Sacral neuromodulation in treatment of fecal incontinence following anterior resection and chemoradiation for rectal cancer.

PURPOSE. Fecal incontinence may occur in patients who have undergone anterior resection for rectal cancer without presenting sphincter lesions. Chemoradiation may contribute to disrupting continence mechanisms. Treatment is controversial. Assessment of fecal incontinence in patients submitted to integrate treatment for rectal cancer, and treatment with sacral neuromodulation are reported. METHODS. Fecal incontinence, following preoperative chemoradiation and anterior resection for rectal cancer, was evaluated in 4 patients. Good response was observed during percutaneous sacral nerve evaluation test; permanent implant of sacral neuromodulation system was carried out. Re-evaluation was performed at least 2 months after implant. RESULTS. After device implantation, mean fecal incontinence scores decreased, and mean number of incontinence episodes dropped from 12 to 2.5 per week (p<0.05). Permanent implant resulted in a significant improvement in fecal continence in 3 patients, while incontinence was slightly reduced in the fourth. Manometric parameters agreed with clinical results: maximum and mean resting tone, aa well as squeeze pressure were normal in 3 patients, and reduced in one; in these same 3 patients, neorectal sensation parameters increased when preoperative value was normal or below normal and decreased when preoperative value was higher than normal, while in one patient in whom very low values were recorded, all decreased significantly. CONCLUSIONS. Fecal incontinence following anterior resection and neoadjuvant therapy should be carefully evaluated. If a suspected neurogenic pathogenesis is confirmed, sacral neuromodulation may be proposed. If the test results are positive, permanent implant is advisable. Failure of this approach does not exclude the use of other, more aggressive treatment.