Transcript Perianal Crohns Disease

Faecal Incontinence
Anterior Sphincter Repair
Normal Continence
Internal sphincter:
- Visceral innervation
- 85% continence
Primary Muscles
of continence
External sphincter:
- Somatic innervation
- 15% continence
Secondary Muscles
of continence
Faecal Incontinence
The Issues
1.
Structure
vs
Function
2.
Surgery
vs
Conservative
No Defect
‘No Repair’
Incidence of Perineal Trauma
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90% of incontinent women with an obstetric history
have a sphincter defect (Burnett, S.J. BJS 1991)
Women with 30/40 tear
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74% Symptomatic
59% Incontinent of Gas
90% Sphincter Defect
(Goffeng, A.R. Act.OGS 1998)
35% of Primiparous women will have a sphincter defect
after delivery (13% symptomatic)
(Sultan, A.H. NEJM 1993)
Forceps
Obstetric Injury
de Parades et al. DCR 2004
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93 females : Single forceps delivery
Results
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Symptoms
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Correlates
– 11% partial external defects
– 1% partial external and complete internal defects
– 18% flatus incontinence
– 4% liquid stool incontinence
– Perineal tear predicts sphincter defect
Pelvic Anatomy
Mechanism Of Injury
Obstetric Trauma
Mechanism Of Injury
The Mechanism Of Injury
Obstetric Injury
Mechanisms
Rectovaginal septum
- rectocoele
Ischaemic injury
- fistula
Sphincter complex
- incontinence
Faecal Incontinence
Structural Defect
Faecal Incontinence
Which Treatment
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Tailored for individual patient
Tailored to degree of perceived symptoms
Tailored to anatomy of sphincter
Tailored to other injury
Start simple
Avoid complex
Faecal Incontinence
Algorithm
Defect
Symptoms +
No defect
Symptoms -
Conservative
Conservative
Surgical
Surgical
Anterior sphincter repair
Stoma
Graciloplasty
Artificial sphincter
Sacral nerve stimulation
Acute Sphincter Repair
‘End to End’
Vs
‘Overlapping’
Obstetric Injury
Fitzpatrick et al. Am J Ob Gyn 2000
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RCT Overlapping vs approximation
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Results
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112 females with third degree tears
– Incontinence scores
– 0/20 (Ov) vs 2/20 (Ap)
– Urgency
– 11 (Ov) vs 17 (Ap)
– Manometry and US
– No differences
– 66% had persistent US defects
Obstetric Injury
Pinta et al. DCR 2004
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52 females : Third and fourth degree tears
Primary repair
Results
– 61% symptoms of anal incontinence
– 20% symptoms of faecal incontinence
– Significantly worse than a control group
– Persistent external defects
– 75% in repair group
– 20% in control group
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Anterior Sphincter Repair
Post Surgical Repair
Predicting Outcome
Residual endosonographic defect after repair
Residual endosonographic defect in
• 30% of Successful Group
• 80% of Failed Group
Positive predictive value of intact repair 70%
Negative predictive value of persistent defect 80%
Predicting Outcome
Length of repaired sphincter
6
Failed repair
Successful Repair
4
2
0
0-5
6 - 10
11 - 15
16 - 20
Length of anterior external anal sphincter (mm)
Anterior Sphincter Repair
Long Term Outcome
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55 pts undergoing overlap repair
Early- 42 continent solid and liquid 15 months
Late
– 46 at least 5 year follow up
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27 symptoms improved
23 improved by at least 50%
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38 pts (7 further surgery, 1 stoma)
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0 continent solid and flatus
4 continent to solid and liquid
6 no urgency, 8 no soiling
20 needed pads, 25 lifestyle restriction
14 evacuation disorder
Malouf et al Lancet 2000
Summary
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Carefully assess patient
Arrange appropriate investigations
Try simple measures
Fix prolapse
If there is a defect repair it
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If there is no defect DO NOT repair it
Tailor your treatment to the patient
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Be aware of long term results