Ageing with sacral nerve modulation for fecal incontinence: how many patients get benefit after more than 10 years?

Long-term Outcomes of Sacral Nerve Stimulation on the Treatment of Fecal Incontinence: A Systematic Review

INTRODUCTION

Sacral nerve stimulation (SNS) has now been used as a treatment for fecal incontinence (FI) for >20 years. The aim of this systematic review was to determine the long-term efficacy of SNS on the treatment of FI.

MATERIALS AND METHODS

A comprehensive search of the MEDLINE, Embase, and Cochrane Central data bases was performed to find publications, excluding case reports, reporting outcomes of SNS treatment for FI in adults with ≥36 months of follow-up. Bias was assessed using the Risk of Bias in Non-randomized Studies-of Interventions tool. Data were summarized per reported FI-related outcomes for symptom severity and quality of life.

RESULTS

In total, 3326 publications were identified, and 36 studies containing 3770 subjects were included. All studies had a serious risk of bias. Success was variably defined by each publication and ranged from 59.4% to 87.5% for per-protocol analyses and 20.9% to 87.5% for intention-to-treat analyses. All studies reporting bowel diary data, St Mark's scores, and Cleveland Clinic Incontinence Scores indicated significant improvement with SNS treatment in the long term. Studies that evaluated quality-of-life outcomes also all showed improvements in quality of life as measured by the Fecal Incontinence Quality of Life Scale. The aggregate revision rate was 35.2%, and the explantation rate was 19.7%.

CONCLUSIONS

Improvements in objective and subjective outcomes at ≥36 months support using SNS for the long-term treatment of FI. Interpretation of these data is limited by a lack of comparative trials and heterogeneity of the included studies.

The Long-term Outcomes of Sacral Neuromodulation for Fecal Incontinence: A Single-Center Experience

BACKGROUND

Sacral neuromodulation is an effective treatment for fecal incontinence.

OBJECTIVE

To assess the long-term outcomes of sacral neuromodulation and establish the outcomes of patients with inactive devices.

DESIGN

This is an observational study of patients treated for >5 years. A positive outcome was defined as a more than 50% reduction in fecal incontinence episodes or improvement in a symptom severity score. Data were reviewed from a prospectively managed database.

SETTINGS

This study was conducted at a single tertiary referral center.

PATIENTS

Data from 74 patients (72 women) were available at long-term follow-up.

MAIN OUTCOME MEASURES

Bowel diary, St. Mark's incontinence score, and Manchester Health Questionnaire data were prospectively recorded at baseline, after percutaneous nerve evaluation, and at last follow-up.

RESULTS

Patients were analyzed in cohorts based on time since sacral neuromodulation implantation: group 1: 5 to 10 years (n = 20), group 2: >10 years (n = 35), and group 3: inactive sacral neuromodulation devices (n = 19). Median St. Mark's incontinence score and Manchester Health Questionnaire improved from baseline to last follow-up in group 1 ( p ≤ 0.05) and group 2 ( p ≤ 0.05), but in group 3, results returned to baseline levels at the last follow-up. Similarly, weekly fecal incontinence episodes improved in both active device groups at the last follow-up. However, in group 3, incontinence episodes were no different from baseline ( p = 0.722). Despite active devices, fecal urgency episodes increased at the last follow-up after >10 years since percutaneous nerve evaluation ( p ≤ 0.05). Complete continence was reported by 44% of patients, and at least a 50% improvement was seen in 77% of patients with active devices.

LIMITATIONS

This study is retrospective with some gaps in the available data at the last follow-up.

CONCLUSIONS

Sacral neuromodulation is an effective treatment for fecal incontinence in the long term, but all outcomes are adversely affected by device inactivity. Therefore, ongoing stimulation is required for continued benefit. See Video Abstract.

RESULTADOS A LARGO PLAZO DE LA NEUROMODULACIN SACRA PARA LA INCONTINENCIA FECAL EXPERIENCIA DE UN SOLO CENTRO

ANTECEDENTES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados a largo plazo de la neuromodulación sacra y establecer los resultados de los pacientes con dispositivos inactivos.DISEÑO:Este es un estudio observacional de pacientes tratados durante más de 5 años. Un resultado positivo se definió como una reducción >50 % en los episodios de incontinencia fecal o una mejoría en la puntuación de gravedad de los síntomas. Los datos se revisaron a partir de una base de datos administrada prospectivamente.ENTERNO CLINICO:Este estudio se realizó en un solo centro de referencia terciario.PACIENTES:Los datos de 74 pacientes (72 mujeres) estaban disponibles en el seguimiento a largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:Diario intestinal, puntuación de incontinencia de St. Mark y datos del Cuestionario de salud de Manchester se registraron prospectivamente al inicio, después de la evaluación de nervio periférico y en el último seguimiento.RESULTADOS:Los pacientes se analizaron en cohortes según el tiempo transcurrido desde la implantación de la neuromodulación sacra: Grupo 1: 5-10 años (n = 20), Grupo 2: >10 años (n = 35) y Grupo 3: dispositivos SNM inactivos (n = 19). La mediana de la puntuación de incontinencia de St. Mark y Questionnaire Cuestionario de salud de Manchester mejoraron desde el inicio hasta el último seguimiento en el Grupo 1 (p = < 0,05) y el Grupo 2 (p = < 0,05), pero en el Grupo 3 los resultados volvieron a los niveles iniciales en el último seguimiento. arriba. De manera similar, los episodios semanales de incontinencia fecal mejoraron en ambos grupos de dispositivos activos en el último seguimiento. Sin embargo, en el Grupo 3 los episodios de incontinencia no fueron diferentes de los basales (p = 0,722). A pesar de los dispositivos activos, los episodios de urgencia fecal aumentaron en el último seguimiento después de más de 10 años desde la evaluación del nervio periférico (p = < 0,05). Continencia completa se reportó en el 44 % de los pacientes, y al menos una mejora del 50 % en el 77 % con dispositivos activos.LIMITACIONES:Este estudio es retrospectivo con algunas vacíos en los datos disponibles en el último seguimiento.CONCLUSIONES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal a largo plazo, pero todos los resultados se ven afectados negativamente por la inactividad del dispositivo. Por lo tanto, se requiere estimulación continua para un beneficio continuo. (Traducción- Dr. Francisco M. Abarca-Rendon ).