Steven D Wexner, MD, PhD.
Chairman, Department of Colorectal Surgery
Cleveland Clinic, Florida (USA)
Fecal incontinence has a major impact on quality of life. The different options for treating fecal incontinence include sphincter repair, sphincter augmentation, replacement therapy, nerve stimulation, and fecal diversion.
Overlapping sphincteroplasty has been performed by Wexner and his team in the past, with a 76% success rate according to results from the ’90s. It is not a durable operation, however, if we check the long-term results.
One of the simplest alternative options is augmentation with injectables (such as silicone, bulkamid, permacol, hyaluronic, PTQ, etc). Perianal implants are not a curative treatment but they improve anal function in the short term.
Nonablative radiofrequency, applied transanally in the internal sphincter, has been shown to improve IQL. Stem cells are rechannelled in their function through this technique, modifying the collagen composition and the muscle bundle height, resulting in improved sphincter function. This process, however, takes 6 to 12 months.
Dynamic graciloplasty is a complex operation that has now been abandoned (in part due to its complexity) but which had a high success rate in some patients.
Artificial bowel sphincter is another option, with a high rate of infections and explantations, but has good results when well tolerated.
Magnetic anal sphincter is approved by the FDA but not in the market any more. It had a significant improvement in continence and was placed through a single incision in the perineum.
Sacral Neuromodulation, the percutaneous placement of an electrode into the 3rd-4th sacral foramina, has proved to have good results in the short and long term, even when there is a sphincter defect.
Finally, Dr. Wexner shows an algorithm for the treatment of fecal incontinence. When it involves an isolated sphincter defect with no associated neuropathy, sphincteroplasty can be proposed as a temporary treatment. When it is a multifocal sphincter defect, sacral nerve stimulation currently seems to be the best option, although in some patients other simple procedures, such as injectables or radiofrequency, can be considered.
