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Desprez C, Leroi AM, Gourcerol G. Gastric and sacral electrical stimulation for motility disorders-A clinical perspective. Neurogastroenterol Motil 2024:e14884. [PMID: 39099155 DOI: 10.1111/nmo.14884] [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] [Received: 01/31/2024] [Revised: 06/04/2024] [Accepted: 07/21/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Electrical stimulation of the gut has been investigated in recent decades with a view to treating various gastro-intestinal motility disorders including, among others, gastric electrical stimulation to relieve nausea and vomiting associated with gastroparesis and sacral neuromodulation to treat fecal incontinence and/or constipation. Although their symptomatic efficacy has been ascertained by randomized controlled trials, their mechanisms of action are not fully understood. PURPOSE This review summarizes the past year's literature on the mechanisms of action of gut electrical stimulation therapies, including their impact on the gut-brain axis.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
| | - Anne-Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
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Brusciano L, Brillantino A, Pellino G, Marinello F, Baeten CIM, Digesu A, Naldini G, Gambardella C, Lucido FS, Sturiale A, Gualtieri G, Riss S, Docimo L. Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function. Updates Surg 2023; 75:1187-1195. [PMID: 37442886 PMCID: PMC10359216 DOI: 10.1007/s13304-023-01570-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/27/2023] [Indexed: 07/15/2023]
Abstract
Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients' baseline median Cleveland Clinic Incontinence Score was 15 (10-18); it decreased to 2 (1-4) and 1 (1-2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.
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Affiliation(s)
- Luigi Brusciano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Franco Marinello
- Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Coen IM Baeten
- Department of Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | - Alex Digesu
- Department of Urogynaecology, Imperial College NHS Healthcare, London, UK
| | - Gabriele Naldini
- Proctology and Perineal Surgical Unit - Proctology and Pelvic Floor Multidisciplinary Clinical Center, Universitary Hospital of Pisa, Pisa, Italy
| | - Claudio Gambardella
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Saverio Lucido
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alessandro Sturiale
- Proctology and Perineal Surgical Unit - Proctology and Pelvic Floor Multidisciplinary Clinical Center, Universitary Hospital of Pisa, Pisa, Italy
| | - Giorgia Gualtieri
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefan Riss
- Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
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Sensory brain activation during rectal balloon distention: a pilot study in healthy volunteers to assess safety and feasibility at 1.5T. MAGMA (NEW YORK, N.Y.) 2023; 36:25-32. [PMID: 36227394 PMCID: PMC9992048 DOI: 10.1007/s10334-022-01044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/15/2022] [Accepted: 10/03/2022] [Indexed: 03/08/2023]
Abstract
OBJECTIVE Although increasing evidence suggests a central mechanism of action for sacral neuromodulation, the exact mechanism remains unclear. We set up a scanning paradigm to measure brain activation related to various stages of rectal filling using rectal balloon distention. MATERIALS AND METHODS Six healthy volunteers underwent rectal balloon distention during MRI scanning at a 1.5T scanner with a Tx/Rx head coil. MR images were collected at four levels of distention: empty balloon (EB), first sensation volume (FSV), desire to defecate volume (DDV), maximum tolerable volume (MTV). Data were analyzed using BrainVoyager 20.4. Whole brain and ROI-based fixed-effects general linear model analyses were performed on the fMRI time-course data from all participants. RESULTS Rectal filling until FSV evoked the most blood-oxygen-level-dependent responses in several clusters throughout the cortex, followed by the responses evoked by rectal filling until DDV. Interestingly, rectal filling until MTV evoked negative responses compared to baseline throughout the cortex. No negative side effects were found. DISCUSSION This study shows that a standardized paradigm for functional MRI combined with rectal filling is feasible and safe in healthy volunteers and is ready to be used in fecal incontinent patients to assess whether their brain activity differs from healthy controls.
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Lin AY, Varghese C, Paskaranandavadivel N, Seo S, Du P, Dinning P, Bissett IP, O'Grady G. Faecal incontinence is associated with an impaired rectosigmoid brake and improved by sacral neuromodulation. Colorectal Dis 2022; 24:1556-1566. [PMID: 35793162 PMCID: PMC10084032 DOI: 10.1111/codi.16249] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/04/2022] [Accepted: 05/20/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The rectosigmoid brake, characterised by retrograde cyclic motor patterns on high-resolution colonic manometry, has been postulated as a contributor to the maintenance of bowel continence. Sacral neuromodulation (SNM) is an effective therapy for faecal incontinence, but its mechanism of action is unclear. This study aims to investigate the colonic motility patterns in the distal colon of patients with faecal incontinence, and how these are modulated by SNM. METHODS A high-resolution fibreoptic colonic manometry catheter, containing 36 sensors spaced at 1-cm intervals, was positioned in patients with faecal incontinence undergoing stage 1 SNM. One hour of pre- and post meal recordings were obtained followed by pre- and post meal recordings with suprasensory SNM. A 700-kcal meal was given. Data were analysed to identify propagating contractions. RESULTS Fifteen patients with faecal incontinence were analysed. Patients had an abnormal meal response (fewer retrograde propagating contractions compared to controls; p = 0.027) and failed to show a post meal increase in propagating contractions (mean 17 ± 6/h premeal vs. 22 ± 9/h post meal, p = 0.438). Compared to baseline, SNM significantly increased the number of retrograde propagating contractions in the distal colon (8 ± 3/h premeal vs. 14 ± 3/h premeal with SNM, p = 0.028). Consuming a meal did not further increase the number of propagating contractions beyond the baseline upregulating effect of SNM. CONCLUSION The rectosigmoid brake was suppressed in this cohort of patients with faecal incontinence. SNM may exert a therapeutic effect by modulating this rectosigmoid brake.
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Affiliation(s)
- Anthony Y Lin
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Sean Seo
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Phil Dinning
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Discipline of Human Physiology, Flinders University, Adelaide, South Australia, Australia
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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Knol ME, Snijders HS, van der Heyden JT, Baeten CI. Fecal Incontinence: The Importance of a Structured Pathophysiological Model. J Anus Rectum Colon 2022; 6:58-66. [PMID: 35128138 PMCID: PMC8801252 DOI: 10.23922/jarc.2021-040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/07/2021] [Indexed: 11/30/2022] Open
Abstract
Fecal incontinence has an enormous social and economic impact and may significantly impair quality of life. Even though fecal incontinence is a common complaint in (aging) adults, a structured pathophysiological model of the clinical presentations of fecal incontinence is missing in current literature. The most frequent manifestations of fecal incontinence are passive fecal loss, urge incontinence, or mixed fecal incontinence. At our institution, we treat 400 patients per year with defecation disorders, including a significant number of patients with fecal incontinence. On the basis of this experience, we have tried to create a concept that merges current insight in causes and treatment options in a clinically useful algorithm. By applying the system of anamnesis and physical examination described in this article and expanding it with simple additional anorectal examination, in most patients, one can determine the type of fecal incontinence and choose a targeted therapy.
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Rao SSC, Yan Y, Xiang X, Sharma A, Ayyala D, Hamdy S. Effects of Translumbosacral Neuromodulation Therapy on Gut and Brain Interactions and Anorectal Neuropathy in Fecal Incontinence: A Randomized Study. Neuromodulation 2021; 24:1269-1277. [PMID: 34156730 PMCID: PMC8542581 DOI: 10.1111/ner.13485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Translumbosacral neuromodulation therapy (TNT) improves symptoms of fecal incontinence (FI), but its mechanism of action is unknown. We tested the hypothesis that TNT at one or more frequency will significantly improve underlying pathophysiology of FI through modulation of ascending and/or descending signaling pathways in the gut and brain axis and anorectal sensorimotor function. MATERIALS AND METHODS We assessed afferent anorectal-cortical evoked potentials (CEP) following electrical stimulation of anorectum, efferent cortico-anorectal and lumbo-anorectal and sacro-anorectal motor evoked potentials (MEP) after transcranial and lumbosacral magnetic stimulations, and anorectal manometry before and after six weekly TNT sessions in FI subjects, randomized to 1, 5, or 15 Hz repetitive magnetic stimulations. Neurophysiology, anorectal sensorimotor function, and symptoms were compared to examine mechanistic effects. Co-primary measures were ano-cortical CEPs, cortico-anal MEPs, and lumbosacral-anal MEPs. Baseline and post-treatment data were compared with Wilcoxon signed-rank test and changes between the three frequencies with one-way ANOVA. RESULTS Thirty-three FI patients participated. After TNT, the afferent anal CEP latencies significantly decreased in the 1 Hz group compared to baseline (p = 0.0029) and 5 Hz or 15 Hz groups (p = 0.032). Cortico-anal MEPs were unchanged in all three groups. Bilateral lumbo-anal and sacro-anal MEP latencies significantly decreased with 1 Hz, lumbo-anal with 15 Hz, and sacro-anal with 5 Hz compared to baseline but without group differences. The 1 Hz group showed significant increase in anal squeeze sphincter pressure (p < 0.005) and maximum tolerable volume (p < 0.019) and demonstrated higher FI responder rate (p < 0.04) compared to the other two groups. The MEP responders were significantly correlated with FI responders (p = 0.006) in 1 Hz group. CONCLUSIONS TNT significantly improves afferent ano-cortical signaling, efferent lumbo-anal and sacro-anal neuropathy and anorectal sensorimotor function. These neurobiologic effects were most prominent with 1 Hz frequency. TNT improves FI by modifying the underlying pathophysiology possibly through neuromodulation.
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Affiliation(s)
- Satish S C Rao
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Xuelian Xiang
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amol Sharma
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Deepak Ayyala
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Shaheen Hamdy
- GI Sciences, School of Medical Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Mosiello G, Safder S, Marshall D, Rolle U, Benninga MA. Neurogenic Bowel Dysfunction in Children and Adolescents. J Clin Med 2021; 10:1669. [PMID: 33924675 PMCID: PMC8069792 DOI: 10.3390/jcm10081669] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 01/07/2023] Open
Abstract
Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.
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Affiliation(s)
- Giovanni Mosiello
- Department of Surgery, Division of Urology, Bambino Gesù Pediatric and Research Hospital, 00165 Rome, Italy
| | - Shaista Safder
- College of Medicine, Center for Digestive, Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL 32806, USA;
| | - David Marshall
- Department of Pediatric Surgery and Pediatric Urology, Royal Belfast Hospital for Sick Children, Belfast BT97AB, UK;
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, Goethe-University Frankfurt, 60596 Frankfurt, Germany;
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
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Cruz E, Miller C, Zhang W, Rogers K, Lee HJ, Wells Y, Cloud GC, Lannin NA. Does non-implanted electrical stimulation reduce post-stroke urinary or fecal incontinence? A systematic review with meta-analysis. Int J Stroke 2021; 17:378-388. [PMID: 33724094 DOI: 10.1177/17474930211006301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Urinary and fecal incontinence are disabling impairments after stroke that can be clinically managed with electrical stimulation. AIM The purpose of this systematic review was to determine the effectiveness of non-implanted electrical stimulation to reduce the severity of post-stroke incontinence. SUMMARY OF REVIEW Clinical trials of non-implanted electrical stimulation applied for the purposes of treating post-stroke incontinence were searched in MEDLINE, EMBASE, CINAHL, PEDro, and CENTRAL. From a total of 5043 manuscripts, 10 trials met the eligibility criteria (n = 894 subjects). Nine trials reported urinary incontinence severity outcomes enabling meta-analysis of transcutaneous electrical nerve stimulation (TENS; five trials) and electroacupuncture (four trials). Studies provide good-to-fair quality evidence that TENS commenced <3 months post-stroke has a large effect on urinary continence (SMD = -3.40, 95% CI -4.46 to -2.34) and a medium effect when commenced >3 months after stroke (SMD = -0.67, 95% CI -1.09 to -0.26). Electroacupuncture has a large effect when administered >5 times a week (SMD = -2.32, 95% CI -2.96 to -1.68) and a small effect when administered five times a week (SMD = -0.44, 95% CI -0.69 to -0.18). Only one trial reported the effect of non-implanted electrical stimulation on post-stroke fecal incontinence. CONCLUSIONS Published trials evaluating the effect of non-implanted electrical stimulation on post-stroke incontinence are few and heterogenous. Synthesized trials suggest that early and frequent treatment using electrical stimulation is probably more effective than sham or no treatment. Further trials measuring incontinence in an objective manner are required.
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Affiliation(s)
- Enrique Cruz
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.,Alfred Health, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Charne Miller
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
| | - WenWen Zhang
- Alfred Health, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,Austin Health, Melbourne, Australia
| | | | | | - Yvonne Wells
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
| | - Geoffrey C Cloud
- Alfred Health, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Natasha A Lannin
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.,Alfred Health, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,John Walsh Centre for Rehabilitation Research, Kolling Institute, The University of Sydney, Sydney, Australia
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Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial. Am J Gastroenterol 2021; 116:162-170. [PMID: 32740081 PMCID: PMC9455260 DOI: 10.14309/ajg.0000000000000766] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy. METHODS Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes. RESULTS Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted. DISCUSSION TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).
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10
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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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Hidaka J, Lundby L, Laurberg S, Duelund-Jakobsen J. Comparison of long-term outcome of sacral nerve stimulation for constipation and faecal incontinence with focus on explantation rate, additional visits, and patient satisfaction. Tech Coloproctol 2020; 24:1189-1195. [PMID: 32856184 DOI: 10.1007/s10151-020-02328-0] [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: 03/09/2020] [Accepted: 08/01/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The aim of the present study was to compare sacral nerve stimulation (SNS) for constipation (SNS-C) with SNS for idiopathic faecal incontinence (SNS-IFI) regarding explantation rate, additional visits, and improvement of patient satisfaction 5 years after implantation. METHODS From our prospective database (launched in 2009), we extracted all SNS-C patients 5 years post-implantation, and the SNS-IFI patients implanted just before and just after each SNS-C patient. We retrospectively evaluated the explantation rate, number of additional visits, and patient satisfaction using a visual analogue scale (VAS). We hypothesized that compared with those in the SNS-IFI group: (1) the explantation rate would be higher in SNS-C patients, (2) the number of additional visits would be higher in SNS-C patients, and (3) in patients with an active implant at 5 years, the improvement in VAS would be the same. RESULTS We included 40 SNS-C patients and 80 SNS-IFI patients. In the SNS-C group 7/40 (17.5%), patients were explanted, compared to 10/80 (12.5%) patients in the SNS-IFI group (p = 0.56). The mean number of additional visits in the SNS-C group was 3.5 (95% CI 2.8-4.1)) and 3.0 (95% CI 2.6-3.6)) in the SNS-IFI group (p = 0.38). Additional visits due to loss of efficacy were significantly higher in the SNS-C patients (p = 0.03). The reduction in VAS score (delta VAS) at 5 years was 37.1 (95% CI 20.9-53.3) in the SNS-C group, and 46.0 (95% CI 37.9-54.0) in the SNS-IFI group (p = 0.27). CONCLUSIONS No significant difference was found regarding explantation rate, number of additional visits, or improvement of VAS at 5 years after SNS implantation between SNS-C patients and SNS-IFI patients.
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Affiliation(s)
- J Hidaka
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark. .,Hidaka Coloproctology Clinic, Kurume, Japan.
| | - L Lundby
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
| | - J Duelund-Jakobsen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
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12
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Fassov J, Liao D, Brock C, Lundby L, Laurberg S, Krogh K. Sacral Nerve Modulation Has No Effect on the Postprandial Response in Irritable Bowel Syndrome. Clin Exp Gastroenterol 2020; 13:235-244. [PMID: 32636665 PMCID: PMC7335277 DOI: 10.2147/ceg.s245209] [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: 01/08/2020] [Accepted: 05/22/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Irritable bowel syndrome is a common gastrointestinal disorder with a global prevalence of approximately 11%. Onset or worsening of symptoms following digestion is one of the characteristics of the condition. The present study aimed at evaluating the postprandial sensory and motor response before and after treatment with sacral nerve modulation. Patients and Methods Twenty-one irritable bowel syndrome patients, 12 diarrhea-predominant and 9 mixed, were eligible for a 6-week sacral nerve modulation test period. Patients were investigated with multimodal impedance planimetry including a standardized meal at baseline and at the end of 2 weeks of suprasensory stimulation embedded in the 6-week sacral nerve modulation period. Results There was no statistical significant difference in the sensory response to heat or cold before and after sacral nerve modulation, p>0.05. At baseline, wall tension increased after the meal (mean 124.79 [range 82.5 to 237.3] mmHg.mm before the meal, mean 207.76 [range, 143.5 to 429] mmHg.mm after the meal), p=0.048 indicating a postprandial response. During sacral nerve modulation, the postprandial increase in wall tension did not reach statistical significance (mean 86.79 [range 28.8 to 204.5] mmHg.mm before the meal, mean 159.71 [range 71.3 to 270.8] mmHg.mm after the meal), p=0.277. However, there was no statistically significant difference between the postprandial wall tension at baseline and during sacral nerve modulation, p=0.489. Likewise, we found no difference between pressure or stretch ratio at baseline and during sacral nerve modulation, p>0.05. Conclusion Sacral nerve modulation does not exert its positive treatments effects in diarrhea-predominant and mixed irritable bowel syndrome through a modulation of the postprandial response.
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Affiliation(s)
- Janne Fassov
- Department Of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Donghua Liao
- GIOME Academia, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute, Faculty of Health Sciences Aalborg University, Aalborg, Denmark
| | - Lilli Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Department Of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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13
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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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14
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Ye F, Liu Y, Li S, Zhang S, Foreman RD, Chen JD. Sacral nerve stimulation increases gastric accommodation in rats: a spinal afferent and vagal efferent pathway. Am J Physiol Gastrointest Liver Physiol 2020; 318:G574-G581. [PMID: 31984783 DOI: 10.1152/ajpgi.00255.2019] [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] [Indexed: 01/31/2023]
Abstract
Impaired gastric accommodation (GA) has been frequently reported in various gastrointestinal diseases. No standard treatment strategy is available for treating impaired GA. We explored the possible effect of sacral nerve stimulation (SNS) on GA and discovered a spinal afferent and vagal efferent mechanism in rats. Sprague-Dawley rats (450-500 g) with a chronically implanted gastric cannula and ECG electrodes were studied in a series of sessions to study: 1) the effects of SNS with different parameters on gastric tone, compliance, and accommodation using a barostat device; two sets of parameters were tested as follows: parameter 1) 5 Hz, 500 µs, 10 s on 90 s off; 90% motor threshold and parameter 2) same as parameter 1 but 25 Hz; 2) the involvement of spinal afferent pathway via detecting c-fos immunoreactive (IR) cells in the nucleus of the solitary tract (NTS) of the brain; 3) the involvement of vagal efferent activity via the spectral analysis of heart rate variability derived from the ECG; and 4) the nitrergic mechanism, Nω-nitro-l-arginine methyl ester (l-NAME), a nitric oxide synthase (NOS) inhibitor, was given before SNS at 5 Hz. Compared with sham-SNS: 1) SNS at 5 Hz inhibited gastric tone and increased gastric compliance and GA. No difference was noted between the stimulation frequencies of 5 and 25 Hz. 2) SNS increased the expression of c-fos in the NTS. 3) SNS increased cardiac vagal efferent activity and decreased the sympathovagal ratio. 4) l-NAME blocked the relaxation effect of SNS. In conclusion, SNS with certain parameters relaxes gastric fundus and improves gastric accommodation mediated via a spinal afferent and vagal efferent pathway.NEW & NOTEWORTHY Currently, there is no adequate medical therapy for impaired gastric accommodation, since medications that relax the fundus often impair antral peristalsis and thus further delay gastric emptying that is commonly seen in patients with functional dyspepsia or gastroparesis. The advantage of the potential sacral nerve stimulation therapy is that it improves gastric accommodation by enhancing vagal activity, and the enhanced vagal activity would lead to enhanced antral peristalsis rather than inhibiting it.
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Affiliation(s)
- Feng Ye
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,The First Affiliated Hospital of Xi'an Jiaotong University, Shannxi, China.,Department of Physiology, University of Oklahoma, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Yi Liu
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,The First Affiliated Hospital of Xi'an Jiaotong University, Shannxi, China.,Department of Physiology, University of Oklahoma, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Shiying Li
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Sujuan Zhang
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Department of Physiology, University of Oklahoma, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland.,Department of Gastroenterology, Tianjin No. 254 Hospital, Tianjin, China
| | - Robert D Foreman
- Department of Physiology, University of Oklahoma, Oklahoma City, Oklahoma
| | - Jiande Dz Chen
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
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15
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Kollmann CT, Pretzsch EB, Kunz A, Isbert C, Krajinovic K, Reibetanz J, Kim M. Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence-a cohort analysis. Int J Colorectal Dis 2020; 35:2293-2299. [PMID: 32812091 PMCID: PMC7648741 DOI: 10.1007/s00384-020-03720-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Sacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence. METHODS Consecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient's characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation. RESULTS From, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°). CONCLUSIONS Anorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.
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Affiliation(s)
- Cathérine T. Kollmann
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wurzburg, Oberduerrbacher Strasse 6, 97080 Wurzburg, Germany
| | - Elise B. Pretzsch
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wurzburg, Oberduerrbacher Strasse 6, 97080 Wurzburg, Germany
| | - Andreas Kunz
- Diagnostic and Interventional Radiology Institute, University Hospital Wurzburg, Oberduerrbacher Strasse 6, 97080 Wurzburg, Germany
| | - Christoph Isbert
- Department of General and Visceral Surgery, Amalie Sieveking Hospital, Haselkamp 33, Hamburg, Germany
| | - Katica Krajinovic
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wurzburg, Oberduerrbacher Strasse 6, 97080 Wurzburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wurzburg, Oberduerrbacher Strasse 6, 97080 Wurzburg, Germany
| | - Mia Kim
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wurzburg, Oberduerrbacher Strasse 6, 97080 Wurzburg, Germany
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16
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Fassov J, Lundby L, Laurberg S, Krogh K. Sacral nerve modulation for irritable bowel syndrome: A randomized, double-blinded, placebo-controlled crossover study. Neurogastroenterol Motil 2019; 31:e13570. [PMID: 30793441 DOI: 10.1111/nmo.13570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/07/2019] [Accepted: 01/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is among the most common gastrointestinal disorders, and a substantial proportion of patients have an insufficient response to treatment. In a single-blinded study, sacral nerve modulation (SNM) significantly reduced symptoms of IBS. The aim of the present double-blinded, randomized, placebo-controlled study was to evaluate the effect of SNM for IBS. METHODS We included patients with diarrhea-predominant or mixed IBS and a minimum baseline IBS-specific symptom score of 40 points (Gastrointestinal Symptom Rating Scale-IBS version). Patients underwent a 6-week period of SNM. In the first 4 weeks, the patients were randomized 1:1 to have the neurostimulator set subsensory or OFF for 2 weeks and then the opposite for another 2 weeks. Patients and investigators were blinded to settings. In the remaining 2 weeks, the stimulation was set suprasensory. IBS-specific symptoms and quality of life were assessed with validated questionnaires and bowel diaries. KEY RESULTS Twenty-one patients were randomized and eligible for analysis. The IBS-specific symptom score was reduced with borderline significance during stimulation (subsensory-OFF median change -1 (-26, 9), OFF-subsensory median change 8 (-11, 36); P = 0.0572). Pain was significantly reduced during stimulation (subsensory-OFF median change -1.5 (-4, 1), OFF-subsensory median change 1 (-4, 3); P = 0.0188), along with the number of daily bowel movements (subsensory-OFF median change 0 (-1.8, 0.2), OFF-subsensory median change 0.2 (-0.5, 1.1); P = 0.0373). The median placebo effect was 14% (0, 55). CONCLUSION AND INFERENCES Sacral nerve modulation for IBS seems promising but should be considered experimental until larger multicenter studies have been performed.
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Affiliation(s)
- Janne Fassov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Lilli Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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17
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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: 28] [Impact Index Per Article: 4.7] [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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18
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19
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Successful Treatment of Paradoxical Puborectalis Contraction and Intractable Anorectal Pain With Sacral Neuromodulation. Female Pelvic Med Reconstr Surg 2018; 24:e21-e22. [PMID: 29570127 DOI: 10.1097/spv.0000000000000570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paradoxical puborectalis contraction (PPC) is a syndrome of obstructed defecation associated with a cluster of complaints including rectal pain, incomplete evacuatory sensation, prolonged repetitive straining with bowel movements, and the need for digital manipulation. Traditional treatment has yielded mixed results. CASE We present a case of PPC successfully treated with staged sacral neuromodulation and review her diagnostic features, medical regimen, and prior unsuccessful interventions tried. Symptoms were analyzed using a visual analog scale pain score (0-10). Criteria to progress to implantation of the pulse generator included a pain score less than 3 during test stimulation and/or greater than 50% decrease in the pain score compared to baseline.Our patient had a pain score of 0 (baseline 8) with stage 1 sacral neuromodulation. In addition, she had dramatic relief in her straining with bowel movements and need for digital manipulation. Her pulse generator was implanted after a 2-week trial, and she has experienced a lasting improvement at her follow-up of 2 years. CONCLUSIONS Sacral neuromodulation is an established therapy for overactive bladder syndrome, urinary retention, and fecal incontinence. In urology, the use of sacral neuromodulation has been described to benefit some patients with pelvic floor pain. Sacral neuromodulation can be a successful treatment for PPC and functional anorectal pain with resulting improvement in quality of life without the sequelae of an invasive and irreversible surgery.
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20
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Rice TC, Paquette IM. Technical considerations for sacral nerve stimulator insertion. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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21
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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
OBJECTIVE Fecal incontinence (FI) has a devastating effect on the quality of life and results in social isolation. Sacral neuromodulation (SNM) is proven to be an effective, minimal invasive treatment modality for FI. Despite the increasing application of SNM, the exact mechanisms of action remain unclear. The initial assumption of peripheral motor neurostimulation is not supported by increasing evidence, which report effects of SNM outside the pelvic floor. A new hypothesis states that afferent signals to the brain are essential for a successful therapy. This study aimed to review relevant studies on the central mechanism of SNM in FI. METHODS Clinical and experimental studies on the central mechanisms, both brain and spinal cord, of SNM for FI up to December 2015 were evaluated. RESULTS In total, 8 studies were found describing original data on the central mechanism of SNM for FI. Four studies evaluated the central effects of SNM in a clinical setting and 4 studies evaluated the central effects of SNM in an experimental animal model. Results demonstrated a variety of (sub)cortical and spinal changes after induction of SNM. CONCLUSION Review of literature demonstrated evidence for a central mechanism of action of SNM for FI. The corticoanal pathways, brainstem, and specific parts of the spinal cord are involved.
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23
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Haas S, Liao D, Gregersen H, Lundby L, Laurberg S, Krogh K. Increased yield pressure in the anal canal during sacral nerve stimulation: a pilot study with the functional lumen imaging probe. Neurogastroenterol Motil 2017; 29. [PMID: 27545307 DOI: 10.1111/nmo.12929] [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: 02/16/2016] [Accepted: 07/27/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sacral nerve stimulation (SNS) is a well-established treatment for fecal incontinence but its mode of action remains obscure. Anal sphincter function is usually evaluated with manometry but resistance to distension may be a more appropriate parameter than luminal pressure. The functional lumen imaging probe allows detailed description of distension properties of the anal canal. Our objective in this study was to characterize the impact of SNS on distension properties of the anal canal in patients with idiopathic fecal incontinence. METHODS We studied 10 women (median age 64 [44-79] years) with idiopathic fecal incontinence at baseline and during SNS. The luminal geometry of the anal canal was examined with the FLIP at rest and during squeeze and the distensibility of the anal canal was investigated during filling of the bag. KEY RESULTS All patients were successfully treated with SNS and the mean Wexner Incontinence Score was reduced from 14.9 ± 4 to 7.1 ± 4.8 (P<.001). The pressure required to open the narrowest point of the anal canal during distension (yield pressure) increased from 14.5 ± 12.2 mmHg at baseline to 20.5 ± 13.3 mmHg during SNS (P<.01). The pressure-strain elastic modulus increased non-significantly from 2.2 ± 0.5 to 2.9 ± 1.6 kPa, indicating increased stiffness of the anal canal. CONCLUSION AND INFERENCES The yield pressure and the resistance to distension increased in response to SNS for idiopathic fecal incontinence. This will inevitably increase the resistance to flow through the anal canal, which may contribute to the benefits of sacral nerve stimulation.
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Affiliation(s)
- S Haas
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - D Liao
- GIOME Academia, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - H Gregersen
- GIOME and the Key Laboratory for Biorheological Science and Technology of Ministry of Education, Bioengineering College of Chongqing University, Chongqing, China.,GIOME, Department of Surgery, Chinese University of Hong Kong and Prince of Whales Hospital, Shatin, Hong Kong
| | - L Lundby
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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24
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Fassov J, Lundby L, Laurberg S, Buntzen S, Krogh K. Three-year follow-up of sacral nerve stimulation for patients with diarrhoea-predominant and mixed irritable bowel syndrome. Colorectal Dis 2017; 19:188-193. [PMID: 27328645 DOI: 10.1111/codi.13428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/04/2016] [Indexed: 01/03/2023]
Abstract
AIM Our unit has recently shown that sacral nerve stimulation (SNS) has a significantly positive short-term effect on selected patients with diarrhoea-predominant or mixed irritable bowel syndrome (IBS). The aim of the present prospective study was to evaluate the medium-term efficacy of SNS for IBS to establish whether SNS could have a future role in the treatment of IBS. METHOD Patients with IBS who had previously been implanted with a permanent neurostimulator as part of a randomized, controlled, crossover study, were assessed for medium-term follow-up. The primary end-point was change in the IBS-specific symptom score (Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire) from baseline to 3-year follow-up. The secondary end-point was a change in the IBS-specific quality of life score (Irritable Bowel Syndrome-Impact Scale questionnaire) from baseline to 3-year follow-up. RESULTS Of 26 patients, 20 were eligible for 3-year follow-up. The median IBS-specific symptom score was significantly lower at 3-year follow-up (30, range 13-71) than at baseline (62, 45-80) (P = 0.0001). The effect was observed in all symptom clusters within the score. Also, the median IBS-specific quality of life score was significantly improved at 3-year follow-up (52, 26-169) compared with baseline (135, 82-180, P = 0.0002). The effect was observed in all domains of the score. As per the protocol, 75% of patients were judged therapeutic successes. Seventy per cent of patients had a more than 50% reduction in daily IBS symptoms. CONCLUSION At medium-term follow-up, SNS continues to be an effective treatment for highly selected patients with diarrhoea-predominant or mixed IBS.
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Affiliation(s)
- J Fassov
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.,Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Aarhus, Denmark
| | - L Lundby
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Buntzen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Aarhus, Denmark
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25
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Jones J, Van de Putte D, De Ridder D, Knowles C, O'Connell R, Nelson D, Goessaert AS, Everaert K. A Joint Mechanism of Action for Sacral Neuromodulation for Bladder and Bowel Dysfunction? Urology 2016; 97:13-19. [DOI: 10.1016/j.urology.2016.05.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/15/2016] [Accepted: 05/01/2016] [Indexed: 12/27/2022]
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26
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Benezech A, Bouvier M, Vitton V. Faecal incontinence: Current knowledges and perspectives. World J Gastrointest Pathophysiol 2016; 7:59-71. [PMID: 26909229 PMCID: PMC4753190 DOI: 10.4291/wjgp.v7.i1.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/31/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools.
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27
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Tipsmark LS, Fassov J, Lundby L, Laurberg S, Ehlers L, Krogh K. Cost-effectiveness analysis of sacral nerve stimulation as treatment for severe irritable bowel syndrome. Colorectal Dis 2016; 18:O30-6. [PMID: 26466156 DOI: 10.1111/codi.13149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/12/2015] [Indexed: 12/19/2022]
Abstract
AIM Early results from sacral nerve stimulation (SNS) for severe irritable bowel syndrome (IBS) are promising but estimates of cost-effectiveness are lacking. Our object was to perform a cost-effectiveness analysis for SNS as an alternative to no treatment of IBS. METHOD This retrospective analysis was based on the results from a randomized controlled crossover study with a cost-utility analysis performed on patient-level data and modelling of censored data over a projected period of time of up to 20 years. The analysis was conducted on an intention-to-treat approach. For estimation of the uncertainty of the incremental cost-effectiveness ratio a bias corrected bootstrap analysis was performed. RESULTS Cost-effectiveness was not reached for 4 years after permanent implantation (£31 270 per quality-adjusted life years), which was the upper limit for patient follow-up, but our data imply a cost-effectiveness from a 7-year perspective onwards. CONCLUSION The study indicates the SNS treatment for IBS is cost effective from a 7-year perspective onwards.
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Affiliation(s)
- L S Tipsmark
- Danish Center for Health Care Improvement, Aalborg University, Aalborg, Denmark
| | - J Fassov
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - L Lundby
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - L Ehlers
- Danish Center for Health Care Improvement, Aalborg University, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Aarhus, Denmark
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Duelund-Jakobsen J, Buntzen S, Lundby L, Sørensen M, Laurberg S. Bilateral compared with unilateral sacral nerve stimulation for faecal incontinence: results of a randomized, single-blinded crossover study. Colorectal Dis 2015; 17:1085-93. [PMID: 26354517 DOI: 10.1111/codi.13111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/02/2015] [Indexed: 02/08/2023]
Abstract
AIM This randomized single-blinded crossover study aimed to investigate whether bilateral sacral nerve stimulation (SNS) is more efficient than unilateral stimulation for faecal incontinence (FI). METHOD Patients with FI who responded during a unilateral test stimulation, with a minimum improvement of 50% were eligible. Twenty-seven patients who were accepted to enter the trial were bilaterally implanted with two permanent leads and pacemakers. Patients were randomized into three periods of 4 weeks' stimulation including unilateral right, unilateral left and bilateral stimulation. Symptoms scores and bowel habit diaries were collected at baseline and in each study period. A 1-week washout was introduced between each study period. RESULTS Twenty-seven (25 female) patients with a median age of 63 (36-84) years were bilaterally implanted from May 2009 to June 2012. The median number of episodes of FI per 3 weeks significantly decreased from 17 (3-54) at baseline to 2 (0-20) during stimulation on the right side, 2 (0-42) during stimulation on the left side and 1 (0-25) during bilateral stimulation. The Wexner incontinence score improved significantly from a median of 16 (10-20) at baseline to 9 (0-14) with right-side stimulation, 10 (0-15) with left-side stimulation and 9 (0-14) with bilateral stimulation. The differences between unilateral right or unilateral left and bilateral stimulation were non-significant, for FI episodes (P = 0.3) or for Wexner incontinence score (P = 0.9). CONCLUSION Bilateral SNS therapy for FI is not superior to standard unilateral stimulation in the short term. Equal functional results can be obtained regardless of the side of implantation.
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Affiliation(s)
- J Duelund-Jakobsen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Buntzen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - L Lundby
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - M Sørensen
- Department of Surgical and Medical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | - S Laurberg
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Mirbagheri N, Sivakumaran Y, Nassar N, Gladman MA. Systematic review of the impact of sacral neuromodulation on clinical symptoms and gastrointestinal physiology. ANZ J Surg 2015; 86:232-6. [PMID: 26245170 PMCID: PMC5054906 DOI: 10.1111/ans.13257] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2015] [Indexed: 12/13/2022]
Abstract
Background Sacral neuromodulation (SNM) has emerged as a treatment option for faecal incontinence (FI). However, its objective effect on symptoms and anorectal function is inconsistently described. This study aimed to systematically review the impact of SNM on clinical symptoms and gastrointestinal physiology in patients with FI, including factors that may predict treatment outcome. Methods An electronic search of MEDLINE (1946–2014)/EMBASE database was performed in accordance with PRISMA guidelines. Articles that reported the relevant outcome measures following SNM were included. Clinical outcomes evaluated included: frequency of FI episodes, FI severity score and success rates. Its impact on anorectal and gastrointestinal physiology was also evaluated. Results Of 554 citations identified, data were extracted from 81 eligible studies. Meta‐analysis of the data was precluded due to lack of a comparison group in most studies. After permanent SNM, ‘perfect’ continence was noted in 13–88% of patients. Most studies reported a reduction in weekly FI episodes (median difference of the mean −7.0 (range: −24.8 to −2.7)) and Wexner scores (median difference of the mean −9 (−14.9 to −6)). A trend towards improved resting and squeeze anal pressures and a reduction in rectal sensory volumes were noted. Studies failed to identify any consistent impact on other physiological parameters or clinicophysiological factors associated with success. Conclusion SNM improves clinical symptoms and reduces number of incontinence episodes and severity scores in patients with FI, in part by improving anorectal physiological function. However, intervention studies with standardized outcome measures and physiological techniques are required to robustly assess the physiological impact of SNM.
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Affiliation(s)
- Naseem Mirbagheri
- Academic Colorectal Unit, Sydney Medical School - Concord, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Colorectal + Pelvic Floor Centre, Concord Private Hospital, Sydney, New South Wales, Australia
| | - Yogeesan Sivakumaran
- Academic Colorectal Unit, Sydney Medical School - Concord, The University of Sydney, Sydney, New South Wales, Australia
| | - Natasha Nassar
- Academic Colorectal Unit, Sydney Medical School - Concord, The University of Sydney, Sydney, New South Wales, Australia.,Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Marc A Gladman
- Academic Colorectal Unit, Sydney Medical School - Concord, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Colorectal + Pelvic Floor Centre, Concord Private Hospital, Sydney, New South Wales, Australia
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Pucciani F, Altomare DF, Dodi G, Falletto E, Frasson A, Giani I, Martellucci J, Naldini G, Piloni V, Sciaudone G, Bove A, Bocchini R, Bellini M, Alduini P, Battaglia E, Galeazzi F, Rossitti P, Usai Satta P. Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists. Dig Liver Dis 2015; 47:628-645. [PMID: 25937624 DOI: 10.1016/j.dld.2015.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/08/2015] [Accepted: 03/28/2015] [Indexed: 02/06/2023]
Abstract
Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.
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Affiliation(s)
- Filippo Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Italy.
| | | | - Giuseppe Dodi
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Ezio Falletto
- I Division of Surgical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Alvise Frasson
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Iacopo Giani
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | - Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Gabriele Naldini
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | | | - Guido Sciaudone
- General and Geriatric Surgery Unit, School of Medicine, Second University of Naples, Italy
| | - Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology - AORN "A. Cardarelli", Naples, Italy
| | - Renato Bocchini
- Gastrointestinal Physiopathology, Gastroenterology Department, Malatesta Novello Private Hospital, Cesena, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Gastroenterology, University of Pisa, Italy
| | - Pietro Alduini
- Digestive Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | | | - Piera Rossitti
- Gastroenterology Unit, S.M. della Misericordia University Hospital, Udine, Italy
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Haas S, Brock C, Krogh K, Gram M, Lundby L, Drewes AM, Laurberg S. Abnormal neuronal response to rectal and anal stimuli in patients with idiopathic fecal incontinence. Neurogastroenterol Motil 2015; 27:954-62. [PMID: 25903483 DOI: 10.1111/nmo.12567] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/16/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The pathophysiology behind idiopathic fecal incontinence (IFI) is poorly understood. We hypothesized abnormal sensory pathways along the brain-gut axis as a key player in this disease, reflected in cortical evoked potentials (CEP) from mechanical stimuli of the rectum and the anal canal. METHODS CEPs were recorded during repeated rapid balloon distensions of the rectum and anal canal in 19 women with IFI (mean age: 60 ± 14, mean Wexner score: 14.7 ± 2.9) and in 19 healthy women (mean age: 56 ± 11, mean Wexner score: 1.1 ± 1.3). Latencies, amplitudes and topography of CEPs elicited by rectal distension were compared between the groups. CEPs from both rectal and anal distensions were examined using spectral band analysis of single sweeps determining the relative amplitude of five spectral bands as a proxy of neuronal processing. KEY RESULTS Compared to controls IFI patients had prolonged latency of CEPs from rectal distension by up to 27% (p < 0.001) while amplitudes and topography were similar (all p > 0.7 and all p > 0.23). Spectral analysis of CEPs from rectal distensions showed no difference (all p > 0.1) between groups. However, analysis of CEPs following distension of the anal canal resulted in abnormally low activity in beta (8-12 Hz; p < 0.001) band and high activity in the gamma (32-70 Hz; p = 0.04) band in patients. CONCLUSIONS & INFERENCES IFI seems to be associated with impaired ano-rectal sensory functions in both the afferent fibers to the brain and the cortical processing of anal sensory pathways. This may play a central role for the pathogenesis of IFI.
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Affiliation(s)
- S Haas
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - L Lundby
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - S Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Ratto C, Ganio E, Naldini G. Long-term results following sacral nerve stimulation for chronic constipation. Colorectal Dis 2015; 17:320-8. [PMID: 25476039 DOI: 10.1111/codi.12857] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 09/20/2014] [Indexed: 12/19/2022]
Abstract
AIM The long-term outcome of sacral nerve stimulation (SNS) for chronic functional constipation was assessed. METHOD Patients who received a definitive SNS implant for chronic functional constipation only (according to the Rome III criteria) and were followed up for at least 3 years were included in this study. Slow transit constipation (STC) was distinguished from obstructed defaecation (OD) and mixed/undetermined constipation (MU). Constipation features, Cleveland Clinic Constipation score (CCCS) and SF-36 questionnaire data were collected; physiological tests were performed. RESULTS Forty-two out of 61 patients suitable for SNS received a definitive implant (14 for STC, 15 for OD, 13 for MU). Following SNS device implantation (mean follow-up 51 ± 15 months), the baseline CCCS (17 ± 6) dropped to 9 ± 6 (P < 0.001) and 47% of patients had an improvement in the CCCS of more than 50%. Such improvement was more significant in patients with OD. Anal pressures did not change, while threshold and urgency rectal sensation significantly decreased, in particular in patients with OD. All aspects of patients' health status (SF-36) improved significantly following SNS; this was more marked in patients with OD. CONCLUSION Data from this study suggest that the clinical efficacy of SNS can be prolonged in constipated patients, but in both the preliminary diagnostic assessment and pathophysiological interpretation every effort should be made to select patients for SNS. Although SNS showed efficacy in a low percentage of patients with STC, patients with OD were more responsive.
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Affiliation(s)
- C Ratto
- Department of Surgical Sciences, Catholic University, Rome, Italy
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Abstract
In recent years, several investigators have successfully regenerated axons in animal spinal cords without locomotor recovery. One explanation is that the animals were not trained to use the regenerated connections. Intensive locomotor training improves walking recovery after spinal cord injury (SCI) in people, and >90% of people with incomplete SCI recover walking with training. Although the optimal timing, duration, intensity, and type of locomotor training are still controversial, many investigators have reported beneficial effects of training on locomotor function. The mechanisms by which training improves recovery are not clear, but an attractive theory is available. In 1949, Donald Hebb proposed a famous rule that has been paraphrased as “neurons that fire together, wire together.” This rule provided a theoretical basis for a widely accepted theory that homosynaptic and heterosynaptic activity facilitate synaptic formation and consolidation. In addition, the lumbar spinal cord has a locomotor center, called the central pattern generator (CPG), which can be activated nonspecifically with electrical stimulation or neurotransmitters to produce walking. The CPG is an obvious target to reconnect after SCI. Stimulating motor cortex, spinal cord, or peripheral nerves can modulate lumbar spinal cord excitability. Motor cortex stimulation causes long-term changes in spinal reflexes and synapses, increases sprouting of the corticospinal tract, and restores skilled forelimb function in rats. Long used to treat chronic pain, motor cortex stimuli modify lumbar spinal network excitability and improve lower extremity motor scores in humans. Similarly, epidural spinal cord stimulation has long been used to treat pain and spasticity. Subthreshold epidural stimulation reduces the threshold for locomotor activity. In 2011, Harkema et al. reported lumbosacral epidural stimulation restores motor control in chronic motor complete patients. Peripheral nerve or functional electrical stimulation (FES) has long been used to activate sacral nerves to treat bladder and pelvic dysfunction and to augment motor function. In theory, FES should facilitate synaptic formation and motor recovery after regenerative therapies. Upcoming clinical trials provide unique opportunities to test the theory.
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Affiliation(s)
- Wise Young
- W. M. Keck Center for Collaborative Neuroscience, Rutgers, State University of New Jersey, Piscataway, NJ, USA
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Khan U, Mason JM, Mecci M, Yiannakou Y. A prospective trial of temporary sacral nerve stimulation for constipation associated with neurological disease. Colorectal Dis 2014; 16:1001-9. [PMID: 25251843 DOI: 10.1111/codi.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 02/12/2014] [Indexed: 02/08/2023]
Abstract
AIM This study assessed the effectiveness of temporary sacral nerve stimulation (SNS) in patients with constipation associated with neurological disease using an off-on-off design, and evaluated the long-term response in patients undergoing permanent SNS. METHOD Patients with chronic constipation associated with neurological disease receiving specialist clinic care at the University Hospital North Durham over a 2-year period were recruited to a trial of SNS. Recordings of bowel function were made for 6 weeks (baseline) and a temporary electrode was then inserted and recordings were made for the next 3 weeks (stimulation). The electrodes were then removed and assessment was continued for a further 3 weeks (posttreatment). Patient-completed questionnaires were used to determine the severity of constipation (Global Assessment of Symptoms, Constipation, GA Constipation), symptoms (Patient Assessment of Constipation Symptoms score, PAC-SYM) and quality-of-life (Patient Assessment of Constipation-Quality Of Life score, PAC-QOL; European Quality of Life-Five-Domain score; European Quality of Life-Visual Analogue Score). Information was obtained on bowel function and medication. Physiological data were also available for transit and laser Doppler flow cytometry to measure mucosal blood flow. RESULTS Twenty-two patients were recruited, of whom 18 completed the trial. GA Constipation reduced significantly during temporary SNS: -1.09 (95% CI -1.59 to -0.59; P = 0.0003). PAC-SYM and PAC-QOL scores showed similar improvements. There was also a significant fall in the time spent in the toilet (P = 0.04) and a decrease in laxative use (P = 0.03). Twelve (67%) patients responded to temporary SNS and received a permanent implant with long-term success in 50%. CONCLUSION Sacral nerve stimulation can be effective in treating some patients with refractory severe neuroconstipation. A response to temporary SNS may predict long-term benefit in only half the patients undergoing permanent SNS.
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Affiliation(s)
- U Khan
- Wrexham Maelor Hospital, Wrexham, UK
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Fassov J, Brock C, Lundby L, Drewes AM, Gregersen H, Buntzen S, Laurberg S, Krogh K. Sacral nerve stimulation changes rectal sensitivity and biomechanical properties in patients with irritable bowel syndrome. Neurogastroenterol Motil 2014; 26:1597-604. [PMID: 25223743 DOI: 10.1111/nmo.12426] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 08/14/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sacral nerve stimulation (SNS) has been demonstrated to alleviate symptoms and improve quality of life in selected patients with irritable bowel syndrome (IBS). The mechanisms of action, however, remain unknown. The aim of the study was to evaluate the effects of SNS on rectal sensitivity and biomechanical properties in patients with IBS. METHODS Twenty patients with diarrhea-predominant (n = 11) or mixed (n = 9) IBS were treated with SNS in a controlled, randomized crossover trial. They were randomized to either 1 month of SNS (ON) or placebo (OFF) with the opposite setting for the next month. Sensory and biomechanical parameters were assessed by multimodal rectal stimulation at the end of each period. IBS-specific symptoms were evaluated at baseline and at the end of each treatment period. KEY RESULTS Cold stimuli were better tolerated in the ON period (19.9 °C[± 0.6]) compared to the OFF period (21.8 °C[± 0.6]; p = 0.03). Significantly lower cross-sectional areas were needed to elicit sensory responses in the ON period (1545 mm(2) [± 95]) compared to the OFF period (1869 mm(2) [± 92]; p = 0.015). The association between reduced sensory threshold and improvement of constipation was of borderline significance (p = 0.05). Wall stiffness was significantly lower in the ON period (192 mmHg[± 10]) compared to the OFF period (234 mmHg[± 10]; p = 0.004). Reduced wall stiffness was significantly associated with improved overall GSRS-IBS symptom score (p = 0.01). Reduced sensory threshold to stretch (p = 0.02) and reduced wall stiffness (p < 0.001) were predictors of the GSRS-IBS symptom score. CONCLUSIONS & INFERENCES SNS for diarrhea-predominant and mixed IBS relaxes the rectal wall, while making it more sensitive to stretch and less sensitive to cold. Reduced wall stiffness and increased sensitivity to stretch are associated with improved GSRS-IBS symptom score.
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Affiliation(s)
- J Fassov
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark; Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Carrington EV, Evers J, Grossi U, Dinning PG, Scott SM, O'Connell PR, Jones JFX, Knowles CH. A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation. Neurogastroenterol Motil 2014; 26:1222-37. [PMID: 25167953 DOI: 10.1111/nmo.12388] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/04/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sacral nerve stimulation (SNS) is now well established as a treatment for fecal incontinence (FI) resistant to conservative measures and may also have utility in the management of chronic constipation; however, mechanism of action is not fully understood. End organ effects of SNS have been studied in both clinical and experimental settings, but interpretation is difficult due to the multitude of techniques used and heterogeneity of reported findings. The aim of this study was to systematically review available evidence on the mechanisms of SNS in the treatment of FI and constipation. METHODS Two systematic reviews of the literature (performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses framework) were performed to identify manuscripts pertaining to (a) clinical and (b) physiological effects of SNS during the management of hindgut dysfunction. KEY RESULTS The clinical literature search revealed 161 articles, of which 53 were deemed suitable for analysis. The experimental literature search revealed 43 articles, of which nine were deemed suitable for analysis. These studies reported results of investigative techniques examining changes in cortical, gastrointestinal, colonic, rectal, and anal function. CONCLUSIONS & INFERENCES The initial hypothesis that the mechanism of SNS was primarily peripheral motor neurostimulation is not supported by the majority of recent studies. Due to the large body of evidence demonstrating effects outside of the anorectum, it appears likely that the influence of SNS on anorectal function occurs at a pelvic afferent or central level.
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Affiliation(s)
- E V Carrington
- National Centre for Bowel Research and Surgical Innovation (NCRBSI) and The Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, London, UK; Biomedical Science Section, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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A randomized, controlled, crossover study of sacral nerve stimulation for irritable bowel syndrome. Ann Surg 2014; 260:31-6. [PMID: 24509204 DOI: 10.1097/sla.0000000000000559] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate whether sacral nerve stimulation reduces irritable bowel syndrome (IBS)-specific symptoms by a randomized, controlled, crossover study. BACKGROUND IBS affects 3% to 22% of the population worldwide, but most patients continue to have symptoms despite treatment. METHODS Patients included from our tertiary center had diarrhea-predominant or mixed IBS, with a minimum baseline IBS symptom score (Gastrointestinal Syndrome Rating Scale-IBS questionnaire) of 40 points reduced by a minimum of 30% during the percutaneous nerve evaluation before permanent implantation. Patients were randomized (1:1) to have the stimulator ON or OFF for 1 month and then the opposite for another month. Investigators and patients were not informed of the setting. IBS-specific symptoms and quality of life were assessed through bowel diaries and validated questionnaires. Primary endpoint was the IBS-specific symptom score. RESULTS Twenty-one patients were randomized. Ten were eligible for analysis in each group. IBS-specific symptom scores were significantly reduced during stimulation: the median difference in the ON-OFF group was 12 (range, -22 to 44) and in the OFF-ON group -17.5 (range, -48 to -1) (P = 0.0009). IBS-specific quality-of-life scores improved significantly during stimulation: the median difference in the ON-OFF group was 16 (range, -24 to 69) and in the OFF-ON group -42.5 (range, -77 to 0) (P = 0.0003). At 1-year follow-up, the median IBS-specific symptom score (25; range, 13-65) was significantly lower than that at baseline (62; range, 45-80) (P = 0.0001). CONCLUSIONS Sacral nerve stimulation significantly reduces symptoms and improves quality of life of highly selected patients with IBS.
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A randomised, controlled study of small intestinal motility in patients treated with sacral nerve stimulation for irritable bowel syndrome. BMC Gastroenterol 2014; 14:111. [PMID: 24965754 PMCID: PMC4099082 DOI: 10.1186/1471-230x-14-111] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 06/02/2014] [Indexed: 12/15/2022] Open
Abstract
Background Irritable bowel syndrome (IBS) is among the most common gastrointestinal disorders worldwide. In selected patients with severe diarrhoea-predominant or mixed IBS subtypes sacral nerve stimulation (SNS) alleviates IBS-specific symptoms and improves quality of life. The mode of action, however, remains unknown. The present study aimed to evaluate the effect of SNS on small intestinal motility in IBS patients. Methods Twenty patients treated with SNS for severe diarrhoea-predominant or mixed IBS were included in a randomised, controlled, crossover study. The neurostimulator was turned ON or OFF for the first one month and then to the opposite setting for the next month. Gastrointestinal transit patterns were investigated with the Motility Tracking System-1 (MTS-1) at the end of each the ON and OFF period. Primary endpoint was change in the velocity of the magnetic pill within the small intestine. Statistical testing was performed with Wilcoxon’s rank sum test and Fisher’s exact test. Results The median velocity of the magnetic pill through the small intestine in the fasting state was not significantly different between periods with and without SNS (Group ON-OFF: median change 0 m/h (range -1.07, 0.63), Group OFF-ON: median change 0.27 m/h (range -0.59, 1.12)) (p = 0.25). Neither, was the median velocity of the magnetic pill through the small intestine in the postprandial state significantly different between periods with and without SNS (Group ON-OFF: median change -0.13 m/h (range -0.46, 0.23), Group OFF-ON: median change 0.015 m/h (range -0.48, 0.59)) (p = 0.14). Conclusion Even though SNS may reduce symptoms of diarrhoea-predominant and mixed IBS, it has no detectable effect on small intestinal transit patterns. Trial registration Clinical.trials.gov, (NCT00919672).
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Lee YY. What's New in the Toolbox for Constipation and Fecal Incontinence? Front Med (Lausanne) 2014; 1:5. [PMID: 25705618 PMCID: PMC4335388 DOI: 10.3389/fmed.2014.00005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 03/13/2014] [Indexed: 12/11/2022] Open
Abstract
Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut-brain-microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.
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Affiliation(s)
- Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia , Kota Bharu , Malaysia ; Section of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Georgia Regents University , Augusta, GA , USA
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Bouguen G, Ropert A, Lainé F, Pequin P, Morcet J, Bretagne JF, Siproudhis L. Effects of transcutaneous tibial nerve stimulation on anorectal physiology in fecal incontinence: a double-blind placebo-controlled cross-over evaluation. Neurogastroenterol Motil 2014; 26:247-54. [PMID: 24304363 DOI: 10.1111/nmo.12256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transcutaneous electrical tibial nerve stimulation (TENS) is of growing interest for the treatment of fecal incontinence (FI), but its mechanism of action remains uninvestigated. We aimed to further assess the anorectal response to TENS in a dynamic model. METHODS We performed a placebo-controlled, randomized, double-blinded crossover study in 19 patients suffering from FI to assess the effects of TENS on anorectal function. Anorectal physiology and perception were recorded through two sequences of rectal isobaric distension using an electronic barostat device to measure anal and rectal pressures, rectal volumes, and perception scores. KEY RESULTS Maximal rectal pressure and volume variation were affected by TENS, with higher mean maximal rectal pressure (5.33 and 4.06 mmHg in the active and sham TENS respectively, p < 0.0001) and lower volume variation (11.45 and 14.7 mL in the active and sham stimulation respectively, p < 0.05). Rectal compliance was not modified by active TENS. Pressure of the upper anal canal was significantly lower with raised isobaric distension in sequences assigned to active TENS. CONCLUSIONS & INFERENCES Acute TENS modified anorectal physiology by strengthening the myogenic response to distension rather than increasing muscle relaxation and related rectal compliance in patients with FI.
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Affiliation(s)
- G Bouguen
- Service des Maladie de l'Appareil Digestif, Centre Hospitalier Pontchaillou et Université de Rennes 1, Rennes, France; INSERM U991, Université de Rennes 1, Rennes, France
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Sacral nerve stimulation at subsensory threshold does not compromise treatment efficacy: results from a randomized, blinded crossover study. Ann Surg 2013; 257:219-23. [PMID: 23001079 DOI: 10.1097/sla.0b013e318269d493] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE : Stimulation amplitude used in sacral nerve stimulation (SNS) is at or just above the sensory threshold (ST). This randomized, blinded crossover study aimed to document if stimulation at 75% or 50% of the ST would be as effective as stimulation at the ST for fecal incontinence (FI). METHOD : FI patients treated with SNS, who were satisfied with current treatment results and had a minimum symptom reduction of 75%, were eligible. Patients were randomized into 3 periods of 4-week stimulation: ST, 75% of the ST, and 50% of the ST. Patients completed a bowel habit diary and questionnaires on bowel functions and patient satisfaction at the study baseline and in each study period. RESULTS : Nineteen patients (18 females) with a mean follow-up of 51.7 ± 29.9 months were included from January to April 2010. The mean FI episodes per 3 weeks decreased from pre-SNS therapy 33.6 ± 31.6 to 1.1 ± 2.2 at the study baseline (P < 0.001). Decreasing the stimulation amplitude to as low as 50% of the ST did not affect the overall number of incontinent episodes (P = 0.078). The Wexner incontinence score dropped from 16.5 ± 2.5 for pre-SNS therapy to 7.4 ± 3.1 at the study baseline (P < 0.001). Decreasing the stimulation amplitude to ST, 75% of the ST or 50% of the ST, did not change the Wexner score when compared with the study baseline (P = 0.581). In general, patient satisfaction was high at the study baseline and did not deteriorate as the stimulation amplitude was decreased to 50% of the ST (P = 0.932). CONCLUSIONS : Subsensory stimulation as low as 50% of the ST is as effective as stimulation at or above the ST. The study was approved by the Regional Committee on Biomedical Research Ethics, Denmark, and registered at ClinicalTrials.gov (NCT01130870).
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Worsøe J, Fassov J, Schlageter V, Rijkhoff NJM, Laurberg S, Krogh K. Turning off sacral nerve stimulation does not affect gastric and small intestinal motility in patients treated for faecal incontinence. Colorectal Dis 2012; 14:e713-20. [PMID: 22738022 DOI: 10.1111/j.1463-1318.2012.03148.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Sacral nerve stimulation (SNS) reduces symptoms in up to 80% of patients with faecal incontinence (FI). Its effects are not limited to the distal colon and the pelvic floor. Accordingly, spinal or supraspinal neuromodulation have been suggested as part of the mode of action. The effect of SNS on gastric and small-intestinal motility was studied. METHOD Using the magnet tracking system, MTS-1, a small magnetic pill was tracked twice through the upper gastrointestinal tract of eight patients with FI successfully treated with SNS. Following a randomized double-blind crossover design, the stimulator was either left active or was turned off for 1 week before investigations with MTS-1. RESULTS The median (range) frequency of gastric con-tractions was 3.05 (2.83-3.40) per min during SNS and 3.04 (2.79?-3.76) per min without (P=NS). The median (range) frequency of contractions in the small intestine during the first 2h after pyloric passage was 10.005 (9.68-10.70) per min during SNS and 10.09 (9.79-10.29) per min without SNS (P=NS). The median (range) velocity of the magnetic pill during the first 2h in the small intestine was 1.6 (1.2-2.8) cm/min during SNS and 1.7 (0.8-3.7) cm/min without SNS (P=NS). Small-intestinal propagation mainly occurred during very fast movements (>15cm/min), accounting for 51% (42-60%) of the distance 3% (2-4%) of the time during SNS and for 53% (18-73%) of the distance 3% (1-8%) of the time without SNS (P=NS). CONCLUSION Turning off SNS for 1week did not affect gastric or small-intestinal motility patterns.
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Affiliation(s)
- J Worsøe
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity. Ann Surg 2012; 255:643-9. [PMID: 22418005 DOI: 10.1097/sla.0b013e318247d49f] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Prospective randomized double-blind placebo-controlled crossover trial of 14 female patients (median age 52 [30-69] years) with proctographically defined evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity (elevated thresholds to balloon distension in comparison with age- and sex-matched controls). BACKGROUND Sacral nerve stimulation (SNS) is an evolving treatment for constipation. However, variable outcomes might be improved by better patient selection. Evidence that the effect of SNS may be mediated by modulation of afferent signaling promotes a role in patients with ED associated with rectal hyposensation. METHODS SNS was performed by the standard 2-stage technique (temporary then permanent implantation). During a 4-week period of temporary stimulation, patients were randomized ON-OFF/OFF-ON for two 2-week periods. Before insertion (PRE), and during each crossover period, primary (rectal sensory thresholds) and secondary (bowel diaries, constipation, and GIQoL [gastrointestinal quality of life] scores) outcome variables were blindly assessed. RESULTS Thirteen patients completed the trial. Following stimulation, defecatory desire volumes to rectal balloon distension were normalized in 10 of 13 patients (PRE: mean 277 mL [234-320] vs ON: 163 mL [133-193] vs OFF: 220 mL [183-257 mL]; P = 0.006) and maximum tolerable volume in 9 of 13 (PRE: mean 350 mL [323-377] vs ON: 262 mL [219-305] vs OFF: 298 mL [256-340 mL]; P = 0.012). There was a significant increase in the percentage of successful bowel movements (PRE: median 43% [0-100] vs ON: 89% [11-100] vs OFF: 83% [11-100]; P = 0.007) and Wexner constipation scores improved (PRE: median 19 [9-26] vs ON: 10 [6-27] vs OFF: 13 [5-29]; P = 0.01). There were no significant changes in disease-specific or generic quality of life measures. Eleven patients progressed to permanent stimulation (9/11 success at 19 months). CONCLUSIONS Most patients with chronic constipation secondary to ED with rectal hyposensitivity responded to temporary SNS. The physiological results presented support a mechanistic role for rectal afferent modulation.
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Lansen-Koch SMP, Govaert B, Oerlemans D, Melenhorst J, Vles H, Cornips E, Weil EHJ, van Heurn E, Baeten CGMI, van Gemert WG. Sacral nerve modulation for defaecation and micturition disorders in patients with spina bifida. Colorectal Dis 2012; 14:508-14. [PMID: 21689346 DOI: 10.1111/j.1463-1318.2011.02678.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIM Sacral nerve modulation is a well accepted method for the treatment of defaecation disorders and voiding dysfunction. Results of sacral nerve modulation in patients with spinal cord lesions are not well assessed, but preliminary results look poor. Therefore, the purpose of this study was to assess the effectiveness of sacral nerve modulation for defaecation disorders and voiding dysfunction in patients with spina bifida. METHOD Consecutive patients with spina bifida suffering from a myelomeningocele and combined faecal and urinary functional disorders that were eligible for peripheral nerve evaluation (PNE) were studied. A permanent sacral nerve modulation implantation was performed after successful PNE. RESULTS Ten patients (four female) were included in this study with a median age of 26.4 (range 11.1-41.0) years. In two the PNE was not possible. The median faecal incontinence days (6.0 vs 3.5) and episodes (8.5 vs 3.5) per 21 days decreased significantly during the 3-week period of PNE (P = 0.033). Only 3/10 (30%) patients had a more than 50% improvement and proceeded to a permanent sacral nerve modulation implantation. In one patient it was not possible to perform the permanent implant. CONCLUSION Preliminary results of sacral nerve modulation in a subgroup of spina bifida patients with combined faecal and urinary functional disorders look promising, but long-term results in larger patient groups need to be studied.
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Affiliation(s)
- S M P Lansen-Koch
- Department of Colorectal Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Sacral neuromodulation therapy: a promising treatment for adolescents with refractory functional constipation. Dis Colon Rectum 2012; 55:278-85. [PMID: 22469794 DOI: 10.1097/dcr.0b013e3182405c61] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sacral neuromodulation therapy has been successfully applied in adult patients with urinary and fecal incontinence and in adults with constipation not responding to intensive conservative treatment. No data, however, are available on sacral neuromodulation therapy as a treatment option in adolescents with refractory functional constipation. OBJECTIVES This study aimed to describe the short-term results of sacral neuromodulation in adolescents with chronic functional constipation refractory to intensive conservative treatment. DESIGN This is a retrospective review. SETTING This study took place at the Department of Surgery, Maastricht University Medical Centre, The Netherlands. PATIENTS Thirteen patients (all girls, age 10-18 years) with functional constipation according to the ROME III criteria not responding to intensive oral and rectal laxative treatment were assigned for sacral neuromodulation. MAIN OUTCOME MEASURES When improvement of symptoms was observed during the testing phase, a permanent stimulator was implanted. Patients were prospectively followed up to at least 6 months after implantation of the permanent stimulator by interviews, bowel diaries, and Cleveland Clinic constipation score. Improvement was defined as spontaneous defecation ≥ 2 times a week. RESULTS At presentation, none of the patients had spontaneous defecation or felt the urge to defecate. All patients had severe abdominal pain. Regular school absenteeism was present in 10 patients. After the testing phase, all but 2 patients had spontaneous defecation ≥ 2 times a week with a reduction in abdominal pain. After implantation, 11 (of 12) had a normal spontaneous defecation pattern of ≥ 2 times a week without medication, felt the urge to defecate, and perceived less abdominal pain without relapse of symptoms until 6 months after implantation. The average Cleveland Clinic constipation score decreased from 20.9 to 8.4. One lead revision and 2 pacemaker relocations were necessary. LIMITATIONS This study is limited by its small sample size, single-institution bias, and retrospective nature. CONCLUSION Sacral neuromodulation appears to be a promising new treatment option in adolescents with refractory functional constipation not responding to intensive conservative therapy. Larger randomized studies with long-term follow-up are required.
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Abstract
BACKGROUND The indications for sacral nerve stimulation are increasing, but the mechanism remains poorly understood. OBJECTIVE This study aimed to examine the effect of sacral nerve stimulation on rectal compliance and rectal sensory function. DESIGN This was a prospective study. SETTINGS This study took place at a university teaching hospital. PATIENTS Twenty-three consecutive consenting patients (22 female; median age, 49 y) undergoing temporary sacral nerve stimulation for fecal incontinence were prospectively studied. Clinical response was assessed by the use of bowel diaries and Wexner scores. MAIN OUTCOME MEASURES Anal manometry, rectal compliance, volume and pressure thresholds to rectal distension (barostat), and rectal Doppler mucosal blood flow were measured before and at the end of stimulation. RESULTS Sixteen patients (70%) had a favorable clinical response. Median anal squeeze pressures increased with stimulation from 40 (range, 6-156) cmH2O to 64 (range, 16-243) cmH2O. Median rectal compliance did not significantly change with stimulation (prestimulation: 11.5 (range, 7.9-21.8) mL/mmHg, poststimulation: 12.4 (range, 6.2-22) mL/mmHg, P = .941). Rectal wall pressures associated with urge (baseline: 15.4 (range, 11-26.7) mmHg, poststimulation: 19 (range, 11.1-42.7) mmHg, P = .054) and maximal tolerated thresholds (baseline: 21.6 (8.5-31.9) mmHg, poststimulation: 27.1 (14.3-43.3) mmHg, P = .023) significantly increased after stimulation. Rectal Doppler mucosal blood flow did not significantly change with stimulation (baseline: 125.8 (69.9-346.8), poststimulation: 112.4 (50.2-404.1), P = .735). Changes in anal resting pressure and rectal wall pressures with stimulation were evident only in responders; however, changes in anal squeeze pressures were evident in both responders and nonresponders. LIMITATIONS The study reports results following short-term stimulation in a small but homogenous group of patients. A larger long-term study will follow. CONCLUSION Temporary sacral nerve stimulation does not change rectal compliance, but is associated with significant changes to the pressure thresholds of rectal distension. This, together with the observation that outcome is not related to sphincter integrity, supports the hypothesis of an afferent-mediated mechanism of action.
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Gourcerol G, Vitton V, Leroi AM, Michot F, Abysique A, Bouvier M. How sacral nerve stimulation works in patients with faecal incontinence. Colorectal Dis 2011; 13:e203-11. [PMID: 21689312 DOI: 10.1111/j.1463-1318.2011.02623.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Sacral nerve stimulation (SNS) reduces incontinence episodes and improves the quality of life of patients treated for faecal incontinence. However, the exact mechanism of action of this technique remains unclear. The present article reviews the pertinent neuroanatomy and neurophysiology related to SNS and provides explanations for potential mechanisms of action. METHOD A systematic review of the literature was performed for studies of the potential mechanisms of action of SNS, using MEDLINE, PubMed, Embase and the Cochrane Library. Articles dealing with the technique, adverse events and economic evaluations of SNS, as well as literature reviews, were excluded, except for reviews dealing with the mechanisms of action of SNS. The following inclusion criteria were used to select articles: (i) articles in English, (ii) randomized, double-blinded, sham-controlled studies, and (iii) cohort studies. Case-control studies or retrospective studies were cited only when randomized or cohort studies could not be found. RESULTS We propose three hypotheses to explain the mechanism of action of SNS: (i) a somato-visceral reflex, (ii) a modulation of the perception of afferent information, and (iii) an increase in external anal sphincter activity. CONCLUSION The mechanism of action of SNS in patients with faecal incontinence almost certainly depends on the modulation of spinal and/or supraspinal afferent inputs. Further research on humans and animals will be required to gain a better understanding of the mechanisms of action of SNS.
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Affiliation(s)
- G Gourcerol
- ADEN EA 3234/IFR MP 23, Physiology Unit, Rouen University Hospital, Rouen, France
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The Effect of Sacral Nerve Modulation on Cerebral Evoked Potential Latency in Fecal Incontinence and Constipation. Ann Surg 2011; 254:90-6. [DOI: 10.1097/sla.0b013e3182196ff4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Damgaard M, Thomsen FG, Sørensen M, Fuglsang S, Madsen JL. The influence of sacral nerve stimulation on gastrointestinal motor function in patients with fecal incontinence. Neurogastroenterol Motil 2011; 23:556-e207. [PMID: 21385289 DOI: 10.1111/j.1365-2982.2011.01683.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Sacral nerve stimulation (SNS) is a well-established treatment for fecal incontinence of various etiologies. However, the mechanism of action remains unclear. The aim of the present study was to determine whether SNS affects gastric emptying, small intestinal transit or colonic transit times. METHODS Seven patients with a permanently implanted sacral nerve stimulator participated in a double-blind randomized cross-over study. The patients were allocated to stimulation ON or OFF for two 7-day periods separated by at least 1week. On days 4-7 of each 7-day period, the patients were examined by gamma camera imaging to measure gastric emptying, small intestinal transit and colonic transit parameters of a radiolabeled, 1600 kJ mixed solid and liquid meal ingested on day 4. KEY RESULTS Sacral nerve stimulation did not change gastric retention at 15 min, gastric mean emptying time, gastric half emptying time, small intestinal mean transit time or colonic geometric center after 24, 48 and 72 h. CONCLUSIONS & INFERENCES Sacral nerve stimulation does not induce major changes in the propulsive capacity of the gastrointestinal tract in patients successfully treated for fecal incontinence with permanent sacral nerve stimulator.
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Affiliation(s)
- M Damgaard
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Griffin KM, Pickering M, O'Herlihy C, O'Connell PR, Jones JFX. Sacral nerve stimulation increases activation of the primary somatosensory cortex by anal canal stimulation in an experimental model. Br J Surg 2011; 98:1160-9. [PMID: 21590761 DOI: 10.1002/bjs.7536] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Sacral and posterior tibial nerve stimulation may be used to treat faecal incontinence; however, the mechanism of action is unknown. The aim of this study was to establish whether sensory activation of the cerebral cortex by anal canal stimulation was increased by peripheral neuromodulation. METHODS A multielectrode array was positioned over the right primary somatosensory cortex of anaesthetized rats. A brief burst of electrical stimulation was applied to either the left sacral root or the left posterior tibial nerve, and evoked potentials from anal canal stimulation were signal-averaged at intervals over 1 h. At the end of the experiment, the cerebral cortex was removed and probed for polysialylated neural cell adhesion molecule (PSA-NCAM). RESULTS Sacral nerve root and posterior tibial nerve stimulation significantly increased the peak amplitude of primary cortical evoked potentials by 54.0 and 45.1 per cent respectively. This change persisted throughout the period of observation. The density of PSA-NCAM-positive cells in the somatosensory cortex underlying the electrode array was increased by approximately 50 per cent in the sacral nerve-stimulated group. CONCLUSION Brief sacral neuromodulation induces profound changes in anal canal representation on the primary somatosensory cortex, providing a plausible hypothesis concerning the mechanism of action of neuromodulation in the treatment of faecal incontinence.
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Affiliation(s)
- K M Griffin
- Health Sciences Centre, School of Medicine and Medical Sciences, University College Dublin, Ireland
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