is sacral neurostimulation reasonable to treat chronic idiopathic constipation ?
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/1.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/2.jpg)
![Page 3: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/3.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/4.jpg)
Marthe
A thirty one years follow up…
![Page 5: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/5.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/6.jpg)
![Page 7: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/7.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/8.jpg)
Somatizationis not
Imagination
![Page 9: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/9.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/10.jpg)
![Page 11: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/11.jpg)
![Page 12: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/12.jpg)
![Page 13: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/13.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/14.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/15.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/16.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/17.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/18.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/19.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/20.jpg)
SUCCESSES
![Page 21: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/21.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/22.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/23.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/24.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/25.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/26.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/27.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/28.jpg)
![Page 29: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/29.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/30.jpg)
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 ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/31.jpg)
Constipationis not a sign which canbe evaluated
scientifically.
It is merelya symptom !
![Page 32: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/32.jpg)
![Page 33: Is Sacral Neurostimulation Reasonable to Treat Chronic Idiopathic Constipation ?](https://reader030.vdocument.in/reader030/viewer/2022032612/56813248550346895d98bd27/html5/thumbnails/33.jpg)
Sacral NeurostimulationSacral Neurostimulationin Constipation :in Constipation :
It may work.It may work.
But when is it reasonable ???But when is it reasonable ???