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Title: Sacral nerve stimulation for bowel dysfunction
Author: Jarrett, Michael Eugene Dominic
ISNI:       0000 0001 3589 2836
Awarding Body: University of Oxford
Current Institution: University of Oxford
Date of Award: 2006
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Sacral nerve stimulation (SNS) was introduced for urge urinary incontinence in 1981. It resulted in a significant improvement in 80% of patients. In the 1990s it was recognised that the treatment had a beneficial effect on bowel function, particularly faecal incontinence. This led to prospective trials to assess its role in this condition's treatment and more recently in the treatment of constipation. SNS has, so far, been assessed in specialist centres for the treatment of faecal incontinence in patients with an intact external. anal sphincter. The aetiology of incontinence has varied in the reported series. This thesis demonstrates that SNS for faecal incontinence may be undertaken on a national scale, in units with a specialist interest, without compromise of the outcome. Specific aetiologies of faecal incontinence including partial spinal injury and full thickness rectal prolapse or following anterior resection for rectal cancer are assessed separately. The results indicate that SNS has a role to playin each of these groups. Supplied by The British Library - 'The world's knowledge' The work leading to this thesis includes new indications. These include patients with obstetric-related external anal sphincter defects, which would otherwise have been treated by overlapping sphincter repair. All patients tested in this group proceeded to pennanent SNS with improvement in faecal incontinent episodes from a median (range) of 5.5 (4.5-21.5) to 2 (0-5.5) episodes per week (p=0.017) at a median (range) follow up of 4.5 (1-12) months. In this group of females of childbearing age sexual activity is investigated by a retrospective sex life questionnaire analysis. Quality of sexual activity is improved in nearly 80% of patients with a statistically greater improvement in younger patients. It had been noted in patients treated with SNS for UrInary incontinence that constipation was improved. Subsequent pilot studies in the UK and Italy have led to a pan-European trial of the use of SNS in patients with slow and normal transit constipation. The thesis presents work undertaken at S1. Mark's Hospital that will be included in the European trial. Results suggest that SNS may be beneficial in both types of constipation. The proportion of patients with constipation proceeding to pennanent implant was 57% as opposed to approximately 85% for incontinence. In those proceeding to permanent implant, bowel opening over a three week period improved from a median (range) of 7 (1-23) at baseline to 21 (4-102) (p=0.003). Significant improvements in abdominal symptoms were associated with an improvement in quality of life. The results suggest that SNS could become an exciting new treatment option for patients in this difficult clinical group. Supplied by The British Library - 'The world's knowledge' Solitary rectal ulcer syndrome (SRUS) is a discrete clinical condition associated with an evacuation disorder and specific histopathological features. The condition is difficult to treat. Biofeedback is often the first line therapy. This research shows that rectal mucosal blood flow in these patients is reduced compared to controls (mean (sd) 163(27) versus 186 (14) flux units (FU) (p<0.01)). The findings are similar to those found in patients with normal transit constipation. It also demonstrates that successful biofeedback results in a significant improvement in rectal mucosal blood flow in patients who feel subjectively better after biofeedback from 165 (30) FU to 190 (40) FU (p=0.001). Knowing SNS increases rectal mucosal blood flow and leads to improvement in patients with constipation, three patients with SRUS were trialed with SNS. No patient proceeded to permanent implantation, although all felt some benefit. The results of physiology testing carried out during the studies into SNS have allowed theorisation concerning the mechanism of action of SNS. This is likely to be multifactorial with effects on the sphincter complex, bowel motility, rectal sensitivity and cerebral cortex all having a role.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available