Choosing a Technique

The recent development of multiple surgical techniques for fecal incontinence offers physicians and patients a variety of options for treatment. Choosing the appropriate therapy is based on the patient risk factors, etiology of the incontinence, procedure-specific contraindications, and associated pelvic floor deficits.

Patient risk factors for surgery have an important role in choosing a procedure. The least invasive is the ACYSTtm procedure, which can be performed during an office visit and is ideal for those who are poor surgical candidates or refuse more invasive techniques. The Secca® and SNS procedures are also minimally invasive but require local anesthesia, complicated equipment, and operating room monitoring for performance. The ACYSTTM, Secca®, and ABS demonstrate very low risk of complications and do not preclude the subsequent use of other techniques that can be used in the case of their failure. The ABS is an invasive procedure reserved for those in whom other techniques have failed and requires a motivated and otherwise healthy patient that is physically fit for possible multiple surgical revisions. It has a high rate of complications, is usually reserved as a last resort, and failure of this technique usually obligates that patient to a stoma.

Another patient factor that needs consideration before choice of therapy is mental capacity with respect to the more complicated techniques. The SNS, stimulated graciloplasty, and ABS procedures require patients with the cognitive ability to understand the technique, incorporate it into daily life, maintain the components, and understand potential complications and failure. In addition, those who undergo the stimulated graciloplasty and ABS should be prepared for possible repeat surgical interventions. Those with psychiatric conditions or emotional instability may not be suitable for these high-maintenance procedures and are probably better candidates for either the ACYSTTM or Secca® procedure, which do not require routine maintenance or follow-up.

Etiology is important to the consideration of the type of therapy chosen. The ACYSTTM and Secca® procedures do not attempt to correct the underlying etiology of the incontinence. Instead, these procedures involve augmenting the resistance of fecal passage by bulking or tightening the mucosa of the anal canal and rectum. Consequently, these techniques can be used in all forms of fecal incontinence, but are more effective in milder forms. Sacral nerve stimulation has also been used in a variety of causes of fecal incontinence but requires adequate neuromuscular architecture demonstrated on electromyography and pudendal nerve testing. Patients with severe neuropathy (absent bilateral pudendal motor latencies) or significant deficits/loss of sphincter muscle may not be amenable to SNS and are better candidates for sphincter replacement with the ABS.

Procedure-specific contraindications relate to the safety in performing the procedures in certain situations or in the placing of the artificial components. The presence of asso ciated anorectal pathology precludes choice of the ACYSTTM, Secca®, and ABS procedures because they all involve direct manipulation of the anus and rectum. Perianal disease (i.e., fistulas, fissures, abscesses, inflammatory bowel disease, perianal infections, anorectal carcinoma) and local radiation are contraindications to these procedures because of the inherently high risk of infectious complications. In contrast, contraindications to SNS include sacral diseases, such as spina bifida or sacral agenesis, cauda equina syndrome, or skin pathology at the site of electrode placement. Patients with a cardiac pacemaker or an implantable defibrillator cannot undergo SNS or the stimulated graciloplasty because of the obvious interference of the electrical stimulators. Lastly,some patients with fecal incontinence have associated pelvic floor dysfunction in the form of concomitant urinary incontinence. These patients may benefit most from SNS because it has shown to improve both of these impairments as opposed to the placement of separate urinary and bowel sphincters.

Multiple options are now available for patients with fecal incontinence without a sphincter defect and for whom conservative measures have failed. Each offers advantages and disadvantages that can be used to tailor specific treatments to individual needs.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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