What is the best option for failed sphincter repair?

Abstract

This study aimed to evaluate the outcome of various procedures for patients with fecal incontinence following failed sphincteroplasty. Patients who underwent surgery for failed sphincteroplasty from January 2000 to June 2011 [corrected] were identified. They were assessed using the Fecal Incontinence Quality of Life (FIQoL) scale and the Cleveland Clinic Florida-Wexner Fecal Incontinence Score (CCFFIS). Fifty-nine patients [97% females; median age 52 (25-81) years] were identified. They underwent either repeat sphincteroplasty (RS; n = 33), artificial bowel sphincter (ABS; n = 11) or sacral nerve stimulation (SNS; n = 15). The median follow-up was 31 (3-138) months. The RS group had a significantly wider external sphincter defect and had undergone fewer previous sphincteroplasties. The most common complication was infection. The incidence of complications was significantly higher after ABS (73%) compared with RS (24%) and SNS (33%) (P = 0.01). Seventeen (29%) patients required re-operation for complications or failure, with a lower rate in the RS group (P = 0.004). There was no difference in the rates of device removal after ABS or SNS. Ten (17%) patients underwent further surgery or re-implantation of the device with no difference between the groups. At follow-up, five (45%) ABS and 10 (67%) SNS patients retained a functioning device (P = 0.4). The mean postoperative CCFFIS decreased from 17.5 to 11.5 in the RS group, from 18.7 to 8.6 in the ABS group, and from 17.6 to 9.1 in the SNS group (P ≤ 0.02 for all). There were no differences in the improvement of CCFFIS or FIQoL scores among groups. RS, ABS and SNS are associated with similar improvements in continence after failed sphincteroplasty. Due to increased complications and re-operation with ABS and SNS, RS may be the first step in managing these patients.