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Schließmuskelprothese vs. Ersatzmuskelplastik bei hochgradiger Stuhlinkontinenz?

Eine quantitative Analyse

Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence

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Zusammenfassung

Die dynamische Grazilisplastik (DGP) und der Acticon™Neosphincter („artificial bowel sphincter“, ABS) sind die zwei klinisch am besten etablierten Verfahren, die bei Patienten mit hochgradiger Stuhlinkontinenz am Ende der therapeutischen Möglichkeiten stehen. Neueingeführte Systeme wie der Prosthetic Anal Sphincter oder das A.M.I. Softanalband befinden sich noch in der klinischen Evaluierung.

In vorliegender Übersichtsarbeit wurden insgesamt 1510 Patienten aus 52 Studien zur DGP (n=29) und ABS (n=23) analysiert und die Studien nach den Oxford EBM-Kriterien evaluiert. Nur 3 Arbeiten zeigten einen Evidenzgrad von ≤3b auf. Des weiteren wurden die Ergebnisse nach Komplikationsraten analysiert und statistisch ausgewertet. Beide Verfahren zeigen postoperativ signifikante Verbesserungen der Kontinenz-Scores p<0,001, mit einem Vorteil für den ABS. Dem stehen hohe Infektions- (21,74% ABS vs. 35,1% DGP) und Revisionsraten (37,53% ABS vs. 40,64% DGP) gegenüber, bei einer deutlich höheren Explantationsrate des ABS (30% ABS vs. 18% DGP). Eine therapeutische Empfehlung kann anhand der wenig evidenten Datenlage nicht ausgesprochen werden. Die Therapie sollte in spezialisierten Zentren durchgeführt werden und unterliegt gerade in Anbetracht der Systemkosten einer hohen Patientenselektion.

Abstract

Dynamic graciloplasty (DGP) and the Acticon™Neosphincter (artificial bowel sphincter, ABS) are well-established therapeutic instruments in patients with severe fecal incontinence. However, the success rates in the literature must be interpreted with caution. The report presented here presents firstly a critical analysis of 1510 patients in 52 studies (29 DGP vs 23 ABS). The evidence of these studies was assessed using the Oxford EBM criteria. All data were statistically analysed. Up to 94% of the studies analysed show EBM levels of only >3b. Both procedures show significant improvements in postoperative continence scores (p<0.001) and a significant advantage of ABS over DGP. Nevertheless, they are associated with a high incidence of morbidity in the long term (infection rate ABS vs DGP 21.74% vs 35.1%, revision rate ABS vs DGP 37.53% vs 40.64%, and ABS explantation rates of 30%). Presently no therapeutic recommendation can be expressed based on the few data available. Furthermore, therapy should be performed in specialized centers and patients should be given a realistic picture of the critical outcome of both surgical techniques.

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Literatur

  1. Adang EM, Engel GL, Rutten FF et al. (1998) Cost Effectiveness of Dynamic Graciloplasty in Patients with Fecal Incontinence. Dis Colon Rectum 41: 725–733

    Article  PubMed  Google Scholar 

  2. Altomare DF, Dodi G, La Torre F et al. (2001) Multicentre retrospective analysis of the outcome of artificial anal sphincter implantation for severe faecal incontinence. Br J Surg 88: 1481–1481

    Article  PubMed  Google Scholar 

  3. Altomare DF, Rinaldi O, Pannarale C, Memeo V (1997) Electrostimulated gracilis neosphincter for faecal incontinence and in total anorectal reconstruction: still an experimental procedure? Int J Colorectal Dis 12: 308–312

    Article  PubMed  Google Scholar 

  4. Baeten CG, Geerdes BP, Adang EM et al. (1995) Anal Dynamic Graciloplasty in the treatment of intractable fecal incontinence. N Engl J Med 332: 1600–1605

    Article  PubMed  Google Scholar 

  5. Baeten CG, Konsten J (1991) Dynamic Graciloplasty for treatment of feacal Incontinence. Lancet 338: 1163–1165

    Article  PubMed  Google Scholar 

  6. Baeten CG, Spaans F, Fluks A (1988) An implanted neuromuscular stimulator for fecal continence following previously implanted gracilis muscle. Report of a case. Dis Colon Rectum 31: 134–137

    PubMed  Google Scholar 

  7. Baeten CG and the Dynamic Graciloplasty Therapy Study Group (2000) Safety and Efficacy of Dynamic Graciloplasty for Fecal Incontinence: Report of a Prospective, Multicenter Trial. Dis Colon Rectum 43: 743–751

    Article  PubMed  Google Scholar 

  8. Carter KB, Finlay IG, Richardson W (1992) Prosthestic Anal Sphincter. International Patent WO92/ 16162: 1–24

  9. Casal E, San Ildenfonso A, Carracedo R et al. (2004) Artificial bowel sphincter in severe anal incontinence. Colorect Dis 6: 180–184

    Article  Google Scholar 

  10. Cavina E, Seccia M, Banti P, Zocco G (1998) Anorectal Reconstruction after abdominoperineal resection: Experience with Double-Wrap Graciloplasty Supported by Low-Frequency Electrostimulation. Dis Colon Rectum 41: 1010–1016

    Article  PubMed  Google Scholar 

  11. Centre of Evidence Based Medicine (2001) Levels of evidence and grades of recommandations. http://www.cebm.net

  12. Chandler JG, Adams RB, Friedman CJ et al. (1984) Assessment of an implantable ileostomy sphincter. Surgery 98: 72–80

    Google Scholar 

  13. Chapman AE, Geerdes B, Hewett P et al. (2002) Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg 89: 138–153

    PubMed  Google Scholar 

  14. Chetwood CH (1902) Plastic operation for restoration of the sphincter ani with report of a case. Med Rec 61: 529

    Google Scholar 

  15. Christiansen J, Lorentzen M (1987) Implantation of artificial anal sphincter for anal incontinence. Lancet 1987 2: 244–245

    Article  Google Scholar 

  16. Christiansen J, Rasmussen OØ, Lindorff-Larsen K (1998) Dynamic graciloplasty for severe anal incontinence. Br J Surg 85: 88–91

    Article  PubMed  Google Scholar 

  17. Christiansen J, Rasmussen OØ, Lindorff-Larsen K (1999) Long–Term Results of Artificial Anal Sphincter Implantation for Severe Anal Incontinence. Annals of Surgery 230: 45–48

    Article  PubMed  Google Scholar 

  18. Christiansen J, Sparsø B (1992) Treatment of anal incontinence by an implantable prosthetic anal sphincter. Ann Surg 215: 383–386

    PubMed  Google Scholar 

  19. Christiansen J (2000) The artificial anal sphincter. Can J Gastroenterol 14 [Suppl D]: 152–154

  20. Coloquahoun PH, Efron J, Wexner SD (2004) Attainment of Continence With J-poch and Artificial Bowel Sphincter for Concomitant Imperforate Anus and Familial Adenomatous Polypsis: Report of a Case. Dis Colon Rectum 47: 538–541

    Article  PubMed  Google Scholar 

  21. Da Silva GM, Jorge MN, Belin B et al. (2004) New Surgical Options for Fecal Incontinence in Patients With Imperforate Anus. Dis Colon Rectum 47: 204–209

    Article  PubMed  Google Scholar 

  22. Devesa JM, Rey A, Hervas PL et al. (2002) Artificial Anal Sphincter. Dis Colon Rectum 45: 1154–1163

    Article  PubMed  Google Scholar 

  23. Dodi G, Melega E, Massin A (2000) Artificial bowel sphincter (ABS) for severe faecal incontinence: a clinical and manometric study. Dis Colon Rectum 2: 207

    Google Scholar 

  24. Enck P, Gabor S, von Ferber L et al. (1991) Prevalence of fecal incontinence and degree of information possessed by family physicians and health insurance. Z Gastroenterol 29: 538–540

    PubMed  Google Scholar 

  25. Finlay IG, Richardson W, Hajivassiliou CA (2004) Outcame after implantation of a novel prosthetic anal sphincter in humans. Br J Surg 91: 1485–1492

    Article  PubMed  Google Scholar 

  26. Hajivassiliou CA, Carter KB, Finlay IG (1996) Anorectal angle enhances faecal continence. Br J Surg 83: 53–56

    PubMed  Google Scholar 

  27. Hajivassiliou CA, Finlay IG (1998) Effect of a novel prosthetic anal neosphincter on human colonic blood flow. Br J Surg 85: 1703–1707

    Article  PubMed  Google Scholar 

  28. Geerdes BP, Zoetmulder FAN, Heineman E et al. (1997) Total anorectal reconstruction with a double dynamic graciloplasty after abdominoperineal reconstruction for low rectal cancer. Dis Colon Rectum 40: 698–705

    Article  PubMed  Google Scholar 

  29. Gelet A, Meunier P, Platet RL et al. (1997) Treatment of dual urinary and fecal incontinence by implantation of two AMS 800 artificial sphincters. Case Report. Eur Urol 31: 115–117

    PubMed  Google Scholar 

  30. Giebel GD, Lefering R, Troidl H, Blöchl H (1998) Prevalence of fecal incontinence: what can be expected. Int J Colorect Dis 13: 73–77

    Article  Google Scholar 

  31. Ho KS, Seow-Choen F (2005) Dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection for rectal tumour. Int J Colorectal Dis 20: 38–41

    Article  PubMed  Google Scholar 

  32. Jarrett ME, Mowatt G, Glazener CM et al. (2004) Systematic review of sacral nerve stimulation for faecal incontinence and constipation. Br J Surg 91: 1559–1569

    Article  PubMed  Google Scholar 

  33. Koch SM, Uludağ Ö, Rongen MJ et al. (2004) Dynamic Graciloplasty in Patients with an anorectal Malformation. Dis Colon Rectum 47: 1711–1719

    Article  PubMed  Google Scholar 

  34. Lehur PA, Michot F, Denis Ph et al. (1996) Results of Artificial Sphincter in Severe Anal Incontinence: Report of 14 Consecutive Implantaions. Dis Colon Rectum 39: 1352–1355

    Article  PubMed  Google Scholar 

  35. Lehur PA, Roig JV, Dunislaeger M (2000) Artificial anal sphincter: prospective clinical and manometric evaluation. Dis Colon Rectum 43: 1100–1106

    Article  PubMed  Google Scholar 

  36. Lehur PA, Zeribib F, Neunlist M et al. (2002) Comparison of Quality of Life and Anorectal Function After Artificial Sphincter Implantation. Dis Colon Rectum 45: 508–513

    Article  PubMed  Google Scholar 

  37. Löhnert M (2006) Erste Deutsche Erfahrungen mit einem neuartigen Sphinkterersatzsystem bei analer Inkontinenz – das AMI-Analband. Coloproctology 28: 77 [Abstr]

    Google Scholar 

  38. Madoff R (1998) Cost-Effectiviness of Dynamic Graciloplasty in Patientst with Fecal Incontinence. Dis Colon Rectum 41: 733–743

    Article  Google Scholar 

  39. Mander BJ, Wexner SD, Williams NS et al. (1999) Preliminary results of a multicentre trial of the electrically stimulated gracilis neoanal sphincter. Br J Surg 86: 1543 –1548

    Article  PubMed  Google Scholar 

  40. Mander BJ, Abercrombie J, George BD, Wiliams NS (1996) The Electrically Stimulated Neosphincter incorporated as Part of total anorectal Reconstruction after abdominoperineal excision of the rectum. Ann Surg 224: 702–711

    Article  PubMed  Google Scholar 

  41. Matzel KE, Madoff RD, LaFontaine LJ et al. the dynamic Graciloplasty Therapy Study Group (2001) Complications of Dynamic Graciloplasty: Incidence, Management, and Impact on Outcome. Dis Colon Rectum 44: 1427–1435

    Article  PubMed  Google Scholar 

  42. Matzel KE, Kamm MA, Stosser M et al. (2004) Sacral spinal nerve stimulation for faecal incontinence: multicentre study. Lancet 363: 1270–1276

    Article  PubMed  Google Scholar 

  43. Mavrantonis C, Wexner SD (1999) Stimulated Graciloplasty for Treatment of Intractable Fecal Incontinence: Critical Influence of the Method of Stimulation. Dis Colon Rectum 42: 497–504

    Article  PubMed  Google Scholar 

  44. Marchal F, Doucet C, Lechaux D et al. (2005) Secondary implantation of an artificial sphincter after abdominoperineal resection and pseudocontinent perineal colostomy for rectal cancer. Gastroenterol Clin Biol 29: 425–428

    PubMed  Google Scholar 

  45. Mercati U, Trancanelli V, Castagnoli GP et al. (1991) Use of the gracilis muscles for sphincteric construction after abdominal resection: technique and preliminary results. Dis Colon Rectum 34: 1085–1089

    Article  PubMed  Google Scholar 

  46. Michot F, Costaglioli B, Leroi AM, Denis Ph (2003) Artificial Anal Sphincter in Severe Fecal Incontinence. Ann Surg 237: 52–56

    Article  PubMed  Google Scholar 

  47. Mundy L, Merlin TL, Maddern GJ, Hiller JE (2004) Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence. Br J Surg 91: 665–672

    Article  PubMed  Google Scholar 

  48. O‘Brien PE, Skinner St (2000) Restoring Control: The Acticon™Neosphincter Artificial Bowel Sphincter in the Treatment of Anal Incontinence. Dis Colon Rectum 43: 1213–1216

    Article  PubMed  Google Scholar 

  49. O‘Brien PE, Dixon JB, Skinner S et al. (2004) A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon™Neosphincter) for the control of fecal incontinence. Dis Colon Rectum 47: 1852–1860

    Article  PubMed  Google Scholar 

  50. Ortiz H, Armendariz P, DeMiguel M et al. (2002) Complications and functional outcome following artificial anal sphincter implantation. Br J Surg 89: 877–881

    Article  PubMed  Google Scholar 

  51. Ortiz H, Armendariz P, DeMiguel M et al. (2003) Prospective study of artificial anal sphincter and dynamic graciloplasty for severy anal incontinence. Int J Colorectal Dis 18: 349–354

    PubMed  Google Scholar 

  52. Parker SC, Spencer MP, Madoff RD et al. (2003) Artificial Bowel Sphincter. Dis Colon Rectum 46: 722–729

    Article  PubMed  Google Scholar 

  53. Penninckx F (2004) Belgian experience with dynamic graciloplasty for faecal incontinence. Br J Surg 91: 872–878

    Article  PubMed  Google Scholar 

  54. Pickrell K, Georgiade N, Richard EF, Morris F (1959) Gracilis muscle transplant for the correction of neurogenic rectal incontinence. Surg Clin North Am 39: 1405–1145

    PubMed  Google Scholar 

  55. Pickrell KL, Broadbent TR, Masters FW, Metzger JT (1952) Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle. Ann Surg 135: 853–862

    PubMed  Google Scholar 

  56. Pickrell KL, Georgiade N, Maguire C, Crawford H (1959) Gracilis Muscle transplant for rectal incontinence. Surgery 4: 349–363

    Google Scholar 

  57. Pickrell KL, Georgiade N, Richard EF, Morris F (1959) Gracilis muscle transposition for the correction of neurogenic rectal incontinence. Surg Clin North Am 39: 1405–1415

    PubMed  Google Scholar 

  58. Pickrell KL, Masters F, Georgiade N, Horton C (1954) Rectal sphincter reconstruction using gracilis muscle transplant. Plast Reconstr Surg 13: 46–55

    PubMed  Google Scholar 

  59. Riedel JG, Festage OA (1999) Eine neue Behandlungsmethode bei schwerer Stuhlinkontinenz im Kindesalter. Chirurg 70: 935–938

    Article  PubMed  Google Scholar 

  60. Romano G, La Torre F, Cutini G et al. (2003) Total anorectal Reconstruction with the Artificial Bowel Sphincter: Report of Eight Cases. Dis Colon Rectum 46: 730–734

    Article  PubMed  Google Scholar 

  61. Rongen MJ, Uludag Ö, El Naggar K et al. (2003) Long-Term Follow-Up of Dynamic Graciloplasty for Feacal Incontinence. Dis Colon Rectum 46: 716–721

    Article  PubMed  Google Scholar 

  62. Rosen HR, Ausch C, Novi G et al. (1999) Analer Schließmuskelersatz mittels dynamischer Gracilisplastik-Ergebnisse der Anwendung an 50 Patienten. Chirurg 70: 469–475

    Article  PubMed  Google Scholar 

  63. Rosen HR, Urbarz C, Novi G et al. (2001) Long-term results of modified graciloplasty for sphincter replacement after rectal excision. Colorectal Dis 4: 266–269

    Article  Google Scholar 

  64. Rouanet P, Senesse P, Bouamrirene D et al. (1999) Anal Sphincter Reconstruction by Dynamic Graciloplasty After Abdominoperineal Resection for Cancer. Dis Colon Rectum 42: 451–456

    Article  PubMed  Google Scholar 

  65. Rullier E, Zerbib F, Laurent C et al. (2000) Morbidity and functional outcome after double dynamic graciloplasty for anorectal reconstruction. Br J Surg 87: 909–913

    Article  PubMed  Google Scholar 

  66. Salmons S, Henriksson J (1981) The adaptive response of skeletal muscle to increased use. Muscle Nerve 4: 94–105

    Article  PubMed  Google Scholar 

  67. Salmons S, Vrbova G (1969) The influence of activity on some contractile characteristics of mammalian fast and slow muscles. J Physiol 201: 535–549

    PubMed  Google Scholar 

  68. Savata RM, King GE (1989) An artificial anal sphincter Phase 2: implantable sphincter with a perineal colostomy. J Surg Res 46: 207–211

    Article  Google Scholar 

  69. Scott FB, Bradley WE, Timms GW (1973) Treatment of urinary incontinence by implantable prosthetic sphincter. Urology 1: 252–259

    Article  PubMed  Google Scholar 

  70. Seccia M, Vincenzo L, Menconi C (2003) Applied electrophysiology of transposed muscle stimulation practical considerations and surgical experience on graciloplasty for orsel incontinence. Acta Bio Medica 74 [Suppl 2]: 84–88

  71. Shoemaker J (1909) Un nouveau proceudre operatoire pour lareconstruction du sphincter anal. Semaine Med 29: 160

    Google Scholar 

  72. Sielezneff I, Malouf AJ, Bartolo D et al. (1999) Dynamic graciloplasty in the treatment of patients with faecal incontinence. Br J Surg 86: 61–65

    Article  PubMed  Google Scholar 

  73. Sofia CA, Rush BF, Koziol J et al. (1988) Experiences with an artificial sphincter to establish continence in dogs. Am Surg 54: 390–394

    PubMed  Google Scholar 

  74. Thornton MJ, Kennedy ML, Lubowski DZ, King DW (2004) Long-Term follow–up of dynamic graciloplasty for faecal incontinence. Colorectal Dis 6: 470–476

    Article  PubMed  Google Scholar 

  75. Tilin T, Chambers M, Feldman R (2005) Outcomes of electrically stimulated gracilis neosphincter surgery. Health Technol Asses 9(28)

  76. Vaizey CJ, Kamm MA, Gold DM et al. (1998) Clinical, physiological, and radiological study of a new purpose–desingned artificial bowel sphincter. Lancet 351: 105–109

    Google Scholar 

  77. Violi V, Boselli AS, De Bernardinis M et al. (2004) Surgical results and functional outcome after total anorectal reconstruction by double graciloplasty supported by external-source electrostimulation and/or implantable pulse generators: an 8 year experience. Int J Colorectal Dis 19: 219–227

    Article  PubMed  Google Scholar 

  78. Violi V, Boselli AS, De Bernardinis M et al. (2005) Anorectal reconstruction by electrostimulated graciloplasty as part of abominoperineal resection. Eur J Surg Oncol 31: 250–258

    Article  PubMed  Google Scholar 

  79. Violi V, Roncoroni L, Borselli AS et al. (1999) Total anorectal reconstruction by double graciloplasty: experience with delayed, selective use of implantable pulse generators. Int J Colorectal Dis 14: 164–171

    Article  PubMed  Google Scholar 

  80. Wexner SD, Baeten C, Bailey R et al. (2002) Long-term efficacy of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 45: 809–818

    Article  PubMed  Google Scholar 

  81. Wexner SD, Gonzalez-Padron A et al. (1996) Stimulated Gracilis Neosphincter Operation: Initial Experience Pitfalls, and Complicatons. Dis Colon Rectum 39: 957–965

    Article  PubMed  Google Scholar 

  82. Wexner SD, Gonzalez-Padron A, Teoh T-A, Moon HK (1996) The Stilmulated gracilis neosphincter for fecal incontinence: A new use for an old concept. Plast Reconstr Surg 98: 693–699

    PubMed  Google Scholar 

  83. Whitehead WE, Wald A, Diamant NE et al. (1999) Functional disorders of the anus and rectum. Gut 45 [Suppl II]: 55–59

  84. Williams C (1893) Ein Vorschlag zur Herstellung des Sphincter nach Mastdarmexstirpation. Centralblatt für Chirurgie 19: 401–403

  85. Williams NS, Patel J, George BD et al. (1991) Development of an electrically stimulated neoanal sphincter. Lancet 338: 1166–1169

    Article  PubMed  Google Scholar 

  86. Wong WD, Congliosi SM, Spencer MP et al. (2002) The Saftey and Efficacy of the Artificial Bowel Sphincter for Fecal Incontinence. Dis Colon Rectum 45: 1139–1153

    Article  PubMed  Google Scholar 

  87. Wong WD, Jensen L, Bartolo D, Rothenberger D (1996) Artificial Anal Sphincter. Dis Colon Rectum 39: 1345–1351

    Article  PubMed  Google Scholar 

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  1. Abteilung für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Hugstetter Straße 55, 79106 , Freiburg im Breisgau

    O. Ruthmann, A. Fischer, U. T. Hopt &  H. J. Schrag

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Ruthmann, O., Fischer, A., Hopt, U.T. et al. Schließmuskelprothese vs. Ersatzmuskelplastik bei hochgradiger Stuhlinkontinenz?. Chirurg 77, 926–938 (2006). https://doi.org/10.1007/s00104-006-1217-0

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