1. Ghislain Devroede Département de chirurgie Faculté de médecine et des Sciences de la Santé Université de Sherbrooke Québec, Canada

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 ?

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

8. Somatization is not Imagination

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

13. Sacral nerve stimulation for 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

14. Sacral nerve stimulation for 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)

15. 10 BaselinePNE STOOL FREQUENCY ROME II IBS EXCLUDED Sacral nerve stimulation for slow transit constipation DINNING 2006 n = 8 5 N / WEEK ***

16. 1 BaselinePNE HIGH – AMPLITUDE PROPAGATING PRESSURE WAVES ANTEGRADE INCREASE IN RIGHT AND LEFT COLON (S3) RETROGRADE INCREASE LIMITED TO THE RIGHT COLON (S2) Sacral nerve stimulation for slow transit constipation DINNING 2006 n = 8 0.5 N / HOUR **

17. Sacral nerve stimulation for 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)

18. Sacral nerve stimulation for 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)

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

20. SUCCESSES

21. 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

22. 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

23. 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

24. 7 DAYS AFTER INGESTION 2008 / 2010 / 2011 RIGHT COLON EMPTIES WELL DAILY STOOLS (1 – 3) ORGASMIC EXPERIENCES SPONTANEOUS 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

25. 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.

26. Sacral nerve stimulation for fecal incontinence by pudendal neuropathy Anorectal manometry Normal resting pressures :24/ 67/ 56 (cm H 2 0) Voluntary contraction : weak0 /+21/+83 (cm H 2 0) Anismus :+25 /+16/+79 (cm H 2 0) 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) PNELeft (13/4/2005)Wexner 0 / 20 Daily stool Right (27/4/2005)Wexner 9 / 20 Constipation D.D.

27. Sacral nerve stimulation for fecal incontinence by pudendal neuropathy 14/7/2005LEFT SNS (1 st trial failed on 16/6/2005) 11/10/2012Wexner 0/20 Stools went from1 – 2 / month to2 – 3 / day Never orgasmic during penetration before SNS Orgasmic during penetration after SNS (retrospective finding) D.D.

29. Laxative anorexia RC :17/1/2006Severe 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.

30. 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 anorexia V.G.

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

33. Sacral Neurostimulation in Constipation : It may work. But when is it reasonable ???