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4th ICI Lecture Series: Surgery for fecal incontinence (Committee 17)

Presented by Robert Madoff, MD, et al., at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.



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This presentation reflects a work-in-progress, and the science contained herein
will be published in textbook format at a future date.



Surgery for Fecal Incontinence Chairman R. MADOFF (USA) Members S. LAURBERG (DENMARK) K. MATZEL (GERMANY A. MELLGREN (USA) T. MIMURA (JAPAN) R. O’CONNELL (IRELAND) M. VARMA (USA) Obstetrical sphincter injury • 3-5% clinical; up to 27% by ultrasound –Primipara>mulitpara –Risk factors • Instrumental delivery • Prolonged second stage • Fetal macrosomia • Persistent occipito-position • ? Episiotomy –Midline>medilateral • Impaired continence –13-17% following primiparous vaginal delivery –Up to 50% following 3rd-4th degree tear [level 2] Immediate sphincter repair • Apposition vs. overlap repair –Inadequate evidence to favor either type [level 1] • Delayed repair –Safe to delay for expert [level 2] • Laxative >constipating regimens [level 1] Sphincteroplasty secondary reconstruction • Evaluation –Endorectal ultrasound • 2-D/3-D • MRI, fMRI, defecating proctography [level 4] • Treatment –<1 quadrant defect- conservative –>1 quadrant defect- sphincteroplasty Sphincteroplasty results • Overlapping repair –? Direct repair –? Individual repair of EAS ad IAS • ‘good to excellent results’ 60-80% –Results deteriorate with time [level 2] –No reliable predictors of outcome available Recommendations • Sphincter repair is indicated for patients with acute traumatic sphincter disruption, such as following obstetrical injury, but many patients experience persisting symptoms. GRADE B • Overlapping sphincteroplasty can be offered to patients with significant fecal incontinence and a documented sphincter injury. Most patients improve after sphincteroplasty, but outcomes deteriorate over time. GRADE B Postanal repair • Described 1975 • Rarely performed today • ‘Success’ rates 21-89% [level 3] • Results deteriorate with time Recommendation • Postanal repair can be performed with modest success in carefully selected patients. However, this procedure is now rarely performed due to the advent of newer treatments. GRADE C Non-stimulated muscle transposition • Gracilis vs. gluteus • Up to 81% ‘success’ but results highly variable [level 3] • Rarely performed today Recommendation • Non-stimulated muscle transposition repair can be performed with modest success in carefully selected patients. However, this procedure is now rarely performed due to the advent of newer treatments GRADE C Stimulated muscle transposition • Gracilis • 55-85% ‘success’ [level 2] • Substantial morbidity (up to 100%) –Early- infection –Late- erosion, pain, obstructed defecation • Salvage procedure in select centers –Restore tissue loss –Surgeon experience critical Recommendation • Stimulated muscle transposition has been shown to have reasonable success but is associated with significant morbidity. It remains a useful technique in selected patients with significant perineal tissue loss or in those who have failed other treatments. GRADE C Artificial sphincter • Predominantly extrasphincteric • 40-83% intention to treat success [level 2] • Substantial morbidity (re-operation 46%) –Early- infection –Late- erosion, pain, obstructed defecation • Select centers –Surgeon experience critical Recommendation • Artificial anal sphincter has been shown to have reasonable success but is associated with significant morbidity. It remains a useful technique in carefully selected patients, particularly those who have failed other treatments. GRADE B Sacral Nerve Stimulation • Most significant advance since last consultation • Minimally invasive • Low morbidity • Therapeutic trial (PNE) before definitive procedure • Expanding indications –Sphincter defect [level 3] Sacral Nerve Stimulation results • Variable reporting –Decreased incontinent episodes 50-100% –Decreased incontinence scores 50-80% • Outcomes –Severity [level 2] –Quality of life [level 2] –Safety [level 2] –Cost-benefit [level 2] Recommendation • SNS is an effective therapy for most patients with clinically significant incontinence who fail conservative management. The technique is safe, minimally invasive, and has the unique advantage of allowing a therapeutic trial prior to permanent stimulator implantation. GRADE B Injectable biomaterials • Multiple agents • Technique –Submucosal –Intersphincteric • Limited data –Small case series –Limited follow-up • Initial improvement 40-60% [level 3] –? Results deteriorate with time Recommendation • Most series of injectable biomaterials report reasonable short-term success rates. However, the optimal injectable bulking agent and the technique for its insertion have not been established. GRADE C Pediatric fecal incontinence • Anorectal malformation, Hirschsprung’s disease, neurologic disorders, overflow • Treatment options –Bowel regimen –Malone antegrade continent enema (ACE) [level 3] –Muscle transposition [level 4] –Colostomy [level 5] Recommendation • Varying treatment options including bowel management, Malone antegrade continent enema (ACE), muscle transpostion and colostomy. GRADE C Colostomy • Technique of last resort –Restores control, not continence –Improves quality of life [level 4] –? Under-utilized • Diversion proctitis –25% proctectomy rate Recommendation • Colostomy provides restoration of a more normal lifestyle and improves quality of life. Colostomy should not be regarded as a treatment failure. An end sigmoid colostomy alone, without proctectomy, is recommended. Some patients who develop significant symptoms from their retained rectal stump may eventually require proctectomy as a secondary procedure. GRADE C Research Priorities • Validation of severity score • Standardization of outcome measures • Role of evaluation in determining optimal treatment Research Priorities • RCT’s –Sphincteroplasty vs. biofeedback –Sphincteroplasty vs. SNS –Sphincteroplasty technique –Injectable biomaterials vs. placebo • Non-RCT’s –Cost analysis (SNS) –Decision analysis Rectal prolapse Major obstetrical injury Cloaca Rectovaginal fistula Appropriate surgical treatment Candidate for surgery for FI Assess patient preference/comorbidities PNE Evaluation EAUS +/- manometry, EMG, MRI, defecograpgy From conservative Sphincter defect 90-180° 0-90° >180° or perineal tissue loss Individualized treatment •Acute sphincter repair •Sphincteroplasty •Tissue transposition •Sacral nerve stimulation •Artificial sphincter •Colostomy Sphincter repair Return to evaluation SNS AS/DG Stoma/ ACE Injection Conservative therapy + - * * * * * Late presentation * = inadequate symptom relief Persistent fecal incontinence

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