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Faecal Incontinence Anterior Sphincter Repair

Faecal Incontinence Anterior Sphincter Repair. Normal Continence. Internal sphincter: - Visceral innervation - 85% continence. External sphincter: - Somatic innervation - 15% continence. Secondary Muscles of continence. Primary Muscles of continence.

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Faecal Incontinence Anterior Sphincter Repair

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  1. Faecal IncontinenceAnterior Sphincter Repair

  2. Normal Continence Internal sphincter: - Visceral innervation - 85% continence External sphincter: - Somatic innervation - 15% continence Secondary Muscles of continence Primary Muscles of continence

  3. Faecal IncontinenceThe Issues 1. Structure vs Function 2. Surgery vs Conservative

  4. No Defect ‘No Repair’

  5. Incidence of Perineal Trauma • 90% of incontinent women with an obstetric history have a sphincter defect (Burnett, S.J. BJS 1991) • Women with 30/40 tear • 74% Symptomatic • 59% Incontinent of Gas • 90% Sphincter Defect (Goffeng, A.R. Act.OGS 1998) • 35% of Primiparous women will have a sphincter defect after delivery (13% symptomatic) (Sultan, A.H. NEJM 1993)

  6. Forceps

  7. Obstetric Injuryde Parades et al. DCR 2004 • 93 females : Single forceps delivery • Results • 11% partial external defects • 1% partial external and complete internal defects • Symptoms • 18% flatus incontinence • 4% liquid stool incontinence • Correlates • Perineal tear predicts sphincter defect

  8. Pelvic AnatomyMechanism Of Injury

  9. Obstetric TraumaMechanism Of Injury

  10. The Mechanism Of Injury

  11. Obstetric InjuryMechanisms Rectovaginal septum - rectocoele Ischaemic injury - fistula Sphincter complex - incontinence

  12. Faecal IncontinenceStructural Defect

  13. Faecal Incontinence Which Treatment • Tailored for individual patient • Tailored to degree of perceived symptoms • Tailored to anatomy of sphincter • Tailored to other injury • Start simple • Avoid complex

  14. Faecal IncontinenceAlgorithm Defect No defect Conservative Symptoms + Symptoms - Conservative Surgical Graciloplasty Artificial sphincter Sacral nerve stimulation Surgical Anterior sphincter repair Stoma

  15. Acute Sphincter Repair ‘End to End’ Vs ‘Overlapping’

  16. Obstetric InjuryFitzpatrick et al. Am J Ob Gyn 2000 • RCT Overlapping vs approximation • 112 females with third degree tears • Results • Incontinence scores • 0/20 (Ov) vs 2/20 (Ap) • Urgency • 11 (Ov) vs 17 (Ap) • Manometry and US • No differences • 66% had persistent US defects

  17. Obstetric InjuryPinta et al. DCR 2004 • 52 females : Third and fourth degree tears • Primary repair • Results • 61% symptoms of anal incontinence • 20% symptoms of faecal incontinence • Significantly worse than a control group • Persistent external defects • 75% in repair group • 20% in control group

  18. Anterior Sphincter Repair

  19. Anterior Sphincter Repair

  20. Anterior Sphincter Repair

  21. Anterior Sphincter Repair

  22. Anterior Sphincter Repair

  23. Anterior Sphincter Repair

  24. Anterior Sphincter Repair

  25. Anterior Sphincter Repair

  26. Anterior Sphincter Repair

  27. Anterior Sphincter Repair

  28. Anterior Sphincter Repair

  29. Post Surgical Repair

  30. Predicting OutcomeResidual endosonographic defect after repair • Residual endosonographic defect in • 30% of Successful Group • 80% of Failed Group • Positive predictive value of intact repair 70% • Negative predictive value of persistent defect 80%

  31. Success Fail Fail Predicting OutcomeLength of repaired sphincter 6 Failed repair Successful Repair 4 Number of women 2 0 6 - 10 11 - 15 16 - 20 0 - 5 Length of anterior external anal sphincter (mm)

  32. Anterior Sphincter RepairLong Term Outcome • 55 pts undergoing overlap repair • Early- 42 continent solid and liquid 15 months • Late • 46 at least 5 year follow up • 27 symptoms improved • 23 improved by at least 50% • 38 pts (7 further surgery, 1 stoma) • 0 continent solid and flatus • 4 continent to solid and liquid • 6 no urgency, 8 no soiling • 20 needed pads, 25 lifestyle restriction • 14 evacuation disorder Malouf et al Lancet 2000

  33. Summary • Carefully assess patient • Arrange appropriate investigations • Try simple measures • Fix prolapse • If there is a defect repair it • Be aware of long term results • If there is no defect DO NOT repair it • Tailor your treatment to the patient

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