Treatment for Fecal Incontinence: Muscle Transposition, Artificial Bowel Sphincter, Magnetic Sphincter, and Stem Cell Regeneration

Abstract

Restoration of continence through restoration of the normal anal sphincter mechanism is a challenge for all colorectal surgeons. The negative quality-of-life impact of fecal incontinence has been a motivation for the development of newer innovative procedures and products. Complex surgical procedures, such as muscle transpositions and artificial sphincters, will be discussed.

Commentary by Donato F. Altomare, Azienda Ospedaliero Universitaria Policlinico Bari, Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy

Commentary

• Donato F. Altomare 

Fecal incontinence is one of the most distressing functional diseases with great impact on the patients’ quality of life, working ability, and social and sexual life. Nevertheless, the interest of researchers on this topic has focused only in the last 30 years because of the reluctance of the patients to discuss their disability with their doctors, and because of the poor knowledge of the pathophysiology of fecal incontinence and the lack of reliable treatments, particularly in the long term. These considerations make fecal incontinence one of the most challenging condition to treat.

This excellent chapter is written by one of the most renowned experts in this field and focuses on the management of a difficult case of fecal incontinence in a mid-age woman. The case is analyzed and described with great experience and any possible diagnostic and therapeutic option is critically discussed showing profound knowledge of the argument and a wise proposal of the possible surgical options.

The author uses this case report to demonstrate how a difficult patient like the one presented in this chapter should be examined, starting from taking a good history and performing a physical and instrumental examination. The use of reliable scoring systems to assess the severity of the diseases, and its effect on the patient’s quality of life, is crucial not only to follow up the effectiveness of the treatment, but also to choose the best surgical option for each patient. A fecal incontinence of moderate severity but with profound impact on the quality of life, for example, could justify the use of some invasive procedures.

In the case reported by Dr. Oliveira, the possible surgical options are gone through, explaining the pros and cons of each surgical technique, including some old and obsolete treatments like the gluteoplasty or the unstimulated graciloplasty. The addition of continuous low-frequency electrostimulation of this muscle in the early 1990s by Cor Baeten and by Norman Williams represented a significant step forward in the treatment of difficult cases like the one presented in this chapter; however, the high percentage of complications and the insufficient long-term results have limited the diffusion of this technique to very few specialized centers, making the production of the electrostimulator device from Medtronic® economically inconvenient. For that reasons, the company recently stopped its production and distribution.

Similarly, the attempts of mimicking the anal sphincter function by an implantable dynamic artificial bowel sphincter resulted in poor long-term outcome and unacceptable percentage of complications [57].

Therefore, several researchers came back to the old idea of the anal encirclement but using new elastic materials or a magnetic beads ring as described in this chapter. But any foreign material placed in that region of the body is destined to fail. Another more conservative option includes the injection of bulking agents or, more recently, the perianal injection of expandable prosthesis. This minimally invasive technique has been reported to achieve good functional result [58] although the correct indication is still questioned.

The proposal of using autologous myoblast stem cells to regenerate the anal sphincter is pretty new and very intriguing. However, the procedure to expand and inject human stem cells is still experimental and very expensive, even if the few researcher experts in this field have reported excellent results [59].

Finally, this chapter does not discuss the use of sacral nerve stimulation for fecal incontinence because it is reported in a separate chapter. However, this surgical option could have been considered in a patient like this, after failure of a sphincteroplasty [19]. The complex and poorly known mechanism of action of this electrostimulation could help patient with different types of incontinence, even if the long-term outcome, like all the techniques described, is disappointing [60].