SACRAL NERVE STIMULATION FOR EXPERIENCE IN CHILDREN

Transcription

1 SACRAL NERVE STIMULATION FOR COLORECTAL DISEASES: EXPERIENCE IN CHILDREN C. LOUIS-BORRIONE - JM. GUYS TIMONE-ENFANTS MARSEILLE

2 SACRAL NEUROMODULATION IN CHILDREN 26 : Humphreys et al - 23 children with functional urinary incontinence/constipation and soiling 8% positive response for constipation (J Urol. 26;176: ) 21 : Guys et al - multicentric prospective randomized cross over study in 33 children with urinary and fecal incontinence of neurological origin - 78% positive response for bowel function (J Urol. 21;184:696-71) 212 : Wunnik et al - 13 adolescents with refractory functional constipation - 11/13 improved (Dis Colon Rectum. 212;55:278-85)

3 NEUROPHYSIOLOGICAL EFFECTS rectal compliance tonus of the external anal sphincter right colonic bowel movements left colonic and rectal bowel movements

4 CLINICAL EFFECTS Wexner score > 5% Spontaneous defecation / week Urgency or incontinent episodes Feeling of the urge to defecate Retention time between bowel movements Improvement of stool consistency Quality of life

5 PREDICTIVE FACTOR OF EFFICIENCY OF SNM? Neurologic diseases Fecal incontinence with urgency episodes Low intensity to achieve a stimulation during the test period

6 INCLUSION CRITERIA FOR SNM IN FECAL INCONTINENCE (French Health Authority) International consensus 27: Severe fecal incontinence : more than one accident per week No defect of the external anal sphincter Failure of conservative treatments > 2 years

7 EXCLUSION CRITERIA FOR SNM (French Health Authority) Congenital Anorectal and pelvic malformations Previous colorectal resection External anal sphincter defect exceeding 9 in circumference Chronic diarrhea resistant to medical treatment IBD Abdominal pain or hard bowel movements So what alternative should we offer to these patients?

8 POSTERIOR TIBIAL NERVE STIMULATION IN CHILDREN Anorectal ( ARM) or pelvic malformations Hirschsprung s disease Easy, non invasive and painless At home Adhesive electrodes

9 EXTERNAL SACRAL NEUROSTIMULATION IN CHILDREN 21 : Hoebeke P, Transcutaneous neuromodulation for the urge syndrome in children. J Urol,166: 2416,21. Bower WF, A pilot study of the home application of transcutaneous neuromodulation in children with urgency or urge incontinence. J Urol,166: 242, : Queralto M, Transcutaneous neuromodulation in the treatment of idiopathic fecal incontinence. Int Colorectal Dis, 26;7:67-2. adhesive electrodes 29 : De la Portilla F: Evaluation of the use of posterior tibial nerve stimulation for the treatment of fecal incontinence preliminary results of a prospective study. Dis Colon Rectum, 52 : 1427, : Vitton V, Transcutaneous posterior tibial nerve stimulation for fecal incontinence in inflammatory bowel disease patients. Inflamm Bowel Dis. 29;15:42-5. adhesive electrodes 212 : Leroi A.M, Transcutaneous electrical tibial nerve stimulation in the treatment of fecal incontinence: a randomized trial. Am j Gastroenterol. 212;doi:1.138/ajg adhesive electrodes 212 : Yik Y.I : Home transcutaneous electrical stimulation to treat children with slow transit constipation. J Pediatric Surg.212;47: Needles 215 : Lecompte J.F Louis-Borrione C, Evaluation of transcutaneous electrical posterior tibial nerve stimulation for the treatment of fecal and urinary leaks in children. J Pediatric Surg.215;5:63-3. adhesive electrodes

10 OUR EXPERIENCE 211/213 8 children : 4 high ARM 3 neurologic malformations- 1 Hirschsprung 3 G 5 B 1 to 13 years All presented soiling and 6 of them urinary leaks Failure of conservative treatments Urostim 2 low frequency (1 Hz) current applied just at the sensory level and under skeletal muscle contractions (1 to 25mA) 2 mn daily Wexner score at 2 and 6 months

11 RESULTS / WEXNER SCORE Patient Sex Pathology Jorge and Wexner score Before treatment by TENS After treatment by TENS 1 M Anorectal malformation + syringomyelia 13 3 (filum cut) 2 M Anorectal malformation + sacral agenesis F Anorectal malformation with a mega rectum (partial proctectomy) 4 F Anorectal malformation (cloaca) +sacral agenesis F Sacrococcygeal teratoma 3 6 M Chiari's malformation 15 7 M Medullar lipoma M Hirschsprung 14 7

12 RESULTS /INCONTINENCE Patient Sex Antegrade irrigation (Malone) Transanal irrigation with Peristeen Spontaneous defecation with TENS Frequency of faecal incontinence Frequency of urinary incontinence Before TENS After TENS Before TENS After TENS Before TENS At 2 months At 6 months Before TENS At 2 months At 6 months 1 M Y N Y Y No >1/week >1/ week >1/day >1/ month >1/month 2 M Y N Y Y No >1/ week >1/ week >1/month 3 F Y Y Y Y Yes >1/ day >1/ week >1/week >1/ day >1/ week 4 F Y N Y Y Yes >1/ week >1/ month >1/ week >1/ month 5 F Y N Y N Yes >1/ month >1/ week >1/ month 6 H N N N N Yes >1/ week >1/ month >1/ week >1/ month 7 H N N N N yes >1/ day >1/ month >1/ day >1/ month 8 H N N Y Y yes >1/ day >1/week >1/month

13 TODAY Patient Sex Pathology today 1 M Anorectal malformation + syringomyelia (filum cut) continence 1/month Other medication Peristeen 2 M Anorectal malformation + sacral agenesis 1/month 3 F Anorectal malformation with a mega rectum (partial proctectomy) 4 F Anorectal malformation (cloaca) +sacral agenesis 5 F Sacrococcygeal teratoma 6 M Chiari's malformation 7 M Medullar lipoma 8 M Hirschsprung >1/month Peristeen Malone +/- Peristeen PTNS

14 CONCLUSION Sacral neuromodulation should have a place in the management of anorectal malformations and perhaps in Hirschsprung disease. We think that posterior nerve tibial stimulation is an alternative to sacral neuromodulation in children and it will be interesting to introduce this procedure early after surgery, specially when dysraphism is associated. Inclusion criteria should be evaluated with a larger multicentric cohort.