EP139 - Using the Wexner score to evaluate sacral nerve stimulation after ileal pouch anal anastomosis

Image or Table (Do Not add text here):

Purpose/Background: Fecal incontinence is a common and devastating complication following ileal pouch-anal anastomosis (IPAA). Many cases fail conservative management, such as bulking agents and pelvic floor physiotherapy. Minimally invasive neuromodulatory techniques can enhance anal sphincter tone, potentially improving continence. This case series aims to evaluate the impact of sacral nerve stimulator (SNS) placement following IPAA and re-do IPAA using the Wexner score for obstructed defecation syndrome.

Methods/Interventions: Charts were reviewed to identify patients with IPAA or redo IPAA and SNS. Demographic and clinical data were collected retrospectively, and pre- and post-intervention Wexner scores were obtained by phone call. The Wexner score incorporates five different areas: incontinence to solids, liquids, and gas, alteration of lifestyle, and pad usage. Responses were quantified using a scale: never = 0 points, rarely = 1, sometimes = 2, usually = 3, and always = 4.

Results/Outcomes: We identified 4 patients undergoing SNS following an IPAA, and their average improvement in Wexner score was 7.5 (43%). Patient A is a 50 year old female with a history of ulcerative colitis (UC). She underwent a proctocolectomy with IPAA at age 26. At age 48, she required a staged J-pouch redo due to incontinence and obstructions. Despite bulking agents, acupuncture, and pelvic floor physiotherapy, she did not achieve relief and underwent SNS placement in two stages, which improved her symptoms. Patient B is a 57 year old male with severe inflammatory bowel disease. Had a proctocolectomy with IPAA at age 33, complicated by multiple small bowel resections, endoscopic dilations, and management of perianal disease. At age 55, he underwent a three stage J-pouch redo. He experienced incontinence and worsening of his perianal disease requiring fistulotomy, steroid injections, and seton placement. His symptoms were unsuccessfully managed with loperamide and fiber. Therefore, he underwent SNS, which improved his incontinence. Patient C is a 72 year old male with UC, underwent proctocolectomy with J-pouch creation at age 71. He had persistent incontinence despite loperamide, diphenoxylate/atropine, and tincture of opium. He underwent SNS placement in two stages. In post operative follow up, he reported only two episodes of incontinence. He continues to have a seepage, but overall, his quality of life has improved. Patient D is a 33 year old male with neurointestinal dysplasia with J pouch at age 26 and worsening incontinence treated with loperamide and fiber. He received an SNS placement at age 33. All patients had a lower Wexner score at follow up.

Conclusion/Discussion: Patients with a redo IPAA are more susceptible to incontinence. Since SNS has successfully treated refractory fecal incontinence following primary IPAA, it is reasonable to explore the effectiveness of SNS in more complex population. Furthermore, standardizing the measurement of treatment response is essential to determining the efficacy of SNS placement after redo IPAA. We present a series of patients who were successfully treated with SNS after IPAA. All patients reported improved Wexner scores with SNS. These results suggest that SNS may be an effective and safe alternative when symptoms are refractory to conventional medical resources. However, evidence supporting the use of SNS in this population is limited. Further studies are needed to better understand the pathophysiology of anorectal incontinence and identify specific patient populations that might benefit the most from this intervention.