Treatment for Fecal Incontinence: Sphincteroplasty and Postanal Repair

Abstract

Management of fecal incontinence requires a multimodal approach including medical and surgical strategies. This chapter details surgical management with overlapping sphincteroplasty and describes the now historic Parks postanal repair. Indications, patient selection, operative technique, revision procedures, outcomes, and patient counseling are explored.

Commentary by Massarat Zutshi, Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, OH, USA

Commentary

• Massarat Zutshi 

The chapter on sphincteroplasty is well written with a focus on why it is no longer a gold standard in the treatment of fecal incontinence. In the era of neuromodulation and the success associated with this treatment, sphincteroplasty does fade from the algorithm of procedures to treat fecal incontinence. With poor long-term outcomes, which may be a result of poor tissues, advancing age, and muscle atrophy, the authors make a valid point about its efficacy. There are very few single surgeon reports that show a good long-term outcome. That it is no longer considered a primary procedure is without doubt. In young patients after an obstetric injury or as part of a recto-vaginal fistula repair, it does still have a place and if done well can achieve good results. However, there are places in the world where neuromodulation may not be available or cost-effective, or it may be that certain patients do not want or cannot have a device, or have an allergy to the metal used; hence, knowledge of the procedure should be part of the curriculum.

The authors describe the operative procedure very well. It should however be noted that often, there may not be scar tissue in the midline that needs to be divided. Often the external sphincter is retracted and has to be identified and dissected. Most often, the sphincter complex is dissected en mass as it is difficult to dissect. Care should be taken to avoid overdissection of the muscle belly to prevent neurological damage, leading to further atrophy. During approximation, the sutures are placed without tension to prevent ischemic necrosis. As end-to-end repairs have been shown to be equally efficient to overlapping tension should be avoided at all costs. If the muscle tissue is insufficient to begin with, augmenting the sphincter with a biologic mesh may be considered [32,33,34,35,36,37,38,39,40].

Redo repairs require expertise as often the anatomy is distorted. Redo sphincteroplasty should be undertaken if the patient has had a previous good outcome and the muscle tissue appears sufficient on an endoanal ultrasound. Redo repair on muscle that looks poor or if the previous repair is still holding is bound to be unsuccessful.

A successful sphincteroplasty should always be followed by biofeedback with electrical stimulation to increase muscle tissue. Good bowel management also contributes to a good outcome.