Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?

Clinical characteristics of phenotypes of fecal incontinence

PURPOSE

Fecal incontinence (FI) is common, but its etiology is complex with large knowledge gaps. Several phenotypes of FI are known, but the phenotype is often not decisive in the chosen therapy. In this study we aimed to assess the association of the clinical characteristics of patients with FI and the various phenotypes, in order to establish a targeted clinical treatment decision tree.

METHODS

We retrospectively studied the charts of patients with FI, who visited our institute from January 2018 until December 2020. Patients were divided into the following groups: passive fecal loss, urge incontinence, combined fecal incontinence with predominantly passive fecal loss, and combined fecal incontinence with predominantly urge incontinence. We compared the characteristics between the passive and urge incontinence groups, the passive  and combined mainly passive groups, and the urge and combined mainly urge groups.

RESULTS

Patients with passive incintinence were older, more often had a flaccid anus with presence of a mucosal prolapse, and had a lower resting pressure on anorectal manometry. Patients with urge incontinence were younger and more often had a history of birth trauma. The combined groups showed characteristics of both of the main types of FI.

CONCLUSION

Differentiating into phenotypes of FI can be clinically meaningful. The patient history and clinical judgement of the consulting specialist, rather than the physical characteristics, seem to be decisive in the categorization. Additional diagnostic testing can be helpful in complicated cases, but should not be used routinely.

Multimodal Management of Fecal Incontinence Focused on Sphincteroplasty: Long-Term Outcomes from a Single Center Case Series

The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985−2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60−173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS > 15 vs. 2.5% postoperatively; p < 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair.

Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management

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.

Non-dynamic graciloplasty is an effective treatment for patients with passive fecal incontinence

BACKGROUND

Fecal incontinence is a multifactorial problem and its etiology is complex. Various therapies are available and different success rates have been described. The aim of this study was to assess the effectiveness and safety of non-dynamic graciloplasty in patients with passive fecal incontinence.

METHODS

We retrospectively studied charts of patients with fecal incontinence treated with graciloplasty at our institution from November 2015 until June 2018. Patients were included according to the following criteria: (1) presence of predominantly passive fecal incontinence and (2) presence of a lax perineal body. Primary outcome was the effectiveness, defined as a significant reduction or absence of the complaints of passive fecal incontinence at 3, 6 and 12 months after surgery. Second, we studied the safety of the procedure evaluating the complications within 30 days after surgery.

RESULTS

Thirty-one patients met the inclusion criteria. Twenty-six of them, in addition to passive incontinence as the main symptom, had some degree of fecal urgency. The median age at the first visit to the outpatient clinic was 64.0 years (IQR 52-68). Most patients were female (n = 29, 94%). At 3 months after graciloplasty, 71% (22 of 31) of patients were successfully treated for their passive fecal incontinence. At 6 months, the success rate of the graciloplasty increased to 77%. At 12 months among the patients who were still seen in the clinic, the success rate was 58% (18/31). Two patients cancelled follow-up visits after 3 months, because of failure to control symptoms in 1 case. After 6 months, 9 patients were given the choice to do telephone follow-up only. Of these 11 patients without in-person follow-up, 10 were contacted 1 year after surgery and in 7 of them, the graciloplasty was effective in controlling their passive fecal incontinence for an overall success rate of 80% (25/31). Of the 26 patients with mixed passive and urge incontinence, 6 (23%) still complained of urge incontinence at 1 year. Of these patients with persistent urge incontinence, 6 underwent sacral nerve stimulation which was successful in 4. Two serious complications occurred within 30 days. A rectal perforation requiring temporary colostomy and a recto-vaginal fistula which was successfully repaired.

CONCLUSION

Non-dynamic graciloplasty is an effective treatment for passive fecal incontinence. Differentiation based on subtypes of fecal incontinence might be important for a pattern-specific approach to treatment. More research is necessary to determine the right indications for more invasive treatments of fecal incontinence.

Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres

AIM

The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013.

METHOD

This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded.

RESULTS

A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05).

CONCLUSION

The paradigm of surgical intervention for FI has changed with increasing use of SNM.

Management of Fecal Incontinence

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.

Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence-a cohort analysis

PURPOSE

Sacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence.

METHODS

Consecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient's characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation.

RESULTS

From, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°).

CONCLUSIONS

Anorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up

AIM

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury.

METHOD

This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale.

RESULTS

Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001).

CONCLUSION

At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

Impact of sphincter lesions and delayed sphincter repair on sacral neuromodulation treatment outcomes for faecal incontinence: results from a Finnish national cohort study

PURPOSE

The aim of this multicentre study was to analyse the effects of patent sphincter lesions and previous sphincter repair on the results of sacral neuromodulation (SNM) treatment on patients with faecal incontinence (FI).

METHODS

Patients examined by endoanal ultrasound (EAUS) with FI as the indication for SNM treatment were included in the study. Data was collected from all the centres providing SNM treatment in Finland and analysed for differences in treatment outcomes.

RESULTS

A total of 237 patients treated for incontinence with SNM had been examined by EAUS. Of these patients, 33 had a history of previous delayed sphincter repair. A patent sphincter lesion was detected by EAUS in 128 patients. The EAUS finding did not influence the SNM test phase outcome (p = 0.129) or the final treatment outcome (p = 0.233). Patient's history of prior sphincter repair did not have a significant effect on the SNM test (p = 0.425) or final treatment outcome (p = 0.442).

CONCLUSIONS

Results of our study indicate that a sphincter lesion or previous sphincter repair has no significant effect on the outcome of SNM treatment. Our data suggests that delayed sphincter repair prior to SNM treatment initiation for FI is not necessary.

International Continence Society best practice statement for use of sacral neuromodulation

AIMS

Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel.

METHODS

Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group.

RESULTS

The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research.

CONCLUSIONS

These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.

Sacral neuromodulation for faecal incontinence - 10 years' experience at a Scottish tertiary centre

INTRODUCTION

Sacral nerve stimulation (SNS) is increasingly popular in the management of faecal incontinence. This paper reports the first 10-year experience of SNS in the management of faecal incontinence at a tertiary referral centre. Data was collected in a prospectively maintained database.

RESULTS

In total 130 patients were referred. The majority were women (94%) under 75-year-old (98%). Seven patients were found to have full-thickness rectal prolapse at the initial work-up and proceeded to rectopexy. Eighty-three patients underwent temporary SNS testing with 73.5% positive outcome, of which 52 patients had permanent implant insertion. There were four failures of SNS (7%) following implantation despite successful temporary testing, seven infection, one lead migration and three post-operative pain/numbness. One patient subsequently developed colorectal cancer requiring SNS removal. A higher frequency of episodes of incontinence was associated with positive SNS outcome (p = 0.007). There was no significant association between age, sex, type of faecal incontinence, previous anorectal/pelvic surgery, colonoscopic or USS findings and the likelihood of successful SNS. Of the 52 patients with SNS implants, 27 patients were seen only once for follow-up; the remaining 25 patients were seen more than once - five of these were part of our initial cases of routine 6- and 12-monthly follow-up, 6 patients were seen for adjustment of voltages, whereas the remaining 14 patients were seen for complications of the implants. If the initial five patients were excluded, only 38% of patients would have been seen more frequently on an as-required basis.

CONCLUSION

SNS is a safe and effective option in the management of faecal incontinence. Of the initial work-up, endoscopy and examination-under-anaesthesia (EUA) or proctogram are essential and more likely to influence the likelihood of suitability of SNS testing. A patient-led drop-in approach to follow-up is feasible to allow patients to be seen on an as-required basis.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Sacral nerve stimulation for faecal incontinence: medium-term follow-up from a single institution

BACKGROUND

Most studies on sacral nerve stimulation (SNS) are either single-centre with small numbers of patients or multi-centre studies. We present the medium-term follow-up results from a single centre for 127 patients undergoing SNS.

METHODS

Consecutive patients treated with SNS for faecal incontinence had preoperative baseline St Mark's continence scores, faecal incontinence quality of life (FIQL) measures and anorectal physiology studies. Follow-up was a postal questionnaire concerning continence, FIQL, patient-perceived change in bowel control (-5 to +5 where 0 is no change), overall satisfaction (0-10 visual analogue scale) and use of medications.

RESULTS

A total of 166 patients underwent temporary nerve stimulation testing, of which 112 progressed to a permanent implantable pulse generator (IPG). Fifteen received an IPG without the testing phase, hence 127 patients in total. Fourteen had the IPG removed, four were deceased, leaving 109 for assessment; 91 (83%) responded to the survey. Mean follow-up was 2.7 years (range: 2 months-8.5 years). Mean baseline St Mark's continence score was 14.4, and mean follow-up score was 10.3 (P < 0.01). FIQL improved in all domains (P < 0.001). Patient-reported improved bowel control mean score was +3.2 (95% CI: 2.9, 3.55). Median satisfaction score was 8.0 (range: 0-10). Complications included 17 lead dislodgements, seven superficial infections, five infections requiring surgery and five repositioning of a rotated IPG. Thirty-two patients used loperamide and 34 used fibre supplements.

CONCLUSION

In this observational study, limited by the absence of a placebo control group, SNS significantly improved continence and quality of life, and patient satisfaction was high.

Systematic Review of Surgical Treatments for Fecal Incontinence

BACKGROUND

No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments.

OBJECTIVE

The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults.

DATA SOURCES

Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources.

STUDY SELECTION

Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980-2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment-outcome combination.

INTERVENTIONS

Surgical treatments for fecal incontinence were included interventions.

MAIN OUTCOME MEASURES

Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured.

RESULTS

Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%-100%). Major surgical complications often required reoperation; few required permanent colostomy.

LIMITATIONS

Most evidence is intermediate term, with small patient samples and substantial methodologic limitations.

CONCLUSIONS

Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

Sacral neuromodulation for persistent faecal incontinence after laparoscopic ventral rectopexy for high-grade internal rectal prolapse

AIM

Internal rectal prolapse is recognized as an aetiological factor in faecal incontinence. Patients found to have a high-grade internal rectal prolapse on routine proctography are offered a laparoscopic ventral rectopexy after failed maximum medical therapy. Despite adequate anatomical repair, faecal incontinence persists in a number of patients. The aim of this study was to evaluate the outcome of sacral neuromodulation in this group of patients.

METHOD

Between August 2009 and January 2012, 52 patients who underwent a laparoscopic ventral rectopexy for faecal incontinence associated with high-grade internal rectal prolapse had persistent symptoms of faecal incontinence and were offered sacral neuromodulation. Symptoms were evaluated before and after the procedure using the Fecal Incontinence Severity Index (FISI) and the Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

Temporary test stimulation was successful in 47 (94%) of the patients who then underwent implantation of a permanent pulse generator. The median FISI score 1 year after sacral neuromodulation was lower than the median score before [34 (28-59) vs. 19 (0-49); P < 0.01], indicating a significant improvement in faecal continence. Quality of life (GIQLI) was significantly better after starting sacral neuromodulation [78 (31-107) vs. 96 (55-129); P < 0.01].

CONCLUSION

Patients may benefit from sacral neuromodulation for persisting faecal incontinence after laparoscopic ventral rectopexy.

Systematic review of the impact of sacral neuromodulation on clinical symptoms and gastrointestinal physiology

Background

Sacral neuromodulation (SNM) has emerged as a treatment option for faecal incontinence (FI). However, its objective effect on symptoms and anorectal function is inconsistently described. This study aimed to systematically review the impact of SNM on clinical symptoms and gastrointestinal physiology in patients with FI, including factors that may predict treatment outcome.

Methods

An electronic search of MEDLINE (1946–2014)/EMBASE database was performed in accordance with PRISMA guidelines. Articles that reported the relevant outcome measures following SNM were included. Clinical outcomes evaluated included: frequency of FI episodes, FI severity score and success rates. Its impact on anorectal and gastrointestinal physiology was also evaluated.

Results

Of 554 citations identified, data were extracted from 81 eligible studies. Meta‐analysis of the data was precluded due to lack of a comparison group in most studies. After permanent SNM, ‘perfect’ continence was noted in 13–88% of patients. Most studies reported a reduction in weekly FI episodes (median difference of the mean −7.0 (range: −24.8 to −2.7)) and Wexner scores (median difference of the mean −9 (−14.9 to −6)). A trend towards improved resting and squeeze anal pressures and a reduction in rectal sensory volumes were noted. Studies failed to identify any consistent impact on other physiological parameters or clinicophysiological factors associated with success.

Conclusion

SNM improves clinical symptoms and reduces number of incontinence episodes and severity scores in patients with FI, in part by improving anorectal physiological function. However, intervention studies with standardized outcome measures and physiological techniques are required to robustly assess the physiological impact of SNM.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Sacral nerve stimulation for faecal incontinence and constipation: a European consensus statement

AIM

In Europe during the last decade sacral nerve stimulation (SNS) or sacral neuromodulation (SNM) has been used to treat faecal incontinence (FI) and constipation. Despite this, there is little consensus on baseline investigations, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the current practice of SNS/SNM for FI and constipation.

METHOD

A systematic literature search of SNS for FI and constipation was conducted using PubMed. A set of questions derived from the search and expert opinion were answered on-line on two occasions by an international panel of specialists from Europe. A 1-day face-to-face meeting of the experts finalized the discussion.

RESULTS

Three hundred and ninety-three articles were identified from the literature search, of which 147 fulfilled the inclusion criteria. Twenty-two specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the set-up of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35-100%).

CONCLUSION

Consensus was achieved on the majority of domains of SNS/SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/SNM in Europe.

Sacral neuromodulation for faecal incontinence: is the outcome compromised in patients with high-grade internal rectal prolapse?

BACKGROUND

High-grade internal rectal prolapse appears to be one of the contributing factors in the multifactorial origin of faecal incontinence. Whether it affects the outcome of sacral neuromodulation is unknown. We compared the functional results of sacral neuromodulation for faecal incontinence in patients with and without a high-grade internal rectal prolapse.

METHOD

One hundred six consecutive patients suffering from faecal incontinence, who were eligible for sacral neuromodulation between 2009 and 2012, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and ultrasound. Symptoms were assessed preoperatively and at 12 months after operation using a standardized questionnaire incorporating the Faecal Incontinence Severity Index (FISI range = 0-61) and the Gastrointestinal Quality of Life Index (GIQLI). Success was defined as a decrease in the FISI score of 50 % or more.

RESULTS

High-grade internal rectal prolapse (HIRP) was found in 36 patients (34%). The patient characteristics were similar in both groups. Temporary test stimulation was successful in 60 patients without HIRP (86%) and in 25 patients with HIRP (69 %) (p = 0.03). A permanent pulse generator was then implanted on these patients. After 1-year follow-up, the median FISI was reduced in patients without HIRP from 37 to 23 (p < 0.01). No significant change in FISI score was observed in patients with a HIRP (FISI, 38 to 34; p = 0.16). Quality of life (GIQLI) was only improved in patients without HIRP. A successful outcome per protocol was achieved in 31 patients without HIRP (52%) versus 4 patients with HIRP (16%) (p < 0.01).

CONCLUSION

The presence of a high-grade internal rectal prolapse has a detrimental effect on sacral neuromodulation for faecal incontinence.

Is sacral neuromodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence

INTRODUCTION

Sacral neuromodulation (SNM) was approved by the FDA for the treatment of fecal incontinence (FI) in 2011, and previous industry-sponsored trials have shown excellent clinical outcomes. The purpose of this study is to examine clinical outcomes of patients treated during our initial experience with SNM.

METHODS

A prospective database of patients treated with SNM for FI by one of three colorectal surgeons at two separate institutions was maintained starting in 2011. Patients showing ≥50% improvement of weekly incontinent episodes during test stimulation were offered permanent implantation of the SNM device. Disease severity was tracked using the Wexner score.

RESULTS

A total of 145 patients received a full system implantation (of 152 who received test stimulation). The median preoperative Wexner score of 14 decreased to 3, 3 months after implantation and persisted to 12 months. At 12 months, 95.2% of patients achieved >50% improvement in Wexner Score and 67.6% achieved >75% improvement. The most common adverse event was infection (3.4%). Three patients (2.1%) required lead revision.

CONCLUSIONS

SNM is a safe and effective therapy for the treatment of FI. Postoperative patient surveillance is important, as many patients require programming changes, and some will require a lead revision over time.

A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation

BACKGROUND

Sacral nerve stimulation (SNS) is now well established as a treatment for fecal incontinence (FI) resistant to conservative measures and may also have utility in the management of chronic constipation; however, mechanism of action is not fully understood. End organ effects of SNS have been studied in both clinical and experimental settings, but interpretation is difficult due to the multitude of techniques used and heterogeneity of reported findings. The aim of this study was to systematically review available evidence on the mechanisms of SNS in the treatment of FI and constipation.

METHODS

Two systematic reviews of the literature (performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses framework) were performed to identify manuscripts pertaining to (a) clinical and (b) physiological effects of SNS during the management of hindgut dysfunction.

KEY RESULTS

The clinical literature search revealed 161 articles, of which 53 were deemed suitable for analysis. The experimental literature search revealed 43 articles, of which nine were deemed suitable for analysis. These studies reported results of investigative techniques examining changes in cortical, gastrointestinal, colonic, rectal, and anal function.

CONCLUSIONS & INFERENCES

The initial hypothesis that the mechanism of SNS was primarily peripheral motor neurostimulation is not supported by the majority of recent studies. Due to the large body of evidence demonstrating effects outside of the anorectum, it appears likely that the influence of SNS on anorectal function occurs at a pelvic afferent or central level.

Baseline factors predictive of patient satisfaction with sacral neuromodulation for idiopathic fecal incontinence

PURPOSE

Sacral neuromodulation (SNM) is an established treatment for fecal incontinence (FI). A recent study from our group found that the relationship between patient satisfaction and clinical outcome is complex and does not match the traditional used success criteria. Therefore, the ability to predict patient satisfaction must be given priority. The aim of the present study is to identify baseline factors predictive of patient satisfaction, with SNM, for idiopathic FI.

METHODS

We analyzed data from patients treated with SNM for idiopathic FI in Aarhus, Denmark, and Maastricht, The Netherlands. A questionnaire considering self-reported satisfaction was mailed to these patients and compared to baseline characteristics. Logistic regression was used to determine the predictive value of baseline demographic and diagnostic variables.

RESULTS

In total, 131 patients were included in the analysis. Patient satisfaction with the current treatment result was reported in 75 patients. Fifty-six patients were dissatisfied with SNM treatment, after median 46 months (range 11-122) with permanent implantation. Pudendal nerve terminal motor latency (PNTML) was the solely identified predictor for long-term patient satisfaction. A subgroup univariate-logistic regression analysis showed that PNTML ≤ 2.3 ms at the side of lead implantation was a statistically significant predictor for patient satisfaction (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.01-5.24, p = 0.048).

CONCLUSION

Baseline PNTML measurement may be predictive of long-term satisfaction with SNM therapy for idiopathic FI. Further studies are needed to confirm this result.

Prospective clinical audit of two neuromodulatory treatments for fecal incontinence: sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS)

BACKGROUND AND PURPOSE

Two types of neuromodulation are currently practised for the treatment of fecal incontinence (FI): sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS). This study compares these therapies, as no data exist to prospectively assess their relative efficacy and costs.

METHODS

The subjects of this study were two distinct cohorts undergoing SNS (between 2003 and 2008) or PTNS (2008-onwards) for FI. Clinical outcomes assessed at 3 months included incontinence scores and the number of weekly incontinence episodes. The direct medical costs for each procedure were calculated from the audited expenditure of our unit.

RESULTS

Thirty-seven patients (94.6 % women) underwent permanent SNS and 146 (87.7 % women) underwent PTNS. The mean pre-treatment incontinence score (± SD) was greater in the SNS cohort (14 ± 4 vs. 12 ± 4) and the mean post-treatment incontinence scores were similar for the two therapies (9 ± 5 vs. 10 ± 4), with a greater effect size evident in the SNS patients. In a 'pseudo case-control' analysis with 37 "matched" patients, the effect of both treatments was similar. The cost of treating a patient for 1 year was £ 11,374 ($ 18,223) for permanent SNS vs. £ 1740 ($ 2784) for PTNS.

CONCLUSION

Given the lesser cost and invasive nature of PTNS, where both techniques are available, a trial of PTNS could be considered for all patients.

Sacral neuromodulation and peripheral nerve stimulation in patients with anal incontinence: an overview of techniques, complications and troubleshooting

Sacral neuromodulation (SNM) therapy has revolutionized the management of many forms of anal incontinence, with an expanded use and a medium-term efficacy of 75% overall. This review discusses the technique of SNM therapy, along with its complications and troubleshooting and a discussion of the early data pertaining to peripheral posterior tibial nerve stimulation in incontinent patients. Future work needs to define the predictive factors for neurostimulatory success, along with the likely mechanisms of action of their therapeutic action.

Sacral nerve stimulation for the treatment of severe faecal incontinence: results after 10 years experience

INTRODUCTION

The objective of this study is to report our experience with sacral nerve stimulation for the treatment of severe faecal incontinence after the first 10 years with this technique.

MATERIAL AND METHODS

Between 2001 and 2011, 49 patients with severe faecal incontinence underwent sacral nerve stimulation. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed. Bowel habit diary, severity of faecal incontinence and quality of life scales were evaluated preoperatively and at the end of follow-up.

RESULTS

Morbidity occurred in a third of patients, mostly minor. Four definitive devices were explanted. With a median follow-up of 37 months, severity of faecal incontinence, urge and incontinence episodes significantly improved at the end of follow-up. Patients' subgroup with major follow-up of 5 years significantly improved the severity of faecal incontinence but not the parameters of the bowel habit diary. Quality of life showed no significant improvement. Descriptive data in patients with sphincter defects did not show worse results than with sphincter integrity.

CONCLUSION

Sacral nerve stimulation is a safe technique for severe faecal incontinence with good functional medium-term results. In the long term, severity of the faecal incontinence also improves but studies with larger sample are necessary to show if other clinical parameters and the quality of life support this information. Preliminary results in patients with sphincter defects suggest that this technique could be effective in this group but future studies will have to confirm these findings.

Systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence

BACKGROUND

Over the past 18 years neuromodulation therapies have gained support as treatments for faecal incontinence (FI); sacral nerve stimulation (SNS) is the most established of these. A systematic review was performed of current evidence regarding the clinical effectiveness of neuromodulation treatments for FI.

METHODS

The review adhered to the PRISMA framework. A comprehensive search of the literature included PubMed, MEDLINE, Embase and Evidence-Based Medicine Reviews. Methodological quality assessment and data extraction were completed in a systematic fashion.

RESULTS

For SNS, 321 citations were identified initially, of which 61 studies were eligible for inclusion. Of studies on other neuromodulation techniques, 11 were eligible for review: seven on percutaneous tibial nerve stimulation (PTNS) and four on transcutaneous tibial nerve stimulation (TTNS). On intention-to-treat, the median (range) success rates for SNS were 63 (33-66), 58 (52-81) and 54 (50-58) per cent in the short, medium and long terms respectively. The success rate for PTNS was 59 per cent at the longest reported follow-up of 12 months. SNS, PTNS and TTNS techniques also resulted in improvements in Cleveland Clinic Incontinence Score and quality-of-life measures. Despite significant use of neuromodulation in treatment of FI, there is still no consensus on outcome reporting in terms of measures used, aetiologies assessed, length of follow-up or assessment standards.

CONCLUSION

Emerging data for SNS suggest maintenance of its initial therapeutic effect into the long term. The clinical effectiveness of PTNS is comparable to that of SNS at 12 months, although there is no evidence to support its continued effectiveness after this period. PTNS may be a useful treatment before SNS. The clinical effectiveness of TTNS is still uncertain owing to the paucity of available evidence. A consensus to standardize the use of outcome measures is recommended in order that further reports can be compared meaningfully.

Seven-year follow-up after anterior sphincter reconstruction for faecal incontinence

PURPOSE

The aim was to evaluate the effects of anterior sphincter repair on faecal incontinence and quality of life.

PATIENTS AND METHODS

Fifty-six patients who underwent anterior anal sphincteroplasty between January 2003 and December 2005 were asked to complete questionnaires containing the Wexner Incontinence Score (a score of 0 corresponds to full continence and 20 to total incontinence) and Faecal Incontinence Quality of Life Scale preoperatively, in May 2006 (mean follow-up time, 22.8 months) and in August 2011 (mean follow-up time, 89.3 months). Thirty-nine (69.6 %) patients completed the questionnaires before the operation and in 2006, and 36 (64.3 %) in 2011.

RESULTS

The overall severity of faecal incontinence improved in 26 patients (67 %), and quality of life improved in 2006 as a whole, but after a longer follow-up (in 2011), the severity of faecal incontinence was about the same as preoperatively (median, 12.0 months) in all the patients. Among younger patients (≤50 years), the situation was better, but older patients (>50 years) had an even worse situation than before the operation. In the group of younger patients, the preoperative median of the overall incontinence score was 10.5, and in 2011, it was 9.0, while in the group of older patients, the corresponding numbers were 13.0 and 15.0. In 2011, quality of life was still better than preoperatively as a whole, but the results had deteriorated from those in 2006.

CONCLUSIONS

Initially, both overall faecal incontinence and quality of life improved, but younger patients achieved a greater benefit. However, the results deteriorated with a longer follow-up. Operative management should be considered preferably in relatively young subjects as their results are better.

The effect of sacral nerve stimulation on distal colonic motility in patients with faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) is an effective treatment for neurogenic faecal incontinence (FI). However, the clinical improvement that patients experience cannot be explained adequately by changes in anorectal function. The aim of this study was to examine the effect of SNS on colonic propagating sequences (PSs) in patients with FI in whom urgency and incontinence was the predominant symptom.

METHODS

In patients with FI a high-resolution fibre-optic manometry catheter, containing 90 sensors spaced at 1-cm intervals, was positioned colonoscopically and clipped to the caecum. A unipolar or quadripolar tined electrode was implanted into the S3 sacral nerve foramen. Colonic manometry was evaluated in a double-blind randomized crossover trial, using true suprasensory stimulation or sham stimulation. Each stimulation period, lasting 2 h, was preceded by a 2-h basal manometric recording.

RESULTS

All 11 patients studied showed a colonic response to SNS. In ten patients there was a significant increase in the frequency of retrograde PSs throughout the colon during true stimulation compared with sham stimulation (P = 0·014). In one outlier, with baseline retrograde PS frequency nine times that of the nearest patient, a reduction in retrograde PS frequency was recorded. Compared with sham stimulation, SNS had no effect on the frequency of antegrade PSs or high-amplitude PSs.

CONCLUSION

SNS modulates colonic motility in patients with faecal urge incontinence. These data suggest that SNS may improve continence and urgency through alteration of colonic motility, particularly by increasing retrograde PSs in the left colon.

Efficacy of cyclic sacral nerve stimulation for faecal incontinence

BACKGROUND

Sacral nerve stimulation (SNS) is an established treatment option for faecal incontinence. Cyclic stimulation will improve the longevity of the implanted stimulator, but little is known about its efficacy. The aim of this retrospective clinical study was to assess the efficacy of cyclic SNS for faecal incontinence.

METHODS

Sixty-three patients underwent percutaneous nerve evaluation (PNE) test with a 2-week period of continuous SNS. The PNE test was deemed positive in 42 patients (67 %) who underwent implantation with permanent stimulator. All 42 patients were initially stimulated in a cyclic manner with stimulation for 20 s followed by 8 s without. During follow-up, the stimulator was explanted in 2 patients and permanently turned off in one due to the loss of effect. A postal questionnaire including the Wexner score, a general quality of life (Qol) score, and a bowel habit diary was distributed to 39 patients.

RESULTS

The questionnaire was returned by 29/39 (74 %) of the patients. Median duration of follow-up was 16 (range 3-34) months. The Wexner score and the general QoL score were significantly improved compared to pre-treatment values. Some 18 patients (62 %) were still treated with cyclic stimulation at follow-up, reporting more frequent episodes of urgency without incontinence (p = 0.020) compared to symptoms during the PNE test. Patients who had changed to continuous stimulation due to a suboptimal effect during follow-up reported more frequent episodes of urgency with incontinence (p = 0.034), minor soiling (p = 0.045) and days wearing pads (p = 0.027) compared with symptoms during the PNE test.

CONCLUSIONS

Cyclic stimulation seems effective for most patients treated with SNS for faecal incontinence.

Cost-effectiveness analysis of sacral neuromodulation for faecal incontinence in The Netherlands

AIM

Sacral neuromodulation (SNM) plays a major part in the algorithm of management of faecal incontinence, but there are limited data on its cost-effectiveness. This study aimed to analyse this and the quality-adjusted life-years (QALYs) associated with two different treatment algorithms. The first (SNM-) included use of an artificial sphincter [dynamic graciloplasty (DGP) (50%) and artificial bowel sphincter (ABS) (50%)]. The second (SNM+) included SNM (80% of cases) and artificial sphincter (DGP 10%; ABS 10%) The incidence of sphincteroplasty was assumed to be equal in both algorithms.

METHOD

A Markov model was developed. A hypothetical cohort of patients was run through both strategies of the model. A mailed EuroQoL-5D questionnaire was used to determine health-related quality of life. Costs were reproduced from the Maastricht University Medical Centre prospective faecal incontinence database. The time scale of the analysis was 5 years.

RESULTS

The former treatment protocol cost €22,651 per patient and the latter, after the introduction of SNM, cost €16,473 per patient. The former treatment protocol resulted in a success rate of 0.59 after 5 years, whereas with the introduction of SNM this was 0.82. Adhering to the former treatment protocol yielded 4.14 QALYs and implementing the latter produced 4.21 QALYs.

CONCLUSION

The study demonstrated that introducing SNM in the surgical management algorithm for faecal incontinence was both more effective and less costly than DGP or ABS without SNM. This justifies adequate funding for SNM for patients with faecal incontinence.

Sacral nerve stimulation in the treatment of fecal incontinence - the experience of a pelvic floor center : short term results

OBJECTIVES

The aim of this paper is to present the data pertinent to the experiences of our Pelvic Floor Center on the utilisation of SNS in the treatment of fecal incontinence and compare these data to the data of current literature.

METHODS

All patients who had had SNS treatment for fecal incontinence between the dates of 1st April 2008 and 1st April 2011 were enrolled in the study. We considered a 50% reduction of fecal incontinence episodes as a success of the test phase. The score used for assessment was the Cleveland Clinic Florida-Fecal Incontinence score (CCF-FI).

RESULTS

The 21 patients treated for fecal incontinence (19 ♀ and 2 ♂, average age 59.7 [ 26-73] years) were sub-divided on the basis of the presence or absence of sphincter damage (group A1 had damage while group A2 did not). A patient (group A1) was excluded from the study as the result of the external connector breaking during the test phase. Of the 20 remaining patients (9 from group A1 and 11 from A2), 14 (70%) felt benefit and subsequently underwent definitive stimulator implantation. The variation between the pre-operative CCF-FI and the value at 6 months was statistically significant both in group A1 (p=0.009) and in group A2 (p=0.003). The only complication reported was one case (7.1%) of infection of the definitive stimulator.

CONCLUSION

SNS represents an effective treatment for patients with fecal incontinence. The results have been encouraging, and in line with current literature.

Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review

AIM

The long-term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect.

METHOD

The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow-up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life.

RESULTS

Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies.

CONCLUSION

Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long-term follow-up, although beset with difficulties, should be conducted.

Sacral nerve stimulation for faecal incontinence: results from a single centre over a 10-year period

AIM

Sacral nerve stimulation (SNS) is considered a first-line surgical treatment option for faecal incontinence. There is little information on long-term results. The results of SNS for faecal incontinence performed at a single centre over a 10-year period are reported.

METHOD

A cohort analysis of consecutive patients treated with SNS for faecal incontinence over a 10-year period was carried out. Data were collected prospectively using bowel habit diaries and St Mark's and Cleveland Clinic incontinence scores. Treatment success was defined as a >50% reduction in episodes of faecal incontinence compared with baseline.

RESULTS

Temporary SNS was performed in 118 patients, and 91 (77%) were considered suitable for chronic stimulation. The median period of follow up was 22 (1-138) months. Seventy patients were followed for 1 year with success in 63 (90%). Of 18 patients followed for 5 years, 15 (83%) reported continued success, 11 (61%) maintained full efficacy, 4 (22%) reported some loss, and 3 (17%) reported complete loss. Three patients with a 10-year follow up had no loss in efficacy. Overall, complete loss of efficacy was observed in 14 (16%) patients at a median of 11.5 months following implantation. A further 5 (6%) patients showed deterioration with time. In 9 (47%), no reason for the deterioration in symptoms could be identified.

CONCLUSIONS

SNS can be effective for up to 10 years. Some patients experience deterioration in symptoms over time. The reasons for this are often not evident.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

How sacral nerve stimulation works in patients with faecal incontinence

AIM

Sacral nerve stimulation (SNS) reduces incontinence episodes and improves the quality of life of patients treated for faecal incontinence. However, the exact mechanism of action of this technique remains unclear. The present article reviews the pertinent neuroanatomy and neurophysiology related to SNS and provides explanations for potential mechanisms of action.

METHOD

A systematic review of the literature was performed for studies of the potential mechanisms of action of SNS, using MEDLINE, PubMed, Embase and the Cochrane Library. Articles dealing with the technique, adverse events and economic evaluations of SNS, as well as literature reviews, were excluded, except for reviews dealing with the mechanisms of action of SNS. The following inclusion criteria were used to select articles: (i) articles in English, (ii) randomized, double-blinded, sham-controlled studies, and (iii) cohort studies. Case-control studies or retrospective studies were cited only when randomized or cohort studies could not be found.

RESULTS

We propose three hypotheses to explain the mechanism of action of SNS: (i) a somato-visceral reflex, (ii) a modulation of the perception of afferent information, and (iii) an increase in external anal sphincter activity.

CONCLUSION

The mechanism of action of SNS in patients with faecal incontinence almost certainly depends on the modulation of spinal and/or supraspinal afferent inputs. Further research on humans and animals will be required to gain a better understanding of the mechanisms of action of SNS.

Sacral nerve stimulation for fecal incontinence: long-term outcomes

BACKGROUND

Numerous studies advocate the short-term benefits of sacral nerve stimulation for fecal incontinence, but there has been a paucity of studies on longer-term outcomes.

OBJECTIVE

The objective of this study was to report the long-term outcome of sacral nerve stimulation performed for fecal incontinence at a single institution.

PATIENTS AND DESIGN

Between January 2004 and May 2007, 53 patients underwent definitive sacral nerve stimulation for fecal incontinence at our institution. Prospectively recorded baseline information, including Wexner incontinence scores and standard short-form (SF-12) health survey scores, were compared with scores at follow-up.

RESULTS

Forty-one patients were available for long-term follow-up with a mean duration of 51 months. The median Wexner score decreased from a baseline of 11.5 (range, 3.0-18.0) to 8.0 (range, 0.0-18.0) at follow-up. The mean difference in Wexner score was 2.7 (P < .001). There was no statistically significant change in SF-12 physical scores, but a small but highly significant change occurred in SF-12 mental scores. The median SF-12 mental domain score was 49.5 (range, 15.0-62.1) at baseline, and 57.0 (range, 20.0-64.0) at follow-up, with a mean difference of 4.5 (P = .006). Subgroup analysis performed comparing patients with or without prior intersphincteric silicon biomaterial implants demonstrated a mean difference in Wexner score of -3.5 (no implant) vs 0.0 (previous implant), with P < .09 (not statistically significant).

CONCLUSIONS

Sacral nerve stimulation results in a statistically significant improvement in fecal incontinence scores in the long term.

Three-dimensional endoanal ultrasonography in daily proctological practice

Three-dimensional endoanal ultrasonography (3D-EAUS) provides unequalled quality in terms of the anatomical image of the anal canal and sphincter complex. In less than one minute it produces a three-dimensional "cube" that can be manipulated in all spatial dimensions, then archived. In just a few years it has become a new gold standard exploration in proctology. In addition to image quality, 3D-EAUS has the advantage of being easily and rapidly performed, well-tolerated and moderate in cost. For anal incontinence, 3D-EAUS contributes to the identification of sphincter defects. The anatomy of the sphincters can be evaluated spatially. Simple scoring systems with good reproducibility and readily applicable in routine practice can be used to evaluate the "damaged" sphincter volume. For the management of anoperineal suppurations, 3D-EAUS provides information on the fistulous track(s) and on potential collections. These data are crucial as the choice of treatment and its efficacy depend on accurate topographic assessment of the suppuration and the state of the sphincter apparatus.