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Besendörfer M, Knorr C, Kirchgatter A, Müller H, Reis Wolfertstetter P, Matzel KE, Diez S. Sacral neuromodulation in children and adolescents with defecation disorders. Neurogastroenterol Motil 2024; 36:e14808. [PMID: 38703048 DOI: 10.1111/nmo.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 04/06/2024] [Accepted: 04/14/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Even if understanding of neuronal enteropathies, such as Hirschsprung's disease and functional constipation, has been improved, specialized therapies are still missing. Sacral neuromodulation (SNM) has been established in the treatment of defecation disorders in adults. The aim of the study was to investigate effects of SNM in children and adolescents with refractory symptoms of chronic constipation. METHODS A two-centered, prospective trial has been conducted between 2019 and 2022. SNM was applied continuously at individually set stimulation intensity. Evaluation of clinical outcomes was conducted at 3, 6, and 12 months after surgery based on the developed questionnaires and quality of life analysis (KINDLR). Primary outcome was assessed based on predefined variables of fecal incontinence and defecation frequency. KEY RESULTS Fifteen patients enrolled in the study and underwent SNM (median age 8.0 years (range 4-17 years)): eight patients were diagnosed with Hirschsprung's disease (53%). Improvement of defecation frequency was seen in 8/15 participants (53%) and an improvement of fecal incontinence in 9/12 patients (75%). We observed stable outcome after 1 year of treatment. Surgical revision was necessary in one patient after electrode breakage. Urinary incontinence was observed as singular side effect of treatment in two patients (13%), which was manageable with the reduction of stimulation intensity. CONCLUSIONS SNM shows promising clinical results in children and adolescents presenting with chronic constipation refractory to conservative therapy. Indications for patients with enteral neuropathies deserve further confirmation.
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Affiliation(s)
- Manuel Besendörfer
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Christian Knorr
- Pediatric Surgery, RoMed Klinikum Rosenheim (former Pediatric Surgery and Orthopedics Hospital Barmherzige Brüder), Rosenheim, Germany
| | - Annemarie Kirchgatter
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Hanna Müller
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care, University Hospital Marburg, University of Marburg, Marburg, Germany
| | | | - Klaus E Matzel
- Department of Surgery, Section of Coloproctology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Sonja Diez
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
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Spivack OK, Dellenmark-Blom M, Dingemann J, ten Kate CA, Wallace V, Bramer WM, Quitmann JH, Rietman A. A Narrative Review of Patient-Reported Outcome Measures and Their Application in Recent Pediatric Surgical Research: Advancing Knowledge and Offering New Perspectives to the Field. Eur J Pediatr Surg 2024; 34:143-161. [PMID: 38272041 PMCID: PMC10920019 DOI: 10.1055/s-0043-1778108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Patient-reported outcome measures (PROMs) can be employed in both research and clinical care to enhance our understanding of outcomes that matter to patients. This narrative review aims to describe PROM use in recent pediatric surgical research, identify and describe psychometrically robust PROMs, providing an overview of those derived from pediatric patient input, and make recommendations for future research. MATERIALS AND METHODS A search was conducted to identify articles published from 2021 to August 2023 describing the availability and/or use of at least one valid or reliable PROM in children with conditions including anorectal malformations, biliary atresia, congenital diaphragmatic hernia, duodenal atresia, esophageal atresia, abdominal wall defects, Hirschsprung's disease, sacrococcygeal teratoma, and short bowel syndrome. Articles were categorized based on their objectives in applying PROMs. Psychometrically robust PROMs were identified and described. RESULTS Out of the 345 articles identified, 49 met the inclusion criteria. Seventeen focused on esophageal atresia and 14 on Hirschsprung's disease. Twenty-nine PROMs were identified, with 12 deemed psychometrically robust. Seven psychometrically robust PROMs were developed using patient input in the primary item generation. Most PROMs were applied to advance understanding of conditions and/or treatment and fewer were developed or psychometrically evaluated. No PROMs were assessed for their impact or incorporated into an implementation study. CONCLUSIONS This review reveals gaps in the application of PROMs in recent pediatric surgical research. Emphasis should be placed on the development and utilization of psychometrically robust PROMs, broadening the scope of covered diseases, conducting impact assessments, and evaluating implementation strategies.
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Affiliation(s)
- Olivia K.C. Spivack
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Quality of Life working group, European Reference Network for rare Inherited Congenital Anomalies (ERNICA)
| | - Michaela Dellenmark-Blom
- Quality of Life working group, European Reference Network for rare Inherited Congenital Anomalies (ERNICA)
- Department of Pediatrics, University of Gothenburg Institute of Clinical Sciences, Gothenburg, Sweden
- Department of Pediatric Surgery, Sahlgrenska University Hospital Queen Silvia Children's Hospital, Gothenburg, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Jens Dingemann
- Quality of Life working group, European Reference Network for rare Inherited Congenital Anomalies (ERNICA)
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Chantal A. ten Kate
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Vuokko Wallace
- Quality of Life working group, European Reference Network for rare Inherited Congenital Anomalies (ERNICA)
- EAT (Esophageal Atresia Global Support Groups), Stuttgart, Germany
- Department of Psychology, University of Bath, Bath, United Kingdom
| | - Wichor M. Bramer
- Medical Library, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Julia H. Quitmann
- Quality of Life working group, European Reference Network for rare Inherited Congenital Anomalies (ERNICA)
- Faculty of Business and Social Sciences, Hamburg University of Applied Sciences (HAW Hamburg), Hamburg, Germany
| | - Andre Rietman
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Quality of Life working group, European Reference Network for rare Inherited Congenital Anomalies (ERNICA)
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
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Besendörfer M, Kirchgatter A, Carbon R, Weiss C, Müller H, Matzel KE, Diez S. Sacral neuromodulation for constipation and fecal incontinence in children and adolescents - study protocol of a prospective, randomized trial on the application of invasive vs. non-invasive technique. Trials 2024; 25:210. [PMID: 38515199 PMCID: PMC10958925 DOI: 10.1186/s13063-024-08052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND A therapeutic effect of sacral neuromodulation (SNM) on fecal incontinence (FI) and quality of life has been proven in adults. SNM is, however, rarely used in pediatric cases. The aim of the study is to investigate effects of SNM in pediatric constipation in a prospective parallel-group trial. METHODS A monocentric, randomized, unblinded, parallel-group trial is conducted. SNM is conducted in the invasive variant and in an innovative, external approach with adhesive electrodes (enteral neuromodulation, ENM). We include patients with constipation according to the ROME IV criteria and refractory to conventional options. Patients with functional constipation and Hirschsprung's disease are able to participate. Participants are allocated in a 1:1 ratio to either SNM or ENM group. Clinical data and quality of life is evaluated in regular check-ups. Neuromodulation is applied continuously for 3 months (end point of the study) with follow-up-points at 6 and 12 months. Findings are analyzed statistically considering a 5% significance level (p ≤ 0.05). Outcome variables are defined as change in (1) episodes of abdominal pain, (2) episodes of FI, (3) defecation frequency, (4) stool consistency. Improvement of proprioception, influence on urinary incontinence, quality of life and safety of treatment are assessed as secondary outcome variables. We expect a relevant improvement in both study groups. DISCUSSION This is the first trial, evaluating effects of neuromodulation for constipation in children and adolescents and comparing effects of the invasive and non-invasive application (SNM vs. ENM). TRIAL REGISTRATION The study is registered with clinicaltrials.gov, Identifier NCT04713085 (date of registration 01/14/2021).
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Affiliation(s)
- Manuel Besendörfer
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Annemarie Kirchgatter
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Roman Carbon
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics, and Information Processing, Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, Haus 3, Ebene 4, Mannheim, 68167, Germany
| | - Hanna Müller
- Neonatology and Pediatric Intensive Care, Hospital for Children and Adolescents, University of Marburg, Baldingerstaße, Marburg, 35043, Germany
| | - Klaus E Matzel
- Department of Surgery, Section of Coloproctology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Maximiliansplatz 2, 91054, Erlangen, Germany
| | - Sonja Diez
- Pediatric Surgery, Department of Surgery, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany.
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Walther M, Müller H, Weiß C, Carbon R, Diez S, Besendörfer M. A comparative observational study on intrasphincteric injections with Botulinum toxin vs. enteral neuromodulation in chronic refractory constipation. BMC Pediatr 2023; 23:448. [PMID: 37684559 PMCID: PMC10486061 DOI: 10.1186/s12887-023-04217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/27/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE Botulinum toxin injections in the anal sphincter apparatus (Botox) and enteral neuromodulation (ENM) are options for treatment of refractory chronic constipation. We present a retrospective comparative observational study. PATIENTS AND METHODS From 2014 to 2022, pediatric patients with chronic constipation were either treated with Botox or ENM with continuation of conservative treatment. Comparison was conducted regarding the primary outcome variables defecation frequency, stool consistency, and abdominal pain. Secondary outcomes were fecal incontinence, enuresis, change of medication and safety of treatment. RESULTS 19 Botox patients (10 boys, 9 girls, 12 patients with Hirschsprung disease (HD), 7 patients with functional constipation (FC)) were compared to 24 ENM patients (18 boys, 6 girls, 12 HD patients, 7 FC patients). Groups differed significantly in age (5.0 years (Botulinum toxin) and 6.5 years (ENM), mean values, p-value 0.008). Improvement of constipation was seen in 68% (n = 13/19) of Botox and 88% (n = 21/24) of ENM patients (p = 0.153). Influence of etiology on therapeutic effects was not observed. Complications were minor. CONCLUSIONS Botox and ENM can be considered as valuable and effective treatment options in refractory chronic constipation. Prospective, large-population studies should be designed to enable improved evidence.
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Affiliation(s)
- Mona Walther
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
| | - Hanna Müller
- Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital Marburg, 35043, Baldingerstraße, Marburg, Germany
| | - Christel Weiß
- Department of Medical Statistics, Biomathematics, and Information Processing, Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Roman Carbon
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
| | - Sonja Diez
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany.
| | - Manuel Besendörfer
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
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