foreign [Music] good evening I'm Dr Jeffrey Speer current president of the El Paso County Medical Society for 2022. we at the El Paso County Medical Society are very proud of this program we are certainly grateful for the collaboration of both star studies Studios and kcos for making this program a reality we're also incredibly grateful to miss Catherine Berg who has been such a terrific partner for the last 25 years being this program's host we hope you continue to join us each and every month for this fantastic program and please enjoy the presentation tonight thank you very much [Music] continents yeah that's what we're going to be speaking about tonight thank goodness for PBS thank goodness for El Paso County Medical Society and thank goodness for these doctors who don't mind talking about it and better yet are very very excited about giving us information that we need to know so fecal incontinence which is also known as ballon continents sometimes is defined as the involuntary leakage of liquid or solid stool it's a long-term chronic condition not just every now and again we have an accident so we're talking about the chronic condition and its unpredictable symptoms which can be caused by many conditions it's also referred to as accidental bowel leakage anal incontinence soiling or lack of bowel control so you've probably heard those words throughout the years it's a hard subject to talk about patients are often embarrassed to talk about it but that's why we're here we're ready to dive into it all and discuss some great new treatments that can make life a little bit easier for those with fecal incontinence this program is underwritten by the University Medical Center and we also want to thank the El Paso County Medical Society for bringing this to you now for 26 years I'm Catherine Berg and this is the El Paso physician foreign [Music] thanks again for joining us tonight we have a very unique topic that people talk about it's not so unique in what happens to people however it's a bit embarrassing which is why we wanted to bring it to you and have three doctors really discuss fecal incontinence it's accidents that happen but sometimes these are accidents that are chronic and we're going to talk about treatments regarding this so I have with me three doctors Dr Richard McCollum who is our veteran gastroenterology and he is uh he calls himself the tummy doc thank you for being here we have also Dr vid fikfak who is a surgeon specializing in colon and rectal surgeries and then we have Dr Nathaniel ing who also specializes in Colon and Rectal Surgery so Dr McCollum I'm going to start with you because we have covered a variety of topics and they're always gross but beautifully explained topics if I can say that because we did get very real on this program is people have questions and we want to be very forthcoming with it so at the end of our digestive digestive cycle we have to go to the restroom we have to have a bowel movement and as we age sometimes things don't operate the way they should and so what are we talking about this evening regarding that process what happened to me first of all say it's great to be back here with you for another year happy New Year thank you you too and of course I I regard you as sort of being a doctor in in quotations you know many many things about many subjects and toys a pleasure to work with you so from the GI point of view as we know every day we could have a feeling or an urge that something is moving in our lower intestines and we call that the urge to go many times we're in a situation driving a car at a meeting walking around where it's clearly not appropriate to even consider that to that next step having a bowel movement so we are very good at squeezing our muscles in the distal colon and in the proximal further down in the rectum written totally is about maybe 20 centimeters total so at about the recto sigmoid colon area we start to squeeze and we're very good at it natural fact some of the best I've seen are Airline stewardesses they can go for hours on International trips never go to the bathroom they end up in my office later with constipation and teachers and teachers so we have the ability to squeeze but sometimes as we age or we've had some events happening from childbirth onwards to our birth trauma we have lost that sensitivity and by the time we get that warning we may not have enough time to squeeze and halt the process and prevent losing some of that stool this is beyond passing gas this is passing stool into your underwear and sometimes even at night waking up with stool in the bed so this is the next step either not getting the message early enough combined with not having a strong squeeze or a strong muscle to hold it and those combinations lead us to seeing gastroenterologists and surgeons if we admit it as you said this is a silent problem very embarrassing and it's oftentimes not admitted to until you have a good relationship and rapport with your patient agreed and Dr Fick fact this is a nice transition over to you um first of all if you can explain to the audience again gastroenterology we've we've done this a lot but when you concentrate with your surgeries on Colo colon erectile surgeries what does that Encompass and then from there I'm going to ask you about what percentage of the population actually has this issue which again is a transition is a lot of people don't want to talk about it they're embarrassed and maybe it gets to a point where they they are almost what else is there to do but to seek help yes there's a lot of confusion among patients a lot of Shame uh which is unfortunate because it's now a treatable disease um yeah as far as Colon and Rectal Surgery you know we literally treat everything that has to do with colon and rectum so Drang and I are both board certified colorectal surgeons here in town and we treat anything from hemorrhoids and perianal abscesses and fistulas to colon cancer now with regards to fecal incontinence and how common it is well we talked before the show about the statistics and if you look up you're going to get a range of numbers but the numbers are actually a lot higher than what you would expect so I can tell you that about one in every 10 patients after age 50 is suffering from this so if you look at a spectrum of diseases and you put let's say diabetes on one side and Asthma on the other side fecal incontinence is going to be right in the middle wow and like you said not a lot of people will talk about it correct um and I think maybe Dr Ing this might be a good way to come talk to you when is it that people in your experience actually decide okay maybe I should go see someone about this maybe it's not just that I can't hold it anymore when is that one in ten at a point where they're like okay maybe I should go number one of my internists or go see gastroenterology man or and then surgery comes later um but in your experience when does that start happening that's a very good question we see patients on a spectrum like uh Dr fickpack can mentioned um those can be patients that are very young um those can be patients that are very old also but it comes from a couple things and I think mainly um one of them is embarrassment they don't want to have this experience that they've had in the past where they had an accident outside or they had to run home to go change or there was some sort of result from leakage of some stool in a public environment and so usually that Tammy a little bit of an impetus to send them to see a provider um however you also have the people that have been very long um in terms of their chronic chronicity of their disease and they're just up to that point where they really need some help and so that's when they give in and then at that point go see a provider and through that hopefully in the pathway be referred to somebody that can help them like us like you guys exactly and I know that some of the things I was reading on today uh you've got IBD IBS um these are some of the and then you've got chronic colonitis is that correct if I'm saying that correctly um colitis sorry colitis so when we're looking at these conditions that people may have throughout their lifetime that may have been controlled for whatever reason up until their 50s or 60s or whenever this starts being an issue what are some other types of conditions that people may have that may lead to this and Dr McConnell I'm asking you sorry I should have asked you that certainly so as an internist and a gastrologist I certainly see a lot of diabetes diabetes eventually affects the nerves in many parts of the body and it affects nerves in the gut so we see a impaired sensation in norectal tissue so you don't get that early warning there's another condition called a connective tissue disease where like the place one is called Scleroderma where again you've lost muscle sensitivity and strength you could have radiation to the rectal area as part of a colon cancer follow-up that has damaged you you can have dementia Parkinson's and probably just in general loss of mentation and that would lead you to have impaired responses to sensation patients with irritable bowel syndrome if they're diarrhea dominant that diarrhea over time may sneak up on them and they can't react quickly colitis chronic Ulster of colitis involves the rectum and sometimes over time it impairs the ability to squeeze your rectum well enough you may have spinal cord injuries for different reasons and even become unfortunately paraplegic which is hope the worst type of incontinence because you can't really protect the area very well over time a lot of infections and then you know we start off with child childhood trauma or trauma and childbirth where females will have physiotomies or other activities but interestingly enough they feel good in their 20s and 30s and 40s maybe their 50s we tend to blame them later by saying you must have had episiotomies why is your muscle so weak but having hysterectomies having prolapsed bladder surgeries having any surgery in the pelvis can change the anatomy which is sort of all held together very nicely by all these structures when you play with those structures will change them it opens the gate for that possibility great because I had two episiotomies that's something I get to look forward to we'll see not necessarily not necessarily and thankfully everything did work out well in in that area so thank goodness for that um when so here here's the questions I'm hearing two things I'm hearing some nerve damage or nerve issues and then I'm also hearing muscle issues and Dr Fick fact just because you're the next person to talk to or whoever would like to take this um let's let's try to separate the two or are they always somehow related together so the nerve tell the muscles what to do could it be a muscle weakness uh the nerves are just shots Etc so take that wherever you want and then feel free to kind of pin in here and there sure so yes you're right that the nerves innervate the muscle and that's where you're you're getting your muscle contractions from so so they're intimately connected um what Dr McCullum was referring to with episiotomy is that the muscle is cut so you have less muscle fibers there to provide that sphincter function that closing function that people need to control their bowel movements but a lot of times what we see in patients is a thought it's not necessarily just the muscle it's also the nerves that are damaged um it I know we haven't talked about this therapy yet but the nice thing about therapy uh the therapy that we're going to talk about is the fact that does affect the nerves it doesn't regrow the muscle but it has very beneficial effect despite not repairing the muscle well let's go there let's do talk about the fair therapy then because I know we're just kegels um and in general what is it what is the first line of defense or the first line of treatment that people come to you and say okay well let's try to to strengthen these muscles and or retrain the nervous system what are some of those types of uh treatments I guess so there are a couple of things that you can do you can bulk up the stool using fiber you can also use certain agents that basically make you a little bit slightly constipated maybe but the exercises are important so you have Kegel exercises you can also get physical therapy with biofeedback where you learn how to use your pelvic floor again so explain that so I hear that and I read about that today explain what that is like what is physiologically happening during biofeedback portion of this right so basically what the physiotherapist the pelvic floor physiotherapist specifically is training you is exactly which muscle you need to contract so you're relearning being what muscle is where and what signal you're sending to that muscle so that that particular muscle contracts so that you can properly do first of all the exercises and then literally relearn what the normal process of emptying your bowels is okay so and I guess where I'm getting lost is if it is for most of us just a natural you have to go you go you're done you don't think twice about it right so let's think about a person now that for the last five years things have just not been as smooth and let's say they're 55 or 60 now and so for the last five years it's like yeah things aren't going well are they are they or is their body retraining their system I guess that's my question how does one get out of the training and Dr Inger and I'll let you off the hook for a while Dr Ing you're on the hook now um so how does your body almost untrain itself to where it needs to be retrained from being a very natural type of a function to now it's like well it's not so natural I have to retrain myself sure that's a very good question we don't think about how complex it is when we poop right to say yeah it's like you gotta go you go and you're done for the most part just sit down and then we automatically expect things to happen which they did at a certain point for patients that suffer from fecal incontinence um when the stool goes down um it hits an area down in the distal rectum where it sends a signal back up to the brain and it tells the brain hey I got something there and so in order to react the body naturally usually closes up the sphincter and keeps stuff from coming out but over time when the body has been altered by habits like sitting on a toilet for a long time for example and then pushing and straining and that alters the anatomy that's there that Dr McCallum and Dr fig facton mentioned in terms of the nerves and over time when the feedback isn't correct normal like we would say um as we were when we were born then that changes how we use the muscles and in that process by modifying sort of how the normal process of excreting stool happens what happens in that situation is that then we start developing bad habits and then the muscles don't react the way that they should and over time chronic damage can occur that could be one of the reasons for it um and so then lead to you know the fecal incontinence of some patients do experience so um process itself does get affected by our habits so it's not just trauma one of the things that we talked about diseases like neuropathies from diabetes and such um so other things can affect it too including the way that we have caused ourselves to have bowel movements no I think that's fascinating and when we're talking about biofeedback is there something inserted into the rectum to see if this type of a movement is good or not so good or Dr McConnell from there well I do when I buy feedback yes we place a small catheter in the rectum by the size of a coffee stirrer and has a little balloon on the end and over time we increase the size of the balloon normally people feel it around 25 to 35 cc's of air and and we we asked them to squeeze and we have a screen there and we show them gee you're not going getting into the red color Zone you're in the green or the blue color Zone we want you to continue to learn how to squeeze for me so I want you to squeeze for the next 20 seconds as tight as you can and see if we can show anything and then we may have to increase the balloon size so they feel the need to squeeze to stop anything coming down so it's a trust and a time because it's you know a difficult area a bit embarrassing but over time we're re-learning you know we we sort of lost some of that sphincter muscle control and we're relearning to make it stronger so it's basically little Catherine the rectum which has electrodes on it and the electrodes are connected to our Monitor and the patient learns to try to get squeezing into that Red Zone and escalate above the blue or the yellow or the green zone and so um it's work in progress It's never alone right yeah we're giving Imodium we're trying to make them pseudo-constipated Kegel exercises at home and we're giving high fiber diets and so that that's our sort of full court press so I'm going to ask you for those people who don't know about cable exercises explain and talk one through what Kegel exercises are just in case there's someone at home that's in the beginning stages of this and we've mentioned it several times but we haven't said What It Is Well it most females in the audience would remember you know after childbirth one of the things to a gynecologist it's going to tell you is to try to squeeze in your pelvic muscles and sort of restore some strength in the bladder and the vagina and learn to squeeze again and tighten yourself so every three you know three or four hours during the day we ask people to take 10 minutes and sort of isolate themselves and sort of do some push-ups contract and squeeze contract and squeeze and try to sort of retrain that muscle so lifting weights trying to get a bit more strength into that muscle um that's that's really what I take Kegel exercises to be perhaps some have gone to college just go to another level but that's about as far as I go you know it's funny I remember after the birth of my second child I'm 55 and had one child at 31 at 35 and the doctor said well you know anytime you're driving and if you're at a red light that's your signal just your Kegel exercises while you're at the red light when the green light's gone you're driving no big deal but red light it signals that and for some reason that stuck in my head yeah because it's something you just do quietly to yourself and you can be singing along to the radio and taking it from there Dr fickvac I um would like to go to you and talk about so we're going to talk about it in just a moment about interstim but over the last and let's say people who are listening have known my grandma or my mother or my uncle they've had this issue in the past what surgically has been the go-to treatment over the last couple of decades and maybe and Dr Ing I'd like you to kind of chime in on this as well over the last couple of decades and what are we leaning into now today as a standard of treatment right so what we historically did was um the workup I think was a little bit different there was a very thorough work up including an anal ultrasound to assess the muscle which we talked about earlier and um when we did find a tear in the muscle there were certain dares that we could be repaired and the repair that was that we do is called the sphincteroplasty it's called that way because the muscle is called a sphincter and a plastic just means that we repair it so so this is a repair that had very good outcomes however after about five years most of these failed so about 50 percent if not more failed okay um the other thing that we did talk about and in some cases it's still an option but very much an option later on in the in the process of having fecal incontinence especially in paralyzed patients is giving them a diverting ostomy so people know that as the bag what it means is we connect a piece of the large intestine to the skin and this tool goes into the bag in patients especially patients who are paralyzed it's actually a very good solution because they don't they can't really clean themselves and it provides them a lot of a lot of relief because it's a lot easier to take care of but we hardly ever do that now that we have new therapy okay and perfect transition your new therapy guy see and again and I feel like sometimes with YouTube I'm just going to be asking questions and kind of do the ping pong thing but when we're talking about new therapy prior to inter-stem were these the two again classic therapies and again too when you're talking about the sphincteroplasty you're talking about repairing the muscle and then there's nerve endings there too right so I'd imagine that's pretty complicated when you're repairing muscle but making sure that the nerves are also you're not necessarily repairing their nerves you just repair the muscles so instead of if you imagine that you have a circle that's cut open you're basically bringing it back together into a circle okay so the nerve endings are they were intact to begin with well they may have been or may not have been and that is the issue you're not fixing the nerves you're just fixing the muscle okay it's a very complex neural plexus that's down there um I bet in the anus yeah and so the ability to repair that I think has been probably one of the bigger challenges that we've had because we haven't been able to do that um some of the other therapies not showing good durability under some injections um that Vulcan the area that have been tried and there's also some what we call metal sphincter uh that are magnetically drawn together that have not shown really good results either in some complications unfortunately associated with it interesting metal sphincters okay and so um those have been um unfortunately not successful okay and so with the inner stem therapy that we're going to be talking about here um that in itself provides the solution in a way um to it's not perfect um but there is a lot of uh obviously benefit the patients receive from it due to the ability to actually augment the signal and we're going to talk about the hearing a little bit I don't want to jump too far ahead um to help with getting the information back to the brain and then also allowing the brain to send the signal back down to the muscle um so sort of covering two bases all at once um and so that's um I think one of the big benefits that this technology offers I agree and Dr McCollum I know we met for quite a bit prior to the to the program starting um and if you can explain just re-explain everything that you explained to me when I walked in because I just thought it was fascinating of sometimes uh I think that you called it uh just very little lead time and that made sense to me it's like sometimes your body is ready to let things go but you're you don't feel what's happening and so you don't have a lot of lead time so you don't get to the bathroom on time and so this kind of helps with helping your body feel a little a little bit of lead time and I what I thought was interesting thing too is the juncture of where the sigmoin colon the sigmoid colon and the rectum come together that's kind of where you're talking about this balloon so explain to the audience that Sensation that we feel when when everything's okay and the sensations that we're not feeling in time when things aren't okay well the theory that the interstem tapped into is the fact that the distal sigmoid colon and rectum area are involved with somatic and autonomic nerves they kind of big big names for the audience to think about but these are so-called your internal nervous system coming from the spine activating sensation in the distal rectum sometimes the pudendal nerve is used as a generic marker but we're talking somatic in that case or spinal as in the case of paralysis or injury to the spinal cord and these all combine to sort of keep you primed up and ready to experience that sensation and react to it by squeezing your muscle assuming it's intact and um and most times it is so if you don't get the signal too late because those nerves are somewhat impaired your squeeze is not going to be probably enough or on time but generally we see a combination that there's been some injury also to the muscle over time and your maximal capacity is not there as well as you don't get the warning that early so we're trying to spiff up your distal nervous system and see if we can sort of upgrade it and return you to somewhat of a normal response to that Sensation that distinction of your rectum that urge try to make it felt quicker and then you have time to squeeze better so that's what we're trying to restore by stimulating What's called the sacral nerve right that the surgeons will go into more detail with but um it's it's been shown in actual fact that after years of using this your muscles are not Reborn it mainly activates your sensation you get a your rectal sensation process is much better it doesn't make your muscle strong you're not doing weight lifting with this stimulator your improving the process of of feeling it quicker and then over time with other exercises your muscle is able to kick in and be stronger so the episodes of incontinence go down each week over time so on that note between Dr fickvac and Dr Ing who wants to start with how this is implanted for the lack of a better word Dr Fick fact since you're on my side and again we'll kind of do the ping-pong thing again but um when you are performing this kind of a surgery and planting and you were talking about uh that there is an implant in there and then also there is a control mechanism on the outside so maybe we'll talk with Dr Ing about the control mechanism and then the implementation with you and again feel free to bounce back and forth on that sure so um I think it's important to understand that um actually the entire process involves two separate procedures okay uh so the first procedure are actually test electrodes so you don't get an implant that would be a permanent implant okay what we do is we put the patient Pro meaning that they're lying on their belly and then we identified based on anatomic landmarks uh the exact spot where the needle needs to go into the S3 foramen basically if you look at the sacrum it has little openings and out of those openings come sacral nerves we're trying to stimulate the nerves so we have to get next to the nerve with the electrode so the first part of the procedure is really just placing the electrodes on both sides um and then testing them if they work and we can see that pretty quickly because we connected to a stimulator that is an external machine and Dr Eng will talk about that but we can see that you know we are in fact stimulating the correct nerve um if that treatment works then we can move on to the second portion in about one or two weeks which is I'm exchanging those leads for a permanent lead that connects to a battery okay so during the first procedure all the electric leads on are on the outside and that there is a little machine that patients can control with their cell phone but during the second part everything is hidden underneath the skin and that is where we're talking about you have a battery in place that'll last for about 15 years and it'll do its job right that's amazing um and the piggyback on that before we go to the external portion of it so um thank you for explaining that there is this test period during this test period when Dr Fick fact said you know we wait to see if it works or see how it works um what are you all studying in those two weeks is it a daily feedback we were talking about biofeedback earlier is it a daily feedback that somehow gets transmitted to you all or does the patient write it down like how how do you know if it's working and if you need to up the the stimulation or bring it down Etc in reference to you know determining progress um it's a combined effort between both the patient keeping the log and seeing when they have the sensation they need to void and whether or not they actually have an accident um and then also there's data that goes back um into um the external component that sits there during the test period um and sends the information to the company that will allow them to make some alterations if necessary and so there's a very close interaction between both the patient and also Medtronic which is the manufacturer of this machine and through that they're able to make changes during that test period also and then see whether or not those changes translate into real world effects um and then during that be able to see whether or not patients actually experience improved fecal continence and so the number that we're looking for basically is a 50 Improvement during those two weeks okay um if you had four accidents before we implanted it and it's just an example number um you only have two after we've implanted it then that's going to be a sign of success but if they're not having that success there's still room for modification during that test period to see whether or not we can achieve that number um in order to you know prove efficacy and that's such a game changer I mean there's a there's a chart that we'll show later that Dr McCallum and I were looking at prior to it's like once that is implanted from what was your chart saying something like yeah there was like 16 times so somebody would uh have uh accidents 16 times a day and it would go to about 1.8 times a day and so again a week sorry a day that's a lot to go during the day but yeah 16 times a week and then going down to about 1.8 uh times a week of having an accents are wrong but leakage or fecal incontinence so that to me is huge when it comes to Quality of Life um so now let's take it to and I'm switching back and forth again now let's take it to this this device that we have outside that is only during the interim these couple of weeks that we're trying to find the right sweet spot is that correct and so um it's almost like a pacemaker I understand so one once you're ready for the permanent implant or for the permanent electrode uh where is that implanted just kind of talk about um say it's in there for two or three years and they're having bigger problems can it go back and be adjusted etc etc right so um you know as far as the first portion of the procedure which talk about just placing the electrodes this is probably one of the only treatments where you can test it before you actually decide that you're gonna do a permanent implant which is which is really nice to have it's not like you can do surgery on somebody and they you know put something back right right so so it gives us a lot of information um Medtronic as a company has been doing this for a very long time and we have a good relationship but I always say that this is a sort of a multi-disciplinary approach between gastroenterology colorectal surgery and the company which is metronic and and the representative uh Mr Pinedale so the the importance of that is that everybody has their role so we work up the patient we treat them but they also have a diary so going back to how how do you know that they're better basically they keep a diary before they they see us after we make the the changes that are conservative management and then after they have the implant they also have a diary and so we can actually see those numbers very clearly if they're getting better or not [Music] um so as far as you know the little device that's on the outside um they have uh on their cell phone they can adjust things they have a direct contact with the perfect with the rep from the company um and they're in constant contact with them they can call them at any point in time and they usually call them with very impressive stories like you know I haven't had a accident or like this this entire day and this is the day after the implant was placed oh my so so all of those adjustments can take place now if let's say that you do have an implant with the battery and everything and there are problems down the road you always check the battery first I just like put everything else right plug it in turn it on and off right but there's always there are always things that we can do if the the system completely fails we can go to the other side and try to implant it there um but you know it's it's just um in most patients I will say that the the the implants are are very effective and you'll see that after five years in most patients they still work so here's my question just again physiologically so we've got the implant is this then you're talking about 10 or 15 years is this then a forever treatment for that person let's say they got it when they were 50 and now they're 65. would they and who am I to say 15 years in the future what our research will hold but is there any physiological retraining that's happening within the body or this really is going to be an external stimulation going forward to help those nerves realize its time and Dr mccullumalo I see you nodding your head so well we've done and others did between us and double blonde trial with the FDA turned on turned off we found that after a year or two your sensitivity was better you could feel a lower threshold than you did before you were stimulated so I don't think we've endorsed stopping your stimulator just based on that because you know even one or two accidents now and again a week or a month is still a few two minutes right absolutely so I think we do Overkill if we can keep it going and then the good thing is these patients have an interrogator they have a a wand where they it's in the buttocks the pulse generator the battery and you can up upgrade or increase the strength of your current any day how do you know you're doing that well the biggest way of knowing is that your big toe begins to Twitch and tingle that that implies that you have hit the sweet spot here you've increased the the voltage coverage and it's going to be transmitted to your rectum it's also transmitted to your big toe so you can back off a bit but the patients can work with and find the right Spectrum as well but I I don't think in general we try to encourage going without it there may be a few people as I said diabetics where there's probably a one or two percent incidence over time where your pulse generator pocket in the buttocks uh by trauma or bad luck could get infected gotcha and then that may have to be replaced but this is a pretty protected area compared even to the cardiac pacemaker which is more vulnerable this is pretty well hidden down here in the buttocks and uh well the life is you know the long-term life expectation is very good and it's so fantastic that the patient is able to control it themselves and increase stimulation or decrease stimulation they can and have you found that through the years I think you may have answered this already but I just want to make sure I'm clear on that through the years that sometimes a stimulation um that you have found thus far and I again this is relatively new last decade or so um after a couple of years of stimulation that they need becomes less and less for the most part is that what I'm what I'm hearing that the stimulation that they are providing for the themselves that they can provide more stimulation or less stimulation that through the years they're finding that they don't need as much stimulation as when they first put it in I think that's probably true uh Catherine because they are also continuing you know the Imodium may be intermittently fiber you know we're we're doing everything at the same time we're not just saying take the stimulator and good luck right there's still a significant medical therapy accompanying uh our surgical colleagues and you talked about follow-up for the most part these patients are followed every six to six months every year is that correct that's right okay perfect so um I don't want to get off topic but I I love giving happiness to the audience but there is Bladder incontinence which in and of itself especially in females and we talked about this earlier can be a very different game and I get it mainly childbearing uh issues but this is kind of in the research slash checking out stages of helping out with Bladder incontinence too and I'll start with Dr McCollum and then feel free to chime in well our surgeons will definitely know this now this it's been well established in females um uh that we can help urinary incontinence with this procedure and we have urologist gynecologist um at uh UMC Texas Tech who is already doing this procedure most of our patients it's not dominated by fecal even though they are female it's nominated by fecal but there's a sprinkling of urinary incontinence and the parameters that are used with this pulse generator I'm not much different whether you maybe turn it up you know a few more vaults for the urine Etc you we often can combine a bit of urinary incontinence with fecal incontinence but there are women mainly obviously who have only Bladder incontinence urinary incontinence and we we have a program for those patients too we have a surgeon who's more in the GYN world who take who does that specific same procedure same Theory uh with those patients our surgeons may want to add some more comments yes please anything you want to Dr fickvac is nodding to Dr Ing so Dr Ing you get to go that's that's what I get to see behind the scenes that the audience doesn't get to see I kind of love that so Dr Ing is there anything you'd like to add to that you know I think Dr McCallum hit it on the head you know very accurately um in reference to the use of the nursetime technology it does apply to Bladder incontinence also um implantation again is pretty much the same um but um it does have that benefit and a lot of times when patients get it for for example bladder urinary incontinence um they'll find a difference in their fecal incontinence also just by default um so there is that benefit that's out there on the crossover exists between the two nice exactly there's a significant overlap so um you know just talking to the urogynecologist they see a lot of patients with fecal incontinence because they're originally seeing them with for urinary incontinence okay um the beauty just like everybody said is that you implant this it provides relief of both so you know um it's like one shot two pills yeah one shot two kills I like that we're kind of at a uh a time where I want to stop with my questions for a little bit because this uh there's so many things that we can talk about with this so Dr McClellan because you are the veteran on the board is there anything that we have not discussed yet that we'd like to get into we still have a good amount of time a good 15 minutes left um but I always feel like it's there's something that you were driving over here and I hope that she hits this and I hope she knows that I I want to make sure we give the message to our audience that they're in very good hands I've run a program already called the gastric stimulator or the gastric pacemaker we've put in the most gastric Pacemakers in the world without general surgery Department and so we have international national reputation for that luckily we now have some great surgeons in the colorectal world that can expand their expertise to doing gastric for doing stimulation of the sacral nerve and treating fecal incontinence but public listening should be very encouraged that they're going to be in the hands of experts who have been doing this this is not something we're doing to just jump on the bandwagon we initiated many of these early ideas about stimulation of the gut and we are continuing to have a total program we measure all the rectal parameters and we follow patients probably the only program certainly in Texas that has a fully integrated surgery GI relationship and where the GI department in particular has had a long experience with stimulating the gut and so they can be rest assured that they're in very good hands so if you don't mind what does that mean when you are stimulating the gut pacemaker for the gut for gastric pacemaker what what are the problems that resulted in needing a gastric Pacemaker and what is this gastric pacemaker doing physiologically in the gut like what is it making the gut do yeah well it's one why are we trying to minimize the word pacemaker unlike the heart we're not Awakening your muscle and making it reborn what we've learned sometimes the hard way is when I give you a gastric pacemaker you come to me with nausea and vomiting and diabetes and other reasons I'm mainly blocking your nausea this stimulator goes up nerves to your brain and in the chemo receptor trigger Zone which is the area of the northern vomiting Center I'm stopping your nausea it's a great the best antiemetic we have and therefore soon after that your your stomach feels better but the one-two punch we offer now with Dr Brian Davis which is new in this country is we're cutting the end of your stomach called the Polaris to make sure the slow emptying process where the food sits there from the diabetic injury it's open food goes out but we stop the nausea and we stop the vomiting but we add the bonus that you will empty your stomach and you can go back to eating fairly normally so it's been a learning curve and we found out that this is the the best approach Peacemaker or stimulator plus cutting the muscle called the Polaris so it's a little more a little more uh distance you know we have a stomach and a small bowel and we have to try to maintain nutrition so we have a little more of a a charge on our hands so you were talking about diabetes specifically um and I feel like this is such a simplistic question yeah but in general what causes nausea what is it that and you know I'll get nauseous maybe 10 times a year for whatever reason but what is it that causes nausea I know when I was pregnant I need to make sure that I ate before I went to bed so I wasn't nauseated in the morning I guess there's you know stuff being in the stomach Etc and I know there's I'm sure a plethora of reasons people get nauseous but what is it well probably the commonest course in the world is pregnancy so you know you've got these progesterone receptors up in the What's called the chemo receptor trigger Zone you're given opiates or narcotics post-operatively or other times often makes you vomit and then your stomach can be distended and stretched and you activate vagal nerves and other fibers that go to the brain and say gee I'm not doing well I'm hyper salivating I'm I'm sweating I'm going to vomit and so you basically serotonin you're basically activating receptors in the brain by stimulating you know parts of the gut I'm distended here I'm distended maybe during pregnancy or I'm just progesterone sensitive you know not all pregnancies are the same but many end up with vomiting from releasing more estrogen and progesterone during the early parts of pregnancy so these are receptors in your brain which are sensitive to external events chemotherapy you can activate them and arouse them very quickly seasickness all these things you will meet a very friendly receptor who will be glad to vomit that's so interesting I've always wondered that because yeah I'm a motion sickness girl yes I threw up like crazy when I was pregnant yeah I'm one of those girls and it's like what's happening to me um but that's the first time I've heard it put into the thought process of just different nerves that are talking to a person a person and you know just distention as a surgeons know when the bowel's obstructed you're very distended pain even severe pain you break your leg right skiing or something you're going to vomit not because something's going on you know in the brain necessarily except the pain is so severe One release is to activate these receptors and I'm going to vomit right so the brain you know tries to handle things but it ends up with limited options one is eventually I have to vomit or a hangover goodness gracious I had one of those once dear Lord um Dr fickba thick back let's go to um anything that we have not talked about that you thought would be important to talk about tonight before we wrap up and if there's nothing there's nothing but I always feel like there's something right so I think it's important like Dr McCullum said for people to understand that there are treatment options that are available now that weren't available before we've actually set this up as an entire program it's a multi-disciplinary program meaning that drain Dr McCollum and I are work together with the company and we've actually started reaching out to patients so not only are we trying to identify new patients with typical incontinence and we've had lectures around town to different practices and delivered the fecal incontinence questionnaire for screening but we've also looked at databases from Texas Tech and University Medical Center and to identify the patients who already have the diagnosis of fecal incontinence and there are tens of thousands of patients with that diagnosis wow tens and thousands so we're trying to reach out to those patients because we want to make them aware that this treatment is available and if they're experiencing these symptoms there is absolutely first of all they need to know that somebody else is suffering from the same problem I mean you know that's half of the burden right there but then there's a solution and we want to make them aware that there is a solution that we're here to provide that treatment and we're going to do it in a very ventricular multi-disciplinary way where they're going to be seeing us and we're going to do the appropriate studies and appropriate workup that they need and administer the right treatment nice and it's nice to I think you hit you hit it on the head when you again this is an embarrassing issue not a lot of people are going to talk about it they're not going to bring it up unless it's in a medical setting so Dr Ing I would love for you to talk about whatever we haven't brought up yet but I appreciate the fact that the show is a topic because this is not a topic that I think I've ever done on this program before and I like embarrassing topics because nobody else talks about them and I feel like oh that's the stuff that people are going to remember so you're going to be remembered people are going to go like hey I saw you and I heard you and they're going to remember you um and and this is a great topic to remember because everyone's got an issue now and again I've had diarrhea should I say it out loud I've had diarrhea I've actually had an accident before and I I was talking to Dr McCollum that I want to make sure that we get across that what we're speaking about tonight is a chronic issue a treatment for a chronic issue not when uh and Dr McCullum you were funny it's like I went on vacation had some bad water for a week and my stomach's not doing well I have diarrhea for a week I've had some accidents that week this is not what we're talking about this is more of a chronic issue um so that's something I meant to say geez 15 minutes ago and I didn't but Dr Ing is there anything that we haven't touched base on yet that you'd like to talk about can we cover excuse me I think we covered a lot already this evening um for those patients that have had the Medtronic stimulator place they understim um I mean it's just like colonoscopies if you don't talk about it then your friends don't understand what you know it means to have that benefit of knowing that all your polyps got removed you got you know cancers prevented and so I think that those patients that do have interest in already place you know could be a little bit more verbal in sharing with their friends and you know seeing whether or not they you know have similar situations or at least talking about the benefits of it um I think that takes away a lot of the taboo away from it um in terms of the stimulator itself um it's really not that big that's one of the things that I just thought about you know people say you put it in my buttocks am I going to sit on it you know this entire time even though I can hold my poop in um but it actually sits a little higher up um right above actually our bone that hip bone um and the fat that's there and so it's the approximate location so it's really comfortable like Dr McCallum had said so I just wanted to sort of clarify that um out there to make it so that patients have a better understanding of where this implantation is going to exist after it gets placed that makes all the sense of the world because you want to make sure again that it's something it's comfortable um I know this is not in any way an oncology show but because we have this discipline here um and you talked about cancer I just I'm always a proponent of saying hey let's get your screenings right so Dr McCallum I'm going to let you take it away from because we have a little bit of extra time which is really nice we rarely do we're always like right at that moment um but fecal incontinence doesn't really have any symptoms or colon cancer usually doesn't have any symptoms let's throw that screening situation in there yeah we'll see it went down to 45 years of age now because of knowledge of how prevalent colon cancer is and we know if you look in the paper that you never really it's never over Pele one of the great soccer player of all time just died of colon cancer and you know he was in his 80s so we are going down possibly into our 40s we're going to go down to 47 because there are still many cases of um missed cancer or cancer that has evolved before age 45 so yes when Preston's Camp breast and Colin if you can attack those aggressively with your family please have them screened and please take it seriously because no one is fed and you won't Escape and Dr Ing you said it really well too when you you know making this part of a normal conversation I feel like colon cancer and colonoscopies for the most part are kind of becoming or have become part of a normal conversation and again at 50 but I'm glad you're saying 40s now at 50 I just feel like women know to get their mammograms guys know to get their prostates checked and then 50 comes the colon colonoscopy so we're looking at maybe 45 to 40 years of age being the case and the nice thing about that is you get your colonoscopy and if you're clean and good you're you're fine for about five years and please correct me if I'm wrong five to ten five to ten but if there is a polyp what happens Dr McCollum well we're going to bring it down closer to three to five and then we might have to throw in a family history but we have all these little check boxes to try to make sure we keep a pretty close tab on you exactly and if there is a polyp in there are two polyps or three polyps uh the the colonoscopy will take those polyps out and so they're done they're gone and so that chance of having that polyp turn into a cancer is no longer a chance of turning into a concert because of the colonoscopy so I just thought I'd throw that in there um I want to say say thank you so much Dr McCollum again uh you always bring the most interesting shows this way so thank you so much for that uh Dr vid fikfak uh and Dr Nathaniel ing thank you so much for being here the surgery part's always the gross part but very fascinating to me and uh UMC for underwriting this program and a big thank you always to the El Paso County Medical Society who has been doing this show again for 26 years and if you didn't catch all of this you were welcome to go to pbselpasso.org you will find this show and all kinds of programs on there just either search for topic or just look for the El Paso physician on there you can do that with the El Paso County Medical Society website which is epcms.com or you can go to YouTube so you can go to YouTube and look up the El Paso physician and from there there'll be a piggyback of different programs that you can kind of spotlights like if I have heart issues or if you want to talk about fecal incontinence so if you only caught part of this program there are the three places that you can go to find it so other than that I thank you guys for being here happy New Year yes go ahead Catherine let's go a real shout out to Patsy Slaughter oh yeah like you as a has been a major player in educating Us in El Paso runs the County Medical Society so efficiently and so quietly in the background and Apache just you've done a great job we all love you and we so I'm wonderful with her all the time I can't do anything without Patsy and Elsa appreciate it thank you they have us they have us going all the time we appreciate you Catherine you uh you've made a major difference in El Paso as far as medical education thank you sir with that you've been watching the El Paso physician I'm Catherine Berg good evening [Music] did you tell I was staring at that clock thank you for turning it off oh my God this has been the longest two and a half minutes of my life foreign [Music]