World J. Surg. 16, 820-825, 1992
World Journal of Surgery @ 1992 by the Soci~t~ lntemationale de Chirurgie
Fecal Incontinence: Indications for Repairing the Anal Sphincter F. Penninckx, M.D., Ph.D. Department of Abdominal Surgery, University Clinics Gasthuisberg, Katholieke Universiteit Leuven, Belgium Incontinent patients should be comprehensively investigated by objective tests, especially manometry, continence tests, and electromyography. Manometry can be used to predict the functional outcome and to calibrate the sphincter repair. Pure anatomical defects of the anal and pelvic musculature deserve surgical correction with or without overlapping the muscle ends. If the repair is delayed it should be done after a 3 month interval. A protective colostomy has to be performed in complex cases and in cases with septic complications. Before closing the colostomy, the ano-rectal function should be assessed. Acceptable continence can be restored in the majority of the patients, the outcome depending on the extent of local defects and the severity of concomitant pelvic floor neuropathy. Skeletal muscle transposition remains an esoteric approach to be used only in selected patients; the implantation of a neuromuscular stimulator seems to be warranted. In the presence of important functional deficits, sphincter repair may create a situation where additional conservative measures become more effective. A post-anal repair may be considered 3-12 months after rectopexy or sphincter repair. Incontinence based on pure functional defects is initially treated conservatively. A post-anal repair may improve the situation in two thirds of the patients but fails to help those who need it most, Failure seems to be related to a continuing ncuropathic process. A peri-anal prosthetic band implant may be a valuable alternative in such patients. A sigmoidostomy is a measure of last resort. The prevention of fecal incontinence is most important and concerns surgeons, obstetricians, and physicians.
Fecal continence is based upon many functional structural factors: normal stool consistency, a compliant rectal reservoir, adequate rectopelvic sensation and anorectal angulation, and a high pressure sphincter barrier that can be heightened by reflex and voluntary contraction. This should be accompanied by normal anal sensation and anal cushions. From a clinical point of view anorectal abnormalities may have anatomical or functional origins or both, The major causes of anal sphincter impairment are obstetric trauma or laceration associated with vaginal delivery; trauma from anal operations, road accidents, or sexual abuse with anal assault; congenital malformations; local infection, mainly suppurative processes; and generalized, spinal, caudal or peripheral neurological problems, e.g,, pudendal neuropathy. Appropriate and effective management is available to treat many of the disorders of continence. However, its success depends on careful pre-operative evaluation followed by surgiReprint requests: Professor Dr. F. Penninckx, University Clinics Gasthuisberg, Department of Abdominal Surgery, Herestraat 49, B-3000 Leuven, Belgium.
cal expertise in handling the various contributing factors. The striated pelvic and peri-anal musculature is essential to the control of feces, but true normal as opposed to "socially acceptable" continence requires a persistently tonic internal sphincter and the presence of a normal anal epithelial lining including hemorrhoidal cushions to fill the gap within the sphincteric ring. Thus, the presence and function of all components of anorectal continence have to be assessed, because the aim of anal sphincter repair should be not only to restore the anatomy to normal, but also to restore or at least improve function in the sense of promoting the regaining of continence. Pre-Operative Investigations
A questionnaire and a checklist of physical signs are very useful and preclude ambiguity and incompleteness [1]. Subjective complaints can be labelled as: incontinence for flatus only; incontinence for flatus, mucus and/or liquid stools but not for solids; incontinence for solid stool but socially acceptable, i.e., occasional incontinence manageable by pads, assisted by drugs and enemas; incontinence for solids with social isolation because of gross soiling. Pseudo-incontinence due to fecal overspill as a result of rectal impaction has to be differentiated from partial or complete incontinence. For medical accuracy patient continence also has to be measured [2, 3]. The need for objectivity is evident if one considers that the same moderate anal disorder can be overplayed by one patient and under-played by another, and that a more subtle functional deficit may pass unrecognized because fecal consistency is normal. This explains why clinical symptoms frequently do not correlate with objective data. Nevertheless, a carefully obtained history and physical examination are very important in planning further investigations and the therapeutic approach to the problem. Tests to assess the different mechanisms of incontinence are summarized in Table 1. These investigations also permit exact assessment of the effect of any kind of therapy. For this reason every incontinent patient seeking specialist advice and treatment should be comprehensively investigated by objective tests. Moreover, medico-legal aspects of anorectal trauma from whatever origin warrant objective and complete documentation of the pre-operative functional state. Unfortunately, some aspects of anorectal function cannot be evaluated objectively
F. Penninckx: Repair of Anal Sphincter
Table 1. Mechanisms of anorectal incontinence investigations. Abnormality Incontinence for liquids Incontinence for semi-solids/ solids Abnormal rectal compliance Impaired rectal/pelvic sensation Impaired anal sensation Irregularity of anal surface Insufficient sphincter barrier Puborectalis/pelvic floor External sphincter/ puborectalis Internal sphincter "Passive" tissue
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and appropriate
PROBE
0.3
1
1.5
50 120
70 145
2 cm
Appropriate test Rectal saline infusion test Balloon retention test
mmHg
Rectal compliance, proctoscopy Compliance + sensory thresholds Anal sensation test Proctoscopy, US, NMR
100
Evacuation proctography Manometry, elastance, CN-EMG, SF-EMG, US, NMR Manometry, elastance, US, NMR Manometry, elastance
US: Ultrasonography; NMR: Nuclear magnetic resonance scanning; CN-EMG: Concentric needle electromyography; SF-EMG: Single fiber electromyography.
on a simple routine basis and require more sophisticated equipment and expertise than is present in a general surgical department. The planning and rationale of the investigations as Well as the results have to be discussed with the patient so that the complexity of the pathology may be emphasized to avoid disappointment if the outcome does not match the patient's anticipation. This is even more the case if the patient requires re-evaluation and eventual further treatment. Manometry provides mainly smooth internal (IAS) and striated external sphincter (EAS) assessment through the measurement by station pull-through of the intraluminal pressure at rest and during squeeze. These pressure profiles can be measured in several axial directions when using a microtip transducer. Vector symmetry index can expose occult anal sphincter injuries [4]. Reflex contractility during abdominal pressure increase (COugh), the residual pressure after maximum IAS relaxation (induced by balloon distension of the rectum), and anal elastance are also of interest. Elastance and maximum squeeze Values can be obtained while using probes of increasing diameter, e.g., 0.3 to 3 cm. Data obtained by these devices can indicate the magnitude of the gap in an interrupted sphincter ring as well as the dynamic effect that shortening of the sphincter ring would have (Fig. 1). Pre-operative and peroperative rnanometry can thus be used to calibrate the sphincter repair and to predict the functional outcome. Pre-operative assessment by electromyography is mandatory, concentric needle EMG (CN-EMG) for striated sphincter mapping and single fiber EMG (SF-EMG) to establish the evidence of re-innervation indicating partial denervation of striated pelvic or sphincter muscles. Fecal incontinence after Childbirth may be due to either obstetric rupture or muscle denervation or both [6, 7]. Sphincter repair gives excellent results in the absence of denervation. Associated prolapse, internal intussusception, and rectocele can be detected by evacuation proctography. This technique can evaluate the level of the pelvic floor, the anorectal angle, and the length of the anal canal at rest, during contraction, and during straining. Double-exposure and digital substraction defecography permits reliable evaluation of functional parameters
150
50
-_2
0 MABP MAC
25 60
70 m m H g 130 m m H g
NC 520929V Fig. 1. Pressure recordings from a patient with an obstetrical sphincter rupture. Pressures were obtained by using a strain gauge of 0.3 cm diameter eventually placed in probes of 1 cm, 1.5 cm, and 2 cm diameter. Anal basal (MABP) and squeeze (MAC) pressures were measured at the level of maximum basal pressure when using the strain gauge in a scar-free area. The MABP and MAC values improve with increasing diameter of the measuring probe until 1.5 cm diameter but no more thereafter. A perfect outcome can be predicted after appropriate sphincter repair in view of the normal pressure values recorded with the 1.5 cm diameter probe.
without the aid of obligatory reference to relevant skeletal parts [5]. Imaging techniques, computerized tomography, nuclear magnetic resonance scanning, and endo-anal ultrasound, are able to document the morphologic characteristics of the anal and pelvic floor muscles. They are reported to be useful in the management of anorectal malformations and associated spinal anomalies, but only anal endosonography has been validated in anal trauma [8]. There is no need for psychiatric screening. Incontinent patients do not differ from controls, but patients who have a bad result after operation have significantly higher pre-operative anxiety and depression scores [9]. This, certainly, is not unique to incontinence. Treatment and Results
General Aspects Pathological conditions of the colon and rectum causing diarrhea must always be excluded or treated first because they may cause incontinence with no sphincteric or pelvic floor lesion. Treatment of anal incontinence has to be directed logically at a cause in the pelvic floor and sphincters whenever possible. Pure anatomical defects of the anus with normal or only slightly disturbed innervation of the striated anal and pelvic musculature deserve direct surgical correction. Treatment of eventual constipation has to be started at least at the time of surgery because abnormal straining will progressively destroy any benefit from the surgery undertaken.
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Anatomical defects may be associated with important functional deficits. In this instance the results of corrective surgery may be imperfect but may nonetheless create a situation where additional conservative therapeutic measures may become more effective, e.g., biofeedback training or bowel management program (BMP). The latter consists of a diet rich in fiber with adequate fluid intake, insertion of a glycerine or bisacodyl suppository 30 minutes after breakfast daily or less often according to the patient's prior bowel habits, attempted defecation 20 minutes later, and the use of stool softeners or bulking or stimulating laxatives. Incontinence based on functional defects is initially treated conservatively. Biofeedback training is used in well selected patients. BMP may be advocated or the bowel emptied by the use of an apparatus similar to colostomy irrigation in combination with constipating drugs. Alpha-adrenergic receptor stimulants and Ioperamide can increase the IAS tone. Anal pacemaking has fallen short of expectations. Surgery should be offered if these measures fail. A postanal repair may improve the situation in about two thirds of the patients by re-arranging the anatomy; this may provide the appropriate conditions for a life-long BMP. It has appeared to some that a band of synthetic material used to encircle the sphincter mechanism is a valid alternative to a postanal repair. A colostomy formed in the sigmoid colon is a last measure and a second opinion may be sought before such a measure is undertaken because it may appear later merely to have transferred the patient's handicap to another site.
Acute Injury Obstetric tears have to be explored carefully. Primary repair should be carried out by apposition of the mucosa or submucosa with 3/0 or 2/0 suture and of the muscle ends with 2/0 or 0 long-term absorbable material in combination with perineal body reconstruction. It is also the procedure of choice for accidental trauma and should follow irrigation and careful wound debridement. Broad spectrum antibiotic therapy and tetanus prophylaxis are mandatory. In patients with complex or severe anorectal trauma the use of a colostomy is indicated.
Delayed Repair of Sphincter Disruption If the repair is delayed it should be done after at least a 3 month interval to allow regression of inflammation and the formation of scar tissue. The procedure has been aptly described by Parks [10]. Scar tissue is removed except for the muscle ends which have to be identified. Both the IAS and EAS muscle ends have to be seen. Coagulation current diathermy facilitates the distinction between these muscles. Normal mucosa is apposed with a continuous suture. The EAS is mobilized but not excessively to avoid neurovascular damage. The muscle ends are apposed or overlapped 1-2 cm. Both techniques have been shown to be of equal benefit [l 1], but overlapping is generally preferred. Peroperative manometry with a small probe is useful in order to calibrate the repair and for the detection and resumption of normal basal tone. Skin and fat are left open to heal by secondary intention. Anterior sphincter tears have to be repaired in the same way but levatorplasty and perineoplasty should be added [12, 13] as
World J. Surg. Vol. 16, No. 5, Sept./Oct. 1992
in posterior colpo-perineorrhaphy. A rectocele is frequently associated with these lesions and dealt with in this way. Acceptable continence can be restored in more than 80% of patients after primary or delayed sphincter repair [11, 14-16]. Patients primarily become continent of solid and semi-formed stools but may have urgency of defecation. Some can control liquid stool or flatus, the outcome depending on the extent of local defects or the severity of concomitant pelvic floor neuropathy [17, 18] and on patient age. Thus the best results are obtained in those patients with better pre-operative function [19]. Anal basal pressure and sphincter strength are reduced after delivery, but return to normal after 3 months in controls. After immediate repair of anal sphincter rupture the basal pressure and sphincter strength are at first reduced, improve over the first 3 months, but no more thereafter [20]. Continence may improve within 1 year as a result of re-innervation. Analysis of anal vector symmetry or imaging techniques may have a role in documenting inappropriate or suboptimal sphincter repair. Postoperative EMG in patients remaining incontinent has demonstrated severe denervation but no muscle discontinuity [I9]. Combined sphincter repair using an overlapping technique and postanal repair has been proposed for the treatment of injuries to the anal musculature and its nerve supply [7, 21]. Muscle transposition has been performed in patients with total incontinence who have no functional anal sphincter. The method is thus far an esoteric approach to be used only in young patients with congenital abnormalities or in those who have sustained severe trauma and in whom several attempts at conservative treatment or conventional operation repair have failed [22]. In these procedures, the sphincter mechanism is supplemented by an intact muscle with its own neurovascular supply. BMP should follow the procedure. Gracilis muscle transposition has been found to be an effective operation by some [22-25] but patients with neurologic impairment and pre-operative bowel management difficulties did less well or even poorly [26]. Others had disappointing results [27] and had to implant a neuromuscular stimulator in order to obtain a controlled sphincter function [28]. Repetitive stimulation of muscle is known to change its characteristics from muscle twitch to muscle tone. Chronic repetitive stimulation may induce the latter. Gluteus maximus muscles, natural synergists of the anal sphincter, may have more therapeutic potential for sphincter replacement but again the use of a skeletal muscle limits the scope of an operation whose effects are lost during sleep, though voluntary day-time control may significantly improve the patient's situation [29-31]. The use of a colostomy must be considered for complex and extended sphincter repair or substitution, these reconstructions involving the whole length of the anal canal, the puborectalis and eventually the rectum. In other cases a colostomy can be prevented with the use of good pre-operative bowel preparation, total parenteral nutrition, and a constipating program for 1 week postoperatively. Colostomy has to be performed in patients with septic complications and the distal bowel has to be washed out. Before closing the co]ostomy, the anorectal function should be assessed so that an eventual secondary procedure can be performed in optimal conditions.
F. Peaninckx: Repair of Anal Sphincter
Idiopathic Fecal Incontinence Postanal repair [32] is the treatment of choice for idiopathic fecal incontinence (IFI) which is mainly caused by pudendal neuropathy, thus by definition having intact sphincters. This operation is also indicated for neurogenic incontinence associated with rectal prolapse or obstetric trauma. In both instances the procedure should be delayed for about 12 months after rectopexy or sphincter repair to allow spontaneous recovery of sphincter function [33] since the first operation may well be satisfactory in the majority of patients. Postanal repair for IFI is associated with good results in one-third of patients, improved incontinence in another one-third, but is followed by failure in the remainder [34, 35]. It is not clear which factors determine the outcome. Previously it was thought that a successful Procedure depended on a reduction of the anorectal angle, an increased anal pressure [13, 34, 36, 37], and increase in sphincter length [34, 38] or improved anal canal sensation [13, 36], but Others have not confirmed these findings (for anorectal angle [36, 39]; for basal pressure ]38--40]; for sphincter length [36]). Over 50% of patients still leak feces from time to time after postanal repair, indicating that the quality of continence achieved is far from optimal [41, 42]. Poor results can be expected in patients with limited pre-operative residual function [38, 39]. Thus the procedure fails to help those who need it most. A significant increase in the pudendal nerve terminal mOtor latency was found in failures, suggesting that there was a continuing neuropathic process [37]. Anterior sphincteroplasty and levatorplasty [13, 43] and especially the modified Thiersch procedure with a peri-anal prosthetic band implant [1, 22, 44, 45] have been reported to be safe, simple, and valuable alternatives to postanal repair. Graellis muscle transposition has been reported as failing comPletely in IFI [46].
POStoperative Care Broad spectrum antibiotic therapy is usually given to patients Undergoing anal repair. A urinary catheter is inserted for 5 days m female patients. Bethanechol and urinary catheterization may be necessary for postoperative urinary retention in males. Inspection of the wound should be made twice daily. The Patient is instructed not to sit for the first 5 days postopera!iVely. An elemental diet or total parenteral nutrition is adminIStered for 5 to 7 days or longer if there are protracted wound dil~culties. A constipating agent such as loperamide or codeine should be administered. After a week, if normal healing is achieved, a normal or high-fiber diet should be resumed with oil laxatives. The patient should have a sitz bath after each bowel movement and cleansing of the wound with an antiseptic. A BMp is instituted so that the patient avoids straining and to Promote confidence in control mechanisms so that the patient naay achieve a form of pseudo-continence if necessary. After l0 to 14 days the skin stitches are removed and the patient is discharged the next day and is re-examined in the out-patient clinic after 3 weeks or earlier, weekly in problem cases. Stenosis has to be prevented or treated to prevent incontinence. Patients are advised to try to obtain easy defecation without excessive straining. For female patients considering future
823
pregnancy Cesarean section delivery is advocated as it does not induce any change in the fiber density of the EAS [47]. New Perspectives
The pre-operative and peroperative use of manometry may in the future help to optimize anal sphincter reconstruction but its benefits have yet to be demonstrated. There are patients who have retained motor function in their sphincters in spite of the absence of spontaneous reflex tone. They may become continent by means of permanent neuroprosthetic implants, e.g., by electro-stimulation of the pudendal nerve [48]. Much is yet to be learned from the efforts being made to construct a neo-rectum and neo-anal sphincters after proctectomy [49-51] but it is hard to conceive that non-sphincteric muscles will ever competently substitute for the anal sphincters, so that a BMP becomes redundant. In the absence of a functional anal sphincter, a magnetic occlusive device [52, 53] as well as the AMS (American Medical Systems) 800 artificial sphincter [54] have been implanted both in primary and reconstructive operations, Prevention
The prevention of fecal incontinence is probably its most important aspect. Surgeons should beware of dividing, dilating, or resetting any component of the ano-rectum or colon without considering the functional consequences. It should be possible to cure 40% of complex anal fistulae without division of the external sphincter [55, 56]. Extensive and prolonged packing of anal wounds has to be avoided as it promotes formation of a thick zone of scar tissue in the anal canal. Obstetricians should avoid difficult childbirth leading to pelvic floor denervation or perineal laceration. Multiparity, forceps delivery, increased duration of the second stage of labor, third degree perineal tear, and high birth weight are important factors leading to pudendal nerve damage [16, 47, 57]. Physicians, too, should be aware that constipation may finally result in pelvic floor denervation and incontinence. R~sum~
L'exploration de I'incontinence anale doit comporter de nombreux examens objectifs et notamment la manom6trie, les tests de continence, et l'61ectromyographie. La manom6trie sert ~t pr6dire l'avenir fonctionnel et ~ calibrer la r6paration sphinct6rienne. Les d6fects anatomiques purs de la musculature anale et pelvienne mfritent une correction chirurgicale avec ou sans suture en paletot des extr6mitfs musculaires. Pour les r6parations en deux temps, I'intervalle s6parant les deux 6tapes devrait 6tre au moins de trois mois. I1 faut fabriquer une colostomie de protection dans certains cas complexes et en cas de complication septique. Avant de proposer la fermeture de la colostomie, il faut r6-fvaluer la fonction ano-rectale. On arrive ~t restaurer une continence acceptable chez la plupart des patients, le r6sultat d6finitif d6pendant surtout de l'importance du d6fect local et de la s6v6rit6 de la neuropathie associ6e du plancher pelvien. La transposition d'un muscle squelettique reste une m6thode esot6rique, ~t n'utiliser que chez certains
824 patients bien sElectionnEs; l'implantation d'un stimulateur neuromusculaire parait justifi6e. En presence d'anomalies fonctionnelles sphinct6riennes importantes, d'autres m6th0des conservatrices sont plus efficaces. Une reparation post-anale est envisager 3 ~t 12 mois apes une rectopexie ou une reconstruction sphinctErienne. L'incontinence, basEe sur des donnEes puremerit fonctionnelles, doit ~tre traitEe d ' a b o r d par des mEthodes conservatrices. Une reparation post-anale peut amEliorer la situation chez deux-tiers des patients, mais g6nEralement ne rEussit pas chez les patients qui en ont le plus besoin. Les Echecs sont surtout en rapport avec la continuation du processus neuropathique. L'implantation d'une proth~se p6ri-anale est une alternative valable darts de tels cas. L a sigmoidostomie est une solution radicale de dernier ressort. La prevention de l'incontinence fEcale est le facteur le plus important et concerne tous tes chirurgiens, obstEtriciens et m6decins. Resumen Los pacientes incontinentes deben ser investigados en forma comprensiva mediante pruebas objetivas, especialmente la mamometrfa, los examenes de continencia y la electromiograffa. L a mamometrfa es de utilidad en la predicci6n del resultado funcional y e n la calibraci6n de una reparaci6n del esf/nter. Los defectos anat6micos puros de la musculatura anal y pglvica merecen correcci6n quirtlrgica con y sin superposici6n de los cabos de los mttsculos. Si se decide posponer la reparaci6n, 6sta debe entonces hacerse tuego de un intervalo de tres meses. En los casos comptejos y en aquellos con complicaciones sEpticas se debe construir una colostomfa protectora; en tales pacientes se debe vaiorar la funci6n ano-rectal antes de proceder con el cierre de la cotostomia. Se puede restaurar continencia de grado aceptable en la mayoria de los pacientes, peroel resultado depende de la magnitud de los defectos locales y de la gravedad de la neuropatfa concomitante del piso pglvico. La transPosici6n del mtisculo esquelEtico sigue representando un aproche esotErico que debe ser usado solamente en pacientes seleccionados; parece justificada la implantaci6n de un estimulador neuromuscular. En presencia de deficits funcionales importantes la reparaci6n del esffnter puede dar lugar a una situaci6n en la cual medidas conservadoras adicionales resultan m~is efectivas. Una reparaci6n post-anal puede ser considerada 3-22 meses despuEs de une rectopexia o de una reparaci6n del esffnter. La incontinencia por defectos funcionales puros es tratada en forma conservadora en un principio, Una reparaci6n post-anal puede mejorar la situaci6n en dos tercios de los pacientes, pero falla en los pacientes que m~is la necesitan. La falla parece estar relacionada con el proceso neuropfitico continuado. Una alternativa vglida puede ser el implante de una banda perianal protgsica. L a sigmoidostomfa es un procedimiento que s61o debe ser emprendido en tlltima instancia. La prevenci6n de la incontinencia fecal es de la m a y o r importancia y concierne a los cirujanos, obstetras e internistas. References 1. Penninckx, F.M., Elliot, M.S., Hancke, E., Henry, M.M., Kodner, I.J., Kuypers, J.H.C., Pemberton, J.H., Schuster, M.M.: Symposium on faecal incontinence. Int. J. Colorect. Dis. 2:173, 1987 2. Read, N.W., Haynes, W.G., Bartolo, D.C.C., Hall, J., Read,
World J. Surg. Vol. 16, No. 5, Sept./Oct. 1992 M.G., Donelly, T.C., Johnson, A.G.: Use of anorectal manometry during rectal infusion of saline to investigate sphincter function in incontinent patients. Gastroenterology 85:105, 1983 3. Penninckx, F.M., Lestar, B., Kerremans, R.P.: A new balloonretaining test for evaluation of anorectal function in incontinent patients. Dis. Colon Rectum 32:202, 1989 4. Perry, R.E., Blatchford, G.J., Christensen, M.A., Thorsen, A.G., Attwood, S.E.: Manometric diagnosis of anal sphincter injuries. Am. J. Surg. 159:!12, 1990 5. Helzel, M.V.: Doppelbelichtungs Def~ikographie nach perinealer Sphinkterplastik. ROFO/49:629, 1988 6. Snooks, S.J., Henry, M.M., Swash, M.: Faecal incontinence due to external anal sphincter division in childbirth is associated with damage to the innervation of the pelvic floor musculature: A double pathology. Br. J. Obstet. Gynaecol. 92:824, 1985 7. Laurberg, S., Swash, M., Henry, M.M.: Delayed external sphincter repair for obstetric tear. Br. J. Surg. 75:786, 1988 8. Law, P.J., Kamm, M.A., Bartram, C,I.: A comparison between electromyography and anal endosonography in mapping external sphincter defects. Dis. Colon Rectum 33:370, 1990 9. Fisher, S.E., Breckon, K., Andrews, H.A., Keighley, M.R.: Psychiatric screening for patients with faecal incontinence or chronic constipation referred for surgical treatment. Br. J. Surg. 76:352, 1989 10. Parks, A.G., McPartlin, J.F.: Surgical repair of anal sphincters following injury. In Operative Surgery: Colon, Rectum and Anus, Ch. Rob, R. Smith, I. Todd, editors, London, Butterworths, 1977, pp. 245-248 !1. Pezim, M.E., Spencer, R.J., Stanhope, C.R., Beart, R.W. Jr., Ready, R.L., llstrup, D,M.: Sphincter repair for fecal incontinence after obstetrical or iatrogenic injury. Dis. Colon Rectum 30:521, 1987 12. Abcarian, H., Orsay, C.P., Pearl, R.K., Nelson, R.L., Briley, S.C.: Traumatic cloaca. Dis. Colon Rectum 32:783, 1989 13. Miller, R., Orrom, W.J., Cornes, H., Duthie, G., Bartolo, D.C.: Anterior sphincter plication and levatorplasty in the treatment of faecal incontinence. Br. J. Surg. 76:1058, 1989 14. Browning, G.G., Motson, R.W.: Anal sphincter injury: Management and results of Parks sphincter repair. Ann. Surg. 199:351, 1984 15. Ctercteko, G.C., Fazio, V.W., Jagelman, D.G., Lavery, I.C., Weakley, F.L., Melia, M.: Anal sphincter repair: A report of 60 cases and review of the literature. Aust. N. Z. J. Surg. 58:703, 1988 16. Haadem, K., Ohrlander, S., Lingman, G.: Long-term ailments due to anal sphincter rupture caused by delivery: A hidden problem. Eur. J. Obstet. Gynecol. Reprod. Biol. 27:27, 1988 17. Browning, G.G., Motson, R.W.: Results of Parks operation for faecal incontinence after anal sphincter injury. Br. Med. J. Clin. Res. 286:1873, 1983 18. Jacobs, P.P.M., Scheuer, M., Kuypers, J.H.C., Vingerhoets, M.H.: Obstetric fecal incontinence: Role of pelvic floor denervation and results of delayed sphincter repair. Dis. Colon Rectum 33:494, 1990 19. Yoshioka, K., Keighley, M.R.: Sphincter repair for fecal incontinence. Dis. Colon Rectum 32:39, 1989 20. Haadem, K., Dahlstrom, J.A., Lingman, G.: Anal sphincter function after delivery: A prospective study in women with sphincter rupture and controls. Eur. J. Obstet. Gynecol. Reprod. Biol. 35:7, 1990 21. Browning, G.G., Henry, M.M., Motson, R.W.: Combined sphincter repair and postanal repair for the treatment of complicated injuries to the anal sphincters. Ann. R. Coll. Surg. Engl. 70:324, 1988 22. Corman, M.L.: Colon and rectal surgery, 2nd edition, Philadelphia, J.B. Lippincott C0., 1989, pp. 171-207 23. Pickrell, K.L.: Gracilis muscle transplant for the correction of neurogenic rectal incontinence. Surg. Clin. North Am. 39:1405, 1959 24. Corman, M.L.: Gracilis muscle transposition for anal incontinence: Late results. Br. J. Surg. 72:$21, 1985 25. Leguit, P. Jr, van Baal, J.G., Brummelkamp, W.H.: Gracilis muscle transposition in the treatment of fecal incontinence: Long-
F, Penninckx: Repair of Anal Sphincter
26. 27. 28. 29. 30. 31.
32,
33. 34. 35. 36. 37. 38. 39. 40. 41.
term follow-up and evaluation of anal pressure recordings. Dis. Colon Rectum 28:i, 1985 Corman, M.L,: Follow-up evaluation of gracilis muscle transposition for fecal incontinence. Dis. Colon Rectum 23:552, 1980 Stelzer, F.: Komplexe Traumen des Perineums, speziell des anorectalen Kontinenzorgans. Erfahrungen und Ergebnisse bei 27 Patienten yon 1956-1988. Langenbecks Arch. Chir. 375:55, 1990 Baeten, C., Spaans, F., Fluks, A.: An implanted neuromuscular stimulator for fecal continence following previously implanted gracilis muscle: Report of a case. Dis. Colon Rectum 31:134, 1988 Prochiantz, A., Gross, P.: Gluteal myoplasty for sphincter replacement: Principles, results and prospects. J. Pediatr. Surg. •7:25, 1982 Skef, Z., Radhakrishnan, J., Reyes, H.M.: Anorectal continence following sphincter reconstruction utilizing the gluteus maximus muscle: A case report. J. Pediatr. Surg. •8:779, 1983 lwai, N., Kaneda, H., Tsuto, T., Yanagihara, J., Takahashi, T.: Objective assessment of anorectal function after sphincter reconstruction using the gluteus maximus muscle: Report of a case. Dis. Colon Rectum 28:973, 1985 Parks, A.G.: Postanal pelvic floor repair (and the treatment of anorectal incontinence). In Operative Surgery: Colon, Rectum and Anus, Ch. Rob, R. Smith, I. Todd, editors, London, Butterworths, 1977, pp. 249-254 Broden, G., Dolk, A., Holmstrom, B.: Recovery of the internal anal sphincter following rectopexy: A possible explanation for continence improvement. Int. J. Colorect. Dis. 3:23, 1988 Browning, G.G., Parks, A.G.: Postanal repair for neuropathic faecal incontinence: Correlation of clinical result and anal canal pressures. Br. J. Surg. 70:101,1983 Keighley, M.R., Fielding, W.: Management of faecal incontinence and results of surgical treatment. Br. J. Surg. 70:463, 1983 Miller, R., Bartolo, D.C., Locke Edmunds, J.C., Mortensen, N.J.: Prospective study of conservative and operative treatment of faecal incontinence Br J Surg. 75:101, 1988 Snooks, S.JI, Swash, M., Henry, M.: Electrophysiologic and manometic assessment of failed postanal repair for anorectal incontinence. Dis, Colon Rectum 27:733, 1984 Womack, N.R., Morrison, J.F., Williams, N.S.: Prospective study of the effects of postanal repair in neurogenic faecal incontinence. Br. J. Surg. 75:48, 1988 Yoshioka, K., Hyland, G., Keighley, M.R.: Physiological changes after postanal repair and parameters predicting outcome. Br. J. Surg. 75:1220, 1988 Scott, A.D.N., Henry, M.M,, Philips, R.K.S.: Clinical assessment and anorectal manometry before postanal repair: Failure to predict outcome. Br. J. Surg. 77:628, 1990 Yoshioka, K., Keighley, M.R.: Critical assessment of the quality of
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42. 43. 44. 45. 46. 47. 48. 49. 50.
51. 52, 53. 54. 55. 56. 57.
continence after postanat repair for faecal incontinence. Br. J. Surg. 76:i054, 1989 Scheuer, M., Kuijpers, H.C., Jacobs, P.P.: Postanal repair restores anatomy rather than function. Dis. Colon Rectum 32:960, 1989 Christiansen, J., Skomorowska, E.: Persisting incontinence after postanal repair treated by anterior perineoptasty. Int. J. Colorect. Dis. 2:9, 1987 Larach, S.W., Vazquez, B.: Modified Thiersch procedure with silastic mesh implant: A simple solution for fecal incontinence and severe prolapse. South. Med. J. 79:307, 1986 Stricker, J.W., Schoetz, D.J. Jr., Coller, J.A., Veidenheimer, M.C.: Surgical correction of anal incontinence. Dis. Colon Rectum 3•:533, 1988 Yoshioka, K., Keighley, M.R.: Clinical and manometric assessment of gracilis muscle transplant for fecal incontinence. Dis. Colon Rectum 3•:767, 1988 Snooks, S.J., Swash, M., Henry, M.M., Setchell, M.: Risk factors in childbirth causing damage to the pelvic floor innervation. Int. J. Colorect. Dis. •:20, 1986 Schmidt, R.A., Kogan, B.A., Tanagho, E.A.: Neuroprosthesis in the management of incontinence in myelomeningocele patients. J. Urol. 143:779, 1990 Ryan, P., Fink, R.: New rectum and new anal canal: Two cases of ileal reservoir-cutaneous anastomosis. Aust. N. Z. J. Surg. 58:161, 1988 Ge, L.Z.: Anal sphincter reconstruction by interposition of an ileo-colonic segment and transposition of musculi glutaeus maximus bundles after resection of anorectal carcinoma. Chung. Hua. Wai. Ko. Tsa. Chih. 27:387, 1989 Williams, N.S., Haltan, R.I., Koeze, T.H., Watkins, E.S.: Construction of a neorectum and neoanal sphincter following previous proctocolectomy. Br. J. Surg. 76:1191, 1989 Willital, G.H., Meier, H.: Der kunstliche Enddarmverschluss, ein neues Konzept in der Behandlung der analen Inkontinenz. 5-Jahres-Ergebnisse. Med. Welt 33:1226, 1982 Fedorov, V.D., Shelygin, Y.A.: Treatment of patients with rectal cancer. Dis. Colon Rectum 32:138, 1989 Christiansen, J., Lorentzen, M.: Implantation of artificial sphincter for anal incontinence: Report of five cases. Dis. Colon Rectum 32:432, 1989 Fazio, V.W.: Complex anal fistulae. Gastroenterol. Clin. North Am. /6:93, 1987 Thomson, J.P., Ross, A.H.: Can the external anal sphincter be preserved in the treatment of trans-sphincteric fistula-in-ano? Int. J. Colorect. Dis. 4:247, 1989 Comes, H., Bartolo, D.C.C.: Effect of vaginal delivery on anal canal sensation. Br. J. Surg. 77:A699, 1990
World Journal of Surgery @ 1992 by the Soci~t~ lntemationale de Chirurgie
Fecal Incontinence: Indications for Repairing the Anal Sphincter F. Penninckx, M.D., Ph.D. Department of Abdominal Surgery, University Clinics Gasthuisberg, Katholieke Universiteit Leuven, Belgium Incontinent patients should be comprehensively investigated by objective tests, especially manometry, continence tests, and electromyography. Manometry can be used to predict the functional outcome and to calibrate the sphincter repair. Pure anatomical defects of the anal and pelvic musculature deserve surgical correction with or without overlapping the muscle ends. If the repair is delayed it should be done after a 3 month interval. A protective colostomy has to be performed in complex cases and in cases with septic complications. Before closing the colostomy, the ano-rectal function should be assessed. Acceptable continence can be restored in the majority of the patients, the outcome depending on the extent of local defects and the severity of concomitant pelvic floor neuropathy. Skeletal muscle transposition remains an esoteric approach to be used only in selected patients; the implantation of a neuromuscular stimulator seems to be warranted. In the presence of important functional deficits, sphincter repair may create a situation where additional conservative measures become more effective. A post-anal repair may be considered 3-12 months after rectopexy or sphincter repair. Incontinence based on pure functional defects is initially treated conservatively. A post-anal repair may improve the situation in two thirds of the patients but fails to help those who need it most, Failure seems to be related to a continuing ncuropathic process. A peri-anal prosthetic band implant may be a valuable alternative in such patients. A sigmoidostomy is a measure of last resort. The prevention of fecal incontinence is most important and concerns surgeons, obstetricians, and physicians.
Fecal continence is based upon many functional structural factors: normal stool consistency, a compliant rectal reservoir, adequate rectopelvic sensation and anorectal angulation, and a high pressure sphincter barrier that can be heightened by reflex and voluntary contraction. This should be accompanied by normal anal sensation and anal cushions. From a clinical point of view anorectal abnormalities may have anatomical or functional origins or both, The major causes of anal sphincter impairment are obstetric trauma or laceration associated with vaginal delivery; trauma from anal operations, road accidents, or sexual abuse with anal assault; congenital malformations; local infection, mainly suppurative processes; and generalized, spinal, caudal or peripheral neurological problems, e.g,, pudendal neuropathy. Appropriate and effective management is available to treat many of the disorders of continence. However, its success depends on careful pre-operative evaluation followed by surgiReprint requests: Professor Dr. F. Penninckx, University Clinics Gasthuisberg, Department of Abdominal Surgery, Herestraat 49, B-3000 Leuven, Belgium.
cal expertise in handling the various contributing factors. The striated pelvic and peri-anal musculature is essential to the control of feces, but true normal as opposed to "socially acceptable" continence requires a persistently tonic internal sphincter and the presence of a normal anal epithelial lining including hemorrhoidal cushions to fill the gap within the sphincteric ring. Thus, the presence and function of all components of anorectal continence have to be assessed, because the aim of anal sphincter repair should be not only to restore the anatomy to normal, but also to restore or at least improve function in the sense of promoting the regaining of continence. Pre-Operative Investigations
A questionnaire and a checklist of physical signs are very useful and preclude ambiguity and incompleteness [1]. Subjective complaints can be labelled as: incontinence for flatus only; incontinence for flatus, mucus and/or liquid stools but not for solids; incontinence for solid stool but socially acceptable, i.e., occasional incontinence manageable by pads, assisted by drugs and enemas; incontinence for solids with social isolation because of gross soiling. Pseudo-incontinence due to fecal overspill as a result of rectal impaction has to be differentiated from partial or complete incontinence. For medical accuracy patient continence also has to be measured [2, 3]. The need for objectivity is evident if one considers that the same moderate anal disorder can be overplayed by one patient and under-played by another, and that a more subtle functional deficit may pass unrecognized because fecal consistency is normal. This explains why clinical symptoms frequently do not correlate with objective data. Nevertheless, a carefully obtained history and physical examination are very important in planning further investigations and the therapeutic approach to the problem. Tests to assess the different mechanisms of incontinence are summarized in Table 1. These investigations also permit exact assessment of the effect of any kind of therapy. For this reason every incontinent patient seeking specialist advice and treatment should be comprehensively investigated by objective tests. Moreover, medico-legal aspects of anorectal trauma from whatever origin warrant objective and complete documentation of the pre-operative functional state. Unfortunately, some aspects of anorectal function cannot be evaluated objectively
F. Penninckx: Repair of Anal Sphincter
Table 1. Mechanisms of anorectal incontinence investigations. Abnormality Incontinence for liquids Incontinence for semi-solids/ solids Abnormal rectal compliance Impaired rectal/pelvic sensation Impaired anal sensation Irregularity of anal surface Insufficient sphincter barrier Puborectalis/pelvic floor External sphincter/ puborectalis Internal sphincter "Passive" tissue
821
and appropriate
PROBE
0.3
1
1.5
50 120
70 145
2 cm
Appropriate test Rectal saline infusion test Balloon retention test
mmHg
Rectal compliance, proctoscopy Compliance + sensory thresholds Anal sensation test Proctoscopy, US, NMR
100
Evacuation proctography Manometry, elastance, CN-EMG, SF-EMG, US, NMR Manometry, elastance, US, NMR Manometry, elastance
US: Ultrasonography; NMR: Nuclear magnetic resonance scanning; CN-EMG: Concentric needle electromyography; SF-EMG: Single fiber electromyography.
on a simple routine basis and require more sophisticated equipment and expertise than is present in a general surgical department. The planning and rationale of the investigations as Well as the results have to be discussed with the patient so that the complexity of the pathology may be emphasized to avoid disappointment if the outcome does not match the patient's anticipation. This is even more the case if the patient requires re-evaluation and eventual further treatment. Manometry provides mainly smooth internal (IAS) and striated external sphincter (EAS) assessment through the measurement by station pull-through of the intraluminal pressure at rest and during squeeze. These pressure profiles can be measured in several axial directions when using a microtip transducer. Vector symmetry index can expose occult anal sphincter injuries [4]. Reflex contractility during abdominal pressure increase (COugh), the residual pressure after maximum IAS relaxation (induced by balloon distension of the rectum), and anal elastance are also of interest. Elastance and maximum squeeze Values can be obtained while using probes of increasing diameter, e.g., 0.3 to 3 cm. Data obtained by these devices can indicate the magnitude of the gap in an interrupted sphincter ring as well as the dynamic effect that shortening of the sphincter ring would have (Fig. 1). Pre-operative and peroperative rnanometry can thus be used to calibrate the sphincter repair and to predict the functional outcome. Pre-operative assessment by electromyography is mandatory, concentric needle EMG (CN-EMG) for striated sphincter mapping and single fiber EMG (SF-EMG) to establish the evidence of re-innervation indicating partial denervation of striated pelvic or sphincter muscles. Fecal incontinence after Childbirth may be due to either obstetric rupture or muscle denervation or both [6, 7]. Sphincter repair gives excellent results in the absence of denervation. Associated prolapse, internal intussusception, and rectocele can be detected by evacuation proctography. This technique can evaluate the level of the pelvic floor, the anorectal angle, and the length of the anal canal at rest, during contraction, and during straining. Double-exposure and digital substraction defecography permits reliable evaluation of functional parameters
150
50
-_2
0 MABP MAC
25 60
70 m m H g 130 m m H g
NC 520929V Fig. 1. Pressure recordings from a patient with an obstetrical sphincter rupture. Pressures were obtained by using a strain gauge of 0.3 cm diameter eventually placed in probes of 1 cm, 1.5 cm, and 2 cm diameter. Anal basal (MABP) and squeeze (MAC) pressures were measured at the level of maximum basal pressure when using the strain gauge in a scar-free area. The MABP and MAC values improve with increasing diameter of the measuring probe until 1.5 cm diameter but no more thereafter. A perfect outcome can be predicted after appropriate sphincter repair in view of the normal pressure values recorded with the 1.5 cm diameter probe.
without the aid of obligatory reference to relevant skeletal parts [5]. Imaging techniques, computerized tomography, nuclear magnetic resonance scanning, and endo-anal ultrasound, are able to document the morphologic characteristics of the anal and pelvic floor muscles. They are reported to be useful in the management of anorectal malformations and associated spinal anomalies, but only anal endosonography has been validated in anal trauma [8]. There is no need for psychiatric screening. Incontinent patients do not differ from controls, but patients who have a bad result after operation have significantly higher pre-operative anxiety and depression scores [9]. This, certainly, is not unique to incontinence. Treatment and Results
General Aspects Pathological conditions of the colon and rectum causing diarrhea must always be excluded or treated first because they may cause incontinence with no sphincteric or pelvic floor lesion. Treatment of anal incontinence has to be directed logically at a cause in the pelvic floor and sphincters whenever possible. Pure anatomical defects of the anus with normal or only slightly disturbed innervation of the striated anal and pelvic musculature deserve direct surgical correction. Treatment of eventual constipation has to be started at least at the time of surgery because abnormal straining will progressively destroy any benefit from the surgery undertaken.
822
Anatomical defects may be associated with important functional deficits. In this instance the results of corrective surgery may be imperfect but may nonetheless create a situation where additional conservative therapeutic measures may become more effective, e.g., biofeedback training or bowel management program (BMP). The latter consists of a diet rich in fiber with adequate fluid intake, insertion of a glycerine or bisacodyl suppository 30 minutes after breakfast daily or less often according to the patient's prior bowel habits, attempted defecation 20 minutes later, and the use of stool softeners or bulking or stimulating laxatives. Incontinence based on functional defects is initially treated conservatively. Biofeedback training is used in well selected patients. BMP may be advocated or the bowel emptied by the use of an apparatus similar to colostomy irrigation in combination with constipating drugs. Alpha-adrenergic receptor stimulants and Ioperamide can increase the IAS tone. Anal pacemaking has fallen short of expectations. Surgery should be offered if these measures fail. A postanal repair may improve the situation in about two thirds of the patients by re-arranging the anatomy; this may provide the appropriate conditions for a life-long BMP. It has appeared to some that a band of synthetic material used to encircle the sphincter mechanism is a valid alternative to a postanal repair. A colostomy formed in the sigmoid colon is a last measure and a second opinion may be sought before such a measure is undertaken because it may appear later merely to have transferred the patient's handicap to another site.
Acute Injury Obstetric tears have to be explored carefully. Primary repair should be carried out by apposition of the mucosa or submucosa with 3/0 or 2/0 suture and of the muscle ends with 2/0 or 0 long-term absorbable material in combination with perineal body reconstruction. It is also the procedure of choice for accidental trauma and should follow irrigation and careful wound debridement. Broad spectrum antibiotic therapy and tetanus prophylaxis are mandatory. In patients with complex or severe anorectal trauma the use of a colostomy is indicated.
Delayed Repair of Sphincter Disruption If the repair is delayed it should be done after at least a 3 month interval to allow regression of inflammation and the formation of scar tissue. The procedure has been aptly described by Parks [10]. Scar tissue is removed except for the muscle ends which have to be identified. Both the IAS and EAS muscle ends have to be seen. Coagulation current diathermy facilitates the distinction between these muscles. Normal mucosa is apposed with a continuous suture. The EAS is mobilized but not excessively to avoid neurovascular damage. The muscle ends are apposed or overlapped 1-2 cm. Both techniques have been shown to be of equal benefit [l 1], but overlapping is generally preferred. Peroperative manometry with a small probe is useful in order to calibrate the repair and for the detection and resumption of normal basal tone. Skin and fat are left open to heal by secondary intention. Anterior sphincter tears have to be repaired in the same way but levatorplasty and perineoplasty should be added [12, 13] as
World J. Surg. Vol. 16, No. 5, Sept./Oct. 1992
in posterior colpo-perineorrhaphy. A rectocele is frequently associated with these lesions and dealt with in this way. Acceptable continence can be restored in more than 80% of patients after primary or delayed sphincter repair [11, 14-16]. Patients primarily become continent of solid and semi-formed stools but may have urgency of defecation. Some can control liquid stool or flatus, the outcome depending on the extent of local defects or the severity of concomitant pelvic floor neuropathy [17, 18] and on patient age. Thus the best results are obtained in those patients with better pre-operative function [19]. Anal basal pressure and sphincter strength are reduced after delivery, but return to normal after 3 months in controls. After immediate repair of anal sphincter rupture the basal pressure and sphincter strength are at first reduced, improve over the first 3 months, but no more thereafter [20]. Continence may improve within 1 year as a result of re-innervation. Analysis of anal vector symmetry or imaging techniques may have a role in documenting inappropriate or suboptimal sphincter repair. Postoperative EMG in patients remaining incontinent has demonstrated severe denervation but no muscle discontinuity [I9]. Combined sphincter repair using an overlapping technique and postanal repair has been proposed for the treatment of injuries to the anal musculature and its nerve supply [7, 21]. Muscle transposition has been performed in patients with total incontinence who have no functional anal sphincter. The method is thus far an esoteric approach to be used only in young patients with congenital abnormalities or in those who have sustained severe trauma and in whom several attempts at conservative treatment or conventional operation repair have failed [22]. In these procedures, the sphincter mechanism is supplemented by an intact muscle with its own neurovascular supply. BMP should follow the procedure. Gracilis muscle transposition has been found to be an effective operation by some [22-25] but patients with neurologic impairment and pre-operative bowel management difficulties did less well or even poorly [26]. Others had disappointing results [27] and had to implant a neuromuscular stimulator in order to obtain a controlled sphincter function [28]. Repetitive stimulation of muscle is known to change its characteristics from muscle twitch to muscle tone. Chronic repetitive stimulation may induce the latter. Gluteus maximus muscles, natural synergists of the anal sphincter, may have more therapeutic potential for sphincter replacement but again the use of a skeletal muscle limits the scope of an operation whose effects are lost during sleep, though voluntary day-time control may significantly improve the patient's situation [29-31]. The use of a colostomy must be considered for complex and extended sphincter repair or substitution, these reconstructions involving the whole length of the anal canal, the puborectalis and eventually the rectum. In other cases a colostomy can be prevented with the use of good pre-operative bowel preparation, total parenteral nutrition, and a constipating program for 1 week postoperatively. Colostomy has to be performed in patients with septic complications and the distal bowel has to be washed out. Before closing the co]ostomy, the anorectal function should be assessed so that an eventual secondary procedure can be performed in optimal conditions.
F. Peaninckx: Repair of Anal Sphincter
Idiopathic Fecal Incontinence Postanal repair [32] is the treatment of choice for idiopathic fecal incontinence (IFI) which is mainly caused by pudendal neuropathy, thus by definition having intact sphincters. This operation is also indicated for neurogenic incontinence associated with rectal prolapse or obstetric trauma. In both instances the procedure should be delayed for about 12 months after rectopexy or sphincter repair to allow spontaneous recovery of sphincter function [33] since the first operation may well be satisfactory in the majority of patients. Postanal repair for IFI is associated with good results in one-third of patients, improved incontinence in another one-third, but is followed by failure in the remainder [34, 35]. It is not clear which factors determine the outcome. Previously it was thought that a successful Procedure depended on a reduction of the anorectal angle, an increased anal pressure [13, 34, 36, 37], and increase in sphincter length [34, 38] or improved anal canal sensation [13, 36], but Others have not confirmed these findings (for anorectal angle [36, 39]; for basal pressure ]38--40]; for sphincter length [36]). Over 50% of patients still leak feces from time to time after postanal repair, indicating that the quality of continence achieved is far from optimal [41, 42]. Poor results can be expected in patients with limited pre-operative residual function [38, 39]. Thus the procedure fails to help those who need it most. A significant increase in the pudendal nerve terminal mOtor latency was found in failures, suggesting that there was a continuing neuropathic process [37]. Anterior sphincteroplasty and levatorplasty [13, 43] and especially the modified Thiersch procedure with a peri-anal prosthetic band implant [1, 22, 44, 45] have been reported to be safe, simple, and valuable alternatives to postanal repair. Graellis muscle transposition has been reported as failing comPletely in IFI [46].
POStoperative Care Broad spectrum antibiotic therapy is usually given to patients Undergoing anal repair. A urinary catheter is inserted for 5 days m female patients. Bethanechol and urinary catheterization may be necessary for postoperative urinary retention in males. Inspection of the wound should be made twice daily. The Patient is instructed not to sit for the first 5 days postopera!iVely. An elemental diet or total parenteral nutrition is adminIStered for 5 to 7 days or longer if there are protracted wound dil~culties. A constipating agent such as loperamide or codeine should be administered. After a week, if normal healing is achieved, a normal or high-fiber diet should be resumed with oil laxatives. The patient should have a sitz bath after each bowel movement and cleansing of the wound with an antiseptic. A BMp is instituted so that the patient avoids straining and to Promote confidence in control mechanisms so that the patient naay achieve a form of pseudo-continence if necessary. After l0 to 14 days the skin stitches are removed and the patient is discharged the next day and is re-examined in the out-patient clinic after 3 weeks or earlier, weekly in problem cases. Stenosis has to be prevented or treated to prevent incontinence. Patients are advised to try to obtain easy defecation without excessive straining. For female patients considering future
823
pregnancy Cesarean section delivery is advocated as it does not induce any change in the fiber density of the EAS [47]. New Perspectives
The pre-operative and peroperative use of manometry may in the future help to optimize anal sphincter reconstruction but its benefits have yet to be demonstrated. There are patients who have retained motor function in their sphincters in spite of the absence of spontaneous reflex tone. They may become continent by means of permanent neuroprosthetic implants, e.g., by electro-stimulation of the pudendal nerve [48]. Much is yet to be learned from the efforts being made to construct a neo-rectum and neo-anal sphincters after proctectomy [49-51] but it is hard to conceive that non-sphincteric muscles will ever competently substitute for the anal sphincters, so that a BMP becomes redundant. In the absence of a functional anal sphincter, a magnetic occlusive device [52, 53] as well as the AMS (American Medical Systems) 800 artificial sphincter [54] have been implanted both in primary and reconstructive operations, Prevention
The prevention of fecal incontinence is probably its most important aspect. Surgeons should beware of dividing, dilating, or resetting any component of the ano-rectum or colon without considering the functional consequences. It should be possible to cure 40% of complex anal fistulae without division of the external sphincter [55, 56]. Extensive and prolonged packing of anal wounds has to be avoided as it promotes formation of a thick zone of scar tissue in the anal canal. Obstetricians should avoid difficult childbirth leading to pelvic floor denervation or perineal laceration. Multiparity, forceps delivery, increased duration of the second stage of labor, third degree perineal tear, and high birth weight are important factors leading to pudendal nerve damage [16, 47, 57]. Physicians, too, should be aware that constipation may finally result in pelvic floor denervation and incontinence. R~sum~
L'exploration de I'incontinence anale doit comporter de nombreux examens objectifs et notamment la manom6trie, les tests de continence, et l'61ectromyographie. La manom6trie sert ~t pr6dire l'avenir fonctionnel et ~ calibrer la r6paration sphinct6rienne. Les d6fects anatomiques purs de la musculature anale et pelvienne mfritent une correction chirurgicale avec ou sans suture en paletot des extr6mitfs musculaires. Pour les r6parations en deux temps, I'intervalle s6parant les deux 6tapes devrait 6tre au moins de trois mois. I1 faut fabriquer une colostomie de protection dans certains cas complexes et en cas de complication septique. Avant de proposer la fermeture de la colostomie, il faut r6-fvaluer la fonction ano-rectale. On arrive ~t restaurer une continence acceptable chez la plupart des patients, le r6sultat d6finitif d6pendant surtout de l'importance du d6fect local et de la s6v6rit6 de la neuropathie associ6e du plancher pelvien. La transposition d'un muscle squelettique reste une m6thode esot6rique, ~t n'utiliser que chez certains
824 patients bien sElectionnEs; l'implantation d'un stimulateur neuromusculaire parait justifi6e. En presence d'anomalies fonctionnelles sphinct6riennes importantes, d'autres m6th0des conservatrices sont plus efficaces. Une reparation post-anale est envisager 3 ~t 12 mois apes une rectopexie ou une reconstruction sphinctErienne. L'incontinence, basEe sur des donnEes puremerit fonctionnelles, doit ~tre traitEe d ' a b o r d par des mEthodes conservatrices. Une reparation post-anale peut amEliorer la situation chez deux-tiers des patients, mais g6nEralement ne rEussit pas chez les patients qui en ont le plus besoin. Les Echecs sont surtout en rapport avec la continuation du processus neuropathique. L'implantation d'une proth~se p6ri-anale est une alternative valable darts de tels cas. L a sigmoidostomie est une solution radicale de dernier ressort. La prevention de l'incontinence fEcale est le facteur le plus important et concerne tous tes chirurgiens, obstEtriciens et m6decins. Resumen Los pacientes incontinentes deben ser investigados en forma comprensiva mediante pruebas objetivas, especialmente la mamometrfa, los examenes de continencia y la electromiograffa. L a mamometrfa es de utilidad en la predicci6n del resultado funcional y e n la calibraci6n de una reparaci6n del esf/nter. Los defectos anat6micos puros de la musculatura anal y pglvica merecen correcci6n quirtlrgica con y sin superposici6n de los cabos de los mttsculos. Si se decide posponer la reparaci6n, 6sta debe entonces hacerse tuego de un intervalo de tres meses. En los casos comptejos y en aquellos con complicaciones sEpticas se debe construir una colostomfa protectora; en tales pacientes se debe vaiorar la funci6n ano-rectal antes de proceder con el cierre de la cotostomia. Se puede restaurar continencia de grado aceptable en la mayoria de los pacientes, peroel resultado depende de la magnitud de los defectos locales y de la gravedad de la neuropatfa concomitante del piso pglvico. La transPosici6n del mtisculo esquelEtico sigue representando un aproche esotErico que debe ser usado solamente en pacientes seleccionados; parece justificada la implantaci6n de un estimulador neuromuscular. En presencia de deficits funcionales importantes la reparaci6n del esffnter puede dar lugar a una situaci6n en la cual medidas conservadoras adicionales resultan m~is efectivas. Una reparaci6n post-anal puede ser considerada 3-22 meses despuEs de une rectopexia o de una reparaci6n del esffnter. La incontinencia por defectos funcionales puros es tratada en forma conservadora en un principio, Una reparaci6n post-anal puede mejorar la situaci6n en dos tercios de los pacientes, pero falla en los pacientes que m~is la necesitan. La falla parece estar relacionada con el proceso neuropfitico continuado. Una alternativa vglida puede ser el implante de una banda perianal protgsica. L a sigmoidostomfa es un procedimiento que s61o debe ser emprendido en tlltima instancia. La prevenci6n de la incontinencia fecal es de la m a y o r importancia y concierne a los cirujanos, obstetras e internistas. References 1. Penninckx, F.M., Elliot, M.S., Hancke, E., Henry, M.M., Kodner, I.J., Kuypers, J.H.C., Pemberton, J.H., Schuster, M.M.: Symposium on faecal incontinence. Int. J. Colorect. Dis. 2:173, 1987 2. Read, N.W., Haynes, W.G., Bartolo, D.C.C., Hall, J., Read,
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