Innovations in fecal incontinence: sacral nerve stimulation

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

BACKGROUND

Sacral neuromodulation is an effective treatment for fecal incontinence.

OBJECTIVE

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

DESIGN

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

SETTINGS

This study was conducted at a single tertiary referral center.

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Sacral neuromodulation for low anterior resection syndrome: current status-a systematic review and meta-analysis

INTRODUCTION

It is estimated that approximately 70% of patients with rectal cancer who undergo surgery will suffer from Low Anterior Resection Syndrome (LARS). In the last decades, sacral neuromodulation (SNM) has been widely used in urinary dysfunction and in faecal incontinence refractory to medical treatment. Its application in LARS has been investigated and has shown promising results. The paper's aim is to present a systematic review and meta-analysis of the available literature and evaluate the therapeutic success of SNM in patients with LARS.

METHODS

A systematic search was performed in international health-related databases: Cochrane Library, EMBASE, PubMed and SciELO. No restrictions on year of publication or language were applied. Retrieved articles were screened and selected according to set inclusion criteria. Data items were collected and processed for each included article and a meta-analysis was done according to the PRISMA guidelines. The primary outcome was the number of successful definitive SNM implants. Further outcomes included changes in bowel habits, incontinence scores, quality of life scores, anorectal manometry data and complications.

RESULTS

A total of 18 studies were included, with 164 patients being submitted to percutaneous nerve evaluation (PNE) with 91% responding successfully. During follow-up of therapeutic SNM some devices were explanted. The final clinical success rate was 77% after permanent implant. Other outcomes, such as the frequency of incontinent episodes, faecal incontinence scores, quality of life scores were overall improved after SNM. The meta-analysis showed a decrease in 10.11 incontinent episodes/week; a decrease of 9.86 points in the Wexner score and an increase in quality of life of 1.56 (pooled estimate). Changes in anorectal manometry were inconsistent. Local infection was the most common post-operative complication, followed by pain, mechanical issues, loss of efficacy and haematoma.

DISCUSSION/CONCLUSION

This is the largest systematic review and meta-analysis concerning the use of SNM in LARS patients. The findings support the available evidence that sacral neuromodulation can be effective in the treatment of LARS, with significant improvement in total incontinent episodes and patients´ quality of life.

A Cadaveric Study on the Efficacy of Surface Marking and Bony Landmarks Used in Sacral Neuromodulation

Background

Anatomical landmarks and surface markings have long been used in out-patient contexts for conducting percutaneous nerve evaluation procedures, but studies testing the reliability of these anatomical landmarks are scant. There have been reports where the procedure has failed. Could it be possible that the anatomical landmarks that are used are not reliable enough? To answer this question, we used this study to understand the reliability of these anatomical landmarks.

Methods

Twenty cadavers, 10 males and 10 females, were dissected in the sacral region; the landmarks were tested, and the angulation and curve made by the sacral 3 (S3) nerve were also studied.

Results

Sacral 3 was identified mainly at the four o’clock position on the right and at the eight o’clock position on the left side. The Sacral 3 foramen was found at a mean distance of 9.17 ± 0.23 cm from the tip of the coccyx. The mean distance of the lateral margin of S3 from the median sacral ridge was found to be 2.16 ± 0.07 cm.

Conclusion 

The landmark of 9 cm from the coccyx tip is a valid landmark for sacral neuromodulation (SNM) procedures. The tip of the lead should follow the curve of the nerve as close as possible at the four and eight o’clock positions on the right and left side, respectively. However, the length of the coccyx differs from person to person. The proximity of the adjacent foramina to each other and the variations in the emerging of the nerve are a few factors to be considered while performing SNM procedures. Further study with a larger sample is required in order to investigate the course of the nerve, and its relationship to response to SNM.

Dynamic Article: Permanent Sacral Nerve Stimulation Under Local Anesthesia: Feasibility, Best Practice, and Patient Satisfaction

BACKGROUND

The increasing incidence of fecal incontinence and the use of sacral neuromodulation have an increasing impact on health care providers and health care costs.

OBJECTIVE

The purpose of this study was to investigate the technical and clinical success rates, complications, and patient satisfaction of the implantation of permanent sacral nerve stimulation under local anesthesia.

DESIGN

A cohort analysis of consecutive patients with sacral nerve stimulation for fecal incontinence over a period of 1 year was performed.

SETTINGS

This study was conducted at a specialized pelvic floor unit in a tertiary care center.

PATIENTS

Sixty-one patients were available for the assessment after 1-year follow-up.

MAIN OUTCOME MEASURES

Technical success, procedural time, and complications were noted. Clinical outcome (including Fecal Incontinence Severity Index, Fecal Incontinence Quality of Life scale, and Gastrointestinal Quality of Life Index were collected prospectively before and after treatment.

RESULTS

All procedures were successfully completed under local anesthesia, with a median total procedural time of 50 minutes (range, 26-72 minutes). All patients were discharged on the day of their procedure. Postoperative complications occurred in 3 patients (4.9%). At 3 months follow-up, the median Fecal Incontinence Severity Index score was reduced from 37 to 27 (p = 0.001). Both the Fecal Incontinence Quality of Life scale and the Gastrointestinal Quality of Life Index had improved from 63 to 82 (p < 0.001) and 72 to 90 (p = 0.012). At a mean follow-up of 13 months, both the Fecal Incontinence Quality of Life scale and the Gastrointestinal Quality of Life Index improved further to 90 (p < 0.001) and 94 (p < 0.001). All patients would recommend the procedure under local anesthesia to other patients. No patients experienced leg pain during follow-up.

LIMITATIONS

This study involved a relatively small group of patients, and patient satisfaction was only recorded for the last 22 patients. No exact cost calculations were made.

CONCLUSIONS

Permanent sacral nerve stimulation implantation under local anesthesia has high technical and clinical success rates. It is safe, well tolerated by patients, and has obvious logistical and financial benefits.

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.

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.

[Treatment of sphincter insufficiency]

Surgical therapy of anal sphincter insufficiency is only indicated if it leads to symptoms and conservative treatment fails to achieve adequate symptom relief. Various new surgical options have evolved over the last decade but evidence of the efficacy varies substantially. Some have gained broader clinical acceptance based on the efficacy, ease of applicability and low risk profile. The paper aims to outline the currently commonly accepted and frequently applied surgical techniques for the treatment of anal sphincter insufficiency and the results, put these into the context of a treatment algorithm and to present novel techniques which carry potential for the future.

Neuromodulation for fecal and urinary incontinence: functional results in 57 consecutive patients from a single institution

BACKGROUND

Sacral nerve stimulation is a recognized treatment for fecal and urinary incontinence. Few articles have been published about patients presenting with both types of incontinence.

OBJECTIVE

The aim of this study was to report the functional results in patients operated on for simultaneous fecal and urinary incontinence by the use of sacral nerve stimulation.

DESIGN

This study is a retrospective analysis of prospectively collected data.

SETTINGS

The investigation was conducted in the academic departments of colorectal surgery and urology.

PATIENTS

Between January 2001 and March 2010, 57 consecutive patients (54 women) with a mean age of 58 years (range, 16-76) were included.

INTERVENTIONS

Two-stage sacral nerve modulation (test and implant) was performed.

MAIN OUTCOME MEASURES

Functional study before testing, at 6 months, and at the end of follow-up after implantation included the use of the Cleveland Clinic incontinence score, Urinary Symptoms Profile, Fecal Incontinence Quality of Life score, and the Ditrovie score. Patient satisfaction with the technique was evaluated at a median follow-up of 62.8 months.

RESULTS

: Fecal incontinence improved from 14.1/20 to 7.2/20 at 6 months and 6.9/20 at the end of follow-up. Urinary incontinence, mainly urge incontinence (47% of patients), and urgency frequency (34% of patients) improved at 6 months and end of follow-up, but not retention and dysuria. Specific quality of life was improved for fecal and urinary incontinence at 6 months and end of follow-up. At the end of follow-up, 73% patients were highly satisfied with the technique, but 9% felt their condition had deteriorated. The reoperation rate was 29%, of which 12% were indicated because of a complication.

LIMITATIONS

This study was limited by its retrospective nature and the multiple causes of incontinence.

CONCLUSION

Fecal and urinary incontinence, studied by symptoms scores and specific quality-of-life scores, are improved in patients receiving sacral nerve stimulation for double incontinence.

Clostridium difficile colitis: factors associated with outcome and assessment of mortality at a national level

BACKGROUND

Previous descriptions of Clostridium difficile colitis (CDC) epidemics may overestimate cost and mortality of CDC.

METHODS

An analysis of the 2007 Nationwide Inpatient Sample was performed. Patients with CDC (N = 41,207) were compared to a propensity score-matched cohort of patients without CDC.

RESULTS

Average length of stay was longer for CDC patients by 5 days (p < 0.001). Mortality was higher for the CDC cohort (9.4% vs. 8.6%; p < 0.001) though the absolute difference was small. Mean hospital costs were 56% higher for CDC patients (p < 0.001). Higher odds of death with CDC were associated with small hospitals and self-pay patients. Chronic renal failure and diabetes were associated with lower hospital costs and lower odds of death in the CDC cohort.

CONCLUSIONS

CDC is not as deadly of a disease as it may be perceived to be at larger hospitals, and mortality was actually unaffected by certain serious comorbidities. CDC is expensive due to a longer hospital stay.

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

BACKGROUND AND OBJECTIVE

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Insertion under local anaesthetic of temporary electrodes for sacral nerve stimulation testing is reliable and cost effective

AIM

The aim of this study was to determine whether temporary electrode implantation under local anaesthesia (LA), with reliance on sensory response rather than motor response, gives as good a result as implantation under general anaesthesia (GA).

METHOD

A retrospective review of a prospectively maintained database of patients with faecal incontinence treated with sacral nerve stimulation (SNS) was performed.

RESULTS

A total of 111 consecutive patients underwent a 2-week trial of SNS. Forty-seven (42%) had the temporary electrode implanted under LA and 64 (58%) under GA. There was no significant difference between the two groups in relation to the improvement in Vaizey score (P = 0.15), incontinent episodes per day (P = 0.73) and incontinent episodes per week (P = 0.93). There was no significant difference (P = 0.14) in the percentage of successful trials between the LA group (64%) and the GA group (77%); however, only 62% of the GA group were discharged home on the same day when compared with 89% of the LA group (P < 0.0001).

CONCLUSION

Similar success rates for temporary trial with SNS can be achieved with LA and GA. Insertion under LA is associated with reduced cost, shorter hospital stay and quicker recovery, and it avoids the risk of general anaesthesia.

The role of sacral neuromodulation in double incontinence

AIM

Urinary and faecal incontinence are common conditions that are frequently associated. When conservative treatments fail, sacral nerve modulation (SNM) is considered to be a first-line treatment for patients with urge urinary incontinence and for patients with faecal incontinence. This article aims to determine the effect of SNM on the treatment of double incontinence (i.e. urinary and faecal incontinence).

METHOD

We searched for relevant articles in MEDLINE, PubMed and Embase, and for reviews in the Cochrane database. Articles were restricted to the English language.

RESULTS

Only a few studies have studied the efficacy of SNM for double incontinence and in a limited number of patients. Between 30% and 100% of patients with double incontinence experience improvement in urinary and faecal incontinence at medium-term follow up.

CONCLUSION

Further prospective trials are needed to determine which patients with combined problems will benefit from SNM at a long-term follow up.

Fecal incontinence

Fecal incontinence is a devastating problem for those afflicted. It can lead to embarrassment and social isolation. Treating the problem begins with a thorough history and physical examination. Further testing (such as anal physiology testing or anal endosonography) depends on the examination and treatment plan. Conservative medical therapies (such as dietary manipulation, medication to slow the stool, and biofeedback) are usually tried first. Surgery includes sphincter repair, SECCA, artificial bowel sphincter, and stoma. New therapies continue to evolve with the intention of further improving quality of life for these afflicted patients.

Six years of experience with sacral nerve stimulation for fecal incontinence

PURPOSE

Sacral nerve stimulation is one of many new surgical modalities for fecal incontinence. Short-term results from sacral nerve stimulation have been more encouraging than those from other modalities. The aim of this study was to report the outcome of percutaneous nerve evaluation tests and sacral nerve stimulation for the treatment of fecal incontinence from a single center covering a period of 6 years since the procedure was introduced.

METHODS

All of the candidates for a percutaneous nerve evaluation test and sacral nerve stimulation seen at our anal physiology unit between March 2001 and March 2007 were included in the study.

RESULTS

A total of 177 patients with fecal incontinence (160 females), median age 59.5 (range, 27-88) years, underwent a percutaneous nerve evaluation test. Of these patients, 142 (80%) had a positive test, including 21 of 25 (84%) patients who required a repeat percutaneous nerve evaluation test. Because of a functional failure, 16 patients underwent a revision of the permanent electrode, 7 of whom (44%) were satisfied with the functional result after the revision. Of 126 patients, 15 (12%) have undergone an explantation, with an infection rate of only 1.6%. Overall, after a median follow-up of 24 (range, 3-72) months, the median Wexner incontinence score decreased from 16 (range, 6-20) to 10 (range, 0-20) (P < .0001). In the 10 patients who underwent at least 6 years of treatment, the effect was sustained, as the median Wexner incontinence score decreased from 20 (range, 12-20) to 7 (range, 2-11) (P < .0001).

CONCLUSION

Sacral nerve stimulation is a simple, safe, and minimally invasive technique with low morbidity and excellent results, which appear to be maintained for the first 6 years after the procedure. For patients who underwent the treatment, median Wexner incontinence score decreased significantly after a median follow-up of 24 (range, 3-72) months. Twelve percent were explanted. The infection rate was 1.6%.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Long-term results of artificial bowel sphincter for the treatment of severe faecal incontinence. Are they what we hoped for?

OBJECTIVE

This study evaluates the long-term morbidity, functional results and quality of life (QOL) after treatment of severe faecal incontinence (FI) with the Acticon Neosphincter (American Medical Systems, Minneapolis, Minnesota, USA).

METHOD

Between 1996 and 2002, 17 consecutive patients (14 female, 3 male; median age 46) underwent sphincter implantation. Clinical evaluation, incontinence severity and QOL were assessed. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed preoperatively and at several stages of follow-up. The study was completed in December 2007.

RESULTS

Mean follow-up was 68 months (range: 3-133). Morbidity occurred in 100% of patients from which 65% required at least one re-operation. After the first implant, 11 devices had to be removed (65%). Seven patients had a new implant. At the final stage, Acticon was activated in 9 cases (53%). Severity of FI improved from a median of 17.5 preoperatively to 9 (P = 0.005), 5.5 (P = 0.005) and 10 (P = 0.092) at 6, 12 months and at the end of follow-up, respectively. There was a significant improvement in QOL in all postoperative controls (P < 0.05). Severity of FI did not show a correlation with QOL in the preoperative period, but did at 6, 12 months and at the end of follow-up. Mean maximum resting pressure significantly increased with the full anal cuff.

CONCLUSION

There is a high rate of morbidity, surgical re-interventions and explants after Acticon implant. Patients should be clearly informed about this before surgery. However, patients who have not had Acticon Neosphincter explanted, experience a significant improvement in anal continence and QOL.

Sacral nerve stimulation for faecal incontinence: long-term outcome

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Sacral nerve stimulation for faecal incontinence alters colorectal transport

Background

Sacral nerve stimulation reduces the frequency of defaecation in patients with faecal incontinence. The aim of this study was to examine the mechanism behind the reduced number of bowel movements in incontinent patients treated with sacral nerve stimulation.

Methods

The study included 20 patients with faecal incontinence and a positive percutaneous nerve evaluation test: 19 women and one man, with a median age of 63 (range 28–78) years. Colorectal scintigraphy was performed to assess colorectal emptying at defaecation before and after implantation. Segmental colorectal transit times were determined using radio-opaque markers.

Results

The median frequency of defaecation per 3 weeks decreased from 56 (range 19–136) to 26 (range 12–78) (P &lt; 0·002). At defaecation, antegrade transport from the ascending colon decreased from a median score of 8 (range 0–23) to 0 (range 0–11) per cent (P = 0·001), while retrograde transport from the descending colon increased from a median score of 0 (range 0–14) to 2 (range 0–30) per cent (P = 0·039). The median defaecation score was unchanged. There was a non-significant increase in median total gastrointestinal transit time from 2·5 (range 0·9–6·2) to 3·3 (range 0·8–6·2) days (P = 0·079).

Conclusion

Sacral nerve stimulation reduces antegrade transport from the ascending colon and increases retrograde transport from the descending colon at defaecation. This may prolong colonic transit time and increase the storage capacity of the colon.

Sacral nerve stimulation for faecal incontinence

BACKGROUND

Faecal incontinence resulting from obstetric injury is a socially disabling condition with a significant impact on quality of life. Sacral nerve stimulation (SNS) is a relatively new treatment modality, which offers patients a potential for improved continence.

METHODS

We reviewed our initial experience of SNS in 14 patients (mean age 54 years, range 30-72) with faecal incontinence from January 2006 to June 2007. Background demographics, past medical and obstetric history, anal manometry, endoanal ultrasound and pudendal nerve studies were recorded on all patients. All patients who had permanent SNS implants inserted had pre and post operative questionnaires consisting of the Wexner Continence Score and the Rockwood and SF-36 Quality of Life Indices.

RESULTS

Out of 14 patients, 13 had incontinence related to obstetric injuries while one was related to a cauda equina syndrome. All patients had a test procedure consisting of placement of temporary electrodes and a 2-week trial of external SNS. Ten patients noted a significant improvement in their continence and these 10 patients subsequently had a permanent SNS device implanted with an overall significant improvement in continence (P < 0.001) and quality of life (P < 0.01). There were no immediate postoperative complications and one late failure consisting of a lead fracture, which was replaced successfully. Four (29%) patients did not have a significant benefit from temporary SNS and two of these patients subsequently had a colostomy.

CONCLUSIONS

SNS offers improvement in continence and quality of life in patients with faecal incontinence whose only other option might otherwise be a permanent colostomy.

Sacral nerve stimulation for fecal disorders: evolution, current status, and future directions

Sacral nerve stimulation (SNS) aims to recruit residual function of the anorectal continence organ by electrostimulation of its peripheral nerve supply. Since its first application for the treatment of fecal incontinence in 1994, its acceptance has been broadened and it is today considered a valuable addition to the therapeutic armentarium. Initially, its use was based on conceptual considerations, but changed to a pragmatic trial and error approach. Thus, the patients selection evolved: patients suffering from fecal incontinence due to a wide variety of causes are today selected for permanent SNS after a phase of temporary test stimulation. This test is highly predictive. If it is of clinical benefit, a neurostimulation device is implanted for chronic stimulation. Permanent stimulation not only improves or restores continence, but also has a substantial impact on quality of life. This has been uniformaly proven in multiple single and multicentre trials in a wide variety of aetiologies causing fecal incontinence. Despite the growing experience with the clinical use of SNS and its therapeutic effectiveness, the knowledge of its mechanism of action remains limited. Current research aims to improve our understanding of its action, to expand the spectrum of clinical applications and to implement recent technical developments.

Sacral nerve stimulation in fecal incontinence: are there factors associated with success?

PURPOSE

Sacral nerve stimulation has been used successfully in treating fecal incontinence. This study was designed to evaluate the proportion of patients with unsuccessful implantation despite positive test stimulation and to examine and compare factors associated with the success of the transitory and permanent sacral nerve stimulation.

METHODS

A total of 61 patients (55 females; median age, 56 (range, 33-77) years) with refractory fecal incontinence underwent temporary stimulation. A 50 percent or greater improvement in the number of episodes of fecal incontinence or urgency was required to proceed to permanent implantation and was the criteria of success of permanent sacral nerve stimulation at the last follow-up visit in implanted patients. The factors compared between the success and the failure groups during temporary and permanent stimulation were patients' age and gender, diagnosis and characteristics of fecal incontinence, previous surgery, quality of life scores, anorectal manometry, endoanal ultrasound, and electrophysiologic tests performed before stimulation.

RESULTS

Temporary stimulation was successful in 35 patients (57.4 percent). A permanent neurostimulation device was implanted in 33 patients. Age was the only factor related to success of the temporary stimulation (P=0.03). After permanent implantation, 31 percent of patients did not attain screening phase results for the number of episodes of fecal incontinence or urgency. A neurologic disorder was more frequently the origin of fecal incontinence in the success group compared with others (P=0.03). The left bulbocavernosus reflex was more frequently delayed in the success group than in the others (P=0.03), and a prolonged or absent bulbocavernosus reflex was more frequent in the success group than in the failure group (P=0.03).

CONCLUSIONS

Patients with fecal incontinence from neurologic origins could be good candidates for sacral nerve stimulation.

Low rectal volumes in patients suffering from fecal incontinence: what does it mean?

BACKGROUND

Rectal perception and adaptation to distension are widely heterogeneous in subjects with faecal incontinence.

AIM

To quantify rectal physiology in patients with incontinence and low maximum rectal volume, according to AGA guidelines on anorectal testing techniques.

PATIENTS AND METHODS

148 patients (12 men, 136 female) with incontinence to liquid and/or solid stools were investigated. Distending isobaric procedures were carried out using an electronic barostat in order to analyse perception and adaptation of the rectum.

RESULTS

Pain during isovolumic rectal distension at a level of 100 mL or less was experienced in 21 subjects (14.2%). As defined by isobaric distensions, incontinent patients with low MTV had more frequently a hypocompliant rectum (62%) when compared with those with higher MTV (31%, P = 0.046). Perception scores tended to be higher at each step of distending rectal pressure: incontinent patients with low MTV had more frequently a hypersensitive rectum (48%) when compared with those with normal or high MTV (24%, P = 0.035). Only four of 21 incontinent subjects with low MTV had an isolated hypersensitive rectum.

CONCLUSION

Both sensitivity and compliance are altered in patients with low MTV. A more extensive study of the role of sensory and compliance aspects of subjects with incontinence is warranted.

Fecal incontinence: an up-to-date critical overview of surgical treatment options

BACKGROUND

Surgery is the last resort for patients suffering from severe fecal incontinence. The armamentarium of surgical options for this condition has increased impressively during the last decade. Nevertheless, this fact seems to make neither patients nor surgeons feel more comfortable. Treatment of fecal incontinence still remains a challenge to modern medicine due to many specific sides of this problem.

AIMS

This article gives an up-to-date overview of existing operative treatment options.

METHODS

An unbiased review of relevant literature was performed to assess the role of all methods of surgical treatment for fecal incontinence available nowadays.

RESULTS

Recent studies have shown poor late results after primary sphincter repair and low predictive value for most preoperative diagnostic tests. New surgical options such as artificial devices and electrically stimulated muscle transpositions are doomed by low success rates and unacceptably frequent complications. That is why current attention has focused on non- or minimally invasive therapies such as sacral nerve stimulation and temperature-controlled radio-frequency energy delivery to the anal canal. However, all these innovative techniques remain experimental till enough high-evidence data are gathered for their objective evaluation.

CONCLUSION

Careful and detailed preoperative assessment to exactly determine the etiology of incontinence and individual approach remain the cornerstones of surgical treatment of fecal incontinence nowadays.