Gastroenterology

Gastroenterology

Volume 126, Supplement 1, January 2004, Pages S48-S54
Gastroenterology

Treatment options for fecal incontinence
Surgical treatment options for fecal incontinence

https://doi.org/10.1053/j.gastro.2003.10.015Get rights and content

Abstract

Although surgical therapy has been shown to be an effective treatment of anal incontinence, few properly controlled randomized studies have confirmed its efficacy or compared it with biofeedback or other less invasive forms of treatment. Overlapping sphincteroplasty, the most common procedure, seems to confer substantial benefits on patients with sphincter disruptions. However, recent data suggest that results following sphincteroplasty deteriorate with time. There is also disagreement about whether pudendal nerve conduction studies can be used to predict outcome after surgical repair. Salvage options for patients with refractory fecal incontinence include passive or electrically stimulated muscle transfer procedures, implantation of an inflatable artificial anal sphincter, and sacral nerve stimulation. Stimulated graciloplasty is the most commonly used muscle transfer procedure; good to excellent results are reported from a small number of high-volume centers, but multicenter trials with less experienced surgeons have shown a high morbidity rate associated with the procedure. The artificial anal sphincter provides good restoration of continence for most patients who retain the device, but a significant explantation rate due to infection or local complications remains problematic. Sacral nerve stimulation has shown promising early results with minimal associated morbidity. There is a critical need for controlled long-term studies that use objective data collection methods, standardized outcome measures, and validated quality-of-life assessment instruments.

Section snippets

Overlapping sphincter repair (sphincteroplasty)

There is general agreement that overlapping sphincter repair is appropriate first-line therapy for incontinent individuals with significant sphincter defects. However, there have been no randomized trials comparing sphincteroplasty with nonsurgical therapies such as biofeedback. Table 1 shows the results of sphincteroplasty series reported since 1984 that included at least 30 patients.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 Varying definitions notwithstanding, approximately two thirds of

Muscle transfer procedures

Pickrell et al. described the use of gracilis transposition to function as a neosphincter in 1952,27 and Corman reported good results with passive gracilis wraps in 1985.28 More recently, Faucheron et al. confirmed that a significant number of patients improve with passive gracilis wraps alone.29 Less common alternatives for passive muscle neosphincters include bilateral nonstimulated graciloplasty30 and bilateral gluteus maximus transposition.31, 32, 33

Dynamic graciloplasty (the addition of

Artificial anal sphincter

The artificial anal sphincter represents an alternate approach to dynamic anal sphincter replacement. Like the dynamic graciloplasty, the artificial anal sphincter is placed around the native sphincter via perianal tunnels. The device remains inflated until the patient wishes to defecate, at which time the device is deactivated by a manual pump implanted in the scrotum or labia majora. The current device (Acticon Neosphincter; American Medical Systems, Minnetonka, MN) and its precursor (AMS

Sacral nerve stimulation

Sacral nerve stimulation, originally developed for urinary voiding dysfunction, has been used to successfully manage fecal incontinence. Matzel et al. first reported this technique in 1995.50 Vaizey et al. evaluated sacral nerve stimulation in 12 patients treated for 1 week with percutaneous leads and external pulse generators.51 Of the 9 evaluable patients (3 had early lead dislodgments), 7 became fully continent and one improved markedly.

There are relatively few reports on the results of

Conclusion

Patients with fecal incontinence now have several surgical options for treating the disorder. Ironically, the most established approach, overlapping sphincteroplasty, has been subject to the least stringent study protocols. Newer competing therapies are now being studied prospectively with diary data and validated quality-of-life instruments. However, experience with novel therapies remains limited and must be expanded before their proper role in incontinence management can be defined.

Important

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