Using sacral nerve modulation to improve continence and quality of life in patients suffering from low anterior resection syndrome

Abstract

Background: Sphincter preserving surgery for the treatment of rectal cancer is very often feasible, avoiding a permanent colostomy. It is well recognized that a large proportion of patients will experience altered bowel habit following low anterior resection (LAR). Faecal incontinence is a common symptom associated with LAR syndrome. The aim of this study is to evaluate the long-term improvement in continence and quality of life (QoL) in LAR patients treated with sacral nerve modulation. Methods: Patients with ongoing faecal incontinence for >1 year after reversal of diverting ileostomy post ultra-LAR were selected for the study. Eligible patients underwent sacral nerve modulator implantation as a two-stage procedure. Bowel diaries and the Cleveland Clinic Faecal Incontinence Score were used to measure faecal incontinence and QoL. Results: Twelve patients underwent permanent implantation of a sacral nerve stimulator. Median follow-up was 34 months (interquartile range (IQR) 20.25-62.5 months). The median improvement in faecal incontinence was 90% (IQR 76.25-98.75%) and the median improvement in patient QoL was 80% (IQR 71.25-93.75%). Patients who had previously been treated with biofeedback showed a median improvement in incontinence of 75% compared to 90% which was found in patients who had not had prior biofeedback treatment. The mean percentage improvement in patients with an internal anal sphincter defect was 80% compared to 90% seen in patients with an intact sphincter. Conclusions: The results of this study suggest that sacral nerve modulation should be more widely considered as an effective treatment strategy for patients with faecal incontinence following LAR. © 2018 Royal Australasian College of Surgeons ANZ J Surg 88 (2018) E787-E791 ANZJSurg.com © 2018 Royal Australasian College of Surgeons E790 Croese et al.

Sacral nerve stimulation for bowel dysfunction following low anterior resection: a systematic review and meta‐analysis

“…Table summarizes the details of PNE and SNS implantation. In seven studies, a two‐staged procedure was performed with permanent SNS implantation after a satisfactory PNE test phase using temporary electrodes . A three‐staged procedure was performed in three studies .…”

“…Two analyses were conducted, based on outcomes as assessed using the CCIS and the LARS score. A meta‐analysis was conducted by using seven studies . Three studies were excluded from forest plots due to incomplete information and study design (case report) .…”

“…The systematic search identified 63 potential eligible articles. Figure 1 shows the review process that led to the final inclusion of 10 studies for review following exclusion of duplicates and articles that did not meet inclusion criteria [5,[12][13][14][15][16][17][18][19][20]. Table 1 summarizes the characteristics of the studies.…”

“…Inclusion criteria are not well defined by any of the studies although all authors indicate that the patients considered for PNE had all failed conservative management. There were four prospective single centre studies [5,13,14,17], five case series [12,15,[18][19][20] and one case report [16]. Table 2 summarizes the details of PNE and SNS implantation.…”

“…Overall median follow-up duration was 18.0 months (range 12.0-34.0). All studies used the Cleveland Clinic Incontinence Score (CCIS) scoring system to define response [5,[12][13][14][15][16][17][18][19][20], whereas the LARS score was used in three studies [5,18,19]. The William classification, Altomare score and Pescatori score were used in one study each, namely the study by Holzer et al [12], Schwandner [13] and Ratto et al [14] respectively.…”