Anal incontinence: surgical treatment

Surgery often seems the only possible treatment of a traumatic analincontinence or the last possibility of an anal incontinence afterfailure of the other treatments, namely medical treatmentsand biofeedback.The surgeon can use the anatomical structures like colon, rectum ormuscles, carrying out a surgery of restoration, or implant in theperineum other structures: muscular transposition or prostheticmaterial carrying out a surgery of substitution.Several techniques of myorraphy were described: anterior myorraphy,posterior myorraphy or postanal repair, anterior and posteriormyorraphy or total pelvic floor repair; these various techniquesare rarely used currently because of the inconstancy of their resultsand the long-term degradation of the results initially obtained.Sphincterorraphy is a direct repair of external anal sphincter,carried out by peri-anal access centered on the sphincter defectlocated by endo-anal sonography. Its functional results are good in70% of the short-term cases; however, they tend to be deterioratedwith time and only 50% of the patients will keep their good initialfunctional result in the long term; 3 factors correlated with abad result were identified: a rupture of the internal anal sphincter, adecrease of resting pressure in ano-rectal manometry, a pudendalneuropathy on the electrophysiological tests. The sphincterorraphyremains the intervention of choice each time the external analsphincter is technically reparable, i.e. when its rupture is lower than50% of its circumference. Over the past ten years, surgical techniquesof substitution developed: dynamic graciloplasty, artificialanal sphincter, sacral nerve stimulation. The dynamicgraciloplasty and the artificial anal sphincter have as a commonobjective: to substitute for the external anal sphincter, either themuscle gracilis, or a prosthesis placed in peri-anal situation.The dynamic graciloplasty is less currently used than the artificialanal sphincter, its technique is more complicated, its follow-up ismore difficult, requiring many consultations, its functional resultsseem lower, finally its cost is twice higher. At all events, the rate offailure of these two interventions is important, approximately 25%,the principal complication being of a septic nature. On the otherhand, the results of the artificial anal sphincter are of good qualityon the anal continence in more than 80% of the cases. The sacralnerve stimulation is the electric stimulation of the sacral nerves viaan electrode placed at their contact by percutaneous way and connectedto a neuromodulator, after one period of test which lastsabout fifteen days and which makes it possible to judge real effectiveness of the neuromodulation on the anal continence. The electiveindication of this technique is an anal incontinence withsphincter anatomically preserved in endo-anal sonography and ofneurological origin is identified by the electrophysiological tests.The results are good on the anal continence among patients selectedafter positivity of the initial test. Recently, other techniquesappeared, in the course of validation, in particular the radiofrequencyof the anal canal whose principle is to create by the hightemperature induced on the level of the anal canal, a tissue contractionand a sclerosis of the internal anal sphincter