Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study

Efficacy of sacral nerve stimulation for the treatment of fecal incontinence

BACKGROUND

Sacral nerve stimulation has been shown to be an effective treatment for fecal incontinence and early studies reported success rates of 67% to 100%. However, "success" has been arbitrarily set at a 50% reduction in symptoms, and data are rarely reported with "intention to treat."

OBJECTIVE

This study aimed to assess the true efficacy of sacral nerve stimulation for fecal incontinence compared with the published literature.

DESIGN

This prospective 5-year study was conducted to assess 50 patients with fecal incontinence treated with sacral nerve stimulation. All analyses were performed on an intention-to-treat basis.

SETTINGS

This study took place in a single tertiary referral colorectal department.

PATIENTS

Fifty consecutive patients with fecal incontinence refractory to conservative management were included in the study.

INTERVENTIONS

The interventions performed were temporary evaluation with or without permanent sacral nerve stimulation.

MAIN OUTCOME MEASURES

: Primary outcome measures were 1) attainment of continence, 2) reduction in fecal incontinence episodes, 3) improvement in Cleveland Clinic Fecal Incontinence scores, and 4) improvement in the ability to defer defecation.

RESULTS

Thirteen patients (26%) did not respond at the temporary evaluation stage or were dissatisfied with the result. Ten further patients (20%) did not achieve a 50% reduction in symptoms following permanent implantation. The median follow-up was 17 months (range, 2-55), at which time 27 patients (54%) experienced a 50% or more reduction in symptoms, including 13 (26%) who achieved apparent continence. Median fecal incontinence episodes per fortnight reduced from 14 (range, 0-53) to 2 (range, 0-20; P < .0001). Median Cleveland Clinic Fecal Incontinence scores reduced from 15 (range, 3-20) to 8 (range, 0-17; P < .0001). The ability to defer defecation improved significantly (P < .0001). These results compare favorably with the published literature.

LIMITATIONS

Quality of life was not assessed.

CONCLUSIONS

This study demonstrates that sacral nerve stimulation can be an effective treatment for patients with fecal incontinence; however, when analyzed by intention to treat, the symptoms of fecal incontinence continue in the majority (74%) of patients.

The acute effect of dorsal genital nerve stimulation on rectal wall properties in patients with idiopathic faecal incontinence

AIM

Faecal continence depends on several factors, including rectal wall properties. Stimulation of the dorsal genital nerve (DGN) can suppress bladder contraction and similar effects are anticipated for the rectum. In this study, the acute effect of DGN stimulation on the rectal cross-sectional area is investigated.

METHOD

Ten female patients (median age 60 years) with idiopathic faecal incontinence were included in the study. Stimulation was applied via plaster electrodes with the maximum tolerable amplitude (pulse width was 200 μs at a pulse rate of 20 Hz). Three series of pressure-controlled phasic (10, 20 and 30 cm H(2) O) and stepwise (5-30 cm H(2) O in steps of 5 cm H(2) O) rectal distensions were conducted (unstimulated, stimulated, unstimulated), and the rectal cross-sectional area (CSA) was measured with impedance planimetry.

RESULTS

All patients completed the investigation. The median stimulation amplitude was 21 (8.5-27) mA. Comparing stimulated with unstimulated phasic distension, there was no significant difference in the median rectal CSA. Comparing stimulated with unstimulated stepwise distension, there was no significant difference in the median rectal CSA. Neither the rectal pressure-CSA relationship (CSA/P(R) ) nor the rectal wall tension changed during stimulation.

CONCLUSION

No acute effect on rectal CSA during pressure-controlled distension was demonstrated during DGN stimulation.

Long-term efficacy and safety of sacral nerve stimulation for fecal incontinence

BACKGROUND AND OBJECTIVE

Sacral nerve stimulation is effective in the treatment of urinary incontinence and is currently under Food and Drug Administration review in the United States for fecal incontinence. Previous reports have focused primarily on short-term results of sacral nerve stimulation for fecal incontinence. The present study reports the long-term effectiveness and safety of sacral nerve stimulation for fecal incontinence in a large prospective multicenter study.

DESIGN AND METHODS

Patients with fecal incontinent episodes more than twice per week were offered participation in this multicentered prospective trial. Patients showing ≥ 50% improvement during test stimulation were offered chronic implantation of the InterStim Therapy system (Medtronic; Minneapolis, MN). The aims of the current report were to provide 3-year follow-up data on patients from that study who underwent sacral nerve stimulation and were monitored under the rigors of an Food and Drug Administration-approved investigational protocol.

RESULTS

One hundred thirty-three patients underwent test stimulation with a 90% success rate, of whom 120 (110 females) with a mean age of 60.5 years and a mean duration of fecal incontinence of 7 years received chronic implantation. Mean length of follow-up was 3.1 (range, 0.2-6.1) years, with 83 patients completing all or part of the 3-year follow-up assessment. At 3 years follow-up, 86% of patients (P < .0001) reported ≥ 50% reduction in the number of incontinent episodes per week compared with baseline and the number of incontinent episodes per week decreased from a mean of 9.4 at baseline to 1.7. Perfect continence was achieved in 40% of subjects. The therapy also improved the fecal incontinence severity index. Sacral nerve stimulation had a positive impact on the quality of life, as evidenced by significant improvements in all 4 scales of the Fecal Incontinence Quality of Life instrument at 12, 24, and 36 months of follow-up. The most common device- or therapy-related adverse events through the mean 36 months of follow-up included implant site pain (28%), paresthesia (15%), change in the sensation of stimulation (12%), and infection (10%). There were no reported unanticipated adverse device effects associated with sacral nerve stimulation therapy.

CONCLUSIONS

Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with fecal incontinence. These data support long-term safety and effectiveness to 36 months.

Antegrade colonic enema for faecal incontinence in adults: long-term results of 75 patients

AIM

Faecal incontinence is a significant source of distress, and a permanent stoma is frequently offered to these patients. The antegrade colonic enema (ACE) procedure is an alternative approach to treat faecal incontinence. The long-term outcome remains unknown in adults with faecal incontinence. The aim of this study was to evaluate the long-term results of the ACE procedure for incontinence in adults and its impact upon quality of life.

METHOD

All patients who underwent an ACE procedure between 1999 and 2009 were included. Clinical and demographic data and postoperative course were obtained from a review of medical records and databases. Each patient underwent a telephone interview. Quality of life was assessed using the GIQLI and SF36 scores, and faecal incontinence was evaluated using the Wexner score.

RESULTS

Seventy-five patients (54 females; 72%) were included. An ileal neoappendicostomy was performed in 68 patients (90%). The mean hospital stay was 9 days (range 6-24 days). Early complications occurred in four patients and late surgical complications (after 3 months) were observed in 12 (16%) patients. At a median follow up of 48 months, 64 (91%) were still performing enemas, and treatment was judged to be successful in 55 (86%) of 64 patients. The Wexner score was 3.4 ± 2.4, showing a significant reduction when compared with the preoperative value (P < 0.0001). Quality of life scores were in the range of a control population.

CONCLUSION

The ACE procedure is an effective long-term strategy in the treatment of faecal incontinence, with low and acceptable morbidity, and should be preferred before definitive colostomy.

Sacral nerve stimulation for faecal incontinence: patient selection, service provision and operative technique

AIM

Faecal incontinence is estimated to affect between 2 and 3% of Western adult populations. In recent years sacral nerve stimulation has become an important treatment modality, often as the first-line surgical therapy. The aim of this article was to review the current evidence regarding patient selection and surgical technique and to evaluate the logistics of providing a neurostimulation service.

METHOD

A Medline search was performed including the keywords and/or MeSH headings of sacral nerve stimulation, neuromodulation, artificial pacemaker, faecal incontinence, patient selection, predictive factors and anal canal. Further studies were identified by cross-referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings.

RESULTS

Despite the success of sacral nerve stimulation for several pathophysiological causes of incontinence, case selection is of paramount importance. Sacral nerve stimulation should not be offered outside a multidisciplinary pelvic floor unit. Temporary evaluation using diary cards can lead to false positive and negative results. Adherence to a meticulous surgical technique, using low amplitude stimulation to guide lead placement, provides optimal clinical outcome.

CONCLUSION

The short-term outcome of sacral nerve stimulation is dependent on patient factors and operative technique. Despite this, specific preoperative predictive factors of treatment success have yet to be identified.

How sacral nerve stimulation works in patients with faecal incontinence

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.

The influence of sacral nerve stimulation on gastrointestinal motor function in patients with fecal incontinence

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.

Effects of neuromodulation with sacral magnetic stimulation for intractable bowel or bladder dysfunction in postoperative patients with anorectal malformation: a preliminary report

BACKGROUND AND PURPOSE

The effects of neuromodulation with sacral magnetic stimulation (SMS) were examined in postoperative patients with bowel or bladder dysfunction.

PATIENTS AND METHODS

SMS was performed at the S3 level using a MagPro® instrument (Medtronic Inc., USA) while the patients were under light sedation. One treatment course consisted of stimulation delivered at 15 Hz for 5 s, 10 times over an interval of 1 min. Three patients with bladder or bowel dysfunction refractory to conservative treatment were examined.

RESULTS

Case 1 is a 7-year-old male with a rectourethral fistula. This patient developed a hyperdynamic bladder after a laparoscopic pull-through operation at the age of 7 months. The administration of an anticholinergic agent slightly improved the condition. SMS was started at the age of 4 years with one trial each year. A marked expansion of bladder volume from 20 ml before trial to 120 ml after the third trial was obtained. Case 2 (a 4-year old female with a recto-vaginal fistula) and Case 3 (a 8-year-old female with an ano-vestibular fistula) showed severe constipation after radical surgery during infancy. Case 2 needed appendicostomy. After SMS, bowel movements could become controllable with enemas. No adverse effects were observed for any of the three cases.

CONCLUSIONS

These results suggest that SMS might be a useful modality to improve postoperative bowel or bladder dysfunction.

Outcome and management of patients in whom sacral nerve stimulation for fecal incontinence failed

BACKGROUND

Sacral nerve stimulation fails in 30% to 50% of patients, the outcome that remains largely unreported.

OBJECTIVE

We report on the management and outcome of this cohort of patients.

DESIGN AND INTERVENTIONS

Ninety-one patients (88 females) with fecal incontinence, median age 63 years (range, 37-81), were candidates for sacral nerve stimulation. The follow-up protocol comprised incontinence and quality-of-life scores.

MAIN OUTCOME MEASURES

Failure was defined on an intention-to-treat basis: after the test (<50% decrease of fecal incontinence episodes) or after permanent implantation (Wexner score >8). Subsequent management and functional results were recorded.

RESULTS

The mean Wexner score for the cohort decreased from 14.3 at baseline to 7.6 after a median follow-up of 31 months (range, 11-69). Sixty-one (67.0%) patients were implanted with a permanent pacemaker; 36 (39.6%) achieved success (group 1). Failure after permanent implantation occurred in 25 (27.5%) patients after a mean of 34.5 months (group 2). Failure after the test occurred in 30 (33.0%) patients, 12 of whom underwent further surgery (group 3) (including stoma, 2; anal reconstruction, 9; and rectopexy, 1), whereas the remainder chose conservative treatment (group 4). At the end of follow-up, group 1 had significantly lower Wexner scores compared with the rest (P < .0001) and superior Fecal Incontinence Quality of Life scores compared with groups 2 and 4 (P < .0001). Group 3 achieved a greater reduction in Wexner scores compared with groups 2 and 4 (P = .04), although the improvement in Fecal Incontinence Quality of Life scores did not reach statistical significance.

LIMITATIONS

This was a nonrandomized study with retrospective stratification of patients.

CONCLUSIONS

On an intention-to-treat basis, success can be achieved in up to 40% of patients undergoing sacral nerve stimulation. In those in whom sacral nerve stimulation fails, further surgical treatment can yield favorable results in adequately motivated patients.

Sacral nerve stimulation for faecal incontinence: its role in the treatment algorithm

AIM

Indications for sacral nerve stimulation (SNS) for faecal incontinence have expanded over the last decade. This report aims to determine the clinical outcome of the current use of SNS in the treatment of faecal incontinence. Its objective is also to review the most recent role of SNS in patients with anal sphincter lesions.

METHOD

The literature was searched using Medline and Cochrane databases. The search was restricted to publications in English. For the analysis, studies with <25 patients were excluded. For SNS in patients with sphincter defects, all papers were included.

RESULTS

Thirteen publications on the clinical outcome of SNS were included. Nine papers were identified reporting the application of SNS in patients with a morphological sphincter lesion. The most common outcome measures of clinical efficacy were frequency of incontinence using the Cleveland Clinic Incontinence Score. All studies demonstrated highly improved function across all outcome measures and improvement was statistically significant in all. Outcomes remain stable at long-term follow up. In patients with sphincteric gaps ranging from 17 to 180°, SNS was clinically effective at short-term follow up. The size of the gap appears to have no impact on outcome.

CONCLUSION

SNS has evolved to become a clinical efficient therapy applicable across a wide spectrum of causes of faecal incontinence with reproducible results. SNS can be considered to be an essential part of the current surgical treatment algorithm for faecal incontinence.

Relief of fecal incontinence by sacral nerve stimulation linked to focal brain activation

OBJECTIVE

This study aimed to test the hypothesis that sacral nerve stimulation affects afferent vagal projections to the central nervous system associated with frontal cortex activation in patients with fecal incontinence.

PATIENTS

Nine women and one man received temporary sacral nerve stimulation with permanent electrodes as a treatment for fecal incontinence.

INTERVENTIONS

We used positron emission tomography to record indices of regional cerebral blood flow before and after 30 minutes of continuous stimulation. We repeated this procedure after 2 weeks of continued stimulation, before and 30 minutes after arrest of the stimulation.

RESULTS

The initial stimulation activated a region of the contralateral frontal cortex that normally is active during focused attention. After 2 weeks of stimulation, this activation had been replaced by activity in parts of the ipsilateral caudate nucleus, a region of the brain thought to be specifically involved in learning and reward processing.

CONCLUSIONS

Sacral nerve stimulation induces changes in cerebral activity consistent with an effect on afferent projections of the vagus. The initial activation of the frontal cortex may reflect focused attention, whereas the subsequent activation of the caudate nucleus may reflect recruitment of mechanisms involved in learning and reward processing. These changes may contribute to the improved continence, which is an acquired result of the stimulation.

Meta-analysis: sacral nerve stimulation versus conservative therapy in the treatment of faecal incontinence

AIM

Sacral nerve stimulation (SNS) has recently been used in the management of faecal incontinence (FI). This study compared SNS to conservative management with regards to functional and quality of life outcomes.

METHODS

Meta-analysis of studies published between 1995 and 2008 on SNS for FI was performed. Outcomes evaluated were functional, physiological and quality of life. A random-effects model was used and sensitivity analyses performed. Subgroup analyses were performed on age and sphincter status.

RESULTS

Thirty-four studies were included, reporting on 944 patients undergoing peripheral nerve evaluation; 665 underwent permanent SNS. Weekly incontinence episodes (weighted mean difference [WMD] -6.83; 95% confidence intervals [CI] -8.05, -5.60; p < 0.001) and incontinence scores (WMD -10.57; 95% CI -11.89, -9.24; p < 0.001) were significantly reduced with SNS; ability to defer defecation (WMD 7.99 min; 95% CI 5.93, 10.05; p < 0.001) was increased. Most SF-36 and FIQL domains improved following SNS, and mean anal pressures increased significantly (p < 0.001). Results remained consistent on sensitivity analysis. The under-56 years age group showed smaller functional but greater physiological and quality of life improvements. Results were similar between sphincter intact and impaired subgroups. The complication rate was 15% for permanent SNS, with 3% resulting in permanent explantation.

CONCLUSION

SNS results in significant improvements in objective and subjective measures for faecally incontinent patients.

Neuromodulation for constipation: sacral and transcutaneous stimulation

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

Sacral neuromodulations for female lower urinary tract, pelvic floor, and bowel disorders

PURPOSE OF REVIEW

In recent years, sacral neuromodulation (SNM) has been investigated for the treatment of various types of lower urinary tract and bowel dysfunctions. This review discusses recently published data related to the therapeutic applications of SNM in female lower urinary tract, pelvic floor, and bowel disorders.

RECENT FINDINGS

SNM has been employed initially in the treatment of refractory idiopathic overactive bladder, urge urinary incontinence, and chronic nonobstructive urinary retention. Since then, several studies, including randomized and controlled trials, have confirmed the therapeutic effects of SNM in these disorders. The applications of SNM are now extended to the treatment of other female pelvic problems, such as fecal incontinence, chronic constipation, interstitial cystitis/painful bladder syndrome, sexual dysfunction, and neurogenic disorders, with similar promising results.

SUMMARY

SNM is approved by the Food and Drug Administration for the treatment of idiopathic overactive bladder, urge urinary incontinence, and chronic nonobstructive urinary retention. SNM is not yet an approved method for the treatment of other pelvic disorders, but data supporting its benefit are emerging. The major advantage of SNM lies in its potential to treat the bladder, urethral sphincter, anal sphincters, and pelvic floor muscles simultaneously, which might result in better therapeutic effects.

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

PURPOSE

Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders.

METHODS

After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007.

RESULTS

A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%).

CONCLUSIONS

This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns.

The role of reprogramming in sacral nerve modulation for faecal incontinence

AIM

After implantation of a sacral nerve modulation (SNM) device for faecal incontinence (FI), patients are subjected to a rigid follow-up schedule. If symptoms recur, it may be necessary to reprogramme the stimulation parameters of the device. The aims of this study was to assess the need for reprogramming in patients with an SNM implant for FI.

METHOD

All patients who received a permanent SNM implant for FI from January 2000 to February 2008 were included in this study. Patients were subjected to a rigid follow-up schedule at 1, 3, 6 and 12 months, and yearly thereafter. Stimulator settings of the SNM device and changes made at every visit were collected and added to the database, and the number of patients in whom the stimulation parameter settings needed reprogramming was determined.

RESULTS

A total of 155 patients (11 men) were analysed. The mean age (± standard deviation) of the patients was 57.7 ± 11.9 years. Median follow-up was 28.1 (range: 1.0-93.6) months. The mean voltage increased significantly from 1.8 V at 1 month to 2.0 V at 3 months. Thirty-nine (25.2%) patients required no reprogramming of their SNM implant during any of their follow-up visits; however, 51 (32.9%) patients required reprogramming at 1-25% of their visits, 42 (27.1%) patients at 26-50% of their visits, 14 (9.0%) patients at 51-75% of their visits and nine (5.8%) patients at 76-100% of their visits.

CONCLUSION

Physicians and patients need to be aware of the fact that reprogramming of the SNM stimulator needs to be carried out at least once during follow-up in the majority of patients. Trained physicians or specialist nurses are imperative to ensure effective follow-up and appropriate SNM reprogramming.

Surgery for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex.

OBJECTIVES

To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques.

SEARCH STRATEGY

Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 26 November 2009), the Cochrane Colorectal Cancer Group Specialised Register (searched 26 November 2009), CENTRAL (The Cochrane Library 2009) and EMBASE (1 January 1998 to 30 June 2009) were undertaken. The British Journal of Surgery (1 January 1995 to 30 June 2009) Colorectal Diseases (1 January 2000 to 30 June 2009) and the Diseases of the Colon and Rectum (1 January 1995 to 30 June 2009) were specifically handsearched. The proceedings of the UK Association of Coloproctology meeting held from 1999 to 2009 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse).

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency.

MAIN RESULTS

Thirteen trials were included with a total sample size of 440 participants. Two trials included a group managed non-surgically. One trial compared levator with anal plug electrostimulation and one compared artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but numbers were small. The other trial showed no difference in primary outcome measures.Eleven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, injection of silicone, hydrogel, physiological saline, carbon beads or collagen bulking agents, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are also considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures.

AUTHORS' CONCLUSIONS

Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Predictors of the outcome of percutaneous nerve evaluation for faecal incontinence

BACKGROUND

The aim was to identify patient-related and operative factors that might predict the outcome of percutaneous nerve evaluation (PNE).

METHODS

Demographic data (age, sex, body mass index), primary cause of incontinence, number and type of incontinence episodes, results of endoanal ultrasonography and manometry, and operative factors from 244 patients who underwent PNE for faecal incontinence were reviewed. Each factor was assessed according to the outcome, and explored by univariable and multivariable analysis to identify predictors.

RESULTS

Some 191 patients (78.3 per cent) had a successful PNE. A low amplitude of sensory threshold during PNE (odds ratio (OR) 0.69 (95 per cent confidence interval 0.59 to 0.81); P < 0.001) and lead placement anterior to the sacral cortex (OR 9.06 (4.70 to 17.45); P < 0.001) were positive predictive factors for successful outcome of PNE. Neither a defect nor an abnormality of either the external (OR 0.88 (0.39 to 1.97); P = 0.749) or internal (OR 0.62 (0.27 to 1.42); P = 0.255) anal sphincter was a negative predictive factor. Demographic variables, number of incontinence episodes and the motor response threshold did not predict outcome.

CONCLUSION

No preoperative predictor of PNE outcome could be identified. Predictors were limited to operative lead placement and sensory response during PNE.

Transcutaneous electrical posterior tibial nerve stimulation for faecal incontinence: effects on symptoms and quality of life

PURPOSE

Faecal incontinence is a disabling symptom which may be particularly difficult to treat. Recent studies showed that transcutaneous electrical posterior tibial nerve stimulation may improve faecal continence. In this study, we aimed to evaluate the effectiveness of this technique and tried to individualize predictive factors of success.

METHODS

Twenty-four patients suffering from faecal incontinence were treated 20 min per day by applying transcutaneous electrical posterior tibial nerve stimulation for 3 months. A clinical evaluation was performed at the end of treatment, with Wexner's score and analogical scales for symptoms. After 3 months, if the treatment was successful, patients were proposed to continue on the treatment. Predictive factors such as age, symptom duration, proctologic history, obstetrical history, ano-rectal manometric data and quality-of-life score were also analysed.

RESULTS

At 3 months, 13 patients (54%) reported a significant symptomatic improvement with a significant modification in the Wexner's score (14 vs 12, p < 0.025). At a median follow-up of 15 months, there were still 11 patients whose condition was improved.

CONCLUSION

This study shows encouraging mid-term results, and even if further randomized studies are necessary, transcutaneous electrical posterior tibial nerve stimulation may be a new and easy-to-use therapeutic option to treat faecal incontinence.

Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up?

PURPOSE

Fecal incontinence is a socially isolating disease that causes physical and psychologic distress. Radiofrequency delivered to the anal canal is a surgical modality for fecal incontinence that has been noted to be safe and potentially effective. The aim of this study was to evaluate improvement in fecal incontinence and quality of life after the radiofrequency procedure at 1-year follow-up.

METHODS

After institutional review board approval, patients with fecal incontinence for at least 3 months were prospectively recruited between March 2003 and June 2004. Patients enrolled in the study underwent the Secca procedure. The Cleveland Clinic Florida Fecal Incontinence Score and the Fecal Incontinence Quality of Life Questionnaire were completed at the first visit and then at 12-month follow-up. Wilcoxon signed rank test was used to analyze the difference between baseline and follow-up.

RESULTS

A total of 24 patients (23 females) were enrolled in the study, and 16 were available at the 12-month follow-up visit. The main causes of fecal incontinence were either idiopathic or included obstetric injury, aging, and trauma from previous anorectal surgeries. The mean operative time was 45.5 +/- 8.3 minutes, and the mean number of radiofrequency lesions in the anal canal was 65.5 +/- 13.8. There were 3 self-limited episodes of postoperative bleeding and 1 instance of constipation that was resolved with laxatives. There were no delayed complications. The mean Cleveland Clinic Florida Fecal Incontinence Score improved from a mean of 15.6 (+/- 3.2) at baseline to 12.9 (+/- 4.6) at 12 months (P = .035). The mean Fecal Incontinence Quality of Life Questionnaire score improved in all subsets except for the depression subscore.

CONCLUSION

Radiofrequency is a safe, minimally invasive tool for treating patients with fecal incontinence. Improvement in fecal incontinence and quality of life was maintained at 12 months without delayed morbidity. The actual significance of this improvement is yet to be determined.

Sacral nerve stimulation induces changes in the pelvic floor and rectum that improve continence and quality of life

PURPOSE

Sacral nerve stimulation (SNS) can improve fecal incontinence, though the exact mechanism is not known. This study examines the following hypotheses: SNS leads to contraction of the pelvic floor, influences rectal perception, and improves continence and quality of life.

METHODS

Fourteen patients with sacral nerve stimulators implanted for fecal incontinence were examined prospectively. Morphological and functional assessment was done by endosonography, manometry, and volumetry with the stimulator turned on and off in direct succession. Questionnaires were used to determine incontinence and quality of life.

RESULTS

With the stimulator turned on, rectal filling conditions were perceived only at higher volumes; in particular, the defecation urge was sensed only at higher volumes. There was also a reduction in the diameters of the external and internal anal sphincters and a decrease in the distance between the anal mucosa and the symphysis as a sign of pelvic floor elevation. Six months after surgery, continence and quality of life were markedly better than before the operation.

CONCLUSIONS

We were able to confirm the hypotheses given above. The improvements of pelvic floor contraction and rectal perception are rapid adjustment processes in response to stimulation of sacral nerves S3/S4 when turning on the stimulator.

Postanal repair--do the long-term results justify the procedure?

OBJECTIVE

Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long-term continence after PAR and relate this to patient satisfaction and quality of life.

METHOD

Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life.

RESULTS

One-hundred one patients from four surgeons were identified. Fifty-four patients were excluded because of loss to follow-up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow-up of 9.1 years (2.2-18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0-5), 26% moderate (CCS 6-12), and 48% (n = 27) severe incontinence (CCS 13-24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow-up, and being able to distinguish flatus and stool.

CONCLUSIONS

In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long-term subjective outcome, despite the fact that many patients have a high incontinence score.

Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study

BACKGROUND

Sacral nerve stimulation has been approved for use in treating urinary incontinence in the United States since 1997, and in Europe for both urinary and fecal incontinence (FI) since 1994. The purpose of this study was to determine the safety and efficacy of sacral nerve stimulation in a large population under the rigors of Food and Drug Administration-approved investigational protocol.

METHODS

Candidates for SNS who provided informed consent were enrolled in this Institutional Review Board-approved multicentered prospective trial. Patients showing > or =50% improvement during test stimulation received chronic implantation of the InterStim Therapy (Medtronic; Minneapolis, MN). The primary efficacy objective was to demonstrate that > or =50% of subjects would achieve therapeutic success, defined as > or =50% reduction of incontinent episodes per week at 12 months compared with baseline.

RESULTS

A total of 133 patients underwent test stimulation with a 90% success rate, and 120 (110 females) of a mean age of 60.5 years and a mean duration of FI of 6.8 years received chronic implantation. Mean follow-up was 28 (range, 2.2-69.5) months. At 12 months, 83% of subjects achieved therapeutic success (95% confidence interval: 74%-90%; P < 0.0001), and 41% achieved 100% continence. Therapeutic success was 85% at 24 months. Incontinent episodes decreased from a mean of 9.4 per week at baseline to 1.9 at 12 months and 2.9 at 2 years. There were no reported unanticipated adverse device effects associated with InterStim Therapy.

CONCLUSION

Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with FI.

Sacral nerve stimulation for faecal incontinence: response rate, satisfaction and the value of preoperative investigation in patient selection

OBJECTIVE

Before undergoing sacral nerve stimulation (SNS) for faecal incontinence (FI), patients are investigated with morphologic, dynamic and electrophysiologic tests. The purpose of our study was to evaluate their value in the selection of patients who may benefit most from neuromodulation.

METHOD

If temporary stimulation resulted in a good objective response, a permanent neuromodulator was implanted. Patients were reviewed at 3 months and then at 6 monthly intervals. Asked by telephone, patient's satisfaction was described as good, satisfactory or poor.

RESULTS

Forty-five consecutive patients (41 females, median age 59 years) with FI (Wexner 16.1 +/- 2.9) underwent SNS. Temporary stimulation was successful in 32 (71)% patients. At a median follow-up of 33 months, the neuromodulator remained in place in 25 (55%) patients, two do whom switched it off, leaving 23 (51%) with a functioning neuromodulator. There was no statistically significant difference between the characteristics (including manometry, ultrasound and electrophysiology) of patients undergoing implantation (n = 32) or not (n = 13) and those with or without a functioning stimulator (n = 23: n = 13). In the 23 patients with a functioning stimulator the result was good in 12, satisfactory in five and poor in six. There was no statistically significant difference in the patient characteristics between those with a good result (n = 12) and the remainder (n = 32).

CONCLUSION

The findings suggest that investigation for FI does not facilitate patient selection for SNS and cannot be used to predict outcome.

Sacral nerve stimulation for fecal incontinence: What has been achieved: Current status

INTRODUCTION: The indications for sacral nerve stimulation (SNS) for fecal incontinence expanded during the last decade. This report aims to analyze the clinical outcome of the current pragmatic use of sacral nerve stimulation in the treatment of fecal incontinence caused by various pathophysiological conditions. Secondly it intends to explore the most recent use of SNS in patients presenting with sphincteric lesions. METHOD: The literature was searched using Medline and Cochrane databases. The search was limited to publications in English. For the analysis, studies with less than 25 patients were excluded. For the presentation of SNS in patients with sphincter defects, all papers were included. RESULTS: Thirteen publications were included in the analysis of clinical outcome of SNS. Ten papers were identified reporting about the application of SNS in patients presenting with a morphological sphincter lesion. The most common outcome measures of clinical efficacy were frequency of incontinence and Cleveland Clinic Incontinence Score. All studies demonstrated a highly improved function, in all outcome measures used. The improvement was significant. The results are reproducible. Also in patients with sphincteric gaps ranging form 17 to 180 degree SNS was clinical efficient. The size of the lesion had not impact on the outcome. CONCLUSION: Sacral spinal nerve stimulation has evolved to become a clinical efficient therapy applicable in a wide spectrum of causes leading to fecal incontinence. It is now considered to be an essential part of the current surgical treatment algorithm for fecal incontinence.

Rectal motility after sacral nerve stimulation for faecal incontinence

Sacral nerve stimulation (SNS) is effective against faecal incontinence, but the mode of action is obscure. The aim of this study was to describe the effects of SNS on fasting and postprandial rectal motility. Sixteen patients, 14 women age 33-73 (mean 58), with faecal incontinence of various aetiologies were examined. Before and during SNS, rectal cross-sectional area (CSA) and ano-rectal pressures were determined with impedance planimetry and manometry for 1 h during fast and 1 h postprandially. Neither in the fasting state nor postprandially did SNS affect the number of single rectal contractions, total time with cyclic rectal contractions, the number of aborally and orally propagating contractions, the number of anal sampling reflexes or rectal wall tension during contractions. Postprandial changes in rectal tone were significantly reduced during SNS (P < 0.02). Before SNS, median rectal CSA was 2999 mm(2) (range: 1481-3822) during fast and 2697 mm(2) (range: 1227-3310) postprandially (P < 0.01). During SNS, median rectal CSA was 2990 mm(2) (1823-3678) during fast and 2547 mm(2) (1831-3468) postprandially (P = 0.22). SNS for faecal incontinence does not affect phasic rectal motility but it impairs postprandial changes in rectal tone.

Conservative and behavioural management of constipation

This article deals with psychological contributions, such as stool withholding or responses to abuse experiences, to the aetiology of evacuation disorders (with a focus on dyssynergic defecation), and with education and behavioural approaches to treatment.

Sympathetic and parasympathetic regulation of rectal motility in rats

INTRODUCTION

The colon and rectum are regulated by the autonomic nervous system (ANS). Abnormalities of the ANS are associated with diseases of the colon and rectum while its modulation is a putative mechanism for sacral nerve stimulation. The purpose of this study is to establish a rat model elucidating the role of the efferent ANS on rectal motility.

MATERIALS AND METHODS

Rectal motility following transection or stimulation of parasympathetic pelvic nerves (PN) or sympathetic hypogastric nerves (HGN) was measured with rectal strain gauge transducers and quantified as a motility index (MI). Colonic transit was measured 24 hours after transection by calculating the geometric center (GC) of distribution of (51)Cr

RESULTS AND DISCUSSION

Transection of PN and HGN decreased MI to 518 +/- 185 g*s (p < 0.05) and increased MI to 5,029 +/- 1,954 g*s (p < 0.05), respectively, compared to sham (975 +/- 243 g*s). Sectioning of PN and HGN decreased transit with GC = 4.9 +/- 0.2 (p < 0.05) and increased transit with GC = 8.1 +/- 0.7 (p < 0.02), respectively, compared to sham (GC = 5.8 +/- 0.3). Stimulation of PN and HGN increased MI to 831 +/- 157% (p < 0.01) and decreased MI to 251 +/- 24% (p < 0.05), respectively.

CONCLUSION

Rectal motility is significantly altered by sectioning or stimulating either HGN or PN. This model may be useful in studying how sacral nerve stimulation exerts its effects and provide insight into the maladies of colonic motility.

Factors associated with percutaneous nerve evaluation and permanent sacral nerve modulation outcome in patients with fecal incontinence

PURPOSE

Sacral nerve modulation is an established treatment for fecal incontinence. Little is known about predictive factors for successful percutaneous nerve evaluation (or test stimulation) and permanent sacral nerve modulation outcome. The purpose of this retrospective study was to discover predictive factors associated with temporary and permanent stimulation.

METHODS

We analyzed data from test stimulations performed in patients with fecal incontinence from March 2000 until May 2007. Successful outcome was defined as >50% improvement of incontinence episodes in three weeks. Patients with a successful test stimulation were eligible for permanent sacral nerve modulation implantation. All patients who subsequently had permanent sacral nerve modulation were analyzed. Logistic regression was used to determine the predictive power of baseline demographics and diagnostic variables.

RESULTS

Test stimulations were performed in 245 patients (226 females; mean age, 56.6 (standard deviation, 12.8) years). Our analysis showed that older age (P = 0.014), external anal sphincter defects (P = 0.005), and repeated procedures after initial failure (P = 0.001) were significantly related to failure. One hundred seventy-three patients (70.6%) were eligible for permanent sacral nerve modulation implantation. The analysis showed no significant predictive factors related to permanent sacral nerve modulation.

CONCLUSION

Three predictive factors were negatively associated with the outcome of test stimulation: older age, repeated procedures, and a defect in the external anal sphincter. These factors may indicate lower chances of success for test stimulation but do not exclude patients from sacral nerve modulation treatment. Although assessed in a selected patient group, no factors were predictive of the outcome of permanent stimulation.

[Anorectal disease: past, present, future]

Over the last decade, therapeutic approaches of anorectal disorders have been profoundly modified by new drugs, new procedures and functional considerations. In fact, the primary goals of these procedures emphasize minimal invasive approaches. Less functional postoperative complaints are often preferred over a radical efficacy. As compared to haemorrhoidectomy, haemorrhoidopexy procedure is today advocated to reduce postoperative care and complaints. As compared to lateral sphincterotomy, nitrates and botulinum toxin represent a second line therapy of chronic anal fissure to avoid faecal incontinence. As compared to fistulotmy, both glue and plug may be used to treat a high tract fistulae for the same reasons.

Can sensory and/or motor reactions during percutaneous nerve evaluation predict outcome of sacral nerve modulation?

PURPOSE

A major advantage of sacral nerve modulation in the treatment of fecal incontinence is the ability to determine the likely treatment outcome before implantation by means of a percutaneous nerve evaluation and a test stimulation period. This study evaluated the predictive value of both sensory and motor responses during percutaneous nerve evaluation for determining the outcome of subchronic test stimulation and permanent stimulation.

METHODS

All percutaneous nerve evaluation procedures performed between 2000 and 2007 were analyzed. Two hundred eight procedures (194 females; mean age, 56.7 years) were included in this study. Correct needle placement was confirmed by typical S-3 sensory and/or motor responses. The sensory and motor responses during the procedure were analyzed in relation to the outcomes of the test stimulation and permanent stimulation.

RESULTS

In all, 72.6% of patients had a successful subchronic test stimulation. A total of 13.9% had no motor response. There was no significant difference in outcome between the group with only sensory responses and the group with both sensory and motor responses (P = 0.89; odds ratio, 1.01; 95% confidence interval, 0.42-2.43). Correlation with permanent implantation showed no significant difference between both groups in outcome (P = 0.53; odds ratio, 0.48; 95% confidence interval, 0.17-1.41).

CONCLUSION

Positive motor responses during percutaneous nerve evaluation are highly predictive of a successful outcome of subchronic test stimulation and permanent sacral nerve modulation. Sensory responses also have the same predictive value. For this reason, percutaneous nerve evaluation preferably should be performed in awake patients under local anesthesia to avoid missing those who may benefit from permanent stimulation but who do not have a motor response during the procedure.

Neuromodulation for functional bowel disorders

In patients with functional bowel disorders not responding to maximal medical treatment, bowel lavage or biofeedback therapy, can nowadays be treated by sacral nerve neuromodulation (SNM). SNM therapy has evolved as a treatment for faecal incontinence and constipation. The exact working mechanism remains unknown. It is known that SNM therapy causes direct stimulation of the anal sphincter and causes changes in rectal sensation and several central nervous system areas. The advantage of SNM therapy is the ability to do a minimally invasive temporary screening phase to assess permanent stimulation outcome. Ideal candidates for SNM therapy are not known. Several studies have described positive and negative predictive factors, but the temporary screening remains the instrument of choice. Clinical results are good and as the technique is developing, fewer complications occur. New indications for SNM include constipation and anorectal or pelvic pain.

Value of sacral nerve stimulation in the treatment of severe faecal incontinence: a comparison to the artificial bowel sphincter

OBJECTIVE

Sacral nerve stimulation (SNS) is a recent treatment option in the management of severe faecal incontinence (FI) that offers promising results. The aim of this study was to compare SNS to artificial bowel sphincter (ABS) implanted patients to assess the rationale of this approach in achieving satisfying functional results and improved quality of life (QoL).

METHOD

Among 27 patients tested (December 2001 and April 2004), 15 patients were successfully managed with SNS. They were compared to 15 matched patients implanted with ABS in a previous period (control group). Assessment of continence level (Cleveland Clinic score), constipation score (Knowles, Eccersley, Scott Score) and QoL (Short-Form 36) were prospectively collected.

RESULTS

Both groups were comparable for clinical parameters (age, gender, anal testing and aetiology of incontinence) and anal physiology. The mean postoperative continence score was significantly higher in the SNS group [9.4 (+/-3.3) vs 5.7 (+/-3.9), P < 0.01]; however, the mean constipation score was higher in the ABS group (6.3 +/- 6.3 vs 12.8 +/- 5.7, P < 0.01). The mean QoL score was similar in both groups. The mean follow-up after implantation was 15 (+/-9) months in the SNS group, and 43 (+/-33) months in the ABS group.

CONCLUSION

In this study, SNS offers satisfying results in terms of QoL, similar to that of ABS. Although it seems to be less effective in restoring continence level, symptoms of outlet obstruction are more frequent after ABS. This SNS approach should be proposed as a first-line treatment of FI in selected patients. ABS should remain an option that can improve function.

Sacral nerve stimulation for faecal incontinence: long-term outcome

AIM

The efficacy of sacral nerve stimulation (SNS) to treat faecal incontinence has been demonstrated in the short- and mid-term. We analysed SNS outcome in the first patients with a permanent neurostimulator in whom follow-up ranges up to 14 years.

METHOD

Of 12 patients who underwent SNS from 1994 to 1999, 9 were eligible for long-term analysis (defined as a minimum of 7 years). In 3 the device had to be removed because of pain or neurological disease. Functional outcome was monitored prospectively by standardized questionnaire. For efficacy, the recorded frequency of incontinent episodes over 2-week periods and the Wexner Score were obtained yearly after implant. Quality of life measures (FIQL scale [QoL]) were introduced in 1998. Stimulation parameter adjustments, battery longevity, and complications were documented.

RESULTS

Mean follow-up in the nine patients was 9.8 years (range 7-14), over which time efficacy persisted. Clinical improvement was significant (baseline vs last follow-up): median percentage of incontinent bowel movements/week 40% (range 9-100) vs 0% (0-60%; P = 0.008), median number of incontinent episodes/week, 9 (range 2-58) vs 0 (0-29; P = 0.012); median Cleveland Clinic Score, 17 (range 12-19) vs 10 (3-14; P < 0.007); QoL improved in all categories. Pulse generator exchange was required in eight of the nine patients after a mean of 7.4 years for battery fatigue (mean 2.1 V). Complications occurred in five of the original 12 and were therapy-related, but not technique-related, in four patients.

CONCLUSION

Sacral nerve stimulation is an effective and safe long-term treatment for faecal incontinence. Clinical outcome is stable over time.

Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience

OBJECTIVE

Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS.

METHOD

Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence.

RESULTS

We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed.

CONCLUSION

We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Does magnetic stimulation of sacral nerve roots modify colonic motility? Results of a randomized double-blind sham-controlled study

Although sacral nerve root stimulation (SNS) can result in a symptomatic improvement of faecal incontinence, the mechanism of action remains unknown. The aim of this study was to assess whether short-term magnetic SNS can inhibit pharmacologically induced propulsive colonic contractions. Twelve healthy volunteers (median age: 43.5 years old) were studied on two separate occasions and randomized into either active (15 Hz, 100% output intensity for 5 s min(-1) for 30 min) or sham rapid rate lumbosacral magnetic stimulation (rLSMS). Colorectal motility was recorded with a manometric catheter located at the most proximal transducer in the left colon and the most distal, in the rectum. Colonic contractions were provoked by instilling Bisacodyl. The effects of rLSMS on colonic, sigmoid and rectal contractions were monitored and recorded after Bisacodyl instillation. The appearance of high-amplitude contractions propagated or not (HAC/HAPC) provoked by Bisacodyl instillation was significantly delayed during active compared to sham stimulation (P = 0.03). There was no difference in the characteristics of HAC/HAPC (i.e. frequency, amplitude, duration, velocity of propagation) or the motility index with active or sham stimulation. The perception of urgency tended to be decreased with rLSMS following Bisacodyl instillation. The catheter was expulsed within a median of 16.5 min (range 8-39) after Bisacodyl administration during active stimulation compared to 14 min (range 5-40) during sham stimulation (P = 0.03). This study suggests that rLSMS could delay the appearance of the first Bisacodyl-induced colonic contractions.

Comparison of clinical outcome between open and percutaneous lead insertion for permanent sacral nerve neurostimulation for the treatment of fecal incontinence

PURPOSE

Results from early studies on sacral nerve stimulation are based on a stimulation electrode lead that was placed under direct vision during an open surgical procedure. A percutaneous inserted lead, introduced in 2002, is now widely used. This study was designed to investigate differences in clinical efficacy and adverse complications between the two methods of lead placement.

METHODS

Prospectively collected data were analyzed for 48 patients who had undergone permanent sacral nerve stimulation for fecal incontinence at a single institution between 1997 and 2006. Eighteen patients had undergone open lead placement (Group 1) and 30 patients percutaneous lead placement (Group 2).

RESULTS

Median follow-up was 51 (range, 22-106) months for Group 1 and 8 (range, 1-40) months for Group 2 patients. There was no difference in patient demographics, severity of incontinence, or physiologic parameters between the two groups. Lead type did not affect the outcome of chronic stimulation with reductions in total episodes of incontinence being similar between the two groups (P = 0.448). No difference in infection or lead dislocation rate between the two groups was identified.

CONCLUSIONS

The percutaneously inserted lead seems to be equal to the open inserted lead in terms of clinical efficacy and complication rate in the short-term.

Transcutaneous posterior tibial nerve stimulation for fecal incontinence in inflammatory bowel disease patients: a therapeutic option?

BACKGROUND

Fecal incontinence associated with inflammatory bowel disease (IBD) may be particularly difficult to treat. Two recent studies showed that transcutaneous posterior tibial nerve stimulation may improve fecal continence. In this pilot study, we tested the usefulness of this noninvasive technique to treat fecal incontinence in IBD.

METHODS

Twelve patients with IBD (7 Crohn's disease, 2 undetermined colitis, 3 ulcerative colitis) were treated by applying transcutaneous posterior tibial nerve electrical stimulation daily for 3 months. A clinical evaluation was performed at the end of treatment, with Wexner's score and Harvey-Bradshaw index and analog scales to assess symptoms and quality of life.

RESULTS

At 3 months, 5 patients (41.6%) reported a significant symptomatic and quality of life improvement, although only 1 reported a significant modification in the Wexner score.

CONCLUSION

These preliminary results are encouraging, although further studies are necessary. Posterior tibial nerve electrical stimulation may represent a new therapeutic option to treat the difficult problem of fecal incontinence in patients with IBD.

Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain?

BACKGROUND

Chronic idiopathic anal pain is a common, benign symptom, the etiology of which remains unclear. Traditional treatments are often ineffective. This study investigated the efficacy of sacral nerve stimulation in treating chronic idiopathic anal pain.

METHODS

Twelve patients (10 women and 2 men; mean age, 61.0 +/- 10.3 years; range, 48-82 years) implanted with a permanent device for sacral nerve stimulation were followed in the Italian Group for Sacral Neuromodulation (GINS) Registry. All patients had frequent chronic anal or perianal pain; 75 percent had previously undergone pelvic surgery. Pharmacologic and rehabilitative therapy had yielded poor results. Changes from baseline to last follow-up examination were evaluated for scores on a visual analog pain scale (0-10) and the Short-Form 36 (SF-36) health status questionnaire. Manometric measurements recorded at last follow-up were compared with preimplantation values.

RESULTS

In one patient, the permanent device was removed because of technical failure. After a mean follow-up of 15 (range, 3-80) months, visual analog pain scores had significantly improved (from 8.2 +/- 1.7 to 2.2 +/- 1.3, P < 0.001). SF-36 physical component scores increased from 26.27 +/- 5.65 to 38.95 +/- 9.08, P < 0.02). Scores on the mental component showed improvement, although not significant. Postimplantation changes in manometric functional data were not significant, but sensitivity thresholds showed a considerable decrease.

CONCLUSIONS

Long-term follow-up data showing improvements in scores on the visual analog pain scale and quality of life questionnaire indicate that, before adopting more aggressive surgical procedures, SNS should be considered for patients with chronic idiopathic anal pain in whom pharmacologic and biofeedback treatments have failed to produce effective results.

Fecal incontinence treated with acupuncture--a pilot study

OBJECTIVES

Acupuncture has been used successfully for the treatment of urinary bladder dysfunction. The aim of this study was therefore to investigate if manual acupuncture might also affect fecal incontinence favorably.

METHODS

The study comprises 15 female patients, median age 60 years (39 -75). Before treatment and at regular intervals after acupuncture sessions the defects of anal continence were assessed. Ano-rectal function was assessed by means of recto anal manovolumetry. Each patient was submitted to one acupuncture treatment per week for a ten-week period. Subsequently, a control session was repeated once per month up to 7 months for six patients. A final functional assessment was performed at 18 months.

RESULT

Patients experienced a significant improvement in anal continence, the overall continence score which changed from 10 (3 -21) estimated before treatment to zero (0 - 7) (p<0.05) at 10 weeks. Patients with irregular bowel habits and/or loose stools reported significant improvement. On the manovolumetric variables a limited increase of resting from 25 (17-35) mmHg to 36 (20-42) mmHg, (p=0.05) and sustained squeeze anal pressure, changing from 41 (32-68) mmHg to 60 (40-100) mmHg (p<0.05) were reported. Rectal sensory function remained unchanged.

CONCLUSION

Acupuncture offers good opportunities for improving fecal incontinence. The mechanism of action is obscure but might be an effect of the "neuromodulation" of the recto-anal function similar to that explaining the favorable results achieved by sacral nerve stimulation. The concomitant regulation of disordered bowel habits may also contribute to the satisfactory results.

Sacral nerve stimulation and rectal function: results of a prospective study in faecal incontinence

The mechanisms of action of sacral nerve stimulation (SNS) to treat faecal incontinence remain poorly understood.

THE AIMS OF OUR STUDY WERE

(i) to measure the effect of SNS on rectal function and (ii) to evaluate rectal function as a predictive factor of clinical response to SNS. Rectal function was studied before and 3 months after permanent SNS in 18 patients (17 women, mean age 58.5 years) with faecal incontinence, using an electronic barostat. Rectal sensitivity and volume variations were recorded during isobaric distensions. Three months after SNS, 14 patients had a significant improvement of faecal incontience symptoms and four had not. Baseline 'maximal tolerated volume' was significantly lower in the positive response group (210 +/- 56 vs 286 +/- 30 mL, P = 0.02). Baseline rectal compliance was lower in patients with a positive response than those without, although this difference did not reach significance (6.2 +/- 3.2 vs 9.2 +/- 2.9 mL mmHg(-1),P = 0.10). Rectal compliance was not significantly modified by SNS. Our results suggest that an increased rectal capacity as measured by the maximal tolerated volume may be a predictive factor of poor response to SNS in faecal incontinence. SNS does not significantly modify rectal function.

Rapid rate magnetic stimulation of human sacral nerve roots alters excitability within the cortico-anal pathway

Sacral nerve root stimulation (SNS) can produce dramatic symptomatic improvement in faecal incontinence (FI). However, the physiological mechanism behind this improvement remains unknown. One hypothesis is that SNS may modulate cortico-anal pathways and drive compensatory changes within the spinal cord or cerebral cortex that beneficially alter sphincter function. Our aim was to assess whether short-term experimental SNS can induce changes in the human cortico-anal pathway. Eight healthy volunteers (mean age 30 years) were studied. Subjects were investigated on three separate occasions and randomized to either active (5 and 15 Hz) or sham rapid-rate lumbosacral magnetic stimulation (rLSMS). Anal sphincter electromyograms (EMG) were recorded from an anal probe following single-pulse transcranial magnetic stimulation, at baseline, immediately, 30 and 60 min following rLSMS at either (i) 5 Hz for 15 min, (ii) 15 Hz for 15 min or (iii) sham stimulation for 15 min. In addition, manometry and anal sphincter sensation was measured in a subset of subjects. Interventions were compared to sham using anova. Fifteen hertz rLSMS increased cortico-anal EMG response amplitude in the 1 h postintervention (F(4, 28) = 3.2, P = 0.027), without a shift in response latency. This effect was not demonstrated with either 5 Hz or sham stimulation. rLSMS had no short-term effect on sensation or physiology. Short-term magnetic stimulation of the sacral nerve roots induces changes in cortico-anal excitability which is frequency specific. These data support the hypothesis that SNS produces some of its beneficial effect in patients with FI by altering the excitability of the cortico-anal pathway.