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Sphincter disorders and dysfunctions could be possible in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (CRT) and sphincter saving surgery, followed by recanalization. Defecography (DRE) evaluates the transport of a semi-solid barium column to the outside during a simulated defecation, investigating the two components of this process, both anatomically and functionally. We performed this study with the aim to evaluate the sphincter functionality by DRE.

Twenty-nine LARC patients (M:W=18:11) underwent neoadjuvant CRT with dose intensification treatment up to 5500 cGy (220 cGy/die) and sphincter saving surgery. DRE was performed evaluating the characteristics of contraction or inhibition of the pubo-rectal muscle and the type of incontinence (at rest/during Valsalva). The number of evacuations per day, including incontinence, was evaluated using the Memorial Sloan Kettering Cancer Center (MSKCC) Score. Furthermore, we performed a comparison of both methods.

All patients completed the prescribed treatment. The median patients age was 66 years (range, 44-79 years). The mean length tumor was 45 mm, sited at a distance from the anorectal ring shorter than 30 mm, between 31 and 50 mm, and longer than 50 mm in 10 (34.5%), 11 (37.9%), and 8 (27.6%) patients, respectively. The majority of patients (22 patients, 75.9%) had cT3 tumors. All patients underwent anterior rectal resection with complete pathological response rate of 51%. With a median follow-up of 3.4 years, all patients had a local control, with distant metastases reported in 6 (21%). Twenty-nine patients underwent DRE: 11 patients within 2 years, 18 after 2 years from the end of CRT. Mostly women reported an anterior rectocele (9 women vs 6 men, in a total of 15 patients). A reduced or poor contraction or inhibition of the pubo-rectal muscle in DRE performed within 2 years was reported in the 73% whereas it resulted of 45% in DRE performed after 2 years (8 patients for each group). Regarding functional assessment, incontinence at rest was showed in 5 (45%) and 7 (39%) patients, at DRE performed within or after 2 years, respectively. Globally, MSKCC score seemed to overestimate functional assessments in 5 (17%) patients. Table 1 reported DRE characteristics and the MSKCC score for each patient.

Despite the small number of analysed patients, sphincter dysfunctions rate in our patients treated with a dose intensification schedule was in line with literature. DRE resulted to be a valid tool to evaluate anorectal function, giving information regarding both sphincter morphology and functionality. DRE is advantageous to evaluate incontinence during Valsalva, completing a qualitative evaluation of the MSKCC score. Both DRE and MSKCC could be considered for an accurate sphincter evaluation.