ASCRS Annual Meeting 2011

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER, B.C. – Anastomotic leaks after colectomy are more likely to be fatal in patients with preoperative hyperglycemia, based on the results of a database analysis.

Patients with diabetes were not at increased risk of an anastomotic leak. When leaks occurred, however, the associated mortality rate was 25% among those with diabetes and 3.6% among those without diabetes, Dr. Matthew Ziegler reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Ziegler, of the William Beaumont Hospital, Royal Oak, Mich., and his colleagues drew their findings from the database of the Michigan Surgical Quality Collaborative. The database included 3,977 patients who had a colectomy from February 2008 to March 2010. Of these, 700 were known to have diabetes. The researchers used a fasting blood glucose value greater than 140 mg/dL as the definition of hyperglycemia.

Fasting glucose values were tested preoperatively in 85% of the patients; 14% had hyperglycemia, and just over half of those patients had diabetes.

At 30 days after surgery, overall mortality was 5.5% for those with diabetes and 2.9% in those without diabetes. Mortality was 8%, which was significantly higher, in the nondiabetic patients with preoperative fasting hyperglycemia.

Parsing the data further, Dr. Ziegler and his colleagues found two risk factors – preoperative steroid use and emergent surgery – that were associated with anastomotic leaks in patients with diabetes. "This may be important, especially in colectomy patients, because of the high morbidity," he said. Dr. Ziegler added that he would hesitate to perform a colectomy on a patient with diabetes who is on preoperative steroids.

Many Americans have diabetes or are on the road to acquiring that disease, said Dr. Ziegler. In addition to the 18 million diagnosed with diabetes in the United States, an estimated 7 million have not yet been diagnosed and 79 million have prediabetes, with elevated fasting glucose or hemoglobin A_1c levels.

"Certainly [the findings] merit more study, and improved preoperative screening is needed to better identify and treat this complicated patient population," he said.

Dr. Ziegler said that his hospital has stepped up screening efforts to include preoperative fasting glucose levels and HbA₁c levels. "We also have just instituted a so-called ‘sugar nurse’ who is a nurse specialist who meets with patients preoperatively and works on their glycemic management perioperatively with hopefully better outcomes."

VANCOUVER – Combined endolaparoscopic surgery may offer a good option for patients with difficult but benign polyps, judging by results of a retrospective study.

Difficult benign colonic lesions are typically treated with bowel resection, but even when this is performed laparoscopically, significant morbidity is seen, according to Dr. Sang W. Lee of the department of surgery at New York–Presbyterian Hospital and Cornell University, New York. He suggested that combined endolaparoscopic surgery (CELS) is a safe and effective alternative.

Photo Laird Harrison/Elsevier Global Medical News

Dr. Lee and his colleagues looked at the records of 66 patients who were taken to the operating room for CELS at New York–Presbyterian. The patients had been referred after failure to clear polyps, mostly because the polyps were large or in difficult locations based on biopsy or endoscopic photographs. Only those patients with at least a year of follow-up including a colonoscopy were included, and those with successful colonoscopic polypectomies were excluded.

The surgeons used CO₂ colonoscopy to avoid bowel distention.

"The idea is that if you have a difficult polyp, or a polyp that is located at difficult location, or a very large polyp, then you can laparoscopically help get exposure of that polyp so you can take it out endoscopically," said Dr. Lee at the annual meeting of the American Society of Colon and Rectal Surgeons. "And if you [damage] the bowel wall, you can recognize and repair it laparoscopically."

Once in the operating room, 10 patients were converted to laparoscopic colectomy before CELS was attempted because of suspicion of cancer.

Of the 56 patients in whom the procedure was attempted, 13 were converted to colectomy because of technical difficulty. Two were converted because of suspicion of cancer after the combination procedure was completed.

Of the 12 patients in whom cancer was suspected (10 before the procedure and 2 after), 4 patients had confirmed cancer, giving the team a 33% successful prediction rate. Conversely, of 54 patients thought to have benign polyps, only 1 patient (1.9%) was later found to have cancer.

The largest polyps were the most likely to contain cancer, but even among those greater than 4 cm in diameter, only 13 (7.6%) contained cancer, suggesting that size alone is not an absolute contraindication to performing CELS, said Dr. Lee.

Almost half of the patients went home the day after the procedure. The median time in the operating room was 150 minutes, and the complication rate was 4.4%, said Dr. Lee. Of 41 patients for whom CELS was successful, 5 had limited recurrence. And of those five, four had repeat colonoscopy to repeat the removal of polyps; one had a delayed laparoscopic colectomy, but in this patient the final pathology was benign, he said.

The presentation drew one question from the audience: "Of those patients that you suspected had cancer and who were converted to colectomy, the majority of them were benign. Is there a way to avoid those colectomies that weren’t needed?"

"I would rather be on the safe side," said Dr. Lee. "Unless you take the polyp out completely, you’re not going to know if there’s a cancer there. It’s a little bit of a conundrum, but if you suspect cancer based on the morphology, go ahead and perform a laparoscopic colectomy."

Dr. Lee disclosed that he has served as a speaker and consultant for Covidien, as a course faculty member for Olympus America and Applied Medical, and as a principal investigator for Applied Medical.

VANCOUVER – Combined endolaparoscopic surgery may offer a good option for patients with difficult but benign polyps, judging by results of a retrospective study.

Difficult benign colonic lesions are typically treated with bowel resection, but even when this is performed laparoscopically, significant morbidity is seen, according to Dr. Sang W. Lee of the department of surgery at New York–Presbyterian Hospital and Cornell University, New York. He suggested that combined endolaparoscopic surgery (CELS) is a safe and effective alternative.

Photo Laird Harrison/Elsevier Global Medical News

Dr. Lee and his colleagues looked at the records of 66 patients who were taken to the operating room for CELS at New York–Presbyterian. The patients had been referred after failure to clear polyps, mostly because the polyps were large or in difficult locations based on biopsy or endoscopic photographs. Only those patients with at least a year of follow-up including a colonoscopy were included, and those with successful colonoscopic polypectomies were excluded.

The surgeons used CO₂ colonoscopy to avoid bowel distention.

"The idea is that if you have a difficult polyp, or a polyp that is located at difficult location, or a very large polyp, then you can laparoscopically help get exposure of that polyp so you can take it out endoscopically," said Dr. Lee at the annual meeting of the American Society of Colon and Rectal Surgeons. "And if you [damage] the bowel wall, you can recognize and repair it laparoscopically."

Once in the operating room, 10 patients were converted to laparoscopic colectomy before CELS was attempted because of suspicion of cancer.

Of the 56 patients in whom the procedure was attempted, 13 were converted to colectomy because of technical difficulty. Two were converted because of suspicion of cancer after the combination procedure was completed.

Of the 12 patients in whom cancer was suspected (10 before the procedure and 2 after), 4 patients had confirmed cancer, giving the team a 33% successful prediction rate. Conversely, of 54 patients thought to have benign polyps, only 1 patient (1.9%) was later found to have cancer.

The largest polyps were the most likely to contain cancer, but even among those greater than 4 cm in diameter, only 13 (7.6%) contained cancer, suggesting that size alone is not an absolute contraindication to performing CELS, said Dr. Lee.

Almost half of the patients went home the day after the procedure. The median time in the operating room was 150 minutes, and the complication rate was 4.4%, said Dr. Lee. Of 41 patients for whom CELS was successful, 5 had limited recurrence. And of those five, four had repeat colonoscopy to repeat the removal of polyps; one had a delayed laparoscopic colectomy, but in this patient the final pathology was benign, he said.

The presentation drew one question from the audience: "Of those patients that you suspected had cancer and who were converted to colectomy, the majority of them were benign. Is there a way to avoid those colectomies that weren’t needed?"

"I would rather be on the safe side," said Dr. Lee. "Unless you take the polyp out completely, you’re not going to know if there’s a cancer there. It’s a little bit of a conundrum, but if you suspect cancer based on the morphology, go ahead and perform a laparoscopic colectomy."

Dr. Lee disclosed that he has served as a speaker and consultant for Covidien, as a course faculty member for Olympus America and Applied Medical, and as a principal investigator for Applied Medical.

VANCOUVER – Combined endolaparoscopic surgery may offer a good option for patients with difficult but benign polyps, judging by results of a retrospective study.

Difficult benign colonic lesions are typically treated with bowel resection, but even when this is performed laparoscopically, significant morbidity is seen, according to Dr. Sang W. Lee of the department of surgery at New York–Presbyterian Hospital and Cornell University, New York. He suggested that combined endolaparoscopic surgery (CELS) is a safe and effective alternative.

Photo Laird Harrison/Elsevier Global Medical News

Dr. Lee and his colleagues looked at the records of 66 patients who were taken to the operating room for CELS at New York–Presbyterian. The patients had been referred after failure to clear polyps, mostly because the polyps were large or in difficult locations based on biopsy or endoscopic photographs. Only those patients with at least a year of follow-up including a colonoscopy were included, and those with successful colonoscopic polypectomies were excluded.

The surgeons used CO₂ colonoscopy to avoid bowel distention.

"The idea is that if you have a difficult polyp, or a polyp that is located at difficult location, or a very large polyp, then you can laparoscopically help get exposure of that polyp so you can take it out endoscopically," said Dr. Lee at the annual meeting of the American Society of Colon and Rectal Surgeons. "And if you [damage] the bowel wall, you can recognize and repair it laparoscopically."

Once in the operating room, 10 patients were converted to laparoscopic colectomy before CELS was attempted because of suspicion of cancer.

Of the 56 patients in whom the procedure was attempted, 13 were converted to colectomy because of technical difficulty. Two were converted because of suspicion of cancer after the combination procedure was completed.

Of the 12 patients in whom cancer was suspected (10 before the procedure and 2 after), 4 patients had confirmed cancer, giving the team a 33% successful prediction rate. Conversely, of 54 patients thought to have benign polyps, only 1 patient (1.9%) was later found to have cancer.

The largest polyps were the most likely to contain cancer, but even among those greater than 4 cm in diameter, only 13 (7.6%) contained cancer, suggesting that size alone is not an absolute contraindication to performing CELS, said Dr. Lee.

Almost half of the patients went home the day after the procedure. The median time in the operating room was 150 minutes, and the complication rate was 4.4%, said Dr. Lee. Of 41 patients for whom CELS was successful, 5 had limited recurrence. And of those five, four had repeat colonoscopy to repeat the removal of polyps; one had a delayed laparoscopic colectomy, but in this patient the final pathology was benign, he said.

The presentation drew one question from the audience: "Of those patients that you suspected had cancer and who were converted to colectomy, the majority of them were benign. Is there a way to avoid those colectomies that weren’t needed?"

"I would rather be on the safe side," said Dr. Lee. "Unless you take the polyp out completely, you’re not going to know if there’s a cancer there. It’s a little bit of a conundrum, but if you suspect cancer based on the morphology, go ahead and perform a laparoscopic colectomy."

Dr. Lee disclosed that he has served as a speaker and consultant for Covidien, as a course faculty member for Olympus America and Applied Medical, and as a principal investigator for Applied Medical.

VANCOUVER, B.C. – Stimulation of the sacral nerve can be an effective treatment for fecal incontinence, lasting for at least a decade, but percutaneous stimulation of the posterior tibial nerve may be a better alternative, according to results of two recent studies.

Although sacral nerve stimulation is considered a first-line procedure for fecal incontinence, the long-term effects are not well known, said Dr. Anil George at the annual meeting of the American Society of Colon and Rectal Surgeons. Nonetheless, in England, sacral nerve stimulation is the standard treatment for patients who have failed conservative treatment and biofeedback, said Dr. George of St. Mark’s Hospital, Harrow.

Previous research suggests that it works in about 30%-80% of patients (Colorectal Dis. 2010 [doi:10.1111/j.1463-1318.2010.02383.x]), but these studies have obtained only short- to medium-term results, according to Dr. George.

He and his colleagues followed 25 patients who underwent sacral nerve stimulation between January 1996 and January 2002 at St. Mark’s. The patients had two or more episodes of fecal incontinence per week, and had failed conservative treatment and biofeedback. Nine of the patients had had previous sphincter surgery.

Of the 25 patients, 23 improved during the trial phase and proceeded to permanent implant. At follow-up last year (88-150 months after the procedure), the researchers found that the treatment was still effective in 21 of the 23 patients.

From a baseline mean of 20 (standard deviation, 3.8), their St. Mark’s incontinence score (SMIS) declined to 7 (3.4) at 3 months, then stayed more or less steady at 8 (3.7) for the latest follow-up.

Similarly, their ability to defer defecation increased from a mean of less than 1 minute (0.9) to 12 minutes (4.7) after 3 months of treatment, and dropped only slightly to 9 minutes (6) at the most recent follow-up. Incontinence episodes dropped from a mean of 27 (3.4) per 2 weeks at baseline to 2 (4.8) at 3 months, and rose slightly to 4 (12.2) at the latest follow-up.

Only two patients lost efficacy, said Dr. George, for unknown reasons. "Our studies show that sacral nerve stimulation can provide a sustained improvement for up to 10 years," he concluded.

As good as these results seemed, Dr. George said that posterior tibial nerve stimulation may prove even better. He noted that it is effective in 60%-80% of patients, but so far the research has been limited to case series (Colorectal Dis. 2010;12:1236-41).

To further examine the possibilities, Dr. George and his colleagues administered the posterior tibial nerve stimulation to two groups of 11 patients twice a week for 30 minutes at a time over the course of 6 consecutive weeks. One group got percutaneous treatment, and the other got transcutaneous treatment.

The researchers used a fixed pulse width of 200 microseconds and a frequency of 20 Hz. A third group of eight patients received a sham transcutaneous treatment with adhesive pads attached and stimulation switched on for less than 10 seconds, then switched off. (The researchers couldn’t think of a sham percutaneous procedure.)

All patients had had two or more episodes of incontinence per week and had failed conservative treatment and biofeedback. Some had sphincter defects.

Of the 11 percutaneous patients, 9 (82%) achieved greater than a 50% reduction in episodes of incontinence. By comparison, 5 of the 11 transcutaneous patients (45%) achieved this response. Only one of the eight sham transcutaneous patients had this good a response.

The percutaneous patients’ ability to defer defecation increased from a mean 1.9 minutes (standard deviation, 0.9) to 6.7 (SD, 4.8), a statistically significant result (P = .009), whereas the transcutaneous patients went from 2.5 minutes (SD, 2.7) to 4.5 (SD, 4.8), a result that approached statistical significance (P = .06). The change in the placebo group was not statistically significant (P = .17), but the difference among the groups was significant (P = .01).

Only the percutaneous group had a statistically significant improvement in SMIS. There were no differences in threshold, urge, and maximal volumes; rectal and anal sensitivity; or resting, endurance squeeze, and involuntary squeeze pressures among the groups.

Although there were no major complications, the patients reported two episodes of mild, self-limiting abdominal pain.

"So what is your belief of why percutaneous is better?" asked an audience member.

"In percutaneous [therapy], we put the needle closer to the nerve," responded Dr. George. "That could be a reason." But he added that previous studies had not found a difference between the transcutaneous and percutaneous approaches.

And transcutaneous posterior tibial nerve stimulation may have at least one advantage, he said. At St. Mark’s, the cost per patient for percutaneous stimulation was £400 ($711), whereas transcutaneous was only £2 ($3) per patient. By comparison, sacral nerve stimulation was £1,500 ($2,423) per patient just for the kit.

"Our results were quite dramatic," said Dr. George. "Tibial nerve stimulation could represent a simple, cheap, and safe option."

Dr. George said he had no disclosures.

VANCOUVER, B.C. – Stimulation of the sacral nerve can be an effective treatment for fecal incontinence, lasting for at least a decade, but percutaneous stimulation of the posterior tibial nerve may be a better alternative, according to results of two recent studies.

Although sacral nerve stimulation is considered a first-line procedure for fecal incontinence, the long-term effects are not well known, said Dr. Anil George at the annual meeting of the American Society of Colon and Rectal Surgeons. Nonetheless, in England, sacral nerve stimulation is the standard treatment for patients who have failed conservative treatment and biofeedback, said Dr. George of St. Mark’s Hospital, Harrow.

Previous research suggests that it works in about 30%-80% of patients (Colorectal Dis. 2010 [doi:10.1111/j.1463-1318.2010.02383.x]), but these studies have obtained only short- to medium-term results, according to Dr. George.

He and his colleagues followed 25 patients who underwent sacral nerve stimulation between January 1996 and January 2002 at St. Mark’s. The patients had two or more episodes of fecal incontinence per week, and had failed conservative treatment and biofeedback. Nine of the patients had had previous sphincter surgery.

Of the 25 patients, 23 improved during the trial phase and proceeded to permanent implant. At follow-up last year (88-150 months after the procedure), the researchers found that the treatment was still effective in 21 of the 23 patients.

From a baseline mean of 20 (standard deviation, 3.8), their St. Mark’s incontinence score (SMIS) declined to 7 (3.4) at 3 months, then stayed more or less steady at 8 (3.7) for the latest follow-up.

Similarly, their ability to defer defecation increased from a mean of less than 1 minute (0.9) to 12 minutes (4.7) after 3 months of treatment, and dropped only slightly to 9 minutes (6) at the most recent follow-up. Incontinence episodes dropped from a mean of 27 (3.4) per 2 weeks at baseline to 2 (4.8) at 3 months, and rose slightly to 4 (12.2) at the latest follow-up.

Only two patients lost efficacy, said Dr. George, for unknown reasons. "Our studies show that sacral nerve stimulation can provide a sustained improvement for up to 10 years," he concluded.

As good as these results seemed, Dr. George said that posterior tibial nerve stimulation may prove even better. He noted that it is effective in 60%-80% of patients, but so far the research has been limited to case series (Colorectal Dis. 2010;12:1236-41).

To further examine the possibilities, Dr. George and his colleagues administered the posterior tibial nerve stimulation to two groups of 11 patients twice a week for 30 minutes at a time over the course of 6 consecutive weeks. One group got percutaneous treatment, and the other got transcutaneous treatment.

The researchers used a fixed pulse width of 200 microseconds and a frequency of 20 Hz. A third group of eight patients received a sham transcutaneous treatment with adhesive pads attached and stimulation switched on for less than 10 seconds, then switched off. (The researchers couldn’t think of a sham percutaneous procedure.)

All patients had had two or more episodes of incontinence per week and had failed conservative treatment and biofeedback. Some had sphincter defects.

Of the 11 percutaneous patients, 9 (82%) achieved greater than a 50% reduction in episodes of incontinence. By comparison, 5 of the 11 transcutaneous patients (45%) achieved this response. Only one of the eight sham transcutaneous patients had this good a response.

The percutaneous patients’ ability to defer defecation increased from a mean 1.9 minutes (standard deviation, 0.9) to 6.7 (SD, 4.8), a statistically significant result (P = .009), whereas the transcutaneous patients went from 2.5 minutes (SD, 2.7) to 4.5 (SD, 4.8), a result that approached statistical significance (P = .06). The change in the placebo group was not statistically significant (P = .17), but the difference among the groups was significant (P = .01).

Only the percutaneous group had a statistically significant improvement in SMIS. There were no differences in threshold, urge, and maximal volumes; rectal and anal sensitivity; or resting, endurance squeeze, and involuntary squeeze pressures among the groups.

Although there were no major complications, the patients reported two episodes of mild, self-limiting abdominal pain.

"So what is your belief of why percutaneous is better?" asked an audience member.

"In percutaneous [therapy], we put the needle closer to the nerve," responded Dr. George. "That could be a reason." But he added that previous studies had not found a difference between the transcutaneous and percutaneous approaches.

And transcutaneous posterior tibial nerve stimulation may have at least one advantage, he said. At St. Mark’s, the cost per patient for percutaneous stimulation was £400 ($711), whereas transcutaneous was only £2 ($3) per patient. By comparison, sacral nerve stimulation was £1,500 ($2,423) per patient just for the kit.

"Our results were quite dramatic," said Dr. George. "Tibial nerve stimulation could represent a simple, cheap, and safe option."

Dr. George said he had no disclosures.

VANCOUVER, B.C. – Stimulation of the sacral nerve can be an effective treatment for fecal incontinence, lasting for at least a decade, but percutaneous stimulation of the posterior tibial nerve may be a better alternative, according to results of two recent studies.

Although sacral nerve stimulation is considered a first-line procedure for fecal incontinence, the long-term effects are not well known, said Dr. Anil George at the annual meeting of the American Society of Colon and Rectal Surgeons. Nonetheless, in England, sacral nerve stimulation is the standard treatment for patients who have failed conservative treatment and biofeedback, said Dr. George of St. Mark’s Hospital, Harrow.

Previous research suggests that it works in about 30%-80% of patients (Colorectal Dis. 2010 [doi:10.1111/j.1463-1318.2010.02383.x]), but these studies have obtained only short- to medium-term results, according to Dr. George.

He and his colleagues followed 25 patients who underwent sacral nerve stimulation between January 1996 and January 2002 at St. Mark’s. The patients had two or more episodes of fecal incontinence per week, and had failed conservative treatment and biofeedback. Nine of the patients had had previous sphincter surgery.

Of the 25 patients, 23 improved during the trial phase and proceeded to permanent implant. At follow-up last year (88-150 months after the procedure), the researchers found that the treatment was still effective in 21 of the 23 patients.

From a baseline mean of 20 (standard deviation, 3.8), their St. Mark’s incontinence score (SMIS) declined to 7 (3.4) at 3 months, then stayed more or less steady at 8 (3.7) for the latest follow-up.

Similarly, their ability to defer defecation increased from a mean of less than 1 minute (0.9) to 12 minutes (4.7) after 3 months of treatment, and dropped only slightly to 9 minutes (6) at the most recent follow-up. Incontinence episodes dropped from a mean of 27 (3.4) per 2 weeks at baseline to 2 (4.8) at 3 months, and rose slightly to 4 (12.2) at the latest follow-up.

Only two patients lost efficacy, said Dr. George, for unknown reasons. "Our studies show that sacral nerve stimulation can provide a sustained improvement for up to 10 years," he concluded.

As good as these results seemed, Dr. George said that posterior tibial nerve stimulation may prove even better. He noted that it is effective in 60%-80% of patients, but so far the research has been limited to case series (Colorectal Dis. 2010;12:1236-41).

To further examine the possibilities, Dr. George and his colleagues administered the posterior tibial nerve stimulation to two groups of 11 patients twice a week for 30 minutes at a time over the course of 6 consecutive weeks. One group got percutaneous treatment, and the other got transcutaneous treatment.

The researchers used a fixed pulse width of 200 microseconds and a frequency of 20 Hz. A third group of eight patients received a sham transcutaneous treatment with adhesive pads attached and stimulation switched on for less than 10 seconds, then switched off. (The researchers couldn’t think of a sham percutaneous procedure.)

All patients had had two or more episodes of incontinence per week and had failed conservative treatment and biofeedback. Some had sphincter defects.

Of the 11 percutaneous patients, 9 (82%) achieved greater than a 50% reduction in episodes of incontinence. By comparison, 5 of the 11 transcutaneous patients (45%) achieved this response. Only one of the eight sham transcutaneous patients had this good a response.

The percutaneous patients’ ability to defer defecation increased from a mean 1.9 minutes (standard deviation, 0.9) to 6.7 (SD, 4.8), a statistically significant result (P = .009), whereas the transcutaneous patients went from 2.5 minutes (SD, 2.7) to 4.5 (SD, 4.8), a result that approached statistical significance (P = .06). The change in the placebo group was not statistically significant (P = .17), but the difference among the groups was significant (P = .01).

Only the percutaneous group had a statistically significant improvement in SMIS. There were no differences in threshold, urge, and maximal volumes; rectal and anal sensitivity; or resting, endurance squeeze, and involuntary squeeze pressures among the groups.

Although there were no major complications, the patients reported two episodes of mild, self-limiting abdominal pain.

"So what is your belief of why percutaneous is better?" asked an audience member.

"In percutaneous [therapy], we put the needle closer to the nerve," responded Dr. George. "That could be a reason." But he added that previous studies had not found a difference between the transcutaneous and percutaneous approaches.

And transcutaneous posterior tibial nerve stimulation may have at least one advantage, he said. At St. Mark’s, the cost per patient for percutaneous stimulation was £400 ($711), whereas transcutaneous was only £2 ($3) per patient. By comparison, sacral nerve stimulation was £1,500 ($2,423) per patient just for the kit.

"Our results were quite dramatic," said Dr. George. "Tibial nerve stimulation could represent a simple, cheap, and safe option."

Dr. George said he had no disclosures.

VANCOUVER, B.C. – Stimulation of the sacral nerve can be an effective treatment for fecal incontinence, lasting for at least a decade, but percutaneous stimulation of the posterior tibial nerve may be a better alternative, according to results of two recent studies.

Although sacral nerve stimulation is considered a first-line procedure for fecal incontinence, the long-term effects are not well known, said Dr. Anil George at the annual meeting of the American Society of Colon and Rectal Surgeons. Nonetheless, in England, sacral nerve stimulation is the standard treatment for patients who have failed conservative treatment and biofeedback, said Dr. George of St. Mark’s Hospital, Harrow.

Previous research suggests that it works in about 30%-80% of patients (Colorectal Dis. 2010 [doi:10.1111/j.1463-1318.2010.02383.x]), but these studies have obtained only short- to medium-term results, according to Dr. George.

He and his colleagues followed 25 patients who underwent sacral nerve stimulation between January 1996 and January 2002 at St. Mark’s. The patients had two or more episodes of fecal incontinence per week, and had failed conservative treatment and biofeedback. Nine of the patients had had previous sphincter surgery.

Of the 25 patients, 23 improved during the trial phase and proceeded to permanent implant. At follow-up last year (88-150 months after the procedure), the researchers found that the treatment was still effective in 21 of the 23 patients.

From a baseline mean of 20 (standard deviation, 3.8), their St. Mark’s incontinence score (SMIS) declined to 7 (3.4) at 3 months, then stayed more or less steady at 8 (3.7) for the latest follow-up.

Similarly, their ability to defer defecation increased from a mean of less than 1 minute (0.9) to 12 minutes (4.7) after 3 months of treatment, and dropped only slightly to 9 minutes (6) at the most recent follow-up. Incontinence episodes dropped from a mean of 27 (3.4) per 2 weeks at baseline to 2 (4.8) at 3 months, and rose slightly to 4 (12.2) at the latest follow-up.

Only two patients lost efficacy, said Dr. George, for unknown reasons. "Our studies show that sacral nerve stimulation can provide a sustained improvement for up to 10 years," he concluded.

As good as these results seemed, Dr. George said that posterior tibial nerve stimulation may prove even better. He noted that it is effective in 60%-80% of patients, but so far the research has been limited to case series (Colorectal Dis. 2010;12:1236-41).

To further examine the possibilities, Dr. George and his colleagues administered the posterior tibial nerve stimulation to two groups of 11 patients twice a week for 30 minutes at a time over the course of 6 consecutive weeks. One group got percutaneous treatment, and the other got transcutaneous treatment.

The researchers used a fixed pulse width of 200 microseconds and a frequency of 20 Hz. A third group of eight patients received a sham transcutaneous treatment with adhesive pads attached and stimulation switched on for less than 10 seconds, then switched off. (The researchers couldn’t think of a sham percutaneous procedure.)

All patients had had two or more episodes of incontinence per week and had failed conservative treatment and biofeedback. Some had sphincter defects.

Of the 11 percutaneous patients, 9 (82%) achieved greater than a 50% reduction in episodes of incontinence. By comparison, 5 of the 11 transcutaneous patients (45%) achieved this response. Only one of the eight sham transcutaneous patients had this good a response.

The percutaneous patients’ ability to defer defecation increased from a mean 1.9 minutes (standard deviation, 0.9) to 6.7 (SD, 4.8), a statistically significant result (P = .009), whereas the transcutaneous patients went from 2.5 minutes (SD, 2.7) to 4.5 (SD, 4.8), a result that approached statistical significance (P = .06). The change in the placebo group was not statistically significant (P = .17), but the difference among the groups was significant (P = .01).

Only the percutaneous group had a statistically significant improvement in SMIS. There were no differences in threshold, urge, and maximal volumes; rectal and anal sensitivity; or resting, endurance squeeze, and involuntary squeeze pressures among the groups.

Although there were no major complications, the patients reported two episodes of mild, self-limiting abdominal pain.

"So what is your belief of why percutaneous is better?" asked an audience member.

"In percutaneous [therapy], we put the needle closer to the nerve," responded Dr. George. "That could be a reason." But he added that previous studies had not found a difference between the transcutaneous and percutaneous approaches.

And transcutaneous posterior tibial nerve stimulation may have at least one advantage, he said. At St. Mark’s, the cost per patient for percutaneous stimulation was £400 ($711), whereas transcutaneous was only £2 ($3) per patient. By comparison, sacral nerve stimulation was £1,500 ($2,423) per patient just for the kit.

"Our results were quite dramatic," said Dr. George. "Tibial nerve stimulation could represent a simple, cheap, and safe option."

Dr. George said he had no disclosures.

VANCOUVER, B.C. – Stimulation of the sacral nerve can be an effective treatment for fecal incontinence, lasting for at least a decade, but percutaneous stimulation of the posterior tibial nerve may be a better alternative, according to results of two recent studies.

Although sacral nerve stimulation is considered a first-line procedure for fecal incontinence, the long-term effects are not well known, said Dr. Anil George at the annual meeting of the American Society of Colon and Rectal Surgeons. Nonetheless, in England, sacral nerve stimulation is the standard treatment for patients who have failed conservative treatment and biofeedback, said Dr. George of St. Mark’s Hospital, Harrow.

Previous research suggests that it works in about 30%-80% of patients (Colorectal Dis. 2010 [doi:10.1111/j.1463-1318.2010.02383.x]), but these studies have obtained only short- to medium-term results, according to Dr. George.

He and his colleagues followed 25 patients who underwent sacral nerve stimulation between January 1996 and January 2002 at St. Mark’s. The patients had two or more episodes of fecal incontinence per week, and had failed conservative treatment and biofeedback. Nine of the patients had had previous sphincter surgery.

Of the 25 patients, 23 improved during the trial phase and proceeded to permanent implant. At follow-up last year (88-150 months after the procedure), the researchers found that the treatment was still effective in 21 of the 23 patients.

From a baseline mean of 20 (standard deviation, 3.8), their St. Mark’s incontinence score (SMIS) declined to 7 (3.4) at 3 months, then stayed more or less steady at 8 (3.7) for the latest follow-up.

Similarly, their ability to defer defecation increased from a mean of less than 1 minute (0.9) to 12 minutes (4.7) after 3 months of treatment, and dropped only slightly to 9 minutes (6) at the most recent follow-up. Incontinence episodes dropped from a mean of 27 (3.4) per 2 weeks at baseline to 2 (4.8) at 3 months, and rose slightly to 4 (12.2) at the latest follow-up.

Only two patients lost efficacy, said Dr. George, for unknown reasons. "Our studies show that sacral nerve stimulation can provide a sustained improvement for up to 10 years," he concluded.

As good as these results seemed, Dr. George said that posterior tibial nerve stimulation may prove even better. He noted that it is effective in 60%-80% of patients, but so far the research has been limited to case series (Colorectal Dis. 2010;12:1236-41).

To further examine the possibilities, Dr. George and his colleagues administered the posterior tibial nerve stimulation to two groups of 11 patients twice a week for 30 minutes at a time over the course of 6 consecutive weeks. One group got percutaneous treatment, and the other got transcutaneous treatment.

The researchers used a fixed pulse width of 200 microseconds and a frequency of 20 Hz. A third group of eight patients received a sham transcutaneous treatment with adhesive pads attached and stimulation switched on for less than 10 seconds, then switched off. (The researchers couldn’t think of a sham percutaneous procedure.)

All patients had had two or more episodes of incontinence per week and had failed conservative treatment and biofeedback. Some had sphincter defects.

Of the 11 percutaneous patients, 9 (82%) achieved greater than a 50% reduction in episodes of incontinence. By comparison, 5 of the 11 transcutaneous patients (45%) achieved this response. Only one of the eight sham transcutaneous patients had this good a response.

The percutaneous patients’ ability to defer defecation increased from a mean 1.9 minutes (standard deviation, 0.9) to 6.7 (SD, 4.8), a statistically significant result (P = .009), whereas the transcutaneous patients went from 2.5 minutes (SD, 2.7) to 4.5 (SD, 4.8), a result that approached statistical significance (P = .06). The change in the placebo group was not statistically significant (P = .17), but the difference among the groups was significant (P = .01).

Only the percutaneous group had a statistically significant improvement in SMIS. There were no differences in threshold, urge, and maximal volumes; rectal and anal sensitivity; or resting, endurance squeeze, and involuntary squeeze pressures among the groups.

Although there were no major complications, the patients reported two episodes of mild, self-limiting abdominal pain.

"So what is your belief of why percutaneous is better?" asked an audience member.

"In percutaneous [therapy], we put the needle closer to the nerve," responded Dr. George. "That could be a reason." But he added that previous studies had not found a difference between the transcutaneous and percutaneous approaches.

And transcutaneous posterior tibial nerve stimulation may have at least one advantage, he said. At St. Mark’s, the cost per patient for percutaneous stimulation was £400 ($711), whereas transcutaneous was only £2 ($3) per patient. By comparison, sacral nerve stimulation was £1,500 ($2,423) per patient just for the kit.

"Our results were quite dramatic," said Dr. George. "Tibial nerve stimulation could represent a simple, cheap, and safe option."

Dr. George said he had no disclosures.

VANCOUVER, B.C. – Stimulation of the sacral nerve can be an effective treatment for fecal incontinence, lasting for at least a decade, but percutaneous stimulation of the posterior tibial nerve may be a better alternative, according to results of two recent studies.

Although sacral nerve stimulation is considered a first-line procedure for fecal incontinence, the long-term effects are not well known, said Dr. Anil George at the annual meeting of the American Society of Colon and Rectal Surgeons. Nonetheless, in England, sacral nerve stimulation is the standard treatment for patients who have failed conservative treatment and biofeedback, said Dr. George of St. Mark’s Hospital, Harrow.

Previous research suggests that it works in about 30%-80% of patients (Colorectal Dis. 2010 [doi:10.1111/j.1463-1318.2010.02383.x]), but these studies have obtained only short- to medium-term results, according to Dr. George.

He and his colleagues followed 25 patients who underwent sacral nerve stimulation between January 1996 and January 2002 at St. Mark’s. The patients had two or more episodes of fecal incontinence per week, and had failed conservative treatment and biofeedback. Nine of the patients had had previous sphincter surgery.

Of the 25 patients, 23 improved during the trial phase and proceeded to permanent implant. At follow-up last year (88-150 months after the procedure), the researchers found that the treatment was still effective in 21 of the 23 patients.

From a baseline mean of 20 (standard deviation, 3.8), their St. Mark’s incontinence score (SMIS) declined to 7 (3.4) at 3 months, then stayed more or less steady at 8 (3.7) for the latest follow-up.

Similarly, their ability to defer defecation increased from a mean of less than 1 minute (0.9) to 12 minutes (4.7) after 3 months of treatment, and dropped only slightly to 9 minutes (6) at the most recent follow-up. Incontinence episodes dropped from a mean of 27 (3.4) per 2 weeks at baseline to 2 (4.8) at 3 months, and rose slightly to 4 (12.2) at the latest follow-up.

Only two patients lost efficacy, said Dr. George, for unknown reasons. "Our studies show that sacral nerve stimulation can provide a sustained improvement for up to 10 years," he concluded.

As good as these results seemed, Dr. George said that posterior tibial nerve stimulation may prove even better. He noted that it is effective in 60%-80% of patients, but so far the research has been limited to case series (Colorectal Dis. 2010;12:1236-41).

To further examine the possibilities, Dr. George and his colleagues administered the posterior tibial nerve stimulation to two groups of 11 patients twice a week for 30 minutes at a time over the course of 6 consecutive weeks. One group got percutaneous treatment, and the other got transcutaneous treatment.

The researchers used a fixed pulse width of 200 microseconds and a frequency of 20 Hz. A third group of eight patients received a sham transcutaneous treatment with adhesive pads attached and stimulation switched on for less than 10 seconds, then switched off. (The researchers couldn’t think of a sham percutaneous procedure.)

All patients had had two or more episodes of incontinence per week and had failed conservative treatment and biofeedback. Some had sphincter defects.

Of the 11 percutaneous patients, 9 (82%) achieved greater than a 50% reduction in episodes of incontinence. By comparison, 5 of the 11 transcutaneous patients (45%) achieved this response. Only one of the eight sham transcutaneous patients had this good a response.

The percutaneous patients’ ability to defer defecation increased from a mean 1.9 minutes (standard deviation, 0.9) to 6.7 (SD, 4.8), a statistically significant result (P = .009), whereas the transcutaneous patients went from 2.5 minutes (SD, 2.7) to 4.5 (SD, 4.8), a result that approached statistical significance (P = .06). The change in the placebo group was not statistically significant (P = .17), but the difference among the groups was significant (P = .01).

Only the percutaneous group had a statistically significant improvement in SMIS. There were no differences in threshold, urge, and maximal volumes; rectal and anal sensitivity; or resting, endurance squeeze, and involuntary squeeze pressures among the groups.

Although there were no major complications, the patients reported two episodes of mild, self-limiting abdominal pain.

"So what is your belief of why percutaneous is better?" asked an audience member.

"In percutaneous [therapy], we put the needle closer to the nerve," responded Dr. George. "That could be a reason." But he added that previous studies had not found a difference between the transcutaneous and percutaneous approaches.

And transcutaneous posterior tibial nerve stimulation may have at least one advantage, he said. At St. Mark’s, the cost per patient for percutaneous stimulation was £400 ($711), whereas transcutaneous was only £2 ($3) per patient. By comparison, sacral nerve stimulation was £1,500 ($2,423) per patient just for the kit.

"Our results were quite dramatic," said Dr. George. "Tibial nerve stimulation could represent a simple, cheap, and safe option."

Dr. George said he had no disclosures.