Surgery for constipation: systematic review and practice recommendations

Abstract

Aim To assess the outcomes of sacral nerve stimulation in adults with chronic constipation.Method Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.Results Seven articles were identified, providing data on outcomes in 375 patients. Length of procedures and length of stay was not reported. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 13 and 34%, with overall device removal rate between 8 and 23%. Although inconsistently reported, pooled treatment success was typically 57-87% for patients receiving permanent implants, although there was significant variation between studies. Patient selection was inconsistently documented. No conclusions could be drawn regarding particular phenotypes that responded favourably or unfavourably to sacral nerve stimulation.Conclusion Evidence supporting sacral nerve stimulation is derived from poor quality studies. Three methodologically robust trials are have reported since this review and all have all urged greater caution.

A randomized double-blinded sham-controlled cross-over trial of tined-lead sacral nerve stimulation testing for chronic constipation

“…Most recently two prospective randomised studies have been completed [14,22] showing poor response rates and no difference between sham and active intervention for primary outcomes. These findings have mirrored both our own clinical experience in over 50 patients followed over 3-4 years (unpublished audit data) and also findings from recent systematic reviews of SNS for both constipation and faecal incontinence [23,24]. If there were effective alternative treatments for these patients there would be little benefit from further study.…”

An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation

“…Sacral nerve stimulation was initially reported to be of benefit in refractory cases of chronic constipation with pooled treatment success ranging between 57% and 86% [48]. However, this data was derived from poor quality, open-label observational studies and has since been refuted by two welldesigned double-blind sham-controlled studies [49,50].…”

“…Additionally, of those who appear to reap benefit from sacral nerve stimulation, the effect is short-lasting as >80% fail treatment within the first few years of long-term follow-up [51]. Finally, sacral nerve stimulation is an invasive surgical procedure with morbidity rates (lead displacement, pain, wound infection, and hematoma) ranging between 13% and 34%, with overall device removal rate between 8% and 23% [48]. In summary, sacral nerve stimulation for refractory chronic constipation is an expensive, invasive procedure which lacks proven benefit.…”

Management der schweren idiopathischen Darmträgheit

“…In der Folge konnten einige Untersucher einen positiven Effekt der SNS auf die Stuhlfrequenz aufzeigen, wobei die Ergebnisse jedoch sehr unterschiedlich ausfielen. Eine rezente systematische Übersichtsarbeit von Pilkington et al [62], die 7 Studien mit insgesamt 375 Patienten inkludierte, zeigte eine erhebliche Heterogenität bez. der funktionellen Ergebnisse bei chronischer Obstipation, wobei Patienten mit einer STC in 6 Studien inkludiert waren, aber nicht gesondert ausgewertet wurden, sodass eine Aussage über diese Patientengruppe noch schwieriger zu treffen ist.…”