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Surgery and Sacral Nerve Stimulation for Constipation and Fecal Incontinence

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Surgery and Sacral Nerve Stimulation for Constipation and Fecal Incontinence Surgery and Sacral Nerve Stimulation for Constipation and Fecal Incontinence Rodrigo A. Pinto, MD, Dana R. Sands, MD, FACS, FASCRS* KEYWORDS Fecal incontinence Constipation Sphincterplasty Sacral nerve stimulation Fecal incontinence and constipation are two colorectal diseases that have a high incidence requiring specialized treatment when medical options are exhausted. This article briefly discusses the etiology, epidemiology, incidence, and pathology history of constipation and fecal incontinence, followed by a detailed review of the surgical options, including SNS. FECAL INCONTINENCE Fecal continence is a complex bodily function, which requires the interplay of sensa- tion, rectal capacity, and neuromuscular function. Multiple factors, such as cognitive function, stool consistency and volume, rectal distensibility, colonic transit, anorectal sensation, anal sphincter function, and anorectal reflexes, can influence a patient’s continence.1 Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients.2,3 This disorder is a debilitating condition that can be personally and socially incapacitating. Incontinence is considered complete when the patient loses control of solid feces and partial when the patient has inadvertent soiling or escape of liquid or flatus. Browning and Parks4 proposed criteria to stage fecal incontinence as follows: A, normal continence; B, incontinence to flatus; C, no control to liquid or flatus; D, continued fecal leakage. Subsequently, many grading scales have been proposed, and most consider the frequency of incontinence episodes as the most important item. Some scales,5,6 which included urgency, clean- ing difficulty, use of pads, and impact on quality of life, are considered more complete. Many authors have proposed scales for fecal incontinence. The Cleveland Clinic Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA * Corresponding author. E-mail address: [email protected] (D.R. Sands). Gastrointest Endoscopy Clin N Am 19 (2009) 83–116 doi:10.1016/j.giec.2008.12.011 giendo.theclinics.com 1052-5157/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved. 84 Pinto & Sands Florida (CCF) fecal incontinence scoring system, described in Table 1, is a validated tool that is commonly used.5 Fecal incontinence has multiple etiologic factors, such as previous operative procedures, childbirth, aging, presence of procidentia, trauma, irradiation, neurogenic causes, primary disease, congenital abnormalities, or idiopathic causes. Each of these causes requires specific management depending on the severity of symptoms, pres- ence of sphincter injury, and improvement after medical therapy. The etiology of fecal incontinence can be stratified into two groups: patients with normal pelvic floor and those with abnormal pelvic floor. Fecal Incontinence with Normal Pelvic Floor Aging Elderly patients with a long history of straining of defecation may have injury to the pudendal nerve, consequently neurogenic incontinence can occur. Gastrointestinal pathologies Diseases that cause chronic diarrhea, such as inflammatory bowel disease, amebic colitis, progressive systemic sclerosis, infections, lymphogranuloma venereum or laxative abuse, can cause local sensory disturbance, mucosal irritability, and/or inter- ference in the sphincter mechanism, resulting in a loss of reservoir function of the rectum. Irradiation Extracavitary or intracavitary irradiation for the treatment of cervical, uterine, and pros- tate carcinomas results in various degrees of proctitis, which can lead to incontinence. Neurogenic causes Patients with myelomeningocele or any disease that affects the central nervous system (CNS) or spinal cord, such as trauma, neoplasm, vascular accident, infection, or demyelization disease can have incontinence resulting from disturbance of sensory and motor nerve supply. Overflow incontinence and soiling Usually associated with fecal impaction, which causes a sensation of fullness, liquid stools can pass around the impaction resulting in seepage of liquid stool. Idiopathic incontinence Patients with no sphincter defects or other anorectal abnormality suffer from idio- pathic incontinence. Neuropathic changes in the internal sphincter and abnormal Table 1 Jorge/Wexner (CCF) continence grading scale (0 5 perfect and 20 5 complete incontinence) Type of Incontinence Never Rarely Sometimes Usually Always Solid 0 1 2 3 4 Liquid 0 1 2 3 4 Gas 0 1 2 3 4 Wears pad 0 1 2 3 4 Lifestyle modification 0 1 2 3 4 Never, 0; Rarely, <1/mo; Sometimes, <1/d, R1/mo; Usually, <1/d, R1/wk; Always, R1/d. Sacral Nerve Stimulation 85 sensation in the anal canal and rectum have been proposed as potential mecha- nisms.2,3 These findings suggest neurologic damage. Fecal Incontinence with Abnormal Pelvic Floor Anorectal surgery Internal sphincterotomy,7 fistula surgery, hemorroidectomy, manual anal dilatation, and sphincter saving procedures have been shown to affect the internal sphincter and the external sphincter with resultant fecal incontinence. Childbirth Female preponderance of fecal incontinence occurs at a ratio of 8:1 in relation to that in males. Childbirth, mainly vaginal delivery, is the most important factor associated with sphincter injury. The reported incidence of occult sphincter defects after vaginal deliveries varies between 7% and 41%.8,9 Trauma Direct trauma or impalement can often disrupt sphincter mechanism. Surgical repair may need protective colostomy depending on the extent of the injury. Congenital abnormalities Imperforate anus and the subsequent repair can result in fecal incontinence. Procidentia Complete rectal prolapse or procidentia may chronically injure the internal and external sphincters. SURGERY FOR FECAL INCONTINENCE Selection of Patients Before any invasive intervention for fecal incontinence, the surgeon should have a through understanding of the etiology of the condition. Appropriate medical management can improve symptoms in the majority of patients. If the symptoms persist despite aggressive efforts to improve stool frequency and consistency and strengthen the anorectal musculature, surgical intervention is warranted. Evaluation of the anal canal with ultrasound is imperative at this point. The presence or absence of an anal sphincter defect dictates the proposed course of surgical intervention and the available treatment options. Overlapping Sphincteroplasty Disruption of the external anal sphincter, most commonly from childbirth or other forms of anorectal trauma, is repaired with the technique of sphincteroplasty. The most common technique is the overlapping repair, first applied by Fang and colleagues,10 Parks and McPartlin.11 A transverse incision is made in the perineum, anterior to the anal canal. Lateral dissection allows for identification of the external anal sphincter muscle. Medial dissection is then performed to identify and preserve the existing scar tissue. An anterior levatorplasty followed by an overlap of the external anal sphincter muscle in the anterior midline is then accomplished. The scar is incor- porated in the repair to strengthen the sphincteroplasty. Figs. 1 and 2 show ultrasound images before and after the sphincter repair. Early results were promising in 70%–80% of the patients.12–16 Frequently, studies that reported better results were associated with a shorter follow-up, generally less than 3 years.17–19 However, some others described poor results in a shorter follow-up 86 Pinto & Sands Fig.1. Anal ultrasound showing anterior external anal sphincter defect. period, ranging from 30% to 50%.20–22 Table 2 summarizes the success rates related to follow-up of the patients. Tjandra and colleagues32 conducted a randomized controlled trial comparing end- to-end and overlapping repair. Similar results were noted after follow-up of 18 months. Use of fecal diversion to improve healing was reported by a recent prospective trial. Stoma-related complications occurred in seven of 13 patients.33 Recently published studies of the long-term follow-up after sphincteroplasty re- ported improvement of continence after more than 5 years.26,30 Repeated sphincteroplasty can be performed in patients who fail to improve in their continence and have a persistent sphincter defect. Success rates range from 50% to 65% in various studies.34–36 Postanal Repair First described by Parks37 in 1975, this procedure aims to reduce the obtuse anorectal angle and improve continence in patients with weak but intact sphincters.38,39 Initially, Fig. 2. Anal ultrasound after overlapping sphincteroplasty showing the external sphincter repaired. Sacral Nerve Stimulation 87 Table 2 Short- and long-term results of sphincteroplasty Results (Good or Author Year No of Patients Follow-up (mo) Excellent) (%) FU < 3 years Osterberg et al20 2000 20 12 50 Malouf et al23 2000 55 12 76 Elton & Stoodley17 2002 55 13 80 Engel et al18 1994 55 15 79 Pinta et al21 2003 39 22 31 Norderval et al22 2005 71 27 41 Oliveira et al19 1996 55 29 71 FU >3 year Rothbarth et al24 2000 39 39 62 Morren et al25 2001 55 40 56 Grey et al26 2007 47 >60 60 Halverson & Hull27 2002 71 69 25 Zorcolo et al28 2005 93 70 55 Malouf et al23 2000 55 77 49 Barisic et al29 2006 65 80 48 Maslekar et al30 2006 72 84 95 Gutierrez et al31 2004 191 120 40 the dissection proceeds through the intersphincteric plane to the presacral space. Ileococcigeus, pubococcigeus, and puborectalis muscles are plicated followed by sphincteric plication.38,39
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