Abstract Background and method This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies). Results From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41–75 per cent of patients achieved complete faecal continence and 75–100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off. Conclusion SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.
The aim of day surgery is to transfer to the day unit surgical procedures traditionally undertaken on an inpatient basis. Although this occurs for hernia repair in some hospitals, nationally it would not seem to be the case. In England in 1990-91, 65,276 inguinal hernias were repaired, 61,380 as inpatients and 3896 (6%) as day cases. The total repaired in 1995-96 was 77,940, 58,927 as inpatients and 19,013 (24.4%) as day cases. Inpatient numbers in the five-year period fell by 2453 (4%) but day cases grew by 15,117(388%).1 A similar trend is seen in varicose vein surgery over the same period, in which a decrease of 3377 (8.7%) inpatient cases and an increase of 17,398 (246%) day surgery cases were seen. The percentage of varicose vein surgery being done on a day basis has increased from 15.5% in 1990-91 to 41.0% in 1995-96.1 These figures show that although there has been a small transference of work, overall, day case surgery has become an addition to inpatient work rather than a substitute.
Abstract Introduction Faecal incontinence affects a percentage of the population and can have a significant effect on their ability to establish and maintain sexual relations. Patients and methods Sixteen consecutive patients with permanent sacral neuromodulation (SNM) for faecal incontinence completed a ‘Sex Life Questionnaire’ at their follow up visit to ascertain whether there was any improvement in this aspect of their life. Results Nine of the sixteen patients was sexually active. These nine patients (median age 56 (35–61) years) had a significant reduction in faecal incontinence episodes per week from a median of 12 (1–55) to 1.5 (0–8.5) ( P = 0.008). All nine patients reported that their sex life had been affected by feacal incontinence prior to SNM and seven had felt benefit from implantation. The median improvement in their sex life was 40% (1–100) and the percentage improvement was inversely correlated to age ( r = −0.834, P = 0.005). Conclusion SNM improves the quality of sexual activity in 78% of patients. More improvement seems to be gained the younger the patients.
Abstract Background This study examined the use of sacral nerve stimulation (SNS) to treat faecal incontinence in patients with partial spinal injury. Methods Patients selected for SNS had experienced more than one episode of faecal incontinence per week to liquid or solid stool for more than 1 year and had failed maximal conservative treatment. All patients had an intact external anal sphincter. Results Temporary SNS was performed in 13 patients (median age 58·5 (range 39–73) years). The spinal insults were disc prolapse (six), trauma (four), spinal stenosis (one) or occurred during neurosurgery (two). Twelve patients (eight women and four men) had successful temporary stimulation and proceeded to permanent implantation. The median follow-up time was 12 (range 6–24) months. The mean(s.d.) number of episodes of incontinence decreased from 9·33(7·64) per week at baseline to 2·39(3·69) at last follow-up (P = 0·012). The number of days per week with incontinence and staining decreased significantly (both P < 0·001). Ability to defer defaecation improved from a median of not being able to defer (range 0–1 min) to being able to defer for 5–15 (range 0 to over 15) min (P = 0·022). Conclusion SNS can benefit patients with faecal incontinence following partial spinal injury.
Sphincter repair is the standard treatment for fecal incontinence secondary to obstetric external anal sphincter damage; however, the results of this treatment deteriorate over time. Sacral nerve stimulation has become an established therapy for fecal incontinence in patients with intact sphincter muscles. This study investigated its efficacy as a treatment for patients with obstetric-related incontinence.Fecally incontinent patients with external sphincter defects who would normally have undergone overlapping sphincter repair as a primary or repeat procedure were included. Eight consecutive women (median age, 46 (range, 35-67) years) completed temporary screening; all eventually had permanent implantation.Six of eight patients had improved continence at median follow-up of 26.5 (range, 6-40) months. Fecal incontinent episodes improved from 5.5 (range, 4.5-18) to 1.5 (range, 0-5.5) episodes per week (P = 0.0078). Urgency improved in five patients, with ability to defer defecation improving from a median of <1 (range, 0-5) minute to 1 to 5 (range, 1 to >15) minutes (P = 0.031, all 8 patients). There was no change in anal manometry or rectal sensation. There was significant improvement in lifestyle, coping/behavior, depression/self-perception, and embarrassment as measured by the American Society of Colon and Rectal Surgery fecal incontinence quality of life score.Sacral nerve stimulation is potentially a safe and effective minimally invasive treatment for fecal incontinence in patients with de novo external anal sphincter defects or defects after unsuccessful previous external anal sphincter repair, although numbers remain small.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of sacral nerve stimulation using implanted eletrodes for the treatment of faecal incontinence in adults.
Background: Effective therapeutics for Alzheimer’s disease are needed. However, previous clinical trials have pre-determined a single treatment modality, such as a drug candidate or therapeutic procedure, which may be unrelated to the primary drivers of the neurodegenerative process. Therefore, increasing data set size to include the potential contributors to cognitive decline for each patient, and addressing the identified potential contributors, may represent a more effective strategy. Objective: To determine whether a precision medicine approach to Alzheimer’s disease and mild cognitive impairment is effective enough in a proof-of-concept trial to warrant a larger, randomized, controlled clinical trial. Methods: Twenty-five patients with dementia or mild cognitive impairment, with Montreal Cognitive Assessment (MoCA) scores of 19 or higher, were evaluated for markers of inflammation, chronic infection, dysbiosis, insulin resistance, protein glycation, vascular disease, nocturnal hypoxemia, hormone insufficiency or dysregulation, nutrient deficiency, toxin or toxicant exposure, and other biochemical parameters associated with cognitive decline. Brain magnetic resonance imaging with volumetrics was performed at baseline and study conclusion. Patients were treated for nine months with a personalized, precision medicine protocol, and cognition was assessed at t = 0, 3, 6, and 9 months. Results: All outcome measures revealed improvement: statistically significant improvement in MoCA scores, CNS Vital Signs Neurocognitive Index, and Alzheimer’s Questionnaire Change score were documented. No serious adverse events were recorded. MRI volumetrics also improved. Conclusion: Based on the cognitive improvements observed in this study, a larger, randomized, controlled trial of the precision medicine therapeutic approach described herein is warranted.
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