constipation Sacral nerve stimulation for intractable

Objective Traditional surgical procedures for intractable idiopathic constipation are associated with a variable outcome and substantial morbidity. The symptomatic response, physiological effect and effect on quality of life of sacral nerve stimulation (SNS) were evaluated in patients with constipation (slow transit and normal transit with impaired evacuation). Methods In a prospective study at five European sites patients who failed conservative treatment underwent 21 days test stimulation. Patients with >50% improvement in symptoms underwent permanent neurostimulator implantation. Primary end points were increased defecation frequency, decreased straining and decreased sensation of incomplete evacuation. Results 62 patients (55 female, median age 40 years) underwent test stimulation, of whom 45 (73%) proceeded to chronic stimulation. 39 (87%) of these 45 patients achieved treatment success. After a median 28 (range 1e55) months follow-up, defecation frequency increased from 2.3 to 6.6 evacuations per week (p<0.001). Days per week with evacuation increased from 2.3 to 4.8 (p<0.001). There was a decrease in time spent toileting (10.5 to 5.7 min, p1⁄40.001), straining (75e46% of successful evacuations, p<0.001), perception of incomplete evacuation (71.5e46% of successful evacuations, p<0.001) and subjective rating of abdominal pain and bloating (p<0.001). Cleveland Clinic constipation score (01⁄4no to 301⁄4severe constipation) decreased from 18 to 10 (p<0.001). Visual analogue scale (VAS) score (01⁄4severe to 1001⁄4no symptoms) increased from 8 to 66 (p<0.001). Patients with slow and normal transit benefited. Quality of life significantly improved. Colonic transit normalised in half of those with baseline slow transit (p1⁄40.014). Conclusion SNS is effective in the treatment of idiopathic slow and normal transit constipation resistant to conservative treatment. Clinical Trial Number NCT00200005. INTRODUCTION A minority of patients with severe constipation, including some with slow transit and some with normal transit but impaired evacuation, fail conventional pharmacological and behavioural treatments. Traditional operations are associated with substantial morbidity and a variable outcome. Modulation of the extrinsic neural control of the large bowel and pelvic floor may provide an alternative to direct bowel surgery for treating intractable idiopathic constipation. Continuous low-amplitude electrical stimulation of sacral nerve roots is an established treatment for urinary voiding disorders and faecal incontinence. 6 In a combination of early studies of 250 patients undergoing sacral nerve stimulation (SNS) for urinary voiding disorders, 28 (78%) of 36 subjects with co-existing symptoms of constipation reported increased frequency of defecation at 6-months follow-up. Other small, preliminary studies, some with limited outcome measures, have reported successful short-term SNS for treating idiopathic constipation. This study aimed to evaluate prospectively the therapeutic efficacy of temporary and permanent SNS in the treatment of idiopathic constipation resistant to medical and behavioural treatment. What is already known about this subject < Many patients with severe idiopathic constipation are resistant to pharmacological and behavioural treatments. < The traditional surgical treatment for severe constipation is a colectomy with ileorectal anastomosis. This treatment has a variable and unpredictable outcome. < Sacral nerve stimulation involves low dose chronic neural stimulation via the sacral nerve roots. It is a proven, established therapy for the treatment of faecal incontinence. What are the new findings < Sacral nerve stimulation for treatment of severe idiopathic constipation improves bowel function and relieves the diverse symptoms associated