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310 Chapter 15 to ACE treatment. One parent reported that before starting SNS treatment, their family was confined to their home every evening because of their child's daily ACE regimen, which would often take an hour or more to complete. After starting SNS treatment, their child was able to decrease and ultimately discontinue ACE use, allowing the family to leave the home without worrying about setting time aside for ACE administration. This parent's experience is supported by our recent findings that SNS can allow decreased ACE use in children with refractory constipation already treated with ACE. 24 A number of parents had negative comments regarding SNS treatment. A few parents felt that the length of time involved in the evaluation prior to starting SNS treatment, the two-stage initiation process, and waiting for symptomatic improvement was longer than anticipated. A handful of parents also noted that urinary symptoms improved more than constipation or fecal incontinence, which likely contributed to their perception of benefit from the treatment. It is concerning that a quarter of our patients experienced complications that required further surgery and that more than one surgery was often required. For example, each of our patients who developed a wound infection underwent two operations, the first for device removal and the second for replacement. One of these patients went on to develop a second infection and another required surgical lead revision. In their series of 27 children, van der Wilt et al. reported that 12 children required further surgery, but these were primarily for repositioning of the lead or stimulator. Only one patient developed an infection. 11 Our experience was consistent with what has been reported in adult studies. In a recent review of nearly 2000 patients reported in the literature to have undergone SNS for fecal incontinence, Bielefeldt reported that 18.6% of patients experienced complications requiring further surgery. Device removal was generally secondary to infection. 25 The complication rate found in our sample emphasizes the need for further studies evaluating for predictors of complication development in our patient population. The comparative evaluation of less-invasive neurostimulation techniques may be useful in identifying safer alternative treatments. Our study has several limitations. The observational nature of our study and the lack of a control or comparison group is a weakness that we will address in future studies. We recently began a study comparing the outcomes of children with refractory constipation treated with various treatment strategies. Although our study includes one of the larger cohorts of children with constipation treated with SNS in the literature, our sample size remains limited and prevents us from performing further subgroup analysis that could allow identification of patient characteristics associated with SNS response or complications. We were also able to reach only 17 of 25 parents during our assessment of patient benefit and parent