Gregory P. Thomas

A review of posterior tibial nerve stimulation for faecal incontinence

This review aimed to assess the published results of posterior tibial nerve stimulation (PTNS) for faecal incontinence.

Seven‐year experience of enterocutaneous fistula with univariate and multivariate analysis of factors associated with healing: development of a validated scoring system

The management of enterocutaneous fistulae (ECF) is complex and challenging. We examined factors associated with fistula healing at a National Intestinal Failure Centre and devised the first scoring system to predict spontaneous fistula healing prior to surgery.

A review of sacral nerve stimulation for faecal incontinence following rectal surgery and radiotherapy

Faecal incontinence may occur following rectal surgery and/or radiotherapy for rectal cancer. The aim of this paper was to review the evidence to support the use of sacral nerve stimulation (SNS) for patients with incontinence who had undergone rectal surgery or received rectal radiotherapy.

Bilateral transcutaneous posterior tibial nerve stimulation for the treatment of fecal incontinence.

BACKGROUND: Unilateral posterior tibial nerve stimulation has been shown to improve fecal incontinence in the short term. Posterior tibial nerve stimulation is believed to work by stimulation of the ascending afferent spinal pathways. Bilateral stimulation may activate more of these pathways. This may lead to an improved therapeutic effect. OBJECTIVE: The aim of this study was to assess the efficacy of bilateral transcutaneous posterior tibial nerve stimulation for fecal incontinence. DESIGN: This was a single-group pilot prospective study. SETTING: The study was conducted from June 2012 to September 2012 at the authors’ institution. PATIENTS: Twenty patients with fecal incontinence were recruited consecutively. Conservative therapy had failed to improve the fecal incontinence in all 20 patients. INTERVENTION: All patients received 30 minutes of daily bilateral stimulation for 6 weeks. The bilateral stimulation was administered by each patient at home. No further stimulation was given after 6 weeks, and the patients were followed up until their symptoms returned to the prestimulation state (baseline). MAIN OUTCOME MEASURE: The primary outcome measure was a change in the frequency of incontinent episodes per week. RESULTS: Seventeen patients completed 6 weeks of treatment. Two patients achieved complete continence. Ten (59%) achieved a ≥50% reduction in frequency of incontinent episodes. Overall, there was a significant reduction in median (interquartile range) frequency of incontinent episodes per week of 6 (8.25) to 2 (7.25) (p = 0.03). There was a significant improvement in the ability to defer defecation from 3 (4) to 5 (8) minutes (p = 0.03). There was no change in the St Marks incontinence score. One domain of the Rockwood fecal incontinence quality-of-life score and of the Medical Outcomes Study Short Form 36 score improved significantly. LIMITATIONS: This study was limited by its small size and its lack of blinding and control. CONCLUSIONS: Bilateral transcutaneous posterior tibial nerve stimulation appears to be a cheap and effective treatment for fecal incontinence. It can easily be used by the patient at home.

A pilot study to compare daily with twice weekly transcutaneous posterior tibial nerve stimulation for faecal incontinence.

Posterior tibial nerve stimulation (PTNS) has been shown to improve faecal incontinence in the short term. The optimal treatment regimen is unclear with wide variations in protocol reported in the literature. The study aimed to assess two different regimens of transcutaneous PTNS and to establish whether increasing the frequency of stimulation increases the effectiveness.

Bilateral transcutaneous tibial nerve stimulation for chronic constipation.

Chronic constipation is difficult to treat when symptoms are intractable. Colonic propulsion may be altered by distal neuromodulation but this is conventionally delivered percutaneously. Transcutaneous tibial nerve stimulation is noninvasive and cheap: this study aimed to assess its efficacy in chronic constipation.

Sacral nerve stimulation: an effective treatment for chronic functional anal pain?

Chronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co‐existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain.

A pilot study of transcutaneous sacral nerve stimulation for faecal incontinence

Although effective in faecal incontinence (FI), sacral nerve stimulation (SNS) is expensive and requires two procedures. It carries a small risk of infection and electrode migration. Transcutaneous SNS is noninvasive and cheap. Two small studies have reported the results when applied to segments S3 but there is no information on its effectiveness when applied to the whole sacral area.

Transcutaneous Sacral Electrical Stimulation for Chronic Functional Constipation.

BACKGROUND: Transcutaneous sacral nerve stimulation is reported to improve symptoms of fecal incontinence. Chronic constipation may also respond to stimulation, but this is poorly reported in the literature. OBJECTIVE: The study assessed the efficacy of transcutaneous electrical stimulation directly over the sacral nerve roots in chronic constipation. PATIENTS: Chronic functional constipation was established in all patients using the Rome III criteria. SETTING: The therapy was self-administered at home. DESIGN/INTERVENTION: A pilot study was conducted of transcutaneous sacral stimulation given over a 4-week period for 12 hours a day. MAIN OUTCOME MEASURES: Patients were assessed using the Patient Assessment of Constipation Symptoms, the Patient Assessment of Constipation Quality of Life, and the Cleveland constipation tool. A Global Rating of Change measure and a 1-week bowel diary was kept for the final week and compared with baseline. RESULTS: Of the 20 patients recruited (16 female, median age 38.5 years), 80% (16) completed the trial. Five (31%) patients reported at least a point reduction in the Patient Assessment of Constipation Symptoms score, 4 (25%) deteriorated, and 7 (44%) improved by less than one point. Median (interquartile range) Patient Assessment of Constipation Symptoms scores were 2.33 (2.34) at baseline and 2.08 (2.58) at follow-up (p = 0.074). Median scores for the Patient Assessment of Constipation Quality of Life and Cleveland systems were 3.00 (1.64) and 17.15 (18) at baseline and 2.22 (3.04) and 15.31 (12) at follow-up (p = 0.096 and 0.111). One-third of patients reported a positive Global Rating of Change measure, although 68% required concurrent laxatives during the trial. LIMITATIONS: This is a pilot study and is limited by its small sample size. CONCLUSIONS: Continuous transcutaneous sacral stimulation in the short term appears to be ineffective for chronic constipation. Larger well-powered studies with intermittent stimulation regimens are required to investigate this further.

Sacral transcutaneous stimulation for faecal incontinence may have a different mechanism of action to sacral nerve stimulation

a patient with a malignant polyp with adverse histology is what is the risk to the patient of surgical resection of the relevant part of the colon or rectum from which the polyp arose? Whilst agreeing with Beaton et al. that a randomized trial of management strategies would the ideal, this would be a Herculean task which would present major difficulties in obtaining consent for inclusion in a trial. What would be much more likely to succeed and produce valuable information to guide future management of this challenging problem is a malignant polyp registry, which would include endoscopic and histological information about the polyp, information about the patient, decision making and follow-up information. Properly resourced and with accurate data submission and follow-up, a large number of polyps could be collated fairly quickly as these lesions are not rare and most multidisciplinary teams regularly discuss the management of these lesions. Such information would add considerably to our understanding of how to manage patients with a malignant polyp.