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ACOI XXIV Congresso Nazionale
Montecatini Terme, 28.05.2005
Incontinenza fecale
Quando operare e Risultati
ALFONSO CARRIERO, MD
Pelvic Floor Center, Montecchio Emilia , RE
Coordinatore Unità di Colon-Proctologia, Modena-Reggio Emilia
Fecal Incontinence
Etiology
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Altered stool consistency
Inadequate reservoir capacity or compliance
Inadequate rectal sensation
Overflow incontinence
Abnormal sphincter mechanism or pelvic floor
Pelvic Floor denervation
Congenital abnormalities
Miscellaneous (aging, rectal prolapse)
IDIOPATHIC
Fecal Incontinence
Preoperative assessment
Anorectal Physiologic Studies
 Sphincter
muscles - electrical activity
(denervation, paradoxical contraction etc.)
 Sphincter
mapping
(sphincter disruption, congenital defects)
 Measurement
of striated muscle function
(Biofeedback Therapy Training)

Pudendal nerve function
(neurogenic incontinence)
SPHINCTEROPLASTY
PNTML & Neuropathy
Is PNTML reliable in predicting poor outcome ?
• difficult to quantify neuropathy
• cut-off value
• value of unilateral prolonged latency
• no negative predictive value
Management of Fecal Incontinence
•
Patient selection is critical
•
Medically manage those with minimal symptoms
or poor surgical candidates (risk or outcome)
•
Surgery reserved for those with repairable,
neurologically intact sphincter
Management of Faecal Incontinence
Normal anatomy
Isolated sphincter defect
Biofeedback
Biofeedback
Multifocal sphincter defect
Sphincter repair
Sacral nerve
stimulation
Dynamic graciloplasty
Neosphincter procedure
Artificial anal sphincter
Baig M.K, Wexner S.D.: Factors predictive of outcome after surgery for fecal incontinence. Br J Surg 2000; 87: 1316-1330.
Surgical Management
• Sphincter Repair
• Post-anal repair
• Direct apposition
• Overlapping sphincteroplasty
• Construction of Neosphincters:
• Stimulated Graciloplasty
• Gluteoplasty
• Artificial Bowel Sphincter (ABS)
Surgical Management
Other Procedures
•
•
•
•
•
•
•
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Biofeedback
Sacral Nerve Stimulation
Procon
Secca
Perineal sling
Durasphere – PTP
Malone Antegrade Enema
Ostomy ?
Faecal Incontinence
Biofeedback and/or sphincter exercises for the
treatment of faecal incontinence in adults
(Cochrane Review)
Reviewers' conclusions
The
limited number of identified trials together with their
methodological weaknesses do not allow a reliable assessment of the
possible role of sphincter exercises and biofeedback therapy in the
management of people with faecal incontinence.
There is a suggestions that some elements of biofeedback therapy and
sphincter exercises may have a therapeutic effect, but this is not certain.
Larger well-designed trials are needed to enable safe conclusions.
Norton C, Hosker G, Brazzelli M. The Cochrane Library,
Issue 3 2002. Oxford: Update Software.
Faecal Incontinence
PostAnal Repair - Results
Authors
Year
N. Of Cases
Successful (%)
Parks
1983
42
81
Henry and Simson
1983
204
58
Habr-Gama
1986
42
52
Scheuer
1989
39
43
Orrom
1991
17
59
Engel
1994
38
50
Mavrantonis
1998
21
35
Overlapping Sphincter Repair
TECHNIQUE
Faecal incontinence
Comparison of surgical procedures
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Cochrane Incontinence Group Trial
Register
Cochrane Controlled Trials Register
Medline
Br J Surg; DCR
1995-1998
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Anterior levatorplasty
Post-anal repair
Total pelvic floor
repair
“All trials excluded women
with anal defects”
Primary outcomes: deterioration in incontinence, failure to achieve full continence,
presence of faecal urgency.
No differences in the primary outcomes were detected
Bachoo P et al: Surgery for faecal incontinence in adults. Cochrane Database Syst Rev 2000; CD001757
Factors Affecting Outcome of
Overlapping Sphincter Repair
•
Diverting stoma: No effect (Hasegawa 2000, Sitzler
1996, Young 1998) Negative (Nikiteas 1996)
•
Obesity: No effect (Hull 2001) Negative
(Nikiteas
1996)
•
Anal canal length post op: Positive (Hool
1999)
•
Age: No Effect (Hull 2001, Simmang 1994, Young 1998)
Negative (Ctercteko 1988, Nikiteas 1996)
Factors Affecting Outcome of
Overlapping Sphincter Repair
•
Duration of incontinence until repair: No
effect (Hull 2001) Negative (Ctercteko 1988)
•
Increased PNTML: Negative (Young 1998, Engel
1994, Gilliland 1998) Still shows improvement
(Chen 1998)
•
Bilateral increased PNTML worse than
unilat: (Terenent 1997)
Long-Term Results Of Overlapping
Sphincter Repair
• Prospective
• EAS defect by ELUS
• Poor results assc with
IAS injury
19%
28%
48%
33%
23%
3 months n=86
Incontinent
Incontinent to gas
Continent
49%
40 months n=74
Karoui et al. DCR June 2000
Long-Term Results Of Overlapping
Sphincter Repair
• 76% continent of solid and
liquid stool av 15 mos
postop
• 36% new evacuation
disorder after sphincter
repair
11%
89%
77 months n=38
Incontinent
Incontinent to gas
Continent
Malouf, Lancet Jan 2000
Long Term Outcome Following
Overlapping Sphincter Repair
Why poor long term results?
o
ELUS not done to assess adequate initial repair
o
Normal aging of these women’s muscles?
o
Some think fibrosis is more pronounced in these
women and affects the results
Overlapping Repair: WHEN TO DO IT
•
Long term results of overlapping sphincter
repair may not be as good as previously
assumed
•
Anterior repair if defect is found
•
Repeat ELUS to look for persistent defect: if
found re-repair
•
Those not candidates for new treatments:
consider stoma
Optimal conditions for Sphincter Repair
 Preoperative
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No previous repair
Scar present
Bilateral intact pudendal nerves
Normal rectal sensation
Young patient
 Intraoperative
 Overlapping scar
 Increased resting and squeeze pressure
 Increased high pressure zone
Levator Repair– Total Pelvic Floor
Reconstruction: WHEN TO DO IT

Procedure has not gained popularity in world literature

ELUS: if anterior defect—repair
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If pudendal neuropathy add ant levatorplasty
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If fails—repeat ELUS—if defect present re-repair
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If no defect—post anal repair
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If nerve injury and no defect on ELUS—total pelvic floor
reconstruction

With TPF repair warn of dyspareunia (42%)
Faecal Incontinence
Stimulated Graciloplasty
 Multicenter trial – 7 Institutions
 64 Patients (17M, 47F)

(median age 44.5 years, range 15-76)

Etiology:
obstetric injury
 Iatrogenic damage
 Perineal trauma
 Pudendal neuropathy
 Proximal Neur. Defect
 Congenital
 Previous proctocolectomy
 Cong. Int. sph. Absence
 Isolated sph. Myopathy
22
8
6
10
6
7
3
1
1
(Mander BJ….Romano G et al., Br. J. Surg 1999)
Faecal Incontinence
Stimulated Graciloplasty
Initial
Good Functional Results 44 (77%)
-Evacuatory problems
-Technical Failure
- Death
-Awaiting Replacement
- Lost of follow-up
(Mild evacuatory disorders 7)
5
5
1
1
3
Median of 10 (range 1-35) months
after stoma closure
Good functional results 29 (56%)
(Mander BJ,… Romano G et al., Br. J. Surg. 1999)
Long term efficacy of Dynamic
Graciloplasty for Fecal Incontinence

Indications
– End stage
– Failed medical-surgical treatment

Methods
– Success : decrease in > 50% in frequency of incontinent episodes
– Physiologic parameters
– QOL (SF-36,VAS,FITS)

Results
– Pt. 115 ( 27 with preexisting stoma)
–
» No Stoma
» Stoma
12 Months
62%
37.5
18 Months
24 Months
55 %
62%
56%
43%
Wexner SD.,Baeten C, Bailey R, Bakka A, Belin B et al : Long term efficacy of
Dynamic Graciloplasty for Fecal Incontinence, DCR,2002,45,809-818
Faecal Incontinence
Indication for ABS
 Ano-Rectal
trauma
Obstetric
 Surgery
 Congenital defect
 Prolapse
 Neurogenic (no previous surgery)

30 %
30 %
5%
19 %
11 %
5%
37 Patients
Parker SC et al:Artificial bowel sphincter – Long Term experience at a single institution
DCR, 2003, 46, 722-729
Faecal Incontinence
Results - ABS
N.° Pt
Explant
.
Revision CCF
Reimpl.
AMSS
Reduction
Follow-up
Lehur
2002
16
4 (25%) 1 (6%)
17
4.5
105
23
78%
25
Vaizey
1998
6
1 (17%) 0
19.5
4.5
n.v.
77%
10
O’Brein
2000
13
3 (23%) 0
18.7
2.1
n.v.
89%
13
Altomare
2001
28
5 (18%) 0
14.9
2.6
98
5.5
94%
19
O’ Brein et al: A prospective,randomized, controlled clinical trial of placement of the artificial
bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence
DCR, 2004, 47, 1852-1860
Faecal Incontinence
Indication for SNS
Idiopathic
Surgery
11.6%
11.2%
10.5%
(fistula,hemorrhoidectomy,SLS,rectopexy,etc. )
Scleroderma
Spinal cord trauma
Low anterior rectal resection
1.8%
7.1%
12.4%
Obstetric
266 Patients
Jarrett MED et al: Systematic review of sacral nerve stimulation for faecal incontinence
and constipation, BJS, 2004, 91, 1559-1569
Faecal Incontinence
Results - SNS
Temp.
Perm.
CCF
FI epis.
week
Fully
cont.
> 50%
improv.
Follow-up
Jarret
2004
59
46
(78%)
14
6
7
1
41%
96%
12
Leroi
2001
11
6
(55%)
n.v.
3
0.5
50%
75%
6
Matzel
2003
16
16
(100%)
17
5
6.2
0 (?)
75%
94%
32.5
Rosen
2001
20
16
(80%)
n.v.
2
0.6
n.v.
100%
15
Uludag
2002
44
34
(77%)
n.v.
8
0.6
50%
95%
11
Ganio
2003
116
7.5
0.15
n.v.
n.v.
25.6
31
14.6
(26.7%) 4.2
Jarrett MED et al: Systematic review of sacral nerve stimulation for faecal incontinence
and constipation, BJS, 2004, 91, 1559-1569
Faecal Incontinence
Indications and Results for SECCA
Idiopathic
 Obstetric
 Surgery
CCF – FI
FIQL
Life-style
Coping
Depression
Embarassment
SF-36
Social function
Mental component
Follow-up

50 %
10 %
40 %
13.8 to 7.3
2.3 to 3.3
1.7 to 2.7
2.4 to 3.4
1.5 to 2.4
50 to 82.5
38.8 to 48.1
24 months
Takahashi T et al:Extended two year results of Radio-Frequency energy for thr treatment
of fecal incontinence ( the SECCA procedure) DCR, 2003, 46, 711-715
Conclusion

Multiple techniques exit

With the use of ELUS defects can be delineated and a
defect should be repaired

With no defect: some will benefit from post anal
repair or total pelvic floor repair

Selection of who will benefit is not clear

Many will be candidates for new procedures