Effects of neuromodulation with sacral magnetic stimulation for intractable bowel or bladder dysfunction in postoperative patients with anorectal malformation: a preliminary report.

BACKGROUND AND PURPOSE: The effects of neuromodulation with sacral magnetic stimulation (SMS) were examined in postoperative patients with bowel or bladder dysfunction. PATIENTS AND METHODS: SMS was performed at the S3 level using a MagPro® instrument (Medtronic Inc., USA) while the patients were under light sedation. One treatment course consisted of stimulation delivered at 15 Hz for 5 s, 10 times over an interval of 1 min. Three patients with bladder or bowel dysfunction refractory to conservative treatment were examined. RESULTS: Case 1 is a 7-year-old male with a rectourethral fistula. This patient developed a hyperdynamic bladder after a laparoscopic pull-through operation at the age of 7 months. The administration of an anticholinergic agent slightly improved the condition. SMS was started at the age of 4 years with one trial each year. A marked expansion of bladder volume from 20 ml before trial to 120 ml after the third trial was obtained. Case 2 (a 4-year old female with a recto-vaginal fistula) and Case 3 (a 8-year-old female with an ano-vestibular fistula) showed severe constipation after radical surgery during infancy. Case 2 needed appendicostomy. After SMS, bowel movements could become controllable with enemas. No adverse effects were observed for any of the three cases. CONCLUSIONS: These results suggest that SMS might be a useful modality to improve postoperative bowel or bladder dysfunction.

Effect of sacral magnetic stimulation on the anorectal manometric activity: a new modality for examining sacro-rectoanal interaction.

We examined the interaction between the sacral neural system and the anorectal activity using a technique comprising repetitive magnetic stimulation. Thirteen control children without any bowel dysmotility (age range; 3 month old to 15 year old), 20 patients with chronic constipation (1 month old to 14 year old), and nine pre-operative patients with Hirschsprung's disease (1 month old to 6 year old) were examined. Magnetic stimulation was applied at the S3 level using the MagPro (Medtronic) device while simultaneously performing manometric recordings of the anorectal activity. In the 13 controls and the 20 patients with chronic constipation, the rectoanal reflex was demonstrated by balloon rectal dilatation. The sphincter response to magnetic stimulation was biphasic in the controls, consisting of an initial rise followed by a decrease in the sphincter pressure, while it varied among the patients with chronic constipation including a biphasic response in 16 patients, no response in three patients, and only a transient rise in pressure in one patient. In nine pre-operative patients with Hirschsprung's disease, no rectoanal reflex was observed, however, the sphincter pressure increased due to magnetic stimulation in six patients, while three patients exhibited no recordable responses. These results suggest that the repetitive magnetic stimulation technique is a valuable modality for investigating the neural interaction between the sacral nervous system and the anorectum.

Fecoflowmetric profiles in postoperative patients with Hirschsprung's disease.

PURPOSE: The objective of this study is to evaluate the anorectal function from the viewpoint of fecoflowmetry in postoperative patients with Hirschsprung's disease (HD). METHODS: This study evaluated 23 long-term follow-up patients who had undergone a radical operation for HD. Their mean age was 11 years. The types of HD included rectosigmoid colon type, 18 cases, and entire colon type, 5 cases. An anorectal manometric study was performed before fecoflowmetry. After normal saline solution was administrated as an imitation stool into the rectal cavity under pressure monitoring, the patients defecated on a fecoflowmeter. After discussing the maximum defecation flow (Flow-max), fecoflow pattern (FFP), tolerance rate (TR), anal canal pressure (AP), and Kelly's clinical scores (Kelly-Scores), the significant parameters were identified to elucidate the anorectal activity. RESULTS: (1) A close relationship was observed between the FFP and Kelly-Scores (P = .0027). (2) Flow-max, TR, and AP in patients with good Kelly-Scores were significantly higher than those in patients with fair Kelly-Scores (P < .05). (3) The Flow-max accurately reflected the TR, Kelly-Scores, and AP. Flow-max >45 mL per second, TR >70%, or AP >30 mm Hg was statistically regarded as a borderline level of fecal continence (P < .002). CONCLUSIONS: The Flow-max and FFP are considered to be useful parameters for postoperative patients with HD.