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Biomedical subjects

J Konsten

Publications and source records attributed to J Konsten.

At least 19 recordsLinked to original sources
PubMed2001

Comparison of epineural or intramuscular nerve electrodes for stimulated graciloplasty.

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

Adolescent↗
PubMed2000

Hemorrhoidectomy vs. Lord's method: 17-year follow-up of a prospective, randomized trial.

PURPOSE: A prospective, randomized trial was performed between 1979 and 1981 comparing anal dilation and hemorrhoidectomy for hemorrhoidal disease at the Maastricht University Hospital. The aim of this study was to update that trial to assess long-term outcome and complications such as fecal incontinence. METHODS: A total of 138 patients with second-degree and third-degree hemorrhoids entered the study. Median follow-up was 17 (range, 8.4-18.3) years and was achieved for 118 (86 percent) patients. Group A (n = 35) underwent hemorrhoidectomy and Group B (n = 39) was treated with anal dilation and aftertreatment (original Lord's procedure), whereas Group C (n = 44) had dilation only. Fourteen of these patients died. RESULTS: Recurrent hemorrhoids were noted for 26 percent of the patients treated with hemorrhoidectomy, for 46 percent with operative dilation with the postoperative dilation program, and for 39 percent with operative dilation without the postoperative program. The percentage of repeated treatment for the three subgroups was 11, 23, and 18 percent, respectively. The continence status remained more or less the same during the first year. However, 17 years later the anal stretch procedures caused various incontinence disorders in 52 percent of these patients. Significance was found for incontinence of flatus (from 11 to 30 patients; P = 0.04) in the anal dilation groups. CONCLUSIONS: Hemorrhoidectomy can be considered to be a safe procedure for treatment of hemorrhoidal disease, with excellent long-term results. Anal dilation is associated with a high percentage of complaints of fecal incontinence. The procedure should be abandoned.

Adult↗
PubMed1999

[General surgery in Paramaribo University Hospital].

Specific health problems in Surinam include high prevalence of infections, mostly gastrointestinal infections in young children, malaria and injuries due to violence. The public health care and medical and surgical training are hampered by a lack of funds, as are most things in the country. Relatively much of the surgery in Paramaribo University Hospital in 1991-1998 was performed because of complications of a diabetic foot (128.17%) and breast lesions (76.10%). No scientific research is being carried out either in the hospital or at the faculty of Anton de Kom University. Retrospective registration of operations may give a new impulse to scientific research.

Academic Medical Centers↗
PubMed1997

Assessment of ischaemia of the distal part of the gracilis muscle during transposition for anal dynamic graciloplasty.

BACKGROUND: Dynamic graciloplasty is used to create a neosphincter in patients with intractable faecal incontinence. When mobilizing the distal gracilis muscle from the upper leg, the minor vascular pedicles have to be ligated. This can interfere with the vascular supply in this part of the muscle. METHODS: The arterial anatomy within the muscle was visualized by means of angiography of 11 postmortem specimens. To quantify potential acute ischaemia, blood flow in the distal gracilis muscle was measured in ten patients with laser Doppler flowmetry during mobilization of the muscle. RESULTS: Angiography showed that the main vascular pedicle and all minor pedicles drain into one and the same arterial system. After clamping of the minor vascular pedicles, blood flow (mean 25.8 (range 6.5-74.3) perfusion units) did not differ from values obtained before clamping (mean 25.4 (range 7.5-68.7) perfusion units). After a mean of 1.8 years, all muscles were vital. No correlation existed between the change in muscle blood flow and either squeeze pressure (r = -0.2) or functional outcome (r = 0.31). CONCLUSION: This study provides direct anatomical and physiological evidence of one arterial system within the gracilis muscle. It is therefore questionable whether ligation of the minor vascular pedicles is the bottleneck in human dynamic graciloplasty. An additional operation for vascular delay may be redundant. A prospective randomized clinical study should be performed to compare the functional outcome in patients with and without a delay procedure.

Adolescent↗
PubMed1996

Dynamic graciloplasty. Complications and management.

PURPOSE: Patients with intractable fecal incontinence, in whom all other treatment failed, can be treated by dynamic graciloplasty. Good results have been reported, but this technique involves specific problems. All problems that occurred over an eight-year period are presented, and management is discussed. METHODS: Dynamic graciloplasty was performed in 67 patients with a mean follow-up of 2.7 years. All patients were monitored by physical examination, anal manometry, defecography, and electromyography at fixed intervals. All complications were noted and treated. Continence was defined as being continent to solid and liquid stools. RESULTS: The technique was successful in 52 patients (78 percent), whereas failures occurred in 15 patients (22 percent). Complications resulted from technical problems, problems with infection, and problems attributable to an abnormal physiology of the muscle or an anorectal functional imbalance. In total, 53 complications were identified in 36 patients. Most technical problems, concerning the transposition and stimulation of the gracilis muscle, could be treated. Failures were attributable to a bad contraction of the distal part of the muscle (n = 4) and perforation of the anal canal during stimulation (n = 1). In eight patients, infection of the stimulator and leads required explantation. Three patients did not regain continence after reimplantation. Apart from moderate constipation, physiologic complications were very hard to treat and resulted in failures in five patients because of overflow incontinence, soiling, a nondistending rectum, strong peristalsis, and strong constipation. In two patients, the technique failed despite a well-contracting graciloplasty; no clear reason for the failure was found. CONCLUSION: Complications associated with the technique of dynamic graciloplasty such as loss of contraction, infection, bad contraction in the distal part of the muscle, and constipation can often be prevented or treated. Difficulties related to an impaired sensation and/or motility, attributable to a congenital cause or degeneration, are impossible to treat, and this signifies that a good selection of patients is essential to prevent disappointment.

Adult↗
PubMed1995

Anal dynamic graciloplasty in the treatment of intractable fecal incontinence.

BACKGROUND: In patients with intractable fecal incontinence, conventional treatment is not always successful. Dynamic graciloplasty (transposition of the gracilis muscle to the anus with the implantation of stimulating electrodes) was developed to provide such patients with functional neosphincters. We evaluated the clinical results of this new surgical approach and the effects on quality of life. METHODS: We treated 52 patients with dynamic graciloplasty. The clinical results of treatment were evaluated in an interview, by anal manometry, and by enema testing. The degree of continence was scored. To assess quality of life, four questionnaires were administered (parts 1 and 2 of the Nottingham Health Profile, the State-Trait Anxiety Inventory, and the Self-rating Depression scale). RESULTS: Among the 52 patients, 38 (73 percent) were continent after a median follow-up of 2.1 years. At 52 weeks the patients' condition had improved with respect to the median frequency of defecation (from five to two times per 24 hours, P < 0.001), the median time defecation could be postponed (from 9 seconds to 19 minutes, P = 0.012), and the median time an enema could be retained (from 0 to 180 seconds, P = 0.005). Patients in whom the technique was successful became less anxious than those in whom it failed (P = 0.002) and improved with regard to effectiveness in their occupations, ability to perform tasks around the home, personal relationships, sexual function, and social life (P = 0.01). They also became less isolated socially (P = 0.05). CONCLUSIONS: Dynamic graciloplasty is a safe and reliable technique in patients with severe incontinence and may result in a better quality of life.

Adolescent↗
PubMed1995

Defecographic evaluation of dynamic graciloplasty for fecal incontinence.

PURPOSE: A prospective defecographic study was performed to evaluate the anorectal physiology of dynamic graciloplasty (gracilis muscle transposition and subsequent implantation of an electric stimulator) for treatment of fecal incontinence. METHODS: From November 1986 until May 1993, 38 consecutive patients with incapacitating fecal incontinence were treated with "anal dynamic graciloplasty." Defecography was performed before and after surgical procedures. Defecographic data (anorectal angle, perineal descent, anal canal length, anal canal width, and anal leakage) were correlated with respect to clinical outcome and anal manometry. RESULTS: Fecal continence was achieved in 24 patients, which correlated significantly with no leakage of barium contrast during defecography (P < 0.01, Kruskal-Wallis one-way analysis of variance). In addition, minimum anal canal width decreased from 7 mm before surgery to 1 mm after dynamic graciloplasty (P < 0.01, paired Student's t-test). CONCLUSION: Defecography is an efficient method to evaluate dynamic graciloplasty for fecal incontinence.

Adolescent↗
PubMed1995

Dynamic myoplasty in growing dogs as a feasibility study for treatment of fecal incontinence.

The feasibility of skeletal muscle transposition and electrical stimulation (dynamic myoplasty) for treatment of fecal incontinence has been shown in adults. It might be attractive to use such a technique in pediatric patients. Therefore, the influence of growth on skeletal muscle transposition and stimulation was studied in five puppies. In each dog, two neosphincters were constructed around a Thiry-Vella loop by using a dissected sartorius muscle with the neurovascular supply intact. In each of these five puppies, one of these muscles was electrically stimulated during a mean of 19 weeks (one puppy died during the first postoperative week). Muscle biopsies showed an increase in the percentage type I, fatigue-resistant muscle fibers from 61 to 94 in electrically stimulated sartorius neosphincters, but also an increase from 57 to 67 percent in transposed nonstimulated sartorius muscles. The diameter of these type I fibers during growth increased 36% in eletrically stimulated sartorius neosphincters and 55% in nonstimulated sphincters. Function of the neosphincters was tested with the inflow of saline in the Thiry-Vella loop. It was shown that the stimulated neosphincters were capable of inhibiting flow (which corresponded to manometric pressure registrations), but the nonstimulated sphincters were unable to inhibit flow. The experiments were complicated by infection and necrosis around the implanted stimulators in four puppies (which required reimplantation). We conclude that a dynamic myoplasty for fecal incontinence is feasible in growing puppies but that the technique is unacceptable during rapid growth because of the risks of infection and dislocation of the implanted device.

Anal Canal↗
PubMed1995

Dynamic graciloplasty for restoration of continence after traumatic destruction of the rectum and sphincters: report of a case.

A thirteen-year-old girl was run down by a speedboat, which resulted in traumatic destruction of the rectum and anal sphincters. She was treated by using a modified Duhamel procedure for rectal reconstruction and a double gracilis muscle transposition as the sphincter replacement procedure. Eight weeks after the first operation, intramuscular electrodes were implanted in both gracilis muscles and connected with an implanted electrical stimulator. This electrically stimulated gracilis muscle neosphincter restored sphincter function while anorectal sensation was preserved as a result of an intact rectovaginal septum. After closure of the temporary colostomy, the patient has good continence.

Adolescent↗
PubMed1994

Canine model for treatment of faecal incontinence using transposed and electrically stimulated sartorius muscle.

A neosphincter was successfully created around each end of a Thiry-Vella loop in five dogs using transposed sartorius muscle to study new treatments for faecal incontinence. One of these dynamic neosphincters in each dog was electrically trained for 8 weeks while the other served as a control. Muscle biopsies demonstrated an increase in type 1 fatigue-resistant fibres from a median of 49 (range 37-54) per cent before electrical stimulation to 78 (range 53-99) per cent 8 weeks later in the stimulated sartorius neosphincters (P < 0.05), whereas the percentage of type 1 fibres in control neosphincters increased only slightly. Retention times of saline increased from a median of 10 (range 5-50)s before to 340 (range 100-470)s after electrical stimulation (P < 0.05) but also increased in control neosphincters (to 370 (range 330-1200)s); this may indicate that electrical stimulation immediately increases acute retention times. It is concluded that construction of a neosphincter is technically feasible with preservation of muscle morphology and that stimulation induces morphological and functional changes towards the characteristics of the external anal sphincter.

Anal Canal↗
PubMed1994

Dynamic graciloplasty for anal atresia.

The aim of this study was to assess whether an electrically stimulated graciloplasty (dynamic graciloplasty) can achieve continence in nine patients with anal atresia (median age, 28 years; range, 18 to 40). As the first procedure, a gracilis muscle was transposed. Six weeks later, intramuscular electrodes were implanted and connected to a pulse generator. Eventually, the muscle was gradually trained, by electrical stimulation, to achieve fecal continence. Continence was obtained in five patients (55%). Manometry demonstrated an increase in mean anal pressure, from 36 mm Hg (without stimulation) to 52 mm Hg (with stimulation), after 8 weeks (mean increase, 16 mm Hg, [95% confidence interval, 8, 24 mm Hg; n = 9; P < .01). Failures resulted from a noncontracting distal part of the gracilis muscle (in three patients) and a nondistending rectum (in one patient). We conclude that dynamic graciloplasty can achieve continence in a substantial number of patients with thus-far untreatable incontinence after surgical correction for anal atresia.

Adult↗
PubMed1993

Long-term follow-up after open cholecystectomy.

The long-term outcome of open cholecystectomy was investigated. Follow-up data at a median of 10 years were obtained from physicians' records on 325 (92.6 per cent) of 351 patients treated for symptomatic gallbladder stones by open cholecystectomy between 1978 and 1980. One 79-year-old patient died after operation, from a pulmonary complication. Of the 325 patients, 81.5 per cent were currently asymptomatic or had not had symptoms during follow-up until death. Sixty patients (18.5 per cent) had complaints after 10 years. Stone recurrence was found in five patients (1.5 per cent); ten others (3.1 per cent) had biliary tract-related complaints during follow-up. Blood samples were obtained in 67.3 per cent of surviving patients with biliary complaints. There were no laboratory findings associated with biliary obstruction. Patients with typical symptoms of gallstone disease before surgery had significantly fewer complaints during follow-up than those with typical as well as atypical symptoms (14.8 versus 26.5 per cent, P < 0.02). However, most of these complaints were not related to the procedure. It is concluded that the majority of patients reported no complaints or postcholecystectomy symptoms 10 years after surgery.

Adolescent↗
PubMed1993

Morphology of dynamic graciloplasty compared with the anal sphincter.

Dynamic graciloplasty for fecal incontinence includes gracilis muscle transposition around the anal canal as a new sphincter and subsequent electrical stimulation. The aim of electrical stimulation is to transform the gracilis fast-twitch, "fatigue-prone" fibers into slow-twitch, "fatigue-resistant" fibers to achieve a sustained tonic contraction. The latter is considered essential for sphincter function. Therefore, the following features of transposed gracilis muscle morphology were studied in nine patients before and after electrical stimulation: 1) the percentage of Type I fibers, 2) the lesser diameter of these fibers, and 3) the positive collagen staining area. Furthermore, the external and sphincter and gracilis muscle histology was investigated in six autopsy cases. The mean percentage of Type I, slow-twitch, fatigue-resistant fibers in transposed gracilis muscle increased from 46 percent before electrical stimulation to 64 percent (P < 0.01, paired Student's t-test) after electrical stimulation. The mean lesser diameter of these fibers did not change significantly (from 32 to 29 microns), and the mean percentage of collagen increased from 4 percent before electrical stimulation to 7 percent (P < 0.01) afterward. The external sphincter in cadavers demonstrated a predominance of Type I fibers (80 percent) with a lesser diameter of 23 microns and a high percentage (12 percent) of collagen. Gracilis muscle histology was uniform at six different sample sites in these cadaver dissections. We conclude that electrical stimulation induces histologic changes in transposed gracilis muscle, allowing this muscle to function as an external anal sphincter.

Anal Canal↗
PubMed1993

Feasibility of stoma continence, using electrically stimulated rectus abdominis muscle in pigs.

To develop surgical techniques to obtain stoma continence with a muscular sphincter, the anatomy (especially innervation and vascularization patterns) of the human abdominal wall muscles was studied in three cadaver dissections. It was found that transposed rectus abdominis muscle might be positioned as a new sphincter (sphincteroplasty). Next, the feasibility was assessed in six pigs, and the rectus muscle was positioned as a sphincter around a Thiry Vella loop. The use of three different surgical procedures has been assessed: 1) a muscular ring of the proximal rectus was constructed and partly denervated the muscle; 2) the distal end of the Thiry Vella loop was pulled through the middle of the rectus muscle, thereby also introducing partial muscle denervation; and 3) a sling was constructed using the distal muscle part. In four of these six pigs, identical procedures were performed also at the left side. These new sphincters were electrically stimulated (with implanted stimulation devices) to study the feasibility of prolonged sphincter contraction independent of will. Stimulation with a frequency of 25 Hz was used at the right and 2 Hz was used at the left sphincters. It was found that electrical stimulation with a frequency of 25 Hz as well as 2 Hz increased the percentage of Type I (relatively fatigue-resistant) muscle fibers significantly from 42 to 65 percent (n = 6) in the right and from 50 to 67 percent (n = 4) in the left rectus muscle into innervated muscle areas of the sphincters. This increase is considered essential for sustained sphincter function. Stoma continence was not achieved because constructing muscular rings (as a sphincter) caused partial atrophy. Construction of a sling using the distal part of the rectus did not cause substantial atrophy, but continence was not achieved because the dorsal side of the Thiry Vella loop was not completely covered with muscle fibers.

Abdominal Muscles↗
PubMed1993

Evaluation of gracilis muscle transposition for fecal incontinence with magnetic resonance imaging.

Ten consecutive patients with incapacitating fecal incontinence were treated with 'anal dynamic graciloplasty' (transposition of the gracilis muscle around the anal canal and implantation of intramuscular electrodes connected with an implanted pulse generator, 6 weeks later) to achieve continence. We measured the gracilis muscle diameter immediately after transposition and before implantation of the stimulation device. It was found that gracilis diameter decreased from 12 (5 days after transposition) to 8 mm, 6 weeks later (mean decrease: 4 mm (95% confidence interval 3.6), n = 10, P < 0.05). In addition, morphology demonstrated a decrease of both Type I and Type II muscle fiber diameter and an increase in endomysial collagen. Despite this decrease in muscle (and muscle fiber) diameter, electrical stimulation of the transposed gracilis muscle increased the pressure into the anal canal from 37 to 55 mmHg (mean increase: 17 mmHg (95% confidence interval 6.29), P < 0.05). Fecal continence was achieved in seven (70%) of these patients. Further analysis revealed no correlations between reduction of the gracilis muscle diameter before implantation of the stimulation device and clinical outcome in terms of achieved continence and/or anal canal pressures. MRI is an excellent method to demonstrate the shape of gracilis muscle after transposition. However, the size of transposed gracilis muscle is not associated with the functional outcome.

Anal Canal↗
PubMed1992

[Anal dynamic plastic surgery of the gracilis muscle; a new surgical technique for the treatment of fecal incontinence].

OBJECTIVE: To study the clinical outcome of anal dynamic graciloplasty (gracilis muscle transposition and implantation of electric stimulation device) in a consecutive series of 12 patients. DESIGN: Prospective study. SETTING: Maastricht University Hospital. PATIENTS AND METHODS: Twelve patients with incapacitating faecal incontinence were treated using anal dynamic graciloplasty because they were not amenable to other medical management. The data were analysed with emphasis on the clinical outcome, anal manometry, and gracilis muscle composition before and after electric stimulation. Results were considered significant if p < or = 0.05, using the paired Student's t-test. RESULTS: Eight patients achieved complete faecal continence, one patient still has a previously constructed colostomy and in three patients no faecal incontinence could be achieved, due to infections. Median follow-up is now over 18 months (range 16 weeks-5 years). Anal manometry demonstrated an anal pressure increased from 39 mmHg (without stimulation) to 66 mmHg with electric stimulation (mean increase 27 mmHg (CI: 19-35; n = 12, p < 0.01). Gracilis muscle composition showed an increase of type I relatively fatigue-resistant fibres, capable of prolonged contractions, from 45% before stimulation to 64% afterwards (mean increase 19% (CI: 14-21; n = 8, p < 0.01). CONCLUSION: Dynamic graciloplasty is capable of replacing the function of damaged or absent anal sphincters. The construction of a colostomy in patients with incapacitating faecal incontinence can be avoided.

Adult↗