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80. Benson-Cooper S, Davenport E, Bissett IP. Introduction of sacral neuromodulation for the
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81. Damon H, Barth X, Roman S, Mion F. Sacral nerve stimulation for fecal incontinence
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of 119 patients. Int J Colorectal Dis. 2013;28(2):227–33.
82. Hull T, Giese C, Wexner SD, Mellgren A, Devroede G, Madoff RD, Stromberg K, Coller JA,
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incontinence. Dis Colon Rectum. 2013;56(2):234–45.
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refractory fecal incontinence. Am J Surg. 2014;207(5):735–7; Discussion 737–88.
84. Moya P, Arroyo A, Lacueva J, Candela F, Soriano-Irigaray L, Lopez A, Gomez MA, Galindo
I, Calpena R. Sacral nerve stimulation in the treatment of severe faecal incontinence: long-
term clinical, manometric and quality of life results. Tech Coloproctol. 2014;18(2):179–85.
85. Maeda Y, Lundby L, Buntzen S, Laurberg S. Outcome of sacral nerve stimulation for fecal
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86. Ruiz Carmona MD, Martin Arevalo J, Moro Valdezate D, Pla Marti V, Checa Ayet F. Sacral
nerve stimulation for the treatment of severe faecal incontinence: results after 10 years expe-
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87. Roy AL, Gourcerol G, Menard JF, Michot F, Leroi AM, Bridoux V. Predictive factors for
successful sacral nerve stimulation in the treatment of fecal incontinence: lessons from a
comprehensive treatment assessment. Dis Colon Rectum. 2014;57(6):772–80.
88. Gorissen KJ, Bloemendaal AL, Prapasrivorakul S, Gosselink MP, Jones OM, Cunningham C,
Lindsey I, Hompes R. Dynamic article: permanent sacral nerve stimulation under local anes-
thesia: feasibility, best practice, and patient satisfaction. Dis Colon Rectum.
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89. Altomare DF, Giuratrabocchetta S, Knowles CH, Munoz Duyos A, Robert-Yap J, Matzel KE,
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90. Duelund-Jakobsen J, Lehur PA, Lundby L, Wyart V, Laurberg S, Buntzen v. Sacral nerve
stimulation for faecal incontinence-efficacy confirmed from a two-centre prospectively main-
tained database. Int J Colorectal Dis. 2016;31(2):421–428.
91. Johnson BL, Abodeely A, Ferguson MA, Davis BR, Rafferty JF, Paquette IM. Is sacral neu-
romodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence.
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92. Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term
results of anterior sphincteroplasty. Dis Colon Rectum. 2004;47(5):727–31; Discussion
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anterior anal sphincter repair. Dis Colon Rectum. 2004;47(6):858–63.
95. Conaghan P, Farouk R. Sacral nerve stimulation can be successful in patients with ultrasound
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96. Vitton V, Gigout J, Grimaud JC, Bouvier M, Desjeux A, Orsoni P. Sacral nerve stimulation
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97. Chan MK, Tjandra JJ. Sacral nerve stimulation for fecal incontinence: external anal sphincter
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98. Melenhorst J, Koch SM, Uludag O, Van Gemert WG, Baeten CG. Is a morphologically intact
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103. Pascual I, Gomez Cde C, Ortega R, Toscano MJ, Marijuan JL, Espadas ML, Cebrian JM,
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T.C. Rice and I.M. Paquette
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439© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_39
Chapter 39
When Is an Anal Sphincter Repair Indicated?
Jan Rakinic and V. Prasad Poola
This chapter will discuss anal sphincter repair in adult fecal incontinence.
Populations not discussed include children, patients with anorectal malformations,
and patients who have undergone rectal resection or pelvic radiation.
Introduction
Any adult patient with a disturbance in fecal continence must have a directed his-
tory taken and appropriate physical examination conducted. Initial therapy usually
consists of dietary manipulation, bulking agents, and occasionally antidiarrheal
medications. The details of these important parts of the therapeutic strategy are well
described elsewhere. Etiology of fecal incontinence and presence of a demonstrable
sphincter defect are key points is to identify, as these will impact therapeutic deci-
sions as well as expected outcomes. Endoanal sonography is most commonly used
to identify anal sphincter defects.
If best conservative management is not sufficient for control of moderate to
severe fecal incontinence symptoms, further interventions may be discussed.
Noninvasive therapies include biofeedback or pelvic floor retraining. While these
therapies are very low risk, expected improvement is modest, variable, and seems
to deteriorate over the short to medium term [1–4]. Standardized pelvic floor func-
tion testing has a limited role in predicting success of biofeedback or pelvic floor
retraining [5]. In addition, literature suggests that these therapies are less effective
in patients with sphincter defects [6].
J. Rakinic, MD, FACS, FASCRS (*) • V.P. Poola, MD
Southern Illinois Department of Surgery, Division of General Surgery, Section of Colorectal
Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
e-mail: jrakinic@siumed.edu
440
Patients with moderate to severe fecal incontinence and a demonstrated sphincter
defect who have not had sufficient response to noninvasive management methods
may be candidates for other, more invasive forms of treatment. The use of bulking
agents injected into the submucosa overlying the sphincter, or targeted radiofre-
quency energy applications to the same area, appear to be low-risk interventions.
However, benefits and short-term outcomes are modest [7, 8]. Additionally, sur-
geons have concerns that these modalities alter the tissue planes in the anal canal
and so may be reluctant to employ them in patients who are or may become candi-
dates for anal sphincter repair.
Surgical Approaches to Fecal Incontinence
Surgical sphincter repair and sacral nerve stimulation are the most frequently per-
formed surgical procedures for adult fecal incontinence. In contemplating interven-
tion for fecal incontinence, treatment must be individualized for each patient.
Functional and quality of life (QOL) related outcomes as well as potential compli-
cations of treatment must be considered. This chapter will present an outline for
surgeon clinicians to use in determining whether a patient may be best served by an
anal sphincter repair, with discussion of patient population (those with a sphincter
defect), intervention (anal sphincter repair), comparator (sacral nerve stimulation),
and outcomes (improvement in fecal continence).
Patient population Intervention Comparator Outcomes evaluated
Pts with sphincter defect
and FI
Sphincter repair SNS QOL, decreased incontinence
episodes
Anal Sphincter Repair
For the patient with moderate to severe fecal incontinence and a demonstrated
sphincter defect in whom best conservative management has not produced suffi-
cient improvement, anal sphincter repair may be considered. A number of authors
have reported good to excellent short term results in 60–80 % of patients as evalu-
ated by follow-up questionnaires and QOL measures over 35 years of accumulated
data (See Table 39.1) [9–18]. However, the reports are generally small series with
retrospective data collection, and few have any comparison groups. It is important
to note that most surgeons exclude gaps over 120° from repair.
Important information regarding the longer term durability of anal sphincter
repair has been accumulated in the past 13 years [17–23]. The proportion of patients
reporting good to excellent outcomes in the long term, approximately 10 years after
sphincteroplasty, varies from 14 to 62 % (See Table 39.2.). This is significantly less
than that reported in the short term, suggesting that function after anal sphincter
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repair tends to deteriorate over time. However, available literature is limited, and as
with the data on short term outcomes, these reports are mostly small series with
retrospective data collection and few have any comparison groups. In addition,
patient populations and methods of assessing outcomes are heterogeneous, which
makes it difficult to draw clear conclusions.
Predicting Outcome After Anal Sphincter Repair
With the realization that long term outcome after anal sphincter repair appears to
deteriorate over time, a number of authors have attempted to define what variables
might predict outcome. Of nine studies that evaluated the effect of age at surgery on
outcome [17, 20–22, 24–27], four [20, 22, 24, 27] reported poorer outcome in
patients over age 50. One [24] of three studies that looked at parity [17, 24, 28]
found that patients with a history of two or more vaginal births had a poorer out-
come after sphincteroplasty. Obstetric injury etiology was associated with better
outcome compared to other causes of incontinence in one study that commented on
this [22]; however, the number of patients with differing etiologies was small. An
observational study of estrogen therapy in postmenopausal women with fecal
Table 39.1 Short term (up to 5 years) outcomes of sphincteroplasty
Author/year N % Excellent/good % Fair % Poor
Fleshman (1991) 55 72 22 6
Wexner (1991) 16 76 19 5
Engel (1994) 55 79 – 21
Oliveira (1996) 55 71 9 20
Felt-Bersma (1996) 18 72 – 28
Nikiteas (1996) 42 60 17 24
Sitzler (1996) 31 74 – 26
Ternent (1997) 16 44 31 25
Zorcolo (2005) 93 65 9 27
Barisic (2006) 65 74 17 9
Table 39.2 Long term (10 year) outcomes of sphincteroplasty
Author/year N % Excellent/good % Fair % Poor
Halverson (2002) 49 14 32 54
Bravo Gutierrez (2004) 130 22 19 57
Zorcolo (2005) 62 45 10 45
Barisic (2006) 65 48 13 39
Maslekar (2007) 64 62 24 15
Mevik (2009) 25 36 – –
Oom (2009) 120 38 23 40
39 When Is an Anal Sphincter Repair Indicated?
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incontinence found symptomatic improvement in 90 % after 6 months of hormone
replacement therapy, with increases in resting and squeeze pressures and an increase
in maximum tolerated rectal volume [29]. The patients with an identifiable sphinc-
ter defect had no difference in outcome. However, the potential application of this
to the population of patients who are candidates for sphincteroplasty is not clear. All
authors felt that older patients should still be considered for anal sphincter repair,
though the risk of a possible inferior outcome should be discussed.
Several studies assessed outcome related to initial physiologic and anatomic
variables, including resting and squeeze pressures, anal canal length, rectal compli-
ance, pudendal neuropathy, and presence of internal anal sphincter defect [17, 19–
21, 25, 28]. None found resting or squeeze pressures, anal canal length, rectal
compliance, or presence of internal anal sphincter defect predictive of outcome.
Only one [30] of the five studies that evaluated pudendal neuropathy [17, 21, 25, 28,
30] reported that this was predictive of a poorer outcome. However, all authors felt
that anal sphincter repair should be offered to patients with pudendal neuropathy,
with a discussion of possible poorer outcome.
There is little solid information regarding predictive value of technical aspects of
anal sphincter repair. Most surgeons perform overlapping repair. One study [22]
evaluated outcome after overlapping repair vs end-to-end repair of the sphincter. No
predictive effect was identified. Maslekar et al. [21] felt their good results (86 %
good outcome at 7 years) were related to their technique of dissecting each sphinc-
ter separately, though they did not include any comparison group. Three studies
compared outcomes using fecal diversion with repair performed without diversion
[28, 30, 31]. No predictive effect regarding outcome was seen; fecal diversion is not
routinely used in anal sphincter repair in the United States.
Relationship of Short and Long Term Outcomes
There does appear to be a predictive relationship between short and long term out-
comes. Vaizey et al. [31] found that patients who had good outcomes in short term
tended to have more durable outcomes, compared to those who did poorly initially.
Malouf et al. [28] reported that the Parks score at 15 months after anal sphincter
repair was predictive of long term success. Bravo Gutierrez et al. [20] found that a
poor outcome at 3 years after surgery was a strong predictor of poor long term
outcome.
Repeat Sphincteroplasty Outcomes
Identification of a recurrent or persistent anal sphincter defect after sphincteroplasty
is important, as these patients may be offered a repeat anal sphincter repair. Giordano
et al. [32] reported on 36 patients who underwent a repeat sphincter repair after
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demonstration of a persistent sphincter defect. The repeat repair group reported
good (50 %) and adequate (11 %) function at a median of 20 months, compared with
the patients undergoing first-time repair (58 % good, 17 % adequate). Vaizey et al.
[31] reported on 23 patients with a repeat anal sphincter repair. Twenty-one were
evaluable at 20 months after repeat repair. One was fully continent, 12 reported
50 % or more symptom improvement over preoperative function, and four were
unchanged. Hong et al. [33] reported retrospectively on 59 patients with failed
sphincteroplasty. In this cohort, 33 underwent repeat sphincteroplasty, 11 had artifi-
cial bowel sphincter (ABS) implant, and 15 underwent sacral nerve stimulation
(SNS). Observed improvements in continence were similar; however, the rate of
complications and reoperations was significantly lower in the repeat sphinctero-
plasty group, leading the authors to suggest that repeat sphincteroplasty should be
considered the first choice in the management of failed anal sphincter repair.
However, function after repeat sphincteroplasty may deteriorate over time more
markedly than after a first repair [34].
Reporting and Comparing Outcomes
Comparing outcomes of anal sphincter repair is made more difficult by the hetero-
geneity of the measures utilized in reporting. Many methods of assessment are com-
mon, and while those most widely used contain elements of incontinence frequency
and severity, not all include patient-defined quality of life measures. However, the
quality of life determination may be the most important consideration for the patient
who must weigh the effect on daily life activities against the possible risks of treat-
ment. Evaluation of function in 62 patients a mean of 70 months after anal sphincter
repair showed that while 70 % had objective clinical improvement, only 55 % con-
sidered their bowel control improved and only 45 % were satisfied with the outcome
[17]. The authors note that urgency was the most important symptom related to
patient satisfaction after anal sphincter repair: 24 of 26 patients in whom urgency
had improved reported that they were happy with the outcome.
Sacral Nerve Stimulation
Sacral nerve stimulation (SNS) has been suggested as the first line of treatment in
adult fecal incontinence regardless of etiology, in part related to the reported dete-
rioration of function after sphincteroplasty. However, the data on SNS for adult
fecal incontinence is still maturing, and concerns exist regarding the rates of com-
plications and reoperation. In a study of 61 patients who underwent temporary
electrode stimulation for refractory fecal incontinence, only 35 (57 %) attained the
50 % or greater improvement in incontinent episodes needed to proceed to perma-
nent implant [35]. Of the 33 patients in this study who eventually underwent
39 When Is an Anal Sphincter Repair Indicated?