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Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?

Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?. Ghislain Devroede Département de chirurgie Faculté de médecine et des Sciences de la Santé Université de Sherbrooke Québec, Canada. CONSTIPATION IS MERELY A SYMPTOM. Surgery for constipation.

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Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?

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  1. Is Sacral Neurostimulation Reasonable to TreatChronicIdiopathic Constipation ? Ghislain Devroede Département de chirurgie Faculté de médecine et des Sciences de la Santé Université de Sherbrooke Québec, Canada

  2. CONSTIPATION IS MERELY A SYMPTOM

  3. Surgery for constipation Surgical results are frequently disappointing in chronic idiopathic constipation : • Anorectal myotomy • Segmental colectomy • Total colectomy with ileorectal anastomosis

  4. Marthe A thirty one years follow up…

  5. Marthe MARCH 29, 1981 REASON FOR CONSULTATION : SEVERE CONSTIPATION • « Always » • 1 stool / 2 months • Slow transit constipation GASTROENTEROLOGY CONSULTATION : TOTAL COLECTOMY ?

  6. Prevalence of sexual abuse in thepast history of patients with functional lower gastrointestinal tract disorders % 50 p = NS 40 PERCENTAGE ABUSED PATIENTS 30 20 10 0 SOURCE : ANORECTAL MANOMETRY (n = 79) UNIVERSITY COLORECTAL PRACTICE (n = 111) PRIVATE PRACTICE GASTROENTEROLOGY (n = 154) NORTH CAROLINA GASTROENTEROGICAL PRACTICE (n = 75)

  7. Somatizationis notImagination

  8. The Ancestors’ Syndrome (Anne Ancelin Schützenberger) Routledge Editors Nurturing carries as much impact as nature on the Irritable Bowel Syndrome (Rona Levy, GASTROENTEROLOGY)

  9. Sacral nerve stimulationfor slow transit constipation MALOUF 2002 n = 8 WOMEN 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

  10. Sacral nerve stimulationfor slow transit constipation DINNING 2006 (n = 8 WOMEN) Patients : Failure of standard treatment, including biofeedback Duration of constipation : 2 – 45 years (24) Stool frequency : 0.8 + 1.1/week

  11. Sacral nerve stimulationfor slow transit constipation DINNING 2006 n = 8 STOOL FREQUENCY N / WEEK *** 10 5 Baseline PNE ROME II IBS EXCLUDED

  12. Sacral nerve stimulationfor slow transit constipation DINNING 2006 n = 8 HIGH – AMPLITUDE PROPAGATING PRESSURE WAVES N / HOUR ** 1 0.5 Baseline PNE ANTEGRADE INCREASE IN RIGHT AND LEFT COLON (S3) RETROGRADE INCREASE LIMITED TO THE RIGHT COLON (S2)

  13. 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)

  14. 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)

  15. Sacral nerve stimulation for idiopathicchronic slow transit constipation SUCCESSES : n = 3 (0 neurological) FAILURES : n = 7 (3 neurological) DEVROEDE 2012

  16. SUCCESSES

  17. Sacral nerve stimulation for idiopathic chronic slow transit constipation R.L. MALE PROBAND CONSULTATION : 06/02/2006 • Constipation frombirth • One stool / 3 – 4 weeks; plugging the toiletbowl • Vasodilation of lefthemi-abdomen from the spine to the xiphoid-pubis line • Evaluation : megarectum (770 cc) anismuscorrected by biofeedback

  18. Sacral nerve stimulation for idiopathic chronic slow transit constipation R.L. MALE • 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 doorhandle - 0 stool 0 markers progression • SNS : 1 – 3 stools/day(3 yearsfollow up)

  19. Sacral nerve stimulation for idiopathic chronic slow transit constipation J.T. FEMALE • Constipation sincechildhood • Up to 37 dayswithoutdefecation • Neurogenicbladder : 4 – 5 catheterizations per day

  20. Sacral nerve stimulation for idiopathicchronic slow transit constipation J.T. N MARKERS 2008 / 2010 / 2011 RIGHT COLON EMPTIES WELL 20 10 2012 POST SNS 1 7 DAYS AFTER INGESTION DAILY STOOLS (1 – 3) ORGASMIC EXPERIENCES SPONTANEOUS VOIDING (5 – 6 / DAY ; NO MORE CATHETERIZATION)

  21. Sacral nerve stimulation for fecal incontinence by pudendal neuropathy D.D. REASON FOR CONSULTATION (12/9/2002) • Constipation : 1 stool / 20 days following the death of herfather • Fecal incontinence : Wexner score 11 / 20 (2 – 0 – 3 – 3 – 3)

  22. Sacral nerve stimulation for fecal incontinence by pudendal neuropathy D.D. Anorectal 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

  23. Sacral nerve stimulation for fecal incontinence by pudendal neuropathy D.D. 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)

  24. FAILURES

  25. Laxative anorexia V.G. 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 daysafter ingestion (transit time > 144 hours) 3. Same as 2. No menstruation Anal electromyography : Mildanismus

  26. Laxative anorexia V.G. 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

  27. Constipation is not a sign which can be evaluated scientifically. It is merely a symptom !

  28. Sacral Neurostimulationin Constipation :It maywork.But whenisitreasonable ???

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