Sacral Neurostimulation reasonable to treat chronic Idiopathie constipation Ghislain Devroede Département de chirurgie Faculté de médecine et des Sciences de la Santé Université de Sherbrooke Québec, Canada

QUALITY OF LIFE IS MARKEDLY IMPROVED IN PATIENTS WITH FECAL INCONTINENCE AFTER SACRAL NERVE STIMULATION

*SNS STUDY GROUP (in alphabetical order) The SNS Study Group included the following members (in alphabetical order): Jennifer M. Ayscue, MD, Washington Hospital Center, Washington, DC; Miranda Chan, MD, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, China; Heidi Chua, MD, Mayo Clinic, Rochester, MN; John A. Coller, MD, Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA; Ghislain Devroede, MD, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Fleurimont, Canada; Michael England, MD, Norman F. Gant Research Foundation, Forth Worth, TX; Tracy Hull, MD, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH; Howard Kaufman, MD, Division of Colorectal Surgery, University of Southern California, Los Angeles, CA; Robert D. Madoff, MD, Division of Colon & Rectal Surgery, University of Minnesota, MN; David Margolin, MD, Department of Colon & Rectal Surgery, Ochsner Clinic Foundation, New Orleans, LA; Richard McCallum, MD, University of Kansas Medical Center, Kansas City, KS; Anders Mellgren, MD, PhD, Division of Colon & Rectal Surgery, University of Minnesota, MN; Ece Mutlu, MD, Rush University Medical Center, Chicago, IL; Deborah Nagle, MD, Colon and Rectal Surgical Division, Beth Israel Deaconess Medical Center, Boston, MA; Susan Parker, MD, Division of Colon & Rectal Surgery, University of Minnesota, MN; Paul Pettit, MD, Mayo Clinic, Jacksonville, FL; Abbas S. Shobeiri, MD, University of Oklahoma, Oklahoma City, OK; William J. Snape, MD, California Pacific Medical Center, San Francisco, CA; Joe Tjandra, MD (Late), Royal Melbourne Hospital, Victoria, Australia; Steven D. Wexner, MD, Department of Colorectal Surgery, Cleveland Clinic Florida, FL.

Sacral Nerve Stimulation (SNS) SNS usually stimulates S Europe - Chronic pelvic and lower urinary and intestinal tract disorders 1997/1999 USA - UI / UF and Retention 2011 USA - Chronic fecal incontinence Note: FDA's approval is based solely on 12-month data.

SNS Therapy Staged Procedure Electrode in S3 Test stimulation days Implantation

Sacral nerve stimulation for fecal incontinence ______________________________________________________ North American SNS Study Group (FDA Approved Protocol) Informed consent :285 Test stimulation :133 (152 rejected by inclusion / (tined lead electrode) exclusion criteria) Interstim Device :120 (47%) Follow up (years) :5 (0.2 – 7.0)

Frequency of incontinent episodes or days per week (follow-up to baseline : P <.001) 3 6

Percent of patients with >50% improvement in incontinent episodes per week

Fecal incontinence severity index assessment (FISI) (follow-up to baseline : P <.001) 3 6

Fecal incontinence quality of life assessment (FIQOL score) (follow-up to baseline : P <.001) 3 6

Score improvement for each question of the FIQOL Note: Question 1 rating “general state of health” has a reverse scale, with 1 being “Excellent” and 5 being “Poor”. The other questions use a scale of 1-4, with 1 being worse and 4 being best.

Individual QOL questions at baseline and 48 months

Improved quality of life after sacral neurostimulation for fecal incontinence FOOD:Amount Restaurants SOCIAL:Going out (movies, church, friends) Staying overnight away from home Traveling (trains, plane) (ALL P < 0.001) n = 120

Improved quality of life after sacral neurostimulation for fecal incontinence INTIMACY:Less frequent sexual encounters than wished Fears of sexual encounters FEELINGS:Different Not enjoying life Ashamed Depressed (ALL P < 0.001) n = 120

Sacral nerve stimulation or modulation ? We know for sure that we stimulate : Variables :- sacral root - body side - voltage - frequency - sensation site (anus, perineal body, vulva) - anal contraction; toe movement We do not know what we modulate

There is focal brain activation during sacral nerve stimulation (L. LUNDBY, A. MOLLER, S. BUNTZEND, K. KROGH, K. VANG, A. GJEDDE, S. LAURBERG, Diseases of the Colon & Rectum 2011; 54; )

Sacral neurostimulation The Sherbrooke experience Percutaneous nerve stimulation (PNS) :81 (extended PNE to days)(2 sides = 162 PNEs) Interstim sacral nerve stimulation (SNS) : 68 (AS OF 1/12/2012)

The ghost of my mother ______________________________________________________ RC :Fecal incontinence by pudendal neuropathy (no effective treatment) Preoperative decision: Wexner 17/20 Anal electromyography : Pudendal neuropathy (EAS/PR) Functional rectal examination : Pudendal neuropathy Interstim implant: Wexner 0/20 SNS Off: Wexner 0/20 No visit for one year SNS Out: Wexner 0/20 Suzanne L.

The ghost of my mother ______________________________________________________ « My mother never loved me » BIRTH :Her mother gives her in adoption Her father brings her back home ORPHAN OF HER FATHER ORPHAN OF HER MOTHER : She is disinherited 21/9/2011 :« Don't say I'm crazy » «The corpse of my dead mother came into my bed. My guardian angel, at the ceiling told me I was cured. » SNS OFFGoes to the Dominican Republic Goes to Mexico No fecal incontinence 23/11/2012 :Interstim removed Suzanne L.

Risk factors for female fecal incontinence 5 BHARUCHA 2006 n = 5300 AGE (per decade ) IBSDIARRHEAANAL FISTULA URGENCY (NO DIARRHEA NO CONSTIPATION) VAGINAL DELIVERY FORCEPS STITCHES ODDS RATIOS

A NEAR MISS ______________________________________________________ WEXNER SCORE FIRST VISIT18/20 SECOND VISIT11/20 THIRD VISIT 4/20 (dismissed)(daily clean pads) Pauline D.

A NEAR MISS ______________________________________________________ Pregnant mother, dying father (Hodgkin’s disease) 9 months old :Death of father Maternal grandmother :Accuses her daughter-in-law of having « killed » her son ____________________________ “You were like a strong wind opening a door widely” “I knew for a long time I was mother to my mother” “You told me she was more attached to me, and needing me, than loving me” Pauline D.