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3.2. Artificial Bowel Sphincter
In the United States, the limited availability of dynamic graciloplasty con-
tributes to a greater enthusiasm for the artificial anal sphincter (Acticon
TM
bowel sphincter, American Medical Systems, Minnetonka, MN).The 2 pro-
cedures are applicable to many of the same patients, unless perineal soft
tissue is inadequate, in which case the artificial anal sphincter is a poor
choice. Several features of the artificial bowel sphincter make it a more
attractive option than the complex dynamic graciloplasty procedure: it is
placed in a single operation, it is operational 6 weeks after placement
without the need for muscle conditioning, and it avoids a painful muscle
transposition.
The artificial anal sphincter currently in use is a modification of an arti-
ficial urinary sphincter (AMS 800). An implantable device, it is composed
of a silicone elastomer that maintains continence via a fluid-filled cuff sur-
rounding and compressing the anal canal. The patient controls the device
via a pump placed in the scrotum or labia. Squeezing the pump 9–12 times
forces the fluid from the cuff into a reservoir balloon, which is implanted
in the space of Retzius.Squeezing deflates the cuff and opens the anal canal,
allowing the passage of stool. The cuff then automatically and slowly rein-
flates and occludes the anal canal, providing continence until defaecation
is again desired.
Christiansen and Lorentzen first reported implantation of an artificial
anal sphincter for faecal incontinence in 1987 [84]. Since then, several
groups have reported their experience with the AMS 800 and with later
modifications [85–90]. In those reports, infections occurred in 15%–25% of
the patients and device explantation was necessary in 20%.The final success
rates were often over 70%. Complications could be successfully treated,
without major morbidity.
A multicentre clinical trial of the artificial anal sphincter consisting of 19
sites in the United Statea, Canada, and Europe was completed in 2000 [91].
In that trial, 112 patients underwent implantation (86 females). The
common protocol consisted of a quality-of-life questionnaire, incontinence
scoring, and physiology testing at 6 months and at 1 year. At 1 year after
implantation, 75 (67%) patients had a functioning device and 3 were lost
to follow up. The infection rate was 25%; 51 patients (46%) had revisional
surgery. A total of 41 patients (37%) had their devices explanted; 7 under-
went successful reimplantation. Quality of life significantly improved for
successfully implanted or reimplanted patients. In the trial, as in other
studies, patients with functioning devices had a significant increase in
resting anal-canal pressures, as compared with their preoperative status
[90,92].
In the trial, a successful clinical result was defined as a decrease in the
faecal incontinence score (FISS) of at least 24 points (score range, 0–120),
indicating a drop of at least 2 levels. For example, a patient incontinent to
12. Innovations in the Treatment of Faecal Incontinence 251
liquid and solid stool daily before surgery could report several incontinent
events a month, but not weekly, for the procedure to be judged clinically
successful. To qualify for the trial, patients needed an FISS of at least 88 or
a stoma. After 1 year of follow up, the mean FISS score for trial partici-
pants had dropped from 105 (incontinent to liquid and solid stool daily) to
48 (incontinent to seepage). A valid criticism of the trial is the use of a
scoring system (instead of diary data) that may not be as accurate, yet
patients whose procedure was a success saw a dramatic drop in their scores.
At the University of Minnesota, we recently reported our long-term
experience with the artificial anal sphincter [93]. Beginning in 1989, 45 con-
secutive patients underwent artificial bowel sphincter placement (Group I,
1989–1992, n = 10; Group II, 1997–2001, n = 35). Of the 10 Group I patients,
7 currently have a functioning device (mean follow up, 91 m; range, 29–143
m). Of the 35 Group II patients, 17 (49%) have a functioning artificial bowel
sphincter (mean follow up, 39 m; range, 12–60m). The criterion of at least a
24-point FISS drop (used for the trial to define functional success) was
easily met by our patients: their average drop was 54 points at 1 year and
90 points at 24 months or more after implantation. The increase seen after
1 year reflects improvement after successful revisions. Such patients may
very well experience unaltered long-term function, as evidenced by Group
I patients whose devices have functioned for over 10 years.
Patients who lack sufficient perineal soft tissue pose a particular chal-
lenge when insertion of an artificial sphincter is contemplated. We have
employed a modified technique for such patients. It consists of initial
perineal reconstruction with a gluteal rotational skin advancement flap,
followed by delayed insertion of an artificial sphincter. Subsequently, the
artificial bowel sphincter is placed with the patient in a prone position,
which facilitates creation of the perianal tunnels and placement of the cuff
higher than usual within the levator ani muscle. The patient is then reposi-
tioned in a lithotomy position, and the implantation of the pump and reser-
voir balloon completed in the usual manner. Of 3 patients in the above
Minnesota series who underwent this modified technique, 2 had a
successful outcome.
3.3. Dynamic Graciloplasty Versus
Artificial Anal Sphincter
No randomised trials have compared the dynamic graciloplasty versus the
artificial anal sphincter. It is unlikely that one could be conducted, given the
limited number of surgeons experienced in both procedures. In a 2000 con-
sensus paper on standards for anal-sphincter replacement, leading experts
in the treatment of faecal incontinence gave these guidelines for the choice
of procedure:
Implantation of the artificial anal sphincter is indicated in patients with anal incon-
tinence caused by neurologic disease that affects the muscles of the lower extrem-
252 S.C. Parker and A. Thorsen
ities, or trauma. The gracilis wrap may be preferable to the artificial anal sphincter
in patients with very thin or scarred perineums caused by previous obstetric trauma,
perianal infections, surgery, or radiation. [94]
This 2000 consensus statement reflected the state of the art in 1998, so it
already may be somewhat outdated. As Madoff et al. pointed out, sphinc-
ter replacement is still in its infancy. At the time of that statement, promis-
ing new techniques, such as sacral stimulation, were untested. The
evaluation of such techniques requires objective evidence of improvement
in continence and in quality of life. The consensus team preferred daily
diary data to continence scores. The suggested quality-of-life instrument
was the form introduced by the American Society of Colon and Rectal
Surgeons [95].
Patients with intractable faecal incontinence who undergo successful
dynamic graciloplasty or artificial anal sphincter placement can expect long-
term improvement in continence and in quality of life. But both procedures
are associated with high morbidity and high infection rates.Any differences
in the degree of continence improvement remain unknown, because dif-
ferent measurement tools (scores vs diaries) have been used for the 2 pro-
cedures. Their varied availability (i.e., dynamic graciloplasty and artificial
anal sphincter in Europe and Canada, but only artificial anal sphincter in
the United States) will influence future studies.
3.4. Sacral Nerve Stimulation
Sacral nerve stimulation, like the artificial anal sphincter, was initially
devised for urinary incontinence. In 1995, Matzel et al. introduced the use
of sacral stimulation to treat patients with functional, but not anatomic,
deficits of the anal sphincter muscle [96]. The procedure entails placing an
electrode in a sacral foramen (S2, S3, or S4) to stimulate the nerve roots.
The desired effect is maximum contraction of pelvic muscles with minimal
stimulation of the fibres to the lower extremity. Once the optimal site is
selected, the lead is connected to a temporary external pulse generator for
a test period of stimulation, currently 3 weeks. If function improves
adequately at the end of the test period, a permanent pulse generator
is implanted. Both the initial operation for lead placement and subsequent
pulse generator placement are well-tolerated procedures done under light
sedation.
Since the initial description by Matzel et al. of neuromodulation for faecal
incontinence, other investigators have reported their experience with sacral
nerve stimulation. Many have used temporary percutaneous leads or per-
manent sacral leads, placed via a closed technique or an open laminectomy.
Whether used for short-term stimulation (usually under 2 weeks) or for
chronic stimulation (for up to 5 years), sacral neuromodulation produces
consistently significant results: it decreases incontinent episodes and alters
anal and rectal physiologic measurements.But all published reports involve
12. Innovations in the Treatment of Faecal Incontinence 253
small numbers of patients, and no randomised trials have been done
[97–100].
The indications for sacral stimulation are quickly being expanded, given
its low morbidity, its promising results in a wide variety of urology patients,
and the finding that the stimulation effect is not confined to the striated
muscle [101]. Stimulation of the efferent motor nerves does seem to
increase anal canal pressures because of contraction of the anal-sphincter
muscles. Conversion of muscle fibres may also occur, as with dynamic
graciloplasty [96]. Some, but not all, studies have reported an increase in
resting anal canal pressures [97–99,101]. Sacral stimulation may modulate
sacral reflexes and sacral parasympathetic nerves, thereby altering rectal
contractile activity and rectal sensitivity [101]. The initial assumption that a
patient needs an intact sphincter and pudendal nerve is already being
challenged: sacral stimulation has been successful in patients with sphinc-
ter disruption [100]. It has also been successful in patients with constipa-
tion, chronic pelvic pain, and complete spinal cord injuries. It modulates
bowel and bladder control and decreases care-related costs [97,102–104].
An international multicentre trial evaluating sacral stimulation for faecal
incontinence will help define the best patients for this promising treatment.
3.5. Anal-Canal Bulking Agents
Unfortunately, few options remain if standard therapy fails for a patient
who is not a candidate for an encirclement procedure or for sacral stimu-
lation (whether because of the degree of incontinence or comorbid condi-
tions). This problematic group also includes patients with minor amounts
of stool leakage: the so-called seepers. Adding a bulking agent to the anal
canal to augment resting tone has obvious appeal; bulking agents are
routinely used for treating urinary incontinence caused by intrinsic urinary
sphincter deficiency. Implantable microballoons, autologous fat, and colla-
gen have all been successful in small series, with low morbidity [105–108].
Success may require repeated injections, and migration of the injected
material has been reported. Manometric pressures are not significantly
altered.
An alternative method under investigation for altering anal-canal resting
tone is radiofrequency. A device is inserted into the anal canal with elec-
trodes that, when deployed, pierce the mucosa to apply radiofrequency
energy to the muscle.Thermal lesions are created in the muscle to alter col-
lagen contractility and to achieve a tissue-tightening effect, while preserv-
ing mucosal integrity [109]. Takahashi et al. reported on a small series of 10
patients whose continence scores decreased by 12 months, but they did not
experience a significant change in their quality of life. Bleeding occurred in
4 of the 10 patients.After application of radiofrequency, all 10 patients had
a reduction in their initial rectal sensation volume and in their maximum
tolerable rectal volume. A multicentre trial is currently underway.
254 S.C. Parker and A. Thorsen
4. Summary
The initial treatment of a patient with faecal incontinence still consists of
medical management, biofeedback, or surgical repair. Innovations in
standard therapies include the introduction of new pharmacologic options,
refinements in surgical and biofeedback techniques, and a better apprecia-
tion of the long-term limitations of sphincter reconstruction. Anal sphinc-
ter replacement is possible with dynamic graciloplasty or with the artificial
anal sphincter; optimal patient selection for each procedure is still being
defined. Sacral stimulation does not preclude the later use of either of the
2 anal sphincter replacement techniques; thus, it may eventually be
accorded an earlier position in the treatment sequence. Other therapies
such as anal-canal bulking agents and radiofrequency have low morbidity,
but are largely untested.
Acknowledgments. The authors thank Alexandra A. Broek, BA, for
assistance in preparation of the manuscript, and Mary E. Knatterud, PhD,
for editorial help.
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