Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: the best alternative? Case report and review of literature

Multiple factors place burn patients at a high risk of pneumothorax development. Currently, no specific recommendations for the management of pneumothorax in large total body surface area (TBSA) burn patients exist. We present a case of a major burn patient who developed pneumothorax after central line insertion. After the traditional large bore (24 Fr) chest tube failed to resolve the pneumothorax, the pneumothorax was ultimately managed by a percutaneous placed pigtail catheter thoracostomy placement and resulted in its complete resolution. We will review the current recommendations of pneumothorax treatment and will highlight on the use of pigtail catheters in pneumothorax management in burn patients.

Developing a percutaneous dilatational tracheostomy service by medical intensivists: experience at one academic institution

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is increasingly becoming the preferred method, compared with open surgical tracheostomy, for patients requiring chronic ventilatory assistance. Little is known regarding the process involved to incorporate PDT as a standard service in the medical intensive care unit. In this report, we describe our experience developing a "PDT service" led by medical intensivists.

MATERIALS AND METHODS

With support from our leadership and surgical colleagues, we developed a credentialing and training process for medical intensivists, formulated a bedside team to perform PDT, refined our technique, and maintained a patient data registry for quality improvement.

RESULTS

To date, our service includes 4 medical intensivists with PDT privileges. Over a 4-year period, we performed 171 PDTs for patients in the medical intensive care unit after 12.1 ± 8.2 days of mechanical ventilation. Our procedure-related complication rates are similar to other reports. No patient required emergent open surgical tracheostomy, and there were no deaths related to PDT. We required minimal to no backup support from our surgical colleagues in performing PDT.

CONCLUSIONS

We successfully developed a medical intensivist-driven PDT service, sharing our unique successes and challenges, to facilitate the care of our patients requiring prolonged ventilator support.

Mid-term outcomes in patients following transcatheter aortic valve implantation in the CoreValve Australia and New Zealand Study

BACKGROUND

Although numerous studies have reported the safety and effectiveness of transcatheter aortic valve implantation (TAVI), integration of this therapy into standard of care varies widely by region. We evaluated mid-term follow-up in 540 patients with severe symptomatic AS at high risk of surgical AV replacement, enrolled in the ongoing Medtronic CoreValve Australia-New Zealand Study.

METHODS

Between August 2008 and July 2013, 10 centres in Australia/New Zealand enrolled 540 patients, which includes initial use of the CoreValve System for all investigators. Patients were deemed suitable for TAVI based on consensus of a multidisciplinary Heart Team. Primary endpoints were cardiovascular death and major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days. Data were fully monitored, and an independent Clinical Events Committee employed.

RESULTS

Baseline characteristics include; 45% female, mean age 84 years, EuroSCORE 17.3±10.7%, and 74.9% had New York Heart Association III/IV symptoms. At 30 days, all deaths were cardiovascular (4.1%); MACCE was 11.5%. At one and two years, all-cause mortality was 11.9% and 21.2%; cardiovascular mortality, 9.9% and 15.2%; and stroke, 8.2% and 10.1%, respectively.

CONCLUSIONS

Early experience with the CoreValve System in a large cohort of fully-monitored patients was associated with good early- and mid-term safety outcomes.

Experience of Percutaneous Trigger Finger Release under Local Anesthesia in the Medical College of Mullana, Ambala, Haryana

Background:

Trigger finger is a common disorder of upper extremity. Majority of the patients can be treated conservatively but some resistant cases eventually need surgery.

Aim:

The aim of this study is to evaluate the results of percutaneous trigger finger release under local anesthesia.

Subjects and Methods:

This is a prospective study carried out from July 2005 to July 2010, 46 fingers in 46 patients (30 females and 16 males) were recruited from outpatient department having trigger finger for more than 6 months. All patients were operated under local anesthesia. All patients were followed for 6 months. The clinical results were evaluated in terms of pain, activity level and patient satisfaction.

Statistical Analysis Used:

Statistical analysis was limited to calculation of percentage of patients who had excellent, good and poor outcomes.

Results:

The results were excellent in 82.6% (38/46) patients, good in 13.0% (6/46) patients and poor in two 4.3% (2/46) patients respectively. Complete Pain relief was achieved in 82.6% (38/46) patients, partial pain relief in 13.0% (6/46) patients and no pain relief in 4.3% (2/46) patients just after surgery. There was no recurrence of triggering. Range of motion was preserved in all cases. There were no digital nerve or tendon injuries. On subjective evaluations, 82.6% (38/46) patients reported full satisfaction, 13.0% (6/46) patients partial satisfaction and 4.3% (2/46) patients dissatisfaction with the results of treatment respectively.

Conclusions:

Percutaneous trigger finger release under local anesthesia is a minimal invasive procedure that can be performed in an outpatient setting. This procedure is easy, quicker, less complications and economical with good results.

Effects of solvent on percutaneous absorption of nonvolatile lipophilic solute

Understanding the effects of solvents upon percutaneous absorption can improve drug delivery across skin and allow better risk assessment of toxic compound exposure. The objective of the present study was to examine the effects of solvents upon the deposition of a moderately lipophilic solute at a low dose in the stratum corneum (SC) that could influence skin absorption of the solute after topical application. Skin permeation experiments were performed using Franz diffusion cells and human epidermal membrane (HEM). Radiolabeled corticosterone ((3)H-CS) was the model permeant. The solvents used had different evaporation and skin penetration properties that were expected to impact skin deposition of CS and its absorption across skin. The results show no correlation between the rate of absorption of the permeant and the rate of solvent evaporation/penetration with ethanol, hexane, isopropanol, and butanol as the solvent; all of these solvents have fast evaporation rates (complete evaporation in <30 min after application). This suggests no differences in solvent-induced deposition of CS in the SC for the fast-evaporating solvents. The results of these fast-evaporating solvents were different from those of water, propylene glycol, and polyethylene glycol 400, that a relationship between permeant absorption and the rate of solvent evaporation was observed.

A quantitative study of intervertebral disc morphologic changes following plasma-mediated percutaneous discectomy

OBJECTIVE

To quantitatively evaluate interval magnetic resonance imaging (MRI) changes in disc morphology following plasma-mediated percutaneous discectomy.

DESIGN/SETTING

A retrospective comparison of pretreatment and posttreatment MRIs at a single university spine clinic.

SUBJECTS

From a group of 60 consecutively treated patients, 15 met the study inclusion and exclusion criteria. All had either failed treatment or had other clinical reasons for a posttreatment MRI.

METHODS

Two independent physicians electronically measured disc protrusion size and disc height at the treatment discs and adjacent discs on pre- and posttreatment MRI scans. Additionally, images were compared for gross anatomic changes including disc degeneration by Pfirrman classification, new disc herniations, high intensity zone (HIZ), vertebral endplate changes, post-contrast enhancement, and changes in segmental alignment. Pearson r correlation was used to determine interobserver reliability between the two physicians' MRI measurements. Paired t-tests were calculated for comparisons of pre- and posttreatment MRI measurements, and an ANOVA was performed for comparison of pre- to posttreatment changes in disc height measurements at treatment levels relative to adjacent levels.

RESULTS

Correlation was high for measurement of disc height change (r = 0.89; P < 0.0001) and good for anteroposterior protrusion size change (r = 0.51; P = 0.0512). Disc height at treated discs demonstrated a small but statistically significant mean interval reduction of 0.48 mm (P = 0.0018). This remained significant when compared with the adjacent control discs (P < 0.0001). Pretreatment mean disc protrusion size (4.74 mm; range 3.75-6.55 mm) did not differ significantly (P = 0.1145) from posttreatment protrusion size (4.42 mm; range 2.55-7.95 mm). Gross anatomic changes at treatment levels included reduced disc protrusion size (N = 6), enlarged protrusion (N = 3), resolution of HIZ (N = 3), and improvement in endplate signal changes (N = 1). Also, 11/15 posttreatment MRIs included post-contrast images that showed epidural fibrosis (N = 1), rim enhancement (N = 2), and enhancement of the posterior annulus (N = 4).

CONCLUSIONS

Based on MRI examinations, subtle anatomic changes may occur following plasma-mediated percutaneous discectomy. Further study is required to determine the clinical relevance of these changes.

[Percutaneous endovascular removal of intracardiac migrated port A catheter in a child with acute lymphoblastic leukemia]

A 2-year-old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.

Percutaneous endoscopic gastrostomy: Indications, technique, complications and management

Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.

Long and wrong way: Unintended pericardial catheter insertion through stomach

Complications of percutaneous pericardial catheter insertion for pericardial effusion are rare. We describe a rare complication of percutaneous pericardial catheter insertion that penetrated the stomach and diaphragm before getting into the pericardial sac in a patient with lymphoma. The misplaced catheter was extracted surgically and subxiphoid pericardial tube insertion with pleural pericardial window was performed. <Learning objective: Although similar outcomes have been reported with both percutaneous and subxiphoid techniques, major complications may arise with the percutaneous technique. This case emphasizes that percutaneous pericardial catheter insertion may have serious complications and these procedures should be performed by experienced clinicians with the standby of a cardiac team.>.

Combination of percutaneous unilateral translaminar facet screw fixation and interbody fusion for treatment of lower lumbar vertebra diseases: a follow-up study

OBJECTIVE

To investigate the feasibility and efficacy of sight-guided percutaneous unilateral translaminar facet screw fixation (TLFSF) with interbody fusion for treatment of lower lumbar vertebra diseases.

METHODS

Twenty-nine adult patients with lower lumbar disease underwent sight-guided percutaneous unilateral TLFSF combined with microsurgical spinal decompression, discectomy, and interbody fusion from June 2007 to June 2008. All 29 patients had low back pain caused by lumbar disc degeneration (20 cases), in situ recurrent lumbar disc herniation (2), primary diskitis (1), lumbar disc herniation with spinal stenosis (3), and first-degree lumbar degenerative spondylolisthesis (3). Twenty-three cases had lesions at L4,5 ; three at L5 S1 , one at L3,4 , L4,5 , and two at L4,5 , L5 S1 .

RESULTS

No patient experienced significant postoperative complications. The mean incision length was 4.48 ± 0.55 cm; operative time 1.34 ± 0.22 h; intraoperative blood loss 280 ± 175 mL; and postoperative drainage volume 165 ± 85 mL. Screw position results: type I, 21 cases (23 segments); type II, 7 cases (8 segments); and type III, 1 case (1 segment). Twenty-eight patients were followed up for 24-60 months (average, 47.5 months). Interbody fusion rate was 93.5%). Postoperative intervertebral height recovered significantly; however, loss of intervertebral height occurred during follow-up.

CONCLUSION

Sight-guided percutaneous unilateral TLFSF with interbody fusion for treatment of lower lumbar disease is simple and minimally invasive, with good screw accuracy and security, high fusion rate, and good efficacy. However, specific surgical indications must be strictly followed.

Minimally invasive osteotomies

As orthopedic surgery continues to head in the direction of less invasive surgical techniques, this article explores the application and evolution of minimally invasive/percutaneous techniques in the surgical correction of hallux valgus deformities. Modern techniques are described and available literature is reviewed.

Percutaneous retrieval and redeployment of an atrial septal occluder under three-dimensional transesophageal echocardiographic guidance: a case report

Percutaneous device closure for secundum atrial septal defects (ASDs) has been performed commonly and safely with high success rates. However, it is still challenging to close ASDs that are surrounded with deficient or hypermobile rims and could be compromised with an unexpected migration of device. We report a case of percutaneous Amplazter Septal Occluder (ASO; St. Jude Medical Inc., St. Paul, Minnesota, USA) device closure for an ASD with a thin and floppy interatrial septum, which immediately migrated into the right atrium and was not pulled back into the delivery sheath. To our knowledge, this is the first report on a successful percutaneous retrieval and redeployment of the device in such a situation, preventing any vascular injury or unplanned emergency open heart surgery.

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently.

METHOD

100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE.

RESULTS

Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). Postoperative outcomes, however, were largely comparable between the two groups. All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue.

CONCLUSIONS

Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.

Bleeding from the apex during transapical transcatheter aortic valve implantation: a simple solution by balloon occlusion of the apex

Bleeding from the apex during transapical transcatheter aortic valve implantation is a potentially catastrophic event, which may seem at first sight to be an uncontrollable circumstance. We describe a simple 'trick' to control this problem that we used successfully in 5 patients. A Fogarty occlusion aortic catheter is gently inserted into the left ventricular cavity through the apical hole used for the transcatheter procedure, the balloon is slowly inflated with 10-15 ml of saline and the catheter is slightly pulled back 1 or 2 cm. This manoeuvre immediately stops the bleeding and enables safe suturing of the apex.

Acetabular fractures in patients aged > 55 years: a systematic review of the literature

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment. With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed. This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients.

Self-expanding prostheses for transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic valve replacement in patients who are considered high surgical risk or inoperable due to advanced age and comorbidities. Randomized trial and registry data have demonstrated the safety and efficacy of TAVR in such patients. Currently available transcatheter heart valves (THVs) employ either balloon-expandable or self-expanding designs, and several new designs have shown promising early results. Differences in valve design may offer specific advantages for accurate deployment and minimizing complications. This article reviews several designs of self-expanding THVs that are currently available or have undergone successful implantation in humans. Additional studies are required to compare the relative performance of these devices.

Percutaneous treatment of cervical and lumbar herniated disc

Therapeutic armamentarium for symptomatic intervertebral disc herniation includes conservative therapy, epidural infiltrations (interlaminar or trans-foraminal), percutaneous therapeutic techniques and surgical options. Percutaneous, therapeutic techniques are imaging-guided, minimally invasive treatments for intervertebral disc herniation which can be performed as outpatient procedures. They can be classified in 4 main categories: mechanical, thermal, chemical decompression and biomaterials implantation. Strict sterility measures are a prerequisite and should include extensive local sterility and antibiotic prophylaxis. Indications include the presence of a symptomatic, small to medium sized contained intervertebral disc herniation non-responding to a 4-6 weeks course of conservative therapy. Contraindications include sequestration, infection, segmental instability (spondylolisthesis), uncorrected coagulopathy or a patient unwilling to provide informed consent. Decompression techniques are feasible and reproducible, efficient (75-94% success rate) and safe (>0.5% mean complications rate) therapies for the treatment of symptomatic intervertebral disc herniation. Percutaneous, imaging guided, intervertebral disc therapeutic techniques can be proposed either as an initial treatment or as an attractive alternative prior to surgery for the therapy of symptomatic herniation in both cervical and lumbar spine. This article will describe the mechanism of action for different therapeutic techniques applied to intervertebral discs of cervical and lumbar spine, summarize the data concerning safety and effectiveness of these treatments, and provide a rational approach for the therapy of symptomatic intervertebral disc herniation in cervical and lumbar spine.

One size does not fit all: case report of two percutaneous closures of aortic pseudoaneurysm and review of the literature

Aortic pseudoaneurysms (PSAs) are common complications following cardiac surgery, and carry significant morbidity and mortality. Surgical management of aortic PSAs is associated with high mortality, however there are emerging reports of transcatheter techniques for closure of aortic PSAs. We present two cases of ascending aorta PSA which developed following cardiac surgery and were treated percutaneously with novel closure devices. We also describe a comprehensive review of the literature of all published cases of ascending aorta PSA which have been closed percutaneously, and report on the success rate and available devices for percutaneous closure.

Implant removal after percutaneous short segment fixation for thoracolumbar burst fracture : does it preserve motion?

Objective

The purpose of this study was to evaluate the efficacy of implant removal of percutaneous short segment fixation after vertebral fracture consolidation in terms of motion preservation.

Methods

Between May 2007 and January 2011, 44 patients underwent percutaneous short segment screw fixation due to a thoracolumbar burst fracture. Sixteen of these patients, who underwent implant removal 12 months after screw fixation, were enrolled in this study. Motor power was intact in all patients, despite significant vertebral height loss and canal compromise. The patients were divided into two groups by degree of osteoporosis : Group A (n=8), the non-osteoporotic group, and Group B (n=8), the osteoporotic group. Imaging and clinical findings including vertebral height loss, kyphotic angle, range of motion (ROM), and complications were analyzed.

Results

Significant pain relief was achieved in both groups at final follow-up versus preoperative values. In terms of vertebral height loss, both groups showed significant improvement at 12 months after screw fixation and restored vertebral height was maintained to final follow-up in spite of some correction loss. ROM (measured using Cobb's method) in flexion and extension in Group A was 10.5° (19.5/9.0°) at last follow-up, and in Group B was 10.2° (18.8/8.6°) at last follow-up. Both groups showed marked improvement in ROM as compared with the screw fixation state, which was considered motionless.

Conclusion

Removal of percutaneous implants after vertebral fracture consolidation can be an effective treatment to preserve motion regardless of osteoporosis for thoracolumbar burst fractures.

Kyphopasty and vertebroplasty

Vertebroplasty and balloon kyphoplasty are percutaneous techniques performed under radioscopic control. They were initially developed for tumoral and osteoporotic lesions; indications were later extended to traumatology for the treatment of pure compression fracture. They are an interesting alternative to conventional procedures, which are often very demanding. The benefit of these minimally invasive techniques has been demonstrated in terms of alleviation of pain, functional improvement and reduction in both morbidity and costs for society. The principle of kyphoplasty is to restore vertebral body anatomy gently and progressively by inflating balloons and then reinforcing the anterior column of the vertebra with cement. In vertebroplasty, cement is introduced directly under pressure, without prior balloon inflation. Both techniques can be associated to minimally invasive osteosynthesis in certain indications. In our own practice, we preferably use acrylic cement, for its biomechanical properties and resistance to compression stress. We use calcium phosphate cement in young patients, but only associated to percutaneous osteosynthesis due to the risk of secondary correction loss. The evolution of these techniques depends on improving personnel radioprotection and developing new systems of vertebral expansion.

Miniopen pedicle subtraction osteotomy: surgical technique and initial results

As minimally invasive surgery (MIS) has advanced to treat diverse diseases, there has been an increasing need for MIS surgery to be able to restore lumbar lordosis and treat sagittal balance abnormalities. In this article, the surgical technique and initial clinical and radiographic outcomes with a new miniopen pedicle subtraction osteotomy technique are outlined. Combining the MIS techniques of interbody fusion, percutaneous screw fixation, and facet fusion with a selective opening for the osteotomy site allows for safe and efficient deformity corrections. This technique resulted in an average increase of 29.2° of lumbar lordosis (range 17°-44°).

Percutaneous closure of patent foramen ovale: “Closed” door after the last randomized trials?

Patent foramen ovale (PFO) percutaneous closure has previously been an accepted intervention for the prevention of recurrent cryptogenic stroke on the basis of observational studies. However, randomized trials have been lacking until now. Three recently published randomized trials (CLOSURE I, PC and RESPECT) do not demonstrate the superiority of this intervention versus optimal medical therapy, therefore making this practice questionable. Nonetheless, these trials have had certain pitfalls, mainly a lower than initially estimated number of patients recruited, therefore lacking sufficient statistical power. On the other hand, different closure devices were used in the three trials. In two of them (PC and RESPECT), the Amplatzer PFO Occluder was used and the STARflex device was used in the other one (CLOSURE I). Taken altogether, a meta-analysis of these three trials does not demonstrate a statistically significant benefit of percutaneous PFO closure (1.9% vs 2.9%; P = 0.11). However, if we analyze only the PC and RESPECT trials together, in which the Amplatzer PFO Occluder was used, a statistically significant benefit of percutaneous PFO closure is observed (1.4% vs 3.0%, P = 0.04). In conclusion, our interpretation of these trials is that the use of a dedicated, specifically designed Amplatzer PFO device could possibly reduce the risk of stroke in patients with PFO and cryptogenic stroke. This consideration equally applies to patients who have no contraindications for anticoagulant or antithrombotic therapy.

Posterior tibial nerve stimulation for fecal incontinence: Where are we?

Neurostimulation remains the mainstay of treatment for patients with faecal incontinence who fails to respond to available conservative measures. Sacral nerve stimulation (SNS) is the main form of neurostimulation that is in use today. Posterior tibial nerve stimulation (PTNS) - both the percutaneous and the transcutaneous routes - remains a relatively new entry in neurostimulation. Though in its infancy, PTNS holds promise to be an effective, patient friendly, safe and cheap treatment. However, presently PTNS only appears to have a minor role with SNS having the limelight in treating patients with faecal incontinence. This seems to have arisen as the strong, uniform and evidence based data on SNS remains to have been unchallenged yet by the weak, disjointed and unsupported evidence for both percutaneous and transcutaneous PTNS. The use of PTNS is slowly gaining acceptance. However, several questions remain unanswered in the delivery of PTNS. These have raised dilemmas which as long as they remain unsolved can considerably weaken the argument that PTNS could offer a viable alternative to SNS. This paper reviews available information on PTNS and focuses on these dilemmas in the light of existing evidence.