New screening technique for sacral nerve stimulation under local anaesthesia

Abstract Background The purpose of this study was to assess the influence of the type of anaesthesia (local vs. general) and of the electrode used (test electrode vs. tined lead) on a successful screening period. Methods Between May 2001 and January 2004, we performed 25 percutaneous nerve evaluation (PNE) tests in 20 patients (11 women). The first 15 PNE tests were followed by introducing a conventional electrode, and since 2003 by a tined lead electrode. Success was defined as reduction of symptoms by more than 50%. Results A stimulator was implanted in 13 (68%) patients, including 4 of 14 screened with the conventional electrode and 9 of 10 screened with tined lead electrode (p=0.005). Eleven (44%) of the PNE tests were done under local anaesthesia, but the success rate was not influenced by the type of anaesthesia (local 46% vs. general 61%, p=0.682). Conclusions PNE testing and implantation of the tined lead electrode can be easily performed at the same time under local anaesthesia. The use of the new tined lead electrode significantly increased the success rate for the screening phase.     

Turning off sacral nerve stimulation does not affect gastric and small intestinal motility in patients treated for faecal incontinence

Aim Sacral nerve stimulation (SNS) reduces symptoms in up to 80% of patients with faecal incontinence (FI). Its effects are not limited to the distal colon and the pelvic floor. Accordingly, spinal or supraspinal neuromodulation have been suggested as part of the mode of action. The effect of SNS on gastric and small‐intestinal motility was studied. Method Using the magnet tracking system, MTS‐1, a small magnetic pill was tracked twice through the upper gastrointestinal tract of eight patients with FI successfully treated with SNS. Following a randomized double‐blind crossover design, the stimulator was either left active or was turned off for 1 week before investigations with MTS‐1. Results The median (range) frequency of gastric con‐tractions was 3.05 (2.83–3.40) per min during SNS and 3.04 (2.79?–3.76) per min without (P = NS). The median (range) frequency of contractions in the small intestine during the first 2 h after pyloric passage was 10.005 (9.68–10.70) per min during SNS and 10.09 (9.79–10.29) per min without SNS (P = NS). The median (range) velocity of the magnetic pill during the first 2 h in the small intestine was 1.6 (1.2–2.8) cm/min during SNS and 1.7 (0.8–3.7) cm/min without SNS (P = NS). Small‐intestinal propagation mainly occurred during very fast movements (> 15 cm/min), accounting for 51% (42–60%) of the distance 3% (2–4%) of the time during SNS and for 53% (18–73%) of the distance 3% (1–8%) of the time without SNS (P = NS). Conclusion Turning off SNS for 1 week did not affect gastric or small‐intestinal motility patterns.     

Neuromodulation for fecal incontinence: An effective surgical intervention

Fecal incontinence is a disabling symptom with medical and social implications,including fear,embarrassment,isolation and even depression.Most patients live in seclusion and have to plan their life around the symptom,with secondary impairment of their quality of life.Conservative management and biofeedback therapy are reported to benefit a good percentage of those affected.However,surgery must be considered in the nonresponder population.Recently,sacral nerve electrostimulation,lately named neuromodulation,has been reported to benefit patients with fecal incontinence in randomized controlled trials more than placebo stimulation and conservative management,by some unknown mechanism.Neuromodulation is a minimally invasive procedure with a low rate of adverse events and apparently favorable cost-efficacy profile.This review is intended to expand knowledge about this effective intervention among the non-surgically skilled community who deals with this disabled group of patients.     

Non-pharmacologic options for the management of voiding dysfunction in multiple sclerosis

Multiple sclerosis is a neuroinflammatory condition that can cause significant bladder dysfunction manifesting either as overactive bladder or impaired bladder emptying.Patients will often complain of urgency,frequency,nocturia,urgency incontinence,hesitancy,straining to void,and incomplete bladder emptying.While these symptoms can be treated with pharmacologic agents,often patients will require more significant treatments.Patients should first be evaluated with urodynamics in order to adequately diagnose the pathologic condition causing their symptoms.These interventions include catheter use,injection of botulinum toxin,neuromodulation,urethral stenting,sphincterotomy,suprapubic catheter with bladder neck closure,bladder augmentation and urinary diversion.The purpose of this review is to examine the evidence supporting each of these treatment options so urologic providers can better provide for this unique and complex patient population.     

Das Parkinson-Syndrom als Modellerkrankung verschiedener Obstipationsformen

Constipation is a common problem in patients suffering from Parkinson’s disease. In Parkinson’s disease, the degenerative process may include both the nucleus of the vagal nerve in the brainstem and Onuf’s nucleus in the sacral spinal cord. Reduced vagal tone may inhibit gastrointestinal motility up to the left colonic flexure. Degeneration of the sacral parasympathetic neurons may reduce motility of the remaining segment of colon and sigmoid. In addition, degeneration of the myenteric and submucosal plexus may lead to intestinal atony. Disease-related immobility as well as the administration of anti-Parkinsonian medication contribute to constipation. The extrapyramidal disorder of anismus is another cause of outlet constipation. As all modes of dysfunction are also observed in non-Parkinsonian patients. Parkinson’s disease can be regarded a model disease for various types of constipation. The study of constipation in Parkinsonian patients is therefore highly suitable to evaluate novel diagnostic or therapeutic strategies.     

Double-blind crossover study of sacral nerve stimulation for fecal incontinence

PURPOSE: Patients with fecal incontinence not amenable to simple repair may have to undergo major reconstructive surgery or resort to a stoma. Sacral nerve stimulation is an alternative approach that may diminish incontinence by altering sphincter and rectal motor function. This study is the first double-blind trial examining the effectiveness of this therapy. METHODS: Two patients with passive fecal incontinence who had been implanted for nine months with a permanent sacral nerve stimulator and electrode were studied using fecal incontinence diaries, anorectal physiological tests, and quality-of-life assessments (SF-36 health survey). The trial period consisted of two two-week periods, with the stimulator turned on for two weeks and off for two weeks. The main investigator and the patients were blinded to the status of the stimulator. RESULTS: There was a dramatic difference between the number and severity of episodes of incontinence when the stimulator was turned onvs. turned off (Patient 1, 20vs. 2 episodes; Patient 2, 4vs. 0 episodes; offvs. on). There was an increase in squeeze pressure (Patient 1, 70vs. 100 cm H₂O; Patient 2, 60vs. 90 cm H₂O; offvs. on), with moderate increases in resting pressure and rectal threshold and urge volumes. Quality-of-life measurements showed a marked improvement prestimulationvs. nine months after permanent stimulation. CONCLUSIONS: There is a marked, unequivocal improvement in symptoms of fecal incontinence with sacral nerve stimulation shown in this double-blind crossover trial. Sacral nerve stimulation improves the quality of life in selected patients with fecal incontinence.A grant and all the equipment used in this study were supplied by Medtronic INTERSTIM, Maastricht, the Netherlands.     

Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps

PURPOSES: In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS: Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS: Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION: The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.Read at the meeting of the Midwestern Association of Plastic Surgeons, Bismarck, North Dakota, June 15 to 18, 1992.     

Sacral Osteomyelitis After Ileal Pouch-Anal Anastomosis: Report of Four Cases

Purpose This study describes an institutional experience with sacral osteomyelitis after proctocolectomy and ileal pouch-anal anastomosis. Methods A total of 2,375 patients underwent ileal pouch-anal anastomosis at the Mayo Clinic between January 1981 and January 2002. In addition, we have served as a tertiary referral base for patients with complications after ileal pouch-anal anastomosis performed at other institutions. Review of our ileal pouch-anal anastomosis prospective database and directed search of the central pathology, microbiology, radiology, and surgical records at the Mayo Clinic was performed using these keywords: osteomyelitis, ileal pouch-anal anastomosis, inflammatory bowel disease, chronic ulcerative colitis, and Crohn's disease. Results Two of 2,375 patients (0.08 percent) with ileal pouch-anal anastomosis performed at our institution have had sacral osteomyelitis. In addition, two patients have been referred for continuing care after construction of an ileal pouch-anal anastomosis and diagnosis of sacral osteomyelitis at another institution. Two of the four patients maintained normal pouch function after sacral debridement and a period of fecal stream diversion. One patient remains diverted with resolved sacral osteomyelitis after debridement. The last patient died from squamous-cell cancer involving the sacrum. Conclusions Sacral osteomyelitis is a rare and heretofore unreported complication of ileal pouch-anal anastomosis. Conservative measures using antibiotics alone proved unsuccessful, and delaying definitive management may have contributed to the degeneration of a chronic sacral abscess into squamous-cell cancer. With more aggressive treatment comprising sacral debridement, long-term antibiotics, and fecal diversion, pouch function can potentially be preserved.     

Video-assisted sacral nerve stimulation

Background Sacral nerve simulation (SNS) is an accepted therapy for patients with urinary or bowel dysfunction. However, infection rates are as high as 20% and can result in removal of the expensive device. We present a new video-assisted technique minimizing the risk of infection. Methods Between April and July 2005, six consecutive women of median age 68 years (range, 60–74), with faecal incontinence (4 patients) and idiopathic constipation (2 patients) underwent video-assisted electrode implantation for SNS. The motor response of the pelvic floor during percutaneous nerve evaluation and implantation of the permanent lead was monitored by a video optic (same as that normally used for laparoscopic or endoscopic procedures) placed between the legs of the patients. The video optic and the perianal area were completely covered with drapes, separating them from the operating field. Results All but one screening was successful, and no wound infections at the electrode or at the pocket of the stimulator were noted (mean postoperative follow-up, 8 weeks). Conclusions With the use of a video optic, the anus and the implantation site can be completely separated and contamination during the operation becomes unlikely. Furthermore, the response of the pelvic floor to the stimulation is better visualized. We routinely recommend the use of video equipment for SNS electrode implantation.     

反向斜引进针行肌间沟臂丛神经阻滞的疗效观察

目的观察反向斜引进针法行肌间沟臂丛神经阻滞在肩部及上臂手术中的麻醉效果和安全性。方法90例肩部和上臂手术的患者,随机分为A、B两组,A组采用反向斜引进针阻滞法,B组采用传统的肌间沟阻滞法。观察比较两组的一次穿刺成功率、麻醉显效时间、麻醉起效时间、麻醉维持时间、运动阻滞起效时间及麻醉效果和有无并发症。结果A组的麻醉显效及起效时间明显短于B组（P〈0．05）,A组的运动阻滞起效时间明显长于B组（P〈0．05）,麻醉效果及一次穿刺成功率明显优于和高于B组,效果确切、安全、无并发症。结论反向斜引进针法行肌间沟臂丛神经阻滞操作简便,较传统肌间沟臂丛神经阻滞法麻醉起效时间快,麻醉效果也更加确切,并发症少,并且有区域阻滞选择性,值得临床推广和应用。