The promise of sacral neuromodulation in idiopathic slow-transit constipation

Dear Editor, Idiopathic slow-transit constipation (STC) is a debilitating condition marked by prolonged colonic transit times, significantly impairing the quality of life of those affected1,2. The pathophysiology of STC is poorly understood, complicating the development of effective treatments. Traditional conservative treatments often fall short for those with refractory STC, leaving patients and clinicians in a quagmire of ineffective therapies and persistent symptoms2. Sacral neuromodulation (SNM), a technique initially developed for urinary incontinence3, has emerged as a promising alternative, offering new hope to those suffering from this perplexing condition4. SNM works by delivering electrical stimulation to the sacral nerves, influencing intestinal motility and offering a novel mechanism of action distinct from traditional laxatives or surgical interventions like subtotal colectomy, which carries higher risks and mixed outcomes3,4. A recent multicenter, open label, randomized clinical trial (NCT02961582), compared the efficacy of SNM to personalized conservative treatment (PCT) in 67 patients4. Forty-one patients received SNM and 26 underwent PCT. The study reported a treatment success rate of 53.7% in the SNM group compared to only 3.8% in the PCT group4. This study sheds light on the role of SNM in managing refractory idiopathic STC, with implications that could reshape current treatment paradigms. First, for patients who have not responded to extensive conservative measures, SNM offers a viable and effective alternative. The significant improvement in defecation frequency and associated symptoms like constipation severity provides a compelling argument for considering SNM early in the management of refractory STC4. Beyond alleviating physical symptoms, SNM has shown remarkable benefits in enhancing patients’ overall quality of life4. These benefits extend beyond mere symptom relief, impacting various aspects of wellbeing, which is particularly important for a condition known to cause significant psychological and social distress. Also, the trial reported manageable adverse events, most of which were minor and resolved without long-term sequelae4. Despite its promise, the implementation of SNM comes with its set of challenges and considerations. First and foremost, accurate patient selection is crucial, as demonstrated by the rigorous inclusion criteria used in the trial4. Patients with co-existing conditions like outlet obstruction or previous significant abdominal surgeries were excluded, which underscores the importance of patient selection in achieving good outcomes with SNM. Moreover, SNM involves the use of implantable devices and potentially multiple surgical interventions, which can be costly. Healthcare systems will need to evaluate the cost-effectiveness of this treatment and consider potential long-term savings from reduced hospital visits and treatments for constipation-related complications. Furthermore, while the trial provides compelling short-term data, long-term outcomes are crucial for a chronic condition like STC. Future studies should focus on the durability of SNM effects and the potential need for repeat interventions. In conclusion, SNM is an emerging treatment modality of refractory idiopathic STC. Its ability to significantly improve symptoms and quality of life in a condition often resistant to other treatments marks a paradigm shift in management. However, the broader application of SNM will depend on continued research, particularly long-term studies, and thoughtful consideration of patient selection, economic factors, and procedural expertise. Ethical approval Ethical approval is not applicable for this correspondence article. Consent Informed consent is not applicable for this correspondence article. Sources of funding None. Author contribution A.A.: conceptualization, project administration, supervision, validation, writing – original draft, and writing – review and editing; N.A.W. and S.B.B.: project administration, validation, writing – original draft, and writing – review and editing; P.S., R.K.S., D.S., M.A., M.N.K., S.G., Q.S.Z, and S.R.: supervision, validation, and writing – review and editing. Conflicts of interest disclosure No conflict of interest to declare. Research registration unique identifying number (UIN) Not applicable. Guarantor Ayush Anand. Data availability statement None. Provenance and peer review Not commissioned, externally peer-reviewed Assistance with the study None.

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