Functional results of anterior levatorplasty and external sphincter plication for faecal incontinence

BACKGROUND AND AIMS: The aim of this study was to assess results of anterior levatorplasty combined with external anal sphincter plication for faecal incontinence. MATERIAL AND METHODS: The study involved 44 female patients, 27 with idiopathic and 17 with traumatic faecal incontinence. All underwent anterior levatorplasty and external sphincter plication in our institution between 1986 and 1997. The patients were followed up clinically for a mean 12 (range 2-54) months and 39 (89%) patients also underwent pre-and postoperative anal manometry. RESULTS: In the idiopathic group 5 patients (19%) estimated that the result of the operation had been good and another 18 (67%) reported feeling better than before; the corresponding figures in the traumatic group were 4 (24%) and 10 (59%). The Wexner incontinence score decreased significantly after the operation in both groups. Nineteen patients (70%) in the idiopathic and 14 (82%) in the traumatic group showed improvement of one or more scores on the Kirwan scale. Three patients regained continence completely, one in the traumatic and two in the idiopathic group. There were no significant improvements in mean resting anal pressure or functional anal canal length in either group. Mean squeeze pressure improved significantly only in the traumatic group. CONCLUSIONS: Although the results of anterior levatorplasty combined with external sphincter plication are not perfect, the approach seems to be a valuable alternative in the treatment of patients with idiopathic or traumatic faecal incontinence. Complete continence is seldom achieved, but the grade of incontinence is reduced in the majority of patients.     

Operative therapy for anal incontinence

Operative therapy for fecal incontinence requires exact understanding of the anatomic and physiologic principles involved and of the potential pathophysiologic mechanisms. Many injuries of the external sphincter can be treated by direct sphincter repair. Extensive obstetric injuries with loss of the perineal body require not only reconstitution of the perineal musculature but also plastic surgical reconstruction of the perineal skin. Patients with descending perineum syndrome and resultant idiopathic fecal incontinence or rectal prolapse with associated incontinence should be treated with postanal plication of the puborectalis sling. Patients who have complex neurologic disorders or who have undergone previous unsuccessful attempts at repair of the puborectalis itself should be considered for placement of a Silastic sling. Diverting colostomy is rarely necessary; it should be performed only after thorough investigation and failure of all reasonable alternative operative procedures.     

Anterior sphincter plication and levatorplasty in the treatment of faecal incontinence

The surgical treatment of faecal incontinence has been traditionally divided into sphincteroplasty for sphincter disruption and postanal repair for idiopathic cases. However, many studies have failed to show a correlation between outcome and change in the anorectal angle. This study was carried out to determine the effectiveness of anterior sphincteroplasty and levatorplasty in the treatment of faecal incontinence, regardless of aetiology. Thirty consecutive patients underwent surgery, 14 with traumatic sphincter injuries and 16 with idiopathic faecal incontinence. A satisfactory clinical result was obtained in ten (71 per cent) patients in the traumatic group and in ten (62 per cent) in the idiopathic group. This was associated with a significant increase in maximum voluntary contraction pressure in the traumatic group and in those patients who had a good result in the idiopathic group (traumatic: preoperative median 80 cmH2O (range 50-115 cmH2O) versus postoperative 115 cmH2O (75-290 cmH2O), P less than 0.005; idiopathic: preoperative 105 cmH2O (45-190 cmH2O) versus postoperative 120 cmH2O (45-230 cmH2O), P less than 0.05; Wilcoxon paired signed ranks test). There was also significant improvement in anal sensation in the upper anal canal in both groups (traumatic: preoperative mean 17 mA versus postoperative 11 mA, P less than 0.05; idiopathic: preoperative 24 mA versus postoperative 9 mA, P less than 0.02). The anorectal angle increased in the idiopathic group at rest (preoperative median 105 degrees (range 86-152 degrees) versus postoperative 118 degrees (95-180 degrees), P less than 0.05). In conclusion, the type of approach (anterior or posterior) and the anorectal angle are irrelevant to the outcome of surgery for idiopathic faecal incontinence. Success appears to be related more to improved sphincter pressure and anal sensation.     

Plastic repair for postoperative anal incontinence

Utilization of the Bunnell type of tendon suture in the repair of severed anal sphincter muscle for successful restoration of continence is recorded and illustrated. This stitch appears to avoid strangulation of muscle fibers involved in the sutures.     

Surgical treatment of anal incontinence

Surgery is mandatory for fecal incontinence when medical treatments and reeducation by biofeedback are ineffective. Sphincter disruption is the most frequent cause. Sphincter repair with or without overlapping is indicated in the large majority of cases. Short-term results are good but result is not ever maintained with time. In case of failure, or when the defect concerns more than 180 degrees, it is necessary to use a substitutive technique. Artificial anal sphincter is often first proposed because of its apparent technical simplicity and because it is cheaper than dynamic graciloplasty. Results are excellent. Failures are due to local infection or device disfunction. Dynamic graciloplastie may be proposed in patients with severe perineal lesions, or failure of the other methods. Its results are also excellent, except for the patients having disordered rectal perception. Sacral nerve stimulation is limited to patients with idiopathic or neurologic incontinence. Because definitive implantation is done only following positive preoperative stimulation test, short-term results are very good.     

Surgical treatment of anal incontinence

The records of 18 consecutive patients operated upon for fecal incontinence between January 1983 and March 1986 were reviewed. Anterior sphincteroplasty was performed on 11 patients with direct sphincter trauma. The results were excellent in eight, fair in two and poor in one. A postanal repair was performed on seven patients, with excellent results only in two, fair in four and poor in one. The indications for surgery and the results were assessed clinically and manometrically. A careful classification of the physiologic and anatomic derangements of the anal sphincter aids in the appropriate selection of candidates for surgical treatment. In general, anterior sphincteroplasty gives good results, whereas results of postanal repairs are less satisfactory. Manometry is of some use in providing objective measurements.     

Prevalence of anal incontinence in 409 patients investigated for stress urinary incontinence.

A clinical questionnaire concerning anorectal symptoms and urodynamic tests was used to investigate 409 women consulting for stress urinary incontinence. To compare urodynamic data, patients were divided into three groups of women who had either stress urinary incontinence associated with incontinence for formed and/or liquid stools or with gas incontinence, or isolated stress urinary incontinence. To take in account the patients'age for data interpretation, a Mantel-Haenszel test or covariate analysis was performed. Anal incontinence was reported in 114 (28%) of the 409 women investigated. The prevalence of incontinence for gas only, for liquid, or for solid stools was 18.3, 9.3, and 1%, respectively. The duration of gas incontinence was longer than that of fecal incontinence or stress urinary incontinence. Difficult defecation was more frequently observed in patients with double incontinence than in patients with only stress urinary incontinence, and the difference was significant between patients with gas incontinence and patients with stress urinary incontinence (53% versus 37%, P = 0. 03). There was no difference in the number of bowel movements per week among the three groups of patients. The number of vaginal deliveries was surprisingly lower in patients with fecal incontinence associated with urinary incontinence than in others. There was no urodynamic feature that could distinguish patients with urinary incontinence and patients with double incontinence. This study confirmed the close relationship between anal and stress urinary incontinence. Neurourol. Urodynam. 18:579-590, 1999.     

Results of one-stage reconstruction of anal sphincter in surgical treatment of fistulas-in-ano combined with fecal incontinence

The investigation included 20 patients. Mean index of the severity of incontinence before operation by the Wexner scale was 9.3+/-2.4 scores. After radical dissection of the fistula and sphincter plasty in 7 patients (the first group) the wound of the rectum mucosa was sutured in longitudinal direction, in 13 patients (the second group) the rectum wall graft was brought down to the edge of the created anal canal. Uncomplicated post-operative period was noted in 15 (75%) patients. Suppuration of the wound developed in 3 (42.9%) patients of the first group and in 2 (15.3%) patients of the second group. The index of incontinence severity decreased to 2.4+/-1.1% scores (reduction of 4.5 scores in the first group and 7.7 scores in the second group).     

Idiopathic anal incontinence. Surgical treatment

Three patients operated upon for idiopathic anal incontinence are reported. This idiopathic incontinence is due to degeneration of the nerves supplying the pelvic floor muscles and results in partial or total disappearance of the double right angle which normally exists between the anal canal and the rectum. This anorectal angulation is essential in the maintenance of anal continence. The aim of the operation is the reconstruction of a normal anatomy with the restoration of this anorectal angulation. The suture of the levators ani and particularly of the puborectalis muscle proposed by Parks is the operation of choice. The results of the operation 1-3 years later are excellent in two cases and satisfactory in one case.     

Treatment of anal incontinence by an implantable prosthetic anal sphincter.

Twelve patients with anal incontinence due to neurologic disease or failure of previous incontinence surgery underwent implantation of an artificial anal sphincter. The system used was a modification of the AMS 800 artificial urinary sphincter. In two patients, infection necessitated removal of the system, and in four patients, eight revisional procedures had to be performed because of mechanical failure. After various modifications of the system, especially reinforcement of the closing mechanism of the cuff, only one case of mechanical failure has occurred. Erosion through the anal canal did not occur. Among 10 patients with the system in function for more than 6 months, the result was considered excellent in 5, with only occasional leakage of flatus, good in 3, who occasionally leaked liquid feces and flatus, and acceptable in 2, in whom the cuff obstructed defecation. It is concluded that implantation of an artificial anal sphincter is a valid alternative to permanant colostomy in patients with anal incontinence due to neurologic disorders and in patients in whom other types of incontinence surgery have failed.