ALFONSO CARRIERO, MD Pelvic Floor Center, Montecchio Emilia , RE Coordinatore Unità di Colon-Proctologia, Modena-Reggio

1. 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

2. Fecal Incontinence Etiology • 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

4. Fecal Incontinence Preoperative assessmentAnorectal 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)

5. 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

6. 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

7. Management of Faecal Incontinence Normal anatomy Isolated sphincter defect Multifocal sphincter defect Biofeedback Biofeedback Sphincter repair Sacral nerve stimulation Neosphincter procedure Artificial anal sphincter Dynamic graciloplasty Baig M.K, Wexner S.D.: Factors predictive of outcome after surgery for fecal incontinence. Br J Surg 2000; 87: 1316-1330.

8. Surgical Management • Sphincter Repair • Post-anal repair • Direct apposition • Overlapping sphincteroplasty • Construction of Neosphincters: • Stimulated Graciloplasty • Gluteoplasty • Artificial Bowel Sphincter (ABS)

9. Surgical ManagementOther Procedures • Biofeedback • Sacral Nerve Stimulation • Procon • Secca • Perineal sling • Durasphere – PTP • Malone Antegrade Enema • Ostomy ?

10. 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.

11. Faecal Incontinence PostAnal Repair - Results

12. Overlapping Sphincter RepairTECHNIQUE

13. 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” Faecal incontinenceComparison of surgical procedures 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

14. 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)

15. 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)

16. Long-Term Results Of Overlapping Sphincter Repair • Prospective • EAS defect by ELUS • Poor results assc with IAS injury 3 months n=86 40 months n=74 • Incontinent • Incontinent to gas • Continent Karoui et al. DCR June 2000

17. 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 77 months n=38 • Incontinent • Incontinent to gas • Continent Malouf, Lancet Jan 2000

18. Long Term Outcome Following Overlapping Sphincter Repair Why poor long term results? • ELUS not done to assess adequate initial repair • Normal aging of these women’s muscles? • Some think fibrosis is more pronounced in these women and affects the results

19. 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

20. 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

21. 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%)

22. 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)

23. Faecal IncontinenceStimulated Graciloplasty Initial Good Functional Results 44 (77%) (Mild evacuatory disorders 7) • Evacuatory problems 5 • Technical Failure 5 • Death 1 • Awaiting Replacement 1 • Lost of follow-up 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)

24. 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

25. 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 institution DCR, 2003, 46, 722-729

26. Faecal IncontinenceResults - ABS 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

27. 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

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

29. 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

30. 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