Medium-term outcome of sacral nerve modulation for constipation.

BACKGROUND: Sacral nerve modulation has been reported as a minimally invasive and effective treatment for constipation refractory to conservative treatment. OBJECTIVE: This study aimed to evaluate the efficacy and sustainability of sacral nerve modulation for constipation in the medium term (up to 6 years) and to investigate potential predictors of treatment success. DESIGN: We performed a retrospective review of prospectively collected data. SETTINGS: The study was performed at 2 tertiary-care centers in Europe with expertise in pelvic floor disorders and sacral nerve modulation. PATIENTS: Patients were eligible if they had had symptoms of constipation persisting for at least 1 year, if conservative treatment (dietary modification, laxatives and biofeedback therapy) had failed, and if predefined excluded conditions were not present. INTERVENTION: The first phase of the treatment process was percutaneous nerve evaluation. If this was successful, patients underwent sacral nerve modulation therapy with an implanted device (tined-lead and implantable pulse generator). MAIN OUTCOME MEASURE: Follow-up was performed at 1, 3, 6, and 12 months, and yearly thereafter. Outcome was assessed with the Wexner constipation score. RESULTS: A total of 117 patients (13 men, 104 women) with a mean age of 45.6 (SD, 13.0) years underwent percutaneous nerve evaluation. Of these, 68 patients (58%) had successful percutaneous nerve evaluation and underwent implantation of a device. The mean Wexner score was 17.0 (SD, 3.8) at baseline and 10.2 (SD 5.3) after percutaneous nerve evaluation (p < .001); the improvement was maintained throughout the follow-up period, although the number of patients continuing with sacral nerve modulation at the latest follow-up (median, 37 months; range, 4-92) was only 61 (52% of all patients who underwent percutaneous nerve evaluation). The sole predictive factor of outcome of percutaneous nerve evaluation was age: younger patients were more likely than older patients to have a successful percutaneous nerve evaluation phase. LIMITATIONS: The study was limited by a lack of consistent outcome measures. CONCLUSIONS: : Despite improvement in Wexner scores, at the latest follow-up sacral nerve modulation was only being used by slightly more than 50% of the patients who started the first phase of treatment. Further studies are needed to reassess the efficacy and sustainability of sacral nerve modulation.

[Oxalate nephropathy due to malabsorption syndrome]. / Oxalaatnefropathie door malabsorptiesyndromen.

Enteric oxalate nephropathy is caused by hyperoxaluria. Factors which contribute to excessive oxalate absorption are an abundance of free fatty acids in the intestine due to malabsorption, changes in the microbiome, and bowel inflammation. We present two cases that illustrate different pathophysiological aspects of this disease. The first patient was a 70-year-old male who developed oxalate nephropathy through malabsorption caused by chronic pancreatitis. It is plausible that the oxalate nephropathy was set off by antibiotic treatment which influenced the microbiome. The second patient was a 63-year-old male who underwent a Roux-en-Y gastric bypass. The associated malabsorption resulted in oxalate nephropathy. Kidney biopsies from both patients showed typical oxalate crystals. Therapeutic regimens using calcium supplementation, steroids, and a low oxalate diet are rational treatments, which have proven to prevent deterioration of renal function in some patients.