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Dourado J, Garoufalia Z, Emile SH, Wignakumar A, Rogers P, Weiss BP, Meknarit S, Mavarantonis S, Wexner SD, DaSilva G. Abnormal Upper Gastrointestinal Motility Reduces the Efficacy of Colectomy for Colonic Inertia: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2025; 59:129-137. [PMID: 39652425 DOI: 10.1097/mcg.0000000000002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 11/10/2024] [Indexed: 01/11/2025]
Abstract
This systematic review aimed to assess the effects of upper gastrointestinal (UGI) dysmotility on outcomes of surgical treatment of colonic inertia (CI). This PRISMA-compliant systematic review and meta-analysis searched PubMed, Scopus, Google Scholar, and clinicaltrials.gov through October 2023 for studies that assessed outcomes of CI patients who underwent colectomy while putting data on UGI motility in context. The primary outcome was postoperative persistence or recurrence of constipation. Secondary outcomes were postoperative complications, continence, and quality of life (QoL) improvements. The revised tool to assess the risk of bias in nonrandomized studies of interventions was used to assess the risk of bias, and the certainty of evidence was graded using the GRADE approach. Eight studies (1991 to 2013) included data on UGI evaluation of CI patients; 12.8 to 24.3% were tested for concomitant GI dysmotility. High rates of motility abnormalities were in the small bowel (31.4%), stomach (34.1%), and esophagus (48.5%). Patients with UGI dysmotility and CI were more likely to experience constipation recurrence (OR: 10.71, 95% CI: 2.17; 52.87, P =0.004) and less likely to have postoperative QoL improvements (OR: 0.16, 95% CI: 0.04; 0.65, P =0.010) compared with patients with CI and no abnormal UGI testing. There were no differences in postoperative complications (OR: 1.59, 95% CI: 0.64; 4.267, P =0.542) or continence (OR: 0.29, 95% CI: 0.06; 1.47, P =0.0136) rates. Large subsets of CI patients with concomitant UGI dysmotility may be preoperatively underdiagnosed. UGI dysmotility may be associated with a higher risk of postoperative recurrence of constipation and suboptimal improvements in QoL. We recommend routine UGI evaluation before surgery for CI.
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Affiliation(s)
- Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Anjelli Wignakumar
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
| | - Brett P Weiss
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
| | - Sarinya Meknarit
- Florida Atlantic University, Department of General Surgery, Boca Raton Regional Hospital, Boca Raton, FL
| | | | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
| | - Giovanna DaSilva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston
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Kennedy LN, Griebling TL, Souders CP. Updates on the use of neuromodulation in geriatric patients. Curr Opin Urol 2024; 34:428-432. [PMID: 39175397 DOI: 10.1097/mou.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
PURPOSE OF REVIEW In light of the updated AUA/SUFU guidelines on the diagnosis and treatment of overactive bladder (OAB), increased utilization of advanced therapies is expected in the coming years. The primary aim of this review is to summarize existing outcome and safety data on the use of neuromodulation in geriatric patients, as well as highlight recent advances in neuromodulation that may be particularly advantageous in the geriatric population. RECENT FINDINGS There are mixed data demonstrating efficacy of sacral neuromodulation by decade of life, with older individuals most often demonstrating lower odds of progressing to stage 2 implantation. However, a large majority of patients still undergo stage 2 implantation with no significant increase in complications reported when compared to younger cohorts. Neuromodulation is broadening to have wider indications outside of OAB, which may be particularly beneficial in the elderly population (fecal incontinence, nonobstructive urinary retention, and constipation). Posterior tibial nerve stimulation remains a well tolerated and efficacious treatment for OAB, with new FDA-approved implantable devices joining the commercial market, which may expand access for elderly populations. SUMMARY The data are encouraging and support the use of neuromodulation in geriatric patients.
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Affiliation(s)
| | - Tomas L Griebling
- Department of Urology, University of Kansas Medical Center
- The Landon Center on Aging, The University of Kansas, Kansas City, Kansas, USA
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Besendörfer M, Knorr C, Kirchgatter A, Müller H, Reis Wolfertstetter P, Matzel KE, Diez S. Sacral neuromodulation in children and adolescents with defecation disorders. Neurogastroenterol Motil 2024; 36:e14808. [PMID: 38703048 DOI: 10.1111/nmo.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 04/06/2024] [Accepted: 04/14/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Even if understanding of neuronal enteropathies, such as Hirschsprung's disease and functional constipation, has been improved, specialized therapies are still missing. Sacral neuromodulation (SNM) has been established in the treatment of defecation disorders in adults. The aim of the study was to investigate effects of SNM in children and adolescents with refractory symptoms of chronic constipation. METHODS A two-centered, prospective trial has been conducted between 2019 and 2022. SNM was applied continuously at individually set stimulation intensity. Evaluation of clinical outcomes was conducted at 3, 6, and 12 months after surgery based on the developed questionnaires and quality of life analysis (KINDLR). Primary outcome was assessed based on predefined variables of fecal incontinence and defecation frequency. KEY RESULTS Fifteen patients enrolled in the study and underwent SNM (median age 8.0 years (range 4-17 years)): eight patients were diagnosed with Hirschsprung's disease (53%). Improvement of defecation frequency was seen in 8/15 participants (53%) and an improvement of fecal incontinence in 9/12 patients (75%). We observed stable outcome after 1 year of treatment. Surgical revision was necessary in one patient after electrode breakage. Urinary incontinence was observed as singular side effect of treatment in two patients (13%), which was manageable with the reduction of stimulation intensity. CONCLUSIONS SNM shows promising clinical results in children and adolescents presenting with chronic constipation refractory to conservative therapy. Indications for patients with enteral neuropathies deserve further confirmation.
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Affiliation(s)
- Manuel Besendörfer
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Christian Knorr
- Pediatric Surgery, RoMed Klinikum Rosenheim (former Pediatric Surgery and Orthopedics Hospital Barmherzige Brüder), Rosenheim, Germany
| | - Annemarie Kirchgatter
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Hanna Müller
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care, University Hospital Marburg, University of Marburg, Marburg, Germany
| | | | - Klaus E Matzel
- Department of Surgery, Section of Coloproctology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Sonja Diez
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
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Seo M, Bae JH. Nonpharmacologic Treatment of Chronic Constipation. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 83:191-196. [PMID: 38783620 DOI: 10.4166/kjg.2024.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Functional constipation is a common clinical diagnosis that affects approximately 14% of the world's population. Non-pharmacological therapies often represent the initial steps in management and may include lifestyle adjustments or changes such as physical activity and diet. Pharmacological options have been used when the non-pharmacological approach has been ineffective. Biofeedback therapy, surgery, sacral nerve stimulation, botulinum toxin injection, and vibrating capsules can be considered in scenarios where the laxatives are ineffective. Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. This paper overviews non-pharmacological therapies for functional constipation.
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Affiliation(s)
- Myeongsook Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - June Hwa Bae
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
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Besendörfer M, Kirchgatter A, Carbon R, Weiss C, Müller H, Matzel KE, Diez S. Sacral neuromodulation for constipation and fecal incontinence in children and adolescents - study protocol of a prospective, randomized trial on the application of invasive vs. non-invasive technique. Trials 2024; 25:210. [PMID: 38515199 PMCID: PMC10958925 DOI: 10.1186/s13063-024-08052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND A therapeutic effect of sacral neuromodulation (SNM) on fecal incontinence (FI) and quality of life has been proven in adults. SNM is, however, rarely used in pediatric cases. The aim of the study is to investigate effects of SNM in pediatric constipation in a prospective parallel-group trial. METHODS A monocentric, randomized, unblinded, parallel-group trial is conducted. SNM is conducted in the invasive variant and in an innovative, external approach with adhesive electrodes (enteral neuromodulation, ENM). We include patients with constipation according to the ROME IV criteria and refractory to conventional options. Patients with functional constipation and Hirschsprung's disease are able to participate. Participants are allocated in a 1:1 ratio to either SNM or ENM group. Clinical data and quality of life is evaluated in regular check-ups. Neuromodulation is applied continuously for 3 months (end point of the study) with follow-up-points at 6 and 12 months. Findings are analyzed statistically considering a 5% significance level (p ≤ 0.05). Outcome variables are defined as change in (1) episodes of abdominal pain, (2) episodes of FI, (3) defecation frequency, (4) stool consistency. Improvement of proprioception, influence on urinary incontinence, quality of life and safety of treatment are assessed as secondary outcome variables. We expect a relevant improvement in both study groups. DISCUSSION This is the first trial, evaluating effects of neuromodulation for constipation in children and adolescents and comparing effects of the invasive and non-invasive application (SNM vs. ENM). TRIAL REGISTRATION The study is registered with clinicaltrials.gov, Identifier NCT04713085 (date of registration 01/14/2021).
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Affiliation(s)
- Manuel Besendörfer
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Annemarie Kirchgatter
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Roman Carbon
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics, and Information Processing, Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, Haus 3, Ebene 4, Mannheim, 68167, Germany
| | - Hanna Müller
- Neonatology and Pediatric Intensive Care, Hospital for Children and Adolescents, University of Marburg, Baldingerstaße, Marburg, 35043, Germany
| | - Klaus E Matzel
- Department of Surgery, Section of Coloproctology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Maximiliansplatz 2, 91054, Erlangen, Germany
| | - Sonja Diez
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany.
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Cerdán Miguel J, Arroyo Sebastián A, Codina Cazador A, de la Portilla de Juan F, de Miguel Velasco M, de San Ildefonso Pereira A, Jiménez Escovar F, Marinello F, Millán Scheiding M, Muñoz Duyos A, Ortega López M, Roig Vila JV, Salgado Mijaiel G. Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology. Cir Esp 2024; 102:158-173. [PMID: 38242231 DOI: 10.1016/j.cireng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 01/21/2024]
Abstract
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
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Affiliation(s)
| | - Antonio Arroyo Sebastián
- Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - Antonio Codina Cazador
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain
| | | | | | | | | | - Franco Marinello
- Unidad de Cirugía Colorrectal, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mónica Millán Scheiding
- Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Arantxa Muñoz Duyos
- Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Mario Ortega López
- Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Guo X, Lei C, Liang H, An J, Fang Y, Zhang X, Wang Z, Hu C, Jiang X. Chronic Sacral Nerve Stimulation Inhibits Visceral Hypersensitivity in Diarrhea-Predominant Irritable Bowel Syndrome Rats Model. Neuromodulation 2024; 27:295-301. [PMID: 37930296 DOI: 10.1016/j.neurom.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/08/2023] [Accepted: 08/08/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Sacral nerve stimulation (SNS) is emerging as a novel treatment for irritable bowel syndrome (IBS). However, its effects are limited, and the underlying mechanisms remain largely unknown. MATERIALS AND METHODS In this study, rats were divided into three groups (n = 12 rats per group): 1) the SNS group; 2) the sham SNS group (the sham group for short); and 3) the control group. The SNS and sham groups were exposed to chronic and acute stress to establish an IBS model. Electrode implantation surgery was performed in rats with the IBS model. The SNS group received electrical stimulation for 30 minutes every day for seven days. Abdominal withdrawal reflex (AWR) was used to evaluate the effect of SNS on visceral sensitivity in diarrhea-predominant IBS (IBS-D) rats. The frequency domain of heart rate variability (HRV) was analyzed to assess the effect of SNS on regulating the autonomic function. The expression of transient receptor potential vanilloid 1 (TRPV1) in the colon, spinal cord, and hippocampus was detected by immunohistochemistry to explore the mechanism of SNS in IBS-D rats. RESULTS Compared with the sham group, AWR scores were significantly decreased under different gas volumes of stimulation of 0.4, 0.6, and 0.8 ml for rectal distention in the SNS group (all p < 0.05). However, there was no significant difference <1.0 ml between the two groups (p > 0.05). Compared with the sham group, the frequency domain indexes of HRV were significantly altered. Normalized low-frequency power and low frequency-to-high frequency ratio were significantly decreased, and normalized high-frequency power was significantly increased in the SNS group (all p < 0.05). Moreover, the expression of TRPV1 in the spinal cord and colon in the SNS group was significantly decreased compared with the sham group (both p < 0.05). These results suggested that chronic SNS not only improved the visceral sensitivity and autonomic dysfunction but also decreased the expression of TRPV1 in the spinal cord-gut tissue in IBS-D rats. CONCLUSION Chronic SNS was found to have an inhibitory effect on visceral hypersensitivity in IBS-D rats, providing experimental evidence for its potential clinical application in IBS.
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Affiliation(s)
- Xiaojuan Guo
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Changsheng Lei
- National Engineering Research Center of Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Hanwei Liang
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiaxu An
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yanbin Fang
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaolu Zhang
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhiyan Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China; Department of Psychology, University of Chinese Academy of Science, Beijing, China
| | - Chunhua Hu
- National Engineering Research Center of Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Xuan Jiang
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
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Zhou S, Nerusu LA, Hussain N, Abd-Elsayed A. Sacral neuromodulation. NEUROMODULATION TECHNIQUES FOR THE SPINE 2024:137-149. [DOI: 10.1016/b978-0-323-87584-4.00026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Martellucci J, Annicchiarico A, Scheiterle M, Trompetto M, Prosperi P. Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery. Int J Colorectal Dis 2023; 39:2. [PMID: 38063973 PMCID: PMC10709257 DOI: 10.1007/s00384-023-04567-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery. METHODS A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time. RESULTS Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001). CONCLUSION SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.
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Affiliation(s)
| | - Alfredo Annicchiarico
- Emergency Surgery, Careggi University Hospital, Florence, Italy.
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
- Department of General Surgery, Vaio Hospital, Fidenza, Italy.
| | | | - Mario Trompetto
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - Paolo Prosperi
- Emergency Surgery, Careggi University Hospital, Florence, Italy
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Diez S, Kirchgatter A, Adam D, Füldner A, Müller H, Matzel KE, Besendörfer M. Noninvasive Sacral Neuromodulation in Children and Adolescents: A Case-Control Study of Patients With Chronic Refractory Constipation. Neuromodulation 2023; 26:1858-1866. [PMID: 36207226 DOI: 10.1016/j.neurom.2022.08.451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/24/2022] [Accepted: 08/22/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In adult patients with chronic refractory constipation, invasive sacral neuromodulation (SNM) has been applied successfully. There is a need for less invasive solutions while providing comparable therapeutic effects in children and adolescents. We present a prospective, interventional case-control study on the application of noninvasive SNM. MATERIALS AND METHODS Patients with chronic constipation refractory to conservative treatment were prospectively included in the study from 2018 to 2021 and randomized to either SNM (SNM group: single current stimulation for 24 h/d, frequency 15 Hz, pulse width 210 μs, intensity 1-10 mA) or conventional treatment (controls: full range of pharmacologic and nonpharmacologic options). Treatment was conducted for 12 weeks. Treatment effects were collected with specialized questionnaires and quality-of-life analysis (KINDLR). Outcome variables were defecation frequency, stool consistency, fecal incontinence (FI) episodes, and abdominal pain. RESULTS Analysis was conducted in 28 patients with SNM and 31 controls (median age 7.0, range 3-16 years). Overall responsiveness to treatment was 86% of the SNM group and 39% of the control group (p < 0.001). All outcome variables were positively influenced by SNM treatment. Defecation frequency improved in 46% of patients with SNM and in 19% of controls (p = 0.026), as did stool consistency in 57% of patients with SNM and in 26% of controls (p = 0.014). Fecal incontinence was significantly reduced in 76% of patients with SNM (n = 16/21 vs 42% of controls [n = 11/26], p = 0.042). Quality of life improved significantly during SNM treatment (71.32 [baseline] vs 85.00 [after 12 weeks], p < 0.001) and confirmed a positive influence of SNM treatment compared with the control group (85.00 [SNM after 12 weeks] vs 79.29 [controls after 12 weeks], p = 0.047). CONCLUSIONS Outcome of noninvasive SNM treatment in patients with chronic refractory constipation is better than conventional treatment.
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Affiliation(s)
- Sonja Diez
- Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Annemarie Kirchgatter
- Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dana Adam
- Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arne Füldner
- Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hanna Müller
- Department of Pediatrics, Neonatology and Pediatric Intensive Care, University of Marburg, Marburg, Germany
| | - Klaus E Matzel
- Department of Surgery, Section of Coloproctology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Besendörfer
- Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Maciaczyk J, Bara G, Kurth F. [Functional-neurosurgical treatment options for functional pelvic floor disorders : Value of sacral neuromodulation]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:835-843. [PMID: 37823893 DOI: 10.1007/s00117-023-01214-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Sacral neuromodulation is an established minimally invasive therapy indicated for the treatment of functional pelvic floor disorders. While it received its original US Food and Drug Administration (FDA) approval for the treatment of overactive bladder symptoms, it is now regarded as a therapeutic option to treat both urinary/fecal incontinence and retention. In addition, it has proven to be a valuable tool in the treatment of chronic pelvic pain, and preliminary results indicate a potential to elicit improvements in sexual functioning. OBJECTIVE This article serves to provide a summary of the therapy and its applications. METHOD Selective literature review. RESULTS Sacral neuromodulation implants allow for the controlled shifting of the autonomic control of bladder and rectum towards an inhibition or facilitation of voiding, dependent on the patient's needs and under the patient's control. At the same time and depending on the applied stimulation, the implants can interfere with the nerve's conduction of pain signals. This makes them a therapeutic option for pelvic pain that fails to respond to conventional treatment. Finally, there have been first reports suggesting improvements in sexual dysfunction under sacral neuromodulation, thus, potentially opening up a new line of therapy for those disorders. DISCUSSION Sacral neuromodulation is a flexible and efficient form of therapy for functional disorders of the pelvic floor. Specifically, the same intervention can treat seemingly contradictory disorders such as urinary/fecal incontinence and retention as well as chronic pain.
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Affiliation(s)
- Jarek Maciaczyk
- Abteilung Stereotaktische und Funktionelle Neurochirurgie, Klinik für Neurochirurgie, Uniklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Gregor Bara
- Abteilung Stereotaktische und Funktionelle Neurochirurgie, Klinik für Neurochirurgie, Uniklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Florian Kurth
- Abteilung Stereotaktische und Funktionelle Neurochirurgie, Klinik für Neurochirurgie, Uniklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
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Bittorf B, Matzel K. [Sacral Neuromodulation for Fecal Incontinence and Constipation: Evidence, Programming and Long-term Management]. Zentralbl Chir 2023; 148:228-236. [PMID: 37267977 DOI: 10.1055/a-2063-3630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence. METHODS AND RESULTS A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up - in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable. CONCLUSION Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.
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Affiliation(s)
- Birgit Bittorf
- Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Klaus Matzel
- Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
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13
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Orhurhu V, Hussain N, Karri J, Mariano ER, Abd-Elsayed A. Perioperative and anesthetic considerations for the management of neuromodulation systems. Reg Anesth Pain Med 2023; 48:327-336. [PMID: 37080581 DOI: 10.1136/rapm-2022-103660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/04/2022] [Indexed: 04/22/2023]
Abstract
The use of neuromodulation systems is increasing for the treatment of various pathologies ranging from movement disorders to urinary incontinence to chronic pain syndromes. While the type of neuromodulation devices varies, they are largely categorized as intracranial (eg, deep brain stimulation), neuraxial (eg, spinal cord stimulation, dorsal root ganglion stimulation, and intrathecal drug delivery systems), or peripheral (eg, sacral nerve stimulation and peripheral nerve stimulation) systems. Given the increasing prevalence of these systems in the overall population, it is important for anesthesiologists, surgeons, and the perioperative healthcare team to familiarize themselves with these systems and their unique perioperative considerations. In this review, we explore and highlight the various neuromodulation systems, their general perioperative considerations, and notable special circumstances for perioperative management.
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Affiliation(s)
- Vwaire Orhurhu
- Anesthesiology, University of Pittsburgh Medical Center, Williamsport, Pennsylvania, USA
- Pain Medicine, MVM Health, East Stroudsburg, Pennsylvania, USA
| | - Nasir Hussain
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jay Karri
- Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Divsion of Pain Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World J Gastroenterol 2023; 29:1261-1288. [PMID: 36925458 PMCID: PMC10011959 DOI: 10.3748/wjg.v29.i8.1261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/05/2022] [Accepted: 02/16/2023] [Indexed: 02/28/2023] Open
Abstract
Functional constipation (FC) is considered the most common functional gastrointestinal disorder in children with a pooled global prevalence of 14.4% (95% confidence interval: 11.2-17.6) when diagnosed based on the Rome IV criteria. Its pathophysiological mechanisms are thought be multifactorial and complicated, resulting in difficult management. Currently, the most effective medication, when used in parallel with toilet training, is osmotic laxatives. Children's adherence to medication and parental concern regarding long-term laxative use are the main contributors to treatment failure. Recently, novel therapies with a high safety profile have been developed, such as probiotics, synbiotics, serotonin 5-hydroxytryptamine 4 receptor agonists, chloride channel activators, and herbal and transitional medicines; nonetheless, well-designed research to support the use of these therapies is needed. This review aims to focus on multiple aspects of FC in children, including global prevalence, pathogenesis, diagnostic criteria, tools, as well as conventional and novel treatment options, such as non-pharmacological management, including adequate fiber and fluid intake, physiotherapy, or neuromodulators. We also report that in very difficult cases, surgical intervention may be required.
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Affiliation(s)
- Duc Long Tran
- Thailand and Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Bangkok, Thailand
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City 9000, Viet Nam
| | - Palittiya Sintusek
- Thai Pediatric Gastroenterology, Hepatology and Immunology Research Unit, Division of Gastroenterology, Department of Pediatrics, King Chulalongkorn Memorial Hospital and Thai Red Cross, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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15
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Sharifiaghdas F, Ahmadzade M, Rouientan H. A case report of sacral neuromodulation tined lead migration into the rectum. Clin Case Rep 2023; 11:e6843. [PMID: 36694656 PMCID: PMC9842787 DOI: 10.1002/ccr3.6843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
This report describes a 26-year-old woman who underwent sacral neuromodulation explant following lead migration and rectal wall penetration. Her device was implanted due to persistent urinary retention. The tined lead wire was dissected to the fascia and cut. The rectal part of the lead was removed with gentle traction.
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Affiliation(s)
- Farzaneh Sharifiaghdas
- Urology and Nephrology Research Center, Department of UrologyShahid Labbafinejad Medical Center, Shahid Beheshti University of Medical SciencesTehranIran
| | - Mohadese Ahmadzade
- Urology and Nephrology Research Center, Department of UrologyShahid Labbafinejad Medical Center, Shahid Beheshti University of Medical SciencesTehranIran
| | - Hamidreza Rouientan
- Urology and Nephrology Research Center, Department of UrologyShahid Labbafinejad Medical Center, Shahid Beheshti University of Medical SciencesTehranIran
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16
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Comparison of surgical techniques for optimal lead placement in sacral neuromodulation: a cadaver study. Tech Coloproctol 2022; 26:707-712. [PMID: 35633425 PMCID: PMC9360091 DOI: 10.1007/s10151-022-02632-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 05/02/2022] [Indexed: 12/05/2022]
Abstract
Background Sacral neuromodulation (SNM) is a common treatment for patients with urinary and faecal incontinence. A close contact of the tined lead electrode with the targeted nerve is likely to improve functional outcome. The aim of this study was to compare the position of the SNM lead in relation to the sacral nerve by comparing different implantation techniques. Methods This cadaver study was conducted at the Division of Anatomy of Vienna's Medical University in October 2020. We dissected 10 cadavers after bilateral SNM lead implantation (n = 20), using two different standardized implantation techniques. The cadavers were categorized as group A (n = 10), representing the conventional guided implantation group and group B (n = 10), where SNM implantation was conducted with the novel fluoroscopy-guided “H”-technique. The primary goal was to assess the distance between the sacral nerve and the lead placement. Results The electrodes were inserted at a median angle of 58.5° (46–65°) in group A and 60° (50–65°) in group B, without reaching statistical significance. In 8 cadavers, the lead entered the S3 foramen successfully. The median distance of the lead to the nerve did not show a significant difference between both groups (E0: Group A: 0.0 mm vs. Group B: 0.0 mm, p = 0.969; E1: Group A: 0.0 mm vs. Group B: 0.5 mm p = 0.754; E2: Group A: 2.5 mm vs. Group B: 2.5 mm p = 1.000; E3: Group A: 3.5 mm vs. Group B: 4.0 mm p = 0.675). In 2 cases (20%) of the conventional group A, the lead was misplaced and located at the gluteal muscle. Perforation of the presacral fascia was observed in one lead placement in group A and in two placements in group B. Conclusions Both standardized implantation techniques may ensure close electrode proximity to the targeted nerve. Misplacement of the electrode was more often observed with the conventional implantation technique.
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17
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The Relationship Between Cortical Activation in Response to Anorectal Stimuli and Continence Behavior in Freely Behaving Rats Before and After Application of Sacral Nerve Stimulation. Dis Colon Rectum 2022; 65:284-294. [PMID: 34990427 DOI: 10.1097/dcr.0000000000002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Changes in anorectal sensation have been reported in patients with fecal incontinence, and there is limited evidence that sacral nerve stimulation can restore normal sensation. OBJECTIVE The aims of the present study were to investigate changes in the transmission of sensory anorectal stimuli in a rodent model of fecal incontinence and to study the effects of sacral nerve stimulation on defecation behavior. DESIGN An established model of fecal incontinence was utilized for this study. INTERVENTION Pudendal nerve stretch and compression were used in 16 adult female Wistar rats and were monitored for 3 weeks: 6 rats received sacral nerve stimulation for 1 week by using an implantable neurostimulator and 10 rats had nonfunctioning "dummy" devices inserted. Five additional rats were sham operated. Anorectal cortical evoked potentials were used as a surrogate marker for anorectal sensory function. MAIN OUTCOME MEASURES The primary outcomes measured were fecal incontinence index, evoked potential amplitude, and latency. RESULTS Fifty percent of rats showed behavioral signs of fecal incontinence measured by the Fecal Incontinence Index (>0.20), calculated by using the pellet distribution outside the cage's latrine area. Anorectal evoked potential amplitude was reduced in rats with a Fecal Incontinence Index >0.20 (p = 0.019). The amplitude of forepaw evoked potentials recorded as a control was not different between groups. Chronic sacral nerve stimulation using the fully implantable device and custom rodent lead was safe and stable during this chronic prospective study. Incontinent rats (n = 3) that received sacral nerve stimulation showed an improvement of Fecal Incontinence Index and an increase of evoked potential amplitude to anorectal stimulation compared with the dummy implant controls (n = 5). LIMITATIONS The main limitation is the small number of animals that received sacral nerve stimulation. CONCLUSIONS Chronic sacral nerve stimulation is feasible in rats when miniature telemetric devices are used. Behavioral signs of fecal incontinence were positively correlated with the latency of anorectal evoked potentials. See Video Abstract at http://links.lww.com/DCR/B712.RELACIÓN ENTRE LA ACTIVACIÓN CORTICAL EN RESPUESTA A LOS ESTÍMULOS ANORRECTALES Y EL COMPORTAMIENTO DE CONTINENCIA EN RATAS QUE SE COMPORTAN LIBREMENTE ANTES Y DESPUÉS DE LA APLICACIÓN DE ESTIMULACIÓN DEL NERVIO SACRO. ANTECEDENTES Se han informado cambios en la sensación anorrectal en pacientes con incontinencia fecal y hay evidencia limitada de que la estimulación del nervio sacro puede restaurar la sensación normal. OBJETIVO Los objetivos del presente estudio fueron investigar los cambios en la transmisión de estímulos anorrectales sensoriales en un modelo de roedor de incontinencia fecal y estudiar los efectos de la estimulación del nervio sacro en la conducta de defecación. DISEO Un modelo establecido de incontinencia fecal. INTERVENCIN Se utilizó estiramiento y compresión del nervio pudendo en 16 ratas Wistar hembras adultas y se les realizó un seguimiento durante 3 semanas: seis ratas recibieron estimulación del nervio sacro durante 1 semana utilizando un neuroestimulador implantable y diez ratas tuvieron insertados dispositivos "ficticios" no funcionantes. Se operaron simuladamente cinco ratas adicionales. Los potenciales evocados corticales anorrectales se utilizaron como marcador subrogado de la función sensorial anorrectal. PRINCIPALES MEDIDAS DE RESULTADO Índice de incontinencia fecal, amplitud de potenciales evocados y latencia. RESULTADOS El cincuenta por ciento de las ratas mostró signos de comportamiento de incontinencia fecal medidos por el Índice de incontinencia fecal (> 0.20), calculado utilizando la distribución de heces fuera del área de la letrina de la jaula. La amplitud del potencial evocado anorrectal se redujo en ratas con un índice de incontinencia fecal >0.20 (p = 0.019). La amplitud de los potenciales evocados de la pata delantera registrados como control no fue diferente entre los grupos. La estimulación crónica del nervio sacro utilizando un dispositivo totalmente implantable y un cable de roedor personalizado fue segura y estable durante este estudio prospectivo crónico. Las ratas con incontinencia (N = 3) que recibieron estimulación del nervio sacro mostraron una mejora del índice de incontinencia fecal y un aumento de la amplitud del potencial evocado a la estimulación anorrectal en comparación con los controles de implante ficticio (N = 5). LIMITACIONES La principal limitación es el pequeño número de animales que recibieron estimulación del nervio sacro. CONCLUSIONES La estimulación crónica del nervio sacro es factible en ratas cuando se utilizan dispositivos telemétricos en miniatura. Los signos conductuales de incontinencia fecal se correlacionaron positivamente con la latencia de los potenciales evocados anorrectales. Consulte Video Resumen en http://links.lww.com/DCR/B712. (Traducción-Dr. Jorge Silva Velazco).
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Wang JT, Miao YD, Guan QL. Comment on "Diagnostic approach to faecal incontinence: What test and when to perform?". World J Gastroenterol 2021; 27:5622-5624. [PMID: 34588756 PMCID: PMC8433609 DOI: 10.3748/wjg.v27.i33.5622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/21/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
We recently read with interest the article "Diagnostic approach to faecal incontinence: What test and when to perform?". This is a comprehensive and practical review, which has particular significance for guiding clinicians to improve the examination strategy. Although we appreciate their work very much, based on the in-depth analysis of this research, we found some detailed problems in the article and will give our comments in this letter. If the author can further improve the relevant research, it will be valuable.
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Affiliation(s)
- Jiang-Tao Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Yan-Dong Miao
- The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Quan-Lin Guan
- Department of Oncology, The First Hospital of Lanzhou University, Lanzhou University, Lanzhou 730000, Gansu Province, China
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19
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Meurette G, Siproudhis L, Leroi AM, Damon H, Urs Josef Keller D, Faucheron JL. Sacral neuromodulation with the InterStim™ system for faecal incontinence: results from a prospective French multicentre observational study. Colorectal Dis 2021; 23:1463-1473. [PMID: 33387373 DOI: 10.1111/codi.15507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
AIM The aim of this work was to evaluate the effectiveness, patient satisfaction and quality of life (QoL) and the safety of sacral neuromodulation (SNM) with the InterStimTM system for the treatment of faecal incontinence (FI) and establish whether results published predominantly by expert sites are generalisable. METHOD This is a prospective, multicentre, observational study that invited all French sites treating FI with the InterStim™ system to enrol subjects indicated for an SNM therapy evaluation. Data were collected at three follow-up visits within 1 and 15 months. Therapeutic effectiveness was evaluated by the reduction in leakages per week and improvements over time in the ability to defer defaecation and QoL (as measured with the Faecal Incontinence Quality of Life score). Safety was assessed through reported adverse events. RESULTS A total of 221 subjects with a mean age of 62.1 years were tested (184 women) and 178 received a permanent implant. For all implanted subjects with diary data at baseline and follow-up, a reduction in leakage of more than 50% was observed in 80%, 76% and 83% at 1-3, 4-8 and 9-15 months, respectively. The mean number of leakage episodes and urgency improved significantly compared with the baseline (p < 0.0001). Subjects showed improvements in QoL and time to defer defaecation and were generally satisfied with their therapy. The main device-related adverse event was the requirement to undertake reprogramming (in 52% of subjects with actions following an event). The rates of infection (in 6% of subjects) and surgical revision (in 10% of subjects) were in agreement with literature reports. CONCLUSION This study confirms the clinical effectiveness, safety and positive effect of SNM on QoL as well as high patient satisfaction for the treatment of FI in real-life.
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Affiliation(s)
| | | | | | - Henri Damon
- Hôpital Edouard Herriot, CHU de Lyon, Lyon, France
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20
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Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractThe aim of this study was to evaluate the published professional association guidelines regarding the current diagnosis and treatment of functional intestinal constipation in adults and to compare those guidelines with the authors’ experience to standardize actions that aid clinical reasoning and decision-making for medical professionals. A literature search was conducted in the Medline/PubMed, Scielo, EMBASE and Cochrane online databases using the following terms: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Conclusively, chronic intestinal constipation is a common condition in adults and occurs most frequently in the elderly and in women. Establishing a precise diagnosis of the physiopathology of functional chronic constipation is complex and requires many functional tests in refractory cases. An understanding of intestinal motility and the defecatory process is critical for the appropriate management of chronic functional intestinal constipation, with surgery reserved for cases in which pharmacologic intervention has failed. The information contained in this review article is subject to the critical evaluation of the medical specialist responsible for determining the action plan to be followed within the context of the conditions and clinical status of each individual patient.
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21
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Mass-Lindenbaum M, Calderón-Pollak D, Goldman HB, Pizarro-Berdichevsky J. Sacral neuromodulation - when and for who. Int Braz J Urol 2021; 47:647-656. [PMID: 33621015 PMCID: PMC7993957 DOI: 10.1590/s1677-5538.ibju.2021.99.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/10/2020] [Indexed: 01/14/2023] Open
Affiliation(s)
| | | | - H B Goldman
- Glickman Urologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Javier Pizarro-Berdichevsky
- Centro de Innovación en Piso Pélvico, Hospital Sótero del Río, Santiago, Chile.,Division de Obstetricia y Ginecología, Hospital Sótero del Río, Pontificia Universidad Católica de Chile, Santiago, Chile
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22
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Seifarth C, Slavova N, Degro C, Lehmann KS, Kreis ME, Weixler B. Sacral nerve stimulation in patients with ileal pouch-anal anastomosis. Int J Colorectal Dis 2021; 36:1937-1943. [PMID: 34160664 PMCID: PMC8346414 DOI: 10.1007/s00384-021-03981-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results after proctocolectomy and ileal pouch-anal anastomosis (IPAA) are generally good. However, some patients suffer from high stool frequency or fecal incontinence. Sacral nerve stimulation (SNS) may represent a therapeutic alternative in these patients, but little is known about indication and results. The aim of this study was to evaluate incontinence after IPAA and demonstrate SNS feasibility in these patients. METHODS This retrospective study includes patients who received a SNS between 1993 and 2020 for increased stool frequency or fecal incontinence after proctocolectomy with IPAA for ulcerative colitis. Proctocolectomy was performed in a two- or three-step approach with ileostomy closure as the last step. Demographic, follow-up data and functional results were obtained from the hospital database. RESULTS SNS was performed in 23 patients. Median follow-up time after SNS was 6.5 years (min. 4.2-max. 8.8). Two patients were lost to follow-up. The median time from ileostomy closure to SNS implantation was 6 years (min. 0.5-max. 14.5). Continence after SNS improved in 16 patients (69%) with a median St. Marks score for anal incontinence of 19 (min. 4-max. 22) before SNS compared to 4 (0-10) after SNS placement (p = 0.012). In seven patients, SNS therapy was not successful. CONCLUSION SNS implantation improves symptoms in over two-thirds of patients suffering from high stool frequency or fecal incontinence after proctocolectomy with IPAA. Awareness of the beneficial effects of SNS should be increased in physicians involved in the management of these patients.
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Affiliation(s)
- C. Seifarth
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - N. Slavova
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - C. Degro
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - K. S. Lehmann
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - M. E. Kreis
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - B. Weixler
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
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23
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Zhang SH, Chen Y. Progress in research of sacral nerve stimulation. Shijie Huaren Xiaohua Zazhi 2020; 28:1266-1271. [DOI: 10.11569/wcjd.v28.i24.1266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sacral nerve stimulation (SNS) is well-known as a minimally invasive treatment. Originally, it was mainly used to treat urinary system diseases such as urge urinary incontinence. Gradually, it is used to treat digestive system diseases such as fecal incontinence and chronic constipation. SNS is a method in which electrical pulse signals are sent out through pulse generators to stimulate the sacral nerve directly or indirectly, thus modulating the nerve reflex of the bladder, urethra, anus, colon, and rectum and improving abnormal nerve regulation to achieve the therapeutic effect. The regulation of the sacral nerve is often carried out by inserting electrodes into the sacral spinal canal S2-4 (mostly S3), and the symptoms are improved by complex regulation of spinal reflex and supraspinal reflex. However, the exact mechanism is still unclear. Many studies have shown that SNS plays a key role in the treatment of many diseases of the urinary system and digestive system. This paper reviews the progress in the research of SNS.
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Affiliation(s)
- Shu-Hui Zhang
- Department of Gastroenterology, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Yan Chen
- Department of Gastroenterology, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
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24
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Chen G, Liao L, Wang Y, Ying X. Effect of sacral neuromodulation on bowel dysfunction in patients with neurogenic bladder. Colorectal Dis 2020; 22:2155-2160. [PMID: 32681678 DOI: 10.1111/codi.15273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/14/2020] [Accepted: 05/24/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this retrospective study was to evaluate the clinical effect of sacral neuromodulation (SNM) on bowel dysfunction in patients with neurogenic bladder using the neurogenic bowel dysfunction (NBD) score. METHOD Between July 2012 and July 2019, 41 patients with both neurogenic bladder and bowel dysfunction underwent permanent SNM implantation. The NBD score was used to evaluate the bowel symptoms before the testing phase and at follow-up. The first follow-up was at the time of discharge after permanent implantation. The second follow-up was conducted by telephone after discharge. RESULTS The mean NBD score before the testing phase was 11.0 ± 5.83, whilst it significantly decreased to 5.2 ± 5.32 (n = 41, P < 0.05) at the first follow-up (32 ± 3.9 days). Before the testing phase, there were 9 patients with very minor NBD, 10 with minor NBD, 13 with moderate NBD and 9 with severe NBD. At the first follow-up, there were 26 patients with very minor NBD, 7 with minor NBD, 4 with moderate NBD and 4 with severe NBD (P < 0.05). Twenty-six patients were interviewed in the long-term follow-up (34 ± 30.9 months). The NBD score in these 26 patients was 5.6 ± 5.18, which was not significantly different from the NBD score (5.5 ± 5.33) at the first follow-up (n = 26, P > 0.05). CONCLUSION SNM facilitates a significant reduction in NBD score in patients with neurogenic bladder and bowel dysfunction. The improvement in NBD symptoms can also be used as a future indicator to determine the clinical efficacy of permanent SNM implantation in the treatment of neurogenic bladder.
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Affiliation(s)
- G Chen
- Department of Urology, China Rehabilitation Research Center, Beijing, China.,Department of Urology, Capital Medical University, Beijing, China
| | - L Liao
- Department of Urology, China Rehabilitation Research Center, Beijing, China.,Department of Urology, Capital Medical University, Beijing, China
| | - Y Wang
- Department of Urology, China Rehabilitation Research Center, Beijing, China.,Department of Urology, Capital Medical University, Beijing, China
| | - X Ying
- Department of Urology, China Rehabilitation Research Center, Beijing, China.,Department of Urology, Capital Medical University, Beijing, China
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Standardized fluoroscopy-guided implantation technique enables optimal electrode placement in sacral neuromodulation: a cadaver study. Tech Coloproctol 2020; 25:215-221. [PMID: 33211205 PMCID: PMC7884365 DOI: 10.1007/s10151-020-02364-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/22/2020] [Indexed: 10/28/2022]
Abstract
BACKGROUND Sacral neuromodulation (SNM) is an established treatment option for patients with faecal incontinence. The location of the stimulating electrode is considered to be essential for treatment success. The purpose of this study was to evaluate the position of SNM electrodes after using a standardized fluoroscopy-guided implantation technique. METHODS For this cadaver study, SNM electrodes were implanted bilaterally in 5 lower body specimens. The lower edge of the sacroiliac joint and the medial edge of the sacral foramina were marked using fluoroscopy to draw an 'H' with the crossing points identifying S3. After electrode placement the pelvis was dissected to describe the exact position of the SNM electrodes. RESULTS The electrodes were inserted at an angle with a median degree measure of 60° (range 50-65°) to the skin, with a median distance of 9 mm (range 0-13 mm) from the S3 marking. All electrodes entered the third sacral foramen. The median distance of the electrodes to the sacral nerve was 0 mm (range 0-3 mm) for the most proximal, 0.5 mm (range 0-5 mm) for the second, 2.25 mm (range 0-11 mm) for the third and 1.75 mm (range 0-16 mm) for the most distant electrode. There was neither a significant difference in the proximity of the electrodes to the nerve between the right and left side (proximal to distal electrode: p = 0.18, p = 0.16, p = 0.07, p = 0.07) nor between male and female cadavers (p = 0.25, p = 0.21, p = 0.66, p = 0.66). CONCLUSIONS A standardized fluoroscopy-guided implantation technique enables a close contact between electrode and nerve. This can potentially result in an improved clinical outcome.
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Bertrand MM, Korajkic N, Osborne PB, Keast JR. Functional segregation within the pelvic nerve of male rats: a meso- and microscopic analysis. J Anat 2020; 237:757-773. [PMID: 32598494 PMCID: PMC7495281 DOI: 10.1111/joa.13221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 01/16/2023] Open
Abstract
The pelvic splanchnic nerves are essential for pelvic organ function and have been proposed as targets for neuromodulation. We have focused on the rodent homologue of these nerves, the pelvic nerves. Our goal was to define within the pelvic nerve the projections of organ-specific sensory axons labelled by microinjection of neural tracer (cholera toxin, subunit B) into the bladder, urethra or rectum. We also examined the location of peptidergic sensory axons within the pelvic nerves to determine whether they aggregated separately from sacral preganglionic and paravertebral sympathetic postganglionic axons travelling in the same nerve. To address these aims, microscopy was performed on the major pelvic ganglion (MPG) with attached pelvic nerves, microdissected from young adult male Sprague-Dawley rats (6-8 weeks old) and processed as whole mounts for fluorescence immunohistochemistry. The pelvic nerves were typically composed of five discrete fascicles. Each fascicle contained peptidergic sensory, cholinergic preganglionic and noradrenergic postganglionic axons. Sensory axons innervating the lower urinary tract (LUT) consistently projected in specific fascicles within the pelvic nerves, whereas sensory axons innervating the rectum projected in a complementary group of fascicles. These discrete aggregations of organ-specific sensory projections could be followed along the full length of the pelvic nerves. From the junction of the pelvic nerve with the MPG, sensory axons immunoreactive for calcitonin gene-related peptide (CGRP) showed several distinct patterns of projection: some projected directly to the cavernous nerve, others projected directly across the surface of the MPG to the accessory nerves and a third class entered the MPG, encircling specific cholinergic neurons projecting to the LUT. A subpopulation of preganglionic inputs to noradrenergic MPG neurons also showed CGRP immunoreactivity. Together, these studies reveal new molecular and structural features of the pelvic nerves and suggest functional targets of sensory nerves in the MPG. These anatomical data will facilitate the design of experimental bioengineering strategies to specifically modulate each axon class.
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Affiliation(s)
- Martin M Bertrand
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Vic., Australia.,Department of Visceral Surgery, CHU de Nîmes, Nîmes, France.,Montpellier Laboratory of Informatics, Robotics and Microelectronics (LIRMM), ICAR Team, French National Centre for Scientific Research (CNRS), Montpellier University, Montpellier, France
| | - Nadja Korajkic
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Vic., Australia
| | - Peregrine B Osborne
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Vic., Australia
| | - Janet R Keast
- Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Vic., Australia
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Efficacy and safety of sacral nerve modulation for faecal incontinence after pelvic radiotherapy. Radiother Oncol 2020; 146:167-171. [PMID: 32171944 DOI: 10.1016/j.radonc.2020.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/12/2020] [Accepted: 02/24/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of sacral nerve modulation (SNM) in patients with faecal incontinence (FI) after pelvic radiotherapy in comparison with results of SNM for FI related to other conditions. METHODS Prospectively collected data from patients who underwent SNM therapy between January 2010 and December 2015 at 7 tertiary colorectal units were reviewed retrospectively. Patients with FI following pelvic radiotherapy were identified and matched (1:2) for age and sex with 38 patients implanted over the same period for FI without previous radiotherapy. The treatment was considered favourable if the patient reported any therapeutic benefit from SNM, had no further complaints or interventions and did not consider stopping the treatment. Long-term results, surgical revision and definitive explantation rates were compared. RESULTS Among 352 patients who received a permanent SNM implant, 19 (5.4%) had FI following pelvic radiotherapy. After a mean follow-up of 3.5 ± 1.9 years, the cumulative successful treatment rates were similar between the groups (p = 0.60). For patients with FI following pelvic radiotherapy, the cumulative success rates were 99.4% [85.4-99.8], 96.7% [78.1-99.6], 91.7% [70.4-98.1] and 74.6% [48.4-94.8] at 1, 2, 3 and 5 years respectively. The revision and definitive explantation rates for infection did not differ significantly. CONCLUSION The long-term success rate of SNM for FI after pelvic radiotherapy is similar to that of SNM for FI related to other more frequent conditions. Our study suggests that FI after pelvic radiotherapy could be improved with SNM without an increased risk of complication.
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Duelund-Jakobsen J, Buntzen S, Laurberg S, Lundby L. Improved longevity and efficacy of sacral nerve stimulation by simple adjustments at follow-up. Colorectal Dis 2020; 22:310-318. [PMID: 31606935 DOI: 10.1111/codi.14874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/06/2019] [Indexed: 02/08/2023]
Abstract
AIM Sacral nerve stimulation (SNS) for faecal incontinence (FI) at subsensory amplitudes as low as 50% of the sensory threshold has been found to be effective at 3 months' follow-up. Furthermore, alternative pacemaker settings may improve functional outcome in patients with suboptimal treatment efficacy. In this work we aim to explore if sub-sensory stimulation as low as 50% of sensory threshold is effective at 1-year follow-up. We also aimed to investigate if 31 Hz (frequency) or 90 µs (pulse width) stimulation improved treatment efficacy in dissatisfied patients. METHOD All patients in whom the stimulation was effective in controlling FI (satisfied group) were encouraged to have the stimulation amplitude reduced. Those in whom the device was less effective (dissatisfied group) were offered alternative frequency settings or pulse width (31 Hz or 90 µs). Patients were follow-up after 12 months and evaluated by a visual analogue scale (VAS) for patient satisfaction, the Cleveland Clinic Continence Score (CCCS), Rockwood Faecal Incontinence Quality of Life Scale (QoL) and a bowel habit diary. RESULTS Two hundred and nineteen patients were contacted, with a response rate of 71% (n = 155). Those who were successfully contacted comprised 110 (71%) patients classed as satisfied and 45 (29%) as dissatisfied. Seventy-five (68%) of the satisfied patients agreed to have their stimulation amplitude reduced. At 1-year follow-up the median amplitude had reduced from 1.5 V [interquartile range (IQR) 0.85-2.0 V] to 0.75 V (IQR 0.45-1.4 V) (P-value < 0.001) representing an overall reduction of 39% (6.6-62.5%). There were no significant differences in VAS, CCCS or QoL despite subsensory stimulation at 1-year follow-up. In 28% of the dissatisfied patients alternative pacemaker settings improved VAS to satisfactory levels. CONCLUSION Subsensory stimulation is as effective as stimulation at or above the sensory threshold. High-frequency stimulation (31 Hz) can improve functional outcome in patients with loss of efficacy.
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Affiliation(s)
- J Duelund-Jakobsen
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - S Buntzen
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - S Laurberg
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - L Lundby
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
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Southwell BR. Electro‐Neuromodulation for Colonic Disorders—Review of Meta‐Analyses, Systematic Reviews, and RCTs. Neuromodulation 2020; 23:1061-1081. [DOI: 10.1111/ner.13099] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 12/11/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Bridget R. Southwell
- Surgical Research Group Murdoch Children's Research Institute Melbourne Australia
- Department of Urology Royal Children's Hospital Melbourne Australia
- Department of Paediatrics University of Melbourne Melbourne Australia
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Besendörfer M, Kohl M, Schellerer V, Carbon R, Diez S. A Pilot Study of Non-invasive Sacral Nerve Stimulation in Treatment of Constipation in Childhood and Adolescence. Front Pediatr 2020; 8:169. [PMID: 32373563 PMCID: PMC7176809 DOI: 10.3389/fped.2020.00169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/25/2020] [Indexed: 12/22/2022] Open
Abstract
Background/Aims: Constipation shows both, a high prevalence and a significant impact. However, it is often perceived as minor and treatment choices are limited. The neuromodulation approach is a valuable option to be considered. This study assesses the use of non-invasive sacral nerve stimulation to reduce constipation in children. Methods: Between February 2013 and May 2015, pediatric patients with chronic constipation were treated with this non-invasive neuromodulation procedure, adapted from classical sacral nerve stimulation. A stimulation device attached to adhesive electrodes on the lower abdomen and back generated an electrical field with a stable frequency of 15 Hz via variable stimulation intensity (1-10 V). The effect of therapy was evaluated in routine check-ups and by specialized questionnaires. Results: The study assessed non-invasive sacral nerve stimulation in 17 patients (9 boys, 8 girls, mean age 6.5 years). They underwent stimulation with 6-9 V for a mean of 11 h per day (range 0.5-24 h) over a mean of 12.7 weeks. Improvement of constipation was achieved in more than half of the patients (12/17) and sustained in almost half of these patients (5/12). Complications were minor (skin irritation, electrode dislocation). Conclusions: Non-invasive sacral nerve stimulation appears to be effective in achieving improvement in pediatric patients with chronic constipation. As an additional external neuromodulation concept, this stimulation may represent a relevant addition to currently available therapeutic options. Further studies are needed to confirm these results.
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Affiliation(s)
- Manuel Besendörfer
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Martin Kohl
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Vera Schellerer
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Roman Carbon
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Sonja Diez
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
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Sphincter repair or Sacral Nerve Modulation: Still debatable? SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Schiano di Visconte M, Pasquali A, Cipolat Mis T, Brusciano L, Docimo L, Bellio G. Sacral nerve stimulation in slow-transit constipation: effectiveness at 5-year follow-up. Int J Colorectal Dis 2019; 34:1529-1540. [PMID: 31309325 DOI: 10.1007/s00384-019-03351-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 02/04/2023]
Abstract
AIM The aim of this study is to evaluate the short- and long-term efficacy of sacral nerve stimulation (SNS) for treating slow-transit constipation (STC). METHOD This is a retrospective cohort analysis of the efficacy of SNS in treating patients affected by STC, who previously failed to respond to conservative therapies. Only patients free of concomitant diseases were enrolled in our study. A temporary stimulation lead was initially implanted; patients with a > 50% symptom reduction were eventually deemed eligible for a permanent implant. RESULTS This study enrolled 25 patients who underwent a SNS test stimulation; 21 patients (13 women; median age 32 years) eventually got a permanent implant. The median preoperative Cleveland Clinic Constipation Score (CCCS) was 21 (16-25). Preoperative colorectal transit time recorded a median of 10 markers (7-19) retained in the colorectal tract. At 6-month postoperative follow-up, the total number of markers retained in the colorectal tract decreased to 3 (0-4). The CCCS score improved during the first postoperative year (P < 0.001), but progressively worsened over the longer term. The SF-36 questionnaire showed an improvement in all 8 scales measuring physical and psycho-emotional states; all parameters recorded into the bowel diary also improved. Overall, at 60-month follow up, the overall neuromodulator removal rate was 48%. CONCLUSIONS The SNS is a minimally invasive surgical procedure that we tested for treating STC. The short-term outcome was promisingly after 6 months; however, there was a declining trend beyond this interval. Thus, the long-term efficacy of SNS needs to be further assessed.
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Affiliation(s)
- Michele Schiano di Visconte
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, Treviso, Italy.
| | - Arianna Pasquali
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, Treviso, Italy
| | - Tommaso Cipolat Mis
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, Treviso, Italy
| | - Luigi Brusciano
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, XI Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Vanvitelli", Naples, Italy
| | - Ludovico Docimo
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, XI Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Vanvitelli", Naples, Italy
| | - Gabriele Bellio
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, Treviso, Italy
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Brochard C, Mege D, Bridoux V, Meurette G, Damon H, Lambrescak E, Faucheron JL, Trilling B, Lehur PA, Wyart V, Sielezneff I, Mion F, Etienney I, Leroi AM, Siproudhis L. Is Sacral Nerve Modulation a Good Option for Fecal Incontinence in Men? Neuromodulation 2019; 22:745-750. [PMID: 31318471 DOI: 10.1111/ner.13017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective was to assess the efficacy and the safety of sacral nerve modulation (SNM) in men with fecal incontinence (FI) compared with those of SNM in women. METHOD Prospectively collected data from patients from seven tertiary colorectal units who underwent an implant procedure between January 2010 and December 2015 were reviewed retrospectively. Outcomes and surgical revision and definitive explantation rates were compared between men and women. RESULTS A total of 469 patients (60 men [12.8%]; mean age = 61.4 ± 12.0 years) were included in the study, 352 (78.1%) (31 men [8.8%]) of whom received a permanent implant. The ratio of implanted/tested men was significantly lower than the ratio of implanted/tested women (p = 0.0004). After a mean follow-up of 3.4 ± 1.9 years, the cumulative successful treatment rates tended to be less favorable in men than in women (p = 0.0514): 88.6% (75.6-95.1), 75.9% (60.9-86.4), 63.9% (48.0-77.3), and 43.9% (26.7-62.7) at one, two, three, and five years, respectively, in men; 92.0% (89.1-94.2), 84.2% (80.3-87.4), 76.8% (72.3-80.7), and 63.6% (57.5-69.3) at one, two, three, and five years, respectively, in women. The revision rate for infection and the definitive explantation rate for infection were higher in men than in women (p = 0.0001 and p = 0.0024, respectively). CONCLUSION Both short- and long-term success rates of SNM for FI were lower in men than in women. The revision and definitive explantation for long-term infection rates were significantly higher in men.
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Affiliation(s)
- Charlène Brochard
- Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France
| | - Diane Mege
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - Valérie Bridoux
- Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Department of Digestive Surgery, Rouen, France
| | - Guillaume Meurette
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Henri Damon
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hospital E Herriot, Lyon, France
| | - Elsa Lambrescak
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Jean-Luc Faucheron
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Bertrand Trilling
- Department of Surgery, Colorectal Unit, Michallon University Hospital, Grenoble, France.,University Grenoble Alps UMR 5525, CNRS, TIMC-IMAG, Grenoble, France
| | - Paul-Antoine Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France.,Department of General Surgery, Ospedale Civico di Lugano, Lugano, Switzerland
| | - Vincent Wyart
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Igor Sielezneff
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Marseille, Timone University Hospital, Marseille, France
| | - François Mion
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hospital E Herriot, Lyon, France
| | - Isabelle Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Anne-Marie Leroi
- Normandie Univ, UNIROUEN, Inserm U1073, Rouen University Hospital, Department of Digestive Surgery, Rouen, France
| | - Laurent Siproudhis
- Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France
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Gortazar de Las Casas S, Rubio-Pérez I, Saavedra Ambrosy J, Sancho de Avila A, Álvarez-Gallego M, Marijuan Martín JL, Pascual Miguelañez I. Sacral nerve stimulation for constipation: long-term outcomes. Tech Coloproctol 2019; 23:559-564. [PMID: 31147802 DOI: 10.1007/s10151-019-02011-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND There has been some controversy regarding the efficacy of sacral nerve stimulation (SNS) for the treatment of chronic constipation, due to less positive outcomes and concerns about cost-effectiveness in the long term. The aim of the present study was to evaluate the long-term outcomes of SNS in patients with chronic constipation. METHODS A retrospective study was conducted on patients who had SNS for chronic constipation in 2008-2017 at our institution. Clinical factors, profile of constipation, physiology studies, and patient satisfaction with SNS therapy were investigated during a follow-up period up to 10 years after the implantation. RESULTS Twenty-nine patients [86% female, median age 49 years (range 17-86)] were tested for SNS, and 24 received implants after a positive test phase [median 47 days (range 21-56 days)]. There were 27 bilateral and 2 unilateral implants, in S3 or S4 depending on best response. Mean follow-up was 59 months. Efficacy was considered as a score > 5 (on a scale of 1-10) in general symptom improvement. Nine (37.9%) implanted patients had a satisfaction score > 5. In 6 cases (25%), patient satisfaction was higher than 9. Due to the small sample size, there were no statistically significant variables considered as predictors of response. CONCLUSIONS Our results agree with current studies which describe around a 30% response of SNS for refractory constipation. However, there is a small group of patients highly satisfied with SNS therapy. More studies are needed to better understand this profile and optimize outcomes.
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Affiliation(s)
| | - I Rubio-Pérez
- Department of Surgery, La Paz University Hospital, Madrid, Spain
| | | | - A Sancho de Avila
- Department of Anaesthesiology and Intensive Care, La Paz University Hospital, Madrid, Spain
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Widmann B, Galata C, Warschkow R, Beutner U, Ögredici Ö, Hetzer FH, Schmied BM, Post S, Marti L. Success and Complication Rates After Sacral Neuromodulation for Fecal Incontinence and Constipation: A Single-center Follow-up Study. J Neurogastroenterol Motil 2019; 25:159-170. [PMID: 30646487 PMCID: PMC6326196 DOI: 10.5056/jnm17106] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/28/2018] [Accepted: 10/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims The aim of this study was to evaluate the sustainability of sacral neuromodulation (SNM) success in patients with fecal incontinence (FI) and/or constipation. Methods This is a retrospective analysis of a prospective database of patients who received SNM therapy for FI and/or constipation between 2006 and 2015. Success rates, complications and reintervention rates were assessed after up to 10 years of follow-up. Results Electrodes for test stimulation were implanted in 101 patients, of whom 79 (78.2%) received permanent stimulation. The mean follow-up was 4.4 ± 3.0 years. At the end of follow-up, 57 patients (72.2%) were still receiving SNM. The 5-year success rate for FI and isolated constipation was 88.2% (95% confidence interval [CI], 80.1-97.0%) and 31.2% (95% CI, 10.2-95.5%), respectively (P ＜ 0.001). In patients with FI, involuntary evacuations per week decreased ＞ 50% in 76.1% of patients (95% CI, 67.6-86.2%) after 5 years. A lead position at S3 was associated with an improved outcome (P = 0.04). Battery exchange was necessary in 23 patients (29.1%), with a median battery life of 6.2 years. Reinterventions due to complications were necessary in 24 patients (30.4%). For these patients, the 5-year success rate was 89.0% (95% CI, 75.3-100.0%) compared to 78.4% (95% CI, 67.2-91.4%) for patients without reintervention. Conclusions SNM offers an effective sustainable treatment for FI. For constipation, lasting success of SNM is limited and is thus not recommended. Reinterventions are necessary but do not impede treatment success.
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Affiliation(s)
- Bernhard Widmann
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Christian Galata
- Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland.,Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Ulrich Beutner
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Önder Ögredici
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Franc H Hetzer
- Department of Surgery, Spital Linth, Uznach, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Stefan Post
- Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Lukas Marti
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland.,Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Yousif N, Vaizey CJ, Maeda Y. Mapping the current flow in sacral nerve stimulation using computational modelling. Healthc Technol Lett 2019; 6:8-12. [PMID: 30881693 PMCID: PMC6407445 DOI: 10.1049/htl.2018.5030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/02/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022] Open
Abstract
Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence involving the implantation of a quadripolar electrode into a sacral foramen, through which an electrical stimulus is applied. Little is known about the induced spread of electric current around the SNS electrode and its effect on adjacent tissues, which limits optimisation of this treatment. The authors constructed a 3-dimensional imaging based finite element model in order to calculate and visualise the stimulation induced current and coupled this to biophysical models of nerve fibres. They investigated the impact of tissue inhomogeneity, electrode model choice and contact configuration and found a number of effects. (i) The presence of anatomical detail changes the estimate of stimulation effects in size and shape. (ii) The difference between the two models of electrodes is minimal for electrode contacts of the same length. (iii) Surprisingly, in this arrangement of electrode and neural fibre, monopolar and bipolar stimulation induce a similar effect. (iv) Interestingly when the active contact is larger, the volume of tissue activated reduces. This work establishes a protocol to better understand both therapeutic and adverse stimulation effects and in the future will enable patient-specific adjustments of stimulation parameters.
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Affiliation(s)
- Nada Yousif
- School of Engineering and Technology, University of Hertfordshire, Hatfield, AL10 9AB, UK
| | | | - Yasuko Maeda
- Sir Alan Parks Physiology Unit, St Mark's Hospital, London, HA1 3UJ, UK.,Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, UK
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Kirss J, Pinta T, Varpe P, Rautio T, Kairaluoma M, Hyöty M, Hurme S, Böckelman C, Kairaluoma V, Salmenkylä S, Victorzon M. Outcomes of treatment of faecal incontinence with sacral nerve stimulation - a Finnish multicentre study. Colorectal Dis 2019; 21:59-65. [PMID: 30192431 DOI: 10.1111/codi.14406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/23/2018] [Indexed: 02/08/2023]
Abstract
AIM The aim of this multicentre study is to report the results of sacral nerve stimulation (SNS) treatment for faecal incontinence (FI) in Finland and determine factors that could influence SNS treatment outcomes. METHOD This is a national multicentre study, involving all patients tested for SNS implantation in Finland from 1999 to 2017. Data were collected retrospectively from electronic patient archives and analysed for possible effects on treatment outcome. RESULTS Of the 432 patients with FI tested for SNS, 365 were women. Three hundred and thirteen (72.5%) of the tested patients advanced to permanent implantation of a stimulator. A successful final treatment outcome, with subjective alleviation of FI, was reported by 59.3% of the patients at the end of follow-up (mean 2.4 years, range 8 days to 13.3 years). Patients with obstetric sphincter injury and idiopathic FI had more permanent stimulator implantations than patients with iatrogenic injury (P = 0.012). Male patients had significantly worse test phase outcomes than female patients (P < 0.001). Age did not influence treatment outcome (P = 0.446) CONCLUSION: Subjective final success of SNS treatment for FI was achieved in 59.3% of patients at a mean of 2.4 years. Gender and the aetiology of FI influenced the test phase and final treatment outcome of SNS treatment.
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Affiliation(s)
- J Kirss
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - T Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - P Varpe
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - T Rautio
- Oulu University Hospital, Oulu, Finland
| | - M Kairaluoma
- Central Finland Central Hospital, Jyväskylä, Finland
| | - M Hyöty
- Tampere University Hospital, Tampere, Finland
| | - S Hurme
- University of Turku, Turku, Finland.,Department of Biostatistics, University of Turku, Turku, Finland
| | - C Böckelman
- Helsinki University Hospital, Helsinki, Finland
| | | | | | - M Victorzon
- University of Turku, Turku, Finland.,Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
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Nuytens F, D’Hondt M. Chronic refractory constipation due to neurogenic bowel dysfunction can be successfully treated by sacral neurostimulation. Acta Chir Belg 2018; 118:246-249. [PMID: 28467281 DOI: 10.1080/00015458.2017.1321267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In the last few decades, sacral neurostimulation (SNS) has proven to be an effective treatment option for functional bowel disorders. Experience concerning the role of SNS in the treatment of chronic constipation due to neurogenic bowel dysfunction (NBD) however is limited. METHODS In this report, we present the case of a 44-year old patient, with chronic refractory neurogenic constipation after a spontaneous cerebral hemorrhage, who was treated with SNS. RESULTS Prior to treatment with SNS, the Constipation Scoring System showed a score of 22/30. Three months after SNS implantation, this score was reduced to 5/30. Patient had successful evacuation of stool every one to two days. Medication could be reduced to 15 drops of picosulphate per day. Patient experienced a significant improvement in quality of life. CONCLUSIONS We believe that SNS could offer a safe, effective and relatively cost-effective treatment for patients with NBD refractory to conservative treatment.
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Affiliation(s)
- Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium
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Goldman HB, Lloyd JC, Noblett KL, Carey MP, Castaño Botero JC, Gajewski JB, Lehur PA, Hassouna MM, Matzel KE, Paquette IM, de Wachter S, Ehlert MJ, Chartier-Kastler E, Siegel SW. International Continence Society best practice statement for use of sacral neuromodulation. Neurourol Urodyn 2018; 37:1823-1848. [PMID: 29641846 DOI: 10.1002/nau.23515] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
AIMS Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel. METHODS Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group. RESULTS The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research. CONCLUSIONS These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.
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Affiliation(s)
- Howard B Goldman
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessica C Lloyd
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karen L Noblett
- Axonics Modulation Technologies and Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Marcus P Carey
- Division of Urogynaecology, Frances Perry House, Parkville, Victoria, Australia
| | | | - Jerzy B Gajewski
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul A Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Universite de Nantes, Nantes, France
| | - Magdy M Hassouna
- Division of Urology, University of Toronto, Toronto, Ontario, Canada
| | - Klaus E Matzel
- Division of Coloproctology, University of Erlangen, Erlangen, Germany
| | - Ian M Paquette
- Department of Surgery, Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stefan de Wachter
- Department of Urology, University Hospital Antwerpen, University of Antwerpen, Belgium
| | | | - Emmanuel Chartier-Kastler
- Department of Urology, Academic Hospital Pitié-Salpétrière, Medical School Sorbonne Université, Paris, France ECK
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Cui Z, Wang Z, Ye G, Zhang C, Wu G, Lv J. A novel three-dimensional printed guiding device for electrode implantation of sacral neuromodulation. Colorectal Dis 2018; 20:O26-O29. [PMID: 29110390 DOI: 10.1111/codi.13958] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
Abstract
AIM The aim was to test the feasibility of a novel three-dimensional (3D) printed guiding device for electrode implantation of sacral neuromodulation (SNM). METHOD A 3D printed guiding device for electrode implantation was customized to patients' anatomy of the sacral region. Liquid photopolymer was selected as the printing material. The details of the device designation and prototype building are described. The guiding device was used in two patients who underwent SNM for intractable constipation. Details of the procedure and the outcomes are given. RESULTS With the help of the device, the test needle for stimulation was placed in the target sacral foramen successfully at the first attempt of puncture in both patients. The time to implant a tined SNM electrode was less than 20 min and no complications were observed. At the end of the screening phase, symptoms of constipation were relieved by more than 50% in both patients and permanent stimulation was established. CONCLUSION The customized 3D printed guiding device for implantation of SNM is a promising instrument that facilitates a precise and quick implantation of the electrode into the target sacral foramen.
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Affiliation(s)
- Z Cui
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Z Wang
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - G Ye
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - C Zhang
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - G Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - J Lv
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Introduction. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.02021-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rydningen MB, Riise S, Wilsgaard T, Lindsetmo RO, Norderval S. Sacral neuromodulation for combined faecal and urinary incontinence following obstetric anal sphincter injury. Colorectal Dis 2018; 20:59-67. [PMID: 28727899 DOI: 10.1111/codi.13820] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 06/13/2017] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate the efficacy of sacral neuromodulation (SNM) in the treatment of faecal incontinence and concomitant urinary incontinence in women with a history of obstetric anal sphincter injury (OASIS). METHOD In this prospective study, consecutive women with faecal incontinence following OASIS accepted for SNM were screened for concomitant urinary incontinence. The primary outcome was the change in urinary incontinence score on the International Consultation on Incontinence Questionnaire for Urinary Incontinence, Short Form (ICIQ-UI-SF), between baseline and 12 months. Secondary outcomes included the change in St Mark's score, sexual function and quality of life, change in grade of urinary incontinence and disappearance of urgency. RESULTS From March 2012 to September 2014, 39 women with combined faecal incontinence and urinary incontinence received SNM. Thirty-seven women were available for analysis after 12 months. The mean reduction in the ICIQ-UI-SF score between the baseline and 12 months was 5.8 (95% CI 3.7-8.0, P < 0.001). ICIQ-UI-SF was reduced in 29 (78%) women, urinary incontinence resolved in 13/37 (35%, 95% CI 20%-50%) patients, and urgency disappeared in 14/33 (42%, 95% CI 26%-59%). The mean reduction in the St Mark's score was 10.6 (95% CI 8.6-12.7, P < 0.001). Disease-specific quality of life, Euroqual 5-dimension visual analogue scale (EQ-5D VAS) and several areas of sexual function changed significantly for the better. CONCLUSION More than three-quarters of the women with combined faecal and urinary incontinence following OASIS reported a successful outcome with reduction in ICIQ-UI-SF at 12 months after SNM.
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Affiliation(s)
- M B Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsø, Norway
| | - S Riise
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsø, Norway
| | - T Wilsgaard
- Department of Community Medicine, Arctic University of Norway, Tromsø, Norway
| | - R O Lindsetmo
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsø, Norway.,Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - S Norderval
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsø, Norway.,Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway.,National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsø, Norway
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Jeganathan AN, Bleier JI. Patient selection and preoperative evaluation for fecal incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gurland B, Aytac E. Anatomy and physiology: Neurologic basis for the function of sacral nerve stimulation. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND Decision-making for pulse generator implantation for sacral nerve stimulation in the management of fecal incontinence is based on the results of a test phase. Its duration is still a matter of debate. OBJECTIVE The purpose of this study was to determine whether an early positive response during the test phase could predict implantation of a permanent sacral nerve pulse generator. DESIGN This was a short-term observational cohort study. A positive response was defined as a >50% decrease of fecal leaks compared with baseline. A multivariate logistic regression was computed to predict pulse generator implantation after the first week of the test phase. SETTINGS The study was conducted in 3 national referral centers. PATIENTS From January 2006 to December 2012, 144 patients with fecal incontinence enrolled in a prospectively maintained database completed a 2- to 3-week bowel diary, at baseline and during test phase. MAIN OUTCOME MEASURES The primary outcome was the clinical decision to implant a pulse generator. The primary predictor was a calculated score including the number of leak episodes, bowel movements, and urgencies and the time to defer defecation expressed in minutes during the first screening test week. RESULTS After the first, second and third week of the test phase, 81 (56%) of 144, 96 (67%) of 144, and 93 (70%) of 131 patients had a positive test. A permanent pulse generator was implanted in 114. Time to defer defecation increased during the 3 weeks of screening. Urgencies were unchanged. The computed score was predictive of a permanent pulse generator implantation (Se = 72.6% (95% CI, 59.8-83.1); Sp = 100% (95% CI, 78.2-100); c-index = 0.86 (95% CI, 0.78-0.94)). LIMITATIONS No cost analysis or projection based on our proposal to reduce the test phase has been made. CONCLUSIONS Permanent pulse generator implantation can be safely proposed early (1-week screening) to fast responders. Nonetheless, permanent implantation may be decided as well in patients exhibiting a delayed response. Whether a rapid response to sacral nerve stimulation could be predictive of a long-term response remains to be determined. See Video Abstract at http://links.lww.com/DCR/A452.
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Matzel KE, Chartier-Kastler E, Knowles CH, Lehur PA, Muñoz-Duyos A, Ratto C, Rydningen MB, Sørensen M, van Kerrebroeck P, de Wachter S. Sacral Neuromodulation: Standardized Electrode Placement Technique. Neuromodulation 2017; 20:816-824. [PMID: 28975677 DOI: 10.1111/ner.12695] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/31/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Sacral neuromodulation (SNM) (sacral nerve stimulation SNS) has become an established therapy for functional disorders of the pelvic organs. Despite its overall success, the therapy fails in a proportion of patients. This may be partially due to inadequate electrode placement with suboptimal coupling of the electrode and nerve. Based on these assumptions the technique of sacral spinal neuromodulation has been redefined. All descriptions relate to the only currently available system licensed for all pelvic indications (Medtronic Interstim® ). METHOD An international multidisciplinary working party of ten individuals highly experienced in performing SNM convened two meetings (including live operating) to standardize the implant procedure. This report addresses the main steps to optimal electrode lead placement in temporal sequence. RESULTS Key elements of the electrode placement are radiological marking, the use of a curved stylet, the entry of the electrode into the sacral foramen and its progression through the foramen, its placement guided by a combination of a typical appearance in fluoroscopy and achieving specific motor/sensory responses with stimulation. The report describes quadripolar electrode placement and then either insertion of a connecting percutaneous extension lead or permanent implantation of the programmable device. CONCLUSION Standardization of electrode placement may ensure close electrode proximity to the target nerve providing a higher likelihood for optimal effect with less energy consumption (better battery longevity), more programming options with more electrode contacts close to the nerve and reduced likelihood of side-effects. The potentially better clinical outcome needs to be demonstrated.
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Affiliation(s)
| | - Emmanuel Chartier-Kastler
- Sorbonne Universités, UPMC, Paris, France.,Urology Department, Academic Hospital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Charles H Knowles
- National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Paul A Lehur
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France
| | - Arantxa Muñoz-Duyos
- Department of General Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Carlo Ratto
- Proctology Unit, Department of Surgical Sciences, Catholic University, Rome, Italy
| | - Mona B Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsö, Norway
| | - Michael Sørensen
- Department of Surgical and Medical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Philip van Kerrebroeck
- Pelvic Care Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stefan de Wachter
- Department of Urology, University Hospital Antwerpen, Antwerpen, Belgium
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Rydningen M, Dehli T, Wilsgaard T, Rydning A, Kumle M, Lindsetmo RO, Norderval S. Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial. Colorectal Dis 2017; 19:O134-O144. [PMID: 28211186 DOI: 10.1111/codi.13632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/09/2016] [Indexed: 02/08/2023]
Abstract
AIM The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS). METHOD This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores. RESULTS Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77). CONCLUSION SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.
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Affiliation(s)
- M Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Dehli
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Wilsgaard
- Department of Community Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - A Rydning
- Department of Gastroenterological Surgery, St Olav's Hospital, Trondheim, Norway
| | - M Kumle
- Department of Radiology, University Hospital of North Norway, Tromsoe, Norway.,Narvik University College, Narvik, Norway
| | - R O Lindsetmo
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - S Norderval
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway.,National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsoe, Norway
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Rydningen MB, Dehli T, Wilsgaard T, Lindsetmo RO, Kumle M, Stedenfeldt M, Norderval S. Sacral neuromodulation for faecal incontinence following obstetric sphincter injury - outcome of percutaneous nerve evaluation. Colorectal Dis 2017; 19:274-282. [PMID: 27463362 DOI: 10.1111/codi.13472] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/30/2016] [Indexed: 12/17/2022]
Abstract
AIM The purpose of this study was to assess the efficacy of percutaneous nerve evaluation (PNE) in women with faecal incontinence (FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect. METHOD This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score. RESULTS Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) (P < 0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence (P = 0.04), body mass index (BMI) (P = 0.03) and pain during PNE (P = 0.046) but not to the extent of the sphincter defect (P = 0.1). Responders had a higher St Mark's score than nonresponders (P = 0.046). CONCLUSIONS The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect.
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Affiliation(s)
- M B Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Dehli
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - T Wilsgaard
- Department of Community Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - R O Lindsetmo
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway
| | - M Kumle
- Department of Radiology, University Hospital of North Norway, Tromsoe, Norway.,Narvik University College, Narvik, Norway
| | - M Stedenfeldt
- National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsoe, Norway
| | - S Norderval
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsoe, Norway.,National Advisory Board of Continence and Pelvic Floor Health of Norway, University Hospital of North Norway, Tromsoe, Norway
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