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Cerdán Miguel J, Arroyo Sebastián A, Codina Cazador A, de la Portilla de Juan F, de Miguel Velasco M, de San Ildefonso Pereira A, Jiménez Escovar F, Marinello F, Millán Scheiding M, Muñoz Duyos A, Ortega López M, Roig Vila JV, Salgado Mijaiel G. Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology. Cir Esp 2024; 102:158-173. [PMID: 38242231 DOI: 10.1016/j.cireng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 01/21/2024]
Abstract
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
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Affiliation(s)
| | - Antonio Arroyo Sebastián
- Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - Antonio Codina Cazador
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain
| | | | | | | | | | - Franco Marinello
- Unidad de Cirugía Colorrectal, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mónica Millán Scheiding
- Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Arantxa Muñoz Duyos
- Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Mario Ortega López
- Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Weledji EP. Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment. Ann Coloproctol 2017; 33:161-168. [PMID: 29159162 PMCID: PMC5683965 DOI: 10.3393/ac.2017.33.5.161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/30/2017] [Indexed: 12/13/2022] Open
Abstract
The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery and Obstetrics and Gynecology, Faculty of Health Sciences, University of Buea, Buea, Cameroon
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Uludağ O, Melenhorst J, Koch SMP, van Gemert WG, Dejong CHC, Baeten CGMI. Sacral neuromodulation: long-term outcome and quality of life in patients with faecal incontinence. Colorectal Dis 2011; 13:1162-6. [PMID: 20955512 DOI: 10.1111/j.1463-1318.2010.02447.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Since 1994 sacral neuromodulation (SNM) has increasingly been used for the treatment of faecal incontinence, but no long-term data in a large group of patients have so far been published. We report long-term outcome and quality of life in the first 50 patients treated by permanent SNM for faecal incontinence. METHOD We began to use SNM in 2000. Data from the first 50 patients with faecal incontinence who underwent permanent SNM are presented. Efficacy was assessed using a bowel diary and the Quality of Life score was assessed by the Faecal Incontinence Quality of Life questionnaire (FIQOL) and the standard short form health survey questionnaire (SF-36). RESULTS Over a median follow up of 7.1 (5.6-8.7) years, forty-two (84%) patients had an improvement in continence of over 50%. Median incontinent episodes and days of incontinence per week decreased significantly during follow up (P<0.002). Improvement was seen in all four categories of the FIQOL scale and in some domains of the SF-36 QOL questionnaire. There were no statistically significant changes in the median resting and squeeze anal canal pressures. CONCLUSION Initial improvement in continence with SNM was sustained in the majority of patients, with an overall success rate of 80% after a permanent implant at 7 years.
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Affiliation(s)
- O Uludağ
- Department of Surgery, Maastricht University Medical Centre, AZ Maastricht, the Netherlands.
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Oberwalder M, Dinnewitzer A, Nogueras JJ, Weiss EG, Wexner SD. Imbrication of the external anal sphincter may yield similar functional results as overlapping repair in selected patients. Colorectal Dis 2008; 10:800-4. [PMID: 18384424 DOI: 10.1111/j.1463-1318.2008.01484.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates. METHOD Patients who had external anal sphincter repair and follow up of at least 3 months were studied. Fecal incontinence was measured using the validated Wexner fecal Incontinence Scoring system (0 = perfect continence, 20 = complete incontinence); postoperative scores 0-10 were interpreted as successful, and scores of 11-20 as failures. RESULTS A total of 131 females who had anal sphincter repair between 1988 and 2000 were analysed. One hundred and twenty-one patients had overlapping external anal sphincter repair (group I), and 10 had external anal sphincter imbrication (group II). Indications for external anal sphincter imbrication were attenuation of the external anal sphincter without overt defect (n = 5), partial disruption of external anal sphincter with muscle fibres bridging the scar (n = 2), thick bulk of scar between the muscle edges (n = 2), and wide lateral retraction of the muscle edges (n = 1). There were no statistically significant differences between the groups relative to preoperative incontinence score (16.5 vs 16.5, P = 0.99), pudendal nerve terminal motor latency assessment (left 9.6%vs 0.0%, P = 0.19; right 13.4%vs 11.1%, P = 0.84), and extent of electromyography pathology (61%vs 47%, P = 0.30). The patients in group I were younger than those in group II (mean age 50.8 years vs. 61.7 years, respectively; P = 0.052) and the length of follow-up was significantly longer (32.3 months vs 14.3 months, respectively; P < 0.0001). Both procedures had similar success rates (59.5%vs 60%; P = 0.98). CONCLUSION Imbrication of the external anal sphincter may yield similar results as overlapping external anal sphincter repair in patients with incomplete external anal sphincter disruptions, external anal sphincter attenuation, and in patients presenting with wide lateral retraction of the muscle edges.
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Affiliation(s)
- M Oberwalder
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston and Naples, Florida 33331, USA
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Interest of retro-anal levator plate myorrhaphy in selected cases of descending perineum syndrome with positive anti-sagging test. BMC Surg 2008; 8:13. [PMID: 18667056 PMCID: PMC2533292 DOI: 10.1186/1471-2482-8-13] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 07/30/2008] [Indexed: 11/25/2022] Open
Abstract
Background Levator plate sagging (LPS), usually called descending perineum syndrome, is one of the main defects encountered in perineology. This defect is classically associated with colo-proctologic functional troubles (dyschesia and anal incontinence) but can also induce perineodynia, gynaecological and lower urinary tract symptoms. Methods A retrospective case series of nine female patients (mean age: 44.3) underwent an isolated retro-anal levator plate myorrhaphy (RLPM) to treat symptomatic LPS confirmed by rectal examination and/or Perineocaliper®. An anti-sagging test (support of the posterior perineum) must significantly improve the symptoms that were resistant to conservative treatment. The effect of the procedure on the symptoms of the 3 axes of the perineum (urological, colo-proctologic and gynecological) and on perineodynia was evaluated during a follow up consultation more than 9 months after surgery. The effect of RLPM on the position of the anal margin and on the levator plate angle was studied using rectal examination, Perineocaliper® and retro-anal ultrasound. Results Before surgery, anti-sagging tests were positive for dyschesia, urinary urgency and pain. After a mean follow-up of 16.1 months, RLPM resolved or improved 2/2 cases of stress urinary incontinence, 3/5 of urinary urgency, 3/4 of dysuria, 3/3 of anal incontinence, 7/8 of dyschesia, 3/4 of cystocele, 4/5 of rectocele, 5/8 of dyspareunia and 6/7 of perineodynia. Rectal examination showed a complete suppression of sagging in 4 patients and an improvement in the 5 others. The mean reduction of perineal descent was 1.08 cm (extremes: 0–1.5). Using retro-anal ultrasound of the levator plate, the mean reduction of sagging was 12.67 degrees (extremes: 1 – 21). Conclusion Anti-sagging tests can be used before surgery to simulate the effect of RLPM. This surgical procedure seems to improve stress urinary incontinence, frequency, nocturia, urgency, dysuria, anal incontinence, dyschesia, dyspareunia, perineodynia, cystocele and rectocele. These results must be confirmed by a larger case series.
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Tjandra JJ, Dykes SL, Kumar RR, Ellis CN, Gregorcyk SG, Hyman NH, Buie WD. Practice parameters for the treatment of fecal incontinence. Dis Colon Rectum 2007; 50:1497-507. [PMID: 17674106 DOI: 10.1007/s10350-007-9001-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Joe J Tjandra
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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Steele SR, Lee P, Mullenix PS, Martin MJ, Sullivan ES. Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence? Int J Colorectal Dis 2006; 21:508-14. [PMID: 16075237 DOI: 10.1007/s00384-005-0014-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects. PATIENTS AND METHODS We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of <or=5, whereas postoperative quality of life was assessed by a standardized questionnaire. RESULTS Twenty-eight patients (mean age 52.3 years) underwent overlapping anal sphincteroplasty. The mean follow-up was 33.8 months. Cleveland Clinic Florida scores postoperatively showed a significant improvement from preoperative values (14.2 vs 5.1, p<0.001). Seventeen patients (61%) underwent concomitant PFR with sphincteroplasty. Three patients (27%) without PFR and one patient (6%) with PFR underwent repeat sphincter repair due to worsening symptoms (p=0.15). Two patients with PFR and one patient without PFR ultimately had an ostomy due to a failed repair (p=0.66). Comparing patients with and without PFR, there was a trend toward higher success rates (71 vs. 45%) when pelvic prolapse issues were addressed during sphincter repair. CONCLUSION Concomitant evaluation and repair of pelvic floor prolapse may be a clinically significant component of a successful anal sphincteroplasty for fecal incontinence but warrant further prospective evaluation.
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Affiliation(s)
- Scott R Steele
- General Surgery Service, Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA
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8
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Abstract
Physiopathological and clinical interpretation of the descending perineum as described by A. Parks in 1970 remains difficult. This review is based on the literature between 1966 and 2004. The observed symptoms are more often due to associated lesions. The descending perineum on X-ray is not always symptomatic. Colpocystography shows the descent of the perineum and pelvic disorders from the anterior and middle parts of the perineum whereas defecography seems to provide a better diagnosis of dyschesia due to posterior damage (such as rectocele or endo-anal intussusception). The first step of treatment is reeducation and medical treatment because there is no consensus for surgical therapy. Soft sacrocolpopexy by the abdominal approach with three meshes, one under the bladder, one in front of and one behind the rectum can be proposed for complete descending perineum. Transanal rectal resection by staple could be useful when the descending perineum is only associated with a rectocele and/or an intra-anal intussusception.
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Affiliation(s)
- Richard Villet
- Service de Chirurgie Viscérale et Gynécologique, Groupe Hospitalier Diaconesses-Croix-Saint-Simon, Site Reuilly, Paris.
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Abbas SM, Bissett IP, Neill ME, Parry BR. Long-term outcome of postanal repair in the treatment of faecal incontinence. ANZ J Surg 2005; 75:783-6. [PMID: 16173992 DOI: 10.1111/j.1445-2197.2005.03520.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence. OBJECTIVES The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence. PATIENTS AND METHODS Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated. RESULTS Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively (P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse. CONCLUSIONS Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.
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Affiliation(s)
- Saleh M Abbas
- Colorectal Unit, Department of Surgery, University of Auckland, Auckland, New Zealand.
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10
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Abstract
Faecal incontinence is common, distressing to the patient and socially incapacitating. The treatment options depend on the severity and aetiology of incontinence. For mild cases of faecal incontinence, medical management and pelvic floor physiotherapy may be adequate. For more severe cases, surgery is often required. Patients who have a distinct sphincter defect are amenable to surgical repair. In many cases, there is a combination of diffuse structural damage of the anal sphincters with pudendal neuropathy. Conventional surgical repairs have a modest degree of success and the results tend to deteriorate with time. Neosphincter procedures such as artificial bowel sphincter and dynamic graciloplasty are potentially morbid and technically complex. Sacral nerve stimulation is innovative and has had a medium-term success with improvement of quality of life in over 80% of patients treated for faecal incontinence. These results are superior to other techniques in treating patients with severe refractory faecal incontinence, where current maximal therapy has failed. The technique is unique because there is a screening phase, which has a high predictive value. It is also associated with minimal complications that are usually minor. However, most published reports of sacral nerve stimulation for treatment of faecal incontinence were case studies and methods of assessing outcome were variable. Criteria for patient selection are evolving and are yet to be defined. The present paper critically reviews the publications to date on sacral nerve stimulation for treatment of faecal incontinence. This will form the basis for future evaluation of this emerging treatment of severe, intractable faecal incontinence. Randomized clinical trials like that of the Melbourne trial will further clarify the role and indications of sacral nerve stimulation for faecal incontinence.
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Affiliation(s)
- Joe J Tjandra
- Department of Colorectal Surgery, Royal Melbourne Hospital and Epworth Hospital, Melbourne, Australia.
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Zorcolo L, Covotta L, Bartolo DCC. Outcome of anterior sphincter repair for obstetric injury: comparison of early and late results. Dis Colon Rectum 2005; 48:524-31. [PMID: 15747083 DOI: 10.1007/s10350-004-0770-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Fecal incontinence is commonly caused by structural sphincter damage secondary to obstetric trauma. Anterior sphincter repair achieves reasonable early improvement rates of between 69 and 97 percent. Few series have reported long-term results. This study was designed to evaluate the long-term outcome and examine whether there are any predictive factors that could refine patient selection and predict long-term outcome. METHODS The case records of all patients who underwent anterior sphincter repair between January 1991 and December 1999 were studied. The patients were sent a questionnaire that asked about preoperative and postoperative and current bowel function, with questions about quality of life and overall satisfaction with the outcome of the procedure. The late outcome after a mean period of 70 months from the operation was compared with the early clinical results. All the preoperative and operative variables were studied to ascertain their significance in predicting success. RESULTS Ninety-three patients were admitted to the study. Anterior sphincter repair was successful in improving continence in 73 percent of patients. Long-term results were obtained for 62 patients. Seventy percent had objective clinical improvement based on the questionnaire, but only 55 percent considered their bowel control had improved and only 45 percent were satisfied by the operation. Urgency was the most important symptom in determining patient satisfaction; 24 of 26 patients in whom urgency had improved were happy with their outcome. None of the preoperative and operative variables predicted the outcome. CONCLUSIONS Patients should be warned that complete continence is difficult to achieve and that symptoms tend to deteriorate with time.
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Affiliation(s)
- Luigi Zorcolo
- Department of Colorectal Surgery, Western General Hospital of Edinburgh, Edinburgh, United Kingdom
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Yamana T, Takahashi T, Iwadare J. Perineal puborectalis sling operation for fecal incontinence: preliminary report. Dis Colon Rectum 2004; 47:1982-9. [PMID: 15622596 DOI: 10.1007/s10350-004-0675-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the safety efficacy, and impact on quality of life of the perineal puborectalis sling operation for fecal incontinence. METHODS Since August 2001, we performed the perineal puborectalis sling operation on eight patients with idiopathic fecal incontinence. A specially designed polyester mesh sling was introduced along the puborectalis muscle, from a posterior perianal incision, running to a small suprapubic incision. The ends were tied together with moderate tension. Patients were evaluated with the Fecal Incontinence Severity Index, the Cleveland Clinic Score of Incontinence, and the Fecal Incontinence Quality of Life Scale. Manometry and defecography were performed before and six months after the operation. RESULTS Eight patients (7 females; mean age, 63 (range, 44-77) years) were evaluated. A wound infection developed in one patient, which subsided with antibiotics. A rectal ulcer developed in one patient, necessitating sling removal. In the remaining seven patients, the Fecal Incontinence Severity Index improved from 27 to 9, and the Cleveland Clinic Score of Incontinence improved from 13 to 5 (P < 0.05). All parameters in the Fecal Incontinence Quality of Life Scale improved: lifestyle from 2.1 to 3.6; coping/behavior from 1.5 to 3.4; depression/self perception from 2.3 to 3.7; and embarrassment from 2 to 3.6 (P < 0.05). No significant difference was found between preoperative and postoperative maximum resting pressure and maximum squeeze pressure. However, the median anorectal angle on defecography after the operation was significantly reduced (P < 0.05). CONCLUSIONS We believe that the perineal puborectalis sling operation is technically feasible, with low morbidity, and can be an effective procedure for idiopathic fecal incontinence.
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Affiliation(s)
- Tetsuo Yamana
- Department of Proctology, Social Health Insurance Hospital, Tokyo, Japan.
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Abstract
Fecal incontinence is the inability to defer release of gas or stool from the anus and rectum by mechanisms of voluntary control. It is an important medical disorder affecting the quality of life of up to 20% of the population above 65 years. The most common contributing factors include previous vaginal deliveries, pelvic or perineal trauma, previous anorectal surgery, and rectal prolapse. Many physicians lack experience and knowledge related to pelvic floor incontinence disorders, but advancing technology has improved this knowledge. Increased experience with endoanal ultrasound and endoanal magnetic resonance imaging have given us a better understanding not only of the anatomy of the anal canal but also of the underlying morphological defects in fecal incontinence. Current imaging methods are emphasized and recent literature is reviewed.
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Affiliation(s)
- Michael H Fuchsjäger
- Department of Radiology, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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14
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Abstract
Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.
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Affiliation(s)
- N A Rotholtz
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida, USA
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Matsuoka H, Mavrantonis C, Wexner SD, Oliveira L, Gilliland R, Pikarsky A. Postanal repair for fecal incontinence--is it worthwhile? Dis Colon Rectum 2000; 43:1561-7. [PMID: 11089593 DOI: 10.1007/bf02236739] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Patients with idiopathic or neurogenic incontinence without an isolated sphincter defect may be suitable candidates for a postanal repair. The aim of this study was to assess the results of postanal repair in patients with idiopathic or neurogenic fecal incontinence and to evaluate the role of various parameters, including preoperative physiologic testing on outcome. METHODS Postanal repair was offered by a single surgeon to patients meeting the following criteria: incontinence score of at least 12 of 20, absence of an isolated anterior external anal sphincter defect, and failed conservative, medical, and biofeedback management. Physiologic investigation and clinical findings of female patients who had postanal repair for fecal incontinence between 1992 and 1998 were reviewed. Physiologic investigation included anorectal manometry, pudendal nerve terminal motor latency, concentric needle electromyography, and endoanal ultrasonography. Follow-up was obtained by telephone questionnaire; moreover, patients were asked to grade the outcome of their surgery as excellent or good (success) or as fair or poor (failure). RESULTS Twenty-one patients of median age 68 (range, 40-80) years had a mean duration of fecal incontinence before postanal repair of 6.8 (range, 0.5-22) years. Twenty patients (95 percent) were available for at least one year of follow-up. Seventeen patients (80.9 percent) had at least one prior vaginal delivery, and prior sphincteroplasty had been performed in 10 patients (47.6 percent). The morbidity and mortality rates were 5 and 0 percent, respectively. After a mean follow-up period of three (range, 1-7.5) years, seven patients (35 percent) considered surgery to be successful and had a statistically significant decrease in their incontinence score. Neither prolongation of pudendal nerve terminal motor latency nor external sphincter damage as noted on electromyography or any of the preoperative manometric parameters correlated with outcome. Furthermore, patients' ages at surgery did not correlate with the degree of postoperative improvement in continence scores nor did the duration of the patients' symptoms, number of vaginal deliveries, or a history of previous surgery for fecal incontinence. CONCLUSION None of the factors assessed was demonstrated to be predictive of outcome after postanal repair; moreover, the currently available preoperative testing has not altered the success rate, which remains low (35 percent). Despite the low success rate, the absence of any mortality and the low morbidity suggest that postanal repair may be a valid therapeutic approach. However, it should be offered only to selected patients with persistent, severe fecal incontinence despite an anatomically intact external anal sphincter who are not candidates for or refuse all other operative modalities.
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Affiliation(s)
- H Matsuoka
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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16
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Abstract
BACKGROUND Surgical treatment of faecal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device. METHODS This article reviews the currently available surgical options for the treatment of faecal incontinence, discusses factors predictive of outcome, and includes an algorithm for treatment. RESULTS AND CONCLUSION Procedures such as postanal repair, direct sphincter repair and reefing are seldom used. Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma. Pudendal neuropathy seems to be a predictive factor of success, although this is not universally accepted. Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter. The success and morbidity rates with the stimulated graciloplasty and artificial bowel sphincter appear similar. The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for faecal incontinence. Presented as the Edinburgh Royal College of Surgeons invited lecture to the Association of Coloproctology of Great Britain and Ireland, Southport, UK, June 1999
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Affiliation(s)
- M K Baig
- Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, Florida 33309, USA
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Shafik A. Neuronal innervation of urethral and anal sphincters: surgical anatomy and clinical implications. Curr Opin Obstet Gynecol 2000; 12:387-98. [PMID: 11111881 DOI: 10.1097/00001703-200010000-00008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present review describes the neuronal innervation of the external urethral and anal sphincters. A knowledge of this innervation helps in understanding the clinical symptoms of urinary and anorectal pathology, and in choosing the appropriate technique of nerve localization or block. An ability to locate the pudendal nerve, on the basis of surgically documented anatomy, has important diagnostic and therapeutic advantages. It can be used to study the integrity of pelvic floor muscles, in biofeedback training, nerve blocks, pudendal canal decompression, chronic stimulation trials to treat urinary or faecal incontinence, and in nerve conduction studies or evoked potential recordings. Furthermore, the superficial location of the sphincteric innervation in the perineum and ischiorectal fossa renders the nerve branches susceptible to injury during operative correction of urinary or faecal incontinence. Supported by a knowledge of anatomy, we can make firm recommendations on which to base safe surgical techniques that avoid damage to urethral and anal sphincteric innervation.
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Affiliation(s)
- A Shafik
- Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Egypt.
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Shafik A. Treatment of fecal and urinary incontinent patients by functional magnetic stimulation of the pudendal nerve. COLOPROCTOLOGY 1999. [DOI: 10.1007/bf03044651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Yoshioka K, Ogunbiyi OA, Keighley MR. A pilot study of total pelvic floor repair or gluteus maximus transposition for postobstetric neuropathic fecal incontinence. Dis Colon Rectum 1999; 42:252-7. [PMID: 10211504 DOI: 10.1007/bf02237137] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to report pilot data comparing the morbidity and functional outcome of total pelvic floor repair with gluteus maximus transposition for women with postobstetric fecal incontinence. METHODS This is a prospective, randomized trial of two surgical procedures in 24 women so far. Functional assessment was performed with use of a 20-point clinical incontinence score and patient questionnaire before and after operation. The physiologic parameters, before and after operation, included resting and squeeze anal pressures, length of the high pressure zone, anal and rectal mucosal sensitivity, and pudendal nerve latency. RESULTS So far, 12 patients have been treated by total pelvic floor repair and 12 by gluteus maximus transposition. Of these, three patients developed wound complications after gluteus maximus transposition compared with none after total pelvic floor repair. Among these cases there was a significant overall improvement in functional score (given as mean +/- standard deviation) after both total pelvic floor repair (13.1 +/- 2.7 vs. 6.6 +/- 4.5; P < 0.001) and gluteus maximus transposition (13.8 +/- 3.8 vs. 7.7 +/- 6.1; P < 0.01), although no difference existed between the groups. There was no change in any of the physiologic measurements after either operation, and preoperative measurements did not identify patients likely to do badly. CONCLUSIONS We conclude from these preliminary data that both total pelvic floor repair and gluteus maximus transposition significantly improve continence in women with postobstetric neuropathic fecal incontinence. Gluteus maximus transposition gives equivalent results to total pelvic floor repair. Neither procedure has any influence on anorectal physiologic parameters.
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Affiliation(s)
- K Yoshioka
- University Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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SURGICAL ANATOMY OF THE SOMATIC TERMINAL INNERVATION TO THE ANAL AND URETHRAL SPHINCTERS: ROLE IN ANAL AND URETHRAL SURGERY. J Urol 1999. [DOI: 10.1016/s0022-5347(01)62072-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gilliland R, Altomare DF, Moreira H, Oliveira L, Gilliland JE, Wexner SD. Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty. Dis Colon Rectum 1998; 41:1516-22. [PMID: 9860332 DOI: 10.1007/bf02237299] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study assessed the efficacy of anterior overlapping sphincteroplasty and parameters predictive of a successful outcome. METHODS Clinical findings and physiologic investigations of female patients who underwent anterior overlapping sphincteroplasty for fecal incontinence between 1988 and 1996 were reviewed. The extent of sphincter damage was assessed at needle electromyography as the number of quadrants exhibiting decreased motor unit potentials. Prolonged pudendal nerve terminal motor latencies were those of greater than 2.2 ms. The size of the endoanal ultrasound defect was assessed as degrees circumference of the external sphincter in which viable muscle was absent. Patients were reviewed by telephone questionnaire and were asked to grade the outcome of their surgery as excellent or good (success) or fair or poor (failure). Incontinence was graded using a scoring system of 0 (perfect continence) to 20 (complete incontinence). RESULTS There were 100 patients who had an overlapping sphincteroplasty; complete follow-tip information was obtained for 77 patients at a median of 24 (range, 2-96) months. The median age was 47 (range, 25-80) years and they had a median duration of incontinence of four (range, 0.1-39) years. Prior sphincteroplasty had been performed in 30 patients with a median of one (range, 1-7) operations. Investigations performed included electromyography (n = 49), pudendal nerve terminal motor latency (n = 71), endoanal ultrasound (n = 49), and manometry (n = 67). Sixty percent of patients had improved continence and 42 (55 percent) considered their surgery to have been successful as attested to by a significant decrease in their incontinence score (from 15.1 +/- 4.5 to 4.3 +/- 4.2; P < 0.0001). Neither patient age, parity, prior sphincteroplasty, cause or duration of incontinence, extent of electromyography damage, size of the endoanal ultrasound defect, nor any manometric parameter correlated with outcome. However, 62 percent of 59 patients with bilaterally normal pudendal nerve terminal motor latencies had a successful outcome compared with only 16.7 percent of 12 patients with unilateral or bilateral prolonged pudendal nerve terminal motor latencies (P < 0.01). CONCLUSION Bilateral normal pudendal nerve terminal motor latencies are the only factors predictive of long-term success after overlapping sphincteroplasty.
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Affiliation(s)
- R Gilliland
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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Abstract
BACKGROUND Improved imaging and refined technology have led to a number of recent advances in the surgical treatment of faecal incontinence. METHODS Original articles, identified using a computer database (Medline), and recently published abstracts of meetings were selected on the basis of greatest clinical relevance; these were reviewed. RESULTS Ultrasonographic characterization has led to improved therapeutic strategies. Simple structural damage is readily identified and external sphincter repair results in a good outcome for a majority of patients. For more complex structural damage, or for the newly recognized primary internal sphincter degeneration, alternative treatment strategies are emerging. The electrically stimulated gracilis neosphincter and the artificial bowel sphincter offer good results. The latter may be a more simple operation. For structurally intact but weak sphincters, sacral nerve stimulation is a promising therapy. Other therapies, such as antegrade irrigation, may be helpful for patients with neurological disorders. CONCLUSION Better imaging, refined classification and new operations are leading to improved surgical techniques for faecal incontinence.
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van Tets WF, Kuijpers JH. Pelvic floor procedures produce no consistent changes in anatomy or physiology. Dis Colon Rectum 1998; 41:365-9. [PMID: 9514434 DOI: 10.1007/bf02237493] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence. METHOD Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test. RESULTS Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant. CONCLUSION Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.
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Affiliation(s)
- W F van Tets
- Department of Surgery, Lukas-Andreas Hospital, Amsterdam, The Netherlands
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Gee AS, Durdey P. Preoperative increase in neuromuscular jitter and outcome following surgery for faecal incontinence. Br J Surg 1997. [DOI: 10.1002/bjs.1800840920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Gee AS, Durdey P. Preoperative increase in neuromuscular jitter and outcome following surgery for faecal incontinence. Br J Surg 1997. [DOI: 10.1046/j.1365-2168.1997.02786.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Körsgen S, Deen KI, Keighley MR. Long-term results of total pelvic floor repair for postobstetric fecal incontinence. Dis Colon Rectum 1997; 40:835-9. [PMID: 9221863 DOI: 10.1007/bf02055443] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18-78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.
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Affiliation(s)
- S Körsgen
- University Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Deen KI, Kumar D, Williams JG, Grant EA, Keighley MR. Randomized trial of internal anal sphincter plication with pelvic floor repair for neuropathic fecal incontinence. Dis Colon Rectum 1995; 38:14-8. [PMID: 7813338 DOI: 10.1007/bf02053851] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This study was designed to examine the role of adjuvant internal anal sphincter plication in women with neuropathic fecal incontinence undergoing pelvic floor repair. METHODS We completed a randomized trial with symptomatic and physiologic assessment before and after surgery. RESULTS There was no symptomatic advantage of adding internal sphincter plication; the mean improvement of functional score was 3.61 +/- 1.82 (standard deviation; P < 0.01) following pelvic floor repair alone compared with 2.80 +/- 1.66 (standard deviation; P < 0.01) when adjuvant internal and sphincter plication was added. The addition of internal sphincter plication was associated with a significant fall in maximum anal resting and squeezing pressures (P < 0.01). CONCLUSIONS Addition of internal sphincter plication is not advised in women with neuropathic fecal incontinence treated by pelvic floor repair.
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Affiliation(s)
- K I Deen
- University Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Deen KI, Oya M, Ortiz J, Keighley MR. Randomized trial comparing three forms of pelvic floor repair for neuropathic faecal incontinence. Br J Surg 1993; 80:794-8. [PMID: 8330179 DOI: 10.1002/bjs.1800800648] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A randomized controlled trial in women with neuropathic faecal incontinence compared total pelvic floor repair (n = 12) with anterior levatorplasty and sphincter plication alone (n = 12) and postanal repair alone (n = 12). Review at 6 and 24 months indicated that results were significantly better for total pelvic floor repair than either of the other procedures. Complete continence was achieved in eight of the 12 patients 2 years after total pelvic floor repair. Only total repair significantly elongated the anal canal. Both total pelvic floor repair and anterior levatorplasty improved sensation in the upper anal canal.
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Affiliation(s)
- K I Deen
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
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