59 The use of sacral nerve stimulation in patients with rectal prolapse

Abstract

Rectal prolapse is a common disorder that can afflict up to 1% of all adults over the age of 65. Once a prolapse has occurred, 50-75% also complain of fecal incontinence from various causes. Some patient’s fecal incontinence resolved after 6 months from surgical repair but for those with long term prolapse, fecal incontinence persist and does not improved. Sacral nerve stimulator (SNS) has long been placed initially for urinary incontinence in 1988 and subsequently for fecal incontinence since 1995, with good success. With the high incidence of fecal incontinence associated with rectal prolapse, we evaluate the placement of SNS for patient with complaint of rectal prolapse prior to their surgical repair, to assess if improving sphincter tone and continence will improve their prolapse and spare them from a surgical pexy and or resection. a prospective study of patients who presented with rectal prolapse was assessed with physical exam, documentation of prolapse, Wexner incontinence score as well as anal manometry. Patient was then offered SNS prior to their surgical repair. If SNS fails, surgical repair includes laparoscopic/robotic rectopexy, laparoscopic/robotic rectopexy with low anterior resection, and Altmeiyer repair. SNS were placed in a single stage and assessed at 1 month, 3 months, 6 month and a year then yearly with history and physical exam as well as anal manometry. If there was no improvement, the patient would then undergo a surgical repair. 28 patients (female median age 79) underwent placement of SNS after presenting with rectal prolapse. Of these, 9 of 28 (30%) patients achieved treatment improvement at 6 months & success without daily prolapse after an average of 21 months. One of the 28 had a perineal resection a month prior by another colorectal surgeon and proceeded to prolapse 36 days later. The other 18 patients went on for abdominal or perineal repair based on medical problems and patient preference. 15 patients had Altmeiyer, 2 laparoscopic resections with rectopexy and 1 laparoscopic rectopexy alone. The median follow-up of 29 months (range 2-52). Of the 9 patients who did not undergo repair, one had 2 episodes of prolapse with a bout of severe constipation but improved and yet to have surgical intervention. None of the devices needed to be explanted. SNS can be effective for those with rectal prolapse whose prolapse is less than 3cm in length. It provides a less invasive options for patients improving their fecal incontinence and prolapse without a more invasive surgery. Unfortunately, this was only successful in 9 patients with short segment prolapse. The numbers are too low at this time without a larger trial. Currently, it cannot replace neither abdominal or perineal resection but does offer an option to both treat fecal incontinence as well as rectal prolapse. Despite the low numbers, SNS can be considered before undertaking resection for short segment rectal prolapse.