fecal incontinence


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fecal incontinence

  1. 1. بسم الله الرحمن الرحيم <ul><li>قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم </li></ul><ul><li>صدق الله العظيم </li></ul><ul><li>سورة البقرة </li></ul><ul><li>آية (32) </li></ul>
  2. 2. ACKNOWLEDGMENT First and foremost I would like to thank ALLAH , the Most Merciful and Gracious, for lightening my path and guiding me. I would like to express my gratitude to Prof. Dr. Osama Abd-Elrahman Khalil , professor of general surgery faculty of medicine Zagazig University, for giving me the honor to perform this essay, and for his kind supervision during all stages of this work.
  3. 3. ACKNOWLEDGMENT <ul><li>In addition, my thanks go to Prof. Dr. Mohammad Selim Abbod , professor of general surgery faculty of medicine Zagazig University, for his constant advice and guidance throughout this work. </li></ul><ul><li>Also I would like to thank Dr. Abd-Elhafez Mohammad El-Shewel , lecturer of general surgery faculty of medicine Zagazig University, who provided me a great support and help all through the time I spend to collect the material for this essay. </li></ul>
  4. 4. ACKNOWLEDGMENT <ul><li>Last I am extremely indebted to my family , to whom I dedicate my successes, which are only a pure product of their answered prayers. </li></ul>
  5. 5. <ul><li>Fecal Incontinence </li></ul>
  6. 6. <ul><li>INTRODUCTION </li></ul>
  7. 7. INTRODUCTION <ul><li>Fecal incontinence (FI) is the involuntary passage of bowel contents through the anus or through an external stoma. It ranges from the unintentional elimination of flatus to the seepage of liquid fecal matter or sometimes the complete evacuation of bowel contents. </li></ul><ul><li>It occurs in about 1% to 7.4% in general populations, and up to 25% in elderly populations. This condition causes considerable embarrassment that in turn causes loss of self-esteem, social isolation and diminished quality of life. </li></ul>
  8. 8. INTRODUCTION <ul><li>The anus is the outlet of the gastrointestinal tract and evacuation of bowel contents depends on action by the muscles of the involuntary internal anal sphincter (IAS), the voluntary external anal sphincter (EAS) and pelvic floor muscles. </li></ul><ul><li>The anorectal region is composed of: </li></ul><ul><li>1) Anus and anal verge </li></ul><ul><li>2) Anal canal </li></ul><ul><li>3) Anorectal ring </li></ul>
  9. 9. INTRODUCTION <ul><li>The factors considered responsible for maintaining anal continence and facilitating defecation are: </li></ul><ul><li>1. The anal canal high-pressure zone </li></ul><ul><li>2. Anorectal angle </li></ul><ul><li>3. Flutter valve </li></ul><ul><li>4. Anorectal sensitivity and reflex mechanism </li></ul><ul><li>5. Rectal compliance and capacity </li></ul><ul><li>6. Rectal motility </li></ul><ul><li>7. Anal canal motility </li></ul><ul><li>8. Colonic transit time </li></ul><ul><li>9. Stool volume and consistency </li></ul><ul><li>10. Rectosigmoidal junction sphincter </li></ul><ul><li>11. Corpus cavernosum of the anus </li></ul>
  10. 10. <ul><li>AIM OF THE ESSAY </li></ul>
  11. 11. AIM OF THE ESSAY <ul><li>The aim of this essay is to discuss the different dimensions of FI and to declare the different tools of making clear diagnosis and the different options of management of this condition and its complications. </li></ul>
  12. 12. <ul><li>ETIOLOGY OF FI </li></ul>
  13. 13. ETIOLOGY OF FI <ul><li>There are many causes as: </li></ul><ul><li>1. Congenital causes: Anorectal anomalies, Spinal cord abnormalities, Isolated sacral agenesis </li></ul><ul><li>2. CNS: Cerebrovascular accidents, Multiple sclerosis, Spinal cord injury </li></ul><ul><li>3. Diabetes Mellitus </li></ul><ul><li>4. Aging </li></ul><ul><li>5. Intestinal Disorders: Inflammatory Bowel Disease, Irritable Bowel Syndrome </li></ul>
  14. 14. ETIOLOGY OF FI <ul><li>6. Pelvic Radiotherapy </li></ul><ul><li>7. Fecal impaction </li></ul><ul><li>8. Rectal Prolapse </li></ul><ul><li>9. Obstetric trauma </li></ul><ul><li>10. Anal Surgery: Sphincterotomy, Anal Dilatation, Fistula Surgery, Hemorrhoidectomy </li></ul><ul><li>11. Rectal Resection </li></ul><ul><li>12. Hysterectomy </li></ul>
  15. 15. <ul><li>EVALUATION OF FI </li></ul>
  16. 16. EVALUATION OF FI <ul><li>Evaluation of FI can be done by: </li></ul><ul><li>Clinical history and assessment of severity </li></ul><ul><li>General examination </li></ul><ul><li>Anorectal examination: Inspection, Palpation and Digital examination </li></ul><ul><li>Investigations: Endoscopy, Anorectal manometry, Balloon expulsion test, Pudendal nerve terminal motor latency, Saline infusion test, Electromyography, Endoanal ultrasound (EAUS), Magnetic resonance imaging (MRI), Defecography </li></ul><ul><li>Psychological and Quality of Life evaluation. </li></ul>
  17. 17. EVALUATION OF FI <ul><li>EAUS showing EAS defect after obstetric injury. </li></ul>
  18. 18. EVALUATION OF FI <ul><li>MRI showing severe thinning of IAS and a disruption of EAS </li></ul>
  19. 19. <ul><li>TREATMENT OF FI </li></ul>
  20. 20. TREATMENT OF FI <ul><li>Indeed, a wide range of therapeutic options is available, including non-surgical and surgical procedures. </li></ul><ul><li>Non-surgical treatment: </li></ul><ul><li>Medical treatment </li></ul><ul><li>Rehabilitation </li></ul><ul><li>Radiofrequency </li></ul><ul><li>Hyperbaric oxygen </li></ul><ul><li>Anal plugs and devices </li></ul><ul><li>Psychological Management </li></ul>
  21. 21. TREATMENT OF FI <ul><li>Medical treatment: </li></ul><ul><li>Diet and Patient Education </li></ul><ul><li>For FI associated with chronic diarrhea, bulking and antidiarrheal agents as Loperamide can be used. </li></ul><ul><li>For FI associated with chronic constipation, bulking agents and laxatives can be used. </li></ul>
  22. 22. TREATMENT OF FI <ul><li>Rehabilitation: </li></ul><ul><li>It is considered the first line option in treating FI in patients who have not responded to simple dietary advice or medication. The rehabilitative techniques include: </li></ul><ul><li>1) Biofeedback therapy: consists of pelvic floor strengthening exercises. </li></ul><ul><li>2) Pelviperineal Kinesitherapy: selectively aims at the levator ani muscles. </li></ul>
  23. 23. TREATMENT OF FI <ul><li>3) Sensory Retraining: to increase rectal sensation. </li></ul><ul><li>4) Electrostimulation: not a clinically effective as it is passive therapy. </li></ul>
  24. 24. TREATMENT OF FI <ul><li>Radiofrequency: </li></ul><ul><li>This procedure is used with a weak or thinned anal sphincter complex. Patients with a history of inflammatory bowel disease, extensive perianal disease or chronic diarrhea should not be offered this treatment. </li></ul><ul><li>The radiofrequency generator produces heat by a high frequency alternating current causing tissue heating and collagen contraction that tightening the tissue. </li></ul>
  25. 25. TREATMENT OF FI <ul><li>Hyperbaric oxygen: </li></ul><ul><li>It has several physiologic effects on damaged nerves in animal models, which lead to an improvement in neurologic function. </li></ul><ul><li>It may used with idiopathic FI secondary to pudendal neuropathy. </li></ul>
  26. 26. TREATMENT OF FI <ul><li>Anal plugs and devices: </li></ul><ul><li>It may be useful for patients with impaired anal canal sensation, neurological disease and in bed-ridden patients. </li></ul>
  27. 27. TREATMENT OF FI <ul><li>Surgical treatment: </li></ul><ul><li>Sphincteroplasty </li></ul><ul><li>Postanal pelvic floor repair </li></ul><ul><li>Dynamic Graciloplasty </li></ul><ul><li>Gluteoplasty </li></ul><ul><li>Artificial Bowel Sphincter </li></ul><ul><li>Sacral Nerve Stimulation </li></ul><ul><li>Injectable Bulking Agents </li></ul><ul><li>Rectal Augmentation </li></ul><ul><li>Antegrade Colonic Enema </li></ul><ul><li>Stomata </li></ul>
  28. 28. TREATMENT OF FI <ul><li>Sphincteroplasty: </li></ul><ul><li>Indicated in obstetrical tears that occur in the anterior midline and in sphincter damage arising from other anorectal procedures. </li></ul><ul><li>Successful outcomes between 70% and 80%. </li></ul>
  29. 29. TREATMENT OF FI <ul><li>Sphincteroplasty: In prone jack knife position, Incision around the anterior portion of the anus over the perineal body: A. Dissection begins with lateral mobilization of muscle edges, which are then B. secured with mattress sutures through the existing scar and healthy muscle in order to C. recreate the sphincter complex. </li></ul>
  30. 30. TREATMENT OF FI <ul><li>wound closure with V-Y advancement. </li></ul>
  31. 31. TREATMENT OF FI <ul><li>Postanal pelvic floor repair: </li></ul><ul><li>It is performed on patients with idiopathic FI with no evidence of sphincter defect on EAUS. </li></ul><ul><li>The patients expected to benefit most from postanal repair are women with a history of multiple vaginal deliveries. </li></ul><ul><li>Successful outcomes between 80% and 88%. </li></ul>
  32. 32. TREATMENT OF FI <ul><li>Postanal pelvic floor repair . In prone jack knife position, Incision is curvilinear posterior to the anal canal, Dissection in the intersphincteric plane to reveal PR and levator ani. </li></ul>
  33. 33. TREATMENT OF FI <ul><li>Sutures in the upper levator ani are loosely tied to create a lattice behind the rectum, Approximation of pubococcygeus, </li></ul>
  34. 34. TREATMENT OF FI <ul><li>Approximation of EAS and PR, skin closure. </li></ul>
  35. 35. TREATMENT OF FI <ul><li>Dynamic Graciloplasty (DGP): </li></ul><ul><li>It is a major procedure and must be reserved for the most severe forms of FI, as in patient with severe trauma that cannot be treated with other methods. </li></ul><ul><li>Contraindications of DGP are intussusception, rectocele, enterocele, and rectal prolapse. </li></ul><ul><li>Success rates from 45% to 80%. </li></ul>
  36. 36. TREATMENT OF FI <ul><li>DGP diagrams. In lithotomy position, skin incision in medial aspect of thigh then gracilis muscle is exposed and isolated, perianal tunnel is prepared by 2 incisions, </li></ul>
  37. 37. TREATMENT OF FI <ul><li>Gracilis muscle has been transposed in perianal space, the tendon is sutured to periosteum of contralateral pubic bone. </li></ul>
  38. 38. TREATMENT OF FI <ul><li>Overview of the end result of DGP: ( 1 ) implantable neurostimulator; ( 2 ) anode and cathode; ( 3 ) position of the neurovascular bundle; ( 4 ) attachment of the tendon of the gracilis. </li></ul>
  39. 39. TREATMENT OF FI <ul><li>Gluteoplasty : </li></ul><ul><li>Gluteoplasty has the same indications as graciloplasty, but graciloplasty is more frequently performed. </li></ul><ul><li>FI secondary to spina bifida or myelomeningocele are absolute contraindications to gluteoplasty. </li></ul><ul><li>Successful outcomes about 72%. </li></ul>
  40. 40. TREATMENT OF FI <ul><li>Bilateral Gluteoplasty: A In prone jack knife position, sigmoid incision near the infragluteal crease, B Perirectal incisions are made, anterior and posterior tunnels are developed, the gluteus is detached, C The gluteal slips are brought to the contralateral ischial tuberosity and secured. </li></ul>
  41. 41. TREATMENT OF FI <ul><li>Artificial Bowel Sphincter (ABS): </li></ul><ul><li>The best indications for the ABS are the anal sphincter lesions inaccessible to local repair, neurological incontinence and not responsive to sacral nerve stimulation test. </li></ul><ul><li>Contraindications to implantation of an ABS are excessive perineal descent, severe constipation, irradiated perineum, perineal sepsis, anal agenesis and anal coitus. </li></ul>
  42. 42. TREATMENT OF FI <ul><li>The ABS comprises 3 parts: perianal occlusive cuff, control pump (implanted in subcutanous tissues of the scrotum or labium) and pressure-regulating balloon (implanted in a pocket created in the subperitoneal space). </li></ul><ul><li>Success rates from 69%-83%. </li></ul>
  43. 43. TREATMENT OF FI <ul><li>Overview of the ABS: Anal opening is achieved by transferring the pressurized fluid from perianal cuff toward the balloon by means of the control pump. </li></ul>
  44. 44. TREATMENT OF FI <ul><li>Sacral Nerve Stimulation (SNS): </li></ul><ul><li>Indications for permanent SNS are FI due to a deficiency of the smooth muscle of the IAS and to functional deficits of both sphincters, as in scleroderma, degeneration or disruption of the IAS and idiopathic sphincteric weakness. </li></ul><ul><li>Contraindications included spina bifida, skin disease at the area of implantation, pregnancy, and presence of cardiac pacemaker. </li></ul><ul><li>Success rates about 95%. </li></ul>
  45. 45. TREATMENT OF FI <ul><li>A permanent SNS system: consisting of an electrode, connecting cable and pulse generator. </li></ul>
  46. 46. TREATMENT OF FI <ul><li>Injectable Bulking Agents : </li></ul><ul><li>The bulking agent should be non-migratory, non-allergic, non-immunogenic, non-carcinogenic and easy to inject. </li></ul><ul><li>Injectable PTQ (polydimethylsiloxane) implant appears to be the most effective injectable agent available. </li></ul><ul><li>Injection of muscle-derived stem cells or couple of magnets are still at a preliminary stage. </li></ul>
  47. 47. TREATMENT OF FI <ul><li>Success rates are about 68% of patients at 1 year after injection. </li></ul><ul><li>Injection is directed into the intersphincteric space in the four quadrants. If there is a defect of the IAS, three injections are directed into the defect, with the fourth injection into the contralateral site to provide symmetry. </li></ul>
  48. 48. TREATMENT OF FI <ul><li>Rectal Augmentation (RA) : </li></ul><ul><li>RA is a new surgical technique that normalizing rectal capacity, compliance and improve rectal reservoir function in patients with severe fecal urgency. </li></ul><ul><li>It is done through longitudinal division of the anterior rectal wall, followed by augmentation of this defect with an ileal patch using a linear cutting stapler. </li></ul>
  49. 49. TREATMENT OF FI <ul><li>Antegrade Colonic Enema (ACE) : </li></ul><ul><li>This technique is an effective surgical option to treat patients with combined FI and severe constipation and recommended as a last option before colostomy. </li></ul><ul><li>ACE through an appendicostomy originally described for FI in children. The appendix is connected to the umbilicus and through which the enema can be administered. </li></ul>
  50. 50. TREATMENT OF FI <ul><li>Another technique using the terminal ileum as a conduit with a side-to-side ileocecal anastomosis. </li></ul><ul><li>Success rates about 90%. </li></ul>
  51. 51. TREATMENT OF FI <ul><li>Stomata: </li></ul><ul><li>A number of patients in whom the surgical procedures described above are inapplicable or not lead to satisfactory bowel control should be offered a permanent colostomy. </li></ul>
  52. 52. <ul><li>CONTINENT STOMATA </li></ul>
  53. 53. CONTINENT STOMATA <ul><li>Patients with an end colostomy are confronted with very severe problems from a social and esthetic viewpoint. </li></ul><ul><li>An external device may used to plug or occlude the colon following an abdominal colostomy. </li></ul>
  54. 54. CONTINENT STOMATA <ul><li>Many surgical trials were done to make the stoma continent, such as: </li></ul><ul><li>Kock technique (nipple valve) </li></ul><ul><li>Autotransplantation of the Pylorus </li></ul><ul><li>Kock pouch </li></ul><ul><li>T-pouch </li></ul><ul><li>Skeletal muscle slips </li></ul><ul><li>Free-muscular colonic graft </li></ul><ul><li>Simultaneous cecostomy and ileostomy </li></ul><ul><li>Continent stoma rectus sheath tunnel. </li></ul>
  55. 55. <ul><li>Thank you </li></ul>