Ghislain Devroede Département de chirurgie Faculté de médecine et des Sciences de la Santé...

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

Surgery for constipation

Surgical results are frequently disappointing in chronic idiopathic constipation :

– Anorectal myotomy

– Segmental colectomy

– Total colectomy with ileorectal anastomosis

Marthe

A thirty one years follow up…

Marthe

MARCH 29, 1981

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

GASTROENTEROLOGY CONSULTATION : TOTAL COLECTOMY ?

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)

%

Somatizationis not

Imagination

The Ancestors’ Syndrome(Anne Ancelin Schützenberger)

Routledge Editors

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

(Rona Levy, GASTROENTEROLOGY)

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

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)

10

Baseline PNE

STOOL FREQUENCY

ROME II IBS EXCLUDED

Sacral nerve stimulationfor slow transit constipation

DINNING 2006

n = 8

5

N / WEEK

***

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

**

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)

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)

Sacral nerve stimulation for idiopathicchronic slow transit constipation

SUCCESSES : n = 3 (0 neurological)

FAILURES : n = 7 (3 neurological)

DEVROEDE 2012

SUCCESSES

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

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

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

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

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.

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.

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.

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.

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.

Constipationis not a sign which canbe evaluated

scientifically.

It is merelya symptom !

Sacral NeurostimulationSacral Neurostimulationin Constipation :in Constipation :

It may work.It may work.

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