A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients Saskia Vande Velde MD, Stephanie Van Biervliet MD PhD, Ruth De Bruyne MD, Myriam Van Winckel MD PhD Department of Pediatric Gastroenterology, University Hospital Ghent Belgium The authors declare no conflict of interest. Correspondence address Saskia Vande Velde Ghent University Hospital De Pintelaan 185 9000 Ghent, Belgium Tel 0032 9 332 64 68 Fax 0032 9 332 21 70 e-Mail: [email protected]1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2
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· Web viewPerturbation of these processes will result in bowel incontinence which is often associated with constipation in SB patients 2,3. Fecal incontinence in SB patients is reported
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A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients
Saskia Vande Velde MD, Stephanie Van Biervliet MD PhD, Ruth De Bruyne MD, Myriam Van Winckel MD PhD
Department of Pediatric Gastroenterology, University Hospital Ghent Belgium
Single centreRetrospective chart reviewProspective bowel program: daily, regular, consistently timed, reflex-triggered bowel evacuation Phone FU /2w & during FU visits
n= 33 SBAge: 5-16yLL: T10-S2 no mentalimpairmentFI: nmConstipation: nm
FU: 12m TT: nm
Not defined Single centreProspective controlled trial. Daily symptom log, 1m before & during19 SB behaviour modification: 10’ toilet sitting every evening14 biofeedback /2w & behaviour modification.
Biofeedback: (before) 5,38 to 1,93 (12m) accidents/week5/14 (36%) continentBehaviour: (before) 5,77 to 2,3 (12m) accidents/week4/19 (21%) became continent.No significant difference between groups
Not defined Single centreProspective controlled trialQuestionnaire evacuation habits10 biofeedback sessions12 conventional treatment (laxatives, stimulants, enema)30 no treatment
Not defined Single centreSelf-controlled clinical trial.Daily record. FU visits at week 0,1,2,5. Anal plug use start at week 1.Effect on FI scale 0-4 (0=not
15/20 completed the studyAccidents/w start: 4(0-28), 5w 0(0-8) (p=.002)
Baseline 50% FI severely impedes daily life.5w 40% slight interference Significant reduction of FI scale (p=.001).
Single centre Descriptive cohort studyStepwise therapeutic strategy
5/80 regular toileting (no FI)13/80 manual evacuation (38% FI)24/80 RCE (13% FI)16/80 ACE (no FI)22/80 (27%) FI
Not evaluated
Shandling and Gilmour, 87 10
n= 112 SBAge: 4-20yLL: nmFI: 112 Constipation: nm
FU: nmTT: 15 to 20 min
Stool loss < 4x/month
Single centreRCE with balloon catheter with saline water 20 ml/kg every 24 to 48h
4 dropped out5 returned to RCE after initially dropping out100% continence rate
Not evaluated
Liptak and Revell,
n= 31, 30 SBAge: 3-19yLL: T-S4
FU: 30 months TT: 21 min
No stool loss Single centreProspective clinical trial.After bowel cleaning, start RCE with
6 dropped out first 3 weeks9 dropped out after 18moFI dropped from 72% (18/25)
Mean satisfaction score increased from 1.1 to 2.8 after 18mo and 3.3 after 30mo
112122
92 16 FI: 18/25 Constipation: 14/25
balloon catheter, every 24 to 48h with saline water 20ml/kg.Standardized questionnaire over telephone or by visit. Satisfaction rate 1-4 (1= extremely dissatisfied, 4= extremely satisfied).
to 29% (7/25) at 18mo and to 6% (1/16) after 30mo (p<.01)
(p<.01)
Schöller-Gyüre et al, 96 17
n= 53 SBAge: 7mo-22yLL: nmFI: 14 Constipation: 14
FU: 33 months TT: nm
No stool loss Single centreCase review and questionnaire.RCE with cone catheter with tap water 20ml/kg every 24h.Frequent telephone contact.
Parental satisfaction high in 63%, good in 37%.Major disadvantage is time and energy to perform RCE (51%), daily burden on family (39%)
Eire et al, 98 18
n= 33 SBAge: 5-22yLL: nmFI: nmConstipation: nm
FU: 30 monthsTT: Median 30 min [15-45 min]
No stool loss Single centreSelected and well-motivated patientsRetrospective case review.After desimpaction, start RCE with balloon catheter saline water, median 500 ml every 24h and at continence, every 48 h
No stool loss Single centreParental questionnaire (8 questions).RCE with cone catheter with tap water, median 300 ml every 24hPlasma sodium levels in 28 SB before start and after 1mo or 1yManometry in 28 SB before and after 1-3y
5 dropped out35/40 were continentAll free of constipation1/40 was independent
35/40 found RCE satisfactoryAll found RCE time consuming36/40 parents reported general improvement in well-being
Ausili et al, 10 20
n= 60 SBAge: 8-17yLL: nmFI: 16 Constipation: 60
FU: 3 monthsTT: nm
Stool loss < 1x/ month
Single centreProspective clinical trial.Validated questionnaire (NBD score, range 0-47 (47= severe bowel dysfunction)45) and QoLVisit at start and after 3moRCE with balloon catheter
36/60 (60%) relief of constipation 12/16 (75%) relief of faecal incontinenceNBD decreased from 17,5 to 8,5 after treatment (p<.001)
parents reported an improvement on QoL and degree of satisfactionNBD score improved from 17.5 to 8.5 (p<.001)
Pereira et al, 10
n= 40, 28 SBAge: 6-25y
FU: 12 monthsTT: average 15-
No stool lossPseudo-
Single centreProspective clinical trial
35 returned questionnairePseudo-continence rose from
Mean grade of satisfaction was 7.3
122324
21 LL: nmFI: nmConstipation: nm
30 min continence: no stool loss with treatment
Standard questionnaire on bowel function and QoL (rate 0-10, 0= great reduction, 10= great improvement)RCE with balloon catheter withaverage 616 ml tap water, every 3 days
10/35 to 28/35 (80%)16/35 partially or total independentSignificant less time spent than conventional bowel management
Choi et al, 13 22
n= 53 SBAge: 3-13.8yLL: nmFI: nmConstipation: nm
FU: 4 monthsTT: 15.9 min
Stool loss <1x/week
Single centreProspective clinical trialSurvey questionnaire on bowel symptoms, QoL and general characteristics (40 items)Stepwise bowel program: first polyethylene glycol 3350 at 0.5g/kg/day, if failure start RCE with cone or balloon catheter with tap water every 48 to 72h
6/53 (11%) success43/47 (81%) successBowel care time decreased from 27 to 15.9 min (p=.003)FI per week decreased from 6.9 to 0.5 defecations per week (p=.004)
Significant reduction in impact on travel and socialization (p=.006)Significant reduction in caregiver support and emotional impact (p<.001)
Table 2: Summary of papers on electrical stimulation in spina bifida patients
Author Sample Follow up/ defecation time
Definition faecal continence
Study design Findings - effectiveness Findings - satisfaction
Marshall and Boston, 97 23
n= 50 SBAge: 4-18yLL: nmFI: nmConstipation: nm
FU: 6 weeksTT: nm
Not defined Single centreRandomized double-blind placebo- controlled trialDaily 1h at home ES stimulation on skin: 26 treatment, 24 shamRegular telephone contact to stimulate complianceOne week diary
49% more spontaneous stools in active ES, but not significant Important placebo effectNo adverse effects
Not evaluated
Palmer et al, 97 24
n= 55 SB Age: 2-14y
FU: 12-72 months
Improvement:- less
Single centreProspective clinical trial
20/55 (36%) complete success (improvement of all parameters)
Inclusion of parental subjective opinion decreased the success
13
229230
231
232
2526
LL: nmFI: nmConstipation: nm
TT: nm defecations- better rectal sensation- ability to hold consciously
Home transrectal ES30min/d, 5 d/w
30/55 (55%) moderate success (improvement of any parameter)71% complete bowel continenceNo adverse effects
rate of this therapy
Han et al, 04 25
n= 24 SB Age: 4-13yLL: nmFI: nmConstipation: nm
FU: 15.8 monthsTT: nm
No stool loss Single centreRetrospective case reviewDaily 1h at home transurethral ES, 5days/w for 4wFU cycles: 2w every 3 to 6moOne week diary before treatment and subsequent cycles
Mean episodes of faecal incontinence decreased significant from 7.3 to 4.8 a week (p<0.05)Complete faecal continence in 50% (12/24)Urinary tract infections in 10 patients during transurethral ES
Not evaluated
Kajbafzadeh et al, 12 26
n= 30 SB Age: 3-12yLL: nmFI: nmConstipation: nm
FU: nmTT: nm
Stool loss < 1x/ week
Single centreRandomized controlled trialHome cutaneous ES for 20 min, 3x/w: 15 treatment, 15 shamBowel habit diary, NBD: range 0-47 (47= severe bowel dysfunction)45
Manometry before and 6mo after treatment
Constipation is decreased in 11/15 (73%) and remained in 8/15 (53%) after 6mo Significant increase of stool frequency from 2.5 to 4.7 stools/w after treatmentSignificant improvement manometry measuresNo adverse effects
30 months Full: totally clean or minor leakage on night of washout
Multicenter retrospective proformaMalone ACE or button (19/273)
68/108 (63%) full success111/273 complications
Not evaluated
Aksnes et al, 02 31
N= 20 SBAge: 6.3-17yLL: nmFI: 16 Constipation: 4
FU: 16 monthsTT: 50 min [30-75]
No stool loss Single centreProspective clinical trialMalone ACE 900ml tap waterStandardized questionnaire before and 6mo after ACE, CBCL, YSR, SPPA 1-4 score (4=describes me very well)Follow up visit and telephone
16/20 gained independency16/20 complete continence6/20 redo surgery
SPPA: postoperative improved self-esteem (p=.04) and close friends (p=.006)CBCL and YSR no difference pre- and postoperative
Dey et al, 03 32
N= 62, 31 SBAge: 3.8-21.4y
FU: 65 monthsTT: 53 min
Stool loss < 1x/ month
Single centreRetrospective casenote reviewAppendix ACE 550ml saline
5 point Likert scale (1=permanent, 2=frequent, 3=occasional, 4=rare, 5=never)
MulticentreClinical interview and medical chart reviewRight ACE: 40, left ACE: 7, 1.2L tap or saline waterConventional treated group (n=382) compared to ACE group (n=41)
6 dropped outACE group is significant youngerACE group significant less FILeft ACE tends to shorter defecation time and worse FI
No stool loss Single centreRetrospective chart reviewMalone ACE daily 642ml tap waterEvaluation of use of additives:- immediate FI: larger volume or more time on toilet- midday FI: bowel cleanout and add 17mg MiraLAX
196/236 (83%) continence rose to 221/236 (94%) using additives
No stool loss Single centreRetrospective chart review Interviews and telephone, structured questionnaire score 0-24 (0=full continence, 24= complete incontinence)Chait cecostomy glycerine or saline water every 48 to 72h
FI score in SB improved from 18 to 728/64 complications
Children FU: 60 monthsTT: 35 min [15-60]Adults FU: 132 monthsTT: 60 min [30-120]
No stool loss Single centreRetrospective cohort descriptionQuestionnaire at clinicComparing RCE and ACE use in children and adults- child 18 RCE, 7ACE- adult 4 RCE, 11 ACE
5 dropped out19/25 (76%) children continent9/15 (60%) adults continent5/25 children independent8/15 adults independentSignificant relation between follow-up and continence
2/6 children perceived incontinence as social problem compared to 4/6 adults did
Legend: SB: spina bifida, ACE: antgrade continence enema, RCE: retrograde continence enema, QoL: quality of life; CTT: colonic transit time; CBCL: child behaviour checklist; YSR: youth self-report; SPPA: self-perception profile for adolescents; FICQoL: fecal incontinence and constipation QoL
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