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Nerve stimulation, antegrade enemas both help kids’ constipation
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SAN DIEGO — Sacral nerve stimulation and antegrade continence enemas, when compared with each other, both offer positive experiences for children with severe constipation and each may best suit a different cohort of children, a presenter at Digestive Disease Week 2019 said.
“Overall, families in both groups had a highly favorable impression of their procedures. Some described their procedures as life changing and some said they wished they knew about the procedures earlier,” Lyon Wang, BA, MS3, a third-year medical student at The Ohio State University, said during his presentation.
In this prospective comparison of sacral nerve stimulation (SNS) vs. antegrade continence enemas (ACE) for children with severe functional constipation, Wang and colleagues used data from two patient registries for patients receiving SNS and ACE aged younger than 18 years who had functional constipation. Patients completed questionnaires at baseline and follow-up encounters at 6 and 12 months and the researchers used additional information from EMR to fill out the study. Researchers also contacted parents by phone to administer the Glasgow Children’s Benefit Inventory and added two questions directed at the parent.
“Both SNS and ACE can be effective in children with severe functional constipation, but no studies thus far have compared these two options,” Wang said.
The baseline group comprised 31 patients who underwent SNS (65% girls) and 10 who underwent ACE (60% girls). Wang pointed out that, at baseline, the SNS group did have more frequent bowel movements with 23% having three or less BMs per week vs. 60% of the ACE group falling into that category. Similarly, only 10% of the SNS group used rectal enemas at baseline compared with 50% of the ACE group.
Wang and colleagues defined success as three or more BMs per week and less than one fecal incontinence (FI) incident per week.
“We found that patients in the SNS group did not significantly improve their bowel movement frequency, but they did show a significant reduction in fecal incontinence at 6 months (P < .05) and 12 months (P < .01) after initiating treatment,” Wang said. “In contrast, patients in the ACE group showed significant improvement in bowel movement frequency (P < .01 at 6 months; P < .05 at 12 months) but not in fecal incontinence.”
The SNS group also showed reduction in hard stools at both time points (P < .05 for both) while the ACE group did not. Also, the SNS group had higher reports of no abdominal pain at both time points (P < .01 at 6 months; P < .05 at 12 months).
In looking at medication use, Wang reported that the SNS group did not improve in use of oral laxatives or rectal enema use.
“In contrast, the ACE group did show significant improvement in use of oral laxatives at 6 months (P < .01) and 12 months (P < .05) as well as reduction of rectal enema use at 12 months (P < .05),” he said.
“SNS may be a better option for the child with more frequent bowel movements but continued fecal incontinence while ACE may be better for the child with less frequent bowel movements,” Wang said.
The SNS group had fewer total complications – 26% vs. 70% with the ACE group (P < .01) – as well as less major complications requiring surgery (6% vs. 30% with the ACE group; P = .05).
In the follow-up looking to measure patient satisfaction, Wang reported positive results from both groups.
“We found that all patients actually reported a positive benefit from their procedures. ... In terms of satisfaction, nearly all SNS patients would repeat the procedure if given the opportunity and all would recommend the procedure to others,” he said. “In terms of the ACE group, there is universal satisfaction in terms of repeating the procedure and in recommending the procedure to others.” – by Katrina Altersitz
Reference: Wang L, et al. Poster 884. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.
Disclosures: The authors report no relevant financial disclosures.
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Joel R. Rosh, MD, FAAP, FACG, AGAF
This is a study from a quaternary center, which means the center deals with some of our most difficult functional motility patients who are suffering with severe constipation. The study defined severe constipation as less than three bowel movements per week, but I’m sure it was even less than that.
A large percentage were having more than one episode of incontinence per week, which can be devastating for anyone at any age, but we can appreciate how devastating incontinence can be for a child in school and the social impact of that. This is a patient population that needs significant intervention for a very serious medical problem and the authors compared clinical outcomes of antegrade continence enemas (ACE) compared with sacral nerve stimulation.
As far as clinical response, both interventions did have positive impacts on these children’s severe constipation.
The sacral nerve stimulation seemed to give an end result of fewer episodes of incontinence, they were able to drive that number to less than one per week.
Additionally, for those patients who were having abdominal pain in association with their severe constipation, they saw great improvement in abdominal pain as well as continence.
The ACE procedure helped to drive more bowel movements per day but did not help with the incontinence nor the abdominal pain. The researchers postulated that those patients plagued by more incontinence might do better with the sacral nerve stimulator.
It was notable that there was a relatively high complication with ACE, 70% had a complication and 30% had what was described as a major complication requiring a repeat surgical procedure to correct. Nonetheless, both groups were satisfied with the intervention, which speaks to how difficult their problems were going into the trial, and they would recommend the procedure for subsequent patients.
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