciloplasty is an oncologically safe procedure that can have an acceptable functional outcome in a well-selected group of patients. However, to improve the outcome, further modifications will be necessary. So far, the addition of a pouch has not resulted in improved outcome.

Adenocarcinoma↗

PubMed1997

Total anorectal reconstruction--fact or fiction.

Continuous electrical stimulation of a transposed gracilis muscle around an anatomically intact, but not functioning anus, proved to give a good continence even after many years. The procedure of pull through the colon and creation of a neo anus is indicated for a limited group of patients after Miles resection, trauma and atresia patients. In a series of 21 patients with abdomino-perineal pull through and the construction of a neo anus with a double dynamic graciloplasty, there was an enormous difference between the patients who underwent this reconstruction in the same operation as the abdomino-perineal resection (n = 14) and the patients who had the pull through several years after the Miles resection (n = 7). Reasonable continence was achieved in 8 out of the primary 14 operated patients and only 3 out of the 7 secondary operated patients. We can conclude that creation of a complete neo anus after a pull through is technically possible, and will result in an acceptable continence in about half the patients. Quality of continence will never be the same as in patients with a normal anatomical anus due to lack of sensibility.

Adult↗

PubMedDate not supplied

High-resolution magnetic resonance imaging of the anorectal region without an endocoil.

BACKGROUND: To evaluate the feasibility of a high-resolution magnetic resonance imaging (MRI) technique in detailed imaging of the anal sphincter and lower pelvic region without the use of an endoluminal coil. METHODS: MRIs with an external phased array coil (T1- and T2-weighted turbo spin echo) were performed in 22 volunteers and 12 patients with an anal fistula, an anal sphincter defect, or a rectal tumor. The normal scans were evaluated by three independent observers. The scans of the patients were compared with surgical and/or histologic findings. RESULTS: The anal sphincter was visualized with detail. In the anal canal, hemorrhoidal tissue and the submucosae ani muscle could be seen. The MRI technique also allowed detailed imaging of anatomical structures above the pelvic floor. The MR findings in the 12 patients showed exact correlation with surgery and/or histology. CONCLUSIONS: High-resolution MRI of the anorectal region without an endoluminal coil is feasible. The MR technique with an external phased array coil allows detailed imaging of the anal sphincter at rest, the rectum, and the surrounding pelvic structures with one single investigation. The results are promising and suggest useful applications in the management of anorectal diseases.

Anal Canal↗