ALFONSO CARRIERO, MDALFONSO CARRIERO, MD

Pelvic Floor Center, Montecchio Emilia , RECoordinatore Unità di Colon-Proctologia, Modena-Reggio Emilia

Montecatini Terme, 28.05.2005

Incontinenza fecaleQuando operare e Risultati

ACOI XXIV Congresso Nazionale

Fecal IncontinenceEtiology

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)

SPHINCTEROPLASTYPNTML & Neuropathy

Is PNTML reliable in predicting poor outcome ?

• difficult to quantify neuropathy

• cut-off value

• value of unilateral prolonged latency

• no negative predictive value

• 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 Fecal Incontinence

Management of Faecal Incontinence

Normal anatomy

Biofeedback

Isolated sphincter defect

Sphincter repair

Multifocal sphincter defect

Neosphincter procedure

Dynamic graciloplasty 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.

Biofeedback

Sacral nerve stimulation

Surgical Management

• Sphincter Repair

• Post-anal repair

• Direct apposition

• Overlapping sphincteroplasty

• Construction of Neosphincters:

• Stimulated Graciloplasty

• Gluteoplasty

• Artificial Bowel Sphincter (ABS)

Surgical ManagementOther Procedures

• Biofeedback• Sacral Nerve Stimulation• Procon• Secca • Perineal sling• Durasphere – PTP • Malone Antegrade Enema• Ostomy ?

Faecal IncontinenceFaecal IncontinenceFaecal IncontinenceFaecal IncontinenceBiofeedback 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 incontinenceComparison of surgical procedures

Cochrane Incontinence Group Trial Register

Cochrane Controlled Trials Register Medline Br J Surg; DCR 1995-1998

Anterior levatorplasty Post-anal repair Total pelvic floor

repair

“All trials excluded women with anal defects”

No differences in the primary outcomes were detected

Primary outcomes: deterioration in incontinence, failure to achieve full continence, presence of faecal urgency.

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

48%33%

19% 28%49%

23%

3 months n=86 40 months n=74

Karoui et al. DCR June 2000

IncontinentIncontinent to gasContinent

• Prospective• EAS defect by ELUS• Poor results assc with

IAS injury

Long-Term Results Of Overlapping Sphincter Repair

89%

11%

77 months n=38

Malouf, Lancet Jan 2000IncontinentIncontinent to gasContinent

• 76% continent of solid and liquid stool av 15 mos postop

• 36% new evacuation disorder after sphincter repair

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

• 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

Overlapping Repair: WHEN TO DO IT

Optimal conditions for Sphincter Repair

Preoperative 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

If pudendal neuropathy add ant levatorplasty

If fails—repeat ELUS—if defect present re-repair

If no defect—post anal repair

If nerve injury and no defect on ELUS—total pelvic floor reconstruction

With TPF repair warn of dyspareunia (42%)

Faecal IncontinenceStimulated Graciloplasty

Multicenter trial – 7 Institutions

64 Patients (17M, 47F) (median age 44.5 years, range 15-76)

Etiology: obstetric injury 22 Iatrogenic damage 8 Perineal trauma 6 Pudendal neuropathy 10 Proximal Neur. Defect 6 Congenital

7 Previous proctocolectomy 3 Cong. Int. sph. Absence 1 Isolated sph. Myopathy 1

(Mander BJ….Romano G et al., Br. J. Surg 1999)

Faecal IncontinenceStimulated Graciloplasty

InitialGood Functional Results 44 (77%)(Mild evacuatory disorders 7)

Median of 10 (range 1-35) monthsafter stoma closureGood functional results 29 (56%)

-Evacuatory problems 5-Technical Failure 5- Death 1-Awaiting Replacement 1- Lost of follow-up 3

(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)

– 12 Months 18 Months 24 Months

» No Stoma 62% 55 % 56%» Stoma 37.5 62% 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

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 IncontinenceIndication for ABS

Ano-Rectal trauma 30 % Obstetric 30 % Surgery 5 % Congenital defect 19 % Prolapse 11 % Neurogenic (no previous surgery) 5%

37 Patients

Parker SC et al:Artificial bowel sphincter – Long Term experience at a single institutionDCR, 2003, 46, 722-729

Faecal IncontinenceResults - ABS

N.° Pt Explant. Revision

Reimpl.

CCF 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 incontinenceDCR, 2004, 47, 1852-1860

Faecal IncontinenceIndication for SNS

Idiopathic 11.6%Obstetric 11.2%Surgery 10.5%

(fistula,hemorrhoidectomy,SLS,rectopexy,etc. )Scleroderma 1.8%Spinal cord trauma 7.1%Low anterior rectal resection 12.4%

266 Patients

Jarrett MED et al: Systematic review of sacral nerve stimulation for faecal incontinence and constipation, BJS, 2004, 91, 1559-1569

Faecal IncontinenceResults - 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 31

(26.7%)

14.6

4.2

7.5

0.15

n.v. n.v. 25.6

Jarrett MED et al: Systematic review of sacral nerve stimulation for faecal incontinence and constipation, BJS, 2004, 91, 1559-1569

Faecal IncontinenceIndications and Results for SECCA

Idiopathic 50 % Obstetric 10 % Surgery 40 %

CCF – FI 13.8 to 7.3

FIQL

Life-style 2.3 to 3.3

Coping 1.7 to 2.7

Depression 2.4 to 3.4

Embarassment 1.5 to 2.4

SF-36

Social function 50 to 82.5

Mental component 38.8 to 48.1

Follow-up 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