Sacral Nerve Stimulation for Fecal Incontinence Following Surgery for Rectal Prolapse Repair: A Multicenter Study

PURPOSE: A proportion of patients have fecal incontinence secondary to a full-thickness rectal prolapse that fails to resolve following prolapse repair. This multicenter, prospective study assessed the use of sacral nerve stimulation for this indication. METHODS: Patients had to have more than or equal to four days with fecal incontinence per 21-day period more than one year after surgery. They had to have failed conservative treatment and have an intact external anal sphincter. RESULTS: Four female patients aged 42, 54, 68, and 65 years met the inclusion criteria. Three of the four patients had had more than one operation for recurrent full-thickness rectal prolapse before sacral nerve stimulation, one of whom had undergone a further operation for recurrence following stimulation. One patient had undergone one operation for prolapse repair. The preoperative duration of symptoms was ten, eight, three, and nine years, respectively. Although patients had an intact external anal sphincter, one patient had a fragmented internal anal sphincter. The frequency of fecal incontinent episodes changed from 11, 24.7, 5, and 8 per week at baseline to 0, 1.5, 5.5, and 1 per week at latest follow-up. Ability to defer defecation was also improved in two of three patients who had this documented. Fecal incontinence-specific quality of life assessment showed an improvement in all four domains. CONCLUSION: Sacral nerve stimulation should be considered for patients with ongoing fecal incontinence following full-thickness rectal prolapse repair if they prove resistant to conservative treatment.     

Innovations in Fecal Incontinence: Sacral Nerve Stimulation

OBJECTIVE The aim of this study was to present an overview of sacral nerve stimulation in the treatment of fecal incontinence. We describe the evolution in technique, patient selection, and indications, and review results and complications.METHODS All articles on sacral nerve stimulation for fecal incontinence that were recovered on MEDLINE search were reviewed. With multiple articles from an institution, the most recent reports with the longest follow-up and largest cohort of patients were selected, unless information from earlier reports was relevant.RESULTS The technique of sacral stimulation is well established, carries little risk, and continues to be refined (e.g., a less invasive approach has been proposed). Patient selection is based on a two-stage diagnostic test stimulation (acute and subchronic), for which the predictive value is high. On this basis, permanent sacral nerve stimulation has proved effective in both single-center and multicenter trials in patients with a functional deficit but limited morphologic lesions or no morphologic lesions. The clinical benefit derives from multiple symptomatic improvements contributing to better bowel control and from substantially improved quality of life. The underlying mechanism of action remains undefined, but both somatic and autonomic function appears affected.CONCLUSION Sacral nerve stimulation offers a safe treatment mode in a patient population in whom conservative treatment has failed and traditional surgical approaches would have limited success. The high predictive value of the diagnostic approach offers a unique therapeutic advantage.Presented in part at the International Colorectal Disease Symposium, Fort Lauderdale, Florida, February 13 to 15, 2003.     

Sacral Resection for Recurrent Rectal Cancer: Analysis of Morbidity and Treatment Results

Purpose Composite sacropelvic resection for locally advanced recurrent rectal cancer is a high-risk procedure that benefits select patients. We reviewed our recent institutional experience to evaluate case selection, morbidity, and outcomes. Methods Between 1987 and 2004, 29 patients underwent composite resection for recurrent locoregional rectal cancer (17 females; median age, 60 years). Clinicopathologic indicators were evaluated as indicators of survival by log-rank test and Cox proportional hazards model. Results Of 29 total patients, 27 (93 percent) received radiotherapy with their previous surgery (n = 10; 34 percent) or before sacrectomy (n = 17; 59 percent), and 12 (41 percent) received intraoperative therapy. Sacral resections were performed at S2/S3 (55 percent) or S4/S5 (45 percent) using anterior (41 percent) or combined anterior-posterior approach (59 percent), with adherence to (62 percent) or cortical invasion in (38 percent) the sacrum. A majority of those who had undergone previous abdominoperineal resection had total exenteration (9/13), whereas most patients who had undergone a previous sphincter-preserving procedure had abdominoperineal resection (12/16) and none had exenteration. Pedicle flaps (omental, 11; abdominal rectus, 7) often were used. A median of five (range, 1–33) units of blood was given intraoperatively. Transfusions were associated with previous abdominoperineal resection (P < 0.03), correlating strongly with postoperative morbidity (P < 0.02). There were 33 complications in 17 (59 percent) patients, most commonly perineal wound breakdown (9 (31 percent)) and pelvic abscess (5 (17 percent)). Median hospital stay was 18 (range, 7–56) days, significantly longer in patients with previous abdominoperineal resection (P < 0.02) or postoperative morbidity (P < 0.03). The only postoperative death was from pelvic sepsis. Resection was complete (R0) in 18 patients (62 percent), with microscopically positive margins (R1) in 10 (34 percent) and grossly positive margins (R2) in 1 (3 percent). Two-year and five-year recurrence rates were 47 and 85 percent, respectively; disease-specific survival was 63 and 20 percent, respectively. Less transfusion (P = 0.03), R0 resection (P = 0.005), lack of anterior organ involvement (P = 0.02), and absence of cortical bone invasion (P < 0.001) were associated with better survival on univariate analysis; original colorectal cancer stage was not. Conclusions Sacrectomy for rectal cancer is a high-risk procedure that can achieve clear resection margins with low mortality in select patients. This procedure has a low cure rate but may provide local disease control with acceptable morbidity. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available.     

Sacral Nerve Stimulation for Fecal Incontinence Related to Obstetric Anal Sphincter Damage

Purpose Sphincter repair is the standard treatment for fecal incontinence secondary to obstetric external anal sphincter damage; however, the results of this treatment deteriorate over time. Sacral nerve stimulation has become an established therapy for fecal incontinence in patients with intact sphincter muscles. This study investigated its efficacy as a treatment for patients with obstetric-related incontinence. Methods Fecally incontinent patients with external sphincter defects who would normally have undergone overlapping sphincter repair as a primary or repeat procedure were included. Eight consecutive women (median age, 46 (range, 35–67) years) completed temporary screening; all eventually had permanent implantation. Results Six of eight patients had improved continence at median follow-up of 26.5 (range, 6–40) months. Fecal incontinent episodes improved from 5.5 (range, 4.5–18) to 1.5 (range, 0–5.5) episodes per week (P = 0.0078). Urgency improved in five patients, with ability to defer defecation improving from a median of <1 (range, 0–5) minute to 1 to 5 (range, 1 to >15) minutes (P = 0.031, all 8 patients). There was no change in anal manometry or rectal sensation. There was significant improvement in lifestyle, coping/behavior, depression/self-perception, and embarrassment as measured by the American Society of Colon and Rectal Surgery fecal incontinence quality of life score. Conclusions Sacral nerve stimulation is potentially a safe and effective minimally invasive treatment for fecal incontinence in patients with de novo external anal sphincter defects or defects after unsuccessful previous external anal sphincter repair, although numbers remain small. Dr. Michael Kamm is a consultant to and received research support from Medtronic, however, study design, performance, analysis, and reporting have been conducted without the influence of Medtronic.     

Sacral Nerve Stimulation in Fecal Incontinence

PURPOSE: The effect of sacral nerve stimulation was studied in 45 patients with fecal incontinence.METHODS: All patients were initially tested in general anesthesia. Sacral nerves 2, 3, and 4 were tested on both sides. If a perineal/perianal muscular response to sacral nerve stimulation could be obtained, electrodes were implanted for a three-week test-stimulation period. If sacral nerve stimulation resulted in at least a 50 percent reduction in incontinence episodes during the test period, a system for permanent sacral nerve stimulation was implanted.RESULTS: When tested in general anesthesia, 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period. Percutaneous electrodes were used in 34 patients, and 23 of these had at least a 50 percent reduction in incontinence episodes, whereas the electrodes dislocated in 7 patients and 4 had a poor response. Permanent electrodes with percutaneous extension electrodes were used primarily in 9 patients and after dislocation of percutaneous electrodes in an additional 6 patients; 14 of these had a good result. In the last patient, no clinical response to stimulation with the permanent electrode could be obtained. A permanent stimulation system was implanted in 37 patients. After a median of six (range, 0–36) months follow-up, five patients had the system explanted: three because the clinical response faded out, and two because of infection. Incontinence score (Wexner, 0–20) for the 37 patients with a permanent system for sacral nerve stimulation was reduced from median 16 (range, 9–20) before sacral nerve stimulation to median 6 (range, 0–20) at latest follow-up (P < 0.0001). There was no differences in effect of sacral nerve stimulation in patients with idiopathic incontinence (n = 19) compared with spinal etiology (n = 8) or obstetric cause of incontinence (n = 5). Sacral nerve stimulation did not influence anal pressures or rectal volume tolerability.CONCLUSIONS: Sacral nerve stimulation in fecal incontinence shows promising results. Patients with idiopathic, spinal etiology, or persisting incontinence after sphincter repair may benefit from this minimally invasive treatment.Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Reprints are not available.     

Rehabilitation of Fecal Incontinence After Sphincter-Saving Surgery for Rectal Cancer: Encouraging Results

Purpose  Some patients, having undergone sphincter-saving operations for rectal cancer, may suffer from fecal incontinence. This study was designed to evaluate the results of rehabilitative treatment in patients with fecal incontinence after sphincter-saving operations and to identify the negative factors that influence therapeutic success. Methods  Between January 2000 and June 2007, 88 incontinent patients (54 women; age range, 47–73 years; 69 had received a low anterior rectal resection; 19 a straight coloanal anastomosis) were included in the study. After a preliminary clinical evaluation, including the Wexner Incontinence Scale score, anorectal manometry was performed. All 88 patients underwent rehabilitative treatment according to the “multimodal rehabilitative program” for fecal incontinence. At the end of program, all 88 patients were reassessed by means of a clinical evaluation and anorectal manometry; their results were compared with the clinical and manometric data from ten healthy control subjects. Postrehabilitative Wexner Incontinence Scale scores were used for an arbitrary schedule of patients divided into three classes: Class I, good (score ≤3); Class II, fair (score >3 to ≤6); Class III, poor (score >6). Results  After rehabilitation, there was a significant improvement in the overall mean Wexner Incontinence Scale score (P < 0.03) for both surgical operation types (low anterior rectal resection: P < 0.05; coloanal anastomosis: P < 0.02). Only 21 patients (23.8 percent) were symptom-free, and 37 (42 percent) were considered Class III. A significant postrehabilitative direct correlation was found between: 1) Wexner Incontinence Scale score and degree of genital relaxation (rρ _s 0.78; P < 0.001); 2) Wexner Incontinence Scale score and irradiation (rρ _s 0.72; P < 0.01); and 3) Wexner Incontinence Scale score and pelvic (rρ _s 0.65; P < 0.01) or anal surgery (rρ _s 0.68; P < 0.01). No significant differences were found between prerehabilitative and postrehabilitative anal pressures in low anterior rectal resection and coloanal anastomosis patients. Conclusions  After rehabilitation, some patients become symptom-free, many patients show an improvement in the Wexner Incontinence Scale score, and others exhibit the highest grades of fecal incontinence. Genital relaxation, radiotherapy, and previous pelvic, and/or anal surgery are impeding factors to rehabilitative success.     

Comparison of Functional Results and Quality of Life Between Intersphincteric Resection and Conventional Coloanal Anastomosis for Low Rectal Cancer

PURPOSE: The technique of intersphincteric resection permits sphincter preservation with good oncologic results in very low rectal cancer. This study aimed to investigate functional results and quality of life after intersphincteric resection compared with conventional coloanal anastomoses.METHODS: From 1990 to 2000, 170 patients underwent total mesorectal excision with coloanal anastomosis for low rectal tumors. Questionnaires were obtained from 77 patients alive without colostomy: 37 had a conventional coloanal anastomosis and 40 had intersphincteric resection. Both groups were similar according to age, gender, anastomotic stenosis, colonic pouch, anastomotic leakage, preoperative radiotherapy, and follow-up (median, 56 months). Assessment included one functional and two quality-of-life questionnaires: the SF-36 Health Status and the Fecal Incontinence Quality of Life score.RESULTS: There was no difference in stool frequency, fragmentation, urgency, dyschesia, and alimentary restriction between patients with and without intersphincteric resection. Patients with intersphincteric resection had significantly worse continence (Wexner score, 10.8 vs. 6.9; P < 0.001) and needed more antidiarrheal drugs (60 vs. 35 percent; P = 0.04) than those without. Compared with conventional coloanal anastomoses, quality of life was altered by intersphincteric resection for the subscale embarrassment (P < 0.01) in the Fecal Incontinence Quality of Life score, whereas no difference of quality of life was observed with SF-36.CONCLUSIONS: Compared with conventional coloanal anastomoses, patients with intersphincteric resection have a higher risk of fecal incontinence and a slightly altered quality of life.Presented at the meeting of the Société Française de Chirurgie Digestive, Lyon, France, December 11 to 12, 2003.Reprints are not available.     

Sacral Nerve Stimulation is more Effective than Optimal Medical Therapy for Severe Fecal Incontinence: A Randomized,Controlled Study

Purpose This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence. Methods Patients (aged 39–86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; n = 60) or best supportive therapy (control; n = 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal incontinence quality of life index. The follow-up duration was 12 months. Results The sacral nerve stimulation group was similar to the control group with regard to gender (F:M = 11:1 vs. 14:1) and age (mean, 63.9 vs. 63 years). The incidence of a defect of ≤ 120° of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved incontinent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 “successful” patients. There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group. Conclusions Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy. *Deceased. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Colonic J-Pouch vs. Coloplasty Following Resection of Distal Rectal Cancer

PURPOSE: In terms of functional outcome, there is evidence of the superiority of the colonic J-pouch over a straight coloanal anastomosis. Even though the colonic J-pouch was created to restore a neorectal reservoir, manometric data show that the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. We speculate that the advantage of the colonic J-pouch is not in creating a larger neorectal reservoir, but rather related to decreased motility. Maurer and Zgraggen recently described a new colonic pouch design, performing a transverse coloplasty pouch. The purpose of this pilot study was to compare the feasibility and functional outcome of the 5-cm colonic J-pouch vs. the coloplasty pouch. METHODS: From February 2000 to June 2001, we randomized 40 consecutive patients with distal rectal cancer (<12 cm from the anal verge) into the J-pouch or coloplasty group. A low rectal resection and coloanal anastomosis was performed in all patients. Functional data were collected by a standardized questionnaire and anorectal manometry, preoperatively and six months postoperatively. Primary end points of the study were potentially differences of both groups regarding technical feasibility, stool frequency, and anorectal manometry. RESULTS: The construction of a coloplasty pouch was feasible in all cases of the coloplasty group, but not in 5 of 20 (25 percent) patients of the J-pouch group, because of colonic adipose tissue. Six months after operation or stoma closure, respectively, stool frequency was 2.75 ± 1 per day in the J-pouch group and 2 ± 2 per day in the coloplasty group. There was no significant difference in resting and squeeze pressure and neorectal volume between both groups, but an increased neorectal sensitivity in the coloplasty group. CONCLUSION: We found similar functional results in the coloplasty group compared to the J-pouch group. The neorectal sensitivity was increased in the coloplasty group. Therefore, the colonic coloplasty seems to be an attractive pouch design because of its feasibility, simplicity, and effectiveness.     

Preoperative Chemoradiation for Rectal Cancer Causes Prolonged Pudendal Nerve Terminal Motor Latency

Purpose A worsened anorectal function after chemoradiation for high-risk rectal cancer is often attributed to radiation damage of the anorectum and pelvic floor. Its impact on pudendal nerve function is unclear. This prospective study evaluated the short-term effect of preoperative combined chemoradiation on anorectal physiologic and pudendal nerve function. Methods Sixty-six patients (39 men, 27 women) with localized resectable (T3, T4, or N1) rectal cancer were included in the study. All patients received 45 Gy (1.8 Gy/day in 25 fractions) over five weeks, plus 5-fluorouracil (350 mg/m²/day) and leucovorin (20 mg/m²/day) concurrently on days 1 to 5 and 29 to 33. Patients who had rectal cancer with a distal margin within 6 cm of the anal verge had the anus included in the field of radiotherapy (Group A, n = 26). Patients who had rectal cancer with a distal margin 6 to 12 cm from the anal verge had shielding of the anus during radiotherapy (Group B, n = 40). The Wexner continence score, anorectal manometry and pudendal nerve terminal motor latency were assessed at baseline and four weeks after completion of chemoradiation. Results The median Wexner score deteriorated significantly (P < 0.0001) from 0 to 2.5 for both Groups A (range, 0–8) and B (range, 0–14). The maximum resting anal pressures were unchanged after chemoradiation. The maximum squeeze anal pressures were reduced (mean = 166.5–157.5 mmHg) after chemoradiation. This change was similar in both Groups A and B. Eighteen patients (Group A = 7, Group B = 11) developed prolonged pudendal nerve terminal motor latency after chemoradiation. These 18 patients similarly had a worsened median Wexner continence score (range, 0–3) and maximum squeeze anal pressures (mean = 165.5–144 mmHg). The results obtained were independent of tumor response to chemoradiation. Conclusions Preoperative chemoradiation for rectal cancer carries a significant risk of pudendal neuropathy, which might contribute to the incidence of fecal incontinence after restorative proctectomy for rectal cancer. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Routine Mobilization of the Splenic Flexure is not Necessary During Anterior Resection for Rectal Cancer

Purpose Splenic flexure mobilization is widely considered to be an essential component of anterior resection for rectal cancer. It was our hypothesis that selective splenic flexure mobilization would reduce operative times without increasing morbidity or affecting cure. Methods A total of 100 consecutive patients with rectal cancer (mean 8 (range, 4–15) cm from anal verge) who underwent anterior resection for cure between 1996 and 2002 had splenic flexure mobilization only as required to achieve a tension-free anastomosis. Operative time, postoperative morbidity, pathologic findings, and recurrence rates were recorded. Results There were no clinicopathologic differences between those who had splenic flexure mobilization (n = 26) and those who did not (n = 74). Mean operative time in the splenic flexure mobilization group was longer, 167 (range, 130–200) minutes vs. 120 (range, 95–180) minutes in the nonmobilized group (P = 0.023). Mean length of specimen resected was longer in the splenic flexure mobilization group: 36 vs. 18 cm (P = 0.008). Anastomotic complications (4 percent), local recurrence (7 percent, median follow-up, 38 months), perioperative morbidity (32 percent) and mortality (2 percent), and survival did not differ between the two groups. Conclusions Routine splenic flexure mobilization is not required for safe anterior resection in patients with rectal cancer. Avoiding splenic flexure mobilization results in shorter operative times and does not increase postoperative morbidity, anastomotic leakage, or local recurrence. Presented at the Freyer Surgical Meeting, Galway, Ireland, September 2 to 3, 2005.     

Carbon-Coated Microbeads Anal Injection in Outpatient Treatment of Minor Fecal Incontinence

Purpose

Anal bulking agents are injected to pose a stronger obstacle to the involuntary passage of feces and gas. This prospective, multicenter study was designed to evaluate the safety and efficacy of Durasphere® anal injection for the treatment of fecal incontinence.

Patients and Methods

Thirty-three unselected patients with incontinence (24 females; mean age, 61.5?±?14 (range, 22–83) years) underwent anal bulking agent submucosal injection with carbon-coated microbeads (Durasphere®) in the outpatient regimen. The causes of incontinence were obstetric lesions in 18.2 percent, iatrogenic in 36.4 percent, rectal surgery in 12.1 percent, and idiopathic in 33.3 percent. Previous unsuccessful treatments for fecal incontinence included diet and drugs in 16 patients, biofeedback training in 7 patients, sacral nerve modulation in 6 patients, sphincteroplasty in 2 patients, artificial bowel sphincter in 1 patient, and PTQ macroplastique bulking agent in 1 patient. Under local anesthesia and antibiotic prophylaxis, a mean of 8.8 (range, 2–19) ml of Durasphere® were injected into the submucosa by using a 1.5-inch, angled, 18-gauge needle.

Results

After a median follow-up of 20.8 (range, 10–22) months, the median Cleveland Clinic continence score decreased significantly from 12 to 8 (P?P?=?0.0074), but the Fecal Incontinence Quality of Life did not change significantly (74 to 76, P = not significant). Anal manometry significantly improved (resting pressure increasing from 34 to 42 mmHg; P?=?0.008) and squeezing pressure from 66 to 79 mmHg (P?=?0.04). Two patients complained of moderate anal pain for a few days after the implant, one patient had asymptomatic leakage of the injected material through a mucosa perforation, and two had distal migration of the Durasphere® along the dentate line.

Conclusions

Anal bulking agent injection is a safe treatment and can mitigate the severity of fecal incontinence by increasing anal pressure but does not significantly improve the quality of life.     

Rectal Volume Tolerability and Anal Pressures in Patients With Fecal Incontinence Treated With Sacral Nerve Stimulation

Purpose Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation. Methods Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29–79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for “first sensation,” “desire to defecate,” and “maximal tolerable volume,” rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up. Results Median Wexner incontinence score decreased from 16 (range, 6–20) to 4 (range, 0–12; P < 0. 0001). Median “first sensation” increased from 43 (range, 16–230) ml to 62 (range, 4–186) ml (P = 0.1), median “desire to defecate” from 70 (range, 30–443) ml to 98 (range, 30–327) ml (P = 0.011), and median “maximal tolerable volume” from 130 (range, 68–667) ml to 166 (range, 74–578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0–109) cm H₂O to 38 (range, 0–111) cm H₂O (P = 0.045). No significant increase in maximum squeeze pressure was observed. Conclusions For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Influence of Intraoperative and Postoperative Radiotherapy on Functional Outcome in Patients Undergoing Standard and Deep Anterior Resection for Rectal Cancer

Purpose This study was designed to investigate the influence of intraoperative and postoperative radiotherapy on functional outcome after rectal resection for rectal cancer. Methods One hundred patients who underwent deep or standard anterior resection for rectal cancer were included in this follow-up study. All patients filled out questionnaires regarding morbidity and functional outcome; a subgroup (n = 63) underwent further clinical evaluation. The results were stratified according to radiation: Group I, no radiation (n = 37); Group II, only intraoperative radiation (n = 12); Group III, intraoperative and postoperative radiation (n = 51). Results Anal continence measured by Kirwan-Parks classification and Wexner score was significantly different within the three groups (P < 0.005, P < 0.0001), whereas continence impairment was least in Group I and greatest in Group III. Patients in Group III demonstrated a significantly worsecategory in the Kirwan-Parks classification and worse Wexner scores compared with patients in Group I (P < 0.0001). Patients only having undergone intraoperative radiotherapy had a significantly worse continence (Kirwan-Parks classification) than patients without any radiotherapy (P < 0.05). More patients after intraoperative and postoperative radiation therapy complained of fragmented stools (P < 0.05) and urgency (P < 0.05) compared with patients only having undergone surgery; the need towear pads was higher (P = 0.001). Vector volume manometry revealed better resting sphincter function in Group I compared with Group III (P ≤ 0.005). Conclusions Patients with anterior resection for rectal cancer who undergo full-dose radiotherapy have significantly more impairment of anorectal function than patients without radiotherapy. Patients who were only exposed to intraoperative radiotherapy showed moderate impairment of continence function, suggesting that the influence of radiotherapy on anal function may be dose-dependent and application-dependent.     

Laparoscopic and Open Anterior Resection for Upper and Mid Rectal Cancer: An Evaluation of Outcomes

Purpose This study was designed to compare the outcomes of laparoscopic anterior resection with open operation for mid and upper rectal cancer. Methods A total of 265 patients who underwent elective laparoscopic or open anterior resection for cancer of the mid and upper rectum from June 2000 to December 2004 were included. Data about the patients’ demographics, operative details, postoperative outcome, and disease status were collected prospectively. Comparison of the outcome between laparoscopic and open resection was performed. Results The median age of the 265 patients was 69 (range, 27–91) years, and laparoscopic anterior resection was performed in 98 patients (37 percent). There was no difference in the age, gender, comorbidities, and level of tumor between the two groups. The operating time was longer in the laparoscopic group (200 vs. 127 minutes; P < 0.01), but the blood loss was less (200 vs. 250 ml; P = 0.027). The overall operative mortality was 1.8 percent, and the complication rate was 27.9 percent. Significantly more patients with early diseases (Stage I and Stage II) were operated with laparoscopic approach. There was no difference in the mortality or morbidity between the two groups. Anastomotic leakage occurred in five patients with open resection and one with laparoscopic resection (P = 0.418). Patients with laparoscopic resection had an earlier return of bowel function and earlier resumption of diet as well as a shorter median hospital stay (7 vs. 8 days; P < 0.001). With the median follow-up of the surviving patients for 21.2 months, the three-year local recurrence rates for those with open and laparoscopic resection were 4.9 and 3.3 percent, respectively (P = 0.513). In patients with Stage I and Stage II disease, the three-year cancer-specific survivals for open and laparoscopic resection were 89.8 and 88.6 percent, respectively (P = 0.882), whereas those of patients with Stage III disease were 65.6 and 55.5 percent, respectively (P = 0.911). Conclusions Laparoscopic anterior resection for mid and proximal rectal cancer is a safe option with short-term advantages compared with open operation. The oncologic outcomes of patients who underwent laparoscopic anterior resection were not compromised, with similar local recurrence rate and the cancer-specific survival rate as patients who underwent open resection. Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Quality of Life after Anterior Resection versus Abdominoperineal Extirpation for Rectal Cancer

Background: Abdominoperineal extirpation has been assumed to put patients at higher risk of disruption to quality of life than sphincter-preserving surgery in rectal cancer surgery. The aim of this study was to investigate quality of life in patients after anterior resection versus abdominoperineal extirpation for rectal cancer and to evaluate the psychometrics of the Danish version of a symptom-specific Fecal Incontinence Quality of Life Scale. Methods: Fourteen patients undergoing abdominoperineal extirpation and 26 undergoing anterior resection. The generic quality of life instrument SF-36 together with a new symptomspecific Fecal Incontinence Quality of Life Scale were used. Psychometric analysis of the symptom-specific scale was carried out. Results: The only significant difference between the two groups was found in the total score of the symptom-specific scale in favour of anterior resection ( P = 0.02). Psychometric evaluation of the symptom-specific fecal incontinence questionnaire proved it reliable and valid. Conclusions: The present study shows that a stoma influences quality of life only slightly, while a relatively high anterior resection does not. However, a few appropriate newer studies indicate that the cost of spinchter-preserving techniques in the form of incontinence disturbances may influence the quality of life seriously, which should be borne in mind when low anterior resection is intended. Further studies in this field are necessary and could benefit from use of the Fecal Incontinence Quality of Life Scale, including its total score.     

Sacral nerve neuromodulation improves physical,psychological and social quality of life in patients with fecal incontinence

There are several therapeutic options for fecal incontinence but often they do not achieve good results in the long run. This study dealt with sacral nerve modulation, a new therapeutic option. Twenty-one patients underwent pudendal nerve evaluation (PNE) at our institution. Nine patients were affected by both fecal and urinary incontinence, 3 had fecal incontinence and anal pain, 5 had fecal incontinence and pelvic floor dyssynergia, and 4 had isolated fecal incontinence. They underwent morphological, functional and psychological tests prior to PNE, showing no sphincter rupture, almost normal anal pressures, impaired rectal sensation and deficient psychological pattern. All patients underwent at least two nerve evaluations. Four of 21 patients (19%) were selected to receive a permanent sacral electrode, as PNE seemed to have improved their symptoms by >75%. A median follow-up of 15 months (range, 6–24 months) showed that this method decreases weekly episodes of incontinence and increases maximal squeeze pressure. We demonstrated an increase in basal pressure in 3 of 4 patients (all with isolated fecal incontinence). Rectal sensation threshold decreased in three patients; urge threshold decreased in two patients and increased in two patients, but in each patient we got a stabilization. We evaluated the quality of life by applying the Short Form Health Survey test (SF-36). All 4 patients showed a significant increase in the scores of physical, emotional and social role functioning after the permanent implant. In conclusion, sacral nerve modulation may improve physical, physiological and social quality of life in selected groups of incontinent patients without gross sphincter lesions and with impaired rectal sensation. Received: 6 June 2002 / Accepted: 10 November 2002     

Response to Preoperative Chemoradiation in Stage II and III Rectal Cancer

PURPOSE: The purpose of this study was to determine whether a complete pathologic response after neoadjuvant therapy in rectal cancer patients improves disease control and survival. METHODS: The study reviewed Stage II and III rectal cancer patients treated with preoperative chemoradiation and resected for cure. Complete pathologic response was defined as no cancer in the resected specimen. The main outcome measures were cancer-specific and disease-free survival in patients achieving a complete pathologic response and a noncomplete pathologic response. Kaplan-Meier curves were evaluated using log-rank analysis. RESULTS: Eighty-nine rectal cancer patients received neoadjuvant chemoradiation followed by radical resection for cure. Twenty-one patients (24 percent) achieved a complete pathologic response. Median follow-up for the complete pathologic response group was 23.5 months and 31 months for the noncomplete pathologic response group. There were more Stage III patients in the noncomplete pathologic response group than the complete pathologic response group (P = 0.005). Complete pathologic response patients were less likely to receive postoperative adjuvant chemotherapy than noncomplete pathologic response patients (P = 0.004). Cancer-specific and disease-free survival were not statistically different between the two groups. However, a trend was noted toward improved survival and decreased recurrence in association with a complete pathologic response. CONCLUSION: Stage III patients were less likely to be in the complete pathologic response group than Stage II patients. Complete pathologic response patients were less likely to receive postoperative adjuvant chemotherapy than noncomplete pathologic response patients. Complete pathologic response after neoadjuvant chemoradiation for rectal cancer patients demonstrated a trend toward improved survival and decreased recurrence compared with noncomplete pathologic response patients.