Surgical Therapy

The key to deciding what kind of surgical therapy should be used depends on whether or not the anal sphincters are intact. This evaluation and treatment are discussed elsewhere in this book in greater detail. Simply stated, those patients in whom surgical therapy is planned who have sphincter defects should have an overlapping sphincter repair. For those patients with intact sphincters, other interventions such as submucosal injection of bulking agents - Durasphere™ (formerly known as ACYSTtm; Boston Scientific Corp., Boston MA), radiofrequency energy delivery to the anal canal - the Secca® procedure (Curon Medical, Sunnyvale, CA) (Chapter 6-10, Figure 610.7, a and b), sacral nerve stimulation (Chapter 6-10, Figure 6-10.9), stimulated or nonstimulated unilateral or bilateral graciloplasty (Chapter 6-10, Figures 6-10.1 and 6-10.2), or artificial bowel sphincter implantation (Chapter 6-10, Figure 6-10.4, a and b) may be considered.

Finally, one must consider the role of fecal diversion in the management of fecal incontinence. Fecal diversion can be used as a temporary or permanent procedure, or as primary or secondary therapy. In a select group of patients, permanent fecal diversion may be the best therapeutic option. For those patients with severe incontinence and altered mobility or mental status, a permanent stoma may significantly improve quality of life.10 In patients with spinal cord injury, ostomies have been shown to improve the quality of life and decrease the amount of weekly time spent on bowel care from 10.3 to 1.9 hours on average .u Other patients in whom permanent fecal diversion may be considered are those with unreparable defects, patients who have failed other attempts at surgery, or those in whom other forms of surgery are undesirable or too risky. Fecal diversion may be the best choice for elderly, debilitated, and institutionalized patients or those who do not wish to have other procedures.10 In appropriately selected cases, ostomies are easier to care for and may in some patients be preferable to a life of restricted social activities, especially because enterostomal therapy has advanced so significantly.12

The other major role for fecal diversion in the management of incontinence is that of a temporary stoma. Patients who have had multiple or complex repairs, severe trauma, and/or perineal contamination (perineal sepsis), associated pelvic injuries, or Crohn's disease may benefit from diversion before repair.13 The decision to divert is dependent on the type of surgery used to restore continence, the patient's comorbidities, and the quality of the tissue used to affect the repair. For example, studies have shown that routine diversion in the setting of overlapping sphinctero-plasty is not necessary.1,14 The goal of diversion is to allow the tissues to heal with less risk of sepsis, and to close the stoma at a later date. Closure of the stoma is individualized based on the healing process and is generally performed within 3 to 6 months after the restorative procedure. Experience at Cleveland Clinic Florida has shown that laparo-scopic creation of colostomies and ileostomies can be performed safely and with a more rapid recovery than if performed by laparotomy.15 Creation of a stoma, although usually considered a relatively simple procedure, is not entirely free of complications. The overall complication rate varies between 25% and 75%16-20 and is usually divided into early complications (less than a month after the procedure) and late complications. Early complications include skin irritation,ischemia, and partial necrosis of the stoma, retraction, dehydration caused by high output (mainly in ileostomies), and bleeding. Late complications occur more than a month after the procedure and may include parastomal hernias, stenosis, and prolapse as well. Obesity and inflammatory bowel diseases predispose to complications whereas enterostomal nursing care may help prevent them.17 There is no consensus as to which is the best method to divert the fecal stream. Some authors prefer colostomies19 whereas others demonstrated the superiority of ileostomies.18 The method of diversion that is used most often in the Cleveland Clinic Florida is a loop ileostomy, preferably performed laparoscopically.21

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