alfonso carriero, md pelvic floor center, montecchio emilia, re coordinatore unità di...
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ALFONSO CARRIERO, MDALFONSO CARRIERO, MD
Pelvic Floor Center, Montecchio Emilia , RECoordinatore Unità di Colon-Proctologia, Modena-Reggio Emilia
Montecatini Terme, 28.05.2005
Incontinenza fecaleQuando operare e Risultati
ACOI XXIV Congresso Nazionale
Fecal IncontinenceEtiology
Altered stool consistency Inadequate reservoir capacity or compliance Inadequate rectal sensation Overflow incontinence Abnormal sphincter mechanism or pelvic floor Pelvic Floor denervation Congenital abnormalities Miscellaneous (aging, rectal prolapse) IDIOPATHIC
Fecal Incontinence Preoperative assessment
Anorectal Physiologic Studies
Sphincter muscles - electrical activity (denervation, paradoxical contraction etc.)
Sphincter mapping (sphincter disruption, congenital defects)
Measurement of striated muscle function (Biofeedback Therapy Training)
Pudendal nerve function (neurogenic incontinence)
SPHINCTEROPLASTYPNTML & Neuropathy
Is PNTML reliable in predicting poor outcome ?
• difficult to quantify neuropathy
• cut-off value
• value of unilateral prolonged latency
• no negative predictive value
• Patient selection is critical
• Medically manage those with minimal symptoms or poor surgical candidates (risk or outcome)
• Surgery reserved for those with repairable, neurologically intact sphincter
Management of Fecal Incontinence
Management of Faecal Incontinence
Normal anatomy
Biofeedback
Isolated sphincter defect
Sphincter repair
Multifocal sphincter defect
Neosphincter procedure
Dynamic graciloplasty Artificial anal sphincter
Baig M.K, Wexner S.D.: Factors predictive of outcome after surgery for fecal incontinence. Br J Surg 2000; 87: 1316-1330.
Biofeedback
Sacral nerve stimulation
Surgical Management
• Sphincter Repair
• Post-anal repair
• Direct apposition
• Overlapping sphincteroplasty
• Construction of Neosphincters:
• Stimulated Graciloplasty
• Gluteoplasty
• Artificial Bowel Sphincter (ABS)
Surgical ManagementOther Procedures
• Biofeedback• Sacral Nerve Stimulation• Procon• Secca • Perineal sling• Durasphere – PTP • Malone Antegrade Enema• Ostomy ?
Faecal IncontinenceFaecal IncontinenceFaecal IncontinenceFaecal IncontinenceBiofeedback and/or sphincter exercises for the
treatment of faecal incontinence in adults (Cochrane Review)
Reviewers' conclusions
The limited number of identified trials together with their methodological weaknesses do not allow a reliable assessment of the possible role of sphincter exercises and biofeedback therapy in the management of people with faecal incontinence.There is a suggestions that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, but this is not certain. Larger well-designed trials are needed to enable safe conclusions.
Norton C, Hosker G, Brazzelli M. The Cochrane Library, Issue 3 2002. Oxford: Update Software.
Faecal Incontinence PostAnal Repair - Results
Authors Year N. Of Cases Successful (%)
Parks 1983 42 81
Henry and Simson 1983 204 58
Habr-Gama 1986 42 52
Scheuer 1989 39 43
Orrom 1991 17 59
Engel 1994 38 50
Mavrantonis 1998 21 35
Overlapping Sphincter Repair TECHNIQUE
Faecal incontinenceComparison of surgical procedures
Cochrane Incontinence Group Trial Register
Cochrane Controlled Trials Register Medline Br J Surg; DCR 1995-1998
Anterior levatorplasty Post-anal repair Total pelvic floor
repair
“All trials excluded women with anal defects”
No differences in the primary outcomes were detected
Primary outcomes: deterioration in incontinence, failure to achieve full continence, presence of faecal urgency.
Bachoo P et al: Surgery for faecal incontinence in adults. Cochrane Database Syst Rev 2000; CD001757
Factors Affecting Outcome of Overlapping Sphincter Repair
• Diverting stoma: No effect (Hasegawa 2000, Sitzler
1996, Young 1998) Negative (Nikiteas 1996)
• Obesity: No effect (Hull 2001) Negative (Nikiteas 1996)
• Anal canal length post op: Positive (Hool 1999)
• Age: No Effect (Hull 2001, Simmang 1994, Young 1998) Negative (Ctercteko 1988, Nikiteas 1996)
Factors Affecting Outcome of Overlapping Sphincter Repair
• Duration of incontinence until repair: No effect (Hull 2001) Negative (Ctercteko 1988)
• Increased PNTML: Negative (Young 1998, Engel
1994, Gilliland 1998) Still shows improvement (Chen 1998)
• Bilateral increased PNTML worse than unilat: (Terenent 1997)
Long-Term Results Of Overlapping Sphincter Repair
48%33%
19% 28%49%
23%
3 months n=86 40 months n=74
Karoui et al. DCR June 2000
IncontinentIncontinent to gasContinent
• Prospective• EAS defect by ELUS• Poor results assc with
IAS injury
Long-Term Results Of Overlapping Sphincter Repair
89%
11%
77 months n=38
Malouf, Lancet Jan 2000IncontinentIncontinent to gasContinent
• 76% continent of solid and liquid stool av 15 mos postop
• 36% new evacuation disorder after sphincter repair
Long Term Outcome Following Overlapping Sphincter Repair
Why poor long term results?
o ELUS not done to assess adequate initial repair
o Normal aging of these women’s muscles?
o Some think fibrosis is more pronounced in these women and affects the results
• Long term results of overlapping sphincter
repair may not be as good as previously
assumed
• Anterior repair if defect is found
• Repeat ELUS to look for persistent defect: if
found re-repair
• Those not candidates for new treatments:
consider stoma
Overlapping Repair: WHEN TO DO IT
Optimal conditions for Sphincter Repair
Preoperative No previous repair Scar present Bilateral intact pudendal nerves Normal rectal sensation Young patient
Intraoperative Overlapping scar Increased resting and squeeze pressure Increased high pressure zone
Levator Repair– Total Pelvic Floor Reconstruction: WHEN TO DO IT
Procedure has not gained popularity in world literature
ELUS: if anterior defect—repair
If pudendal neuropathy add ant levatorplasty
If fails—repeat ELUS—if defect present re-repair
If no defect—post anal repair
If nerve injury and no defect on ELUS—total pelvic floor reconstruction
With TPF repair warn of dyspareunia (42%)
Faecal IncontinenceStimulated Graciloplasty
Multicenter trial – 7 Institutions
64 Patients (17M, 47F) (median age 44.5 years, range 15-76)
Etiology: obstetric injury 22 Iatrogenic damage 8 Perineal trauma 6 Pudendal neuropathy 10 Proximal Neur. Defect 6 Congenital
7 Previous proctocolectomy 3 Cong. Int. sph. Absence 1 Isolated sph. Myopathy 1
(Mander BJ….Romano G et al., Br. J. Surg 1999)
Faecal IncontinenceStimulated Graciloplasty
InitialGood Functional Results 44 (77%)(Mild evacuatory disorders 7)
Median of 10 (range 1-35) monthsafter stoma closureGood functional results 29 (56%)
-Evacuatory problems 5-Technical Failure 5- Death 1-Awaiting Replacement 1- Lost of follow-up 3
(Mander BJ,… Romano G et al., Br. J. Surg. 1999)
Long term efficacy of Dynamic Graciloplasty for Fecal Incontinence
Indications– End stage– Failed medical-surgical treatment
Methods– Success : decrease in > 50% in frequency of incontinent episodes– Physiologic parameters– QOL (SF-36,VAS,FITS)
Results– Pt. 115 ( 27 with preexisting stoma)
– 12 Months 18 Months 24 Months
» No Stoma 62% 55 % 56%» Stoma 37.5 62% 43%
Wexner SD.,Baeten C, Bailey R, Bakka A, Belin B et al : Long term efficacy of Dynamic Graciloplasty for Fecal Incontinence, DCR,2002,45,809-818
Wexner SD.,Baeten C, Bailey R, Bakka A, Belin B et al : Long term efficacy of Dynamic Graciloplasty for Fecal Incontinence, DCR,2002,45,809-818
Faecal IncontinenceIndication for ABS
Ano-Rectal trauma 30 % Obstetric 30 % Surgery 5 % Congenital defect 19 % Prolapse 11 % Neurogenic (no previous surgery) 5%
37 Patients
Parker SC et al:Artificial bowel sphincter – Long Term experience at a single institutionDCR, 2003, 46, 722-729
Faecal IncontinenceResults - ABS
N.° Pt Explant. Revision
Reimpl.
CCF AMSS Reduction Follow-up
Lehur
2002
16 4 (25%) 1 (6%) 17
4.5
105
23
78% 25
Vaizey
1998
6 1 (17%) 0 19.5
4.5
n.v. 77% 10
O’Brein
2000
13 3 (23%) 0 18.7
2.1
n.v. 89% 13
Altomare
2001
28 5 (18%) 0 14.9
2.6
98
5.5
94% 19
O’ Brein et al: A prospective,randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinenceDCR, 2004, 47, 1852-1860
Faecal IncontinenceIndication for SNS
Idiopathic 11.6%Obstetric 11.2%Surgery 10.5%
(fistula,hemorrhoidectomy,SLS,rectopexy,etc. )Scleroderma 1.8%Spinal cord trauma 7.1%Low anterior rectal resection 12.4%
266 Patients
Jarrett MED et al: Systematic review of sacral nerve stimulation for faecal incontinence and constipation, BJS, 2004, 91, 1559-1569
Faecal IncontinenceResults - SNS
Temp. Perm. CCF FI epis. week
Fully cont.
> 50% improv.
Follow-up
Jarret
2004
59 46 (78%)
14
6
7
1
41% 96% 12
Leroi
2001
11 6
(55%)
n.v. 3
0.5
50% 75% 6
Matzel
2003
16 16
(100%)
17
5
6.2
0 (?)
75% 94% 32.5
Rosen
2001
20 16
(80%)
n.v. 2
0.6
n.v. 100% 15
Uludag
2002
44 34
(77%)
n.v. 8
0.6
50% 95% 11
Ganio
2003
116 31
(26.7%)
14.6
4.2
7.5
0.15
n.v. n.v. 25.6
Jarrett MED et al: Systematic review of sacral nerve stimulation for faecal incontinence and constipation, BJS, 2004, 91, 1559-1569
Faecal IncontinenceIndications and Results for SECCA
Idiopathic 50 % Obstetric 10 % Surgery 40 %
CCF – FI 13.8 to 7.3
FIQL
Life-style 2.3 to 3.3
Coping 1.7 to 2.7
Depression 2.4 to 3.4
Embarassment 1.5 to 2.4
SF-36
Social function 50 to 82.5
Mental component 38.8 to 48.1
Follow-up 24 months
Takahashi T et al:Extended two year results of Radio-Frequency energy for thr treatment of fecal incontinence ( the SECCA procedure) DCR, 2003, 46, 711-715
Conclusion Multiple techniques exit
With the use of ELUS defects can be delineated and a defect should be repaired
With no defect: some will benefit from post anal repair or total pelvic floor repair
Selection of who will benefit is not clear
Many will be candidates for new procedures