Good afternoon to both our live and virtual audience. This presentation is being live-streamed. My name is Mike Salino. I'm the chair of Physical Medicine and Rehabilitation at Cooper University Health Care in Camden, New Jersey and South Jersey in the Delaware Valley. Welcome to Enhancing Your Understanding of Management of Neurogenic Bowel. How many folks have young kids in the audience, you know, under the age of 10? How many people knew who Professor Poopypants is? There you go. For those of you who don't know, he is Captain Underpants's arch nemesis. It is really an honor to share the podium today with some close friends and colleagues. One of my close friends and colleagues is actually stuck in Charlotte and will not be able to make it today, but she did forward me her slides and I'll be presenting for her. I will let each presenter introduce themselves and their affiliation, but they are all highly talented clinicians, two of which are outside of our specialty, which I think is good for a conference like this for us to kind of see different opinions and how other specialties look at this. For our first presenter, we are going to have Dr. Christina Morton-Schaaf from Across the River at Temple University. She is an assistant professor of neurology. Thank you so much. It is a pleasure to be here with you all. So I'm going to start the talk off with just simply speaking about the gastrointestinal changes that occur as a result of neurologic injury and disease. I have no disclosures. So naturally, we all know that the nervous system is comprised of a number of different components. We have the central, the peripheral, and the autonomic nervous systems. Central, of course, is brain and spinal cord. Peripheral, I think of as the motor unit. I'm a neuromuscular neurologist. This is the anterior horn cell, the nerve, neuromuscular junction, and muscle, and then the autonomic nervous system. This is typically thought of as our sympathetic and parasympathetic systems, but we're going to be speaking today about the enteric nervous system. As a subdivision of the autonomic nervous system, the enteric nervous system is responsible for motor activity, for secretion and blood flow in the gut. Embryologically, it's formed by neural crest cells, and it includes nearly as many neurons as the entire spinal cord, which is quite impressive. It extends anatomically from the pharyngeal junction to the internal anal sphincter, so quite longitudinally extensive, and it's comprised of a number of different neurons, the types that we're going to talk about today are the ascending and descending neurons. The ascending neurons activate excitatory motor neurons, and what that means is it leads to smooth muscle contractions, cranially or orally, to a stimulation, food bolus in this case. For the descending neurons, this is going to activate inhibitory motor neurons, leading to smooth muscle relaxation, caudal to the stimulation, and so with that contraction, cranially, relaxation, caudally, naturally we get the combination to lead to peristalsis, which is simply the motility of the gut that starts all the way up in the esophagus and is mediated all the way down to the rectum. However, the enteric nervous system doesn't operate alone to control our gut's function, and so what we're going to take a look at during the next few minutes is a few of the influences on GI motility by other aspects of the nervous system, starting with the rest of the autonomic nervous system, sympathetics and parasympathetics. Naturally, we all know that the sympathetics is our fight-or-flight response, and so when we're in that fight-or-flight response, we don't want our gut to be functioning, so the sympathetics, which come from the thoracolumbar preganglionics, the T2 to L2 intermedial lateral cell column, innervate the intestines and the rectum. The increase in sympathetics in this fight-or-flight leads to decreased enteric nervous system neurotransmission and decreased gut motility. Seems fairly straightforward. Our parasympathetics, on the other hand, that happens when we're nice and relaxed, when our guts allowed to function, and this comes from a couple of different ways. It's fed by the vagal axons, which innervate the stomach, small intestine, ascending and transverse colons, and also from the sacral preganglionic neurons, which are in our S2 to S3 intermedial lateral cell columns. This innervates the descending and sigmoid colons, as well as the rectum, and so naturally, activation of our parasympathetics then leads to a prokinetic effect and defecation, and the schematic on the right-hand side is just a really complicated representation of how extensive the sympathetic, parasympathetic, and motor control of the gut is. In addition to our autonomic nervous system implications on the enteric nervous system, we have our central nervous system, so the brain and the brainstem work very closely to communicate and control our enteric nervous system. Two areas in particular, we have the dorsal motor nucleus of the vagus, which is in the medulla, and this contains the aria prostrema and the chemotrigger zone. Aria prostrema is our vomiting center, and the chemotrigger zone is the cholinergic preganglionic neurons, which innervate the small intestine in the proximal colon. The second is the Barrington's nucleus, which is located in the pons, and this is our micturition and defecation center. Lastly, and I'm not going to spend time on this today, because this is an up-and-coming field, we have the gut microbiome, so I do want to just very briefly mention this, and this is just a inclusion of over a thousand species that are natural to each of our colons and guts that work to strengthen the intestinal epithelial barrier, to facilitate absorption of nutrients, and to maintain immunity. And what we're starting to learn about is that gut dysbiosis happens in a number of different neurologic disorders and in injuries, leading to inflammation and gut immotility and gut dysfunction. So again, something that we'll learn about more in the coming years, I think, but something important just to briefly mention. So of course, the big question is how does all of this influence the experience of our patients? So as Dr. Salino had mentioned, you know, we have neurogenic bowel, which is a very important question for, and implication for, a lot of our patients. This is a collection of colonic disorders that occur as consequence of the image to the brain and our spinal cord, resulting in loss of nervous system control and regulation of the gastrointestinal system. And so given the intricate network of the entire nervous system and its connections to the GI system, it makes sense to infer that damage to the neurologic system in any capacity has at least the potential to affect the inner workings of the GI tract. Many of our patients come to us with GI concerns, whether this is constipation, early satiety, the list can go on and on. But it's only more recently becoming clear to us that this is due to intrinsic damage of the neurologic system, rather than just purely extrinsic factors, such as immobility that comes from a lot of these disorders. And so we're going to highlight a few of disease processes that have implications for the GI nervous, GI function, and then, you know, what the consequences are. And this is the list of the disorders that I'm going to speak about. We'll take them one by one. The first is amyotrophic lateral sclerosis, or ALS, and this is an area of neurologic medicine that's really near and dear to my heart as a neuromuscular neurologist. And it's actually the disease process that first turned me on to the idea that there's intrinsic damage to the gastrointestinal tract as consequence of neurologic injury. So we think of ALS as a motor neuron disease, meaning there's degeneration of the anterior horn cell and the corticospinal tracts. It presents in a number of different ways, typically with motor onset, limb weakness, one arm or leg, bulbar weakness, difficulty speaking, chewing, swallowing, and more rarely respiratory weakness as its onset. Patients have progression with this disorder, paralysis, dysarthria turning into muteness, dysphagia, respiratory failure, and then ultimately each of our patients has an untimely death. But more recently we're beginning to have an understanding that there's intrinsic autonomic involvement as consequence of ALS as well. This manifests as cardiac malfunctions, pseudomotor, and gastrointestinal dysfunction. And so my patients come to me with complaints specifically of constipation, abdominal pain, abdominal distension, nausea, early satiety, and in large part this has historically been attributed to the medications that we put our patients on out of necessity. Anticholinergics for excessive saliva, opiates for pain management, and of course antidepressants for mood. But what we're starting to learn is we're going to see with each of these disease processes is that there are GI changes that are intrinsic to the disease process itself. And this results in delayed gastric emptying and prolonged colonic transit time. And so this is research that myself and some of my colleagues are doing, taking a look at how long it takes for food to actually transit through the gastrointestinal tract in individuals with ALS as compared to their healthy age match controls. And what we found is when we fasted individuals, when we stripped them of the medications that can we know to alter GI motility, there's actually almost a doubling in time that it takes for a food bolus with blactulose to reach the large intestine, and we did this with a hydrogen breath test, on the order of 118 minutes as opposed to 65 minutes in healthy age sex match controls. And so this got me thinking, you know, where else are we seeing GI changes in neurologic injury and disease? Of course, let's talk about spinal cord injury. Now I don't need to tell any of you in this room, but this is an unfortunately common condition globally. It's thought to have had 900,000 new cases in the year 2019, and the prevalence is 20.6 million cases. So of course, major implications for our healthcare system. And for me, as a neurologist, when I think of spinal cord injury, you know, the first thing that comes to my mind immediately is the motor and sensory changes that happen distal to the injury. But, you know, as we've already discussed, the autonomic nervous system and the function, including the enteric nervous system, depends very tremendously on the neuronal connections between the spinal cord and the brain, leading to the GI tract to allow for proper neurotransmission. And so, again, not unsurprisingly, spinal cord injury will lead to a direct interruption of these connections and subsequent autonomic dysfunction. And so this will manifest in individuals with spinal cord injury in a number of ways. Again, cardiac, respiratory, urinary, pseudomotor, sexual thermoregulation, and of course gastrointestinal. A little bit surprisingly to me, as I was putting together this talk, gastrointestinal complications account for about 11% of hospitalizations post spinal cord injury. So really quite tremendous, and the extent of the injuries, the symptoms, and the complications naturally is dependent on the level of the injury. A higher cervical injury, of course, will have bigger implications than a lower thoracic or lumbar. And this is going to be broken down into upper GI dysfunction and lower GI dysfunction. The upper GI dysfunction is going to typically manifest as dysphagia, esophageal dysfunction, typically secondary to loss of voluntary motor control. They'll have gastroparesis, typically thought to be secondary to vagal reflexes being lost. And then there's also going to be gastroesophageal reflux. On the other hand, our lower GI dysfunction is going to be that classic neurogenic bowel. This is going to be broken down into upper motor neuron and lower motor neuron bowel. Upper motor neuron bowel is going to be due to damage of the descending supraspinal pathways, which are going to be proximal, cranial, or oral to the conus medullaris, leading to constipation and fecal retention, and downstream to that fecal distension. It's also going to lead to spastic anal sphincter, upper motor neuron. This is going to lead to excessive colonic wall and anal tone, again constipation. Lower motor neuron bowel is typically going to be due to lesions distal to the conus or our caudate quina or pelvic nerves. And in this case, motor and parasympathetic neuronal projections to the colon and rectum are damaged. Those signals are not getting through. And from there you'll see what's called flexic colon, which leads to slowed peristalsis, slowed propulsion and constipation, common theme here. But also denervation of the anal sphincter is going to lead to fecal overflow and incontinence, so you're going to get a mixed bag there. The next disorder to talk about is cerebral vascular accident, another shared disorder that we see in our specialties, also known as stroke. This is the third most common cause of human disability and there are 12.2 million new strokes annually, which is tremendous. So similar to the spinal cord injury, huge ramifications for our health care system. And there are a number of different ways in which strokes manifest with GI dysfunction. Dysphagia, constipation and fecal incontinence being three of them that I see commonly in our practice. Dysphagia is typically going to be due to just simple damage to the structures in the brain responsible for voluntary swallowing. Any region in the corticospinal tract that causes motor control being damaged in the stroke will lead to inability to swallow properly. Constipation has a number of different etiologies. Severe strokes generally cause gradual loss of parasympathetic tone, as we talked about pretty extensively early on. You'll see that that loss of parasympathetics leads to a shift in sympathetics, leads to slowed peristalsis, decreased GI motility. It's also going to affect the gut-brain axis, which is a bidirectional talk between the GI tract and the central nervous system. And those two organ systems working together mediates gut control. In addition to the intrinsic changes to the neurologic system, there's also going to be those extrinsic changes that I very briefly touched upon that we're all again very familiar with. And for example, if a stroke causes someone to have inability to move, they're going to have decreased GI motility. They're also going to have decreased fluid and fiber intake, just naturally. It's also going to be sequela of dysphagia. And they're going to be more dependent on intentional toileting and rehabilitation. And so that's going to, in a lot of our patients, they're uncomfortable with that process. And so they end up going back, not eating as much, not drinking enough, and it's a self-fulfilling cyclical process here. And then similar to my patients with ALS, we put our patients on medications, including analgesics, anti-seizure medications, which also contribute extrinsically to constipation. And lastly, we have fecal incontinence. And so this is due to anal sphincter dysfunction with abnormal rectal compliance, as well as decreased rectal sensation as consequence of stroke, leading to incontinence. And then also the impaired mobility dependence on others, leading to constipation and fecal overflow. Parkinson's disease is a movement disorder syndrome, of course. And while it was known that individuals with Parkinson's disease experienced GI symptoms, there's a newer understanding that the GI manifestations actually take place years and even decades before the motor symptoms of rigidity, bradykinesia, tremor, postural instability start to occur. And so 65% of patients with Parkinson's disease and Parkinsonian syndromes complain of GI dysfunction. Again, those constipation, early satiety, and so on. And what's been found is that there's actually Lewy bodies, which is the pathologic hallmark of our movement disorders, found in both upper and lower GI tracts, and particularly in the S2, the S2S3 intermedial lateral cell columns, in addition to having a breakdown and loss of the neuron volume. So those two together leads to GI hypomotility. And on the right hand side we have a picture of Lewy bodies that have been found in the enteric nervous system. And so similarly, and I won't belabor the point, but GI symptoms such as excess of saliva, dysphagia, early satiety, reflux, excuse me, constipation, and so on, and even some more serious adverse effects such as megacolon, volvulus, and perforation can occur as consequence of Parkinson's disease and similar movement disorders. And last but certainly not least is multiple sclerosis. And we know this to be a neuroimmunologic disorder, typically autoimmune in nature. There's a lot of neuroinflammation, breakdown of the myelin. And when we have myelin injury, those neurons are no longer protected, we have neurodegeneration. And so when we have demyelination in the areas of the brain and the spinal cord directly implicated in the enteric nervous system function, such as the aria prostrima, we can get downstream effects that affect the gut as well. So with the aria prostrima we can get vomiting, hiccuping, and paralytic ileus. This is a very commonly implicated region of the brain typically in other neuroimmunologic disorders. But our patients also complain of constipation, dyspepsia, dysphagia, and fecal incontinence. And so for my conclusion, you know, of course the enteric nervous system is very intricately linked to the remainder of the nervous system. And I hope I've shared that the GI tract is very important where there is both direct and indirect injury as a consequence of neurologic disease and injury. And these changes can have very significant consequences with symptoms for our patients. So we all should pay special care and attention to the gastrointestinal tract, its proper functioning, and our patients comfort and safety, both in rehabilitation and beyond in their post-rehabilitation care. So these are my references and I'll turn it over to my colleagues who are going to speak about various interventions for the management of neurogenic bowel. Thank you. Thank you, Dr. Schaaf. That was an excellent foundation upon which we will build upon. I am not Marianne Petticone, a rehabilitation nurse at Moss Rehab. She is somewhere cursing our transportation system in the Charlotte Airport, if I had to guess. Marianne is a tremendous colleague of mine. We worked together for about 16 years when I was at Moss. And one of the things that Marianne and I did together was we ran a clinic for adults with spina bifida. And almost invariably, the subject of how to manage your bowels came up on almost every visit. As a prologue to this talk, it reminds me of a particular patient that I will never ever forget in my life. This young man had relatively little motor involvement from his spinal cord injury, a little bit of atrophy in his gastroc but was ambulatory, didn't need his bracing. But literally, his life evolved around his bowel program. He essentially created an apartment in his bathroom. It had a computer stand, it had a telephone, it had a television, because his bowel program would take five or six hours and was horribly unpredictable, very difficult for him to maintain employment. We actually utilized some of the interventions that Marianne would talk about, and we didn't have to see him again. It literally changed his life. So Marianne was going to talk about transanal irrigation. So she did not have any disclosures. The only disclosure I'll make on her behalf is if there are some trade names mentioned during the presentation, it is for educational purposes only. She or I did not get any funding for any of these discussions. So her objectives to discuss exactly what transanal irrigation is, who's a good candidate for it, who is not appropriate for it, and how to establish a good training program. I really want to focus a lot on that third bullet. Many of you may have heard of this system but may have had difficulty implementing it. We did initially. We just thought, oh, well, you know, we'll just, you know, get this out to patients and things will fly off, and it actually didn't. And her and I, along with some of the therapists, created this program and is now a well-oiled machine. Feel free to plagiarize it on behalf of our patients. So as Dr. Schaaf mentioned, there are a lot of people with neurologic disease who have bowel problems, especially that lower motor neuron bowel. That is the toughest neurogenic bowel syndrome to meet. And by definition, those spina bifida patients are almost uniformly going to have that, and it impacts all sorts of aspects of their life, their self-esteem, their ability to work, etc. This pyramid algorithm actually came from our European colleagues, the PM&R societies of Europe, talking about the hierarchy of what you should look at in terms of interventions for management of the neurogenic bowel. As you'll see, very prominent from our European colleagues, transanal irrigation really comes right behind oral medications and lifestyle changes and dietary management before we'll go on to some of the other interventions that we'll talk about a little bit later on this afternoon. So basically, this is a minimally invasive technique that helps patients with neurogenic bowel. It wasn't exactly completely designed for neurogenic bowel, but it really has emerged into that that helps them to be continent, or a better way to say it, sometimes there's a little bit of semantics. The full definition of continence is to be able to know when you're having a bowel movement. For most of our neurogenic patients, we're not going to regain continency, but we're going to make them not incontinent. In other words, they're going to have a predictable bowel movement on their schedule. They're not always retaining full control, though that might be a little bit possible. We're just getting them in a predictable pattern. Basically, it's an installation of water into the colon that has a balloon that seals off the anal orifice that allows the passage of stool after an irrigation. We'll show you some pictures and actually a quick video of that. So why do we do it? First of all, it actually originated in kids. This actually started in Europe with children with spina bifida, and it actually is an easier technique than utilizing enemas and suppositories in children. These individuals can have to decide when they can have their bowel movement and reduces the incontinence episode, and again, all of the associated benefits with that. Who is not a candidate? Those are listed here for you. The biggest one that we should pay attention to, obviously, is the risk of autonomic dysreflexia in the spinal cord injured patients. Because we actually have the potential to distend the bladder. Not the bladder, distend the bowel. There is actually a pressure relief valve on the two most common systems available in the United States, so you should not be able to overpressurize the bowel, but there is a potential risk for that. There is actually a couple of case reports in the literature, again, from our European colleagues, where they actually did a sacral posterior rhizotomy to prevent autonomic dysreflexia, but still allowed the use of this system. As long as you're over two years of age, so children in that three and above can actually use this. Most of the other contraindications are structural issues with the bowel. In the United States, there are two FDA approved systems. The Peristine system and the Novena system. Make sure you know when you write your prescription and you get denied by your insurance company, many insurers will say that this is experimental therapy. That is completely false. They are both FDA approved. Peristine Plus is manufactured by Coloplast, is newer in the United States, but as mentioned has been with our European colleagues for many years. Novena is a trademark of WellSpan, and you'll see that there are actually two versions of it, the Novena Classic and the Novena Smart, which has a mechanical assistive unit. Both of the systems, both Peristine and Novena, have smaller units designed for children. This is the Novena system, on the left is the Novena Classic, on the right is the Novena Smart. I know we had, there's the pointer. So I'm losing my pointer, I'll use it this way. So this is the rectal catheter in which a balloon will inflate behind it, and then through in the Classic, a gravity assistance will allow water to flow out of the catheter, distending the lower part of the rectum, and allowing stool for passage, then the whole thing gets removed and both water and bowel contents are evacuated. The difference between the Classic and the Plus is there's actually a mechanically assisted pump, instead of having to pump it up with these balloon systems, you just push a couple of buttons. This is the Peristine Plus syndrome system, again, you manipulate when the water comes in in the shutoff valve by this little knob here, and then there's a different knob to inflate the balloon through the rectal catheter. The catheters for both systems are replaced after each use. The pump usually has between 90 and 100 uses, and the biggest disadvantage of this system, one of the two disadvantages, is that of cost. We'll talk about it in just a moment. While it is FDA approved, there is no coverage for it from a Medicare perspective, because it doesn't kind of classically fit the DME profile. The second layer is state Medicades do provide some coverage, at least in our neck of the woods, but the coverage is actually less than the cost of the product. So while it is FDA approved and they get a little bit of coverage, the manufacturers can't accept it because it doesn't cover their costs. Those folks, individuals with commercial plans, actually the coverage is pretty good. So if you have a commercial insurance, if a spouse has commercial insurance, it's actually a pretty decent option for coverage. This is a little video, actually, from the Peristine folks that actually gives a pretty good diagram. Fecal irrigation is a well-documented technique for emptying the bowels and is very effective in preventing fecal incontinence and chronic constipation. Irrigating your bowels with water on a regular basis using a rectal catheter is very effective. The water causes peristaltic movements of the bowels, pushing stool towards the rectum. After a short while, the water and stool is expelled from the rectum. If carried out every day or every other day, the technique will help you stay continent until your next irrigation. The irrigation process also encourages mass movement of the entire bowel, which helps prevent chronic constipation. So sometimes when you show that video to patients, you know, they get a little distracted that, you know, what am I putting into my rectum? It's actually smaller than an enema. So it actually is something that's fairly well-tolerated. So we learned about this, you know, 15 years ago, and we're like, yeah, this is great. Let's give it to all our spina bifida patients. And you know, we got it approved on some patients, and we wrote the prescription, and they came back to see us in follow-up, and they say, yeah, I can't use it. And like, well, why can't you use it? Well, I didn't know how to insert it. We didn't, we couldn't figure out how to work it, all this sort of thing. The reps, and this is not to denigrate the reps. The reps are very informative, very helpful, they'll show you videos. But the reps aren't healthcare providers. They can't physically treat a patient, per se, on how to use this. So our next thought, all right, well, you know, Marianne's a rehab nurse, you know, bowel, blood, or skin, that's her, that's her sweet spot, right? Well, why don't we just get her, you know, kind of set up to provide instruction on this therapy? The challenge is that there's no coverage for it. You could take an hour out of her day, but that's sort of uncovered time, and in the outpatient setting, that makes a big difference. So one of the things that we did was, is we coupled Marianne with an occupational therapist. After we wrote the prescription and the patient got the equipment, they had an OT evaluation. The OT worked on the patient's transfers, made sure that they comfortably know how to get on a commode that was similar to their environment. On the second session, Marianne and the OT co-treated, and now other rehab nurses do the same thing. So we were getting payment for the OT session, and after just two sessions of OT, sometimes three in some patients, we found the success rate to be very, very effective. We have to tell patients that this is not going to be the be-all and end-all of your bowel program. You still may need to maintain some medications. You still have to maintain a good, healthy lifestyle and diet. Some folks found that instead of just putting plain tap water into the solution, they actually put a little bit of enema solution in it. Usually they broke open an enemy's and squirted it in. Sometimes that will act a little bit more stimulating. And again, these are folks who may have a very ingrained and entrenched neurogenic bowel program. They may need to take a little time, take a couple of weeks to actually get this up and running. So this was our algorithm that we worked through at Moss. First, we obtained authorization for equipment and supplies. I wrote the orders for the equipment as well as the OT eval. Again, the OT kind of addressed all sort of the mechanical components of toileting, toiling transfers. If someone needed an adaptation for their commode, we made sure that was taken care of. And then on the second visit, they got both a co-treat with an OT and a rehab nurse. It allows for billing for education. It also kind of gets the patient comfortable with the idea of working with a team. While we certainly had coverage issues with regards to the equipment and the DME, we never had a difficulty with getting an OT session approved for this therapy. Cost. So as I mentioned, not covered by Medicare or Medicare products. Commercial coverage is good. It can be costly. A couple of hundred dollars a year, when you add up some of the other costs that are associated with disability, that can get a little bit prohibitive. As I said, the control pump is usually good for about 90 to 100 uses. And at least the Paristine system, which was the system we used more commonly, was about $156 each time it was purchased. So if you're talking about, you know, in every other day braille program, which is kind of the typical guideline that we utilize, you're talking about, just for the pump, about $300 a year. The catheters come in boxes of 15 with the water bag, and each 15 bag was about $300. So again, you're talking about $300 every month. You could see it adds up pretty quickly in a disabled population. That may make a difference. Hopefully at some point we would get some Medicare coverage. As I mentioned, Medicaid has some coverage, but it's not enough to cover the supplies. So Mary Ann's summary is that this is a pretty nice tool in your toolbox to have for it. Don't just expect it to hand these to patients and they take it home and fly with it. But if you do get a nice program like we had set up at Moss, it could really make a life sustaining and a life changing decision. Again, I hearken back to that one patient whose literally his life revolved around his bowel program. And after we got his bowel straightened out, he didn't come back to see us, because he didn't need us. He was ambulatory. He was working. He was educated. Had a family, et cetera. So that is Mary Ann's presentation. I am now going to turn the podium over. Somehow I lost my... Can I get some help here? I lost my cursor. I got the cursor here, but I need it up here to switch to Dr. Gore. While we're... Oh, you don't want the mouse. Oh, there it is. Gotcha. Sorry about that. It was your presence that helped. So I am now going to turn the podium over to my good friend and colleague at Cooper, Dr. Rona Gore, who is the director of reconstructive urology at our same institution. So, Dr. Gore. All right. Well, I want to thank the AAPMNR for having me, and Dr. Salina for inviting me. The story that you just told, I did a lot of spina bifida in my fellowship, a lot of patients with congenital urologic conditions, and that's where my enthusiasm for this field sort of came about. And not a lot of urologists have a lot of interest in this field, and it's really a passion of mine, and I'm honored to be here. And I think if someone would have told me 10 or 15 years ago in med school that I'd be giving a talk at a national meeting about the surgical management of neurogenic bowel as a urologist, I would think that they were crazy. But life takes you in very interesting ways, and so if there are any trainees in the room, just kind of keep your mind open to what your career will end up and allow it to happen. And just because everyone before you did a certain thing doesn't mean you have to do the same thing. So that's the little, the side note there. This is... Up and down. Oh, here. I was actually doing it here, yeah. Let's try... I think we need a little help again. Our slide's not advancing. Clicker is... It's not clicking. I'm not doing what I would like. Which presentation are we at? Here. That looks better. There you go. All right. This guy's the man. All right. So I am a consultant for both of these companies, but they're not really relevant to this talk. So outside of personal or professional passion, neurogenic bowel management sort of gets in this complex Venn diagram of specialties where you have obviously PMNR, oftentimes being the quarterback of the role, PCPs, colorectal surgeons, GI doctors, and neurologists. And I would say, you know, unless things have changed tremendously over the past 12 years, that there's not a lot of education in the mainstream curriculum on management here. And you know, when something like this is everyone's responsibility, oftentimes it also becomes no one's responsibility. And then you end up seeing these patients and you just want to do what's best for them, but you can't spend an hour with each patient. So I'm glad we're having this discussion. I'm actually very glad that Dr. Salino is here now because I feel like, you know, I have a lot of partners now in my institution for like-minded individuals who really want to take care of these patients. So we're all aware of the significant amount of complications that happen with patients with neurogenic bowel dysfunction, and these are just some of them. It is an expensive problem as well, over $4,000 per person annually and over a billion dollars for constipation-related complications in the emergency room, a significant portion of which are due to neurogenic bowel dysfunction. So getting to the meat of my topic, which, you know, I was assigned to talk about, which is the surgical management. And we're going to talk about antigrade continence enemas, acostomy tubes, and fecal diversion. How many people here are familiar with antigrade continence enemas? All right, so a good amount. What about the costomy or chait tubes? A vast amount. And I know everyone's familiar with what a colostomy is, so this just helps them understand, you know, the level of background here, so that's very helpful. So we'll start with antigrade continence enemas. We call that an ACE or a MACE. The M is for Malone, who described this initially. And it's a principle of antigrade enema for colonic irrigation with the Mitrophanof principle. When we hear the word Mitrophanof, the first thing most people think of, urologists included, is an appendicovasocostomy, which is basically this, right? A piece of appendix connected to the bladder, connected to the abdominal wall for clean intermittent catheterization. Mitrophanof, and this is just for nomenclature semantics, but I find this stuff important. Mitrophanof is simply a principle. It does not imply you are using the appendix. Mitrophanof simply means you are creating a flat valve mechanism by placing, whether it's appendix or small bowel, within a tunnel through a muscular structure. So here you have the appendix going through the serosa of the bladder, then an intramuscular tunnel, usually at least three centimeters, with the opening on the intraluminal side. When the bladder distends, it provides continence by compressing this portion to prevent reflux of urine. So that is simply what Mitrophanof actually stands for. So in terms of a continence enema, what you're doing is you're taking the appendix, which is already attached here, you're creating a tunnel in the tinea coli here, and you're placing the appendix in there, and then you will place imbricating sutures around the appendix to provide you some continence for when the catheter is placed. So when the cecum distends, you don't have reflux of stool or colonic material into that conduit. What does this allow? This allows for anti-grade administration of your enema. Now similar to trans-anal irrigation, the principles are the same, right? There's no difference in terms of what your goals are and the physiology of what you're trying to achieve, whether you're going in an anti-grade or you're doing it in a retrograde fashion. The, you know, perceived advantages of doing it in an anti-grade fashion are obviously that your stool burden is typically going to be stuck here, as you all know, and hitting it from a proximal portion can help, you know, potentially get things out a little bit better, right? So that's simply what an ACE does. It allows things to be a little bit easier. The benefits are that it's more comfortable and there's more caregiver access. Now, you know, we had a patient just like what Mike was talking about who, you know, really revolutionized the way he was able to live with a peristine or a trans-anal irrigation, but if you have someone who's, who can't do that, right? Someone who has a congenital issue, someone who has movement issues, someone who has heterogeneous care, doing that type of regimen every other day can be very challenging. And so if they can just sit where they are, insert a catheter, and whether they have a stoma like this patient, or if they're toileting themselves by sitting on the toilet, it becomes a lot easier for them to do. And as we know, if they are compliant and they're able to do it every day, that's much more important than the nuances of, you know, do we use this laxative or do we use that laxative or do we do this enema or how much do we do and should we add mineral oil and what time of the day should we do it? It's just about doing it and doing it frequently and doing it on schedule, which is what allows patients to have success. And this is where an ACE can be very helpful. In children, which is predominantly where we see these surgeries, it is relatively simple. I say that because you're still, you know, reconstructing the bowel and doing surgery and there's no easy surgery, but you have the appendix that is relatively long compared to the distance between the cecum and the anterior abdominal wall. All right? So this is actually an ACE that's been performed and they put what's called a mini ACE device in that is just makes it a little bit easier once the ACE is actually mature to access it. But generally, you do have kids who have very, very thin abdominal walls and the distance between the cecum and the abdominal wall is a couple of inches. Humans grow, but appendices do not. After age three, there is no more growth of your appendix, and so what you're left with is what you're left with. And I picked this picture, when you look in Google for pictures of patients in wheelchairs, it's difficult to find the appropriate patient that you need, but I wanted to find someone that, for all intents and purposes, for someone who is not able to ambulate, this would not be considered someone who was quote unquote overweight, right? This would be someone that we would say is doing a great job and being as physical as they can. And still, if you look at the distance between the perceived abdominal wall and the cecum, it's gonna be much greater than any child that comes into your office. So this is what makes an ACE significantly more difficult in adults than in kids. And a lot of the time, what I see is our patients who have an ACE from childhood, and they're now coming to me in their 20s or 30s, and their abdominal wall has grown, they have a bit of a pannus, and now they have a very tortuous or stenotic ACE, they can't catheterize it normally, and salvaging that can be very difficult. But creating an ACE in an individual is very challenging. So I've got a couple patients that have been sent to me, and what I do now is I basically, I get a CT, and very specifically in the notes, I'll say, please measure the length of the appendix, and please measure the distance from the anterior aspect of the cecum to the abdominal wall in centimeters. So if it's a significant delta, then I know I can't do it. If it's at least two centimeters, probably the appendix is greater than the length, then it might be possible. But the therapeutic sort of index for that group of patients is relatively narrow. In terms of the data, there's honestly pretty poor data in the adult literature about outcomes from an ACE. So they say basically, sure, it's an effective long-term option if it's done right, should be considered before colostomy, the pooled success is heterogeneous, and the risk of complications is moderate. There's some data suggesting this is more recent, saying that the success rate overall with the primary endpoint of actually treating these individuals is overall a little bit disappointing. So how do we mitigate that? So this is something I'm a little more excited about, and some of you are familiar with this, and some of you are not, but this is what's called a CHATE tube, or a C-costomy tube. Dr. CHATE is an interventional radiologist who devised this device. It is basically a very rigid sort of plastic tube with coils here that are adjustable to some degree, but basically end up kind of securing itself inside the colon with a curled loop here to allow for irrigation, and what they call the CHATE trap door, which is this mechanism that allows you to access it for irrigation. And what's nice about this is you can place this in the cecum, you can place this at the hepatic flexure, you can place this at the splenic flexure, and interestingly, the splenic flexure seems to be where the money is, because it is easier to place there, and the trends at times are significantly better because you don't have to go all the way from the cecum, all the way around down to the left colon into the sigmoid colon. So for the most part, if we're doing this, this is where we're going to end up placing it. In terms of inserting it, just from a procedural perspective, we don't put this tube in directly at the first go, and we've only learned that out of trial and error. This is an extremely, extremely rigid tube, and getting it into the appropriate position and having it cinched there is very difficult. So what we do is laparoscopically, we'll mobilize enough of the cecum and basically cinch it to the abdominal wall and place a different type of catheter, more like a Foley-type catheter with a balloon and place it on traction against the abdominal wall for two months almost. And that creates a mature tract from the anterior abdominal wall into the colon. And then that tract, after two months, you can exchange that catheter for a chait tube. And then once the tract's mature, you can actually change this in the office relatively quickly. Why is it such a benefit? Well, again, the average appendix is seven to 10 centimeters and you can get greater than 20 centimeters of length if needed, but typically you don't need that much length. As you can see, this is a very standard patient that we'll see in the office. This is obviously not an appendix. I don't care where you get it from. It's probably not going to end up safely traversing that abdominal wall. So again, not a lot of data on this, but this is a six-month follow-up for 15 patients who had a chait tube or a C-tube placed at the splenic flexure. At six months, most of them, the vast majority, are still using them and about 400 cc's of fluid is used for these individuals. These complications are both for ACE and chait. Obviously, any intra-abdominal complications, you're doing laparoscopic surgery, you're doing open surgery. Many of these patients have had a lot of operations, so just getting into the belly can be challenging to begin with. You can certainly have leakage of stool, which is obviously a big problem. You can have a failed stoma or chait maturation. Stomal stenosis is common, perforation. You need to be careful with folks with VP shunts. Some patients don't even remember that they have VP shunts. We all know patients with spina bifida, if they don't have always a clear history of what they've been through and what they have and what they don't have, and the records can be a bit heterogeneous. So making sure that if they have that and you're going to do this, that you either take care in that situation or talk with their surgeon and see if they can change that to a different type, like a ventral, a pleural shunt or something else for the surgery. I also, another thing that, you know, we have a mutual patient right now we're dealing with, if they have a baclofen pump, it's gonna be oftentimes in the right lower quadrant. If we're going to do a CEQL ACE or a C-cosme tube, obviously that would have to be moved. But now after I've honestly given this talk, I think for that patient, we're just gonna put it in the splenic flexure. And I actually have a meeting with the cook rep coming up to get the CHATE approved at our institution. So I'm looking forward to doing that. In terms of fecal diversion, we're all familiar with what this is. We have patients, you know, with colostomies, ileostomies all the time. And yeah, you know, having seen enough of these patients and you as well, you know, this is a difficult conversation that probably should have occurred a little bit earlier. Though we know patient's quality of life is improved, oftentimes after diversion, patients often look at this as a failure. I'm excited about, you know, folks on TikTok and Instagram kind of normalizing the experience. And I'm hoping that we have more patients with neurogenic bowel and bladder who are displaying their videos, especially for our younger congenital patients to help realize that, you know, your quality of life will actually get better and it's okay to have this. And it actually is going to be a level up for you as opposed to kind of making you feel like you're, that you're an end resort. And I look forward to that paradigm shift. In terms of intestinal diversion, colostomy, ileostomy in patient with severe bowel dysfunction, spinal cord injury, you know, the quality of life is equivocal or superior. Significant decrease in time for bowel management, which I think is very important. And then, but, you know, it requires significant and enduring wound ostomy care support. And this is key, right? Because we all have patients who have stomas, whether it's urinary or colon, where it takes, there's a couple iterations before they get their appliance situation figured out to be, to work well for them. You know, you have some patients, they have a little bit of retraction. It's a little bit of a fold. They end up losing weight and it used to be on a hump and now it's in a fold. And really the nurses are able to take those patients who are frustrated and they're leaking and they're miserable and turn them into happy patients. If you don't have that type of support for these individuals, then it can be very challenging. And so it is not a simple, okay, you get a colostomy and you'll never have to worry about anything again. Everything's gonna be fine. You have to really consider that with where their resources are, your institution, and what type of support that you have. So, you know, in terms of spinal cord injury patients, again, we look at early versus late colostomy creation and early is defined as essentially having it done during the acute inpatient rehab or within the first year and late being after a year or after they've tried other bowel regimens. And the number one reason to do this is reduce reliance on caregivers. The early complication rates are similar, but the late patients or patients who have colostomy later, the need for further surgery is greater. Now, I think this is, you know, you have to be very careful. This is obviously for patients with spinal cord injury and they're very different than patients with congenital issues, right? These are individuals who are lived 44 years normally, had an acute event, have been independent and actually taking care of other people for most of their adult life and they acutely have to go to becoming taken care of and they obviously, they want to gain that independence with much more vigor perhaps than patients who have been taken care of from their birth, right? So this is really, I think, just for patients with spinal cord injury. It may not hold true for patients with, you know, spina bifida or cerebral palsy or other issues like that. When should we encourage it? These are things we all know. If you have non-healing wounds, sphincteric deficiency and if actually, you know, having someone to do the irrigations, whether it's transanal or whether it's from a C-costomy tube, if you don't have someone that can reliably do that, then this can be a good option for these individuals. The ancillary benefits, you know, it's a significant reduction in the time spent on bowel care, significant improvement on quality of life if you compare it with having incontinence and reduce hospitalization for complications related to bowel dysfunction. However, and this is stuff that we see not uncommonly. Parasomal hernia, we see frequently, right? I mean, I'm not the one that ends up fixing these individuals, but our colorectal surgeons certainly see it on the OR schedule relatively frequently. Prolapse, I've seen periodically. And just know that, you know, if this prolapse bowel as, you know, abnormal as it looks, if it is draining fine, they don't need urgent surgery, right? They can certainly live with it. It's not what you want, but it is not a surgical emergency provided the bowel looks healthy. Significant, you know, peristomal skin irritation. Stomal stenosis can be a big problem. And if you, you know, and this usually needs to be corrected surgically relatively, you know, somewhat urgently. So in closing, you know, I would say that, you know, I'm a reconstructive urologist. The vast majority of my time I'm spent taking care of men with urethral reconstruction. I do a lot of prosthetic urology, penile implants, artificial sphincters, BPH. This is still, even though I have a passion for this, a small portion of my practice. You have at all of your institutions, whether it's a colorectal surgeon or a urologist or someone that would love to be involved in this the procedures that you do are life-changing and it's true reconstructive surgery. And you get to treat a patient group that, you know, is so much more rewarding than any penile implant that I've ever, you know, placed. It just is, you know, and I do a lot of them. And so I would just say, you may not have someone who has that passion yet, but just saying, hey, you know, I heard this talk and I have this patient, you know, you can do all these crazy colorectal surgeries. I'm sure you can put this little tube into someone's colon. Can we talk about maybe partnering and at least having a conversation about doing something surgically for neurogenic bowel? You know, the ACE is really reserved for folks who have the appropriate habits. So younger patients, someone who has a thin abdominal wall, you know, acute spinal cord injury and they have significant constipation, this is that group. The Chait-C tube has potential for a lot of other patients as well. And we're gonna start a program at Cooper and it's something that you can certainly start at yours. Colostomies can significantly increase quality of life, decrease toileting time and increase independence. So again, I'm just really honored to be here. I wanna, you know, thank Dr. Salina for inviting me. It's been such a blessing to have him at Cooper now and I'm lucky to have an awesome partner and I'm grateful for all of you for the opportunity and happy to take any questions. I think it might wait till the end, but thanks again. Dr. Gore, you have my word that I will make you busier. Okay, so I'm batting clean up in this great lineup. And those of you who know me in sort of a general way, you know that my particular interest in physiatry is neuromodulation. And I think it's appropriate to talk about neuromodulation when you talk about neurogenic bowel management. And I think it's an evolving question as to where it fits in this algorithm. For those of us who don't have young children, this is Professor Poopy Pants. And I am going to turn you from Professor Poopy Pants into—why am I not moving forward here? Let's go over here maybe. What did I do wrong? I don't know. Let's try this. There you go. I'm going to turn you from Professor Poopy Pants into Captain Underpants. And it's a cute little cartoon and that sort of thing. So these are my disclosures. Nothing super relevant to this talk. We will be talking about some off-label discussions, and I will only use branded names when it is needed for educational purposes. As having a position of leadership within Cooper, I have to say that any opinions that I state do not necessarily represent the opinion of Cooper University Health Care. I can't imagine that I'm going to say anything controversial that they would disagree with, but for keeping everybody happy. So first of all, kind of laying the ground rule, first of all, what is neuromodulation? I think all of us have some degree of understanding. Basically, we understand that the nervous system communicates through electricity. And can you modify those electrical signals to undo any pathology? And the indications for neuromodulation continue to explode. For years and years and years, all we really had were invasive options for neuromodulation. Kind of the hotter topic in neuromodulation now is non-invasive neuromodulation. And Dr. Schaff did a terrific job in describing what neurogenic bowel is, and we're going to combine these two terms and see if we can help some patients out. This is the epidemiology of neurogenic bowel. Almost 100% of spinal cord injured patients have some degree of bowel dysfunction, and it kind of goes down the list from there. The most common target for neuromodulation in neurogenic bowel is spinal cord injury, spina bifida probably being the second. My thought process there is, you know, not only is it a high prevalence, but it's folks who are going to live for decades with neurogenic bowel function. So if you can get it under better control, you have a potential impact for not just a few years, but actually several decades. The neurologic control of bowel function is a really complex undertaking. You can see all the different sympathetic, parasympathetic, and somatic targets that are potentially amenable for modulation. What we will find is that the primary target for neuromodulation, not the exclusive one, but the primary one, is the sacral nerve. And we're going to work on stimulating the sacral nerve and the sacral foramen in just a moment. So here are all the potential targets. Sacral nerve stimulation, stimulating the anterior root of the sacral nerve. As mentioned earlier with the transanal irrigation, sometimes in the spinal cord injured patients, because of the risk of autonomic dysreflexia, there are some centers that are also doing a posterior root rhizotomy. There's also transcutaneous nerve stimulation, direct rectal nerve stimulation, tibial nerve stimulation, epidural stimulation in the spinal cord, and actually vagal nerve stimulation also. So these are the formal indications for sacral nerve stimulation. The big two are overactive bladder and non-obstructive urinary retention. That's why we have talented urologists like Dr. Gore who become interested in neurogenic bladder because they are often the ones doing sacral nerve stimulation. There actually is a third indication for chronic fecal incontinence. So it's important if you are sending a patient over to someone to consider this, that needs to be one of your referring diagnoses. It's technically not indicated for neurogenic bowel, but neurogenic bowel and chronic fecal incontinence kind of go hand-in-hand. It is also used in an off-label fashion for chronic pelvic pain. So this is basically what you're looking to do. For all spinal cord stimulation, there is a pulse generator. Where's my pointer? So there's your stimulator that generates the electricity that goes down a lead. The lead is insulated so there's no electrical loss. And it goes through typically the S3 foramen. And there are areas on the lead that are then uninsulated where electrical activity can flow. These are these little tines here. So this is what it looks like on an x-ray. An implanted pulse generator sending electricity into the lead that comes out at the electrode. And there's typically four electrodes in a sacral nerve stimulator paradigm. I lost my up-down again. I'm sorry. I think I'm probably going back and forth between the computer and this. It's a mess of... So similar to other neuromodulation procedures, there's a trial program. So you place the lead in the appropriate position, and before putting a permanent pulse generator in, there is a temporary battery source. The trial usually is usually left in for 7 to 14 days. If the trial is successful, the lead is then connected to a permanent implant. For as long as sacral nerve stimulation has been around, it's actually been around for a few decades, especially for urinary indications, truly the mechanism is not well understood. it may be stimulation of direct fibers to help increase peristaltic movement. There's actually increased somatosensory representation of the anal region in the central cortex, so it's not in the periphery. There's some thought that it actually is a more central neuromodulatory effect. And similarly, there's activation of the left dorsolateral prefrontal cortex. So even though it's been around for decades, the true mechanism is not well understood. Procedurally, this involves placing a needle through the S3 foramen, usually with fluoroscopic guidance for individuals with somewhat difficult or challenging anatomy. CT guidance can also be utilized. You then elicit motor and sensory responses that are congruent to where you're hopefully getting that stimulation. The papers describe, when doing this in spinal cord injured patients, again, needing to be sensitive to the potential for autonomic dysreflexia. As mentioned, there are four leads on the electrode. Two and three should actually straddle foramen, and zero and one should actually be placed anterior to the bony sacrum and then connected to the stimulation device. Like other stimulating neuromodulation, there is a variety of parameters that can be programmed into the stimulation. Patients have the ability to switch from one program to another. You could change the pulse width. You could change the current. You could change the amplitude, et cetera. Older models require battery replacement. More newer models have rechargeable systems that do not require repeat surgery. Systems that were placed prior to 2020 were MRI incompatible. There was actually a period in 2019 where it was actually compatible for MRIs of the head and neck, but not anything further distal, and now all current systems are MRI compatible. There are other stimulation challenges, just like we see in other areas of neuromodulation. Neurotraumic challenges, lead migration, pain at the implant site, loss of efficacy over time. This doesn't seem to be too much of a prominent problem, but what it is can be quite distressing. There's actually a couple of papers that talk about first to make sure that the lead still has good continuity, that you've changed programming a little bit to see if you could recapture it. Occasionally, it could actually be done again and do a bilateral stimulation to recover efficacy. In my review, there are 11 clinical trials looking at sacral nerve stimulation in neurogenic bowel patients for about 300 patients. Not the greatest of all study, high quality studies. Only three were truly randomized controlled trials. It can be hard to do RCTs in neuromodulation because patients can actually perceive whether they're getting stimulation or not. The majority of them were sort of pre and post studies. Most of them were in spinal cord injured patient, and there's actually a pretty sketchy description of the actual levels and severity of spinal cord injury, whether they were neurologically complete, incomplete, whether they were upper or lower motor neuron. There is a fair degree of bias. I would call it moderate, and the outcome measures were variable. Most of the studies looked at incontinence episodes as their primary outcome measure. Either the number of episodes they would have per unit time or their frequency of it. Rarely there was elimination of fecal incontinence. So I think that's an important teaching point when you're educating your patients, is that you're probably not going to get down to zero incontinence levels, but you probably will improve. If you look at some of the other parameters for neurogenic bowel, such as bowel time, need for medication and physical assistance, it's very available. Again, only looking at 300 patients of a number of studies. Actually all across the world, although most of them are here in the United States. Another mechanism of neuromodulation is tibial nerve stimulation. Basically this involves getting to the sacral nerve in a rather indirect fashion. As the tibial nerve traverses back towards the spinal cord, it comes in close proximity to the sacral nerve, so you're kind of getting indirect stimulation. There are transcutaneous, percutaneous, and implantable systems that have been described in the literature. This is actually one of the more common systems. This is the urgent system, where it is percutaneous. You can actually see the needle kind of going after the posterior tibial nerve and the ground electrode. On the right-hand side of the screen, you see two of the fully implantable systems. The left-hand side of that actually has a pulse generator implanted. The other just has the stimulating electrode implanted, and you put a pulse generator over the top. This is a completely transcutaneous approach to tibial nerve stimulation. The formal indication for tibial nerve stimulation is actually overactive bladder, so you're kind of using this in an off-label fashion. Mostly it's just case reports in the literature. There actually was one small case series of actually kids with spina bifida for neurogenic bowel function. Their big take-home message is the kids tolerated it okay. It was safe and well-tolerated. Less episodes of incontinence was kind of hidden in the message, but basically they were saying that just doing transcutaneous stimulation was pretty well-tolerated by kids before doing anything more invasive. Spinal cord stimulation is off-label at the moment. There are both implantable and non-invasive systems, as described here. The new kind of kid on the block in spinal cord stimulation is closed-loop stimulation. What that means is the older systems had a battery system. It sent signals up the lead into the electrode, and there was no feedback loop that modulated or attenuated the stimulation based on some other stimulus. Now closed-loop systems have the ability to sense some electrical activity at the tip of the electrode and can attenuate the stimulation parameters based on real-time feedback. There is a group at UT San Diego, UCSF, who's actually doing a whole big project on closed-loop stimulation. Most of the spinal cord stimulation literature falls under a small case series, and there's really pretty variable results with that. Lastly, auricular nerve stimulation. This is actually an FDA-approved device in which you have a pulse generator that's externally behind the ear with three electrode points, either in front of the ear or on the ear, kind of mimicking auricular acupuncture. I have two acupuncturists on my faculty, and they've taught me a lot about acupuncture in the time I've been at Cooper. It actually has formal indications for GI symptoms, irritable bowel symptoms, functional abdominal pain, and abdominal migraine. So it's not technically indicated for neurogenic bowel. The biggest discussion point in those diagnoses is a decrease in constipation and a more frequent and predictable bowel movement. There are no human spinal cord injury or other neurogenic bowel reports, but there actually are a couple of animal models that look at this, and the results are quite promising. So this is also where I work with Dr. Gorham. We do great things. We finished up with a little bit of about 15 minutes time, so open for questions both from our live audience as well as our hybrid audience. Again, we appreciate the opportunity to talk to you today and spend some time in a nice New Orleans afternoon. So at this point, if you have any questions, please go to the microphone, because the session is being recorded for posterity. Diane Chapuis, Courage County Rehab, Minnesota. I have quite a few patients with Peristine systems, and for the most part, we have some success, but I have a decent percentage of patients who just persistently have right-sided constipation, and we have a hard time trying to figure out what's the best strategy. If they take too much oral, then they're having fecal incontinence in between time. So I'm just wondering if there's any strategy that's worked better for you. So this is where kind of the art and science meet a little bit. So trying to find what oral stimulation, you know, our oral mechanism is most appropriate to kind of partner with the trans-anal irrigation is a challenge. Sometimes one of the techniques that we've done is sort of, for lack of a better term, wipe the sleep clean, do almost like a colonoscopy prep, and start from scratch. And that's probably my atomic bomb solution for you. And then if that doesn't work, I find colleagues like Dr. Gore to maybe consider a surgical option. Thanks. Thank you. Great presentation. Sure. A few questions, but we'll start with. Is the irrigation of the bowel better to start in the cecum, or is it better to do it in the descending colon? Which works better? More likely in the cecum. Because you want to get bowel motility for the entire colon? Yeah, it's harder to get to. Okay. Sure. For Dr. Martin Schaaf, I have a vague recollection of the nucleus of Vonifrovich in the lower spinal cord. I think it's S2, S4. Is it for bowel and bladder, or one or the other? And which one? Sorry. So you're asking if the S2 to S4 controls just the bowel or bowel and bladder? Correct. My understanding in looking at the literature is that it was predominantly the bowel. But my recollection from medical school training many, many years ago was that it does have implications for both bowel and bladder control. And Dr. Kor is nodding again. So again, my literature search for this was bowel, but yes, both. All right. Thank you. I just want to say thank you for talking about interventions for neurogenic bowel. And then just a couple comments about comparing Parastine and Novena. So the Novena actually does have, in addition to the balloon, you can have a cone. So for people with erectile prolapse, that system can be a little bit better because you can accommodate for the prolapse. And then additionally, if you are looking to use Parastine in someone with autonomic dysreflexia, I have worked with my urology colleagues in the past to do that trial in the aerodynamic suite to figure out what volume you can use with the transanal irrigation to avoid autonomic dysreflexia in our kids that have really difficult to manage neurogenic bowel with SCI. Super good point. When we first started doing the Parastine system, we sent everyone for animal manometry. And then we kind of figured out maybe if we're cautious, we could get away without it. So only in those folks that are super sensitive for dysreflexia do we do the animal manometry study. Otherwise, we go straight to it. Great points. Thanks. Hello again. The sacral nerve, I guess I'm not familiar with it. I have a vague recollection of a sacral plexus apart from the sciatic nerve and lumbar plexus. Can you go over the anatomy of the sacral nerve, please? Sure. Let's go back to this complex structure here. So sacral nerve, where's my pointer? Sacral nerve here are actually direct branches right off here that innervate these muscles here. So they're actually direct branches. And these will actually live on the anterior surface of the bony sacrum. So these are the anterior sacral roots. So it's S1 to S5. But it's really 2, 3, and 4 are the primary contributors. Going to the external anal sphincter? Yes. OK. Is it part of the sacral plexus, or it's an individual nerve? They create an individual nerve, but they are direct branches out of the sacral spinal cord. OK. Thank you very much. Sure. I'm wondering if you have any concerns about or thoughts about doing the more invasive procedures, the stimulation as well as the surgical procedures for individuals with degenerative conditions including ALS or MSA or Parkinson's disease? I suspect the answer is we haven't done very many. But with people who have expected shorter lifespans, are there any concerns or thoughts or discussions about whether it's worth it? So I'm going to plagiarize from my own patients. All my patients who I have sent for surgical interventions for management of neurogenic bladder, their uniform response is, I should have done this earlier. Whether it's a complete fecal diversion or whether it's a C-tube or an ACE, why didn't I do this five years ago is almost always the response. I don't want to paint an overly rosy picture, as Dr. Gore mentioned. There can be complications. I haven't seen a whole lot of them. About the most common thing that I've seen with either the C-tube or the ACE is stricture, the required dilation. But it's a relatively straightforward situation for our surgeons to handle. But almost every, I can't think of a patient who says, I regretted doing it. The response is, why didn't I do this 10 years ago? So I think it's a reasonable question to ask. Now, if someone's doing fine with their bowel regimen, terrific. But if they're not, it's worth the conversation. Go ahead. Yeah. My question is about the neuromodulatory devices, like a sickle stem. I know for other devices, you have to perform some sort of pilot or test dosing or some thing like that that shows demonstrable results afterwards. Does the same thing go here before you go to surgical implantation? I mean, you have to demonstrate failure of more conservative measures first to get it authorized. But after that, the coverage is pretty decent. Thank you. Thanks for a great discussion. For patients with incomplete spinal cord injuries, I was wondering if you could talk a little bit about some of the considerations you have as far as timing for some of the more invasive either surgical or neuromodulation options. Do you tend to allow some time to see what recovery happens before doing this? Or if the bowel program is really distressing and not functional for people, do you tend to do it early? So I can't say, and I'll turn it over to my colleagues, I have no experience with doing it early. I would say the earliest I've ever seen it might have been someone 10 years into either injury or diagnosis. It's an intriguing thought. Certainly if someone is neurologically complete, where you really have limited expectation that you're going to get functional recovery, that maybe they don't have a whole lot of functional support. I think the biggest problem just kind of conceptually about doing it early is, are they psychologically ready for it? Have they even truly accepted that they're a spinal cord injured? Ron, if you want to add some. For the acute indication for neuromodulation spinal cord injury, there is a, when I was a fellow in 2016, so they were starting a Department of Defense trial on partial and complete spinal cord injury and doing, during the acute phase, immediately within a few months from the spinal cord injury doing sacral nerve modulation to prevent neurogenic bladder dysfunction as well, but that hasn't panned out quite yet. So for now, if you have an incomplete or acute injury, you would not probably proceed until they sort of achieve steady state, at least for neuromodulation, right? In terms of doing urinary diversion or fecal diversion, it's, I wouldn't think about it in the sense of finality, right? So if they have a secondary complication that requires diversion, so wounds or infections or whatever it may be, you can do temporary interventions. You can do a suprapubic catheter. You can do a loop colostomy instead of a end colostomy and reversing a loop colostomy, again, it is a surgery, but it is not the most involved surgery for a colorectal surgeon. So you can still introduce those things, letting the patients know that, listen, you haven't kind of figured out, we haven't figured out where you're going to end up per se, but you can still do this. It will give you the relief that you need, the independence that you need in the short term. And then if you progress and get better or whatever it may be, it can always be reversed. Great. Thank you. Fecal diversion in patients with many, many, many years of neurogenic bowel, really floppy colons, right-sided colostomy, ileostomy. Any thoughts about that versus the standard place where I've had patients just get constipated there? So this is where I lay my cards as a urologist and say, I don't know. Generally it's easier on the left side, again, broadly from talking to my colorectal colleagues, but when you have that situation where they've had 15, 20 plus years of issues, I don't know the answer to that. But I will look into it and see if I can somehow get it back to the group. Dr. Salino, any experience for you? I'm going to punt too. Those are difficult questions to answer. And yeah, I would definitely have our colorectal folks help with that. Awesome. A couple of questions from the audience or from our virtual audience. One was, for trans-aneal irrigation, can the catheters be reused? The answer is no. Is it suitable for both upper and lower motor neuron? The answer is yes, although I would say that we use it more often in our lower motor neuron patients than our upper motor neuron patients. And the last question from our virtual audience says that we have not had as good results with TAI as you. Any thoughts on improving efficacy? I think patience is a virtue for that discussion, recognizing that this is probably not their only mechanism of management of neurogenic bowel, that they're going to continue to need diet, lifestyle, and oral medication use, and finding that magic mixture can be a challenge. And again, sometimes that wipe-the-slate-clean-start-from-scratch is a really good technique. We are a couple of minutes over, so I'm going to thank our colleagues for making the travels down here to New Orleans. Enjoy the rest of the conference, and if you're ever in the Philadelphia area, come see one of us and we'll show you the great places that we work at. Thanks again. Thank you.

neurogenic bowel dysfunction

gastrointestinal changes

constipation

abdominal pain

comprehensive care

transanal irrigation

anorectal biofeedback therapy

medications

surgical interventions

antegrade colonic enema

CHAIT

neuromodulation