Shared learning database

 
Organisation:
University Hospital of South Manchester
Published date:
August 2009

In order to allow greater access to trial of sacral nerve stimulation, we now routinely insert all temporary SNS electrodes under local anaesthetic and have found that this has no effect on results of the trial of SNS, nor on the long term outcome from permanent implantation. We therefore conclude that temporary SNS electrodes can be inserted under local anaesthetic without adversely affecting patient outcomes and with the advantage of minimising anaesthetic risks and costs.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
No
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Yes

Example

Aims and objectives

This implementation was to determine if insertion of temporary sacral nerve stimulator under local anaesthetic affects outcome from trial of sacral nerve stimulation and improvement in symptoms over the long term. We found that insertion of these electrodes under local anaesthetic is logistically easier in the community treatment centre than admitting patients to inpatient surgical beds. 1. Does the insertion of temporary sacral nerve stimulator under local anaesthetic adversely affect the outcome of the trial of sacral nerve stimulation or long term outcome after insertion of permanent sacral nerve stimulator? 2. How does the cost compare between insertion of the temporary sacral nerve stimulator under local anaesthetic or general anaesthetic?

Reasons for implementing your project

Treatment with sacral nerve stimulation for faecal incontinence involves insertion of a temporary stimulating electrode for a trial period to assess response to this treatment. Where an improvement in continence is achieved, a permanent stimulator is then implanted. The temporary electrode is simple to implant with a percutaneous technique. Previously, these were all implanted under general anaesthetic. To do this required admission to a general surgical bed, a general anaesthetic with its associated risks and prone positioning on the operating table. However, insertion under local anaesthetic can be carried out as an outpatient procedure in a community treatment centre. This avoids the difficulty of obtaining inpatient beds, the risks of general anaesthetic and the additional risks of prone positioning, as the patient can position herself on the table.

How did you implement the project

1. There is no significant difference between the improvement in symptoms achieved after implantation of temporary sacral nerve stimulator under local anaesthetic or general anaesthetic (64% compared with 77%, p = 0.14). There is also no significant difference in the improvement in symptoms over long term follow up between those who had their temporary electrode implanted under local or general anaesthetic, indicating that a trial period with the temporary electrode implanted under local anaesthetic is just as effective in predicting success of permanent sacral nerve stimulation as implantation of temporary electrode under general anaesthetic. 2. Costs are lower when the temporary electrode is implanted under local anaesthetic. The local anaesthetic procedure cost at our institution is £613, compared with £743 for insertion under general anaesthetic. Length of stay is also significantly shorter for local anaesthetic patients, with only 63% of general anaesthetic patients being discharged home the same day, which also impacts on the costs of the procedure.

Key findings

The outcome of treatment with sacral nerve stimulation is evaluated through standard bowel habit diary and questionnaires - the Vaizey score of faecal incontinence and the Manchester Health Questionnaire, a symptom-specific, validated quality of life questionnaire. Those who achieve a 70% improvement in Vaizey score or number of incontinent episodes are offered implantation of a permanent sacral nerve stimulator. Using the results of these diaries and questionnaires, we found no difference in the proportion who achieved a successful trial of sacral nerve stimulation, nor any difference in the long term improvement achieved after permanent implantation. These results have been submitted to the surgical journal Colorectal Disease for publication.

Key learning points

We can give greater access to sacral nerve stimulation by inserting the temporary electrode under local anaesthetic, thereby removing the requirement for inpatient beds, with no adverse effects on patient outcome.

Contact details

Name:
Mrs. Kirsty Cattle
Job:
Pelvic floor clinical fellow
Organisation:
University Hospital of South Manchester
Email:
kirstymcdowell@doctors.org.uk

Sector:
Tertiary care
Is the example industry-sponsored in any way?
No