C.G.M.I. Baeten

Neuromodulation for constipation: Sacral and transcutaneous stimulation

Constipation is a frequently occurring digestive ailment that is usually treated conservatively. Neuromodulation is altering function of an organ by altering neural activity. This paper reviews methods of neuromodulation used to treat constipation. This includes direct stimulation of sacral nerves and stimulation across the skin. Direct stimulation of sacral nerves is the most well developed method and is presented in detail. It is generally accepted that the mechanism of action is modulation rather than stimulation so it is called sacral neuromodulation (SNM). SNM involves percutaneous placement of an electrode in the third sacral foramen and implanting a stimulating device under the skin in the buttocks. SNM is founded on the physiological principle that activity in one neural pathway modulates pre-existing activity in another through synaptic interaction. The mechanism of action in constipation may be neuromodulation of the extrinsic neural control of the large bowel or modulation of reflexes inhibiting large bowel function. Limited evidence is available to assess the outcome of SNM in constipation. Results in the medium term seem promising for selected patients with idiopathic slow and normal transit constipation not responding to optimal conservative treatment. Adverse events include electrode migration and infection. The availability of a testing phase provides a predictor of treatment outcome. In addition, transcutaneous stimulation using sticky pad electrodes over the lumbosacral region or acupuncture points has been reported to improve constipation symptoms. In general, the level of evidence is low and further studies are needed.

Patient experience and satisfaction with sacral neuromodulation: results of a single-center sample survey

PURPOSE: Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders. METHODS: After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007. RESULTS: A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%). CONCLUSIONS: This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns.

Transperineal ultrasound compared to evacuation proctography for diagnosing enteroceles and intussusceptions

IntroductionThis study concerns the level of agreement between transperineal ultrasound and evacuation proctography for diagnosing enteroceles and intussusceptions.MethodIn a prospective observational study, 50 consecutive women who were planned to have an evacuation proctography underwent transperineal ultrasound too. Sensitivity, specificity, positive (PPV) and negative predictive value, as well as the positive and negative likelihood ratio of transperineal ultrasound were assessed in comparison to evacuation proctography. To determine the interobserver agreement of transperineal ultrasound, the quadratic weighted kappa was calculated. Furthermore, receiver operating characteristic curves were generated to show the diagnostic capability of transperineal ultrasound.ResultsFor diagnosing intussusceptions (PPV 1.00), a positive finding on transperineal ultrasound was predictive of an abnormal evacuation proctography. Sensitivity of transperineal ultrasound was poor for intussusceptions (0.25). For diagnosing enteroceles, the positive likelihood ratio was 2.10 and the negative likelihood ratio, 0.85. There are many false-positive findings of enteroceles on ultrasonography (PPV 0.29). The interobserver agreement of the two ultrasonographers assessed as the quadratic weighted kappa of diagnosing enteroceles was 0.44 and that of diagnosing intussusceptions was 0.23.ConclusionAn intussusception on ultrasound is predictive of an abnormal evacuation proctography. For diagnosing enteroceles, the diagnostic quality of transperineal ultrasound was limited compared to evacuation proctography.

Cost-effectiveness analysis of sacral neuromodulation for faecal incontinence in The Netherlands.

Aim  Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost‐effectiveness. This study aimed to analyse this and the quality‐adjusted life‐years (QALYs) associated with two different treatment algorithms. The first (SNM−) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms.

Local giant cell foreign body reaction after silicone injection for fecal incontinence in humans: two case reports.

Since the 1990s, one of the methods used for treating fecal incontinence due to internal anal sphincter defects has been the injection of bulking agents. The aim of this paper is to report two cases of local giant cell foreign body reaction after injection of PTQTM in humans. To the best of the authors’ knowledge, this is the first report of an adverse immune response to silicone injection in humans.

Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence

The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT.

Intra-abdominal dilation of artificial bowel sphincter pressure-regulating balloon: a case report

IntroductionFecal incontinence is a debilitating condition with considerable impact on quality of life. The artificial bowel sphincter may be used as a treatment option in severe cases in which no less invasive form of therapy is sufficient.ResultsRisk of infection and mechanical failure is of particular concern in this artificial device.ConclusionWe report a rare late complication: balloon dilation due to hypertonic fillings.

269 Sacral Nerve Neuromodulation Therapy; a Promising New Treatment for Children with Refractory Functional Constipation

Background: Sacral nerve neuromodulation (SNM) therapy has been successfully applied in adult patients with urinary and fecal incontinence. Recently, SNM therapy showed good results in adults with refractory functional constipation. No data, however, are available of SNM therapy as a treatment option in children with refractory functional constipation. Aim: To describe the preliminary results of SNM therapy in children with chronic functional constipation refractory to intensive conservative treatment. Material and methods: Children with functional constipation according to the ROME III criteria not responding to intensive conservative treatment (laxatives, enemas and colonic lavage) were assigned for SNM therapy. When improvement of symptoms was seen during the percutaneous nerve evaluation (PNE) with a permanent electrode in the 3 weeks testing phase, a permanent sacral nerve neuromodulator was implanted. Patients were followed up for at least six months after implantation by interviews and bowel diaries. Improvement was defined as spontaneous defecation ≥ 3 times a week. Results: 5 patients (all females) 14 - 18 years old with functional constipation were included. None of them had spontaneous defecation at presentation. Duration of symptoms varied from 6 - 18 years and the duration of treatment from 1 -17 years. In all patients the testing phase was successful. After implantation of the permanent neuromodulator, all children had spontaneous defecation ≥ 3 times a week without medication. Conclusion: SNM is a promising new treatment option in children with refractory functional constipation not responding to intensive conservative therapy. However, larger prospective studies with long-term follow up are required.