GASTROENTEROLOGY/HEPATOLOGY

Dan Teitelbaum, M.D., leads one of only a few programs in the country with experience implanting sacral nerve stimulators in pediatric patients. SNS uses a small neurotransmitter to send electrical impulses that influence the rectal sphincters and pelvic floor muscles.

Positive influence

Sacral nerve stimulation offers new hope for children with refractory constipation

issue 24 | Summer 2015

From the day Piper Shumar was born, she suffered from constipation. "Her bowel movements were infrequent, and when she did have one it was softball-sized and hurt her terribly, often causing her to bleed," says Kimberly Shumar, Piper's mom.

Year after year, Piper's constipation issues continued. She also had a hard time gaining weight. Even with supplemental nutrition, Piper remained chronically constipated as she turned 4 years old.

"Severe, long-term constipation in children needs to be treated aggressively," says Dan Teitelbaum, M.D., pediatric surgeon and director of the Colorectal Pediatric Surgery Program at C.S. Mott Children's Hospital. "Because there can be a number of causes for constipation, accurate diagnosis is the first step in either resolving the issue or ruling out more serious causes."

A search for a cause

In Piper's case, her original physicians initially believed she may have Hirschsprung's disease and recommended an ileostomy. Piper's parents sought out a second opinion and were referred to C.S. Mott Children's Hospital.

The Shumar family met with Teitelbaum, who performed additional colon biopsies as part of her evaluation. Rather than an ileostomy, Teitelbaum and the colorectal team at Mott recommended an appendicostomy, which would allow Piper's parents to flush her entire colon to evacuate a bowel movement through a tube in her abdomen once a night.

"Appendicostomy has proven to be effective in select children with intransigent constipation that has failed maximum medical treatment," says Teitelbaum. "For many children, this has provided significant relief and a better quality of life."

Once Piper was placed under anesthesia for the appendicostomy, however, her body relaxed and she had a bowel movement.

"That indicated, to me, that Piper's problem was actually related to a failure to relax her distal rectum and anal sphincters," says Teitelbaum. "Based on that information, sacral nerve stimulation was a better alternative for Piper."

Teitelbaum left the OR and met with the Shumars to discuss his recommendations with the family, who were pleased to hear that about this new, reversible treatment option.

A pacemaker for the sacral nerve

Sacral nerve stimulation (SNS) therapy uses a small a neurotransmitter, similar to a pacemaker, implanted under the skin in the upper buttock area. The device sends mild electrical impulses through a lead that is positioned close to the sacral nerve to positively influence the rectal sphincters and pelvic floor muscles.

The Colorectal Pediatric Surgery Program at C.S. Mott Children's Hospital is one of only a few programs in the country with experience implanting sacral nerve stimulators in pediatric patients.

"Nerve stimulation can be particularly effective for select children with refractory constipation or intractable incontinence caused from injury to the sphincteric complex or congenital problems of the anal canal," says Teitelbaum.

A two-stage procedure

The procedure is performed in two stages, which allows the team to assess improvement in bowel function during an initial procedure before implanting the subcutaneous device. Both procedures are performed on an outpatient basis, under general anesthesia by a team of surgeons specially trained in SNS placement.

For most patients, the nerve stimulator can remain in place for three to five years before the battery has to be replaced. "At that point, we'll be able to determine if the stimulation has jump-started her system to the point where it's not necessary anymore," says Teitelbaum.

In Piper's case, as soon as the nerve stimulator was implanted and turned on, Piper had a bowel movement. Since the surgery, she's been having regular bowel movements.

"Piper is like a new kid now. She's eating well, gaining weight and full of energy," says Mrs. Shumar. "She calls the stimulator her 'battery' and says she loves it."

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The Colorectal Pediatric Surgery Program team specializes in caring for children with a multitude of conditions.