LAUSR

Surgery for defaecation disturbances is a growing field and maybe the most important recent development is sacral nerve modulation (SNM). Although its effectiveness is proven, its place in the treatment algorithm of faecal incontinence is still based on large patient series. This month’s Editor’s Choice by Mege et al. [1] evaluated 352 patients who underwent SNM for faecal incontinence, collected from seven French tertiary referral centres in the time period between 2010 and 2015. Fifty-four percent of patients had a significant sphincter defect. The median follow-up was 3.4 years. Their aim was to determine if patients older than 70 years of age had similar outcomes after SNM. We know from colorectal cancer surgery that fitness, rather than age per se, is an important prognostic indicator for postoperative outcomes. One could argue that in surgical treatment of faecal incontinence, age is more relevant, as the pelvic floor function deteriorates with time. Comparing patients under the age of 70 years with those of 70 years or more, Mege et al. [1] found favourable outcome in 79% and 76% of patients, respectively. The reduction of the Cleveland Clinical Faecal Incontinence (CCFI) score was similar in both groups (42% and 35%, respectively). Non-controlled studies on SNM should be interpreted with caution. Firstly, the patient selection is based on a successful test stimulation. Secondly, the placebo effect following SNM contributes largely to the overall treatment response. In one of the few randomized double-blinded trials on this topic, the median frequency of FI episodes decreased by 76% and the CCFI improved 38% during sham stimulation [2]. Finally, the life expectancy of the battery necessitates an expensive replacement operation. In the study by Mege et al., 48% of all patients had revision surgery at 3 years after implantation. Fifty percent of them because of battery depletion. Looking at the long-term probability of success after SNM in the present study (figure 2), there is a striking similarity with the deteriorating success-rate after anterior spincteroplasty (AS). Studies, conducted to assess the long-term outcome after AS show acceptable to excellent outcomes in 60% of patients after an 8-years follow-up [3,4]. However, there is one important difference: the long-term success rate after AS is age dependent. Comparing patients under the age of 50 years, with those of 50 years or more, acceptable outcomes were achieved in 71–75% and 27–47%, respectively [3,4]. Despite the potential appeal of SNM, we need more evidence to show its cost-effectiveness over other established treatments for faecal incontinence. There is already a paucity of trials comparing surgical and nonsurgical treatments for faecal incontinence, and studies comparing the different surgical techniques are almost non-existent [5]. Future research will hopefully provide more guidance to the surgeon in terms of patient selection. We can use the data from Mege et al. for the design of future clinical trials. Going forward, there is a need for a randomized trial comparing SNM and AS in younger patients with an external sphincter defect. To find alternatives for SNM in older patients with disabling faecal incontinence is more difficult, but it could be interesting to compare SNM with coping strategies, such as retrograde colonic irrigation or promising new treatment modalities such as for example intrasphincteric injection of autologous myoblasts.