Advances in the surgical treatment of fecal incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.     

The artificial sphincter: therapy for faecal incontinence

Introduction: Faecal incontinence (FI) challenges a patient's professional, social and sexual life. Often the patient becomes depressive and socially isolated. If able to break open for therapy the patient should receive as first line a conservative treatment (like dietary measures, pelvic re-education, biofeedback, bulking agents, irrigation).Discussion: When is the time to implant an artificial anal sphincter? If conservative therapy fails as well as surgical options (like a sphincteroplasty - if indicated a reconstruction of the pelvic floor if insufficient, or a sacral nerve stimulation) an ultimo surgical procedure should be offered to appropriate and compliant patients: an artificial anal sphincter. Worldwide, there are two established devices on the market: the artificial bowel sphincter? (ABS) from A. M. S. (Minnetonka, MN, USA) and the soft anal band? from A. M. I. (Feldkirch, Austria). How to implant the artificial anal sphincter? Both devices consist of a silicon cuff which can be filled with fluid. Under absolute aseptic conditions this cuff is placed in the lithotomy position by perianal incisions around the anal canal below the pelvic floor. A silicon tube connects the anal cuff with a reservoir (containing fluid) which is placed either behind the pubis bone in front of the bladder (ABS) or below the costal arch (anal band). With a pump placed in the scrotum/labia (ABS) or by pressing the balloon (anal band) in both types operated by the patient the fluid is shifted forth and back between the anal cuff and the reservoir closing or opening the anal canal. Both systems are placed completely subcutaneously.Conclusions: Both devices improve significantly the anal continence. Both systems have a high rate of reoperations. However, the causes for the redos are different. The ABS is associated with high infection and anal penetration rates of the cuff leading to an explantation rate to up to 60 % of the implants. This kind of complication seems to be much lower with the anal band. The major problem in the anal band is a defunctioning valve which occasionally has to be replaced. Despite these problems both types of artificial anal sphincters improve faecal incontinence significantly and, thus, quality of life of incontinent patients.     

Artificial anal sphincter in severe fecal incontinence: outcome of prospective experience with 37 patients in one institution

OBJECTIVE: To evaluate the outcome of artificial anal sphincter implantation for severe fecal incontinence in 37 consecutive patients operated on in a single institution from 1993 through 2001. SUMMARY BACKGROUND DATA: Implantation of an artificial anal sphincter is proposed in severe fecal incontinence when local treatment is unsuitable or has failed. The results of this technique have not been determined yet, and its place among the various operative procedures is still debated. METHODS: Artificial anal sphincters were implanted in 37 patients from 1993 through 2001. All patients had complete fecal incontinence and had failed to respond to medical treatment. Median duration of incontinence was 16 years. The causes of incontinence were sphincter disruption (19 patients), hereditary malformations (2 patients), and neurologic disease (16 patients). Six patients had had previous surgery for fecal incontinence. Assessment was made by physical examination (anal continence, rectal emptying) and anorectal manometry. RESULTS: In the first 12 patients, six devices had to be removed (50%); the cause of failure was found in all cases, and this allowed contraindications to be defined. Among the next 25 patients, 23 had an uncomplicated postoperative follow-up, and 5 developed seven complications: control pump change (n = 3), balloon migration (n = 1), and major rectal emptying difficulties in patients with obstructive internal rectal procidentia (n = 2). The artificial anal sphincter had to be removed definitively in three cases, representing the failure rate of this technique in the authors' experience (12%); two other devices had to be removed temporarily and the patients are awaiting reimplantation. In this latter group of 25 patients, 80% have an activated sphincter: continence for liquid stool is normal in 78.9%, continence for gas in 63.1%. Seven patients have rectal emptying difficulties, minor in five and major in two. Manometric studies showed mean pressures of 110 and 37 cm H(2)O with closed and open sphincter, respectively, with a mean duration of artificial sphincter opening of 128 seconds. CONCLUSIONS: The long-term functional outcome of artificial anal sphincter implantation for severe fecal incontinence is satisfactory; adequate sphincter function is recovered and the definitive removal rate is low. Good results are directly related to careful patient selection and appropriate surgical and perioperative management after a learning curve of the surgical team.     

Other options in the treatment of fecal incontinence

Fecal incontinence (FI) is a debilitating condition. Luckily, there are several new treatment options recently introduced or being introduced in the near future. Conservative or “non-operative” management of FI is the first step in management of a patient suffering from FI. Retrograde colonic irrigation is one alternative and is especially valuable in patients suffering from concomitant constipation. Anal plugs are disposable devices that control continence by blocking the passage of stool and may be helpful in selected groups of patients. Sacral nerve stimulation is widely used in the treatment of patients with FI and surgical repair of internal and external procidentia in patients with fecal incontinence has recently gained more interest. At the same time, dynamic graciloplasty and artificial bowel sphincter are rarely used any longer in the management of these patients. There are several treatments that are yet not FDA approved for treatment of patients with FI. The Magnetic anal reinforcement system is a novel device designed to augment the native anal sphincter. This treatment option has demonstrated good results in limited sized series of patients. The post-anal sling procedure, Topas™, has a concept similar to the TVT procedure for urinary stress incontinence. The sling is implanted dorsal to the anal canal with the aim to augment the puborectalis muscle and to restore a normal anorectal angle and a better anal sphincter function. An FDA regulated trial is presently conducted in the US. Regenerative medicine, stem cell therapy, may be the ultimate option to treat FI by regenerating impaired anal muscle. There are currently no validated techniques using this approach but there is an active research ongoing.     

可控性人工肛门装置的研究进展

人工肛门是结直肠外科治疗低位直肠癌的重要术式,然而其导致的粪便失节制严重影响患者生活。为了解决这个问题,国内外研究了一系列新型可控性人工肛门装置,按使用方式可分为夹闭式和封堵式,一定程度上实现了粪便的可控性。夹闭式人工肛门为植入性装置,使用较为自动化,但装置庞大复杂,患者发生感染、炎性反应和消化道不适等并发症的概率较大。相比之下,封堵式人工肛门自动化程度低,患者需每日清洗或更换装置,使用较为不便,但其舒适度、隐蔽性和安全性更好。相信随着技术的发展及研究的深入,一定能够实现人工肛门装置的更加智能化、自动化和微型化。     

Long-Term Results of Artificial Anal Sphincter Implantation for Severe Anal Incontinence

OBJECTIVE: To evaluate the long-term results of implantation of an artificial anal sphincter (AAS) for severe anal incontinence. SUMMARY BACKGROUND DATA: Implantation of an AAS is one of the options for treatment of anal incontinence when standard operations have failed. It is the only surgical option for treatment of anal incontinence in patients with neurologic disease that affects the pelvic floor and the muscles of the lower limb. METHODS: Seventeen patients underwent implantation of an AAS before 1993. These patients have been followed and their continence status evaluated. RESULTS: Two patients died of unrelated causes within the first 3 years after surgery, and in three patients the AAS was explanted because of infection. During the follow-up period, four patients had the AAS removed because of malfunction, and eight patients had a functioning AAS > or =5 years after the primary implantation. Five of these patients had revisional procedures, mainly because of technical problems in the early part of the study, when a urinary sphincter or slightly modified urinary sphincter was used. Continence at follow-up was good in four patients and acceptable in three, whereas one patient still had occasional leakage of solid stool. One patient had rectal emptying problems, which she managed by enema. CONCLUSIONS: An AAS based on the same principles as the artificial urinary sphincter seems to be a valid alternative in selected patients when standard surgical procedures have failed or are unsuitable. Approximately half of the patients have an adequate long-term result. Infectious complications still present a problem, whereas mechanical problems are less frequent with the modification of the device now available.     

Therapie der Sphinkterinsuffizienz

Surgical therapy of anal sphincter insufficiency is only indicated if it leads to symptoms and conservative treatment fails to achieve adequate symptom relief. Various new surgical options have evolved over the last decade but evidence of the efficacy varies substantially. Some have gained broader clinical acceptance based on the efficacy, ease of applicability and low risk profile. The paper aims to outline the currently commonly accepted and frequently applied surgical techniques for the treatment of anal sphincter insufficiency and the results, put these into the context of a treatment algorithm and to present novel techniques which carry potential for the future.     

Reconstruction of anal function after abdomino-perineal resection

After abdomino-perineal resection for rectal cancer, most surgeons believe that colostomy is necessary after anal function is abolished and that patients are satisfied with this. Recently, reconstruction of anal function has been performed using new surgical techniques such as creation of an artificial sphincter, dynamic graciloplasty, gluteoplasty with pudendal nerve anastomosis, and smooth muscle implanted neoanus. However, most surgeons do not have sufficient knowledge of reconstruction of anal function. Since all reconstruction methods are associated with low mortality and morbidity rates, and can be converted to conventional colostomy when required, surgeons must consider first-line reconstruction of anal function after resection of the anal sphincter.     

Surgical treatment of fecal incontinence secondary to obstetric trauma

Fecal incontinence (FI) is associated to elevated costs related to diagnostic work-up, surgical treatment and instrumental follow-up. The real incidence is unknown and prevalence is higher after 45 years with a ratio F:M ratio of 8:1. Frequently FI is due to pelvic damage secondary to obstetric trauma. The Authors analyze surgical treatment results of FI secondary to obstetric trauma evaluating pathogenesis and instrumental diagnostic preoperative work-up. In case of muscular injury, "overlapping" of external sphincter represents the treatment of choice allowing a good medium long term results. In the treatment of patients with more complex injures or after overlapping failures, direct sphincteroplasty are indicated. After multiple surgical failures, or in case of pure neural damage, sacral nerve stimulation, graciloplasty or artificial anal sphincter may be offered by referral centers.     

Factors predictive of outcome after surgery for faecal incontinence

BACKGROUND: Surgical treatment of faecal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device. METHODS: This article reviews the currently available surgical options for the treatment of faecal incontinence, discusses factors predictive of outcome, and includes an algorithm for treatment. RESULTS AND CONCLUSION: Procedures such as postanal repair, direct sphincter repair and reefing are seldom used. Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma. Pudendal neuropathy seems to be a predictive factor of success, although this is not universally accepted. Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter. The success and morbidity rates with the stimulated graciloplasty and artificial bowel sphincter appear similar. The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for faecal incontinence. Presented as the Edinburgh Royal College of Surgeons invited lecture to the Association of Coloproctology of Great Britain and Ireland, Southport, UK, June 1999     

Surgical management of faecal incontinence in adults

Faecal incontinence has a long list of aetiology. Definitive treatment depends on the underlying condition. If a non‐surgical cause is identified, conservative treatment is often appropriate. Surgical management is more often successful when a structural damage of the anal sphincter is found. Overlapping sphincter repair has a high success rate when the anal sphincter is disrupted. Surgery has a clear role to play in the case of idiopathic faecal incontinence; and sacral nerve stimulation is the most promising treatment presently available. Dynamic muscle transposition and artificial bowel sphincter are the remaining alternatives after unsuccessful attempts at sphincter repair or in the case of end‐stage faecal incontinence. Spinal cord injury or diseases contribute significantly to faecal incontinence. Malone’s antegrade continence enema has been shown to be helpful to these patients. The greatest benefit of this treatment modality appears to occur with children. With adults, experience is sparse. For the debilitated geriatric patient whose faecal incontinence has led to perianal skin excoriation, bed sores or perianal sepsis, a well‐sited colostomy is sometimes the kindest option apart from diligent nursing care. Biofeedback and pelvic floor exercises are helpful adjuncts and sometimes the primary mode of therapy. It carries no risk in its own right and is worth trying provided the patient is motivated and a dedicated therapist is available.     

Artificial bowel sphincter in severe anal incontinence

OBJECTIVE: The artificial anal sphincter has been suggested as an alternative in the treatment of severe anal incontinence when conventional surgical methods are not possible or have failed. Experience in this procedure is still limited and the results have not yet been sufficiently established. The aim of this study is to evaluate the efficacy of the ACTICON (American Medical Systems, Minneapolis, MN) on patients operated upon in our Unit. PATIENTS AND METHOD: In this prospective study an ACTICON sphincter was implanted in 10 patients (8 women) with an average age of 56 years and with an average period of severe anal incontinence of 151 months. The origin of incontinence was obstetric injury (n: 4), neuropathy (n: 3) and sphincteral injury from previous anal surgery (n: 3). The degree of continence was measured using the Fecal Incontinence Scoring System (FISS) and the pre- and postoperative anal manometric parameters at 6-month intervals. The average follow-up time for the efficacy of the implanted system was 29 months. RESULTS: A total of 6 patients [60%] displayed complications in the immediate postoperative period: subaponeurotic reimplantation of the connecting tubes was necessary after infection of the abdominal wound (n:1); superficial dehiscence of the perianal wound (n: 2), infection of the perianal wound (n: 1) and perianal haematoma (n: 2) that were resolved by conservative treatment. For 3 patients [30%] the system was explanted, definitively in one and in 2 of them reimplanted successfully. At the end of the follow-up period, 9 patients [90%] still have an activated artificial sphincter. The score on the Fecal Incontinence System decreased significantly after the system was activated (P < 0.0001) and the pressure with the cuff closed was significantly higher than pre-operative anal pressure (P < 0.0001). All the patients are now continent for solid stool, 56% have occasional involuntary losses of gases and 33% occasionally have involuntary losses of gases and liquid stool. Only 2 patients [22%] have complete continence. CONCLUSIONS: Our findings indicate that the ACTICON artificial anal sphincter is well tolerated and can be an effective alternative in the treatment of severe anal incontinence. Although complete continence is only achieved in a low percentage of cases, for the rest of the patients the ACTICON neosphincter reduces the symptoms considerably.     

Indicacion actual,técnica quirúrgica y resultados de la reparación anterior esfinteriana en el tratamiento de la incontinencia fecal

Faecal incontinence is a high prevalence disease in the general population. This pathology is commonly under-estimated and causes a great impact on clinical status and on the quality of life of affected patients. The prevalence of faecal incontinence in several studies has been estimated between 2% and 15% of the general population. The prevalence increases if we study selected populations, such as elderly people. The main cause of faecal incontinence is obstetric anal sphincter damage. In the past years, the presence of incontinence due to sphincter lesions, especially the obstetric ones, was an absolute indication of anterior anal sphincter repair. Actually, after knowing the long term follow up results of this technique, as well as the evolving knowledge on faecal incontinence and the development of new diagnostic and therapeutic techniques, this technique might be selected for cases with large sphincter defects. However there is limited information in the current literature on indications, surgical technique and results of anterior sphincter repair. The aim of this review is to analyse scientific evidence on current indications, surgical technique features and results of anterior sphincter repair as a therapy for faecal incontinence, also giving our point of view on controversial issues. A bibliography search was undertaken using Medline database including articles published from January 1985 to January 2009.     

High and intermediate imperforate anus: results after surgical correction with special respect to internal sphincter function.

Embryologically a fistula in an anorectal malformation can be regarded as an ectopic anus. Since 1984 the so-called fistula has been saved and used as the new anal canal in the surgical reconstruction of 48 patients with high or intermediate imperforate anus. A positive rectoanal inhibitory reflex indicating internal sphincter function was recorded in 32 of 43 patients investigated with anorectal manometry. These patients showed significantly better anal continence. It is concluded that there is an internal sphincter "anlage" in the fistulous connection from the bowel to the urogenital tract. Internal sphincter function can be obtained in the majority of the patients, which seems advantageous for their anal function.     

Artificial urinary sphincter for post-prostatectomy incontinence: impact of prior collagen injection on cost and clinical outcome

PURPOSE: We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. MATERIALS AND METHODS: The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. RESULTS: Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. CONCLUSIONS: Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.     

Sphinkterersatzplastiken

An anal sphincter replacement graft can be carried out when sphincter lesions occur after unsuccessful conservative or other treatment. Today, two different techniques are used to take over the function of the sphincter. The dynamic gracilis graft can be carried out if a non-atrophied,well innervated m. gracilis is present. This technique is carried out on patients whose incontinence is the result of a trauma,pudendopathy or imperforate anus. It can be extended to the construction of a neo-anus after abdominal resection. The artificial anal sphincter is used whenever the previous method fails or can not be used due to a non-vital, denervated or the lack of the m. gracilis. Older methods such as non-stimulated gracilis, glureus or Thiersch grafts are not commonly used.     

Modern concepts for the treatment of fecal incontinence

Anal incontinence is estimated to be present in approximately 2% of the total population. However, the incidence of this disorder increases with age, affecting up to 11% of men and 26% of women after the age of 50 years. In general, the causes of long-standing fecal incontinence may be divided into anorectal or congenital malformations, perineal trauma (due to surgery or accident), pudendal nerve lesions with or without muscular injury, and low-motor neuron lesions. Classical surgical treatment includes direct repair of the circumscribed gap in the anal sphincter, the so-called overlapping sphincteroplasty or anal repair. In the short term, this method was shown to be very effective in improving continence. Surgical repair of a diffuse weakness of the pelvic floor by application of the postanal repair method has led to more controversial results. While the short-term results are frequently beneficial, full continence is rarely achieved in the long run, especially in patients with imparied pudendal nerve function. All currently used surgical methods focus on the direct mechanical approach to the pelvic floor muscles and/or the anal sphincter. Therefore, the response to this kind of therapy is limited by the presence of a simultaneously existing neurogenic lesion (pudendal nerve damage), as well as by the magnitude and intensity of muscular injury. These problems have been addressed by the development of new methods that focus on the replacement of large muscular defects (Dynamic Graciloplasty) and the treatment of neurogenic causes of fecal incontinence (Sacral Nerve Stimulation-SNS).     

New anal retractor in pelviperineology: preliminary experience

The authors illustrate the technical characteristics and the clinical results of a new anal retractor in proctology and pelviperineology This new device, designed and produced by the authors, enables the surgeon to operate in a traditional or isostatic modality. The small external diameter and the original morphology seem to guarantee a less invasive introduction into the anal canal with minimal mechanical damage to the anal sphincter. The main indications for its use are pelvic floor surgery and patients with a diagnosis of anal incontinence or with suspected sphincter damage. Forty consecutive patients referred to our Coloproctological Unit have been operated on with the new anal retractor with no complications. The operative results obtained with the new device are defined as good in 75% and optimal in 10%. The anal retractor seems easy to use in all the surgical procedures with a much better safety profile with regard to anal sphincter.     

Novel techniques in the treatment of anal incontinence

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread.     

Treatment of anal fissures with botulinum toxin

Chronic anal fissure is a common proctological disease. Botulinum toxin (BTX) can be used for temporary chemical denervation. The administration is by intramuscular injections into either the external or the internal anal sphincter muscles. The mode of action, administration techniques and possible complications or adverse effects of BTX therapy are discussed. The healing rate is dependent on the BTX dosage. The short-term healing rate (< or = 6 months) is between 60 and 90 %. In long-term follow-up studies (> 1 year), about 50 % of patients show a complete response. Adverse effects are generally mild but relapses occur more often compared to surgery. Conservative therapies including BTX are currently considered mostly as the first-line treatment. Among the surgical procedures, lateral sphincterotomy is the most effective treatment but shows higher incontinence and general morbidity rates than BTX.