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S1233 Anorectal Toxicity After High Dose 3D Conformal Radiotherapy for Prostate Cancer
S1232
AGA Abstracts
Electrically Stimulated Gracilis Neosphincter Construction for End Stage Faecal Incontinence: Evaluation of Long-Term Functional Outcome Chetan Bhan, Jamie Murphy, Derek J. Boyle, S Mark Scott, Norman S. Williams Introduction: Electrically stimulated gracilis neosphincter (ESGN) construction is an established treatment for patients with end stage faecal incontinence who wish to avoid a permanent stoma. However, few data are available describing the long-term efficacy of this procedure. The aim of this study was to assess the functional outcome of patients who have undergone ESGN construction at the 2 and 10-year time points. Methods: 119 patients (median age 42 [range 13-75]; 81F), with Williams' continence score ≥5 underwent ESGN construction between 1988 and 1999. ESGN was performed for: traumatic childbirth (n=52), surgical trauma (n=23), atresia (n=20), anorectal excision (n=11), idiopathic incontinence (n=9), and ileo-anal pouch incontinence (n=4). Symptomatic assessment by standardised questionnaires preoperatively was repeated following surgery, and at 2 and 10 years. Anorectal physiological investigation was also performed preoperatively and at 2 years. Results:119 patients consented to immediate postoperative follow up; 117 consented at 2-years, while 57 patients consented at 10-years. Continence improved for all patients postoperatively (median score - 2 [1-6]; P < 0.0001) and at 2-years (score - 2 [1-6]; P < 0.0001). When assessing all patients, no significant difference was found between continence scores preoperatively and at 10-years (score - 4 [1-6]). However, a sustained improvement at 10-year follow up (score - 3 [1-6]; P = 0.0013) was noted for patients in the surgical trauma group. 25/119 patients required further interventions (colonic conduit - 23; ACE - 2) for postoperative rectal evacuatory disorder (RED). Postoperative RED was more common in patients undergoing ESGN construction for obstetric injury (P = 0.0079), with previous hysterectomy conferring additional risk (P = 0.013). Discussion: These data suggest that ESGN results in significant and sustained symptomatic improvement in both the short and medium term. However, long-term functional outcome is influenced by both the indication for surgery and preoperative state of the patient. Currently the effect of improvements in ESGN technique introduced after 1999 are unknown. Nevertheless, the reported data support the continued use of this procedure in highly selected patients.
HDM-Colour Plots S1230 Characterization and Pathophysiologic Mechanisms of Anorectal Dysfunction in Patients with Diabetes Mellitus Thomas Hester, Noemi A. Montes, Freya T. Hickey, Marc A. Gladman Purpose: Gastrointestinal symptoms are frequently experienced by patients with diabetes mellitus (DM). A proportion of such patients report anorectal dysfunction, which is assumed to reflect neuropathy. As the prevalence of DM is increasing in Western populations, improved understanding of the etiology of such symptoms is required. The aim of the present study was to characterize clinical symptoms and pathophysiologic mechanisms in patients with DM referred for assessment of anorectal dysfunction. Methods: The study population comprised 158 patients with DM (132 NIDDM,; 122 female; median age 62 years [range 2387]), identified from a population of 3627 patients referred consecutively to a tertiary centre for anorectal physiological investigation from 1997-2007. The control group consisted of 159 non-diabetic, age and sex matched patients (123 female; median age 55 [range 22-83]) who were investigated during the same period. All subjects underwent detailed symptom assessment and comprehensive physiologic investigation, including colonic transit studies / defecography, as indicated. Results: Patients with DM presented most commonly with fecal incontinence (46%), constipation (25%), and combined constipation and incontinence (17%). The corresponding percentages were similar in non-diabetic patients (35%, 34% and 18%, respectively; p=0.124). Anorectal manometry revealed that a significantly greater proportion of patients with DM (47/158, 30%) had reduced anal squeeze pressures compared to controls (25/159, 16%) (p=0.007), but anal resting pressures, rectal sensitivity, pudendal terminal motor latencies and the proportion of patients with anal sphincter defects on ultrasound were similar between the groups. Colonic transit studies revealed delayed transit in a significantly smaller proportion of patients with DM (11/34, 32%) compared to controls (34/55, 62%) (p=0.009). Defecography was abnormal in a significantly greater proportion of patients with DM (86/93, 92%) compared to controls (100/123, 81%) (p=0.03). Conclusion: Diabetic patients experience similar symptoms of anorectal dysfunction to non-diabetic controls. Anorectal physiologic investigation did not reveal direct evidence of a sensorimotor neuropathy in such patients. However, reduced anal squeeze pressures and impaired rectal evacuation, but not delayed colonic transit, appear to be important mechanisms for the development of symptoms in diabetic patients. Directed therapies to address the underlying pathophysiology may improve outcomes in the management of anorectal dysfunction in these patients.
S1233 Anorectal Toxicity After High Dose 3D Conformal Radiotherapy for Prostate Cancer Adeel A. Bajwa, Kumaran Thiruppathy, Paul Boulos, Anton V. Emmanuel Introduction: Studies indicate that maximising radiotherapy dose improves outcomes in prostate cancer. Three-dimensional conformal radiotherapy (3DCRT) is a technique in which the profile of each radiation beam is shaped to fit the profile of the prostatic target theoretically reducing toxicity to the surrounding normal tissues and allowing a higher dose of radiation to be delivered to the tumour. We aimed to assess the anorectal toxicity after high dose 3DCRT . Methods: 18 consecutive prostate cancer patients with no anorectal symptoms (Mean age 68.4, mean Wexner score 0) receiving 74 grays of 3DCRT for localised prostate cancer were recruited. Faecal incontinence scores, anal manometery, rectal distension thresholds, mucosal electrosensitivity, rectal mucosal blood flow and rectal elastance (barostat) were measured before and 4 months (mean follow up=18.5 weeks) after radiation. Data are presented as mean (SD) pre- and post-treatment. Results: Mean post treatment Wexner score increased to 2.6 (SD 2.1) with 13/18 (72%) patients developing new symptoms. There was a significant reduction in anal canal resting pressure (72.2(22.7) v 64.7(22.7) cmH20, p=0.043) but not squeeze pressure (189.7(53.9) v 185.9(58.1) cmH20, p=0.36). Rectal electrosensitivity, a measure of mucosal innervation, was attenuated (27.4(11.8) v 33.3(7.8) mA, p=0.028), with an increase seen in 8/13 (62%) of symptomatic patients. . Finally, mean rectal elastance increased significantly (0.046(0.026) v 0.067(0.023) mmHG/mL, p=0.003), with an increase seen in 10/13 (77%) of symptomatic patients. Conclusions: At 4 months, three-quarters of patients treated with high dose 3D conformal RT for prostate cancer developed symptoms. This was associated with modest alterations in anal pressure and rectal sensation and elasticity, comparing favourably with traditional radiotherapy modalities. Longer term and larger studies are underway to compare this.
S1231 Levator Ani: What Is Left of Idiopathic Anal Incontinence? Christian Thomas, Isabelle Etienney Anal incontinence (AI) is most often due to rupture of the internal and/or external sphincter and /or pudendal neuropathy. When these are not present, anal incontinence is said to be idiopathic. This classification however ignores a possible role of the the puborectal fasciculus (PR) of the levator ani, which is not always innervated by the pudendal nerve. The aim of our study was to evaluate how far the puborectal fasciculus has an influence in patients suffering from AI, either isolated or associated with urinary incontinence. 78 female patients, mean age 61.3 years [29.5-84.3], were investigated for isolated or mixed AI, between January 2007 and June 2008, by the same two people working consecutively and using anorectal manometry (ARM), three-dimensional endoanal ultrasound examination (3D echography), and concentric needle electromyography (EMG) of the PR muscles and the external anal sphincter (EAS). The pudendal nerve motor terminal latencies (PNMTL) were determined. Defect and volume of the PR were evaluated by 3D echography. A Wexner index was calculated for each patient. Damage to the PR was defined as the presence of an ultrasound defect and/or an abnormal EMG of the PR. EMG of the PR was only performed in 73 female patients, including 71 bilaterally. The EMG revealed damage of the PR in 39 cases, which was isolated in 4 cases and associated with damage to the EAS in 35 patients. The frequency of neurogenic damage increased with the number of EMG tests undertaken:unilateral or bilateral increase of PNMTL was found in 61% (44/77) of the cases. The frequency of neurogenic AI increased to 86% (67/78) of the cases if one took into account the damage associated with the EAS, and to 90% (70/78) of the cases if damage to the PR was considered. An echography fault was discovered in 23% (18/78) of the cases. It concerned the IAS, the EAS and the PR in 10, 9 and 3 cases respectively. The mean Wexner index score was not increased by the existence of a damage of the PR nor by abnormal PR EMG. It was not increased as a function of the number of childbirths nor by the existence of both anal and urinary incontinence. On the other hand, voluntary contraction evaluated by ARM was significantly reduced when the PR was damaged (26 vs 38 cm H2O p<0.05) and/or the ES (28 vs 39 cm H2O p<0.05) and the volume of the PR was also significantly reduced in these circumstances (6.2 vs 7.2 cm3 p<0.05). Conclusion Exploration of the PR is based on 3D echography and EMG examination; it allows the number of so-called idiopathic AI cases to be reduced. If it is not possible to undertake an EMG examination,the PR volume may help predict damage to it.
AGA Abstracts
S1234 The Anal Band for Severe Faecal Incontinence Dave R. Chatoor, Anton V. Emmanuel, Richard Cohen, Mostafa Abdel-Halim, Stuart A. Taylor, Ulrich Baumgartner Introduction For patients with severe faecal incontinence who fail conservative and minimally invasive treatments there is a need for salvage procedures. The previously available artificial bowel sphincter was plagued with infection, erosion, device malfunction and evacuation difficulty. Our multicentre experience of a new device which has become available is reported in this study. Methods 14 patients (10 female) with severe faecal incontinence were treated in two specialised units; all failed optimum conservative treatment with biofeedback, 9 of these were deemed suitable for sacral nerve stimulation but failed this. As an alternative to stoma formation, these patients underwent implantation of a subcutaneous soft anal band system. It is composed of a soft silicone band that encircles the anal sphincter, attached to a valve that controls bidirectional flow of fluid from the balloon implanted under the skin of the anterior abdominal wall, and a calibration port used for adjusting the fluid in the system. Results Mean patient age was 59 (39 -71), mean duration of follow up 13 months (3- 40). The aetiology of incontinence was post colorectal resection in 6 patients, obstetric in 4, scleroderma-related in 2, post-radiotherapy in 1 and spinal injury associated in 1. Self reported quality of life improvement of 70-100% was reported in 7/14 patients, 30-70% improvement in 4/14 (no data was available in 3/14). Wexner incontinence scores improved from a median of 16 (12-18) pre treatment to 2 (0-6) post operatively (P = 0.001). Complications occurred in 7/14 patients: 5 had device-related problems requiring revisional procedures (repositioning in 2 and device failure in 3); 1 had chronic pain requiring explantation and 1 had minor evacuation difficulty requiring regular suppositories. Of note there were no infections or erosions. Conclusion This largest reported series of the new anal band device
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AGA Abstracts
Electrically Stimulated Gracilis Neosphincter Construction for End Stage Faecal Incontinence: Evaluation of Long-Term Functional Outcome Chetan Bhan, Jamie Murphy, Derek J. Boyle, S Mark Scott, Norman S. Williams Introduction: Electrically stimulated gracilis neosphincter (ESGN) construction is an established treatment for patients with end stage faecal incontinence who wish to avoid a permanent stoma. However, few data are available describing the long-term efficacy of this procedure. The aim of this study was to assess the functional outcome of patients who have undergone ESGN construction at the 2 and 10-year time points. Methods: 119 patients (median age 42 [range 13-75]; 81F), with Williams' continence score ≥5 underwent ESGN construction between 1988 and 1999. ESGN was performed for: traumatic childbirth (n=52), surgical trauma (n=23), atresia (n=20), anorectal excision (n=11), idiopathic incontinence (n=9), and ileo-anal pouch incontinence (n=4). Symptomatic assessment by standardised questionnaires preoperatively was repeated following surgery, and at 2 and 10 years. Anorectal physiological investigation was also performed preoperatively and at 2 years. Results:119 patients consented to immediate postoperative follow up; 117 consented at 2-years, while 57 patients consented at 10-years. Continence improved for all patients postoperatively (median score - 2 [1-6]; P < 0.0001) and at 2-years (score - 2 [1-6]; P < 0.0001). When assessing all patients, no significant difference was found between continence scores preoperatively and at 10-years (score - 4 [1-6]). However, a sustained improvement at 10-year follow up (score - 3 [1-6]; P = 0.0013) was noted for patients in the surgical trauma group. 25/119 patients required further interventions (colonic conduit - 23; ACE - 2) for postoperative rectal evacuatory disorder (RED). Postoperative RED was more common in patients undergoing ESGN construction for obstetric injury (P = 0.0079), with previous hysterectomy conferring additional risk (P = 0.013). Discussion: These data suggest that ESGN results in significant and sustained symptomatic improvement in both the short and medium term. However, long-term functional outcome is influenced by both the indication for surgery and preoperative state of the patient. Currently the effect of improvements in ESGN technique introduced after 1999 are unknown. Nevertheless, the reported data support the continued use of this procedure in highly selected patients.
HDM-Colour Plots S1230 Characterization and Pathophysiologic Mechanisms of Anorectal Dysfunction in Patients with Diabetes Mellitus Thomas Hester, Noemi A. Montes, Freya T. Hickey, Marc A. Gladman Purpose: Gastrointestinal symptoms are frequently experienced by patients with diabetes mellitus (DM). A proportion of such patients report anorectal dysfunction, which is assumed to reflect neuropathy. As the prevalence of DM is increasing in Western populations, improved understanding of the etiology of such symptoms is required. The aim of the present study was to characterize clinical symptoms and pathophysiologic mechanisms in patients with DM referred for assessment of anorectal dysfunction. Methods: The study population comprised 158 patients with DM (132 NIDDM,; 122 female; median age 62 years [range 2387]), identified from a population of 3627 patients referred consecutively to a tertiary centre for anorectal physiological investigation from 1997-2007. The control group consisted of 159 non-diabetic, age and sex matched patients (123 female; median age 55 [range 22-83]) who were investigated during the same period. All subjects underwent detailed symptom assessment and comprehensive physiologic investigation, including colonic transit studies / defecography, as indicated. Results: Patients with DM presented most commonly with fecal incontinence (46%), constipation (25%), and combined constipation and incontinence (17%). The corresponding percentages were similar in non-diabetic patients (35%, 34% and 18%, respectively; p=0.124). Anorectal manometry revealed that a significantly greater proportion of patients with DM (47/158, 30%) had reduced anal squeeze pressures compared to controls (25/159, 16%) (p=0.007), but anal resting pressures, rectal sensitivity, pudendal terminal motor latencies and the proportion of patients with anal sphincter defects on ultrasound were similar between the groups. Colonic transit studies revealed delayed transit in a significantly smaller proportion of patients with DM (11/34, 32%) compared to controls (34/55, 62%) (p=0.009). Defecography was abnormal in a significantly greater proportion of patients with DM (86/93, 92%) compared to controls (100/123, 81%) (p=0.03). Conclusion: Diabetic patients experience similar symptoms of anorectal dysfunction to non-diabetic controls. Anorectal physiologic investigation did not reveal direct evidence of a sensorimotor neuropathy in such patients. However, reduced anal squeeze pressures and impaired rectal evacuation, but not delayed colonic transit, appear to be important mechanisms for the development of symptoms in diabetic patients. Directed therapies to address the underlying pathophysiology may improve outcomes in the management of anorectal dysfunction in these patients.
S1233 Anorectal Toxicity After High Dose 3D Conformal Radiotherapy for Prostate Cancer Adeel A. Bajwa, Kumaran Thiruppathy, Paul Boulos, Anton V. Emmanuel Introduction: Studies indicate that maximising radiotherapy dose improves outcomes in prostate cancer. Three-dimensional conformal radiotherapy (3DCRT) is a technique in which the profile of each radiation beam is shaped to fit the profile of the prostatic target theoretically reducing toxicity to the surrounding normal tissues and allowing a higher dose of radiation to be delivered to the tumour. We aimed to assess the anorectal toxicity after high dose 3DCRT . Methods: 18 consecutive prostate cancer patients with no anorectal symptoms (Mean age 68.4, mean Wexner score 0) receiving 74 grays of 3DCRT for localised prostate cancer were recruited. Faecal incontinence scores, anal manometery, rectal distension thresholds, mucosal electrosensitivity, rectal mucosal blood flow and rectal elastance (barostat) were measured before and 4 months (mean follow up=18.5 weeks) after radiation. Data are presented as mean (SD) pre- and post-treatment. Results: Mean post treatment Wexner score increased to 2.6 (SD 2.1) with 13/18 (72%) patients developing new symptoms. There was a significant reduction in anal canal resting pressure (72.2(22.7) v 64.7(22.7) cmH20, p=0.043) but not squeeze pressure (189.7(53.9) v 185.9(58.1) cmH20, p=0.36). Rectal electrosensitivity, a measure of mucosal innervation, was attenuated (27.4(11.8) v 33.3(7.8) mA, p=0.028), with an increase seen in 8/13 (62%) of symptomatic patients. . Finally, mean rectal elastance increased significantly (0.046(0.026) v 0.067(0.023) mmHG/mL, p=0.003), with an increase seen in 10/13 (77%) of symptomatic patients. Conclusions: At 4 months, three-quarters of patients treated with high dose 3D conformal RT for prostate cancer developed symptoms. This was associated with modest alterations in anal pressure and rectal sensation and elasticity, comparing favourably with traditional radiotherapy modalities. Longer term and larger studies are underway to compare this.
S1231 Levator Ani: What Is Left of Idiopathic Anal Incontinence? Christian Thomas, Isabelle Etienney Anal incontinence (AI) is most often due to rupture of the internal and/or external sphincter and /or pudendal neuropathy. When these are not present, anal incontinence is said to be idiopathic. This classification however ignores a possible role of the the puborectal fasciculus (PR) of the levator ani, which is not always innervated by the pudendal nerve. The aim of our study was to evaluate how far the puborectal fasciculus has an influence in patients suffering from AI, either isolated or associated with urinary incontinence. 78 female patients, mean age 61.3 years [29.5-84.3], were investigated for isolated or mixed AI, between January 2007 and June 2008, by the same two people working consecutively and using anorectal manometry (ARM), three-dimensional endoanal ultrasound examination (3D echography), and concentric needle electromyography (EMG) of the PR muscles and the external anal sphincter (EAS). The pudendal nerve motor terminal latencies (PNMTL) were determined. Defect and volume of the PR were evaluated by 3D echography. A Wexner index was calculated for each patient. Damage to the PR was defined as the presence of an ultrasound defect and/or an abnormal EMG of the PR. EMG of the PR was only performed in 73 female patients, including 71 bilaterally. The EMG revealed damage of the PR in 39 cases, which was isolated in 4 cases and associated with damage to the EAS in 35 patients. The frequency of neurogenic damage increased with the number of EMG tests undertaken:unilateral or bilateral increase of PNMTL was found in 61% (44/77) of the cases. The frequency of neurogenic AI increased to 86% (67/78) of the cases if one took into account the damage associated with the EAS, and to 90% (70/78) of the cases if damage to the PR was considered. An echography fault was discovered in 23% (18/78) of the cases. It concerned the IAS, the EAS and the PR in 10, 9 and 3 cases respectively. The mean Wexner index score was not increased by the existence of a damage of the PR nor by abnormal PR EMG. It was not increased as a function of the number of childbirths nor by the existence of both anal and urinary incontinence. On the other hand, voluntary contraction evaluated by ARM was significantly reduced when the PR was damaged (26 vs 38 cm H2O p<0.05) and/or the ES (28 vs 39 cm H2O p<0.05) and the volume of the PR was also significantly reduced in these circumstances (6.2 vs 7.2 cm3 p<0.05). Conclusion Exploration of the PR is based on 3D echography and EMG examination; it allows the number of so-called idiopathic AI cases to be reduced. If it is not possible to undertake an EMG examination,the PR volume may help predict damage to it.
AGA Abstracts
S1234 The Anal Band for Severe Faecal Incontinence Dave R. Chatoor, Anton V. Emmanuel, Richard Cohen, Mostafa Abdel-Halim, Stuart A. Taylor, Ulrich Baumgartner Introduction For patients with severe faecal incontinence who fail conservative and minimally invasive treatments there is a need for salvage procedures. The previously available artificial bowel sphincter was plagued with infection, erosion, device malfunction and evacuation difficulty. Our multicentre experience of a new device which has become available is reported in this study. Methods 14 patients (10 female) with severe faecal incontinence were treated in two specialised units; all failed optimum conservative treatment with biofeedback, 9 of these were deemed suitable for sacral nerve stimulation but failed this. As an alternative to stoma formation, these patients underwent implantation of a subcutaneous soft anal band system. It is composed of a soft silicone band that encircles the anal sphincter, attached to a valve that controls bidirectional flow of fluid from the balloon implanted under the skin of the anterior abdominal wall, and a calibration port used for adjusting the fluid in the system. Results Mean patient age was 59 (39 -71), mean duration of follow up 13 months (3- 40). The aetiology of incontinence was post colorectal resection in 6 patients, obstetric in 4, scleroderma-related in 2, post-radiotherapy in 1 and spinal injury associated in 1. Self reported quality of life improvement of 70-100% was reported in 7/14 patients, 30-70% improvement in 4/14 (no data was available in 3/14). Wexner incontinence scores improved from a median of 16 (12-18) pre treatment to 2 (0-6) post operatively (P = 0.001). Complications occurred in 7/14 patients: 5 had device-related problems requiring revisional procedures (repositioning in 2 and device failure in 3); 1 had chronic pain requiring explantation and 1 had minor evacuation difficulty requiring regular suppositories. Of note there were no infections or erosions. Conclusion This largest reported series of the new anal band device
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