Stimulating Hope: Sacral Nerve Stimulation (SNS) for Fecal Incontinence

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Fecal incontinence can be a debilitating condition, leaving those who suffer from it in a state of anxiety and embarrassment. But, now, there’s hope. Sacral nerve stimulation (SNS) is a procedure that can provide an improvement of symptoms leading to a higher quality of life for those with fecal incontinence. Dr. Dawn Wietfeldt presents on this innovative procedure—and how it can change your life.

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  • The Cleveland Clinic (Wexner) fecal incontinence score takes into account five parameters that are scored on a scale from zero (absent) to four (daily) frequency of incontinence to gas, liquid, solid, of need to wear pad, and of lifestyle changes
  • Patients with moderate incontinence and small or no sphincter defects are candidates for injectables (Solesta®) and radiofrequency (SECCA®). Patients with complete sphincter destruction or absence of a sphincter (usually due to trauma or congenital defects) require sphincter replacement by procedures such as dynamic graciloplasty and the artificial bowel sphincter.
  • Patients with moderate incontinence and small or no sphincter defects are candidates for injectables (Solesta®) and radiofrequency (SECCA®).
  • Patients with severe FI and an intact anal sphincter are best treated by Sacral Nerve Stimulation (SNS). This is a minimally invasive procedure that involves installation of a permanent neurostimulator (Medtronic Inc, Minneapolis, MN) into the third sacral nerve plexus as an out-patient day surgery procedure with sedation. SNS was first reported for effective treatment of FI in 1994 by K. Matzel. To date, it has been shown to have excellernt (>80%) success rates, minimal complication rates, and sustained long-term (5 year) results with a dramatic impact on quality of life.
  • Stimulating Hope: Sacral Nerve Stimulation (SNS) for Fecal Incontinence

    1. 1. Fecal Incontinence:Stimulating HopeDawn Wietfeldt, MDSpringfield Clinic Colon & Rectal SurgeryAssociate Program Director, SIU/SPC Colon and Rectal SurgeryResidency
    2. 2. www.SpringfieldClinic.com
    3. 3. Fecal Incontinence• Goes by many names• Debilitating condition• Causes anxiety and embarrassment
    4. 4. Fecal Incontinence• Multifactorial– Obstetric trauma– Previous surgery– Injury– Other• More frequent in women
    5. 5. Fecal Incontinence• Symptoms vary• Fecal incontinence score• Work-up– Physical exam– Endoanal u/s– Anal Manometry– EMG– MRI/Defecography
    6. 6. Never(0)Less thanonce permonth (1)Less thanonce/wk &greater thanonce/mth (2)Less thanonce/day &greater thanonce/wk (3)Once/daymore thanonce perday (4)Accidents to solidstoolAccidents to liquidstool/diarrheaHow often does gasescape w/o yourknowledge or controlHow often do youwear a pad/dependsor changeunderwear b/c ofsoilageHow much do theabove answers alterWexner Fecal Incontinence Score
    7. 7. Fecal Incontinence• Strategy of treatment– Dietary changes– Fiber– Anti-diarrheal Medication– Pelvic Floor Training (Biofeedback)**Patients with significant and persistentsymptoms (FIS >10) are candidates forsurgical therapy
    8. 8. Standard Surgical Option• Stoma
    9. 9. Surgical Options for Preservationof Sphincter1. Repair– Sphincteroplasty– Postanal repair2. Augmentation– Injectables– Radiofrequency3. Replacement– Dynamic Graciloplasty– Artificial Bowel Sphincter4. Stimulation– Sacral Nerve Stimulation– Posterior Tibial Nerve Stimulation
    10. 10. Overlapping Sphincteroplasty:Short-Term Results< 3 yearsAuthor Year n Success (%)Fleshman 1991 55 72Wexner 1991 16 76Fleshman 1991 28 75Engel 1994 55 76Engel 1994 28 75Simmang 1994 14 93
    11. 11. Overlapping Sphincteroplasty:Long-Term Results6-10 yearsAuthor Year n Success (%)Karoui 2000 74 49Halverson 2002 49 46Gutierrez 2004 191 40Zutshi 2009 31 none fully continentMevik 2009 21 53
    12. 12. Long-term Outcomes of OverlappingSphincteroplasty:Meta-analysis• 16 studies• 900 patients• Variable outcome measures• Clear trend toward decay of functionaloutcomes over time• No predictors for long-term successGlascow et al. DCR 2012
    13. 13. Augmentation Methods• Injectables• Radiofrequency
    14. 14. Artificial Bowel Sphincter (ABS)CuffBalloonPumpFDA approved in 1999
    15. 15. SNSSacral Neuromodulation (SNM) isstimulation of the sacral nerves tomodulate the reflexes that influencethe colon, sphincter, and pelvic floor.SNM uses mild electrical pulses toimprove or restore normal function.
    16. 16. Sacral Nerve Stimulation - SNS• Criteria– At least two episodes of incontinence perweek– <90 degree sphincter defect– Failed two conservative therapies
    17. 17. Sacral Nerve Stimulator - SNS• Two step process– Stage 1 (1 hour procedure)• MAC sedation• Outpatient procedure• Test phase for two weeks• Must have a 50% improvement in symptoms– Stage 2 (30 minute procedure)• MAC sedation• Outpatient procedure
    18. 18. Test Period
    19. 19. SymptomControl• Allows the patient to feel stimulation• Assess the viability of InterStim Therapy• Helps the physician and patient make an informed choiceabout the long-term therapeutic value of InterStim TherapyBenefits of Test Stimulation Period
    20. 20. SNS Stage II
    21. 21. InterStim System1. Tined lead is placed parallel to thesacral (S2, S3, or S4) nerve.2. Implantable neurostimulatorgenerates mild electrical pulsesthat are delivered through the leadelectrodes.3. Clinician and patientprogrammers are usedto set the parametersof the electrical pulses.123
    22. 22. Long-term efficacy & Safety120-Patient Prospective Multi-center Study• Mean Follow-up: 36 (2-73) months• Therapeutic Success ( 50% improvement)– 12 months → 83%– 24 months → 86%– 36 months → 85%• Perfect continence– 12 months → 41%– 24 months → 38%– 36 months → 37%Mellgren et al. DCR 2011
    23. 23. Adverse Events• Implant site pain• Implant site infection• Lead fracture• Parasthesia• Diarrhea• Urinary Incontinence
    24. 24. Infectious Complication• High Risk– Age >65– BMI >30– NIDDM– Previous back surgery
    25. 25. Sacral nerve StimulationMeta-AnalysisSignificant improvements Number of incontinent episodes Wexner Fecal Incontinence Score Ability to defer evacuation Most SF-36 and FIQL domains Mean anal resting pressures-15 % Morbidity and 3% Explantation
    26. 26. Sphincter Defect, PudendalNeuropathy or Previous SphincterRepairConclusions:– Significant and sustained improvement inincontinence for all patients– Similar improvement in incontinence forpatients who had an external sphincterdefect on endoanal u/s, a prolongedPNTML, and 1 or more previous sphincterrepairs
    27. 27. • Inclusion criteria:– ≥ 3 incontinence episodesper week– Age < 80 years– Failed conservative treatment– External anal sphincter:• no defect• defect < 90º• Failed previous sphincterrepair• Exclusion criteria:– Congenital anorectalmalformation– Neurological disease– Chronic diarrhea– IBD– Psychiatric disease– PregnancyFecal incontinence associatedwith pelvic floor injuryOom et al. DCR 2010
    28. 28. • Conclusions– Pelvic floor injury was present in the majorityof patients with fecal incontinence who wereeligible for sacral neuromodulation– This type of injury seems to have nodetrimental effect on the efficacy of SNSFecal incontinence associatedwith pelvic floor injuryOom et al. DCR 2010
    29. 29. Isolated sphincter defectPudendal neuropathySphincteroplastyAlternative procedureSimple proceduresSuccessIntactrepairInjectablesRadiofrequencyPerianal sepsisStimulatedGraciloplastyABSSevere musclelossYesFailureSpinal deformitySimpleprocedures, SNSABS,Radiofrequency,InjectablesSNSPersistentDefectNoYesNoSNS
    30. 30. Conclusions• Many promising surgical options– Varying success and complication profiles• Tailored treatment to each patient– Integrity of sphincter– Motivation
    31. 31. THANK YOU!!• Questions??
    32. 32. More ResourcesFind videos, handouts and moreresources atwww.SpringfieldClinic.com/DoctorIsIn

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