In 2005 Madiba and Baig described complete or full thickness rectal prolapse as “formidable” with no “clear predominant operation of choice” [1]. This remains true today. Full thickness rectal prolapse is a condition where the rectum, and in some, part of the colon extrudes through the anus. This usually occurs with defaecation and straining, but may extrude all of the time. Patients complain of significant discomfort, rectal bleeding, constant wetness from mucus, incontinence and embarrassment. The passage of the four layers of bowel wall through the anus, stretches the anal sphincters. Over time this renders them weak and increases the risk of longterm incontinence. Weak anal sphincters are also a risk for recurrence of the full thickness rectal prolapse. Timely repair, even with the risk of complications, is indicated in almost all cases. There are known underlying conditions which cause rectal prolapse. The most common are chronic straining to pass bowel movements, laxative abuse, eating disorders, ageing and dementia [2]. All efforts should be made to address any reversible factors in order to prevent recurrence. Prolapse surgery should therefore be performed in units with access to pelvic floor rehabilitation services. To do so without, should be seen as poor practice (akin to replacing a knee without subsequent physiotherapy). There are now said to be over 100 operations available for rectal prolapse, via either a perineal or abdominal route [3]. When multiple surgical operations have been developed, it can generally be inferred that none are universally successful, or without complication. Perineal approaches to a rectal prolapse can be surgically challenging when the takeoff of the prolapse is high. Abdominal operations using hitching with or without resection often employ mesh, which has been shown to reduce the rates of recurrence [4]. The laparoscopic ventral mesh rectopexy (LVMR) operation [5], has published recurrence rates of less than 4% [6]. Mesh may also be placed posterior to the rectum. Using Hospital Episodes Statistics (HES) data, ElDhuwaib and colleagues estimated a 15 fold increase in laparoscopic prolapse repairs in England between 2001 and 2012 [9]. Mesh complications have become of increasing concern in recent years. However, there is variation in the type of mesh used and mesh characteristics vary widely with respect to contracture, rigidity, adhesion, strength, tissue ingrowth, inflammatory and histological responses. Synthetic mesh will remain in the body and has the potential to cause complications, even after many years. Biological meshes vary with respect to integration into the tissues, strength, inflammatory response and resistance to infection [7]. There are also hybrid meshes, which claim to possess all the virtues of prosthetic and biological meshes and none of the problems. The type of fixation, absorbable or nonabsorbable, used to secure the mesh to the rectum may also cause complications and can confound outcomes [8]. Ventral mesh rectopexy has also been used in those with rectal intussusception, rectocele or enterocele. Encouraging shortterm results have been published from high volume centres for this indication. However, The CapaCiTY working group, after review of the literature, highlighted the paucity of highquality evidence for this approach [10]. The lack of consistent reliable outcome measures is one significant problem. It is the authors' opinion that this correction of these rectal deformities is unlikely to offer a complete cure for the patient's evacuatory difficulty. At best, an improvement in symptoms is all that can be hoped for. Databases such as the UK's Hospital Episode Statistics (HES), using centrally collected current data available through NHS England, simply define whether or not mesh was used. There is no differentiation between type of mesh, type of fixation or indication for surgery. Any blunt analysis of this data may prove detrimental to patient care. To report on meshes as a whole, may mean that those which are used without complication, or with very few complications, are damned within the morass of data relating to the vast array of historical and existing products. Furthermore, any registry data must allow meaningful measurement of the impact on a patient's quality of life (QOL) to establish if the improvement in QOL gained by a mesh rectopexy outweighs the potential impact on QOL from a mesh related complication.

Aim The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. Method Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t(0)) and at three (t(3)), six (t(6)), nine (t(9)) and 12 (t(12)) months after restoration of intestinal continuity. ARP measurements were recorded at T-0, T-3 and T-12. Endoanal ultrasound was performed at T-0 and T-12. Results Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. Conclusions Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.

ANZ Journal of SurgeryVolume 90, Issue 3 p. E50-E51 IMAGES FOR SURGEONS Emergency presentation of a dermoid cyst of the groin: a diagnostic confounder on the acute surgical take Sheah Lin Lee MRCS, PhD, Sheah Lin Lee MRCS, PhD Department of General Surgery, Southampton General Hospital, Southampton, UKSearch for more papers by this authorJacqueline Lai MBBS, BMedSci, Jacqueline Lai MBBS, BMedSci Department of Pathology, Southampton General Hospital, Southampton, UKSearch for more papers by this authorThomas Dudding MD, FRCS, Thomas Dudding MD, FRCS Department of General Surgery, Southampton General Hospital, Southampton, UKSearch for more papers by this authorHenry D. De'Ath FRCS, PhD, Henry D. De'Ath FRCS, PhD henryde-ath@doctors.org.uk orcid.org/0000-0001-7601-4474 Department of General Surgery, Southampton General Hospital, Southampton, UKSearch for more papers by this author Sheah Lin Lee MRCS, PhD, Sheah Lin Lee MRCS, PhD Department of General Surgery, Southampton General Hospital, Southampton, UKSearch for more papers by this authorJacqueline Lai MBBS, BMedSci, Jacqueline Lai MBBS, BMedSci Department of Pathology, Southampton General Hospital, Southampton, UKSearch for more papers by this authorThomas Dudding MD, FRCS, Thomas Dudding MD, FRCS Department of General Surgery, Southampton General Hospital, Southampton, UKSearch for more papers by this authorHenry D. De'Ath FRCS, PhD, Henry D. De'Ath FRCS, PhD henryde-ath@doctors.org.uk orcid.org/0000-0001-7601-4474 Department of General Surgery, Southampton General Hospital, Southampton, UKSearch for more papers by this author First published: 06 May 2019 https://doi.org/10.1111/ans.15216Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume90, Issue3March 2020Pages E50-E51 RelatedInformation

Botulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection.

Introduction To compare short and medium-term outcomes of surgery for external full thickness rectal prolapse at a single university institution, where Delorme’s procedure, laparoscopic posterior suture rectopexy and laparoscopic ventral mesh rectopexy are performed. Method Patients were identified from a prospective database. Consecutive patients undergoing surgery for rectal prolapse over a five year period between 2009 and 2014 were included. Patient data including age, gender, type of operation, hospital stay, complications, readmissions, duration of follow up, recurrence and mortality were recorded. The type of surgery was selected after careful discussion with each patient including the potential risks and complications specific to each of the three surgical procedures. Cases were also discussed at a pelvic floor multidisciplinary team meeting. Results During the study period, 77 patients underwent surgery with a median age of 74 years (range 18–90). A total of 69 (89.6%) were female. There were 20 (25.9%) patients who had previously undergone surgery for prolapse. A total of 20 (26%) Delorme’s procedures, 15 (19%) laparoscopic posterior suture rectopexies and 42 (55%) laparoscopic ventral mesh rectopexies were performed. The median (range) patient age was 79 (48–90) years, 74 (30–89) years and 79 (18–88) years respectively. Median follow-up was 35 (1–120) months. Recurrence rates were 23.8%, 13.3% and 4.7% respectively. Length of hospital stay was a median (range) of 2 (1–21) days, 3 (1–7) days and 2 (1–7) days respectively. There were no mesh related complications and no 60-day mortality. Conclusion Multiple operations have been described for rectal prolapse. At our institution, laparoscopic mesh ventral rectopexy had the lowest rate of recurrence with a similar length of hospital stay when compared with the alternatives of Delorme’s procedure and laparoscopic posterior suture rectopexy. Despite this, some patients may still opt for an operation with a higher recurrence rate to avoid potential complications such as mesh erosion. Longer term data is needed to assess these risks and inform patient choice. Disclosure of interest None Declared.

Aim Sacral nerve stimulation (SNS) may be offered to patients with constipation who have failed to improve with conservative treatment. The response to SNS is variable, with a significant loss of efficacy in some patients. An increased frequency of stimulation may improve the efficacy of SNS for faecal incontinence. This study aimed to see if alteration of the pulse width or frequency improved the outcome for those with constipation.Method Eleven patients with constipation currently being treated by SNS were recruited from three centres. They were randomized to five different protocols of stimulation each applied for 5weeks. Group 1 used standard settings (pulse width 210s, frequency 14Hz); in the other four groups (Groups 2-5) the pulse width and/or frequency were halved or doubled. Patients and investigators were blinded to the group allocation.Results The Cleveland Clinic constipation score varied significantly between the five groups. Group 1 achieved the lowest score mean (SD) 13.4 (+/- 4.4) (P=0.03). The number of digitations per defaecation was the lowest in Group 4, 90s and 14Hz (P<0.01). No other variable changed significantly. Standard settings were the most preferred by the recruited patients.Conclusion Alteration of pulse width or frequency of stimulation had no significant effect on the outcome of SNS for constipation.

Introduction Self-expandable metal stents (SEMS) may be used in patients presenting with large bowel obstruction (LBO) and offer a less invasive alternative to surgery and thus avoid the potential need for a stoma. Method A retrospective analysis of all patients who underwent attempted SEMS placement for LBO between 2001 and 2014 at a university teaching hospital. Patients were identified from the radiology database and hospital coding via the hospital’s informatics system. Results Over the 13-year review period, a primary SEMS was attempted in 143 patients, median age 72 (range 25–108) years, sex ratio 83 males: 60 females. Indications for SEMS were palliative treatment of colorectal cancer (CRC) 101; as bridging prior to resectional surgery for CRC 14; extrinsic compression in 19 and for benign disease in 8 patients. SEMS placement was successful in 110 (77%) patients: in 83 (82%) palliative; 13 (93%) bridging; 12 (63%) compression and 2 (25%) benign groups. 85% of SEMS were placed in the distal colon. In the bridged patients 54% did not require a stoma at subsequent surgery. 91(83%) patients successfully stented had no complication. Of the complications that occurred, 13(15.7%) occurred in palliative, 3(23.1%) bridging, and 3(25%) compression groups. Early complications (<48hrs) occurred in 8 patients: 3 perforations; 4 failures to open; 1 migration and 1 PR bleed. There was 1 death and 7 proceeded to surgery. There were 6 late complications (<1 month): 5 perforations and 1 reobstruction, of which there were 2 deaths and 4 had surgery. Delayed complications (>1 month) occurred in 4 patients, 3 required surgery. Overall median survival post SEMS was 212 days. According to indication for SEMS, 30- and 90-day survival was respectively: palliative 81.2% and 68.2%; bridging 92.3%; compressive 50% and 33.3% and benign 100%. Median (IQR) survival was: palliative 205 (49–425); bridging 766 (408–960) and compression 27 (12–158) days. Conclusion The commonest indication for SEMS placement was malignant LBO from CRC. In palliative patients it has a good success rate and avoids the need for surgery in patients with a limited median survival. As a bridge to surgery in patients undergoing subsequent surgery it has a high success rate but does not always avoid the need for a stoma. Disclosure of interest None Declared.

Sacral nerve stimulation (SNS) is used as a first-line treatment for faecal incontinence when conservative measures have failed. However, one-third of patients fail to benefit from this treatment. We hypothesised that sacral afferent stimulation can be maximised using pudendal nerve stimulation (PNS) and this may be of benefit in this patient group. The aim of this study was to assess chronic PNS for those who failed to improve with SNS.

AIM:This review aimed to assess the published results of posterior tibial nerve stimulation (PTNS) for faecal incontinence. METHOD:A search was performed of PubMed, MEDLINE and Embase to identify studies describing the clinical outcome of PTNS for faecal incontinence. RESULTS:Thirteen studies were identified. These described the outcome of PTNS for faecal incontinence in 273 patients. Four described transcutaneous PTNS, eight percutaneous PTNS and one compared both methods of PTNS with a sham transcutaneous group. One investigated patients with faecal incontinence and spinal cord injury and another with inflammatory bowel disease. There was marked heterogeneity of the treatment regimens and of the end points used. All reported that PTNS improved faecal incontinence. A > 50% improvement was reported in episodes of faecal incontinence in 63-82% of patients. An improvement was seen in urgency (1-5 min). Improvement was also described in the Cleveland Clinic faecal incontinence score in eight studies. Patients with urge and mixed incontinence appear to benefit more than those with passive incontinence. Treatment regimens ranged in duration from 1-3 months. A residual therapeutic effect is seen after completion of treatment. Follow-up ranged from 1-30 months. CONCLUSION:PTNS is effective for faecal incontinence. However, many of the published studies are of poor quality. Comparison between studies is difficult owing to differences in the outcome measures used, technique of PTNS and the timing and duration of treatment.

AimChronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain.MethodTen patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a >50% reduction in pain score.ResultsOf the 10 patients recruited, five were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had >50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of 5years; the remaining two patients obtained no benefit and had their devices removed or deactivated. These two patients both had depression that was also not improved by SNS.ConclusionThis study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.

BACKGROUND:Percutaneous, transcutaneous and sham transcutaneous posterior tibial nerve stimulation was compared in a prospective blinded randomized placebo-controlled trial.METHODS:Patients who had failed conservative treatment for faecal incontinence were randomized to one of three groups: group 1, percutaneous; group 2, transcutaneous; group 3, sham transcutaneous. Patients in groups 1 and 2 received 30-min sessions of posterior tibial nerve stimulation twice weekly for 6 weeks. In group 3, transcutaneous electrodes were placed in position but no stimulation was delivered. Symptoms were measured at baseline and after 6 weeks using a bowel habit diary and St Mark's continence score. Response to treatment was defined as a reduction of at least 50 per cent in weekly episodes of faecal incontinence compared with baseline.RESULTS:Thirty patients (28 women) were enrolled. Nine of 11 patients in group 1, five of 11 in group 2 and one of eight in group 3 had a reduction of at least 50 per cent in weekly episodes of faecal incontinence at the end of the 6-week study phase (P = 0·035). Patients undergoing percutaneous nerve stimulation had a greater reduction in the number of incontinence episodes and were able to defer defaecation for a longer interval than those undergoing transcutaneous and sham stimulation. These improvements were maintained over a 6-month follow-up period.CONCLUSION:Posterior tibial nerve stimulation has short-term benefits in treating faecal incontinence. Percutaneous therapy appears to have superior efficacy to stimulation applied by the transcutaneous route.REGISTRATION NUMBER:NCT00530933 (http://www.clinicaltrials.gov).

AIM:Posterior tibial nerve stimulation (PTNS) has been shown to improve faecal incontinence in the short term. The optimal treatment regimen is unclear with wide variations in protocol reported in the literature. The study aimed to assess two different regimens of transcutaneous PTNS and to establish whether increasing the frequency of stimulation increases the effectiveness.METHOD:Thirty patients were randomized to receive once daily or twice weekly PTNS for a 6-week period. The treatment was carried out by the patient at home after instruction. The primary investigator was blinded to the patient allocation until the study had ended, at which point the symptoms were assessed. No further stimulation was given after 6 weeks and the patients were followed until their symptoms returned to the pre-stimulation state (baseline). The primary outcome measure was a change in the frequency of incontinent episodes.RESULTS:Three patients in the daily group and none in the twice weekly group achieved complete continence. Only patients from the daily group showed a significant reduction in median (interquartile range) incontinent episodes per week from 5 (11.13) to 3.5 (4.31) (P = 0.025). There was no significant change in the frequency of defaecation nor in the ability to defer defaecation. Patients in the daily group experienced a significant improvement in the domains of lifestyle [2.2 (1.7) to 2.6 (1.65), P = 0.04] and embarrassment [1.7 (0.85) to 2.15 (0.4), P = 0.04] on the Rockwood Fecal Incontinence Quality of Life assessment. No adverse events were reported.CONCLUSION:Transcutaneous PTNS can safely be used by the patient at home. Daily treatment may be more effective than twice weekly treatment. Larger studies are needed to investigate this further.

Aim Pudendal nerve stimulation (PNS), which is an alternative to sacral nerve stimulation, requires neurophysiological confirmation of correct siting of the electrode. We describe a modification of the existing technique where placement is assisted by guidance to the ischial spine by a finger introduced per anum.Method Cadaveric dissection was carried out to confirm the accuracy of this new approach. The surface marking of the ischial spine is marked. A stimulating needle electrode inserted through a skin incision at this point, is advanced towards the ischial spine using a finger introduced per anum as a guide. Once effective stimulation of the pudendal nerve is confirmed by observed and palpated contraction of the anal musculature, a permanent stimulating electrode is inserted and the position confirmed by radiological screening.Results Using cadaveric studies, the correct surface markings for needle placement were confirmed. This technique was then applied successfully for in vivo insertion of the needle electrode in 20 patients with bowel dysfunction, with only one lead displacement occurring over a mean follow-up period of 12 months.Conclusion Finger-guided assistance of PNS electrode insertion is simple and reproducible without requiring neurophysiological confirmation of nerve stimulation to ensure correct lead location.

BACKGROUND:For over 10 years sacral nerve stimulation (SNS) has been used for patients with constipation resistant to conservative treatment. A review of the literature is presented.METHODS:PubMed, MEDLINE and Embase databases were searched for studies demonstrating the use of SNS for the treatment of constipation.RESULTS:Thirteen studies have been published describing the results of SNS for chronic constipation. Of these, three were in children and ten in adults. Test stimulation was successful in 42-100 per cent of patients. In those who proceeded to permanent SNS, up to 87 per cent showed an improvement in symptoms at a median follow-up of 28 months. The success of stimulation varied depending on the outcome measure being used. Symptom improvement correlated with improvement in quality of life and patient satisfaction scores.CONCLUSION:SNS appears to be an effective treatment for constipation, but this needs to be confirmed in larger prospective studies with longer follow-up. Improved outcome measures need to be adopted given the multiple symptoms that constipation may be associated with. Comparison with other established surgical therapies also needs consideration.

Aim A knowledge of the principles of neurostimulation is essential to achieve optimal efficacy and minimize adverse effects. The aim of this article was to review the current evidence regarding device programming in the management of patients having sacral nerve stimulation (SNS) for faecal incontinence.Method A Medline search was performed including the keywords and/or MeSH headings of sacral nerve stimulation, neuromodulation, artificial pacemaker, faecal incontinence, programming, adverse effects and complications. Further studies were identified by cross-referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings.Results Neurostimulator programming is an important component of SNS. Efficacy can be improved or restored with reprogramming. Adverse stimulation is often reversible, and nonstimulation-related complications are correctable. A total loss of efficacy can be explained in over one-half of patients.Conclusion An improved outcome of SNS can be achieved by selecting the best possible stimulation parameters individualized to each patient. Further research into the optimal settings is needed.

Objective: Pudendal nerve stimulation (PNS) aims to maximize afferent or efferent stimulation from the sacral plexus.Background: We hypothesized this may be a promising new treatment for patients with bowel dysfunction in complete cauda equina syndrome (CES).Methods: Thirteen patients with complete CES [8 constipation predominant (group 1) and 5 incontinence predominant (group 2)] had a 3-week trial of PNS. Patients who showed a 50% or more improvement in symptoms during the trial phase proceeded to permanent neurostimulator implantation.Results: Five (63%) of the 8 patients in group 1 showed a 50% or more improvement in bowel symptoms during the trial phase and were permanently implanted. The mean Cleveland Clinic constipation score, sense of incomplete evacuation (%), and straining during defecation (%) improved from 17 3.2 to 10 +/- 4.5, 94 +/- 18% to 30 +/- 35%, and 81 +/- 23% to 44 +/- 38%, respectively. All 5 patients in group 2 showed a 50% or more reduction in incontinent episodes during the trial phase. The mean St Mark's score, ability to defer defecation, and the number of incontinent episodes per week improved from 18 +/- 1.0 to 3.8 +/- 2.5, 2.2 +/- 1.8 to 11 +/- 5.5 minutes, and 9.4 +/- 10.7 to 0.4 +/- 0.5 episodes, respectively, per week. During a median follow-up of 12 (10-22) months of permanent implantation, one patient lost efficacy at 6 months due to lead migration and another required removal and reimplantation of the neurostimulator due to wound infection.Conclusions: PNS is an effective treatment in the short term for bowel dysfunction in some patients with complete CES.

Aim The aim of this article was to determine the effect of sacral nerve stimulation (SNS) on the treatment of faecal incontinence, constipation, irritable bowel syndrome, mixed urinary and bowel disorders, spinal injury and neurodegenerative disease, pain syndromes, and sexual dysfunction.Method A Medline search was performed including the keywords and/or MeSH headings of 'sacral nerve stimulation', 'neuromodulation', 'artificial pacemaker', 'faecal incontinence', 'constipation' and 'anal pain'. Further studies were identified by cross-referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings.Results SNS has been used for the treatment of urinary, bowel and sexual dysfunction, as well as pain resulting from such disorders, and dysfunction arising from nerve injury and degenerative disease. There is a paucity of high quality evidence to support the use of SNS for the majority of novel indications at present.Conclusion Good quality prospective, cross-over studies are required to determine the true benefits of SNS. Further research into patient selection, operative technique and stimulation parameters for existing indications will ensure a place for SNS in the future treatment algorithm of functional pelvic floor disorders.