Sakralnervmodulation in der Therapie der Stuhlinkontinenz und Obstipation: Evidenz, Programmierung und Langzeitmanagement

Zusammenfassung

Hintergrund Die sakrale Neuromodulation (SNM) hat sich in den letzten 2 Jahrzehnten fest in der Therapie funktioneller Beckenbodenerkrankungen etabliert. Trotz nicht vollständig geklärtem Wirkungsmechanismus ist sie zum bevorzugten Verfahren in der chirurgischen Therapie der Stuhlinkontinenz geworden.

Methoden und Ergebnisse Es wurde eine aktuelle Literaturanalyse zur Schrittmacherprogrammierung sowie zu Langzeitergebnissen der SNM bei Stuhlinkontinenz und Obstipation durchgeführt.

Die SNM bei Stuhlinkontinenz zeigt sich auch im Langzeitverlauf erfolgreich. Über die Jahre konnte das Indikationsspektrum auf Patienten mit Sphinkterläsionen ausgeweitet werden. Die Anwendung beim Low Anterior Resection Syndrome (LARS) nach Rektumresektion ist aktuell in klinischer Erprobung. Bei den verschiedenen Formen der Obstipation hingegen ist die Wirkung der SNM nicht eindeutig belegbar. In mehreren randomisierten Cross-over-Studien konnte kein Erfolg nachgewiesen werden, auch wenn dieser möglicherweise für Untergruppen der Obstipation besteht. Zum jetzigen Zeitpunkt kann die Anwendung nicht allgemein empfohlen werden.

Die Schrittmacherprogrammierung definiert Elektrodenkonfiguration, Stimulationsamplitude, Pulsfrequenz und Pulsbreite. Während die Einstellung von Pulsfrequenz und -breite eher anhand standardisierter Werte erfolgt und meist als Niederfrequenzstimulation mit einer Frequenz von 14 Hz und einer Pulsbreite von 210 s durchgeführt wird, werden Elektrodenkonfiguration und Stimulationsamplitude individuell an den einzelnen Patienten angepasst. Insbesondere im 1. postoperativen Jahr können Reprogrammierungen aufgrund von Wirkungsverlust oder Nebenwirkungen erforderlich werden.

Trotz geringer Häufigkeit von Infektionen und Elektroden-/Impulsgeberfehlfunktionen benötigen im Langzeitmanagement bis zu 65% der Patienten operative Revisionen. Diese sind bei etwa 50% bedingt durch erwartbare Batterieerschöpfung des Impulsgebers. Auch mindestens eine Reprogrammierung wird bei 75% der Patienten im Verlauf erforderlich, meist aufgrund einer Wirkungsveränderung, seltener aufgrund von Schmerzen. Regelmäßige Nachuntersuchungen sind empfehlenswert.

Schlussfolgerung Die SNM hat sich in der Langzeittherapie der Stuhlinkontinenz als sicheres und erfolgreiches Verfahren bewährt. Um einen optimalen Therapieerfolg zu erzielen, ist eine strukturierte Nachsorge erforderlich.

Abstract

Background Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence.

Methods and Results A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.

Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.

The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.

Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up – in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable.

Conclusion Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.

Schlüsselwörter

sakrale Neuromodulation - Stuhlinkontinenz - Programmierung - Langzeitmanagement

Keywords

sacral neuromodulation - fecal incontinence - programming - long-term management

Publication History

Received: 02 February 2023

Accepted after revision: 22 March 2023

Article published online:
02 June 2023

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