Restoring control: the Acticon Neosphincter artificial bowel sphincter in the treatment of anal incontinence

Surgical Treatment Alternatives to Sacral Neuromodulation for Fecal Incontinence: Injectables, Sphincter Repair, and Colostomy

Fecal incontinence is a prevalent health problem that affects over 20% of healthy women. Many surgical treatment options exist for fecal incontinence after attempts at non-operative management. In this article, the authors discuss surgical treatment options for fecal incontinence other than sacral neuromodulation.

Hypothesized summative anal physiology score correlates but poorly predicts incontinence severity

AIM

To explore the relationship between such a construct and an existing continence score.

METHODS

A retrospective study of incontinent patients who underwent anal physiology (AP) was performed. AP results and Cleveland Clinic Continence Scores (CCCS) were extracted. An anal physiology score (APS) was developed using maximum resting pressures (MRP), anal canal length (ACL), internal and external sphincter defects and pudendal terminal motor latency. Univariate associations between each variable, APS and CCCS were assessed. Multiple regression analyses were performed.

RESULTS

Of 508 (419 women) patients, 311 had both APS and CCCS measured. Average MRP was 51 mmHg (SD 23.2 mmHg) for men and 39 mmHg (19.2 mmHg) for women. Functional ACL was 1.7 cm for men and 0.7 cm for women. Univariate analyses demonstrated significant associations between CCCS and MRP (P = 0.0002), ACL (P = 0.0006) and pudendal neuropathy (P < 0.0001). The association between APS and CCCS was significant (P < 0.0001) but accounted for only 9.2% of the variability in CCCS. Multiple regression showed that the variables most useful in predicting CCCS were external sphincter defect, pudendal neuropathy and previous pelvic surgery, but only improving the scores predictive ability to 12.5%.

CONCLUSION

This study shows that the ability of AP tests to predict continence scores improves when considered collectively, but that a constructed summation model before and after multiple regression is poor at predicting the variability in continence scores.

Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013

BACKGROUND

Evidence-based guidelines for the management of neurological disease and lower bowel dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance.

AIMS

To update clinical management of neurogenic bowel dysfunction from the recommendations of the 4th ICI, 2009.

MATERIALS AND METHODS

A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and modifications applied to deliver evidence based conclusions and recommendations for the scientific report of the 5th edition of the ICI in 2013.

RESULTS

The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic bowel dysfunction. The pathophysiology is described in terms of spinal cord injury, multiple sclerosis, and Parkinson's disease. Assessment requires detailed history and clinical assessment, general investigations, and specialized testing, if required. Treatment primarily focuses on optimizing stool consistency and regulating bowel evacuation to improve quality of life. Symptom management covers conservative and interventional measures to promote good habits and assist stool evacuation, along with prevention of incontinence. Education is essential to achieving optimal bowel management.

DISCUSSION

The review offers a pragmatic approach to management in the context of complex pathophysiology and varied evidence base.

Characteristics Associated With Successful Fitting of a Vaginal Bowel Control System for Fecal Incontinence

OBJECTIVES

We previously showed that management with a novel vaginal bowel control system was efficacious in women with moderate to severe fecal incontinence. The objective of this secondary analysis was to evaluate the clinical characteristics associated with device-fitting success.

METHODS

This is a secondary analysis of an institutional review board-approved, multicenter, prospective, open-label clinical study of women aged 19 to 75 years with 4 or more episodes of fecal incontinence recorded on a 2-week baseline bowel diary. Those successfully fitted with the vaginal bowel control device entered a 1-month treatment period, and efficacy was assessed with a repeat bowel diary. Demographic data, medical and surgical history, and pelvic examination findings were compared across women with successful and unsuccessful completion of the fitting period. Multivariate logistic regression analysis was performed.

RESULTS

Six clinical sites in the United States recruited from August 2012 through October 2013. Overall, 110 women underwent attempted fitting, of which 61 (55.5%) of 110 were successful and entered the treatment portion of the study. Multivariate logistic regression analysis revealed that previous prolapse surgery (P = 0.007) and shorter vaginal length (P = 0.041) were independently associated with unsuccessful fitting. Women who have not undergone previous prolapse surgery had 4.7 times the odds (95% confidence interval [CI], 1.53-14.53) of a successful fit. In addition, for every additional centimeter of vaginal length, women had 1.49 times the odds (95% CI, 1.02-2.17) of a successful fit.

CONCLUSIONS

Shorter vaginal length and previous prolapse surgery were associated with an increased risk of fitting failure. These findings may be used to inform patients regarding their expectation of successful fitting.

Advances in the Surgical Treatment of Fecal Incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.

Challenges faced in the clinical application of artificial anal sphincters

Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials.

Systematic Review of Surgical Treatments for Fecal Incontinence

BACKGROUND

No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments.

OBJECTIVE

The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults.

DATA SOURCES

Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources.

STUDY SELECTION

Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980-2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment-outcome combination.

INTERVENTIONS

Surgical treatments for fecal incontinence were included interventions.

MAIN OUTCOME MEASURES

Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured.

RESULTS

Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%-100%). Major surgical complications often required reoperation; few required permanent colostomy.

LIMITATIONS

Most evidence is intermediate term, with small patient samples and substantial methodologic limitations.

CONCLUSIONS

Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

A vaginal bowel-control system for the treatment of fecal incontinence

OBJECTIVE

To evaluate the effectiveness and safety of a vaginal bowel-control device and pump system for fecal incontinence treatment.

METHODS

Women with a minimum of four fecal incontinence episodes over 2 weeks were fit with the intravaginal device. Treatment success, defined as a 50% or greater reduction of incontinent episodes, was assessed at 1 month. Participants were invited into an optional extended-wear period of another 2 months. Secondary outcomes included symptom improvement measured by the Fecal Incontinence Quality of Life, Modified Manchester Health Questionnaire, and Patient Global Impression of Improvement. Adverse events were collected. Intention-to-treat analysis included participants who were successfully fit entering treatment. Per protocol, analysis included participants with a valid 1-month treatment diary.

RESULTS

Sixty-one of 110 (55.5%) participants from six clinical sites were successfully fit and entered treatment. At 1 month, intention-to-treat success was 78.7% (48/61, P<.001); per protocol success, 85.7% (48/56, P<.001) and 85.7% (48/56) considered bowel symptoms "very much better" or "much better." There was significant improvement in all Fecal Incontinence Quality of Life (P<.001) and Modified Manchester (P≤.007) subscales. Success rate at 3 months was 86.4% (38/44; 95% confidence interval 73-95%). There were no serious adverse events; the most common study-wide device-related adverse event was pelvic cramping or discomfort (25/110 participants [22.7%]), the majority of events (16/25 [64%]) occurring during the fitting period.

CONCLUSION

In women successfully fit with a vaginal bowel-control device for nonsurgical treatment for fecal incontinence, there was significant improvement in fecal incontinence by objective and subjective measures.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01655498.

LEVEL OF EVIDENCE

: II.

Current and emerging treatment options for fecal incontinence

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

Current status: new technologies for the treatment of patients with fecal incontinence

Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.

Sacral nerve stimulation in the treatment of severe faecal incontinence: long-term clinical, manometric and quality of life results

BACKGROUND

Faecal incontinence (FI) is a complex and multifactorial health problem. Treatment has to be individualised, analysing the aetiology and gravity in every case. Sacral nerve stimulation (SNS) has been shown to effectively improve treatment of FI.

METHODS

Fifty patients with severe FI treated with SNS between March 2002 and December 2010 were analysed. Preoperative assessment included physical examination, anorectal manometry and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale (FIQLS). Follow-up appointments were scheduled at 1, 6 and 12 months and annually thereafter. Wexner score, FIQLS and the ability to defer defecation were assessed at each visit.

RESULTS

Fifty patients underwent a permanent implant. The overall mean follow-up period was 55.52 ± 31.84 months. After 6 months, SNS significantly improved FI and positively impacted quality of life, as evidence by significant improvements in all 4 scales of the FIQLS. Anorectal manometry showed a trend towards an increase in maximum resting pressure and maximum pressure. After the first assessment at 6 months, Wexner score and FIQLS remained stable. Ability to defer defecation was also maintained. During follow-up, 3 patients (6 %) experienced implant site pain and episodes of extremity pain and paresthesias that were refractory to medical management and required device explantation. The implant site infection rate was 2 %.

CONCLUSIONS

Analysis of our long-term results confirms the safety and effectiveness of SNS in the management of patients with FI.

Technical and functional results of the artificial bowel sphincter for treatment of severe fecal incontinence: is there any benefit for the patient?

BACKGROUND

Fecal incontinence is a socially devastating problem that can be cured by the artificial bowel sphincter in selected cases.

OBJECTIVE

This study evaluates short- and long-term morbidity and functional results of the artificial bowel sphincter.

DESIGN

This study is a retrospective evaluation of consecutive patients.

SETTINGS

This study was conducted at 2 academic colorectal units.

PATIENTS

Between May 2003 and July 2010, all consecutive patients who underwent artificial bowel sphincter implantation for severe fecal incontinence were included in the study.

INTERVENTION

The artificial bowel sphincter was implanted through 2 incisions made in the perineum and suprapubic area.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, and 12, and then annually. Mortality, morbidity (early infection within the first 30 days after implant, and late thereafter), and reoperations including explantations were analyzed. Anal continence was evaluated by means of the Cleveland Clinic Florida score. Mean follow-up was 38 months (range, 12-98).

RESULTS

Between May 2003 and July 2010, 21 consecutive patients with a mean age of 51 years (range, 23-71) underwent surgery. There was no mortality. All patients presented with at least 1 complication. Infection or cutaneous ulceration occurred in 76% of patients, perineal pain in 29%, and rectal evacuation disorders in 38%. The artificial bowel sphincter was definitely explanted from 17 patients (81%). The artificial sphincter was able to be activated in 17 patients (81%), and continence was satisfactory at 1 year in those who still had their sphincter in place (n = 12).

CONCLUSION

There is a very high rate of morbidity and explantation after implantation of an artificial bowel sphincter for fecal incontinence. Four of 21 patients who still had an artificial sphincter in place had satisfactory continence at a mean follow-up of 38 months.

[Treatment of sphincter insufficiency]

Surgical therapy of anal sphincter insufficiency is only indicated if it leads to symptoms and conservative treatment fails to achieve adequate symptom relief. Various new surgical options have evolved over the last decade but evidence of the efficacy varies substantially. Some have gained broader clinical acceptance based on the efficacy, ease of applicability and low risk profile. The paper aims to outline the currently commonly accepted and frequently applied surgical techniques for the treatment of anal sphincter insufficiency and the results, put these into the context of a treatment algorithm and to present novel techniques which carry potential for the future.

Biomechanical modeling of the rectum for the design of a novel artificial anal sphincter

This paper discusses biomechanical issues that are related to the option of a novel artificial anal sphincter around the human rectum. The prosthesis consists of a compression cuff system inside and a reservoir cuff system outside, which is placed around the debilitated sphincter muscle. The micropump shifts fluid between the cuffs and thus takes over the expansion and compression function of the sphincter muscle. However, the human rectum is not a rigid pipe, and motion in it is further complicated by the fact that the bowel is susceptible to damage. With the goal of engineering a safe and reliable machine, the biomechanical properties of the in-vivo porcine rectum are studied and the tissue ischemia is analyzed.

Artificial anal sphincter for severe fecal incontinence implanted by a transvaginal approach: experience with 32 patients treated at one institution

PURPOSE

Our aim was to evaluate medium-term results of transvaginal implantation of an artificial anal sphincter in a large series of patients.

METHODS

Women undergoing treatment for severe fecal incontinence at Rouen University Hospital, Rouen, France, from January 2003 through December 2007 were eligible for the study if the fecal incontinence had lasted for 6 months and if they had attempted other therapies without success. All patients received implantation of an artificial anal sphincter via a transvaginal approach. Incontinence was assessed with the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score).

RESULTS

A total of 32 women entered the study. Their median age was 63 (range, 26-79) years. At entry, 20 (63%) had severe destruction and scarring of the perineum, which was a contraindication for implantation via a perineal approach. Nine patients (28.1%) had previously undergone implantation of an AAS which had been removed because of complications, and 5 had had a Pickrell procedure for anal agenesia. No deaths occurred during the study. The device was removed in a total of 9 patients (28.1%): in 7 because of septic adverse events within the first 6 months after the operation, in 1 because of poor function, and in 1 for psychological reasons despite good functional results. Implantation was successful in 23 patients (71.9%), and the device remained activated for a mean follow-up of 41 (range, 18-75) months, with a mean decrease in Cleveland Clinic incontinence score from 18.4 to 6.8 (P < .0001). None of the patients complained of dyspareunia.

CONCLUSIONS

The transvaginal approach for implantation of an artificial anal sphincter permits treatment of women with fecal incontinence who have severe damage and scarring of the anterior perineum. This route provides an alternative for patients whose only therapeutic option would previously have been a defunctioning stoma.

Long-term results of artificial bowel sphincter for the treatment of severe faecal incontinence. Are they what we hoped for?

OBJECTIVE

This study evaluates the long-term morbidity, functional results and quality of life (QOL) after treatment of severe faecal incontinence (FI) with the Acticon Neosphincter (American Medical Systems, Minneapolis, Minnesota, USA).

METHOD

Between 1996 and 2002, 17 consecutive patients (14 female, 3 male; median age 46) underwent sphincter implantation. Clinical evaluation, incontinence severity and QOL were assessed. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed preoperatively and at several stages of follow-up. The study was completed in December 2007.

RESULTS

Mean follow-up was 68 months (range: 3-133). Morbidity occurred in 100% of patients from which 65% required at least one re-operation. After the first implant, 11 devices had to be removed (65%). Seven patients had a new implant. At the final stage, Acticon was activated in 9 cases (53%). Severity of FI improved from a median of 17.5 preoperatively to 9 (P = 0.005), 5.5 (P = 0.005) and 10 (P = 0.092) at 6, 12 months and at the end of follow-up, respectively. There was a significant improvement in QOL in all postoperative controls (P < 0.05). Severity of FI did not show a correlation with QOL in the preoperative period, but did at 6, 12 months and at the end of follow-up. Mean maximum resting pressure significantly increased with the full anal cuff.

CONCLUSION

There is a high rate of morbidity, surgical re-interventions and explants after Acticon implant. Patients should be clearly informed about this before surgery. However, patients who have not had Acticon Neosphincter explanted, experience a significant improvement in anal continence and QOL.

Modeling of human colonic blood flow for a novel artificial anal sphincter system

A novel artificial anal sphincter system has been developed to simulate the normal physiology of the human anorectum. With the goal of engineering a safe and reliable device, the model of human colonic blood flow has been built and the relationship between the colonic blood flow rate and the operating occlusion pressure of the anorectum is achieved. The tissue ischemia is analyzed based on constitutive relations for human anorectum. The results suggest that at the planned operating occlusion pressure of less than 4 kPa the artificial anal sphincter should not risk the vascularity of the human colon.

[Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]

Dynamic graciloplasty (DGP) and the Acticon Neosphincter (artificial bowel sphincter, ABS) are well-established therapeutic instruments in patients with severe fecal incontinence. However, the success rates in the literature must be interpreted with caution. The report presented here presents firstly a critical analysis of 1510 patients in 52 studies (29 DGP vs 23 ABS). The evidence of these studies was assessed using the Oxford EBM criteria. All data were statistically analysed. Up to 94% of the studies analysed show EBM levels of only >3b. Both procedures show significant improvements in postoperative continence scores (p<0.001) and a significant advantage of ABS over DGP. Nevertheless, they are associated with a high incidence of morbidity in the long term (infection rate ABS vs DGP 21.74% vs 35.1%, revision rate ABS vs DGP 37.53% vs 40.64%, and ABS explantation rates of 30%). Presently no therapeutic recommendation can be expressed based on the few data available. Furthermore, therapy should be performed in specialized centers and patients should be given a realistic picture of the critical outcome of both surgical techniques.

Third-party prospective evaluation of patient outcomes after dynamic graciloplasty

Background

Dynamic graciloplasty (DGP) is a complex procedure designed to improve bowel function in patients with end-stage faecal incontinence. Outcomes of DGP were examined in comparison with stoma formation or continued medical management.

Methods

This third-party evaluation comprised a prospective case–comparison study of patient-based and clinical outcomes at a London hospital. Forty-nine patients who underwent DGP during 5 years from 1997 were compared with 87 patients with similar bowel disorders who did not undergo DGP. Outcome measures were quality of life (QoL), symptoms, anxiety and depression.

Results

At 2 years after surgery, bowel-related QoL and continence had improved by more than 20 per cent compared with the preoperative status for two-thirds of patients who had DGP (P &lt; 0·001). Two-thirds were continent all or most of the time, although one-third experienced disordered bowel evacuation. Large deteriorations on the Nottingham Health Profile pain score occurred in 11 of 34 patients who had DGP, compared with seven of 57 patients in comparison groups (P = 0·027). Patients in comparison groups experienced no significant changes in measured outcomes over the 2 years of follow-up.

Conclusion

Although DGP is associated with a high level of morbidity, it deserves consideration as an alternative to life with severe and refractory faecal incontinence or stoma formation in people in whom conventional treatments have failed.

Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature

Up until about 15 years ago the only realistic option for end-stage fecal incontinence was the creation of a permanent stoma. There have since been several developments. Dynamic graciloplasty (DGP) and artificial bowel sphincter (ABS) are well-established surgical techniques, which offer the patient a chance for continence restoration and improved quality of life; however, they are unfortunately associated with high morbidity and low success rates. Several trials have been done in an attempt to clarify the advantages and disadvantages of these methods and define their place in the second-line treatment of severe, refractory fecal incontinence. This review presents a critical and unbiased overview of the current status of neosphincter surgery according to the available data in the world literature.

Investigation and treatment of faecal incontinence

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Técnicas novedosas en el tratamiento de la incontinencia anal

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread.

Fecal incontinence: an up-to-date critical overview of surgical treatment options

BACKGROUND

Surgery is the last resort for patients suffering from severe fecal incontinence. The armamentarium of surgical options for this condition has increased impressively during the last decade. Nevertheless, this fact seems to make neither patients nor surgeons feel more comfortable. Treatment of fecal incontinence still remains a challenge to modern medicine due to many specific sides of this problem.

AIMS

This article gives an up-to-date overview of existing operative treatment options.

METHODS

An unbiased review of relevant literature was performed to assess the role of all methods of surgical treatment for fecal incontinence available nowadays.

RESULTS

Recent studies have shown poor late results after primary sphincter repair and low predictive value for most preoperative diagnostic tests. New surgical options such as artificial devices and electrically stimulated muscle transpositions are doomed by low success rates and unacceptably frequent complications. That is why current attention has focused on non- or minimally invasive therapies such as sacral nerve stimulation and temperature-controlled radio-frequency energy delivery to the anal canal. However, all these innovative techniques remain experimental till enough high-evidence data are gathered for their objective evaluation.

CONCLUSION

Careful and detailed preoperative assessment to exactly determine the etiology of incontinence and individual approach remain the cornerstones of surgical treatment of fecal incontinence nowadays.

A review of contemporary surgical alternatives to permanent colostomy

OBJECTIVES

To review the options available to patients with faecal incontinence with failed conservative treatment and/or failed anal sphincter repair and assessing the current indications and results of these options.

METHODS

A literature search of MEDLINE, EMBASE and Cochrane databases was performed using the relevant search terms.

RESULTS

Continent options for patients with severe or end stage faecal incontinence include the creation of a form of an anal neosphincter and more recently sacral nerve stimulation. Over half the patients, who are candidates, may benefit from these procedures, although long term results of sacral nerve stimulation are unknown. Dynamic graciloplasty improves the continence in 44-79% of the patients. The complications include frequent reoperations, high incidence of infection and obstructive defaecation. The success rates of artificial bowel sphincter vary between 24% and 79%. Once functional, the artificial bowel sphincter seems to improve the continence in the majority of the patients. Device removal due to infection, obstructive defaecation and pain is a frequent problem. Sacral nerve stimulation is claimed to result in improvement in continence in 35-100% of patients. The main risks in this procedure are infection, electrode displacement and pain.

CONCLUSIONS

All these procedures have high complication rates and have moderate success rates only. A major proportion of patients will need reoperations and hence high motivation is necessary for patients who undergo these procedures. A uniform standard for measurement of success is also necessary so that these procedures can be compared with each other.

A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence

BACKGROUND

Severe fecal incontinence remains a disabling condition for the patient and a major therapeutic challenge for the physician. A series of observational studies have indicated that placement of an artificial bowel sphincter is associated with marked improvement of continence and quality of life. We have performed a prospective, randomized, controlled trial to evaluate the effect of placement of an artificial bowel sphincter (Acticon Neosphincter) on continence and quality of life in a group of severely incontinent adults.

METHODS

Fourteen adults (male:female, 1:13; age range, 44-75 years) were randomized to placement of the artificial bowel sphincter or to a program of supportive care and were followed for six months from operation or entry into the study. The principal outcome measure was the level of continence, measured with the Cleveland Continence Score, which provides a scale from 0 to 20, representing perfect control through to total incontinence. Secondary outcome measures were perioperative and late complications in the artificial bowel sphincter group, and the changes in quality of life in both groups.

RESULTS

In the control group, the Cleveland Continence Score was not significantly altered, with an initial value of 17.1 +/- 2.3 and a final value of 14.3 +/- 4.6 at six months. The artificial bowel sphincter group showed a highly significant improvement, changing from 19.0 +/- 1.2 before placement to 4.8 +/- 4.0 at six months after placement. One patient in the artificial bowel sphincter group had failure of healing of the perineal wound and explantation of the device (14 percent explantation rate). There were two other significant perioperative events of recurring fecal impaction initially after placement in one patient and additional suturing of the perineal wound in another. There were major improvements in the quality of life for all measures in the artificial bowel sphincter group. There was significant improvement in all eight subscales of the Medical Outcome Study Short Form-36 measures. The American Medical Systems Quality of Life score was raised from 39 +/- 6 to 83 +/- 14 and the Beck Depression Inventory showed reduction from a level of mild depression (10.8 +/- 9.3) to a normal value (6.8 +/- 8.7). No significant changes in any of the quality of life measures occurred for the control group.

CONCLUSIONS

Through a prospective, randomized trial format, we have shown that placement of an artificial bowel sphincter is safe and effective when compared with supportive care alone. Perioperative and late problems are likely to continue to occur and between 15 percent and 30 percent of patients may require permanent explantation. For the remainder, the device is easy and discrete to use, highly effective in achieving continence, and able to generate a major improvement in the quality of life.

Outcome after implantation of a novel prosthetic anal sphincter in humans

Background

A novel prosthetic anal sphincter (PAS) has been developed that aims to occlude by flattening and angulating the bowel, reproducing the action of the puborectalis muscle. The safety of the PAS has been confirmed in biomechanical, in vitro and long-term animal survival studies. The Medical Devices Agency approved implantation in 12 patients.

Methods

The PAS was placed in the pelvis around the anorectal junction via a transabdominal approach in 12 patients with severe faecal incontinence. The device was activated 6 weeks after surgery. Fibreoptic examination of the mucosa below the device was undertaken at various intervals during review.

Results

At a median follow-up of 59 (range 30–72) months nine of the 12 patients had a functioning PAS. There were no device-related infective complications after the initial operation but one patient developed pseudomembranous colitis and had the device removed. The PAS was effective in restoring continence in ten of 11 patients. Median (range) Cleveland Clinic continence scores improved from 16 (7–20) before to 3 (0–7) after surgery. In two patients the PAS was eventually removed owing to infection after revisional surgery. There was no clinical or histological evidence of gastrointestinal mucosal ischaemia.

Conclusion

The PAS was effective in restoring continence. There was no device-related infection after the initial operation, no device erosion and no clinical or histological evidence of gastrointestinal ischaemia.

Avaliação da qualidade de vida na incontinência anal: validação do questionário FIQL (Fecal Incontinence Quality of Life)

RACIONAL: A incontinência anal acarreta incapacitação física e psicológica, determinando impacto na qualidade de vida. Para quantificar esse impacto em nosso meio, não existem instrumentos específicos validados. OBJETIVOS: Avaliar a qualidade de vida na incontinência anal, através da validação do questionário "Fecal Incontinence Quality of Life" (FIQL), que é composto por 29 questões distribuídas em 4 domínios: estilo de vida, comportamento, depressão e constrangimento, sua escala de pontuação varia de 1 a 4 com exceção das questões 1 e 4 que variam de 1 a 5 e 1 a 6, respectivamente. MATERIAL E MÉTODO: Após tradução e adaptação cultural, estudou-se a validação do instrumento através das propriedades de medida de reprodutibilidade e validade. Para a avaliação da reprodutibilidade aplicou-se o questionário em 50 pacientes com incontinência anal por dois examinadores, sendo reaplicado por um dos examinadores após período de 7 a 10 dias. A validade construtiva foi testada através da comparação do FIQL e o SF-36, questionário genérico de qualidade de vida e entre o FIQL e um índice de incontinência anal. O índice de incontinência anal utilizado foi o de Jorge-Wexner, que varia de 0 (continência perfeita) a 20 (incontinência total). A validade discriminativa foi avaliada através da aplicação do FIQL em dois grupos controle: indivíduos voluntários hígidos e portadores de constipação intestinal. RESULTADOS: Verificou-se que o FIQL apresentou correlação significativa com outros instrumentos (SF-36 e índice de incontinência) e que a qualidade de vida no portador de incontinência anal está comprometida em todos os domínios: estilo de vida: 2,4 comportamento: 2,0, depressão: 2,5 e constrangimento: 1,9, quando comparado com os indivíduos voluntários hígidos (3,9, 3,9, 4,1 e 4,0), e pacientes com constipação intestinal (3,7, 3,8, 3,6 e 3,8), respectivamente. CONCLUSÃO: O FIQL é útil para a avaliação da qualidade de vida na incontinência anal em nossa população.

Faecal incontinence in adults

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.

Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence

BACKGROUND

The aim was to determine the safety and effectiveness of the implantation of an artificial bowel sphincter for the treatment of severe faecal incontinence.

METHOD

Medical bibliographic databases, the internet and reference lists were searched from January 1966 to January 2003. Only the lowest level of evidence was available for inclusion in this systematic review. Case series and case reports were selected to assess safety, whereas only case series were selected to assess effectiveness.

RESULTS

Fourteen studies met the inclusion criteria. A number of safety issues were reported, including high explantation rates, and rates of adverse events owing to infection, device malfunction, ulceration and pain. Results in published reports were not analysed on an intention-to-treat basis. Continence, quality of life and manometry scores were reported for patients with a functioning device at the end of follow-up. These patients experienced a significant improvement in their level of continence. As no outcome data were presented for those with a non-functioning or explanted device, it is possible that such patients may have a worsened degree of incontinence or decreased quality of life.

CONCLUSION

Implantation of an artificial bowel sphincter is of uncertain benefit and may possibly harm many patients. Patient selection is therefore critical and should be enhanced by higher-quality research.

Artificial bowel sphincter in severe anal incontinence

OBJECTIVE

The artificial anal sphincter has been suggested as an alternative in the treatment of severe anal incontinence when conventional surgical methods are not possible or have failed. Experience in this procedure is still limited and the results have not yet been sufficiently established. The aim of this study is to evaluate the efficacy of the ACTICON (American Medical Systems, Minneapolis, MN) on patients operated upon in our Unit.

PATIENTS AND METHOD

In this prospective study an ACTICON sphincter was implanted in 10 patients (8 women) with an average age of 56 years and with an average period of severe anal incontinence of 151 months. The origin of incontinence was obstetric injury (n: 4), neuropathy (n: 3) and sphincteral injury from previous anal surgery (n: 3). The degree of continence was measured using the Fecal Incontinence Scoring System (FISS) and the pre- and postoperative anal manometric parameters at 6-month intervals. The average follow-up time for the efficacy of the implanted system was 29 months.

RESULTS

A total of 6 patients [60%] displayed complications in the immediate postoperative period: subaponeurotic reimplantation of the connecting tubes was necessary after infection of the abdominal wound (n:1); superficial dehiscence of the perianal wound (n: 2), infection of the perianal wound (n: 1) and perianal haematoma (n: 2) that were resolved by conservative treatment. For 3 patients [30%] the system was explanted, definitively in one and in 2 of them reimplanted successfully. At the end of the follow-up period, 9 patients [90%] still have an activated artificial sphincter. The score on the Fecal Incontinence System decreased significantly after the system was activated (P < 0.0001) and the pressure with the cuff closed was significantly higher than pre-operative anal pressure (P < 0.0001). All the patients are now continent for solid stool, 56% have occasional involuntary losses of gases and 33% occasionally have involuntary losses of gases and liquid stool. Only 2 patients [22%] have complete continence.

CONCLUSIONS

Our findings indicate that the ACTICON artificial anal sphincter is well tolerated and can be an effective alternative in the treatment of severe anal incontinence. Although complete continence is only achieved in a low percentage of cases, for the rest of the patients the ACTICON neosphincter reduces the symptoms considerably.

Attainment of continence with J-pouch and artificial bowel sphincter for concomitant imperforate anus and familial adenomatous polyposis: report of a case

Numerous proven surgical therapies now exist to compensate for loss of anal sphincter function or loss of rectal reservoir capacity. Fecal incontinence that results from the combined loss of rectal reservoir and anal sphincter tone remains a surgical challenge. This case describes what may be the first successful treatment of a patient with imperforate anus and familial adenomatous polyposis using an ileal J-pouch and artificial bowel sphincter.

Surgical treatment options for fecal incontinence

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.

Measuring fecal incontinence

The measurement of fecal incontinence is challenging. Because fecal incontinence is a symptom, the subjective perception of the patient must be the foundation of any evaluation of incontinence or the impact of incontinence. The lack of a criterion standard makes testing measures for reliability and validity more difficult. Despite this, many measures are available and can be divided into three broad categories: descriptive measures that do not provide summary scores; severity measures that assess the frequency and type of incontinence; and impact measures that assess the effect of incontinence on quality of life. The strengths and weaknesses of currently available measures are presented in this review.

Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the anal canal (Secca procedure) for the treatment of fecal incontinence

PURPOSE

This multicenter study evaluated the safety and efficacy of radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence.

METHODS

Fifty patients at five centers were enrolled. All reported fecal incontinence at least once per week for three months, and medical and/or surgical management failed to help their symptoms. At baseline and at six months, patients completed questionnaires (Cleveland Clinic Florida Fecal Incontinence score (0-20), fecal incontinence-related quality of life, Short Form-36, and visual analog scale) and underwent anorectal manometry, endoanal ultrasound, and pudendal nerve terminal motor latency testing. On an outpatient basis using local anesthesia, radio-frequency energy was delivered via an anoscopic device with multiple needle electrodes (Secca system) to create thermal lesions deep to the mucosa of the anal canal.

RESULTS

Forty-three females and seven males (aged 61.1 +/- 13.4 (mean +/- standard deviation); range, 30-80 years) were treated. Mean duration of fecal incontinence was 14.9 years. Treatment time was 37 +/- 9 minutes. At six months, the mean Cleveland Clinic Florida Fecal Incontinence score improved from 14.5 to 11.1 (P < 0.0001). All parameters in the Fecal Incontinence Quality of Life scales were improved (lifestyle (from 2.5-3.1; P < 0.0001); coping (from 1.9-2.4; P < 0.0001), depression (from 2.8-3.3; P = 0.0004); embarrassment (from 1.9-2.5; P < 0.0001)). Responders, as assessed by a systematic referenced analog scale, reported a median 70 percent resolution of symptoms. The mean Short Form-36 social function improved from 64.3 to 76 (P = 0.003). There were no changes in endoanal ultrasound or pudendal nerve terminal motor latency assessment, or in anal manometry. Complications included mucosal ulceration (one superficial, one with underlying muscle injury) and delayed bleeding (n = 1).

CONCLUSION

This multicenter trial demonstrates that radio-frequency energy can be safely delivered to the lower rectum and anal canal. The Secca procedure significantly improved the Cleveland Clinic Florida Fecal Incontinence score and the overall quality of life for most patients having undergone the procedure.

Novel surgical approaches to fecal incontinence: neurostimulation and artificial anal sphincter

Neurostimulation, neosphincters with neurostimulation, and implanted artificial sphincters are recently developed therapeutic options for patients with end-stage fecal incontinence. Of these approaches, sacral nerve electric stimulation appears to be the most promising because of its relative simplicity and low morbidity. However, it is best suited for patients with anatomically intact sphincters. The other procedures target patients with gross structural defects in the sphincter but are still in their infancy. In this article we discuss these techniques and review their rationale, mechanisms of action, indications, outcomes, and complications.

Prospective study of artificial anal sphincter and dynamic graciloplasty for severe anal incontinence

BACKGROUND AND AIMS

Dynamic graciloplasty and artificial anal sphincter are two options for refractory incontinence, the efficacy of which was compared in a prospective study.

PATIENTS AND METHODS

Between November 1966 and June 1998, 16 patients were operated on (artificial anal sphincter 8, dynamic graciloplasty 8). Four consecutive operations with each technique were performed by two colorectal surgeons (one initiated the study with the neosphincter and the other with dynamic graciloplasty). Two independent observers assessed postoperative results at 4-month intervals. Patients were followed up to January 2001, with a median (interquartile range) of 44 (13) months and 39 (15) months for the nesophincter and the dynamic graciloplasty, respectively.

RESULTS

Fourteen patients had complications. In the immediate postoperative period; there were eight cases of wound healing-related problems (four in the graciloplasty group). Perineal infection occurred in one patient in the graciloplasty group. At follow-up there were 11 complications (6 in the neosphincter group). Four patients undergoing neosphincter implantation had erosion or pain at the cuff site and had the implant removed (a new device was reimplanted in one). Four patients undergoing dynamic graciloplasty had the stimulator removed. Postoperatively the neosphincter was associated with a significantly lower score on the continence grading scale of the Cleveland Clinic Florida than graciloplasty.

CONCLUSION

The artificial anal sphincter is a more convenient technique than dynamic graciloplasty for institutions treating small number of patients. However, technical failures and complications during follow-up that require reoperation are very high in both types of treatments.

Fecal incontinence

The treatment of fecal incontinence is particularly gratifying because the loss of fecal control has a devastating effect on a patients lifestyle. One must consider the myriad factors that influence bowel control to properly diagnose and treat each patient. Physiology testing, particularly the use of ultrasound, is essential when treatment extends beyond dietary and medical management. Recent reports suggest that the success of typical treatments may diminish with time. This may indicate a greater need in the future for innovative options such as the artificial bowel sphincter or sacral stimulation.

Anal trauma and foreign bodies

Although anal trauma is rare, iatrogenic injury is not uncommon. Immediate recognition is vital to a successful outcome and may obviate the need for a diverting stoma. Evaluation must include a search for involvement of other structures and an evaluation of the anal sphincters. Foreign bodies most often do not cause significant anorectal injuries. Extraction of these diverse objects requires ingenuity. Superficial injuries may be left open or sutured closed. There are number of options for repair of anal sphincter injuries, either immediately or in a delayed fashion. A review of the clinical environment will dictate the procedure chosen.

[Surgical treatment of anal incontinence]

Surgery is mandatory for fecal incontinence when medical treatments and reeducation by biofeedback are ineffective. Sphincter disruption is the most frequent cause. Sphincter repair with or without overlapping is indicated in the large majority of cases. Short-term results are good but result is not ever maintained with time. In case of failure, or when the defect concerns more than 180 degrees, it is necessary to use a substitutive technique. Artificial anal sphincter is often first proposed because of its apparent technical simplicity and because it is cheaper than dynamic graciloplasty. Results are excellent. Failures are due to local infection or device disfunction. Dynamic graciloplastie may be proposed in patients with severe perineal lesions, or failure of the other methods. Its results are also excellent, except for the patients having disordered rectal perception. Sacral nerve stimulation is limited to patients with idiopathic or neurologic incontinence. Because definitive implantation is done only following positive preoperative stimulation test, short-term results are very good.

Artificial anal sphincter: complications and functional results of a large personal series

PURPOSE

This study was undertaken to evaluate the technique of artificial sphincter for fecal incontinence, with its complications and risk factors, the functional results, and which variables derived from demographic data, preoperative studies, device characteristics, technical details, perioperative findings, and complications could influence the outcome.

METHODS

The Acticon Neosphincter was implanted in 53 patients (35 females), median age 46 years, with total anal incontinence not amenable to sphincter repair or after failed sphincteroplasty. In females with associated rectocele, this was synchronously corrected. Six (11 percent) patients already had a colostomy, but no proximal stoma was constructed at the time of implantation. Causes of incontinence were congenital, 13; iatrogenic, 13; obstetric, 10; neurogenic, 9; trauma, 4; idiopathic, 2; and perineal colostomy, 2. Physiologic testing before and after the operation and preoperative endosonography were done when they were available. Quality of life was assessed in 25 patients. Mean follow-up was 26.5 (range, 7-55) months.

RESULTS

Perioperative events occurred in 14 (26 percent) patients: abnormal bleeding, 7; vaginal perforation, 4; rectal perforation without apparent contamination, 2; and unobserved urethral perforation, 1. Early complications were mainly related to sepsis in 8 (15 percent) patients and wound complication in 8 (15 percent). Sepsis could not be statistically associated with any of the variables studied here. Wound separation was associated with fibrosis (p = 0.003) and tension of the wound (p = 0.001). Late complications were: cuff and/or pump erosion, 9 (18 percent) patients; infection, 3 (6 percent); impaction, 11 (22 percent); pain, 4 (8 percent); and mechanical failures, 2 (4 percent). None of those complications showed a statistical association with any of the variable studied here. There were 10 (19 percent) definitive explants caused by septic or skin complications. Only 26 (60 percent) of 43 patients with the device in action use the pump (patients' decision). Normal continence was achieved in 65 percent of patients and continence to solid stool in 98 percent. The Cleveland Clinic score of incontinence (0-20, maximal incontinence) changed from 17 +/- 3 preoperatively to 4 +/- 3 postoperatively (p = 0.000). An early complication of the perianal wound influenced the functional results: postimplant score > 4 < or = 4 (p = 0.009). Resting and squeeze pressures changed significantly after activation (p = 0.000). Quality of life measured in four subscales changed significantly in all the subscales (p = 0.000).

CONCLUSIONS

The artificial anal sphincter restores continence to solid stool in almost all severely incontinent patients, two-thirds of whom achieve practically normal continence. Quality of life improves significantly. Infection and skin erosion are the cause of the majority of explants. No predictable factors of functional success could be found in this study.