The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on sacral nerve stimulation for faecal incontinence.
It replaces the previous guidance on sacral nerve stimulation for faecal incontinence (Interventional Procedures Guidance no. 5, October 2004) after reviewing the results a systematic review, requested in the original guidance.
Faecal incontinence occurs when a patient loses control over the passing of faeces from the rectum to the outside of the body. Faecal incontinence may result from degeneration of the anal sphincter, spinal injury or other neurologic disorders.
Faecal incontinence is associated with a high level of physical and social disability. If left untreated, the patient may end up wearing pads to control the condition. Faecal incontinence is the second leading cause of admission to long-term care facilities in the United States.
In patients with a weak but structurally intact sphincter it may be possible to alter sphincter and proximal bowel behaviour using the surrounding nerves and muscles. Sacral nerve stimulation is a treatment option for these patients. It involves low-level electrical stimulation applied via electrodes through the sacral foramina to the sacral nerve supply of the lower bowel and sphincters. Shortly after surgery continuous stimulation begins. The patient interrupts the pulse for defaecation and voiding, using an external magnet.
Depending on the details of the procedure performed, one of the following OPCS-4 codes is utilised:
A70.1 Implantation of neurostimulator into peripheral nerve
A70.2 Maintenance of neurostimulator in peripheral nerve
A70.3 Removal of neurostimulator from peripheral nerve
A70.4 Insertion of neurostimulator electrodes into peripheral nerve
In addition to one of the above OPCS-4 codes the following site code would be assigned:
Z11.2 Sacral nerve.
Note: OPCS-4 code Y70.5 Temporary operations would be assigned in addition to A70.4 Insertion of neurostimulator electrodes into peripheral nerve if temporary electrodes are inserted to test whether the intervention is likely to be effective, but the pulse generator device is not implanted under the skin.
In addition, the ICD-10 code R15.X Faecal incontinence is assigned.
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.