Fecal Incontinence: Stimulating Hope

Dawn Wietfeldt, MDSpringfield Clinic Colon & Rectal SurgeryAssociate Program Director, SIU/SPC Colon and Rectal Surgery Residency

www.SpringfieldClinic.comwww.SpringfieldClinic.com

Fecal Incontinence• Goes by many names

• Debilitating condition

• Causes anxiety and embarrassment

Fecal Incontinence• Multifactorial

– Obstetric trauma– Previous surgery– Injury– Other

• More frequent in women

Fecal Incontinence

• Symptoms vary• Fecal incontinence score• Work-up

– Physical exam– Endoanal u/s– Anal Manometry– EMG– MRI/Defecography

Never (0)

Less than once per month (1)

Less than once/wk & greater than once/mth (2)

Less than once/day & greater than once/wk (3)

Once/day or more than once per day (4)

Accidents to solid stool

Accidents to liquid stool/diarrhea

How often does gas escape w/o your knowledge or control

How often do you wear a pad/depends or change underwear b/c of soilage

How much do the above answers alter your lifestyle or activities

Wexner Fecal Incontinence Score

Fecal Incontinence• Strategy of treatment

– Dietary changes– Fiber– Anti-diarrheal Medication– Pelvic Floor Training (Biofeedback)

**Patients with significant and persistent symptoms (FIS >10) are candidates for surgical therapy

Standard Surgical Option

• Stoma

Surgical Options for Preservation of Sphincter

1. Repair– Sphincteroplasty– Postanal repair

2. Augmentation– Injectables– Radiofrequency

3. Replacement– Dynamic Graciloplasty– Artificial Bowel Sphincter

4. Stimulation– Sacral Nerve Stimulation– Posterior Tibial Nerve Stimulation

Overlapping Sphincteroplasty:

Short-Term Results< 3 yearsAuthor Year n Success (%)

Fleshman 1991 55 72

Wexner 1991 16 76

Fleshman 1991 28 75

Engel 1994 55 76

Engel 1994 28 75

Simmang 1994 14 93

Overlapping Sphincteroplasty: Long-Term Results

6-10 yearsAuthor Year n Success (%)

Karoui 2000 74 49

Halverson 2002 49 46

Gutierrez2004 191 40

Zutshi 2009 31 none fully continent

Mevik 2009 21 53

Long-term Outcomes of Overlapping Sphincteroplasty:Meta-analysis

• 16 studies• 900 patients• Variable outcome measures

• Clear trend toward decay of functional outcomes over time

• No predictors for long-term success

Glascow et al. DCR 2012

Augmentation Methods • Injectables

• Radiofrequency

Artificial Bowel Sphincter (ABS)

Cuff

Balloon

Pump

FDA approved in 1999

SNS

Sacral Neuromodulation (SNM) is

stimulation of the sacral nerves to

modulate the reflexes that influence

the colon, sphincter, and pelvic floor.

SNM uses mild electrical pulses to

improve or restore normal function.

Sacral Nerve Stimulation - SNS• Criteria

– At least two episodes of incontinence per week

– <90 degree sphincter defect– Failed two conservative therapies

Sacral Nerve Stimulator - SNS• Two step process

– Stage 1 (1 hour procedure) • MAC sedation • Outpatient procedure• Test phase for two weeks• Must have a 50% improvement in symptoms

– Stage 2 (30 minute procedure) • MAC sedation• Outpatient procedure

Test Period

SymptomControl

• Allows the patient to feel stimulation

• Assess the viability of InterStim Therapy

• Helps the physician and patient make an informed choice about the long-term therapeutic value of InterStim Therapy

Benefits of Test Stimulation Period

SNS Stage II

InterStim System

1. Tined lead is placed parallel to the sacral (S2, S3, or S4) nerve.

2. Implantable neurostimulator generates mild electrical pulses that are delivered through the lead electrodes.

3. Clinician and patient programmers are used to set the parameters of the electrical pulses.

1

2

3

Long-term efficacy & Safety120-Patient Prospective Multi-center Study

• Mean Follow-up: 36 (2-73) months• Therapeutic Success (50% improvement)

– 12 months → 83%– 24 months → 86%– 36 months → 85%

• Perfect continence– 12 months → 41%– 24 months → 38%– 36 months → 37%

Mellgren et al. DCR 2011

Adverse Events• Implant site pain• Implant site infection• Lead fracture• Parasthesia• Diarrhea• Urinary Incontinence

Infectious Complication

• High Risk

– Age >65– BMI >30– NIDDM– Previous back surgery

Sacral nerve Stimulation Meta-Analysis

Significant improvements Number of incontinent episodes Wexner Fecal Incontinence Score Ability to defer evacuation Most SF-36 and FIQL domains Mean anal resting pressures

-15 % Morbidity and 3% Explantation

Tan et al. Int J Colorectal Dis 2011

Sphincter Defect, Pudendal Neuropathy or Previous Sphincter

Repair

Conclusions:– Significant and sustained improvement in

incontinence for all patients

– Similar improvement in incontinence for

patients who had an external sphincter

defect on endoanal u/s, a prolonged

PNTML, and 1 or more previous sphincter

repairs

Brouwer and Duthie. Dis Colon Rectum 2010

• Inclusion criteria:– ≥ 3 incontinence episodes

per week– Age < 80 years– Failed conservative treatment– External anal sphincter:

• no defect• defect < 90º• Failed previous sphincter

repair

• Exclusion criteria:

– Congenital anorectal malformation

– Neurological disease– Chronic diarrhea– IBD– Psychiatric disease– Pregnancy

Fecal incontinence associated with pelvic floor injury

Oom et al. DCR 2010

• Conclusions– Pelvic floor injury was present in the majority

of patients with fecal incontinence who were

eligible for sacral neuromodulation

– This type of injury seems to have no

detrimental effect on the efficacy of SNS

Fecal incontinence associated with pelvic floor injury

Oom et al. DCR 2010

Isolated sphincter defect

Pudendal neuropathy

Sphincteroplasty

Alternative procedure

Simple procedures

Success

Intact repair

Injectables

Radiofrequency

Perianal sepsis

Stimulated Graciloplasty

ABS

Severe muscle loss

Yes

Failure

Spinal deformity

Simple procedures, SNS

ABS, Radiofrequency, Injectables

SNS

Persistent Defect

No

Yes

NoSNS

Conclusions

• Many promising surgical options

– Varying success and complication profiles

• Tailored treatment to each patient

– Integrity of sphincter

– Motivation

THANK YOU!!

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