Tolopka Tyler Cameron, Messick Craig A
Department of Surgical Oncology, Section of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Neuromodulation. 2017 Dec;20(8):783-786. doi: 10.1111/ner.12562. Epub 2017 Feb 1.
This case report provides evidence for our hypothesis that use of a sacral nerve stimulator may be considered in patients with fecal incontinence (FI) following chemoradiation and transanal operations in the setting of cancer including partial internal sphincter resections.
A 57-year-old female with a history of anal melanoma was treated with neoadjuvant chemoradiation followed by wide local, transanal tumor excision with partial internal anal sphincter resection that resulted in ≥2 full fecal incontinent episodes/week with gas, liquid, and solid stool leakage ≥10/day requiring pad changes. After seven years of progressive FI, a sacral nerve stimulator was implanted following pre-placement anorectal manometry. Pre and post implant validated Cleveland Cleveland Clinic/Wexner Fecal Incontinence questionnaires and daily stool diaries (Medtronic) were completed. Data was stored in and collected from the patient's electronic health record.
The patient had a single episode of FI during the two week trial phase, but reports complete resolution of FI, urgency, and leakage since implantation through her 1-year post-implant follow-up visit. Additional improvements were noted in FI questionnaires: Cleveland Clinic/Wexner Fecal Incontinence Score of 17 at baseline to 3 post-implant and Fecal Incontinence Quality of Life Score of 3.585 at baseline to 3.93 post-implant.
The application of sacral nerve stimulation may not be as limited as previously thought and should be considered for cancer survivors following chemoradiation and sphincter-sparing rectal and transanal resections. Though this single case report is suggestive, further research is necessary and would include a research protocol designed specifically for patients who have undergone chemoradiation and/or sphincter-sparing operations. We are currently working on such protocol at our institution.
本病例报告为我们的假设提供了证据，即在癌症患者接受放化疗和经肛门手术后出现大便失禁（FI），包括部分内括约肌切除的情况下，可考虑使用骶神经刺激器。
一名57岁有肛门黑色素瘤病史的女性接受了新辅助放化疗，随后进行了广泛的局部经肛门肿瘤切除及部分肛门内括约肌切除，术后每周出现≥2次完全性大便失禁，气体、液体和固体粪便泄漏≥10次/天，需要更换护垫。在经历了7年逐渐加重的大便失禁后，在植入前进行肛门直肠测压后植入了骶神经刺激器。植入前后完成了经过验证的克利夫兰诊所/韦克斯纳大便失禁问卷和每日大便日记（美敦力）。数据存储在患者的电子健康记录中并从中收集。
患者在两周的试验阶段仅有一次大便失禁发作，但报告称自植入后至术后1年随访期间，大便失禁、尿急和泄漏症状完全消失。在大便失禁问卷中还发现了其他改善：基线时克利夫兰诊所/韦克斯纳大便失禁评分为17分，植入后为3分；基线时大便失禁生活质量评分为3.585分，植入后为3.93分。
骶神经刺激的应用可能不像以前认为的那样有限，对于接受放化疗以及保留括约肌的直肠和经肛门切除术后的癌症幸存者应予以考虑。尽管这一单一病例报告具有启发性，但仍需要进一步研究，这将包括专门为接受过放化疗和/或保留括约肌手术的患者设计的研究方案。我们目前正在我们机构开展这样的方案。
