Transcript
Page 1: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

Page 2: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 3: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Surgery for constipation

Surgical results are frequently disappointing in chronic idiopathic constipation :

– Anorectal myotomy

– Segmental colectomy

– Total colectomy with ileorectal anastomosis

Page 4: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Marthe

A thirty one years follow up…

Page 5: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Marthe

MARCH 29, 1981

REASON FOR CONSULTATION : SEVERE CONSTIPATION « Always » 1 stool / 2 months Slow transit constipation

GASTROENTEROLOGY CONSULTATION : TOTAL COLECTOMY ?

Page 6: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 7: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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)

%

Page 8: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Somatizationis not

Imagination

Page 9: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

The Ancestors’ Syndrome(Anne Ancelin Schützenberger)

Routledge Editors

Nurturing carries as much impact as nature on the Irritable Bowel Syndrome

(Rona Levy, GASTROENTEROLOGY)

Page 10: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 11: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 12: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 13: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

Page 14: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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)

Page 15: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

10

Baseline PNE

STOOL FREQUENCY

ROME II IBS EXCLUDED

Sacral nerve stimulationfor slow transit constipation

DINNING 2006

n = 8

5

N / WEEK

***

Page 16: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

**

Page 17: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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)

Page 18: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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)

Page 19: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Sacral nerve stimulation for idiopathicchronic slow transit constipation

SUCCESSES : n = 3 (0 neurological)

FAILURES : n = 7 (3 neurological)

DEVROEDE 2012

Page 20: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

SUCCESSES

Page 21: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

Page 22: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

Page 23: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

Page 24: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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

Page 25: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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.

Page 26: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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.

Page 27: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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.

Page 28: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 29: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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.

Page 30: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

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.

Page 31: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Constipationis not a sign which canbe evaluated

scientifically.

It is merelya symptom !

Page 32: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?
Page 33: Is Sacral Neurostimulation  Reasonable to  Treat Chronic Idiopathic  Constipation ?

Sacral NeurostimulationSacral Neurostimulationin Constipation :in Constipation :

It may work.It may work.

But when is it reasonable ???But when is it reasonable ???


Top Related