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Neuromodulation for Pediatric GI Motility
Saleem Islam, MD, MPH, helps us understand the role of the autonomic nervous system in controlling intestinal function. He shares the role of Neuromodulation in conditions affecting the gastrointestinal tract and speaks about an algorithm by which to consider referral of patients for neuromodulation.
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Learn more about Saleem Islam, MD, MPH
Saleem Islam, MD, MPH
Saleem Islam, M.D., M.P.H., is a professor of surgery and pediatrics and director of pediatric minimally invasive surgery in the University of Florida’s College of Medicine. He also is the associate medical director of the pediatric integrated care system (PediCare) in the department of pediatrics at UF and program director of the pediatric surgery fellowship program in the department of surgery at UF.Learn more about Saleem Islam, MD, MPH
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're examining neuromodulation for pediatric GI motility. Joining me is Dr. Saleem Islam. He's a professor and Chief of Pediatric Surgery at the University of Florida College of Medicine. Dr Islam, it's a pleasure to have you join us today. Can you start a little bit by telling us the role of the autonomic nervous system in controlling intestinal function for providers that may not really be up on all of that?
Dr Saleem Islam: Sure. It's actually a relatively new concept. We didn't think that the GI tract had either its own intrinsic nervous system or that the nervous system that we have, either the central or autonomic, exerted tremendous control over it. So this is something relatively new over the last maybe two to three decades.
And our understanding has continued to work with this. And it's now fairly well understood that there are many levels of control that the autonomic nervous system, which works below the level of consciousness and kind of just works behind the scenes and as the name suggests automatic in certain ways, it really affects the gastrointestinal tract from the top. If we smell food, we generally start to salivate, that's the autonomic nervous system, to the very bottom where when we're sleeping, we maintain control of our continence and we don't leak out fecal material while we're sleeping. So it really exerts its control from the top to the bottom.
Melanie: What an excellent explanation, Dr. Islam. Thank you. So why are gastrointestinal disorders notoriously difficult to diagnose? We know that functional and motility-related GI problems present with some common symptoms, but why is this a tough diagnosis, especially in children?
Dr Saleem Islam: Well, part of it, Melanie, is that it's not recognized very well. And it's not anyone's fault necessarily. These conditions are only now beginning to be understood. And when I say beginning to be understood, I really mean beginning. A lot of the conditions that we see are in fact termed as functional disorders, which is a nice way of seeing that we don't fully understand why these happen and functional disorders can affect the stomach, can affect the gallbladder and the colon or the large intestine.
And so these functional disorders are things that are very poorly understood in adults, much less in kids. And certainly, if you look at functional gastrointestinal disorders, whether it be gastroparesis, biliary dyskinesia or colonic inertia or what's sometimes called irritable bowel syndrome, they all are more prevalent in adults than in children.
And it's very unfortunate that when we look at the typical child who will present with these symptoms, it's going to be a teenage girl. And the unfortunate part is that it's typically in that patient population ascribed to psychological eating or other disorders, as opposed to likely what it is, is a hormonal pubertal effect that's being exerted on the autonomic nervous system, which is driving these issues. And that's why we see it most often in girls.
Melanie: That's fascinating. So now tell us a little bit about the role of neuromodulation in conditions that are affecting the GI tract. Tell us what it is, how it works, and really, while you're doing that, you can briefly say what has been available to children up until now and what's different now.
Dr Saleem Islam: Sure, Melanie. I mean, that's a great question as well. You know, neuromodulation is a technology that basically acts on nerves. And by doing so, it alters or modulates nerve activity by delivering electrical impulses to a specific target area. And depending upon which area is affected, it exerts different results.
People will most commonly associate neuromodulation when we attach it to the spinal cord for chronic pain issues or to the brain itself as in DBS or deep brain stimulation for Parkinson's disease and things like that.
When we talk about the gastrointestinal tract, however, we really are talking about two different things. And that is gastric electrical stimulation for gastroparesis or functional dyspepsia, which is the sensation of nausea, vomiting, bloating, getting full very quickly and pain after eating or for sacral nerve stimulation, which we use in patients who have a severe constipation with or without fecal incontinence, which is when you can't control the stool and you keep leaking stool out inadvertently. And so those are the two areas of neuromodulation where we use it in the gastrointestinal tract.
And the sacral nerve stimulation works on what's called the S3 or the third sacral nerve root. And from there, it acts on the autonomic nervous system to modulate that, and it actually helps both fecal incontinence and urinary incontinence. And it's used much more frequently in adults than it is in kids.
The gastric stimulator is attached to the stomach wall with leads. And then they're brought out to a device which is then implanted underneath the skin, and that sends constant impulses to the intrinsic gastric nervous system and the cells that are in there and causes the stomach to really start to feel better and to not send those impulse signals, which makes patients feel nauseated, et cetera. And so those are the two things that we've used.
Now, Melanie, you'd asked which of these is available for children. And I kind of have to say that there are no devices that are really developed for kids themselves. We really have to kind of take these devices off the shelf and use them in children in an off-label capacity, because obviously kids do get afflicted with these conditions. And even though the device manufacturer has not expressly made them for kids, we feel that kids deserve the care that all the adults get. And so we've used it and we've used it very successfully in these patients with great relief.
Melanie: Well then, doctor, is there an algorithm by which you're considering referral of patients for neuromodulation if it's not really in the general population? And you're using it in adults with great success, tell us a little bit about referral and when it can be used.
Dr Saleem Islam: So I'm a pediatric surgeon, of course. And I've used this device extensively in children. And if we talk about the gastric stimulator, for example, I've implanted about 154 of these in children. These are permanent devices. But our algorithm consists of, one, trying to do the best medical management that we have available for these functional dyspepsia or gastroparesis patients who frequently have other problems as well that effect the autonomic nervous system.
And once we maximize that and we don't get tremendous benefit, that's when we consider gastric stimulation. And we will do a trial of that gastric stimulation either by putting a special lead through the nose or a special lead through the stomach if they have a feeding tube that's been already implanted. We go through that site and we implant those leads and do a temporary trial for about five to greater than 10 days. And we make sure that that works for these patients.
We do actually an on and off trial in a blinded fashion so that the family, the child and the care team can be very sure that this works for them. We've done this in over 270 patients now, of which 150 eventually get implanted. And that's the largest experience for children in the world actually.
Melanie: And how have been your outcomes with those children that got the implanted neuromodulation?
Dr Saleem Islam: Sure. When we talk about gastric stimulators and the 150 that we've implanted, over long-term results, which have been over a decade now, we have seen really good responses. And 85% to 90% have had long-term success, meaning greater than five years of it continuing to work and provide relief. We see these patients consistently afterwards and they follow up in our clinics. And we monitor the device, we change the settings as needed and then of course, change the batteries, which is just explanting the device and putting a new one in when the battery gets depleted.
When we talk about sacral nerve stimulation, our experience is not as broad, but we've done about 20 patients in that. And when we look at other centers and combine all of our data with them, probably around 250 to 300 children have had sacral nerve stimulators implanted for fecal incontinence and severe constipation. And we've had great results with that. Again, we always do a temporary trial for those patients and we try for up to a month and make sure that this is something that'll work before we implant the device.
Melanie: What an informative episode this has been. As we wrap up, Dr. Islam, what would you like other providers to know about neuromodulation for pediatric GI motility disorders and when you feel it's important that they refer to you at UF Health Shands Hospital, as this is something that you are a leader in?
Dr Saleem Islam: I think that what I really would like the message is that if you have patients who have these chronic symptoms of a very severe nausea, vomiting, getting full very quickly or pain after eating, consider gastroparesis, consider those problems. And, in addition, we didn't talk about billary dyskinesia, which is the problem of the gallbladder, but we can help distinguish between those two and certainly we provide the long-term care for them.
There is an option available for them. These children don't have to suffer or just get a feeding tube and feel that is their life. We feel very strongly that this can really benefit and change their lives around to the point where they become tremendously productive members of society and can fulfill their potential, which we know is immense.
And similarly, I want providers not to feel that if a child has fecal incontinence, that their only ability to get treatment is to either suffer with diapers when they're adolescents or to just get enemas all the time or deal with laxatives of some kind. We do have options and we certainly want to explore them.
Melanie: That's really amazing. Dr. Islam, thank you so much for joining us and telling us about this exciting way to help these children. It's a complex condition and thank you again for joining us.
To refer your patient, you can call (352) 265-8800 or you can visit UFHealth.org/pediatricsurgery to learn more. And to listen to more podcasts from our experts, please visit UFHealth.org/medmatters.
That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're examining neuromodulation for pediatric GI motility. Joining me is Dr. Saleem Islam. He's a professor and Chief of Pediatric Surgery at the University of Florida College of Medicine. Dr Islam, it's a pleasure to have you join us today. Can you start a little bit by telling us the role of the autonomic nervous system in controlling intestinal function for providers that may not really be up on all of that?
Dr Saleem Islam: Sure. It's actually a relatively new concept. We didn't think that the GI tract had either its own intrinsic nervous system or that the nervous system that we have, either the central or autonomic, exerted tremendous control over it. So this is something relatively new over the last maybe two to three decades.
And our understanding has continued to work with this. And it's now fairly well understood that there are many levels of control that the autonomic nervous system, which works below the level of consciousness and kind of just works behind the scenes and as the name suggests automatic in certain ways, it really affects the gastrointestinal tract from the top. If we smell food, we generally start to salivate, that's the autonomic nervous system, to the very bottom where when we're sleeping, we maintain control of our continence and we don't leak out fecal material while we're sleeping. So it really exerts its control from the top to the bottom.
Melanie: What an excellent explanation, Dr. Islam. Thank you. So why are gastrointestinal disorders notoriously difficult to diagnose? We know that functional and motility-related GI problems present with some common symptoms, but why is this a tough diagnosis, especially in children?
Dr Saleem Islam: Well, part of it, Melanie, is that it's not recognized very well. And it's not anyone's fault necessarily. These conditions are only now beginning to be understood. And when I say beginning to be understood, I really mean beginning. A lot of the conditions that we see are in fact termed as functional disorders, which is a nice way of seeing that we don't fully understand why these happen and functional disorders can affect the stomach, can affect the gallbladder and the colon or the large intestine.
And so these functional disorders are things that are very poorly understood in adults, much less in kids. And certainly, if you look at functional gastrointestinal disorders, whether it be gastroparesis, biliary dyskinesia or colonic inertia or what's sometimes called irritable bowel syndrome, they all are more prevalent in adults than in children.
And it's very unfortunate that when we look at the typical child who will present with these symptoms, it's going to be a teenage girl. And the unfortunate part is that it's typically in that patient population ascribed to psychological eating or other disorders, as opposed to likely what it is, is a hormonal pubertal effect that's being exerted on the autonomic nervous system, which is driving these issues. And that's why we see it most often in girls.
Melanie: That's fascinating. So now tell us a little bit about the role of neuromodulation in conditions that are affecting the GI tract. Tell us what it is, how it works, and really, while you're doing that, you can briefly say what has been available to children up until now and what's different now.
Dr Saleem Islam: Sure, Melanie. I mean, that's a great question as well. You know, neuromodulation is a technology that basically acts on nerves. And by doing so, it alters or modulates nerve activity by delivering electrical impulses to a specific target area. And depending upon which area is affected, it exerts different results.
People will most commonly associate neuromodulation when we attach it to the spinal cord for chronic pain issues or to the brain itself as in DBS or deep brain stimulation for Parkinson's disease and things like that.
When we talk about the gastrointestinal tract, however, we really are talking about two different things. And that is gastric electrical stimulation for gastroparesis or functional dyspepsia, which is the sensation of nausea, vomiting, bloating, getting full very quickly and pain after eating or for sacral nerve stimulation, which we use in patients who have a severe constipation with or without fecal incontinence, which is when you can't control the stool and you keep leaking stool out inadvertently. And so those are the two areas of neuromodulation where we use it in the gastrointestinal tract.
And the sacral nerve stimulation works on what's called the S3 or the third sacral nerve root. And from there, it acts on the autonomic nervous system to modulate that, and it actually helps both fecal incontinence and urinary incontinence. And it's used much more frequently in adults than it is in kids.
The gastric stimulator is attached to the stomach wall with leads. And then they're brought out to a device which is then implanted underneath the skin, and that sends constant impulses to the intrinsic gastric nervous system and the cells that are in there and causes the stomach to really start to feel better and to not send those impulse signals, which makes patients feel nauseated, et cetera. And so those are the two things that we've used.
Now, Melanie, you'd asked which of these is available for children. And I kind of have to say that there are no devices that are really developed for kids themselves. We really have to kind of take these devices off the shelf and use them in children in an off-label capacity, because obviously kids do get afflicted with these conditions. And even though the device manufacturer has not expressly made them for kids, we feel that kids deserve the care that all the adults get. And so we've used it and we've used it very successfully in these patients with great relief.
Melanie: Well then, doctor, is there an algorithm by which you're considering referral of patients for neuromodulation if it's not really in the general population? And you're using it in adults with great success, tell us a little bit about referral and when it can be used.
Dr Saleem Islam: So I'm a pediatric surgeon, of course. And I've used this device extensively in children. And if we talk about the gastric stimulator, for example, I've implanted about 154 of these in children. These are permanent devices. But our algorithm consists of, one, trying to do the best medical management that we have available for these functional dyspepsia or gastroparesis patients who frequently have other problems as well that effect the autonomic nervous system.
And once we maximize that and we don't get tremendous benefit, that's when we consider gastric stimulation. And we will do a trial of that gastric stimulation either by putting a special lead through the nose or a special lead through the stomach if they have a feeding tube that's been already implanted. We go through that site and we implant those leads and do a temporary trial for about five to greater than 10 days. And we make sure that that works for these patients.
We do actually an on and off trial in a blinded fashion so that the family, the child and the care team can be very sure that this works for them. We've done this in over 270 patients now, of which 150 eventually get implanted. And that's the largest experience for children in the world actually.
Melanie: And how have been your outcomes with those children that got the implanted neuromodulation?
Dr Saleem Islam: Sure. When we talk about gastric stimulators and the 150 that we've implanted, over long-term results, which have been over a decade now, we have seen really good responses. And 85% to 90% have had long-term success, meaning greater than five years of it continuing to work and provide relief. We see these patients consistently afterwards and they follow up in our clinics. And we monitor the device, we change the settings as needed and then of course, change the batteries, which is just explanting the device and putting a new one in when the battery gets depleted.
When we talk about sacral nerve stimulation, our experience is not as broad, but we've done about 20 patients in that. And when we look at other centers and combine all of our data with them, probably around 250 to 300 children have had sacral nerve stimulators implanted for fecal incontinence and severe constipation. And we've had great results with that. Again, we always do a temporary trial for those patients and we try for up to a month and make sure that this is something that'll work before we implant the device.
Melanie: What an informative episode this has been. As we wrap up, Dr. Islam, what would you like other providers to know about neuromodulation for pediatric GI motility disorders and when you feel it's important that they refer to you at UF Health Shands Hospital, as this is something that you are a leader in?
Dr Saleem Islam: I think that what I really would like the message is that if you have patients who have these chronic symptoms of a very severe nausea, vomiting, getting full very quickly or pain after eating, consider gastroparesis, consider those problems. And, in addition, we didn't talk about billary dyskinesia, which is the problem of the gallbladder, but we can help distinguish between those two and certainly we provide the long-term care for them.
There is an option available for them. These children don't have to suffer or just get a feeding tube and feel that is their life. We feel very strongly that this can really benefit and change their lives around to the point where they become tremendously productive members of society and can fulfill their potential, which we know is immense.
And similarly, I want providers not to feel that if a child has fecal incontinence, that their only ability to get treatment is to either suffer with diapers when they're adolescents or to just get enemas all the time or deal with laxatives of some kind. We do have options and we certainly want to explore them.
Melanie: That's really amazing. Dr. Islam, thank you so much for joining us and telling us about this exciting way to help these children. It's a complex condition and thank you again for joining us.
To refer your patient, you can call (352) 265-8800 or you can visit UFHealth.org/pediatricsurgery to learn more. And to listen to more podcasts from our experts, please visit UFHealth.org/medmatters.
That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.