Patient Selection

Baseline evaluation of symptoms described by a patient presenting with FI is fundamental in order to establish severity of continence dysfunction and its impact on the patient's lifestyle. Usually, this can be derived from a clinical assessment (including clinical history and physical examination), as well as from the evaluation of a diary kept by the patient concerning normal bowel movements and episodes of FI, specifying which kind of material has been lost (gas, liquid, solid stool). Frequency, circumstances, and the patient's sensations and attempts to avoid leakage before and during stool passage, are of interest.

Clinical features allow the physician to establish an FI score according to different available scales. Thereafter, more information about the pathophysiology of FI can be gleaned from instrumental examination, including anorectal manometry (ARM) and sensory testing, endoanal ultrasound (EAUS), anorectal elec-trophysiology (AREP), magnetic resonance (MR), and defecography.

Instrumental assessment is worthwhile because clinical findings alone are not sufficient to correctly plan treatment. Ternent et al. [1] found that using ARM, EAUS, and pudendal nerve terminal motor latency (PNTML) changes the treatment plan in 20% of patients. This tendency was confirmed by the same group of researchers [2] on 90 patients submitted initially to a clinical evaluation from which a pretest therapeutic plan was documented (medical for 45 patients, surgical for 45 patients). Thereafter, ARM, EAUS, and PNTML were performed, and a posttest management consensus was reached. In 10% (nine patients), a change of treatment plan was observed after the physiological tests (from medical to surgical in five patients; from surgical to medical in three patients; change of surgical procedure in one patient). Within patients assigned to a pretest medical treatment, EAUS was the only anorectal test significantly responsible of changing the strategy: among patients indicated for pretest surgical approach, EAUS and PNTML prompted the variation. In a similar study performed at our institution in 2002 involving 63 patients (unpublished data), we found that clinical features alone were unable to indicate treatment in 25 patients (39.7%), whereas after ARM, EAUS, and AREP, these "undefined" patients were assigned to medical treatment in 13 cases and to surgery in 12 cases. For the entire group of patients, including those "undefined," a disagreement between pretest and posttest treatment plan was found in 30 cases (47.6%). In five patients (7.9%), there was a change of pretest approach (from medical to surgical in two; from surgical to medical in three). Numerous other studies have supported the integration of clinical assessment and physiological tests to improve the understanding of FI and patient treatment selection [3-6].

Medical Treatment

Medical treatment includes diet, drugs, supportive measures, rehabilitation, and biofeedback. They are usually chosen for either "elective" reasons or for patients who cannot be treated by a surgical approach. Specifically, poor clinical conditions limiting anesthesia and/or surgery could be valid criteria for a nonoperative approach, whereas a patient's age could be only relatively limiting. On the other hand, psychological problems or disturbances should suggest avoidance of very complex surgical procedures that require patient compliance. Specific bowel diseases (chronic inflammatory diseases; irritable bowel syndrome) with uncontrolled symptoms should contraindicate a major surgical approach. When life-threatening clinical conditions are involved (evolving diseases; chronic diseases; neoplasms not radically treated), the choice of treatment should consider the patient's life expectancy and the possible benefits in quality of life.

"Elective" indication for medical therapy should include minor FI without physiologic or morphologic alterations; in cases with minor abnormalities, a medical approach could be considered as a first-line intervention. Also, individuals with continence dysfunctions related to altered feces quality (i.e., diarrhea) should be expected to gain benefit from a conservative treatment approach. In this area, the patient must be advised to improve perianal hygiene, carefully use absorbent cotton diapers and tampons, and reduce or avoid foods that induce loose stools and increase gastrointestinal transit and gas production (milk derivates; legumes; excess fiber). Diarrhea needs to be fully investigated and, consequently, treated with medication when appropriate. Specific drug treatment has to be initiated in cases of chronic bowel disease. Also, the pathophysiology of soiling should be fully elucidated to determine between operative and nonoperative treatment; when it is minor, occasional, or without either significant physiologic dysfunction or sphincter lesions, a conservative approach can be attempted using postevacuation irrigating water enema or anal plugs as supportive measures.

Pelvic floor rehabilitation, including biofeedback, kinesitherapy, sensory retraining, and electrostimu-lation, is frequently regarded as a first-line treatment for FI. However, disagreement exists about indications for rehabilitative techniques. Lack of standardized methods makes it difficult to compare results of this approach, even in patients accurately selected. Moreover, in the limited number of well-conducted studies, there is no agreement concerning outcome parameters to measure or predict therapy outcome [7, 8]. A rational modulation of the algorithm for rehabilitation could play a key role for therapy success. Patient compliance and good psychological status are preliminary requirements for rehabilitation, being predictors of therapy success [9,10]. Selection criteria cannot be based on anal pressures [11-14], whereas altered threshold and rectal urgency sensations have been found to be predictive of a positive treatment response [7, 14-16]. Sensory retraining could be used both in individuals with reduced rectal sensation and in patients with very high sensory levels [16-18]. Although controversies exist about the outcome predictive value of PNTML in individuals undergoing rehabilitation [7, 8, 13], its alteration seems to be regarded as a predictor of negative response [7, 8]. However, an external anal sphincter defect is not an absolute negative predictor of success [7, 8,19]. Biofeedback, electrostimulation, and kine-sitherapy could be scheduled in patients with such a defect.

Surgical Treatment

Until the recent past, in cases of intractable severe FI, criteria for selecting patients to surgical treatment concerned sphincter lesions or pudendal neuropathy with perineal descent and altered anorectal angle. In the former condition, a sphincteroplasty was indicated in cases of limited lesion without PNTML alteration, whereas a sphincter replacement operation (dynamic graciloplasty, artificial sphincter, gluteo-plasty) was indicated when a wide lesion, fragmented sphincters, or failure of previous sphincteroplasty occurred. In the latter condition, a postanal repair was indicated. Recently, other therapies have been more widely used, such as injectable bulking agents or the recently introduced radiofrequency. Since 1995, sacral nerve stimulation (SNS) has been introduced into the panorama of treatment options, determining a significant rearrangement of selection criteria.

Sphincteroplasty

Sphincter lesions due to obstetric trauma (third- and fourth-degree tears) have traditionally been submitted electively to sphincteroplasty. This technique can be performed by edge-to-edge approximation or overlapping of the external anal sphincter (Fig. 1). Immediate repair, at the time of delivery or delayed to 24 h, has been suggested to obtain best results. However, sphincteroplasty can frequently be performed a few decades after childbirth, when the patient presents clinically with FI. Manometric parameters (squeeze pressure; resting pressure; anal canal length) seem not to be useful for patient selection to sphincteroplasty, whereas a pudendal neuropathy, measured by a prolonged PNTML (particularly if bilateral), should be considered as a predictor of poor outcome [20-26]. However, conflicting results are also reported [27-31], attributable to correct definition of PNTML normality, adequate evalu

Sphincter Operation

Fig. 1a-f. Sphincteroplasty. a Perineal incision. b The external anal sphincter is isolated at the level of a scar. c The external anal sphincter is incised at the level of the scar. d The overlapping sphincteroplasty is prepared. e Multiple stitches are placed. f The overlapping sphincteroplasty is completed

Fig. 1a-f. Sphincteroplasty. a Perineal incision. b The external anal sphincter is isolated at the level of a scar. c The external anal sphincter is incised at the level of the scar. d The overlapping sphincteroplasty is prepared. e Multiple stitches are placed. f The overlapping sphincteroplasty is completed ation of pudendal neuropathy when assessed by standard PNTML measurement with St. Mark's electrode, and the role of symmetric pudendal innervation [31]. Although EAUS is determinant today in diagnosing a sphincter tear, ultrasonographic aspects are not considered valid criteria to select patients to this procedure. To improve the long-term results displayed by sphincteroplasty alone, which are sometimes limited [32-34], this operation has been performed within a total pelvic floor repair [35] or with anterior levator-plasty [36]. However, again, anorectal physiological parameters were not predictive of symptom improvement.

ed as part of a total pelvic floor repair in conjunction with anterior levatorplasty.

Postanal Repair

Neuropathic FI associated with perineal descent and without sphincter lesions seems, theoretically, to be the best indication to postanal repair. Unfortunately, no physiological parameters have been found to be indicative for this approach [37-40]. Considering the limited long-term effectiveness of this treatment, patients with these indications could be more effectively approached by other procedures. Indeed, indications for postanal repair have been significantly reduced over time. The procedure has been advocat

Dynamic Graciloplasty, Artificial Bowel Sphincter, Gluteoplasty

These procedures must be regarded as major sphincter replacement operations, dedicated only to patients with very severe FI due to a wide sphincter lesion (more than half the circumference) or fragmented sphincters not amenable to neither sphinc-teroplasty or other surgical approaches (i.e., SNS). In case of failure of previous sphincteroplasty (when there is no indication to redo it), which is not suitable for SNS, these techniques can also be indicated. Moreover, if severe FI is consequent to neuropathy or anorectal malformations, one of these operations could be performed (specifically, in cases of neuropathy when SNS has failed). Usually, patients present a very low or absent squeeze pressure, which is associated with a decreased or absent resting pressure if an internal sphincter lesion/alteration coexists. When pudendal neuropathy occurs, PNTML could be altered. Dysfunctions of rectal sensations should be regarded as negative predictors of success, as reported in different experiences [41-43]. The

Fig. 2a-f. Dynamic graciloplasty, a skin incision, b gracilis muscle is exposed and c isolated, d perianal tunnel is prepared, e gracilis muscle has been transposed in perianal space and a "gamma" loop is prepared, f the electrostimulator (connected to the electrodes implanted close to the nerve pedicle of the gracilis muscle) is placed in a subfascial pocket at the level of the rectum abdominis muscle

Fig. 2a-f. Dynamic graciloplasty, a skin incision, b gracilis muscle is exposed and c isolated, d perianal tunnel is prepared, e gracilis muscle has been transposed in perianal space and a "gamma" loop is prepared, f the electrostimulator (connected to the electrodes implanted close to the nerve pedicle of the gracilis muscle) is placed in a subfascial pocket at the level of the rectum abdominis muscle

Fig. 3a-f. Sacral nerve stimulation, a patient's position in the operating room, b following local anesthesia, a needle is inserted through the right third sacral foramen, c a needle has been inserted into the left third sacral foramen, and the electrode introducer has been placed through the right third sacral foramen; a permanent quadripolar electrode is shown, d insertion of the permanent quadripolar electrode through the introducer, e bilateral placement of permanent electrodes into the right and left third sacral foramina, f subcutaneous placement of the electrostimulator. Reprinted with permission from [88]

Fig. 3a-f. Sacral nerve stimulation, a patient's position in the operating room, b following local anesthesia, a needle is inserted through the right third sacral foramen, c a needle has been inserted into the left third sacral foramen, and the electrode introducer has been placed through the right third sacral foramen; a permanent quadripolar electrode is shown, d insertion of the permanent quadripolar electrode through the introducer, e bilateral placement of permanent electrodes into the right and left third sacral foramina, f subcutaneous placement of the electrostimulator. Reprinted with permission from [88]

only major contraindications to the sphincter replacement procedures are very severe chronic bowel diseases causing intractable defecation dysfunctions (severe diarrhea as well as severe constipation) and coexistence of rectal prolapse, intussusception, rectocele, or enterocele.

Although indications for dynamic graciloplasty (Fig. 2), artificial bowel sphincter, and gluteoplasty overlap, there are various differences between them concerning surgeon preference and expertise, techniques and materials used, evaluation of perioperative morbidity, and long-term results [44-56]. These aspects are treated in details in other chapters in this book. It must be noted that because all outcome variables can reach very poor or very good levels primarily in relation to correct indications and surgeon expertise, it seems reasonable that these operations must be performed by surgeons dedicated to the management of severe FI.

Sacral Nerve Stimulation

SNS now plays a central role in the algorithm of FI management (Fig. 3). Even if of recent clinical application in anorectal dysfunction [57], this approach has rapidly expanded, and step by step, acceptable indications have been suggested. Initial applications concerned patients with dysfunctions of nonlesioned striated anal muscles, then with a prevalent neuro-genic etiology [58-64]. Thereafter, as clinical use and understanding of action mechanisms made progress, SNS expanded to other indications, including idio-pathic sphincter degeneration, iatrogenic internal sphincter damage, partial spinal cord injury, sclero-derma, limited lesions of internal or external anal sphincters, rectal prolapse repair, and low anterior resection of the rectum [65-78]. Actually, alterations of the sacrum or skin in the implantation area, very wide sphincter tears, pregnancy, and very severe uncontrolled chronic bowel diseases are regarded as the main contraindications for SNS.

A variety of physiological patterns has been observed at patient presentation, and, in most studies, none of these parameters has been elucidated as a prognostic indicator of outcome. Alterations of any one manometric parameter did not contraindicate this therapy. Variations of rectal sensation between baseline to postimplant toward normal range seem to be related to better results, despite whether baseline values were higher or lower than normal [79,80]; this would demonstrate the "modulation" effect of SNS.

Fig. 4a-f. Implantation of a new bulking agent for fecal incontinence (FI), the Anal Gatekeeper (Medtronic, Inc., Minneapolis, MN, USA), a endoanal ultrasound (EAUS) of a patient with FI following rectal prolapse previously repaired with Delorme procedure, b following locoregional anesthesia (perineal block), insertion of the introducer through a small skin incision to reach the intersphincteric space; introducer site should be confirmed by EAUS, c placement of the thin solid prosthesis through the introducer to reach the intersphincteric space, followed by removal of the introducer, d final check by EAUS, e coronal and f longitudinal views of EAUS 6 months after four prostheses implant; in 24 h, each prosthesis became thicker and very soft

Fig. 4a-f. Implantation of a new bulking agent for fecal incontinence (FI), the Anal Gatekeeper (Medtronic, Inc., Minneapolis, MN, USA), a endoanal ultrasound (EAUS) of a patient with FI following rectal prolapse previously repaired with Delorme procedure, b following locoregional anesthesia (perineal block), insertion of the introducer through a small skin incision to reach the intersphincteric space; introducer site should be confirmed by EAUS, c placement of the thin solid prosthesis through the introducer to reach the intersphincteric space, followed by removal of the introducer, d final check by EAUS, e coronal and f longitudinal views of EAUS 6 months after four prostheses implant; in 24 h, each prosthesis became thicker and very soft

Prolonged PNTML, previously considered a negative prognostic factor for treatment success, now is regarded, per se, as a noninfluencing indicator. Other studies have underlined the influence of SNS on the central nervous system [81, 82], explaining why this approach could be effective in partial spinal cord lesions but ineffective in cases of total lesions. Very recently, Gourcerol et al. [83] investigated prognostic factors associated with SNS success during temporary and definitive stimulation. They found that only patient age was prognostic of outcome during temporary test, whereas bulbocavernosus reflex latency was the only factor influencing success after definitive device implantation. In their opinion, patients with neurogenic FI should be candidates for SNS.

Injectable Bulking Agents

This treatment approach is regarded as attractive because it is not invasive. However, only a very accurate patient selection can allow positive effects of bulking agents on FI. Usually, patients with either limited inter nal sphincter lesion or a weak anus without tears are indicated to this kind of treatment. Moreover, individuals who cannot be submitted to other major surgical approaches due to their poor general clinical conditions could be amenable to injection of bulking agents. The increasing variety of agents proposed and used (Fig. 4) to create a bulking effect, with different methods of injection (through anal mucosa or transsphincteric), different placement sites (submucosal or intersphinc-teric), and different check procedures (digital examination or EAUS), have determined criteria incomparable for selecting the most appropriate approach [84].

Radiofrequency

This therapy also seems to be indicated in individuals with weak anal sphincters, but lesions contraindicate its use, as does chronic diarrhea, inflammatory bowel disease, or anal sepsis. Due to the recent clinical application [85-87] and lack of large studies, it is not possible, at this time, to determine stricter selection criteria.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

Get My Free Ebook


Post a comment