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Ghislain DevroedeGhislain DevroedeDépartement de chirurgieDépartement de chirurgieFaculté de médecine et des Sciences de la Faculté de médecine et des Sciences de la SantéSantéUniversité de SherbrookeQuébec, Canada
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Surgery for constipation
Surgical results are frequently disappointing in chronic idiopathic constipation :
– Anorectal myotomy
– Segmental colectomy
– Total colectomy with ileorectal anastomosis
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Marthe
A thirty one years follow up…
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Marthe
MARCH 29, 1981
REASON FOR CONSULTATION : SEVERE CONSTIPATION « Always » 1 stool / 2 months Slow transit constipation
GASTROENTEROLOGY CONSULTATION : TOTAL COLECTOMY ?
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Prevalence of sexual abuse in thepast history of patients with functional lower
gastrointestinal tract disorders
40
10
0
30
20
50
PERCENTAGEABUSEDPATIENTS
SOURCE :
p = NS
ANORECTAL MANOMETRY (n = 79)
UNIVERSITY COLORECTAL PRACTICE (n = 111)
PRIVATE PRACTICE GASTROENTEROLOGY (n = 154)
NORTH CAROLINA GASTROENTEROGICAL PRACTICE (n = 75)
%
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Somatizationis not
Imagination
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The Ancestors’ Syndrome(Anne Ancelin Schützenberger)
Routledge Editors
Nurturing carries as much impact as nature on the Irritable Bowel Syndrome
(Rona Levy, GASTROENTEROLOGY)
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Sacral nerve stimulationfor slow transit constipation
Patients : Failure of standard treatment
including biofeedback
Duration of constipation : 9 – 47 years (31)
Stool frequency : 1 per 2 – 21 days (6)
________________________________________
Results : Site of SNS : S3 (6 on left)
Results of SNS : Cure 1
Relief 1
No normalization of colonic transit
MALOUF 2002
n = 8 WOMEN
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Sacral nerve stimulationfor slow transit constipation
Patients : Failure of standard treatment,
including biofeedback
Duration of constipation : 2 – 45 years (24)
Stool frequency : 0.8 + 1.1/week
DINNING 2006
(n = 8 WOMEN)
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10
Baseline PNE
STOOL FREQUENCY
ROME II IBS EXCLUDED
Sacral nerve stimulationfor slow transit constipation
DINNING 2006
n = 8
5
N / WEEK
***
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1
Baseline PNE
HIGH – AMPLITUDE PROPAGATING PRESSURE WAVES
ANTEGRADE INCREASE IN RIGHT AND LEFT COLON (S3)RETROGRADE INCREASE LIMITED TO THE RIGHT COLON (S2)
Sacral nerve stimulationfor slow transit constipation
DINNING 2006
n = 8
0.5
N / HOUR
**
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Sacral nerve stimulationfor intractable constipation
KAMM 2010
MULTICENTRIC
(5 CENTERS)
TEST STIMULATION : 62 (55 females)
CHRONIC STIMULATION : 45 (73%)
SUCCESSES : 39 (87% of 45)
BEFORE SNS AFTER SNS
STOOL FREQUENCY 2.3 6.6 (p < 0.001)
(per week)
DAYS WITH DEFECATION 2.3 4.8 (p < 0.001)
(per week)
TOILETING TIME 10.5 5.7 (p < 0.001)
(min)
CLEVELAND CLINIC 18 10 (p < 0.001)
CONSTIPATION SCORE
DELAYED MARKERS TRANSIT 20 9 (p = 0.014)
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Sacral nerve stimulationfor intractable constipation
KAMM 2010
Questions about colorectal transit time
Technique : Multiple markers ingestion – single Xray of abdomen
Duration : 5 days (No steady state conditions)
Abnormality : 12 / 62 with normal transit time
Segments : No evaluation of segmental colonic transit
Paired evaluation : 23 / 62
Transit : No change in stool frequency if no change in transit
_______________________________________
Questions about follow up duration
Before enrollment : 1 – 60 years (median of 10)
After SNS : 1 – 55 months (median of 28)
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Sacral nerve stimulation for idiopathicchronic slow transit constipation
SUCCESSES : n = 3 (0 neurological)
FAILURES : n = 7 (3 neurological)
DEVROEDE 2012
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SUCCESSES
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Sacral nerve stimulation for idiopathic chronic slow transit constipation
CONSULTATION : 06/02/2006
•Constipation from birth
•One stool / 3 – 4 weeks; plugging the toilet bowl
•Vasodilation of left hemi-abdomen
from the spine to the xiphoid-pubis line
•Evaluation : megarectum (770 cc)
anismus corrected by biofeedback
R.L.
MALE
PROBAND
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Sacral nerve stimulation for idiopathic chronic slow transit constipation
• Left PNS (1 week) : 1 – 2 stools / day
• Right PNS : no effect (technical ?)
• Left PNS (2 weeks): - 1 – 2 stools / day for 5 days
with markers progression
- unplugging in door handle
- 0 stool 0 markers progression
• SNS : 1 – 3 stools/day (3 years follow up)
R.L.
MALE
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Sacral nerve stimulation for idiopathic chronic slow transit constipation
• Constipation since childhood
• Up to 37 days without defecation
• Neurogenic bladder : 4 – 5 catheterizations per day
J.T.
FEMALE
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7 DAYS AFTER INGESTION
2008 / 2010 / 2011RIGHT COLON EMPTIES WELL
DAILY STOOLS (1 – 3)ORGASMIC EXPERIENCESSPONTANEOUS VOIDING (5 – 6 / DAY ; NO MORE CATHETERIZATION)
10
Sacral nerve stimulation for idiopathic chronic slow transit constipation
J.T.
20
N MARKERS
1
2012 POST SNS
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Sacral nerve stimulation for fecal incontinence by pudendal neuropathy
REASON FOR CONSULTATION
(12/9/2002)
•Constipation : 1 stool / 20 days
following the death of her father
•Fecal incontinence : Wexner score 11 / 20
(2 – 0 – 3 – 3 – 3)
D.D.
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Sacral nerve stimulation for fecal incontinence by pudendal neuropathyAnorectal manometry
Normal resting pressures : 24/ 67/ 56 (cm H20)
Voluntary contraction : weak 0 /+21/+83 (cm H20)
Anismus : +25 /+16/+79 (cm H20)
corrected by biofeedback
Rectal accomodation : microrectum 80 ml
normal sensation
Anal EMG Pudendal neuropathy
polyphasic units
PNTML 2.5 ms, and weak (right)
Radiopaque markers transit :
Delay in left colon (25 / 74/ 10 // 109) (hours)
PNE Left (13/4/2005) Wexner 0 / 20
Daily stool
Right (27/4/2005) Wexner 9 / 20
Constipation
D.D.
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Sacral nerve stimulation for fecal incontinence by pudendal neuropathy
14/7/2005 LEFT SNS
(1st trial failed on 16/6/2005)
11/10/2012 Wexner 0/20
Stools went
from 1 – 2 / month
to 2 – 3 / day
Never orgasmic during penetration before SNS
Orgasmic during penetration after SNS
(retrospective finding)
D.D.
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Laxative anorexia
RC : 17/1/2006 Severe constipation
1 stool / 14 days (Zelnorm)
4 stools / 19 days (no medication)
Markers transit
1. 3 days (transit time : 45 hours)
2. 20 / 20 markers retained
6 days after ingestion
(transit time > 144 hours)
3. Same as 2.
No menstruation
Anal electromyography : Mild anismus
V.G.
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PNS : Left (24/11/2006) – Right (8/12/2006) = Failures
2008 : Malone
2009 : Malone undone
2010 : Suicidal attempt
Transfer to psychiatry
Diagnosis of laxative anorexia
2012 : Prucalopride
Occasional stool
Laxative anorexiaV.G.
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Constipationis not a sign which canbe evaluated
scientifically.
It is merelya symptom !
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Sacral NeurostimulationSacral Neurostimulationin Constipation :in Constipation :
It may work.It may work.
But when is it reasonable ???But when is it reasonable ???