1
|
Eggers E, Crouss T, Beausang J, Smith D, Spector S, Saracco B, Adams A, Dickinson T, Lipetskaia L. Long-term Outcomes of Sacral Nerve Stimulation on the Treatment of Fecal Incontinence: A Systematic Review. Neuromodulation 2024:S1094-7159(24)00649-4. [PMID: 39152989 DOI: 10.1016/j.neurom.2024.06.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 06/06/2024] [Accepted: 06/24/2024] [Indexed: 08/19/2024]
Abstract
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.
Collapse
Affiliation(s)
- Erica Eggers
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA.
| | - Tess Crouss
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA
| | - Jasjit Beausang
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA
| | - Devon Smith
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA
| | - Sean Spector
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA
| | | | - Amanda Adams
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Taylor Dickinson
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA
| | - Lioudmila Lipetskaia
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Cooper University Healthcare, Camden, NJ, USA
| |
Collapse
|
2
|
Gefen R, Strassmann V, Stefano Hernandez FD, Garoufalia Z, Horesh N, Emile SH, Da Silva G, Wexner S. Risk factors for complications following sacral neuromodulation for faecal incontinence: Long-term follow-up. Colorectal Dis 2024; 26:1597-1607. [PMID: 38997819 DOI: 10.1111/codi.17092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/19/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024]
Abstract
AIM Sacral neuromodulation (SNM) has become a standard surgical treatment for faecal incontinence (FI). Prior studies have reported various adverse events of SNM, including suboptimal therapeutic response, infection, pain, haematoma, and potential need for redo SNM. The aim of this study was to identify the risk factors associated with long-term complications of SNM. METHOD This retrospective cohort reviewed patients who underwent two-stage SNM for FI at our institution between 2011-2021. Preoperative baseline characteristics and follow-up were obtained from the medical record and/or by telephone interview. Management and outcome of each postoperative event were evaluated by univariate and multivariate regression analyses. RESULTS A total of 291 patients (85.2% female) were included in this study. Postoperative complications were recorded in 219 (75.2%) patients and 154 (52.9%) patients required surgical intervention to treat complications. The most common postoperative event was loss of efficacy (46.4%). Other common adverse events were problems at the implant site (pain, infection, etc.) in 16.5% and pain during stimulation in 11.7%. Previous vaginal delivery (OR 2.74, p = 0.003) and anal surgery (OR = 2.46, p = 0.039) were independent predictors for complications. Previous colorectal (OR = 2.04, p = 0.026) and anal (OR = 1.98, p = 0.022) surgery and history of irritable bowel syndrome (IBS) (OR = 3.49, p = 0.003) were independent predictors for loss of efficacy. CONCLUSION Postoperative adverse events are frequently recorded after SNM. Loss of efficacy is the most common. Previous colorectal or anal surgery, vaginal delivery, and IBS are independent risk factors for complications.
Collapse
Affiliation(s)
- Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Victor Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Felice De Stefano Hernandez
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Surgery and Transplantation, Sheba Medical Centre, Ramat-Gan, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Giovanna Da Silva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| |
Collapse
|
3
|
Cerdán Miguel J, Arroyo Sebastián A, Codina Cazador A, de la Portilla de Juan F, de Miguel Velasco M, de San Ildefonso Pereira A, Jiménez Escovar F, Marinello F, Millán Scheiding M, Muñoz Duyos A, Ortega López M, Roig Vila JV, Salgado Mijaiel G. Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology. Cir Esp 2024; 102:158-173. [PMID: 38242231 DOI: 10.1016/j.cireng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 01/21/2024]
Abstract
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
Collapse
Affiliation(s)
| | - Antonio Arroyo Sebastián
- Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - Antonio Codina Cazador
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain
| | | | | | | | | | - Franco Marinello
- Unidad de Cirugía Colorrectal, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mónica Millán Scheiding
- Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Arantxa Muñoz Duyos
- Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Mario Ortega López
- Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | | |
Collapse
|
4
|
Katuwal B, Thorsen A, Kochar K, Bhullar R, King R, Drelichman ER, Mittal VK, Bhullar JS. Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study. World J Radiol 2024; 16:32-39. [PMID: 38455883 PMCID: PMC10915907 DOI: 10.4329/wjr.v16.i2.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/24/2023] [Accepted: 02/02/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Fecal incontinence (FI) is an involuntary passage of fecal matter which can have a significant impact on a patient's quality of life. Many modalities of treatment exist for FI. Sacral nerve stimulation is a well-established treatment for FI. Given the increased need of magnetic resonance imaging (MRI) for diagnostics, the InterStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility. Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used. AIM To evaluate the efficacy, outcomes and complications of the MRI-compatible InterStim. METHODS Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport, University of Minnesota, Advocate Lutheran General Hospital, and University of Wisconsin-Madison was pooled and analyzed. Patient demographics, clinical features, surgical techniques, complications, and outcomes were analyzed. Strengthening the Reporting of Observational studies in Epidemiology(STROBE) cross-sectional reporting guidelines were used. RESULTS Seventy-three patients had the InterStim implanted. The mean age was 63.29 ± 12.2 years. Fifty-seven (78.1%) patients were females and forty-two (57.5%) patients had diabetes. In addition to incontinence, overlapping symptoms included diarrhea (23.3%), fecal urgency (58.9%), and urinary incontinence (28.8%). Fifteen (20.5%) patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement. Thirty-two (43.8%) patients underwent rechargeable InterStim placement. Three (4.1%) patients needed removal of the implant. Migration of the external lead connection was observed in 7 (9.6%) patients after the stage I procedure. The explanation for one patient was due to infection. Seven (9.6%) patients had other complications like nerve pain, hematoma, infection, lead fracture, and bleeding. The mean follow-up was 6.62 ± 3.5 mo. Sixty-eight (93.2%) patients reported significant improvement of symptoms on follow-up evaluation. CONCLUSION This study shows promising results with significant symptom improvement, good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI. Further long-term follow-up and future studies with a larger patient population is recommended.
Collapse
Affiliation(s)
- Binit Katuwal
- Department of Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| | - Amy Thorsen
- Department of Colon and Rectal surgery, Alina Health Abbott Northwestern Hospital, Minneapolis, MN 55407, United States
| | - Kunal Kochar
- Colon and Rectal Surgery, Advocate Illinois Masonic, Park Ridge, IL 60068, United States
| | - Ryba Bhullar
- Volunteer Student, Department of Research, Ascension Providence Hospital, Southfield, MI 48075, United States
| | - Ray King
- Colon and Rectal Surgery, University of Wisconsin, Madison, WI 53715, United States
| | - Ernesto Raul Drelichman
- General and Colorectal Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| | - Vijay K Mittal
- Department of Surgery, Department of Medical Education, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| | - Jasneet Singh Bhullar
- General and Colorectal Surgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI 48075, United States
| |
Collapse
|
5
|
Dexter E, Walshaw J, Wynn H, Dimashki S, Leo A, Lindsey I, Yiasemidou M. Faecal incontinence-a comprehensive review. Front Surg 2024; 11:1340720. [PMID: 38362459 PMCID: PMC10867159 DOI: 10.3389/fsurg.2024.1340720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date. Methods A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities. Result and discussion This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).
Collapse
Affiliation(s)
- Eloise Dexter
- Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Josephine Walshaw
- Leeds Institute of Medical Research, St James’ University Hospital, University of Leeds, Leeds, United Kingdom
- Department of Health Research, University of York, York, United Kingdom
| | - Hannah Wynn
- Upper Gastrointestinal Surgery, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Safaa Dimashki
- Plastic Surgery, Mid Yorkshire Teaching NHS Trust, Wakefield, United Kingdom
| | - Alex Leo
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ian Lindsey
- Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Marina Yiasemidou
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
6
|
Martin S, O'Connor AD, Selvakumar D, Baraza W, Faulkner G, Mullins D, Kiff ES, Telford KJ, Sharma A. The Long-term Outcomes of Sacral Neuromodulation for Fecal Incontinence: A Single-Center Experience. Dis Colon Rectum 2024; 67:129-137. [PMID: 37738178 DOI: 10.1097/dcr.0000000000002937] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
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 ).
Collapse
Affiliation(s)
- Sarah Martin
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Alexander D O'Connor
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Deepak Selvakumar
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Wal Baraza
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Gemma Faulkner
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Domini Mullins
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Edward S Kiff
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Karen Jane Telford
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Abhiram Sharma
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| |
Collapse
|
7
|
Luchristt D, Kawasaki A. Successful sacral neuromodulation treatment of refractory faecal incontinence in a patient with spina bifida and partial sacral agenesis. BMJ Case Rep 2023; 16:e254835. [PMID: 37669822 PMCID: PMC10481722 DOI: 10.1136/bcr-2023-254835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
A woman in her early 20s with a history of lumbosacral lipomyelomeningocele with associated partial sacral agenesis and tethered cord was referred for possible sacral neuromodulation treatment of her refractory faecal incontinence. Anorectal testing revealed a thinned and weakened anal sphincter complex with absent left-sided bulbocavernosus and anal wink reflexes.Through a two-stage approach, she underwent successful placement of a chronic tined quadripolar sacral nerve lead and implanted pulse generator. Despite significant distortion of normal bony anatomic landmarks, bilateral S3 and S4 foraminal entry was possible, with intraoperative motor and sensory testing providing key confirmation of appropriate lead placement. The patient had a substantial improvement in her baseline frequency and urgency with a near-complete resolution of faecal incontinence episodes during her test phase.
Collapse
Affiliation(s)
- Douglas Luchristt
- Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amie Kawasaki
- Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
8
|
Bordeianou LG, Thorsen AJ, Keller DS, Hawkins AT, Messick C, Oliveira L, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum 2023; 66:647-661. [PMID: 37574989 DOI: 10.1097/dcr.0000000000002776] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Deborah S Keller
- Colorectal Center, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lucia Oliveira
- Anorectal Physiology Department of Rio de Janeiro, CEPEMED, Rio de Janeiro, Brazil
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
9
|
Manegold P, Herold A. Anale Inkontinenz. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-023-00684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
10
|
Pudendal, but not tibial, nerve stimulation modulates vulvar blood perfusion in anesthetized rodents. Int Urogynecol J 2022:10.1007/s00192-022-05389-x. [PMID: 36326861 PMCID: PMC10154432 DOI: 10.1007/s00192-022-05389-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Preclinical studies have shown that neuromodulation can increase vaginal blood perfusion, but the effect on vulvar blood perfusion is unknown. We hypothesized that pudendal and tibial nerve stimulation could evoke an increase in vulvar blood perfusion. METHODS We used female Sprague-Dawley rats for non-survival procedures under urethane anesthesia. We measured perineal blood perfusion in response to 20-minute periods of pudendal and tibial nerve stimulation using laser speckle contrast imaging (LSCI). After a thoracic-level spinalization and a rest period, we repeated each stimulation trial. We calculated average blood perfusion before, during, and after stimulation for three perineal regions (vulva, anus, and inner thigh), for each nerve target and spinal cord condition. RESULTS We observed a significant increase in vulvar, anal, and inner thigh blood perfusion during pudendal nerve stimulation in spinally intact and spinalized rats. Tibial nerve stimulation had no effect on perineal blood perfusion for both spinally intact and spinalized rats. CONCLUSIONS This is the first study to examine vulvar hemodynamics with LSCI in response to nerve stimulation. This study demonstrates that pudendal nerve stimulation modulates vulvar blood perfusion, indicating the potential of pudendal neuromodulation to improve genital blood flow as a treatment for women with sexual dysfunction. This study provides further support for neuromodulation as a treatment for women with sexual arousal disorders. Studies in unanesthetized animal models of genital arousal disorders are needed to obtain further insights into the mechanisms of neural control over genital hemodynamics.
Collapse
|
11
|
|
12
|
Bharucha AE, Knowles CH, Mack I, Malcolm A, Oblizajek N, Rao S, Scott SM, Shin A, Enck P. Faecal incontinence in adults. Nat Rev Dis Primers 2022; 8:53. [PMID: 35948559 DOI: 10.1038/s41572-022-00381-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/09/2022]
Abstract
Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.
Collapse
Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Charles H Knowles
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Isabelle Mack
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Satish Rao
- Department of Gastroenterology, University of Georgia, Augusta, GA, USA
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Enck
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany.
| |
Collapse
|
13
|
Menees S, Chey WD. Fecal Incontinence: Pathogenesis, Diagnosis, and Updated Treatment Strategies. Gastroenterol Clin North Am 2022; 51:71-91. [PMID: 35135666 DOI: 10.1016/j.gtc.2021.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Fecal incontinence (FI) is defined as the involuntary loss or passage of solid or liquid stool in patients. FI is a common and debilitating condition in men and women. The incidence increases with age and also often goes unreported to health care providers. It is crucial that providers ask at-risk patients about possible symptoms. Evaluation and management is tailored to specific symptoms and characteristics of the incontinence. If conservative methods fail to improve symptoms, then other surgical options are considered, such as sacral nerve stimulation and anal sphincter augmentation. This review provides an update on current and future therapies.
Collapse
Affiliation(s)
- Stacy Menees
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine Health System, Ann Arbor, MI, USA
| |
Collapse
|
14
|
Mittal RK, Tuttle LJ. Anorectal Anatomy and Function. Gastroenterol Clin North Am 2022; 51:1-23. [PMID: 35135656 DOI: 10.1016/j.gtc.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Anatomy of pelvic floor muscles has long been controversial. Novel imaging modalities, such as three-dimensional transperineal ultrasound imaging, MRI, and diffusion tensor imaging, have revealed unique myoarchitecture of the external anal sphincter and puborectalis muscle. High-resolution anal manometry, high-definition anal manometry, and functional luminal imaging probe are important new tools to assess anal sphincter and puborectalis muscle function. Increased understanding of the structure and function of anal sphincter complex/pelvic floor muscle has improved the ability to diagnose patients with pelvic floor disorders. New therapeutic modalities to treat anal/fecal incontinence and other pelvic floor disorders will emerge in the near future.
Collapse
Affiliation(s)
- Ravinder K Mittal
- Department of Medicine/Gastroenterology, University of California, San Diego, ACTRI, 9500 Gilman Drive, MC 0061, La Jolla, CA 92093-0990, USA.
| | - Lori J Tuttle
- Department of Medicine/Gastroenterology, University of California, San Diego, USA; San Diego State University, San Diego, CA, USA
| |
Collapse
|
15
|
Picciariello A, Rinaldi M, Dibra R, Trigiante G, Tomasicchio G, Lantone G, De Fazio M. Ageing with sacral nerve modulation for fecal incontinence: how many patients get benefit after more than 10 years? Updates Surg 2022; 74:185-191. [PMID: 34982410 PMCID: PMC8724665 DOI: 10.1007/s13304-021-01229-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/24/2021] [Indexed: 11/15/2022]
Abstract
Sacral nerve modulation (SNM) has represented a major advancement in the minimally invasive management of patients with fecal incontinence (FI). Although the success rate in the short–medium term has widely been demonstrated, the very long-term outcomes are poorly investigated. This study aims to assess the effectiveness of SNM in a cohort of patients with a follow-up longer than 10 years. Clinical records of patients submitted to SNM for FI in our tertiary referral colorectal Unit between 1998 and 2010 were retrospectively reviewed looking for status of the implantable pulse generator (IPG), follow-up duration, severity of FI by the St Marks’ score and quality of life. 58 patients fulfilled the entry criteria and 36 (58%, median follow-up, 12 years) accepted to take part to the telephone interview, while 22 (38%) were lost to the follow-up. Nineteen patients had their IPG removed (Group A) while 17 (27%) had the SNM still active after a median follow-up of 13 years (Group B). In the group A, the median baseline St Marks’ score was 13 and did not change after the IPG removal. In group B, the median baseline St Marks’ score was 14, at last IPG substitution, it was of 7 and at the last follow-up dropped to 4. In the group A, the median SF-12 physical and mental scores did not change significantly while they improved significantly in group B. A progressive deterioration of the success rate of SNM with the time has been documented after a very long-term follow-up.
Collapse
Affiliation(s)
- A Picciariello
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy.
| | - M Rinaldi
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - R Dibra
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - G Trigiante
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - G Tomasicchio
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - G Lantone
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| | - M De Fazio
- Surgical Unit "M. Rubino", Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy
| |
Collapse
|
16
|
Diseases of the Rectum and Anus. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
17
|
Sarveazad A, Yari A, Babaei-Ghazani A, Mokhtare M, Bahardoust M, Asar S, Shamseddin J, Yousefifard M, Babahajian A. Combined application of chondroitinase ABC and photobiomodulation with low-intensity laser on the anal sphincter repair in rabbit. BMC Gastroenterol 2021; 21:473. [PMID: 34911454 PMCID: PMC8672605 DOI: 10.1186/s12876-021-02047-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022] Open
Abstract
Background Photobiomodulation with low-intensity laser (LIL) and chondroitinase ABC (ChABC) can repair damaged muscle tissue, so the aim of this study was to investigate the effect of co-administration of these two factors on anal sphincter repair in rabbits. Methods Male rabbits were studied in 5 groups (n = 7): Control (intact), sphincterotomy, laser, ChABC and laser + ChABC. 90 days after intervention were evaluated resting and maximum squeeze pressures, number of motor units, collagen amount, markers of muscle regeneration and angiogenesis. Results Resting pressure in the Laser + ChABC group was higher than the sphincterotomy, laser and ChABC groups (p < 0.0001). Maximum squeeze pressure in the all study groups was higher than sphincterotomy group (p < 0.0001). In the laser + ChABC and ChABC groups, motor unit numbers were more than the sphincterotomy group (p < 0.0001). Collagen content was significantly decreased in the laser (p < 0.0001) and laser + ChABC groups. ACTA1 (p = 0.001) and MHC (p < 0.0001) gene expression in the Laser + ChABC group were more than the laser or ChABC alone. VEGFA (p = 0.009) and Ki67 mRNA expression (p = 0.01) in the Laser + ChABC group were more than the laser group, But vimentin mRNA expression (p < 0.0001) was less than the laser group. Conclusion Co-administration of ChABCs and photobiomodulation with LIL appears to improve the tissue structure and function of the anal sphincter in rabbits more than when used alone. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-02047-2.
Collapse
Affiliation(s)
- Arash Sarveazad
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.,Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abazar Yari
- Department of Anatomy, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran.,Dietary Supplements and Probiotics Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Arash Babaei-Ghazani
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Tehran, Iran.,Department of Physical Medicine and Rehabilitation, University of Montreal Health Center, Montreal, Canada
| | - Marjan Mokhtare
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mansour Bahardoust
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siavash Asar
- Department of Anesthesiology, Kerman University of Medical Sciences, Kerman, Iran
| | - Jebreil Shamseddin
- Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Hemmat Highway, P.O Box: 14665-354, Tehran, Iran.
| | - Asrin Babahajian
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, P.O Box: 14665-354, Sanandaj, Iran.
| |
Collapse
|
18
|
Abstract
Anal incontinence describes the uncontrolled transanal passage of gaseous, solid or liquid intestinal contents. It can be a considerable psychosocial burden and impairment of the quality of life for those affected. The cause can be primary damage to the continence organ or incontinence can be a secondary symptom of other diseases. The detailed patient history and clinical examination document the severity of incontinence, impairment of quality of life and pathomorphological changes. The treatment is primarily conservative. A combination of conservative therapeutic approaches can often achieve satisfactory symptom relief. If conservative treatment remains insufficient, surgical measures can be considered. Sphincteroplasty and sacral neuromodulation are the preferred surgical interventions.
Collapse
Affiliation(s)
- Philipp Manegold
- Deutsches End- und Dickdarmzentrum Mannheim, Bismarckplatz 1, 68167, Mannheim, Deutschland.
| | - Alexander Herold
- Deutsches End- und Dickdarmzentrum Mannheim, Bismarckplatz 1, 68167, Mannheim, Deutschland
| |
Collapse
|
19
|
Meyer I, Richter HE. Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management. Obstet Gynecol Clin North Am 2021; 48:467-485. [PMID: 34416932 DOI: 10.1016/j.ogc.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.
Collapse
Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA.
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
| |
Collapse
|
20
|
Abstract
Sacral neuromodulation (SNM) has been available in the United States for more than 20 years and is a guideline-recommended therapy by both the American Urological Association and the American Society of Colon and Rectal Surgeons, with proven long-term success for urinary urgency incontinence, urinary urgency frequency, nonobstructive urinary retention, and fecal incontinence. Initially the therapy involved a more invasive surgical approach that included a large cut down over the sacrum. This article reviews recent advancements in SNM therapy including updates in best practices for implant technique, technological innovations, and the new clinical literature relevant to contemporary practice.
Collapse
|
21
|
Vassiliu P, Patoulis F, Naar L, Dendias G, Arkadopoulos N. Case Report: Sacral Nerve Root Pelvic Neural Retraining, With Long-Term Sustainability After the Device Explantation. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:655400. [PMID: 36188844 PMCID: PMC9397735 DOI: 10.3389/fresc.2021.655400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022]
Abstract
Introduction: Sacral-Nerve-Neuromodulation (SNM) is an effective treatment increasingly used in patients with urinary (UI) and fecal incontinence (FI). The way it acts in the body at its full potential have not yet been elucidated. The authors review the literature on SNM and the way it possibly works, relating it to a case with an unusually favorable outcome. Case Presentation: A female presented with UI and FI. Operated for meningocele as a neonate. It the age of 5 bilateral Cohen ureter reimplantation performed for persistent urinary infections due to vesicourethral reflux. At the age of 13, she started complaining about UI associated with a hyper functional detrusor muscle. After a diary incontinence evaluation with a standardized questionnaire, SNM was applied at the age of 18 and was retained for 4 years. She was re-evaluated with a yearly follow-up. Results: The patient retained the positive effect of SNM even after its removal and in addition showed signs of improvement. The patient developed the sensation of fillingness of the bladder and the rectum, which she never had before the SNM implantation, sensation which she retained 29 months after (last follow-up) device removal, allowing her to control her voids. Discussion: The modern literature hypothesis that SNM contributes to the plasticity of the nerves through the stimulated area is supported by the present case, in which the SNM effect remained and led to improvements even after its removal. Device settings are presented as they may correlate with the result. This reinforces and expands the frontiers of SNM application and research.
Collapse
Affiliation(s)
- Panteleimon Vassiliu
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Filippos Patoulis
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- *Correspondence: Filippos Patoulis ; orcid.org/0000-0001-7210-4237
| | - Leon Naar
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Nikolaos Arkadopoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
22
|
Spinelli A, Laurenti V, Carrano FM, Gonzalez-Díaz E, Borycka-Kiciak K. Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives. J Clin Med 2021; 10:3261. [PMID: 34362045 PMCID: PMC8347477 DOI: 10.3390/jcm10153261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries-OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.
Collapse
Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Virginia Laurenti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Francesco Maria Carrano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Enrique Gonzalez-Díaz
- Pelvic Floor Unit, Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain;
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain
| | - Katarzyna Borycka-Kiciak
- Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, 80, Ceglowska Street, 01810 Warsaw, Poland;
| |
Collapse
|
23
|
Dudding TC, Lehur PA, Sørensen M, Engelberg S, Bertapelle MP, Chartier-Kastler E, Everaert K, Van Kerrebroeck P, Knowles CH, Lundby L, Matzel KE, Muñoz-Duyos A, Rydningen MB, de Wachter S. Reprogramming Sacral Neuromodulation for Sub-Optimal Outcomes: Evidence and Recommendations for Clinical Practice. Neuromodulation 2021; 24:1247-1257. [PMID: 34264542 PMCID: PMC9291141 DOI: 10.1111/ner.13494] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 06/07/2021] [Indexed: 12/11/2022]
Abstract
Objectives In some patients treated for urinary or fecal incontinence with sacral neuromodulation (SNM) persistence of symptoms, a reduction in efficacy or adverse effects of stimulation can occur. In such situations, further programming of the SNM device can help resolve problems. Infrequently hardware failure is detected. This article aims to provide practical guidance to solve sub‐optimal outcomes (troubleshooting) occurring in the course of SNM therapy. Materials and Methods A systematic literature review was performed. Collective clinical experience from an expert multidisciplinary group was used to form opinion where evidence was lacking. Results Circumstances in which reprogramming is required are described. Actions to undertake include changes of electrode configuration, stimulation amplitude, pulse frequency, and pulse width. Guidance in case of loss of efficacy and adverse effects of stimulation, developed by a group of European experts, is presented. In addition, various hardware failure scenarios and their management are described. Conclusions Reprogramming aims to further improve patient symptoms or ensure a comfortable delivery of the therapy. Initial changes of electrode configuration and adjustment of stimulation parameters can be performed at home to avoid unnecessary hospital visits. A logical and stepwise approach to reprogramming can improve the outcome of therapy and restore patient satisfaction.
Collapse
Affiliation(s)
- Thomas C Dudding
- Pelvic Floor Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul A Lehur
- Coloproctology Unit, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Michael Sørensen
- Department of Surgical and Medical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | | | - Maria Paola Bertapelle
- Neurourology Maria Adelaide Hospital, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | | | - Karel Everaert
- Department of Urology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Philip Van Kerrebroeck
- Pelvic Care Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London & Barts Health NHS Trust, London, UK
| | - Lilli Lundby
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus E Matzel
- Chirurgische Klinik, Sektion Koloproktologie, Universität Erlangen, Erlangen, Germany
| | - Arantxa Muñoz-Duyos
- Coloproctology Unit, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Spain
| | - Mona B Rydningen
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor Health, University Hospital of North Norway, Tromso, Norway
| | - Stefan de Wachter
- Department of Urology, Faculty of Health Sciences, University Hospital Antwerpen, University Antwerpen, Edegem, Belgium
| |
Collapse
|
24
|
Meurette G, Siproudhis L, Leroi AM, Damon H, Urs Josef Keller D, Faucheron JL. Sacral neuromodulation with the InterStim™ system for faecal incontinence: results from a prospective French multicentre observational study. Colorectal Dis 2021; 23:1463-1473. [PMID: 33387373 DOI: 10.1111/codi.15507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
AIM The aim of this work was to evaluate the effectiveness, patient satisfaction and quality of life (QoL) and the safety of sacral neuromodulation (SNM) with the InterStimTM system for the treatment of faecal incontinence (FI) and establish whether results published predominantly by expert sites are generalisable. METHOD This is a prospective, multicentre, observational study that invited all French sites treating FI with the InterStim™ system to enrol subjects indicated for an SNM therapy evaluation. Data were collected at three follow-up visits within 1 and 15 months. Therapeutic effectiveness was evaluated by the reduction in leakages per week and improvements over time in the ability to defer defaecation and QoL (as measured with the Faecal Incontinence Quality of Life score). Safety was assessed through reported adverse events. RESULTS A total of 221 subjects with a mean age of 62.1 years were tested (184 women) and 178 received a permanent implant. For all implanted subjects with diary data at baseline and follow-up, a reduction in leakage of more than 50% was observed in 80%, 76% and 83% at 1-3, 4-8 and 9-15 months, respectively. The mean number of leakage episodes and urgency improved significantly compared with the baseline (p < 0.0001). Subjects showed improvements in QoL and time to defer defaecation and were generally satisfied with their therapy. The main device-related adverse event was the requirement to undertake reprogramming (in 52% of subjects with actions following an event). The rates of infection (in 6% of subjects) and surgical revision (in 10% of subjects) were in agreement with literature reports. CONCLUSION This study confirms the clinical effectiveness, safety and positive effect of SNM on QoL as well as high patient satisfaction for the treatment of FI in real-life.
Collapse
Affiliation(s)
| | | | | | - Henri Damon
- Hôpital Edouard Herriot, CHU de Lyon, Lyon, France
| | | | | | | |
Collapse
|
25
|
Speer AL, Ren X, McNeill EP, Aziz JM, Muir SM, Marino DI, Dadhich P, Sawant K, Ciccocioppo R, Asthana A, Bitar KN, Orlando G. Bioengineering of the digestive tract: approaching the clinic. Cytotherapy 2021; 23:381-389. [PMID: 33840629 DOI: 10.1016/j.jcyt.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/18/2022]
Abstract
The field of regenerative medicine is developing technologies that, in the near future, will offer alternative approaches to either cure diseases affecting the gastrointestinal tract or slow their progression by leveraging the intrinsic ability of our tissues and organs to repair after damage. This article will succinctly illustrate the three technologies that are closer to clinical translation-namely, human intestinal organoids, sphincter bioengineering and decellularization, whereby the cellular compartment of a given segment of the digestive tract is removed to obtain a scaffold consisting of the extracellular matrix. The latter will be used as a template for the regeneration of a functional organ, whereby the newly generated cellular compartment will be obtained from the patient's own cells. Although clinical application of this technology is approaching, product development challenges are being tackled to warrant safety and efficacy.
Collapse
Affiliation(s)
- Allison L Speer
- McGovern Medical School, The University of Texas Health Science Center, Houston, Texas, USA
| | - Xi Ren
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Eoin P McNeill
- McGovern Medical School, The University of Texas Health Science Center, Houston, Texas, USA
| | - Justine M Aziz
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sean M Muir
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Domenica I Marino
- College of Arts and Sciences, Ohio State University, Columbus, Ohio, USA
| | | | - Ketki Sawant
- Cellf Bio LLC, Winston-Salem, North Carolina, USA
| | - Rachele Ciccocioppo
- Department of Medicine, Gastroenterology Unit, Giambattista Rossi University Hospital, University Hospital Integrated Trust of Verona, University of Verona, Verona, Italy
| | - Amish Asthana
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Khalil N Bitar
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Cellf Bio LLC, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| |
Collapse
|
26
|
Knowles CH, de Wachter S, Engelberg S, Lehur P, Matzel KE, Zirpel L, Chartier‐Kastler E, Dudding T, Everaert K, van Kerrebroeck P, Knowles CH, Lehur PA, Lundby L, Matzel KE, Muñoz‐Duyos A, Rydningen MB, Sørensen M, de Wachter S. The science behind programming algorithms for sacral neuromodulation. Colorectal Dis 2021; 23:592-602. [PMID: 33010084 DOI: 10.1111/codi.15390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/20/2020] [Accepted: 09/10/2020] [Indexed: 02/08/2023]
Abstract
AIM Sacral neuromodulation (SNM) is a widely adopted treatment for overactive bladder, non-obstructive urinary retention and faecal incontinence. In the majority, it provides sustained clinical benefit. However, it is recognized that, even for these patients, stimulation parameters (such as amplitude, electrode configuration, frequency and pulse width) may vary at both initial device programming and at reprogramming, the latter often being required to optimize effectiveness. Although some recommendations exist for SNM programming, the scientific data to support them are understood by few clinicians. METHODS This is a narrative review of the literature covering some of the science behind stimulating a mixed peripheral nerve and available preclinical data in the field of SNM. It covers electrode configuration, amplitude, frequency, pulse width and cycling considerations. The review is targeted at clinicians with an interest in the field and does not seek to provide exhaustive detail on basic neuroscience. RESULTS AND CONCLUSIONS Knowledge of the science of neuromodulation provides some guiding principles for programming but these are broad. These principles are not refuted by preclinical data but specific parameters in clinical use are not strongly supported by animal data, even after the limitations of small and large animal models are considered. The review presents a shortlist of programming principles on a theoretical basis but acknowledges that current practice is as much derived from evolved experience as science.
Collapse
Affiliation(s)
- Charles H Knowles
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Stefan de Wachter
- Department of Urology, Faculty of Health Sciences, University Hospital Antwerpen, University Antwerpen, Antwerp, Belgium
| | | | - Paul Lehur
- Coloproctology Unit, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Klaus E Matzel
- Chirurgische Klinik, Universität Erlangen, Erlangen, Germany
| | - Lance Zirpel
- Global Neuromodulation Research, Medtronic Inc, Minneapolis, Minnesota, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Nurse- and Pelvic Floor Physical Therapist-Led Bowel Training in Patients With Fecal Incontinence in a Tertiary Care Center. Gastroenterol Nurs 2021; 44:39-46. [PMID: 33538522 DOI: 10.1097/sga.0000000000000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/07/2019] [Indexed: 11/25/2022] Open
Abstract
Little is known about nurse- and pelvic floor physical therapist-led bowel training in fecal incontinence after previous conservative management has been deemed unsatisfactory. The objective of this study was to evaluate combined nurse- and physical therapist-led bowel training sessions in a tertiary care center. This was a prospective, cross-sectional study. All patients with fecal incontinence between 2015 and 2016 with and without previous conservative management were included. Combined conservative treatment was defined as the use of stool-bulking agents (psyllium fibers) with or without antidiarrheal medication (loperamide) in combination with biofeedback or pelvic floor muscle training. Questionnaires regarding fecal incontinence (Vaizey incontinence score) and quality of life (Short Form Health Survey-36) were used. A decrease in the Vaizey incontinence score of 5 or more points was deemed to be clinically significant. Vaizey incontinence scores in all 50 patients decreased from 14.7 (SD = 4.5) to 9.9 (SD = 4.8) at follow-up (p < .001). Forty percent of patients reported an improvement in their Vaizey incontinence score (change of 5 or more points). Improvement was noted in those with and without previous treatment. Quality of life improved significantly. The limitation of the study includes lack of a standardized treatment protocol. Fecal incontinence reduced after nurse- and physical therapist-led bowel training sessions in patients with and without previous treatment, increasing their quality of life.
Collapse
|
28
|
Maeda K, Katsuno H, Tsunoda A, Seki M, Takao Y, Mimura T, Yamana T, Yoshioka K. Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version. J Anus Rectum Colon 2021; 5:84-99. [PMID: 33537503 PMCID: PMC7843139 DOI: 10.23922/jarc.2020-075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/30/2020] [Indexed: 12/04/2022] Open
Abstract
In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.
Collapse
Affiliation(s)
- Kotaro Maeda
- International Medical Center Fujita Health University Hospital, Toyoake, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Mihoko Seki
- Nursing Division, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshihiko Takao
- Division of Colorectal Surgery, Department of Surgery, Sanno Hospital, Tokyo, Japan
| | - Toshiki Mimura
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Tetsuo Yamana
- Department of Coloproctology, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Kazuhiko Yoshioka
- Department of Surgery, Kansai Medical University Medical Center, Osaka, Japan
| |
Collapse
|
29
|
Gehrich AP, McClellan E, Gillern S. Surgical repair of an obstetric cloaca with review of the literature. BMJ Case Rep 2021; 14:14/1/e234321. [PMID: 33500293 PMCID: PMC7839897 DOI: 10.1136/bcr-2020-234321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.
Collapse
|
30
|
Hendrickson WK, Amundsen CL. Sacral neuromodulation: troubleshooting needle placement. Int Urogynecol J 2021; 32:2549-2551. [PMID: 33416966 DOI: 10.1007/s00192-020-04614-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to develop an instructional video that utilizes fluoroscopic images and anatomical landmarks to increase the surgeon's ability to troubleshoot optimal placement of the foramen needle and lead during a stage I sacral neuromodulation (SNM) procedure. METHODS Eight different examples of suboptimal foramen needle placement with subsequent corrections during a SNM procedure were performed and recorded on a fresh female cadaver. RESULTS Fluoroscopic images were obtained during the procedure, and illustrations of the posterior aspect of the sacrum highlighting the S3 foramina and nerve are shown for anatomical comparison. CONCLUSIONS This video demonstrates how to efficiently identify and correct suboptimal foramen needle placement in order to obtain optimal lead placement during an SNM procedure. Understanding the relationship between the bony landmarks on fluoroscopy and the S3 nerve and foramen are important in order to understand how to correct a suboptimal foramen needle and thus achieve optimal lead placement.
Collapse
Affiliation(s)
- Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, 5324 McFarland Drive, Unit 310, Durham, NC, 27707, USA.
| | - Cindy L Amundsen
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, 5324 McFarland Drive, Unit 310, Durham, NC, 27707, USA
| |
Collapse
|
31
|
Katuwal B, Bhullar J. Current Position of Sacral Neuromodulation in Treatment of Fecal Incontinence. Clin Colon Rectal Surg 2021; 34:22-27. [PMID: 33536846 PMCID: PMC7843948 DOI: 10.1055/s-0040-1714247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Fecal incontinence (FI) is defined as uncontrolled passage of feces or gas for at least 1-month duration in an individual who previously had control. FI is a common and debilitating condition affecting many individuals. Continence depends on complex relationships between anal sphincters, rectal curvatures, rectoanal sensation, rectal compliance, stool consistency, and neurologic function. Factors, such as pregnancy, chronic diarrhea, diabetes mellitus, previous anorectal surgery, urinary incontinence, smoking, obesity, limited physical activity, white race, and neurologic disease, are known to be the risk factors for FI. Conservative/medical management including biofeedback are recognized as the first-line treatment of the FI. Those who are suitable for surgical intervention and who have failed conservative management, sacral nerve stimulation (SNS) has emerged as the treatment of choice in many patients. The surgical technique involves placement of a tined lead with four electrodes through the S3 sacral foramen. The lead is attached to a battery, which acts as a pulse generator, and is placed under the patient's skin in the lower lumbar region. The use of SNS in the treatment of FI has increased over the years and the beneficial effects of this treatment have been substantiated by multiple studies. This review describes SNS as a modality of treatment for FI and its position in the current medical diaspora in patients with FI.
Collapse
Affiliation(s)
- Binit Katuwal
- Department of Surgery, Providence Hospital & Medical Centers, Southfield, Michigan
| | - Jasneet Bhullar
- Department of Surgery, UPMC Williamsport, Williamsport, Pennsylvania
| |
Collapse
|
32
|
Bharucha AE, Oblizajek NR. Translumbosacral Neuromodulation Therapy Is a Promising Option for Fecal Incontinence. Am J Gastroenterol 2021; 116:80-81. [PMID: 33273260 PMCID: PMC7775327 DOI: 10.14309/ajg.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
ABSTRACT Fecal incontinence is a common symptom that can significantly impair quality of life. The treatment options range from conservative measures (e.g., Kegel exercises, pelvic floor biofeedback therapy, fiber supplementation, or medications) to noninvasive nerve stimulation (e.g., posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation), implanted neurostimulation (i.e., sacral nerve stimulation), perianal injection of dextranomer, and anal sphincteroplasty. In this issue of the journal, a promising, uncontrolled study suggests that noninvasive, repetitive magnetic stimulation of the lumbosacral nerves significantly improved symptoms, increased anal squeeze pressure, and increased rectal compliance in patients with fecal continence. Sham-controlled studies are necessary to confirm these findings.
Collapse
Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
| | | |
Collapse
|
33
|
Sacral neuromodulation: sacral anatomy and optimal lead placement. Int Urogynecol J 2020; 32:2545-2547. [PMID: 33237358 DOI: 10.1007/s00192-020-04615-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOSTHESIS To develop an instructional video that correlates cadaveric anatomy with fluoroscopic images to assist in conceptualization of optimal placement of the foramen needle and lead to complete an efficient and successful sacral neuromodulation (SNM) procedure. METHODS A SNM procedure was performed and recorded on a fresh female cadaver. Fluoroscopic images were obtained during the procedure to highlight the bony relationships to the S3 foramen and nerve. Dissection of the anterior and posterior sacrum was completed to highlight the tract of the S3 nerve. Techniques to increase the likelihood of optimal foramen needle and thus lead placement were highlighted. CONCLUSIONS This video demonstrates how achieving optimal foramen needle placement within the S3 foramen is key to optimal lead placement. Understanding the relationship of the bony landmarks on fluoroscopy to the S3 nerve and foramen, seen in the cadaveric dissections, are important in understanding how to achieve optimal lead placement. This optimization should lead to decreased operating room time, maximization of programming options, and decreased amplitude requirements.
Collapse
|
34
|
D’Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 PMCID: PMC7707876 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
Collapse
Affiliation(s)
- Ferdinando D’Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| |
Collapse
|
35
|
Abstract
Nine percent of adult women experience episodes of fecal incontinence at least monthly. Fecal incontinence is more common in older women and those with chronic bowel disturbance, diabetes, obesity, prior anal sphincter injury, or urinary incontinence. Fecal incontinence negatively affects quality of life and mental health and is associated with increased risk of nursing home placement. Fewer than 30% of women with fecal incontinence seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals. Even among women with both urinary and fecal incontinence presenting for urogynecologic care, the rate of verbal disclosure of fecal incontinence symptoms remains low. This article provides an overview of the evaluation and management of fecal incontinence for the busy obstetrician-gynecologist, incorporating existing guidance from the American College of Obstetricians and Gynecologists, the American College of Gastroenterology, and the American Society of Colon and Rectal Surgeons. The initial clinical evaluation of fecal incontinence requires a focused history and physical examination. Recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment. Invasive diagnostic testing and imaging generally are not needed to initiate treatment but may be considered in complex cases. Most women have mild symptoms that will improve with optimized stool consistency and medications. Additional treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and, for severely affected individuals for whom other interventions fail, colonic diversion.
Collapse
Affiliation(s)
- Heidi W Brown
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, California; and the Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin Texas
| | | | | |
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly. RECENT FINDINGS Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.
Collapse
Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
| |
Collapse
|
37
|
Gevelinger MM, Jaworski EM, Speranza JR, Sanderson DJ. Improvements in Self-Reported Depression Following Treatment of Fecal Incontinence with Sacral Neuromodulation. Neuromodulation 2020; 23:1158-1163. [PMID: 32803836 DOI: 10.1111/ner.13249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/01/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate changes in self-reported depression after treatment of fecal incontinence (FI) with sacral neuromodulation. MATERIALS AND METHODS This is a subanalysis of data collected from March 2016 to October 2017 for an Institutional Review Board-approved retrospective cohort study. Demographic information, medical history, psychiatric comorbidities, and the Patient-Reported Outcomes Measurement Information System item bank t-scores were extracted from the electronic medical record. The differences in t-scores were compared with a two-sided paired t-test, and a p value <0.05 was considered statistically significant. RESULTS Of the cohort (n = 24), most were Caucasian (88%), female (92%), nonsmokers (92%). Median age was 63.5 years (interquartile range 57.5-71.0 years) and median body mass index was 27.7 kg/m2 (range 18.3-42.9 kg/m2 ). A significant decrease in mean depression t-scores occurred after implantation of a sacral neuromodulation device, -4.5 (95% confidence interval [CI]: -8.7, -0.2, p = 0.04). Self-reported pain interference (p = 0.37) and physical function (p = 0.47) scores were similar following implantation. Individuals with comorbid anxiety reported the greatest improvement in depression (-6.5, 95% CI: -11.8, -1.1, p = 0.02). CONCLUSIONS Treatment of FI with sacral neuromodulation was associated with improvement in self-reported depression with the greatest improvement in those with anxiety. Further prospective research is needed to corroborate these findings.
Collapse
Affiliation(s)
- Matthew M Gevelinger
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | | | - Jenny R Speranza
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Derrick J Sanderson
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| |
Collapse
|
38
|
Ten-year Evaluation of a Large Retrospective Cohort Treated by Sacral Nerve Modulation for Fecal Incontinence: Results of a French Multicenter Study. Ann Surg 2020; 275:735-742. [PMID: 32740249 DOI: 10.1097/sla.0000000000004251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effectiveness of sacral nerve modulation (SNM) in a large cohort of patients implanted for at least 10 years, quantify adverse event rates, and identify predictive factors of long-term success. SUMMARY BACKGROUND DATA Few studies have evaluated the long-term success of SNM. METHODS Data collected prospectively from patients implanted for fecal incontinence (FI) in 7 French centers between January 1998 and December 2008 were retrospectively analyzed. Patient FI severity scores were assessed before and 10 years after implantation. The main evaluation criterion was the success of SNM defined by the continuation of the treatment without additional therapies. The secondary evaluation criteria were the rate of device revisions and explantations. Preoperative predictors of success at 10 years were sought. RESULTS Of the 360 patients (27 males, mean age: 59 ± 12 years) implanted for FI, 162 (45%) had a favorable outcome 10 years post-implantation, 115 (31.9%) failed, and 83 (23.1%) were lost to follow-up. The favorable outcome derived from the time-to-event Kaplan-Meier curve at 10 years was 0.64 (95% CI 0.58-0.69). FI severity scores were significantly better 10 years post-implantation compared to preimplantation (7.4 ± 4.3 vs 14.0 ± 3.2; P < 0.0001). During the 10-year follow-up, 233 patients (64.7%) had a surgical revision and 94 (26.1%) were explanted. A history of surgery for FI and sex (male) were associated with an increased risk of an unfavorable outcome. CONCLUSIONS Long-term efficacy was maintained in approximately half of the FI patients treated by SNM at least 10 years post-implantation.
Collapse
|
39
|
Varghese C, Wells CI, O'Grady G, Bissett IP. Costs and outcomes of sacral nerve stimulation for faecal incontinence in New Zealand: a 10‐year observational study. ANZ J Surg 2020; 90:569-575. [DOI: 10.1111/ans.15656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
| | - Cameron I. Wells
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- Department of SurgeryAuckland District Health Board Auckland New Zealand
| | - Gregory O'Grady
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- Department of SurgeryAuckland District Health Board Auckland New Zealand
- Auckland Bioengineering InstituteThe University of Auckland Auckland New Zealand
| | - Ian P. Bissett
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- Department of SurgeryAuckland District Health Board Auckland New Zealand
| |
Collapse
|
40
|
Ramakrishnan K. Diseases of the Rectum and Anus. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_98-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
41
|
Zifan A, Mittal RK, Kunkel DC, Swartz J, Barr G, Tuttle LJ. Loop analysis of the anal sphincter complex in fecal incontinent patients using functional luminal imaging probe. Am J Physiol Gastrointest Liver Physiol 2020; 318:G66-G76. [PMID: 31736339 PMCID: PMC6985842 DOI: 10.1152/ajpgi.00164.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cardiac loops have been used extensively to study myocardial function. With changes in cardiac pump function, loops are shifted to the right or left. Functional luminal imaging probe (FLIP) recordings allow for loop analysis of the anal sphincter and puborectalis muscle (PRM) function. The goal was to characterize anal sphincter area-pressure/tension loop changes in fecal incontinence (FI) patients. Fourteen healthy subjects and 14 patients with FI were studied. A custom-designed FLIP was placed in the vagina and then in the anal canal, and deflated in 20-ml steps, from 90 to 30 ml. At each volume, subjects performed maximal voluntary squeezes. Area-pressure (AP) and area-tension (AT) loops were generated for each squeeze cycle. Three-dimensional ultrasound imaging of the anal sphincter and PRM were obtained to determine the relationship between anal sphincter muscle damage and loop movements. With the increase in bag volume, AP loops and AT loops shifted to the right and upward in normal subjects (both anal and vaginal). The shift to the right was greater, and the upward movement was less in FI patients. The difference in the location of AP loops and AT loops was statistically significant at volumes of 50 ml to 90 ml (P < 0.05). A similar pattern was found in the vaginal loops. There is a significant relationship between the damage to the anal sphincter and PRM, and loop location of FI patients. We propose AP and AT loops as novel ways to assess the anal sphincter and PRM function. Such loops can be generated by real-time measurement of pressure and area within the anal canal.NEW & NOTEWORTHY We describe the use of area-pressure (AP) and area-tension (AT)-loop analysis of the anal sphincters and puborectalis muscles in normal subjects and fecal incontinent patients using the functional luminal imaging probe (FLIP). There are differences in the magnitude of the displacement of the loops with increase in the FLIP bag volume between normal subjects and patients with fecal incontinence. The latter group shifts more to the right in AP and AT space.
Collapse
Affiliation(s)
- Ali Zifan
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - Ravinder K. Mittal
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - David C. Kunkel
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - Jessica Swartz
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| | - Garrett Barr
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| | - Lori J. Tuttle
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| |
Collapse
|
42
|
Dadhich P, Bohl JL, Tamburrini R, Zakhem E, Scott C, Kock N, Mitchell E, Gilliam J, Bitar KN. BioSphincters to treat Fecal Incontinence in Nonhuman Primates. Sci Rep 2019; 9:18096. [PMID: 31792260 PMCID: PMC6888838 DOI: 10.1038/s41598-019-54440-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/12/2019] [Indexed: 02/07/2023] Open
Abstract
Loss of anorectal resting pressure due to internal anal sphincter (IAS) dysfunctionality causes uncontrolled fecal soiling and leads to passive fecal incontinence (FI). The study is focused on immediate and long-term safety and potential efficacy of bioengineered IAS BioSphincters to treat passive FI in a clinically relevant large animal model of passive FI. Passive FI was successfully developed in Non-Human Primates (NHPs) model. The implantation of autologous intrinsically innervated functional constructs resolved the fecal soiling, restored the resting pressure and Recto Anal Inhibitory Reflex (RAIR) within 1-month. These results were sustained with time, and efficacy was preserved up to 12-months. The histological studies validated manometric results with the regeneration of a well-organized neuro-muscular population in IAS. The control groups (non-treated and sham) remained affected by poor anal hygiene, lower resting pressure, and reduced RAIR throughout the study. The pathological assessment of implants, blood, and the vital organs confirmed biocompatibility without any adverse effect after implantation. This regenerative approach of implanting intrinsically innervated IAS BioSphincters has the potential to offer a better quality of life to the patients suffering from FI.
Collapse
Affiliation(s)
- Prabhash Dadhich
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jaime L Bohl
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Riccardo Tamburrini
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Elie Zakhem
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Christie Scott
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Nancy Kock
- Department of Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Erin Mitchell
- Animal Resources Program, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - John Gilliam
- Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Khalil N Bitar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Program in Neuro-Gastroenterology and Motility, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC, USA.
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA.
| |
Collapse
|
43
|
Gevelinger MM, Sanderson DJ, Jaworski E, Doyle PJ. Evaluation of Sacral Nerve Stimulation Device Revision and Explantation in a Single Center, Multidisciplinary Study. Neuromodulation 2019; 23:1201-1206. [DOI: 10.1111/ner.13050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew M. Gevelinger
- Department of Obstetrics and Gynecology University of Rochester, School of Medicine and Dentistry Rochester NY USA
| | - Derrick J. Sanderson
- Department of Obstetrics and Gynecology University of Rochester, School of Medicine and Dentistry Rochester NY USA
| | - Elaine Jaworski
- School of Medicine and Dentistry University of Rochester Rochester NY USA
| | - Paula J. Doyle
- School of Medicine and Dentistry, Department of Obstetrics and Gynecology, Department of Urology University of Rochester Rochester NY USA
| |
Collapse
|
44
|
Kosteneffektivität der Nervenstimulationsmethoden bei Stuhlinkontinenz. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-00409-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
45
|
Oliveira L, Hagerman G, Torres ML, Lumi CM, Siachoque JAC, Reyes JC, Perez-Aguirre J, Sanchez-Robles JC, Guerrero-Guerrero VH, Regadas SM, Filho VG, Rosato G, Vieira E, Marzan L, Lima D, Londoño-Schimmer E, Wexner SD. Sacral neuromodulation for fecal incontinence in Latin America: initial results of a multicenter study. Tech Coloproctol 2019; 23:545-550. [DOI: 10.1007/s10151-019-02004-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/13/2019] [Indexed: 12/17/2022]
|
46
|
Murad-Regadas SM, Regadas FSP, Regadas Filho FSP, Mendonça Filho JJD, Andrade Filho RS, Vilarinho ADS. PREDICTORS OF UNSUCCESSFUL OF TREATMENT FOR FECAL INCONTINENCE BIOFEEDBACK FOR FECAL INCONTINENCE IN FEMALE. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:61-65. [PMID: 31141067 DOI: 10.1590/s0004-2803.201900000-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/27/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Biofeedback is an effective method of treatment for fecal incontinence but there is controversy regarding factors that may be correlated with its effectiveness. OBJECTIVE To evaluate the efficacy of biofeedback in the treatment of fecal incontinence, identifying the predictive factors for unsuccessful treatment. METHODS Consecutive female patients who had fecal incontinence and were treated with a full course of biofeedback were screened. The symptoms were evaluated using Cleveland Clinic incontinence (CCF) score before and six months after the completion of therapy. Patients had a satisfactory clinical response to biofeedback if the CCF score had decreased by more than 50% at six months (GI) and an unsatisfactory response if the CCF score did not decrease or if the score decreased by <50% (GII). The groups were compared with regard to age, score, anal resting and squeeze pressures and sustained squeeze pressure by manometry, history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery. RESULTS Of 124 women were included, 70 (56%) in GI and 54 (44%) in GII. The median CCF score decreased significantly from 10 to 5 (P=0.00). FI scores were higher in GII. Patients from GII had more previous vaginal deliveries and previous surgeries. The mean sustained squeeze pressure was higher in GI. Patients from GI and GII had similar ages, number of vaginal deliveries, menopause, hysterectomy, anal pressures, and sphincter defects. The median sustained squeeze pressure increased significantly before and after biofeedback in GI. CONCLUSION Biofeedback therapy shows effective treatment with 50% reductions in FI score in half of patients. Factors associated with unsuccessful outcome include FI score ≥10, previous vaginal delivery, previous anorectal and/or colorectal surgery, and reduced mean sustained squeeze pressure.
Collapse
Affiliation(s)
- Sthela M Murad-Regadas
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Cirurgia, Fortaleza, CE, Brasil.,Universidade Federal do Ceará, Hospital das Clínicas, Unidade de Piso Pélvico e Fisiologia Anorretal, Fortaleza, CE, Brasil.,Hospital São Carlos, Departamento de Cirurgia Colorretal, Unidade de Piso Pélvico e Fisiologia Anorretal, CE, Brasil
| | | | | | | | - Roberto S Andrade Filho
- Hospital São Carlos, Departamento de Cirurgia Colorretal, Unidade de Piso Pélvico e Fisiologia Anorretal, CE, Brasil
| | - Adjra da Silva Vilarinho
- Hospital São Carlos, Departamento de Cirurgia Colorretal, Unidade de Piso Pélvico e Fisiologia Anorretal, CE, Brasil
| |
Collapse
|
47
|
Adelstein SA, Lee W, Gioia K, Moskowitz D, Stamnes K, Lucioni A, Kobashi KC, Lee UJ. Outcomes in a contemporary cohort undergoing sacral neuromodulation using optimized lead placement technique. Neurourol Urodyn 2019; 38:1595-1601. [DOI: 10.1002/nau.24018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 11/07/2022]
Affiliation(s)
| | - Wai Lee
- Virginia Mason, Section of Urology and Renal TransplantationSeattle Washington
| | - Kevin Gioia
- Hackensack Meridian Health GroupRumson New Jersey
| | - Dena Moskowitz
- Department of UrologyUniversity of California IrvineIrvine California
| | - Kelsey Stamnes
- Virginia Mason, Section of Urology and Renal TransplantationSeattle Washington
| | - Alvaro Lucioni
- Virginia Mason, Section of Urology and Renal TransplantationSeattle Washington
| | - Kathleen C. Kobashi
- Virginia Mason, Section of Urology and Renal TransplantationSeattle Washington
| | - Una J. Lee
- Virginia Mason, Section of Urology and Renal TransplantationSeattle Washington
| |
Collapse
|
48
|
Husk KE, Norris LD, Willis-Gray MG, Borawski KM, Geller EJ. Variation in bony landmarks and predictors of success with sacral neuromodulation. Int Urogynecol J 2019; 30:1973-1979. [PMID: 30729252 DOI: 10.1007/s00192-019-03883-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/16/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We assessed variations in sacral anatomy and lead placement as predictors of sacral neuromodulation (SNM) success. Based solely on bony landmarks, we also assessed the accuracy of the 9 and 2 protocol for locating S3. METHODS This is a retrospective cohort study performed from October 2008 to December 2016 at the University of North Carolina at Chapel Hill. Fluoroscopic images were used to assess sacral anatomy and lead location. Success was defined as >50% symptom improvement after stage I and clinical response at most recent follow-up. RESULTS Of 249 procedures, 209 were primary implants and 40 were revisions among 187 (89.5%) women and 22 (10.5%) men. Success rate was 83.3% for primary implants and 89.4% for revisions. Success was associated with shorter implant duration (21.3 ± 22.2 vs 33.6 ± 25.8 months), higher body mass index (30.3 ± 7.8 vs 27.6 ± 6.1 kg/m2), and straight vs curved lead (90.5% vs 80.5%) (all p = .05), but not with sacral anatomy or lead placement. In assessing the 9 and 2 protocol, mean distance from coccyx to S3 did not equal 9 cm: 7.4 ± 1.0 vs 7.2 ± 0.8 cm (p = .26), while mean distance from midline to S3 did equal 2 cm: 1.9 ± 0.4 vs 2.0 ± 0.7 cm (p = .37). CONCLUSIONS Variations in sacral anatomy and lead placement did not predict SNM success. The 2-cm protocol was verified while the 9-cm protocol was not, although neither was predictive of success, which may obviate the need to mark bony landmarks prior to fluoroscopy.
Collapse
Affiliation(s)
- Katherine E Husk
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC, 27599-7570, USA
| | - Lauren D Norris
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC, 27599-7570, USA
| | - Marcella G Willis-Gray
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC, 27599-7570, USA
| | - Kristy M Borawski
- Department of Urology, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth J Geller
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC, 27599-7570, USA.
| |
Collapse
|
49
|
Widmann B, Galata C, Warschkow R, Beutner U, Ögredici Ö, Hetzer FH, Schmied BM, Post S, Marti L. Success and Complication Rates After Sacral Neuromodulation for Fecal Incontinence and Constipation: A Single-center Follow-up Study. J Neurogastroenterol Motil 2019; 25:159-170. [PMID: 30646487 PMCID: PMC6326196 DOI: 10.5056/jnm17106] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/28/2018] [Accepted: 10/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims The aim of this study was to evaluate the sustainability of sacral neuromodulation (SNM) success in patients with fecal incontinence (FI) and/or constipation. Methods This is a retrospective analysis of a prospective database of patients who received SNM therapy for FI and/or constipation between 2006 and 2015. Success rates, complications and reintervention rates were assessed after up to 10 years of follow-up. Results Electrodes for test stimulation were implanted in 101 patients, of whom 79 (78.2%) received permanent stimulation. The mean follow-up was 4.4 ± 3.0 years. At the end of follow-up, 57 patients (72.2%) were still receiving SNM. The 5-year success rate for FI and isolated constipation was 88.2% (95% confidence interval [CI], 80.1-97.0%) and 31.2% (95% CI, 10.2-95.5%), respectively (P < 0.001). In patients with FI, involuntary evacuations per week decreased > 50% in 76.1% of patients (95% CI, 67.6-86.2%) after 5 years. A lead position at S3 was associated with an improved outcome (P = 0.04). Battery exchange was necessary in 23 patients (29.1%), with a median battery life of 6.2 years. Reinterventions due to complications were necessary in 24 patients (30.4%). For these patients, the 5-year success rate was 89.0% (95% CI, 75.3-100.0%) compared to 78.4% (95% CI, 67.2-91.4%) for patients without reintervention. Conclusions SNM offers an effective sustainable treatment for FI. For constipation, lasting success of SNM is limited and is thus not recommended. Reinterventions are necessary but do not impede treatment success.
Collapse
Affiliation(s)
- Bernhard Widmann
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Christian Galata
- Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland.,Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Ulrich Beutner
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Önder Ögredici
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Franc H Hetzer
- Department of Surgery, Spital Linth, Uznach, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland
| | - Stefan Post
- Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Lukas Marti
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, Switzerland.,Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| |
Collapse
|
50
|
Moskowitz D, Adelstein SA, Lucioni A, Kobashi KC, Lee UJ. Practice patterns in the diagnosis and treatment of fecal incontinence with sacral neuromodulation: Can urologists impact this gap in care? Turk J Urol 2019; 45:37-41. [PMID: 30668308 DOI: 10.5152/tud.2018.94041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/12/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The prevalence of fecal incontinence (FI) is 8% in the United States. Many patients will not seek treatment and the condition is underdiagnosed. Sacral neuromodulation (SNM) is effective in treating FI, and so urologists can play a key role in its treatment. We examine the practice patterns and treatment of FI with SNM in our institution. MATERIAL AND METHODS The electronic medical record was queried for the proportion of patients seen for FI in the institution, the urology department, and among the female pelvic medicine and reconstructive surgery (FPMRS) urologists. The patients who underwent SNM for FI were evaluated for progression to second stage procedure. RESULTS The proportion of patients seen for FI is 0.96% in the institution as a whole, 7.9% in the urology department, and 17.9% among FPMRS urologists. Fourteen patients underwent first stage SNM for FI or dual urinary/fecal incontinence, and they all progressed to a second stage procedure. Thirteen of these were performed by FPMRS urologists. CONCLUSION In our institution, the proportion of patients seen for FI was lower than the prevalence of this condition. Because patients with urinary incontinence are more likely to have FI, urologists are in a unique position to identify these patients and offer treatment that can improve their quality of life. We acknowledge a gap in care of the patients with FI and an opportunity for urologists to help patients with this devastating yet treatable condition.
Collapse
Affiliation(s)
- Dena Moskowitz
- Department of Urology, University of California Irvine, Orange, CA, USA
| | - Sarah A Adelstein
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Alvaro Lucioni
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA, USA
| | - Kathleen C Kobashi
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA, USA
| | - Una J Lee
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA, USA
| |
Collapse
|