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C J Vaizey

Publications and source records attributed to C J Vaizey.

At least 19 recordsLinked to original sources
PubMed2006

Improving the morbidity of anorectal injury from pelvic radiotherapy.

OBJECTIVE: Radiation anorectal injury due to pelvic radiotherapy for non intestinal cancer is a significant cause of morbidity which may limit the treatment dose required. Conservative treatment options are of limited value and surgery is reserved only for the most severe complications. This review addresses radioprotection of the anorectum and aims to increase awareness amongst surgeons of the strategies that have been in practice in order to minimize the side-effects of radiotherapy while preserving its therapeutic efficacy. METHODS: This review is based on a literature search (Medline and NLM PubMed) with manual cross-referencing of all articles related to anorectal radiation injury. RESULTS: Optimization of radiation dose, the use of radioprotective agents and improvement in radiation delivery are the main areas of development. There are few data on the potential of altered fractionation schedules in reducing anorectal injury. A few phase I and II studies suggest that the pharmacological agents amifostine and misoprostol could be beneficial in limiting radiation damage but larger phase III studies are awaited. CONCLUSION: The introduction of 3-dimensional conformal radiation therapy and intensity modulated radiation therapy has been the most significant advance in reducing radiation morbidity.

Anal Canal↗
PubMed2006

Gastrointestinal manifestations of chronic granulomatous disease.

OBJECTIVE: Chronic granulomatous disease is a rare clinical entity characterized by recurrent infective and inflammatory complications. Patients are usually assigned to specialist centres, but nonspecialist clinicians may be required to treat these patients in the emergency setting. This review serves as a management guide to those clinicians who are faced with patients presenting with gastrointestinal manifestations of chronic granulomatous disease. METHODS: This review is based on a literature search (Medline and NLM PubMed) with manual cross-referencing of all articles related to gastrointestinal chronic granulomatous disease. RESULTS: Gastrointestinal tract involvement is present in most affected patients. Clinical presentation can mimic common surgical complications such as colitis, perianal sepsis, gastric outlet obstruction and liver abscess. A history of recurrent infections during childhood is common. Management involves haematological, microbiological, endoscopic and radiological investigations. Treatment modalities include early aggressive empirical antimicrobial therapy for sepsis, immunomodulation for inflammatory complications and surgical drainage of abscesses. CONCLUSION: Early involvement of a centre with immunological expertise combined with aggressive management of complications significantly improves morbidity and mortality from this rare condition.

Bacterial Infections↗
PubMed2005

Injectable bulking agents for treating faecal incontinence.

BACKGROUND: Reports of the use of injectable bulking agents for faecal incontinence are currently confined to a small number of pilot studies. However, the use of these agents is rapidly becoming widespread based on this limited knowledge. METHODS: This review provides an overview of the products available and the methods of delivery based on the pilot studies, selected articles reporting experience of these agents in urology, plastic surgery and laryngology, and some animal studies. RESULTS AND CONCLUSIONS: Although bulking agents have been used to treat urinary incontinence for over four decades, their use in faecal incontinence has so far been limited. The large choice of products now available and the lack of a defined injection strategy will hamper efforts to produce meaningful prospective randomized trials.

Biocompatible Materials↗
PubMed2004

Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow.

AIMS: The aim of the study was to determine if there is a permanent disorder of mucosal blood flow in patients with solitary rectal ulcer syndrome (SRUS) or a disorder related to autonomic gut innervation and physiological function that is reversible concomitant with successful treatment. Rectal mucosal blood flow was used as a validated measure of extrinsic autonomic nerve function. METHODS: Sixteen consecutive patients with SRUS (12 women; mean age 35 years) and 26 healthy controls (17 women; mean age 36 years) were studied. Laser Doppler mucosal flowmetry was performed before and after biofeedback treatment. Symptoms were documented before and after biofeedback treatment using a standardised prospectively applied questionnaire. RESULTS: Twelve of 16 patients (75%) reported subjective symptomatic improvement after treatment. Five of the 16 patients (31%) had sigmoidoscopic ulcer resolution. Pretreatment rectal mucosal blood flow was significantly lower in patients with SRUS compared with controls (163 (27) v 186 (14) flux units (FU) (mean (SD)); p<0.01). Biofeedback resulted in a significant improvement in rectal mucosal blood flow in subjects who felt subjectively better after biofeedback (p = 0.001), from 165 (30) FU to 190 (40) FU. CONCLUSION: Gut directed biofeedback is an effective behavioural treatment for the majority of patients with SRUS. Mucosal blood flow is reduced to a similar level seen in normal transit constipation, suggesting similar impaired extrinsic autonomic cholinergic nerve activity. Successful outcome following biofeedback is associated with increased rectal mucosal blood flow, suggesting that improved extrinsic innervation to the gut may be partially responsible for the response to treatment.

Adult↗
PubMed2002

Gut mucosal response to food antigens in Crohn's disease.

BACKGROUND: Food antigens may contribute to gut inflammation in Crohn's disease. AIM: To assess in vivo sensitization to food antigens, ascertain whether sensitivity is gut specific, assess food sensitization in vitro, and correlate in vivo changes with histological and blood changes. METHODS: Skin testing and rectal exposure to six food antigens (cereal, cabbage, citrus, milk, yeast and peanut) and control saline were assessed double-blind by immediate and 3.5-h laser Doppler blood flowmetry, and rectal biopsies were taken. Peripheral blood lymphocyte proliferation was measured in response to the same antigens. RESULTS: Ten patients with Crohn's disease and 10 healthy controls were studied. Blood flow increased in 24 of 60 antigen sites in Crohn's disease patients and six of 60 antigen sites in controls (P < 0.0001) after 3.5 h. The Crohn's disease group demonstrated higher rectal blood flow than controls in response to all food antigens, and this was significantly different for the responses to yeast (P = 0.036) and citrus fruits (P = 0.038). Lymphocyte proliferation occurred in 32 of 60 tests in Crohn's disease patients and eight of 60 tests in controls (P < 0.0001). There were no skin responses. Submucosal oedema corresponded to increased mucosal flow. CONCLUSIONS: Crohn's disease patients demonstrate in vivo and in vitro sensitization to food antigens, which is gut specific. Mucosal flowmetry allows the identification of sensitization to gut antigens.

Adult↗
PubMed2002

Medium-term results of permanent sacral nerve stimulation for faecal incontinence.

BACKGROUND: Anal sphincter surgery for faecal incontinence is associated with significant morbidity and a variable outcome. Sacral nerve stimulation may provide a good functional outcome with minimal morbidity. This paper reports the experience in a single centre over 5 years. METHODS: Fifteen consecutive patients (14 women), median age 60 (range 37-71) years, underwent temporary, and subsequent permanent, stimulation. All had incontinence to solid or liquid stool; the aetiology was obstetric injury (seven patients), scleroderma (four), idiopathic (two), fistula surgery (one) and repaired rectal prolapse (one). Median duration of symptoms was 6 (range 2-15) years. Clinical evaluation, endoanal ultrasonography, bowel diary, quality of life questionnaire (Short Form (SF) 36) and anorectal physiological testing were performed before and after stimulation. RESULTS: Continence had improved in all patients at median follow-up of 24 (range 3-60) months. Eleven patients were fully continent. Episodes of faecal incontinence decreased from median (range) 11 (2-30) per week before stimulation to 0 (0-4) per week after permanent stimulation (P < 0.001). Urgency improved in all patients (median (range) ability to defer less than 1 (0-1) versus 8 (1-15) min; P = 0.01). 'Social function' and 'role-physical' subscales of the SF36 improved significantly. Mean resting pressure (35 versus 49 cmH2O with temporary stimulation; P < 0.05) and squeeze pressure increment (43 versus 69 cmH2O with permanent stimulation; P < 0.01) increased. Rectal sensitivity to initial distension changed (mean 47 versus 34 ml air; P < 0.05). There were no major complications. CONCLUSION: Sacral nerve stimulation is a safe and effective treatment for faecal incontinence when conventional treatment has failed. There is minimal morbidity. The benefit is maintained in the medium term.

Adult↗
PubMed2002

Injectable silicone biomaterial for faecal incontinence due to internal anal sphincter dysfunction.

BACKGROUND: A weak or disrupted internal anal sphincter can cause passive faecal incontinence. Conservative measures may help some patients but there is no simple surgical solution for those who fail conservative treatment. A successful technique using trans-sphincteric injection of a bulking agent to augment the internal anal sphincter was developed in a previous pilot study. AIM: To determine the clinical results and underlying physiological effects of biomaterial injection. PATIENTS: Six patients (four males, median age 53 years (range 36-65)) with faecal incontinence to solid or liquid stool related to poor internal anal sphincter function, of varied aetiology, were recruited. METHODS: Silicone based biomaterial injections were performed, under local anaesthesia, with antibiotic cover. Three injections were placed circumferentially, trans-sphincterically, entering away from the anal margin and injecting at or just above the dentate line. Anorectal physiological studies, endoanal ultrasound, a bowel symptom diary, a validated incontinence score, and quality of life questionnaires were completed before treatment and on completion of follow up. RESULTS: At a median follow up of 18 months (range 15-19), five of six patients had marked symptom improvement. Faecal incontinence scores improved from a median of 14/24 (range 11-20) before to 8/24 (6-15) after injection. Short form-36 quality of life physical and social function scores improved from a median of 26/100 (5-33) to 79/100 (25-100) and from 10/100 (5-37) to 100/100 (50-100), respectively. There was a corresponding physiological increase in maximum anal resting and squeeze pressures. Ultrasound showed the Bioplastique to be retained in the correct position in the improved patients without migration. There were no complications. CONCLUSION: Trans-sphincteric injection of silicone biomaterial can provide a marked improvement in faecal incontinence related to a weak or disrupted internal anal sphincter. This is associated with improved sphincter function and quality of life.

Adult↗
PubMed2002

Sacral nerve stimulation for faecal incontinence due to systemic sclerosis.

BACKGROUND: Faecal incontinence occurs in over one third of patients with systemic sclerosis. The aetiology is multifactorial. Conventional treatment is often unsuccessful. Sacral nerve stimulation is a new effective treatment for resistant faecal incontinence. AIMS: To evaluate sacral nerve stimulation in patients with systemic sclerosis. PATIENTS: Five women, median age 61 years (30-71), with scleroderma associated faecal incontinence were evaluated. All had failed maximal conventional treatment. Median number of preoperative weekly episodes of incontinence was 15 (7-25), median duration of incontinence was five years (5-9), and scleroderma 13 years (4-29). METHODS: All patients were screened with temporary stimulation. Those who benefited underwent permanent implantation. At baseline and after stimulation a bowel diary, the SF-36 quality of life assessment, endoanal ultrasound, and anorectal physiology were performed. RESULTS: Four patients were continent at a median follow up of 24 months (6-60). One patient failed temporary stimulation and was not permanently implanted. The weekly episodes of incontinence decreased from 15, 11, 23, and 7 to 0. Urgency resolved (median time to defer <1 minute (0-1) v 12.5 minutes (5-15)). Quality of life, especially social function, improved. Endoanal ultrasound showed an atrophic internal anal sphincter (median width 1.0 mm (0-1.6)). Anorectal physiology showed an increase in median resting pressure (37 pre v 65 cm H(2)O post) and squeeze pressure (89 v 105 cm H(2)O). Stimulation produced enhanced rectal sensitivity to distension. There were no major complications. CONCLUSIONS: Sacral nerve stimulation is a safe and effective treatment for resistant faecal incontinence secondary to scleroderma. The benefit is maintained in the medium term.

Adult↗
PubMed2002

Battle injuries of the rectum: options for the field surgeon.

Historically, battle wounds of the rectum have had high mortality and morbidity. This has improved greatly over several decades as a result of battle experience. This article highlights the value of civilian gunshot experience and its possible use in the military setting. The standard principles of rectal examination, followed by proctosigmoidoscopy after initial resuscitation, remain unchanged. Thereafter, the surgical decisions are made at laparotomy. Rectal injuries commonly have other injuries in association which must also be dealt with. In the stable patient rectal repair may be possible. Where repair is hazardous due to extensive injury (rectum or adjacent structures), the well-proven protective colostomy is used. A loop colostomy with or without distal closure is effective and is used to protect most injuries; possible exceptions being injuries dealt with early, in which there is minimal contamination and repair is easy. Presacral drainage can generally be reserved for severely destructive wounds or those in which repair has not been done. Rectal washout remains an option in patients with inspissated faeces. The basic military surgical principles remain valid, their extent and degree of implementation depending on the anatomical location of injury, degree of damage and any delay in presentation to surgery.

Colostomy↗
PubMed2001

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

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

Adult↗
PubMed2001

Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome.

BACKGROUND: Treatment of solitary rectal ulcer syndrome with behavioral techniques (biofeedback) has been shown to be successful in a majority of patients in the short term. We aimed to determine the longer-term outcome of patients treated with this therapy. PATIENTS AND METHODS: Thirteen consecutive patients (3 male; median age, 34 years) with solitary rectal ulcer who had been treated by biofeedback and assessed a median of nine months after treatment were reassessed by questionnaire. Three patients were also examined using rigid sigmoidoscopy. RESULTS: Median follow up was 36 (range, 32-59) months after initial biofeedback treatment. One patient (previously reported as failing biofeedback therapy) was lost to follow-up. Of the four patients previously reported as asymptomatic, one remained asymptomatic, one maintained marked improvement, and another slight improvement; one had reverted to pretreatment status. Of the three patients previously reported as having marked improvement, one maintained moderate improvement, and two had reverted to pretreatment status. The patient previously reporting slight improvement had reverted to pretreatment status. Of the five previously reported failures, two patients experienced no improvement after further courses of biofeedback. At the three different times of review (pretreatment vs. 9 months vs. 36 months after biofeedback), reported bowel function was as follows: the need to strain (12 vs. 5 vs. 9 patients), anal digitation (10 vs. 3 vs. 8 patients), laxative use (9 vs. 4 vs. 4 patients), median time spent in the toilet per attempt at defecation (30 vs. 10 vs. 25 minutes), median visits to the toilet (5.5 vs. 2 vs. 4 per day), and ability to maintain employment (3 vs. 7 vs. 6 patients). CONCLUSION: Improvement in symptoms of solitary rectal ulcer syndrome after biofeedback retraining deteriorates in some patients with time. Half the patients with an early clinical response to retraining, however, can be expected to have ongoing clinical benefit at a median of three years.

Adult↗
PubMed2001

Anorectal injury following pelvic radiotherapy.

BACKGROUND: Current knowledge of the effects of radiation on the anorectum is based on a limited number of studies. Variability in delivery techniques, both currently and historically, combined with a paucity of prospective and randomized studies makes interpretation of the literature difficult. This review presents the existing evidence and identifies areas that require further work. METHODS: This review is based on a literature search (Medline and PubMed) and manual cross-referencing. RESULTS AND CONCLUSION: More than three-quarters of patients receiving pelvic radiotherapy experience acute anorectal symptoms and up to one-fifth suffer from late-phase radiation proctitis. About 5 per cent develop other chronic complications, such as fistula, stricture and disabling faecal incontinence. The risk of rectal cancer may be increased. Conservative treatment options are of limited value. Surgery may be considered if symptoms are severe, provided sphincter function is adequate and recurrent disease is excluded. Large prospective studies with accurate dosimetric data and long-term follow-up are needed to provide meaningful information on which to base new strategies to minimize the side-effects from radiotherapy.

Anal Canal↗
PubMed2001

Feasibility study of colonoscopy as the primary screening investigation in relatives of patients with colorectal cancer.

AIM: Relatives of patients with colorectal cancer are thought to be at a higher risk for this disease than the average population. We aimed to determine whether colonoscopy is a feasible primary screening investigation for this group to identify premalignant and malignant lesions. METHODS: A total of 449 people underwent colonoscopy and all had one or more relatives with colorectal cancer, of these, 212 were classified as 'asymptomatic' and 237 as being 'symptomatic'. Colonoscopy commenced at 40 years of age or 10 years younger than the youngest affected relative. RESULTS: Neoplastic change, benign and malignant, was found in 25.5% of the 'asymptomatic' group and 24% of the 'symptomatic' group; in 26% of those with one first degree relative, 39% with two or more first degree relatives and only 19% with second degree relatives. 38% of lesions were out of reach of a flexible sigmoidoscope. No known complications occurred. CONCLUSIONS: It is feasible to perform colonoscopy as the primary investigation for the first degree relatives of patients with colorectal cancer. The yield of neoplastic lesions is sufficient to make this appropriate.

Adenoma↗
PubMed2000

Reassessing artificial bowel sphincters.

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

Anal Canal↗
PubMed2000

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

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

Aged↗
PubMed2000

Permanent sacral nerve stimulation for fecal incontinence.

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

Adult↗