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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 11-13

A review of treatment for fecal incontinence


Department of Gastrointestinal, Laparoscopic and Endocrine Surgery, Noble Hospital and Research Centre; Department of General Surgery, Bharati Vidyapeeth Medical College and Hospital; Department of General Surgery, Jehangir Hospital, Pune, Maharashtra, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Pradeep Sharma
Department of Gastrointestinal, Laparoscopic and Endocrine Surgery Noble Hospital and Research Centre, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_5_18

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  Abstract 


The treatment option for faecal incontinence varies from medical management to various surgical options. This article gives an overview of the various treatment modalities for faecal incontinence.

Keywords: Faecal Incontinence, surgical options, treatment


How to cite this article:
Sharma P. A review of treatment for fecal incontinence. Indian J Colo-Rectal Surg 2018;1:11-3

How to cite this URL:
Sharma P. A review of treatment for fecal incontinence. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2018 Dec 9];1:11-3. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/1/11/241299




  Introduction Top


Fecal incontinence (FI) can be defined as the recurrent uncontrolled passage of fecal material in a person with a developmental age of at least 4 years. FI is emotionally devastating of all nonfatal conditions, resulting in considerable shame and anxiety to one who suffers from it. It affects 2%–17% of adults living in the community.[1],[2]

The treatment options include:

  1. Injectable bulking agents
  2. Anal prosthesis
  3. Neuromodulation
  4. Sphincteroplasty
  5. Antegrade continence enema
  6. Radiofrequency (RF) energy
  7. Neosphincter procedures.



  Treatment Options Top


Injectable bulking agents

A variety of biomaterials, including autologous fat, silicone, cross-linked collagen, dextranomer in hyaluronic acid gel, carbon-coated beads, and others, have been used for injection into the submucosa or the intersphincteric space to augment the anal sphincter and improve continence.

Ideal candidates for treatment with bulking agents are patients with mild FI without significant external anal sphincter (EAS) defects.

A systematic review published in 2011 highlighting efficacy and safety of injectables showed that of a total of 1070 patients, continence improved in 70% in the early postoperative period, though it reduced to 42% at 12-month follow up.[3] A Cochrane review published in 2013, comprising of five randomized trials concluded that there was no evidence of its long-term efficacy.[4] A multicenter randomized trial comparing submucosal injections of dextranomer in stabilized hyaluronic acid gel with sham injections showed reductions by 50% in episodes of FI in 52% of the patients. However, it also showed improvement in 31% of the patients in the sham injection group.[5] In a follow-up study published in 2014, 83 out of 115 patients in the treatment arm were further followed revealing improvement in success rate to 63%.[6]


  Anal Prosthesis Top


This procedure was introduced by Ratto et al. in 2011. It included that the placement of self-expandable prosthesis placed in the intersphincteric space of the anal canal. Preliminary results from his study on 14 patients showed a significant decrease in episodes of major FI, with significant improvement in quality of Life. While no complications were reported, its long-term results are awaited.[7]


  Neuromodulation Top


Neuromodulation is indicated, when other conservative measures fail. It has to some extent replaced overlapping sphincter repair and other extensive surgical procedures, which is associated with high morbidity and poor long-term efficacy.[8]

Neuromodulation is done by sacral nerve stimulation using the implantable Interstim therapy system (Medtronic, Minneapolis, MN, USA) or alternatively, a Tibial neuro-modulation using a peripheral electrode with the Urgent PC neuromodulation system (Uroplasty Ltd., Manchester, UK) can be made. Although the exact mechanism remains to be established, direct or peripheral stimulation of sacral roots modulating afferent or efferent central pathways controlling colorectal motility and perception is proposed.[9]


  Sphincteroplasty Top


Sphincteroplasty has been the standard treatment to reconstruct defects in the EAS for documented external sphincter defects. Short-Term improvement in FI has been reported in up to 86% of patients.[10] At the end of 3 months, almost two-thirds of the patients reported excellent or good results with improved quality of life. However, most of the studies show a deterioration of the functional outcome in the long term. At 5–10 years, only 25%–40% of the patients remained acceptably continent.[11]


  Antegrade Continence Enema Top


Antegrade colonic irrigation through an appendectomy was first described in children with FI by Malone and colleagues in 1990.[12] It leads to a scheduled controlled emptying of the colon and is carried out for FI in children with anorectal malformations or neurological disorders. Long-term results in adults appear to be good with a rate of success around 75%.[13] However, complications such as appendicostomy stenosis, leakage of mucus, or intestinal content from the stoma and surgical site infections may require surgical revision.


  Radiofrequency Energy Top


Takahashi et al. in 2002 described the SECCA procedure wherein temperature-controlled RF energy was administered to the sphincters with an anoscope.[14] The Secca® System (Curon Medical, Inc., Fremont, CA, USA) is used which is designed to deliver temperature-controlled RF energy to the internal sphincter. In a study of 39 patients, improved continence was seen for at least 6 months and also showed continuance of improvement for a further 5 years.[15] A recently published animal study found that SECCA causes restructuring of the internal anal sphincter and EAS rather than fibrosis and scarring.[16]


  Neosphincter Procedures Top


Failures of other available treatment modalities are indications for neosphincter procedures. Neosphincters are constructed using either the gracilis muscle transposition (dynamic graciloplasty), or implantation of an artificial bowel sphincter or the magnetic anal sphincter.

Graciloplasty is performed with the patient's gracilis muscle to create a new sphincter around the anus. To sustain muscle tone, an electrode is placed in the gracilis muscle and connected to a stimulator implanted in the abdominal wall. In a systematic review, the success rate of graciloplasty ranged from 42% to 85%.[17] Complications include pain, surgical site infections, and problems related to the electronic device.

The artificial sphincter consists of an inflatable cuff placed around the anal canal, a reservoir balloon and a pump positioned in the labia or scrotum connecting the cuff and the balloon. In a single center study [18] of 52 patients and the follow up of over 5 years, 50% required revision, mainly due to a leaking cuff, with 27% requiring explanation due to infection. At 5 years, 67.3% had an active device with significant improvements in both Wexner incontinence and quality of life scores.


  Colostomy Top


Colostomy is the last resort, when all other therapies have failed or if the patient is not suitable for conservative or other above-mentioned surgical procedures. Patients are often reluctant to have a colostomy, assuming that the quality of life with stoma is poor. However, several studies have shown that colostomy formation actually improves quality of life in majority of patients of FI.[19]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ditah I, Devaki P, Luma HN, Ditah C, Njei B, Jaiyeoba C, et al. Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005-2010. Clin Gastroenterol Hepatol 2014;12:636-430.  Back to cited text no. 1
    
2.
Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: State of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015;110:127-36.  Back to cited text no. 2
    
3.
Hussain ZI, Lim M, Stojkovic SG. Systematic review of perianal implants in the treatment of faecal incontinence. Br J Surg 2011;98:1526-36.  Back to cited text no. 3
    
4.
Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev 2013;2:CD007959.  Back to cited text no. 4
    
5.
Graf W, Mellgren A, Matzel KE, Hull T, Johansson C, Bernstein M, et al. Efficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: A randomised, sham-controlled trial. Lancet 2011;377:997-1003.  Back to cited text no. 5
    
6.
La Torre F, de la Portilla F. Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence. Colorectal Dis 2013;15:569-74.  Back to cited text no. 6
    
7.
Ratto C, Parello A, Donisi L, Litta F, De Simone V, Spazzafumo L, et al. Novel bulking agent for faecal incontinence. Br J Surg 2011;98:1644-52.  Back to cited text no. 7
    
8.
Glasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence: A systematic review. Dis Colon Rectum 2012;55:482-90.  Back to cited text no. 8
    
9.
Gourcerol G, Vitton V, Leroi AM, Michot F, Abysique A, Bouvier M. How sacral nerve stimulation works in patients with faecal incontinence. Colorectal Dis 2011;13:e203-11.  Back to cited text no. 9
    
10.
Barisic GI, Krivokapic ZV, Markovic VA, Popovic MA. Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months. Int J Colorectal Dis 2006;21:52-6.  Back to cited text no. 10
    
11.
Lehto K, Hyöty M, Collin P, Huhtala H, Aitola P. Seven-year follow-up after anterior sphincter reconstruction for faecal incontinence. Int J Colorectal Dis 2013;28:653-8.  Back to cited text no. 11
    
12.
Malone PS, Ransley PG, Kiely EM. Preliminary report: The antegrade continence enema. Lancet 1990;336:1217-8.  Back to cited text no. 12
    
13.
Poirier M, Abcarian H, Nelson R. Malone antegrade continent enema: An alternative to resection in severe defecation disorders. Dis Colon Rectum 2007;50:22-8.  Back to cited text no. 13
    
14.
Takahashi T, Garcia-Osogobio S, Valdovinos MA, Mass W, Jimenez R, Jauregui LA, et al. Radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence. Dis Colon Rectum 2002;45:915-22.  Back to cited text no. 14
    
15.
Frascio M, Mandolfino F, Imperatore M, Stabilini C, Fornaro R, Gianetta E, et al. The SECCA procedure for faecal incontinence: A review. Colorectal Dis 2014;16:167-72.  Back to cited text no. 15
    
16.
Herman RM, Berho M, Murawski M, Nowakowski M, Ryś J, Schwarz T, et al. Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence – A blinded assessment in an animal model. Colorectal Dis 2015;17:433-40.  Back to cited text no. 16
    
17.
Chapman AE, Geerdes B, Hewett P, Young J, Eyers T, Kiroff G, et al. Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg 2002;89:138-53.  Back to cited text no. 17
    
18.
Wong MT, Meurette G, Wyart V, Glemain P, Lehur PA. The artificial bowel sphincter: A single institution experience over a decade. Ann Surg 2011;254:951-6.  Back to cited text no. 18
    
19.
Colquhoun P, Kaiser R Jr., Efron J, Weiss EG, Nogueras JJ, Vernava AM 3rd, et al. Is the quality of life better in patients with colostomy than patients with fecal incontience? World J Surg 2006;30:1925-8.  Back to cited text no. 19
    




 

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  In this article
Abstract
Introduction
Treatment Options
Anal Prosthesis
Neuromodulation
Sphincteroplasty
Antegrade Contin...
Radiofrequency E...
Neosphincter Pro...
Colostomy
References

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