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also influence nerve sparing: male gender, tumor
size, intraoperative blood loss, and surgeon expert-
ise. When urinary incontinence and/or disturbances
of sexual function occur as secondary effects of nerve
damage, they contribute to worsening of the patient’s
clinical condition [39].
Pelvic radiotherapy can play an important role in
the pathogenesis of functional disturbances of conti-
nence [40–42]. In patients treated with pelvic radio-
therapy for prostate, gynecological, bladder, anal, or
rectal cancer, the incidence of FI is 3–53% [43]. This
is despite progress in irradiation procedure. The
patient’s age and presence of “anal symptoms” are
described as risk factors. In their review article, Putta
and Andreyev [43] assessed that rectal cancer seems
to present the highest incontinence rate, probably
due to the additive effects of surgery to those of
radiotherapy. In this work, only 8–56% of inconti-
nent patients were found affected in their quality of
life. The authors interpreted this finding because
patients “do not feel or seem ill, will not report symp-
toms, as they believe they are inevitable conse-
quences of radiotherapy treatment, of being old, or
that there is nothing that can be done”. With the aim
of investigating bowel dysfunctions, Peeters et al.
[44] sent a questionnaire to 597 patients enrolled in
the prospective randomized TME trial (5×5 Gy
before TME surgery vs. TME surgery alone), with a
median follow-up of 5.1 years after the treatment.
Irradiated patients compared with nonirradiated
patients reported increased rates of FI (62% vs. 38%,
respectively; p<0.001), pad wearing as a result of
incontinence (56% vs. 33%, respectively; p<0.001),
anal blood loss (11% vs. 3%, respectively; p=0.004),
and mucus loss (27% vs. 15%, respectively; p=0.005).
Satisfaction with bowel function was significantly
lower and the impact of bowel dysfunction on daily
activities was greater in irradiated patients compared
with patients who underwent TME alone. Pollack et
al. [45] recently reported results of a randomized
trial within the Stockholm Radiotherapy Trials on 64
patients submitted to low anterior resection with or
without preoperative radiotherapy (21 and 43
patients, respectively) followed up with quality-of-
life questionnaires, clinical examination, anorectal
manometry, and endoanal ultrasound. An impaired
anorectal function was common after low anterior
resection for rectal cancer, and the risk was increased
after radiotherapy. Irradiated patients had signifi-
cantly more symptoms of FI (57% vs. 26%, p=
0.01),
soiling (38% vs. 16%; p=0.04), and bowel movements
per week (20 vs. 10; p=0.02). Significantly lower rest-
ing (35 mmHg vs. 62 mmHg; p<0.001) and squeeze
pressures (104 mmHg vs. 143 mmHg; p=0.05) and
more scarring of the anal sphincters (33% vs. 13%;
p=0.03) were documented in irradiated patients. A
worse quality of life affected incontinent patients.
Multiple factors are supposed to produce the
effects of radiotherapy on the pelvic structures
involved in the continence mechanisms, including
radiotherapy dose as well as physical, patient-related,
treatment, and genetic factors [43]. Effects could be
found on both anal canal structures and the rectum.
In most studies, anal maximum resting pressure
decreased following pelvic irradiation [46–54], hypo-
thetically due to damage of endovascular cushions,
internal anal sphincter thinning or atrophy, or both.
However, disagreement exists on manometric assess-
ment of resting pressure, as it was unchanged in
other reports [50, 55–57]. Even if pressure increment
due to squeezing is decreased in most studies [47, 48,
50, 51–54, 57, 58] and thickness of the external anal
sphincter has been reported after radiotherapy for
prostate cancer [54], the influence of pudendal neu-
ropathy in a change of muscle morphology is
unclear. A significant prolonged pudendal nerve ter-
minal motor latency (PNTML) has been observed in
patients treated with neoadjuvant chemoradiation
(irrespective to the inclusion or not of the anal canal
to the irradiation field) and is associated to the FI
severity score [57]. Moreover, being that the puden-
dal nerve is also responsible for anal sensitivity, dam-
age to it can be a significant cause of fecal seepage.
A lumbosacral plexopathy may be a concomitant
cause of incontinence and can cause perianal anes-
thesia and alterations to the pudendal nerve [59
].
Myenteric plexus degeneration within the bowel wall
has been thought to influence continence [46]. The
rectal sensation to distension is primarily transmit-
ted along the S2, S3, and S4 parasympathetic nerves,
which traverse the pelvic splanchnic nerves. Damage
to these nerves induced by radiotherapy could alter
rectal compliance. Regarding rectal physiology, most
studies report a significant decrease in threshold vol-
ume and maximum tolerated volume in incontinent
patients following pelvic irradiation [46–52, 54, 56,
58]. Moreover, radiotherapy induces an inflammato-
ry response within the pelvic vessels and an increased
secretion of growth factors, with consequent damage
to the microcircle of the rectum.
Diagnostic Assessment
In patients submitted to RR for cancer, clinicians
must dedicate attention in investigating defecation
disorders. In fact, a variety of dysfunctions can occur
considering the multifactorial etiology of FI in these
patients, particularly when integrated therapies have
been associated to surgery. Increased bowel frequen-
cy only or associated with fecal soiling or seepage
should be of concern. Tenesmus is not infrequent,
242
G.B. Doglietto, C. Ratto, A. Parello, L. Donisi, F. Litta
Chapter 25 Rectal Resection
and incontinence to gas could coexist. In more severe
cases, incontinence to liquid and/or solid feces is
reported, up to many episodes per day, altering sig-
nificantly daily activities and quality of life. FI sever-
ity index could be very high in these patients. Calcu-
lation of a specific score is usually useful not only to
measure baseline FI severity but also to compare this
to the condition reached after a given treatment. In
each case, special efforts must be made to assess
alteration of rectoanal sensitivity, and patients must
be asked about their ability to distinguish gas from
liquid and solid stools, defer defecation, and feel the
bowel completely empty.
The aim of clinical examination is to investigate
perianal/perineal scars, patulous anus, perineal soil-
ing, anal ectropion, sphincter deficit, loss of perineal
body, and perineal descent. During digital examina-
tion, resting and squeeze tones must be evaluated,
whereas the puborectalis muscle needs to be assessed
at rest, squeezing, and straining. Proctoscopy or, if
necessary, colonoscopy is needed to ascertain
absence of tumor recurrence or other bowel neo-
plasms. Physiology evaluation is of utmost impor-
tance. Anorectal manometry can offer information
about alterations in resting and squeeze pressures,
sphincter asymmetry by vector manometry, anom-
alies of rectoanal inhibitory reflex (sometimes
absent, sometimes normal, sometimes not identifi-
able when resting pressure is very low), and rectal
compliance. Assessment of rectal sensation (measur-
ing threshold, urge, and maximum tolerated vol-
umes) could be of help in interpreting pathophysiol-
ogy in these patients. Endoanal ultrasound (or mag-
netic resonance, as an alternative) is mandatory to
detect sphincter lesions. Electrophysiology study can
investigate anal and rectal sensory and PNTML.
Treatment
Due to the multifactorial pathogenesis of FI following
RR with or without (chemo)radiotherapy, primary
aims of any treatment should be intervention on the
underlying causes to restore or, at least, significantly
improve continence. Although various therapies
(medical and surgical) are available as effective treat-
ment of FI, a gold standard has not yet been estab-
lished.
Medical Therapy
A number of therapeutic agents and options have
been proposed (bulking agents and high-fiber diet,
valproate sodium, diazepam, topical phenylephrine,
biofeedback [60–65]). Theoretically, loperamide
should have the best mechanism of action when com-
pared with other antidiarrheal drugs, because it
potentially can improve internal anal sphincter pres-
sure [66]. Biofeedback and pelvic floor training could
have the best possibilities of success if dysfunctional
external anal sphincter or puborectalis is one of the
main reasons of FI following RR, although only few
reports have been published in this specific clinical
condition [65].
Surgery
When intractable FI occurs, surgical treatment must
be considered. Traditionally, two assumptions have
guided treatment choice. First, stoma formation rep-
resents the “radical” approach, but the impact on
patient’s quality of life, as yet undetermined, should
be questioned. Second, a few alternatives for surgical
sphincter repair (sphincteroplasty) or substitution
(gracilis/gluteus transposition, artificial sphincter)
could be considered, but this approach is often
thought hazardous because of the high risk of non-
healing, infection, chronic pain, and fistula forma-
tion [43, 67]. Finally, a palliative approach, i.e., anal
plugs and rectal irrigation, will only minimize the
effects of FI. A new, promising treatment could be
sacral nerve stimulation.
Dynamic Graciloplasty
In 1990, Baeten and Spaans and Williams et al. [68,
69] introduced a new technique for the treatment of
FI in the presence of large sphincter defects: the
dynamic graciloplasty. Cavina applied this therapy
after abdominoperineal resection of the rectum [70].
This “sphincterial” substitution can be achieved as a
synchronous procedure or after several years and can
involve one or both gracilis muscles [71–73]. The pri-
mary reconstruction is more frequently applied
because more technical difficulties can be encoun-
tered during such a sphincter restoration in a previ-
ously “mutilated” pelvic floor. At the long-term fol-
low-up, about two thirds of the patients with dynam-
ic graciloplasty after abdominoperineal resection of
the rectum achieved satisfactory continence. Howev-
er, no reports are available on the application of
dynamic graciloplasty following sphincter-saving RR
for cancer.
Artificial Sphincter
Indications for application of an artificial sphincter
are very similar to those for dynamic graciloplasty.
Even if reports on this approach have documented
positive impact on restoration of continence in the
243
majority of patients [74–77], postoperative and
short-term morbidity as well as long-term results
reduce the overall efficacy of this treatment. Unfortu-
nately, no series has been reported of FI patients
treated with artificial sphincter following RR for rec-
tal cancer. Only a case report is documented, in
which the device needed to be explanted due to
intense perineal pain [74].
Sacral Nerve Stimulation
Electrical stimulation of sacral nerves has been
thought to excite these nerves and thus “modulate”
specific functions due to this complex nerve supply.
Expected results of such stimulation should be to
stimulate additional impulses not only to an inade-
quate pelvic floor musculature and pelvic organs but
also to the sensitive pelvic fibers. This therapeutic
approach is called sacral nerve stimulation (SNS). It
presents peculiar characteristics if compared with
other surgical options for FI treatment. The first step,
the percutaneous nerve evaluation (PNE), is both a
diagnostic procedure and a test of therapeutic effica-
cy. It permits implantation of an electrode adjacent
to the sacral nerves (through the sacral foramina, the
S3 foramen being generally preferred (Fig. 1) to both
evaluate the nerves’ response to stimulation during
the implantation procedure and during the following
period and to assess the clinical efficacy on defeca-
tion disturbances. Indeed, the PNE test, when affect-
ing significant improvement, allows a 100% positive
predictive value of response to permanent chronic
stimulation. Actually, there is a tendency to use the
new-model self-fixing definitive quadripolar elec-
trode for the PNE test. The electrode can be implant-
ed by a percutaneous technique (Fig. 2) under local
anesthesia and connected to the external stimulator
during the test period. The second step is permanent
implant of the sacral neuromodulation (SNM) sys-
tem. Only if the PNE test produced good results in
improving FI can a permanent implant be consid-
ered. When the quadripolar electrode has already
been implanted, only the definitive electrostimulator
has to be placed into a subcutaneous pocket located
in the gluteal area (Fig. 3) and connected to the elec-
trode. This procedure is usually performed under
local anesthesia. One or two electrodes can be placed,
which are connected to a single electrostimulator.
Primarily, inclusion criteria for SNS were poor FI
(at least one episode of either solid or liquid stool
leakage per week) and failure of conservative treat-
ment. Thereafter, functional defects of the striated
pelvic musculature (without sphincter lesion) were
the main criteria used in the early studies [20].
Enrolled patients had decreased manometric squeeze
pressure but normal PNTML. More recently, other,
more precise, indications have been investigated suc-
244
G.B. Doglietto, C. Ratto, A. Parello, L. Donisi, F. Litta
Fig. 1. Schema of percutaneous implantation of self-fixing
definitive quadripolar electrode for sacral nerve stimula-
tion (SNS). Courtesy of Medtronic S.p.A, Italy
Fig. 2. Percutaneous implantation of self-fixing definitive
quadripolar electrodes for sacral nerve stimulation (SNS),
under local anesthesia, in a patient with fecal incontinence
(FI) following chemoradiotherapy and rectal resection (RR)
for rectal cancer. Reprinted with permission from [80]
Chapter 25 Rectal Resection
cessively, including FI due to idiopathic sphincter
degeneration, iatrogenic internal sphincter damage,
partial spinal cord injury, scleroderma, limited
lesions of internal or external anal sphincters, rectal
prolapse repair, and low anterior resection of the rec-
tum.
In the 2002, Matzel et al. [78] described a single
case report of SNS for FI after low anterior rectum
resection. Two sacral electrodes were used. Complete
resolution of FI was reported 18 months after the
implant, with significant improvement not only in
the continence score but also in the quality-of-life
score. Moreover, squeeze pressure improved, and
resting pressure and neorectal sensation parameters
appeared not to be affected. Our preliminary experi-
ence concerning definitive SNS implant in four
patients has been published [79]. After device
implantation, the mean FI scores decreased, and the
mean number of incontinence episodes dropped
from 12.0 to 2.5 per week (p<0.05). Permanent
implant resulted in a significant improvement in
fecal continence in three patients, and incontinence
was slightly reduced in the fourth. Manometric
parameters agreed with clinical results: maximum
and mean resting tone and the squeeze pressure were
normal in three patients and reduced in one. In these
same three patients, neorectal sensation parameters
increased when the preoperative value was normal
or below normal and decreased when the preopera-
tive value was higher than normal, whereas in one
patient in whom extremely low values were record-
ed, all parameters decreased significantly.
At present, in our series, a PNE test was performed
in eight patients after chemoradiation and RR for
rectal cancer. Patients were evaluated with anorectal
manometry (Fig. 4), endoanal ultrasound (Fig. 5),
and electrophysiology study. In one of these patients,
functional results were poor and the PNE test was
interrupted; in another, they were not very good, and
the test was also stopped. The other six patients had
an excellent functional recovery of FI, so the defini-
tive implant was completed. At long-term follow-up,
the results are very good and have been stable over
time (unpublished data).
Conclusion
Patients presenting with FI following RR with or
without neoadjuvant therapy must be carefully eval-
uated. Skepticism by patients and clinicians nega-
tively affects the possibility to rightly assess the clin-
ical condition and to plan therapy. In this view, an
accurate clinical and physiological evaluation is
mandatory. Even if traditional therapeutic proce-
dures are not always successful, they can be
attempted in selected patients. If suspected “neuro-
genic” FI is confirmed by the physiological tests,
SNS may be proposed and tested. Positive results of
the PNE test suggest that a permanent SNM device
must be implanted. Long-term results of SNS are
encouraging. Failure of this approach does not pre-
vent the use of other, more aggressive, forms of
treatment.
245
Fig. 4. Anorectal manometry: normal resting and squeeze
pressure profiles in a patient with fecal incontinence (FI)
following chemoradiotherapy and rectal resection (RR) for
rectal cancer
Fig. 3. Electrostimulator implant for sacral nerve stimula-
tion (SNS) in a patient with fecal incontinence (FI) follow-
ing chemoradiotherapy and rectal resection (RR) for rectal
cancer. Reprinted with permission from [80]
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249
Introduction
Iatrogenic faecal incontinence can be split into two
broad categories by aetiology. The largest group
comprises patients undergoing proctological surgery
for haemorrhoids, fissures, sepsis, rectoceles and
local excision of rectal neoplasia. A second surgical
group includes patients who have received anal
instrumentation for the purpose of performing an
anastomosis in the pelvis, most commonly by
transanal insertion of a stapling device.
Proctological Procedures
General Introduction
Studies often underestimate iatrogenic incontinence,
as follow-up is often short and trials are powered to
show difference in intervention efficacy, not effect on
continence. Anal-canal pressures decrease with age,
and the initial iatrogenic injury may be compounded
by subsequent obstetric injury [1]. Therefore, incon-
tinence resulting from the proctological procedure
may not be unmasked for a number of years.
We recently published our experience of patients
with incontinence after proctological procedures [2].
This study evaluated a cohort of patients referred for
investigation and treatment of faecal incontinence
having undergone a proctological procedure. Ninety-
three patients were evaluated: 27 after manual anal
dilatation, 17 after lateral sphincterotomy, 20 after
fistulotomy and 29 after haemorrhoidectomy. As
expected, internal sphincter defects were found in
patients who had undergone sphincterotomy and
many who had had fistula surgery. However, less
expected was the finding of an additional, unexpect-
ed, external sphincter injury in around one third of
patients. From the anatomy of this injury, the aetiol-
ogy was thought to be poorly performed surgery or
occult obstetric injury. Patients who had undergone
haemorrhoidectomy and had symptoms of inconti-
nence were also found to have sphincter defects.
Twenty-six of 29 patients had an internal anal
sphincter injury, and external anal sphincter injuries
were seen in 19 patients. From the distribution of the
external sphincter injury, we considered that obstet-
ric injury was the likely cause of external sphincter
damage in 12 patients, whilst in the other seven, the
damage appeared to be related to haemorrhoidecto-
my injury.
Manual Anal Dilatation
Anal dilatation has been a mainstay of treatment of
many colorectal diseases and was popularised for
treating haemorrhoids by Lord [3]. Techniques have
been variable. Watts et al. used four fingers in the
anal canal to provide lateral distraction “with consid-
erable force” and reported “occasionally some bleed-
ing from the mucocutaneous junction” [4]. Others
have tried to standardise the procedure, using a
Parks’ retractor opened to a set distance [5].
There have been many reports of incontinence
after manual anal dilatation. This appears to be relat-
ed to internal anal sphincter fragmentation. A study
from St. Mark’s Hospital in the UK of 12 men with
incontinence after manual anal dilatation found that
resting anal pressures were low. Eleven of the men
had a disrupted internal anal sphincter, with frag-
mentation in ten of these cases (Figs. 1 and 2). Three
patients also had external anal sphincter fragmenta-
tion [6]. A further study [7] examined 32 consecutive
patients who had undergone manual dilatation and
found minor anal incontinence in 12.5%. Of 20
patients who agreed to endoanal ultrasound, sphinc-
teric defects were found in 13. In a retrospective
study of 100 patients undergoing anal stretch in a
single centre in Scotland [8], clinical indication was
anal fissure in 46 patients, first- or second-degree
haemorrhoids in 22 patients and anal stenosis in
seven patients. In 25 patients, manual dilatation was
performed without a diagnosis. Incontinence
episodes occurred in 27 patients, of whom 21 were
women. Other authors report lower incontinence
Iatrogenic Sphincter Lesions
Oliver M. Jones, Ian Lindsey
26
rates. A retrospective single-centre review analysed
241 patients who had undergone manual dilatation
for anal fissure. Patients were contacted either by
phone or by postal questionnaire [9]. Nine patients
(3.8%) were reported to have persistently impaired
continence as a result of the dilatation and eight
patients had temporary symptoms of incontinence.
None of these patients had either manometric or
endoanal ultrasound evidence of sphincter disrup-
tion. Reports from other centres suggest very low
rates of significant incontinence [10]. Despite a
recent review suggesting that manual dilatation
“should probably be abandoned” as a treatment for
anal fissure [11], there is little doubt that it is still a
widely practised procedure [12].
Lateral Sphincterotomy
Lateral sphincterotomy aims to divide the internal
anal sphincter. This causes a reduction in anal rest-
ing pressure [13], and it is generally thought that it
overcomes sphincter spasm and results in better anal
canal perfusion to allow fissure healing.
Incontinence to flatus may be seen in around one
third of patients undergoing sphincterotomy [14,
15]. Other studies have suggested lower rates of
incontinence: Vafai and Mann [16] reported an inci-
ces after closed lateral internal sphincterotomy, and
Hoffmann and Goligher [17] reported a 6% rate of
flatus incontinence and 1% faecal incontinence. The
true incidence of incontinence may be difficult to
assess, as it has been suggested that patients underre-
port their symptoms to their surgeon [18].
Surgical and anaesthetic technique may play a role
in the incidence of incontinence. Closed internal
sphincterotomy has been suggested to be marginally
safer than open sphincterotomy [15]. Combining
sphincterotomy with other anorectal procedures
seems to be higher risk [19]. Keighley et al. [20] rec-
ommended that sphincterotomy should be per-
formed only under general anaesthesia.
Sphincterotomy length is closely related to symp-
toms of incontinence. Garcia-Aguilar et al. [21] com-
pared 13 patients with symptoms of incontinence
after sphincterotomy to 13 control patients who had
undergone the same operation without symptoms.
They found that whilst manometric characteristics
and rectal sensory parameters were similar in both
groups, sphincterotomy length was significantly
greater in the incontinent group (75% vs. 57%). Fur-
thermore, the external sphincter was also thinner at
the site of sphincterotomy in patients with inconti-
nence, raising the concern that iatrogenic damage to
this structure might also contribute to symptoms.
A similar study from St. Mark’s Hospital reported
on ten women and five men after lateral sphincteroto-
my [22]. Of the women, endoanal ultrasound showed
that the entire length of the internal sphincter had
been divided in nine, three of whom had flatus incon-
tinence (Fig. 3). The sphincterotomy was only partial
in the men. This discrepancy was thought to be related
to the shorter anal sphincter in women.
O.M. Jones, I. Lindsey
Fig. 1. Endoanal ultrasound appearances after manual anal
dilatation showing internal anal sphincter fragmentation
(deficient between 2 and 3 o’clock and 4 and 8 o’clock).
Reprinted with permission from [2]
Fig. 2. Gross disruption and fragmentation of both internal
and external anal sphincters following manual anal dilata-
tion. Reprinted with permission from [2]
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