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Chapter 30 Long-term Results After Fecal Incontinence Surgery
30.5 Overlapping Sphincteroplasty
Parks and McPartlin in 1971 first reported their results with overlapping repair (Parks
and McPartlin 1971). A 180-degree curvilinear incision is made over the defect, most
often the perineal body, a flap is raised and the muscle with its scar is delineated. No
attempt is made to dissect the internal muscle from the external muscle. The ends of
the muscle are dissected (although this is not mandatory [Slade and McPartlin 1977]),
and the muscle is sewn in place in an overlapping fashion (Soffer and Hull 2000).Although it is not finally proven that direct apposition of the muscle ends provides worse
results,this is usually performed at the time of injury,while the overlapping sphincteroplasty is the operation of choice in incontinent patients with an isolated sphincter defect operated years after the injury (Baig and Wexner 2000). A diverting stoma is unnecessary in most cases, but might be advisable in redo cases or technically difficult
cases (Baig and Wexner 2000; Soffer and Hull 2000).The morbidity is low,usually below 10%,and mortality has been described rarely in older series (Slade et al. 1977; Fang
et al. 1984).
Details on the patient populations and the long-term results are given in the Tables 30.2 and 30.3. Factors predictive of a treatment failure,such as age,the duration of
incontinence,obesity, a prolonged pudendal nerve latency,a perineal descent, a previous sphincter repair, a persistent anal sphincter defect, a short anal canal length after
sphincteroplasty or an internal anal sphincter defect have been identified (Laurberg et
al. 1988;Londono-Schimmer et al.1994; Briel et al. 1998; Cook 1998; Gilliland et al.1998;
Hool 1999; Baig and Wexner 2000; Soffer and Hull 2000; Gutierrez et al. 2004), but other studies have refused age, neuropathy and prior incontinence surgery as negative
predictive factors (Simmang et al.1994; Chen et al. 1998;Young et al. 1998; Giordano et
al. 2002).As study results are contradictory on the one hand and the presence of a negative predictive factor does not preclude a successful outcome on the other hand (Soffer and Hull 2000),overlapping sphincteroplasty can be offered to most patients with
an isolated sphincter defect.
In the short term, a significant improvement of fecal incontinence can be achieved
in approximately 60%–90% of patients (Cook 1998; Baig and Wexner 2000; Soffer and
Hull 2000).However, results deteriorate with time (Rothbarth et al. 2000),and beyond
5 years of follow-up, patients are rarely fully continent.In three true long-term studies,
a successful outcome has been observed in 8%, 22% and 37% only (Malouf et al. 2000a;
Gutierrez et al. 2004; Halverson and Hull 2002).
407
30.6 Postanal Repair
The postanal repair devised by Parks offers the possibility of increasing the anal canal
length by plicating the iliococcygeus, the pubococcygeus, the puborectalis and the
sphincter ani externus muscles at the dorsal aspect of the anal canal (Parks 1975). The
procedure has been mainly reserved for patients with idiopathic or neuropathic etiology of incontinence, where medical and physical incontinence treatment failed. The
morbidity is usually low (between 5% and 20% [Henry and Simson 1985;Yoshioka and
Keighley 1989; Matsuoka et al. 2000]), and mortality has been reported only rarely
(Yoshioka and Keighley 1989).
Details on the patient populations and the long-term results are given in the Tables 30.4 and 30.5.A variety of factors potentially predictive of a treatment failure have
408
Tilman T.Zittel
37% 66% 83%
230/628 426/647 481/581
30
age (o/s/t) surgery (mean) (range) continence
Fang et al. 1984 76 62 43/27/7 20/76 35 2–62 44/76 68/76 73/76
Christiansen and Lorentzen 1987 23 14 34 5/10/8 26 6–96 15/23 22/23
Aut hor Yea r N F Mean Etiology Previous Follow-up Follow-up Full Success Improvement
Table 30.2. Long-term results of overlapping sphincteroplasty (mean follow-up,2–5 years)
Yoshioka and Keighley 1989 27 14 34 9/11/4 5/27 48 16–108 7/27 20/27
Engel 1994 28 25 41 15/11/2 4/28 50 15–116 16/28 21/28 22/28
Sangalli 1994 36 36 37 36 4/36 34 3–121 21/36 29/36 35/36
Nikitas 1996 42 37 45 26/11 3/42 38 12–66 16/42 25/42 32/42
Oliveira 1996 55 55 48 55 30/55 29 3–61 13/55 39/55 44/55
Briel 1998 55 55 45 55 7/55 24 36/55
Chen et al. 1998 12 12 45 12 50 20–72 8/12 10/12
Gilliland et al. 1998 77 77 47 53/16/2 30/77 24 2–96 20/77 42/77 48/77
Karoui et al. 2000 74 68 56 61 0/74 40 9–98 21/74 38/74 56/74
Rothbarth et al. 2000 39 39 51 39 39 12–114 24/39
Buie 2001 158 158 36 143 28/158 43 6–120 36/158 97/158 139/158
Cumulative 702
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female, etiology: o obstetric, s surgical,t trauma.
Chapter 30 Long-term Results After Fecal Incontinence Surgery
10% 32% 58%
59 12–98 13/94 47/94 71/94
409
disease
age (o/s/t) surgery (mean) (range) continence
Londono-Schimmer et al. 1994 94 43
Malouf et al. 2000 47 47 43 47 77 60–96 0/47 4/47 27/47
Scott 1989 6 5 Crohn 94 18–192 5/6 5/6 5/6
Aut hor Yea r N F Mean Etiology Previous Follow-up Follow-up Full Success Improvement
Table 30.3. Long-term results of overlapping sphincteroplasty (mean follow-up,5 years and more)
Halverson and Hull 2002 49 47 39 31/7/3 2/49 69 48–141 6/49 18/49 24/49
Cumulative 196 32/326 104/326 189/326
Gutierrez et al. 2004 130 47 120 84–192 8/130 29/130 62/130
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female, etiology: o obstetric, s surgical, t trauma.
410
Tilman T.Zittel
9% 33% 57%
12/127 76/233 133/233
30
24 22–28 4/12 5/12
31 2/47 8/47 29/47
age surgery (mean) (range) continence
42 18–60 0/11 3/11 5/11
Womack 1988 16 14 59 Mixed 26 15–48 6/16 14/16 14/16
Pinho et al. 1992 47
Aut hor Ye ar N F mean Etiology Previous Follow-up Follow-up Full Success Improvement
Table 30.4. Long-term results of postanal repair (mean follow-up, 2–5 years)
Deen et al. 1993 12 12 51 Neuropathic
Le Blanc 1993 22 22 58 Idiopathic 34 2/22 12/22 19/22
Engel 1994 38 34 57 Idiopathic 43 15–126 8/38 17/38
Jameson et al. 1994 36 33 57 Idiopathic 25 6–72 10/36 19/36
Athanasiadis 1995 31 30 66 Idiopathic 20/31 50 24–90 2/31 10/31 16/31
Van Tets et al. 1998 11 20 55 Neuropathic
Matsuoka et al. 2000 20 20 68 Mixed 10/20 36 12–90 7/20 9/20
Cumulative 233
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female, etiology.
Chapter 30 Long-term Results After Fecal Incontinence Surgery
? 27% 69%
411
age surgery (mean) (range) continence
Yoshioka and Keighley 1989 116 59 Mixed 39/116 60 12–120 94/116
Setti-Carraro 1994 34 34 64 Neuropathic 73 61–95 9/34 28/34
Buttafuoco and Keighley 2000 47 51 Mixed 114 13/47 13/47
Aut hor Yea r N F Mean Etiology Previous Follow-up Follow-up Full Success Improvement
Table 30.5. Long-term results of postanal repair (mean follow-up 5 years and more)
Cumulative 197 ? 22/81 135/197
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female.
30
412
Tilman T.Zittel
been tested such as age, the duration of incontinence,a prolonged pudendal nerve latency, a previous sphincter repair, and the results of anorectal manometry, but none
has shown a correlation with treatment outcome (Matsuoka et al.2000).
In Parks’ study, postanal repair improved continence in 81% of patients (Parks
1975), but a successful outcome might vary between 26% and 85% of patients (Athanasiadis 1996; Matsuoka et al. 2000).The results seem to deteriorate with time. Jameson
reported improvement of incontinence in 83% of patients after 6 months, which was
maintained in only 53% after 25 months (Jameson et al. 1994).Two to 5 years postoperatively, around 10% of patients are fully continent, about 30% can control liquid and
solid stool, and around 60% report an improvement.These results do not seem to further deteriorate beyond 5 years of follow-up (Yoshioka and Keighley 1989; Setti-Carraro 1994; Buttafuoco and Keighley 2000).
30.7 Preanal Repair (Anterior Levatorplasty and Sphincteroplasty)
Preanal repair consists of an anterior levatorplasty in combination with an anterior
plication of the external sphincter, which is done via a curved anterior perineal incision and a dissection of the rectovaginal septum (Athanasiadis 1996). The procedure
has been used for incontinence of idiopathic,neuropathic and traumatic origin as well
as for patients after an unsatisfactory result of postanal repair (Miller et al. 1989; Deen
et al. 1993; Österberg et al. 1996). There is a limited number of study reports, but the
morbidity seems to be low (5%–10%) with no mortality reported (Deen et al. 1993;
Österberg et al. 1996,2000).
Details on the patient populations and the long-term results are given in Table 30.6.
There are only limited data available, suggesting that the usage of this procedure is not
widely distributed. Accordingly, the results must be taken with care. The procedure
may achieve results similar to those of overlapping sphincteroplasty (Österberg et al.
2000), but a small randomized trial (n=12 per arm) indicated that total pelvic floor repair achieved better results (Deen et al.1993).
The results seem to deteriorate with time, as the only true long-term study with a
mean follow-up of 8.5 years reported continence for liquid and solid stool in only 38%
of patients and improvement in 64% of patients (Österberg et al.1996).
30.8 Total Pelvic Floor Repair
The procedure combines postanal and preanal repair as described above. It has been
described for neuropathic incontinence and as a staged pelvic floor repair after failed
postanal repair (Pinho et al.1992; Deen et al. 1993).There is a limited number of study
reports, but the morbidity seems to be very low (<5%), with no mortality reported
(Pinho et al.1992; Deen et al. 1993,1995; van Tets and Kuijpers 1998). Details on the patient populations and the long-term results are given in Table 30.7. Obesity, a history of
straining at stool and perineal descent were associated with a poor outcome (Körsgen
et al. 1997).Total pelvic floor repair was superior to preanal or postanal repair in one
randomized trial (Deen et al. 1993), but was equal to postanal repair in another (van
Tets and Kuijpers 1998).Total pelvic floor repair was more cost-effective than postanal
repair due to an increased reoperation rate and an increased postoperative number of
visits after postanal repair (Buttafuoco and Keighley 2000). There are no true longterm reports that provide detailed incontinence outcomes following this procedure.
Chapter 30 Long-term Results After Fecal Incontinence Surgery
3/18 67/146 102/146
17% 46% 71%
102 18–216 32/85 54/85
413
Table 30.6. Long-term results of preanal repair (mean follow-up at least 1 year)
age surgery (mean) (range) continence
Aut hor Ye ar N F Mean Etiology Previous Follow-up Follow-up Full Success Improvement
Deen et al. 1993 12 12 51 Neuropathic 24 22–28 4/12 6/12
Athanasiadis 1994 18 18 62 Idiopathic 6/18 22 6–39 3/18 13/18 15/18
Österberg et al. 1996 85 85 45 Mixed
Österberg et al. 2000 31 31 68 Idiopathic 12 12–12 18/31 27/31
Cumulative 146
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female.
414
Tilman T.Zittel
11/45 43/170 119/170
24% 25% 70%
30
Table 30.7. Long-term results of total pelvic floor repair (mean follow-up at least 1 year)
age surgery (mean) (range) continence
Aut hor Yea r N F Mean Etiology Previous Follow-up Follow-up Full Success Improvement
Pinho et al. 1992 36 36 51 Mixed 14/36 15 3–18 11/36 18/36 34/36
Deen et al. 1993 12 12 51 Neuropathic 24 22–28 8/12 10/12
Deen et al. 1995 18 18 57 Neuropathic 16 6/18 15/18
Körsgen et al. 1997 63 63 57 Neuropathic 36 18–78 8/63 27/63
van Tets and Kuijpers 1998 9 9 55 Neuropathic 42 18–60 0/9 2/9 3/9
Buttafuoco and Keighley 2000 32 51 Mixed 79 17/32 30/32
Cumulative 170
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female.
Chapter 30 Long-term Results After Fecal Incontinence Surgery
30.9 Dynamic Graciloplasty
Graciloplasty was first described by Pickrell in 1952 for fecal incontinence treatment in
children, and Baeten was the first to describe the continuous stimulation of the transposed gracilis muscle in an adult (Pickrell et al.1952; Baeten et al. 1988).The stimulated, so-called dynamic graciloplasty, is more effective than the unstimulated graciloplasty and the standard graciloplasty today. Stimulation by a given frequency and voltage is increased stepwise over weeks,allowing the muscle fibers to adapt to a continuous contraction by changing from fast-twitch,fatigable type II muscle fibers into slowtwitch, fatigue-resistant type I muscle fibers (Chapman et al. 2002). Intramuscular
stimulation seems to achieve better results than direct nerve stimulation (Mavrantonis and Wexner 1999; Konsten et al.2001). The stimulator is implanted subcutaneously under the belly or in the buttock and can be turned off by an external magnet to allow defecation.The procedure is complex with a high morbidity rate (average of more
than one complication per patient) and a mortality of about 1% (Chapman et al. 2002).
In a prospective multicenter study, morbidity was 77%, the device correction or removal rate 19%, and the reoperation rate for complications 38% (Matzel et al. 2001).
The stimulator and the electrodes cost around 1,000 euros (Ortiz et al. 2003), and the
battery of the stimulator has to be changed after a median of 7–8 years (Rongen et al.
2003). However, compared to the costs of colostomy, the procedure seems to be costeffective (Adang et al.1998).
Details on the patient populations and the long-term results are given in Table 30.8.
It was very difficult to extract the actual patient numbers or to categorize the postoperative incontinence improvement from some of the studies cited. Study results of dynamic graciloplasty differ with respect to etiology, anal atresia being more difficult to
treat (see Tables 30.9). Studies describing graciloplasty after abdominoperineal resection for rectal cancer (total anorectal reconstruction) were not included, as double
graciloplasty is mostly used, patients are often irradiated and tumor recurrence occurs. Study results do not seem to deteriorate in the long run, once the procedure has
been completed successfully (Wexner et al. 2002; Rongen et al. 2003), but true longterm studies are not available yet.
415
30.10 Artificial Bowel Sphincter
Christiansen 1987 first described the implantation of an artificial bowel sphincter
(ABS) for fecal incontinence with a prosthesis originally designed to treat urinary incontinence (Christiansen and Lorentzen 1987).This device, called AMS 800, was later
modified to better fit the anatomical structures of the lower rectum and the anal canal.
This new device was named Acticon Neosphincter, and is the device now used by many
colorectal surgery centers.The procedure is complex and in a prospective multicenter
study, a morbidity of 86% was observed, revisional operations became necessary in
46%, and in 37% of patients,the device had to be explanted, resulting in a success rate
of 53% on an intention-to-treat analysis (Wong et al.2002). On the other hand, no mortality was reported from this and other studies. The ABS costs around 10,000 euros,
but the hospital costs assessed by diagnosis-related groups and the price of the devices were similar at around 11,000 euros for dynamic graciloplasty and ABS (Ortiz et al.
2003). In an institution employing both the dynamic graciloplasty and the ABS, the
ABS was judged more convenient for institutions treating small numbers of patients,
416
Tilman T.Zittel
>24 4–78 5/9
40/206 446/684 147/223
19% 66% 66%
30
Table 30.8. Long-term results of dynamic graciloplasty (mean follow-up at least 1 year)
age surgery (mean) (range) continence
Christiansen 1998 13 10 48 Mixed 13/13 7–27 3/13 6/13 11/13
Rosen 1998 10 Mixed 8/10 19 3–53 3/10 9/10 9/10
Madoff et al. 1999 104 72 50 Mixed 65/104 24 69/104
Baeten 1994 9 3 28 Anal atresia
Baeten et al. 1995 52 37 44 Mixed 39/52 25 3–88 12/52 38/52 40/52
Sonnino 1991 7 4 13 Anal atresia 53 6–150 4/7 7/7
Baeten 1991 10 7 38 Mixed 10/10 13 6–60 6/10 8/10
Aut hor Yea r N F Mean Etiology Previous Follow-up Follow-up Full Success Improvement
Williams 1991 32 23 49 Mixed 20/32 16 3–38 0/32 14/32 19/32
Geerdes 1996 67 48 44 Mixed 32 4–104 52/67
Sielezneff 1999 16 11 42 Mixed 14/16 20 6–37 10/16 10/16 13/16
Baeten 2000 123 98 50 Mixed 76/123 >18 18–18 47/81
Wexner et al. 2002 115 92 50 Mixed 86/115 24 24–24 12/83 42/83 40/83
Rongen et al. 2003 200 153 48 Mixed 130/200 45 144/200
Cumulative 746
Previous surgery,previous surgery for fecal incontinence.
Follow-up is given in months.
See text for the definition of “success” and “improvement”.
F female.
patients with dynamic graciloplasty for incontinence after rectal cancer treatment were extracted (except for Williams 1991,n=7).
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