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Approaches to Internal Anal Sphincter Augmentation

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Reconstructive Surgery of the Rectum, Anus and Perineum

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Abstract

As disappointing as the results have been relative to surgically improving external anal sphincter function, the ability to improve internal anal sphincter function has been even worse. A plethora of techniques including direct repair, overlapping repair, dynamic ­graciloplasty, stimulated graciloplasty, gluteoplasty, artificial bowel sphincter, and sacral nerve stimulation are designed as treatments for external anal sphincter defects. Attempts have been made for direct repair of the internal anal sphincter, but these results have been uniformly disappointing. Specifically, the internal anal sphincter is a thin muscle that does not readily hold sutures, and it is a difficult muscle in which to obtain any satisfactory healing. A surrogate for repair was the postanal repair, but this operation had a long-term success rate of approximately 35 % and therefore has largely fallen into the pages of history rather than being widely embraced in the current surgical era. Over the past several years, injectible material have been developed and assessed. Although no single agent has proven to be a panacea, the mere concept that the sphincter can be augmented seems intriguing. In addition to injectible agents, radiofrequency energy has been administered with some modicum of success. A detailed discussion of the various agents as well as a review of results is contained in this chapter. It is hoped that during the next several years we will be able to be comfortable with offering patients with internal anal sphincter defects one or more options with the anticipation of success with a low morbidity profile.

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References

  1. Nelson R, Norton N, Cautley E, Furner S. Community based ­prevalence of anal incontinence. JAMA. 1995;274:559–61.

    Article  PubMed  CAS  Google Scholar 

  2. Macmillan AK, Merrie AE, Marshall RJ, Parry BR. The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum. 2004;47:1341–9.

    Article  PubMed  Google Scholar 

  3. Gibbons CP, Trowbridge EA, Bannister JJ, Read NW. Role of anal cushions in maintaining continence. Lancet. 1986;1(8486):886–8.

    Article  PubMed  CAS  Google Scholar 

  4. Rao SS. Pathophysiology of adult fecal incontinence. Gastroenterology. 2004;126:14–22.

    Article  Google Scholar 

  5. Vaizey CJ, Kamm MA, Bartram CI. Primary degeneration of the internal anal sphincter as a cause of passive fecal incontinence. Lancet. 1997;349:612–5.

    Article  PubMed  CAS  Google Scholar 

  6. Da Silva GM, Berho M, Wexner SD, Efron J, Weiss EG, Nogueras JJ, et al. Histologic analysis of the irradiated anal sphincter. Dis Colon Rectum. 2003;46:1492–7.

    Article  PubMed  Google Scholar 

  7. Altomare DF, Rinaldi M, Sallustio PL, Martino P, De Fazio M, Memeo V. Long-term effects of stapled hemorrhoidectomy on internal anal function and sensitivity. Br J Surg. 2001;88:1487–91.

    Article  PubMed  CAS  Google Scholar 

  8. Leroi AM, Kamm MA, Weber J, Denis P, Hawley PR. Internal anal sphincter repair. Int J Colorectal Dis. 1997;12:243–5.

    Article  PubMed  CAS  Google Scholar 

  9. Morgan R, Patel B, Beynon J, Carr ND. Surgical management of anorectal incontinence due to internal anal sphincter deficiency. Br J Surg. 1997;84:226–30.

    Article  PubMed  CAS  Google Scholar 

  10. Takahashi-Monroy T, Morales M, Garcia-Osogobio S, Valdovinos MA, Belmonte C, Barreto C, et al. SECCA procedure for the treatment of fecal incontinence: results of five-year follow-up. Dis Colon Rectum. 2008;51:355–9.

    Article  PubMed  Google Scholar 

  11. Edden Y, Wexner SD. Therapeutic devices for fecal incontinence: dynamic graciloplasty, artificial bowel sphincter and sacral nerve stimulation. Expert Rev Med Devices. 2009;6:307–12.

    Article  PubMed  Google Scholar 

  12. de la Portilla F, Rada R, Vega J, González CA, Cisneros N, Maldonado VH. Evaluation of the use of posterior tibial nerve ­stimulation for the treatment of fecal incontinence: preliminary results of a prospective study. Dis Colon Rectum. 2009;52:1427–33.

    Article  PubMed  Google Scholar 

  13. Keegan PE, Atiemo K, Cody J, McClinton S, Pickard R. Periurethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev. 2007;18:CD003881.

    Google Scholar 

  14. van Kerrebroeck P, ter Meulen F, Farrelly E, Larsson G, Edwall L, Fianu-Jonasson A. Treatment of stress urinary incontinence: recent developments in the role of urethral injection. Urol Res. 2003;30:356–62.

    PubMed  Google Scholar 

  15. Pycha A, Klinger CH, Haitel A, Heinz-Peer G, Marberger M. Implantable microballoons: an attractive alternative in the management of intrinsic sphincter deficiency. Eur Urol. 1998;33:469–75.

    Article  PubMed  CAS  Google Scholar 

  16. Menard S, Porta GD. Incidence, growth and antigenicity of fibrosarcomas induced by Teflon disc in mice. Tumori. 1976;62:565–73.

    PubMed  CAS  Google Scholar 

  17. Witherspoon P, Bryson G, Wright DM, Reid R, O’Dwyer PJ. Carcinogenic potential of commonly used hernia repair prostheses in an experimental model. Br J Surg. 2004;91:368–72.

    Article  PubMed  CAS  Google Scholar 

  18. Shafik A. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Int Surg. 1993;78:159–61.

    PubMed  CAS  Google Scholar 

  19. Politano VA. Periurethral polytetrafluoroethylene injection for urinary incontinence. J Urol. 1982;127:439–42.

    PubMed  CAS  Google Scholar 

  20. Chaliha C, Williams G. Periurethral injection therapy for the treatment of urinary incontinence. Br J Urol. 1995;76:151–5.

    Article  PubMed  CAS  Google Scholar 

  21. Malizia AA, Reiman HM, Myers RP, Sande JR, Barham SS, Benson RC, et al. Migration and granulomatous reaction alter periurethral injection of polytef (Teflon). JAMA. 1984;251:3277–81.

    Article  PubMed  Google Scholar 

  22. Lightner DJ. Review of the available urethral bulking agents. Curr Opin Urol. 2002;12:333–8.

    Article  PubMed  Google Scholar 

  23. Shafik A. Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis Colon Rectum. 1995;38:583–7.

    Article  PubMed  CAS  Google Scholar 

  24. Currie I, Drutz HP, Deck J, Oxorn D. Adipose tissue and lipid droplet embolism following periurethral injection of autologous fat: case report and review of the literature. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8:377–80.

    Article  PubMed  CAS  Google Scholar 

  25. Malouf AJ, Vaizey CJ, Norton CS, Kamm MA. Internal anal sphincter augmentation for fecal incontinence using injectable silicone material. Dis Colon Rectum. 2001;44:595–600.

    Article  PubMed  CAS  Google Scholar 

  26. Kenefick NJ, Vaizey CJ, Malouf AJ, Norton CS, Marshall M, Kamm MA. Injectable silicone biomaterial for fecal incontinence due to internal anal sphincter dysfunction. Gut. 2002;51:225–8.

    Article  PubMed  CAS  Google Scholar 

  27. Uroplasty. Product-overview. Access online in http://www.­uroplasty.com/Products.asp.

  28. Smith DP, Kaplan WE, Oyasu R. Evaluation of polydimethylsiloxane as an alternative in the endoscopic treatment of vesicoureteral reflux. J Urol. 1994;152:1221–4.

    PubMed  CAS  Google Scholar 

  29. Henly DR, Barrett DM, Weiland TL, O’Connor MK, Malizia AA, Wein AJ. Particulate silicone for use in periurethral injections: local tissue effects and search for migration. J Urol. 1995;153:2039–43.

    Article  PubMed  CAS  Google Scholar 

  30. Nijhuis PH, van den Bogaard TE, Daemen MJ, Baeten CG. Perianal injection of polydimethylsiloxane (bioplastique implants) paste in the treatment of soiling: pilot study in rats to determine migratory tendency and locoregional reaction. Dis Colon Rectum. 1998;41:624–9.

    Article  PubMed  CAS  Google Scholar 

  31. de la Portilla F, Vega J, Rada R, Segovia-Gonzáles MM, Cisneros N, Maldonado VH, et al. Evaluation by three-dimensional anal endosonography of injectable silicone biomaterial (PTQ) implants to treat fecal incontinence: long-term localization and relation with the deterioration of the continence. Tech Coloproctol. 2009;13:195–9.

    Article  PubMed  Google Scholar 

  32. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 2000;342:781–90.

    Article  PubMed  CAS  Google Scholar 

  33. Bar-Meir E, Eherenfeld M, Shoenfeld Y. Silicone gel breast implants and connective tissue disease – a comprehensive review. Autoimmunity. 2003;36:193–7.

    Article  PubMed  Google Scholar 

  34. Kumar D, Benson MJ, Bland JE. Glutaraldehyde cross-linked ­collagen in the treatment of fecal incontinence. Br J Surg. 1998;85:978–9.

    Article  PubMed  CAS  Google Scholar 

  35. Stegman SJ, Chu S, Bensch K, Armstrong R. A light and electron microscope evaluation of Zyderm collagen and Zyplast implants in ageing human facial skin. A pilot study. Arch Dermatol. 1987;123:1644–9.

    Article  PubMed  CAS  Google Scholar 

  36. Leonard MP, Canning DA, Epstein JI, Gearhart JP, Jeffs RD. Local tissue reaction to the subureteral injection of glutaraldehyde cross-linked bovine collagen in humans. J Urol. 1990;143:1209–12.

    PubMed  CAS  Google Scholar 

  37. Appell RA. New developments: injectables for urethral incompetence in women. Int Urogynecol J. 1990;1:117–9.

    Article  Google Scholar 

  38. Davis K, Kumar D, Poloniecki J. Preliminary evaluation of an ­injectable anal sphincter bulking agent (Durasphere) in the management of fecal incontinence. Aliment Pharmacol Ther. 2003;18:237–43.

    Article  PubMed  CAS  Google Scholar 

  39. Pannek J, Brands FH, Senge T. Particle migration alter transurethral injection of carbon coated beads for stress urinary incontinence. J Urol. 2001;166:1350–3.

    Article  PubMed  CAS  Google Scholar 

  40. Ganio E, Marino F, Giani I, Luc AR, Clerico G, Novelli E, et al. Injectable synthetic calcium hydroxylapatite ceramic microspheres (Coaptite) for passive fecal incontinence. Tech Coloproctol. 2008;12:99–102.

    Article  PubMed  CAS  Google Scholar 

  41. Danielson J, Karlbom U, Sonesson AC, Wester T, Graf W. Submucosal injection of stabilized nonanimal hyaluronic acid with dextranomer: a new treatment option for fecal incontinence. Dis Colon Rectum. 2009;52:1101–6.

    Article  PubMed  Google Scholar 

  42. Dodi G, Jongen J, De la Portilla F, Raval M, Altomare DF, Lehur PA. An open-label, non comparative, multicenter study to evaluate efficacy safety of Nasha/Dx Gel as a bulking agent for the treatment of fecal incontinence, Castroenterol RES PRACT 2010; 2010: 467736.

    Google Scholar 

  43. Stenberg A, Larsson G, Johnson P, Heimer G, Ulmsten U. DiHA dextran copolymer, a new biocompatible material for endoscopic treatment of stress incontinent women. Short team results. Acta Obstet Gynecol Scand. 1999;78:436–42.

    Article  PubMed  CAS  Google Scholar 

  44. Stenberg AM, Sundin A, Larsson BS, Lackgren G, Stenberg A. Lack of distant migration after injection of a 125Iodine labeled dextranomer based implant into the Rabbit bladder. J Urol. 1997;158:1937–41.

    Article  PubMed  CAS  Google Scholar 

  45. Maeda Y, Vaizey CJ, Kamm MA. Pilot study of two new injectable bulking agents for the treatment of fecal incontinence. Colorectal Dis. 2008;10:268–72.

    Article  PubMed  CAS  Google Scholar 

  46. Feretis C, Benakis P, Dailianas A, Dimopoulos C, Mavrantonis C, Stamou KM, et al. Implantation of microballoons in the management of fecal incontinence. Dis Colon Rectum. 2001;44:1605–9.

    Article  PubMed  CAS  Google Scholar 

  47. Mitterberger M, Pinggera GM, Marksteiner R, Margreiter E, Plattner R, Klima G, et al. Functional and histological changes after myoblast injections in the porcine rhabdosphincter. Eur Urol. 2007;52:1736–43.

    Article  PubMed  Google Scholar 

  48. Kwon D, Kim Y, Pruchnic R, Jankowski R, Usiene I, de Miguel F, et al. Periurethral cellular injection: comparison of muscle-derived progenitor cells and fibroblasts with regard to efficacy and tissue contractility in an animal model of stress urinary incontinence. Urology. 2006;68:449–54.

    Article  PubMed  Google Scholar 

  49. Feki A, Faltin DL, Lei T, Dubuisson JB, Jacob S, Irion O. Sphincter incontinence: is regenerative medicine the best alternative to restore urinary or anal sphincter function? Int J Biochem Cell Biol. 2007;39:678–84.

    Article  PubMed  CAS  Google Scholar 

  50. Kang SB, Lee HN, Lee JY, Park JS, Lee HS, Lee JY. Sphincter contractility after muscle-derived stem cells autograft into the cryoinjured anal sphincters of rats. Dis Colon Rectum. 2008;51:1367–73.

    Article  PubMed  Google Scholar 

  51. Aghaee-Afshar M, Rezazadehkermani M, Asadi A, Malekpour-Afshar R, Shahesmaeili A, Nematollahi-mahani SN. Potential of human umbilical cord matrix and rabbit bone marrow-derived mesenchymal stem cells in repair of surgically incised rabbit external anal sphincter. Dis Colon Rectum. 2009;52:1753–61.

    Article  PubMed  Google Scholar 

  52. Miranda KYC, Tjandra JJ. Injectable silicone biomaterial (PTQTM) to treat fecal incontinence after hemorrhoidectomy. Dis Colon Rectum. 2006;49:433–9.

    Article  Google Scholar 

  53. Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for fecal incontinence in adults. Cochrane Database Syst Rev. 2010:CD007959.

    Google Scholar 

  54. Smart M, Merce-Jones M, Response to Maeda Y, Vaizey CJ, Kamm MA. Pilot study of two new injectable bulking agents for the treatment of fecal incontinence. Colorectal Dis. 2008;10:628.

    Google Scholar 

  55. Tjandra JJ, Chan MK, Yeh HC. Injectable silicone biomaterial (PTQ) is more effective than carbon-coated beads (Durasphere) in treating passive fecal incontinence-a randomized trial. Colorectal Dis. 2009;11:382–9.

    Article  PubMed  CAS  Google Scholar 

  56. Siproudhis L, Morcet J, Lainé F. Elastomer implants in fecal incontinence: a blind, randomized placebo-controlled study. Aliment Pharmacol Ther. 2007;25:1125–32.

    Article  PubMed  CAS  Google Scholar 

  57. Tjandra JJ, Lim JF, Hiscock R, Rajendra P. Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective. Dis Colon Rectum. 2004;47:2138–46.

    Article  PubMed  CAS  Google Scholar 

  58. Bernardi C, Favetta U, Pescatori M. Autologous fat injection for treatment of fecal incontinence: manometric and echographic assessment. Plast Reconstr Surg. 1998;102:1626–8.

    Article  PubMed  CAS  Google Scholar 

  59. Weiss EG, Efron JF, Nogueras JJ, Wexner SD. Submucosal injection of carbon coated beads is a successful and safe office-based treatment for fecal incontinence. Dis Colon Rectum. 2002;45:A46–7.

    Google Scholar 

  60. Altomare DF, La Torre F, Rinaldi M, Binda GA, Pescatori M. Carbon-coated microbeads anal injection in outpatient treatment of minor fecal incontinence. Dis Colon Rectum. 2008;51:432–5.

    Article  PubMed  CAS  Google Scholar 

  61. Aigner F, Conrad F, Margreiter R, Oberwalder M. Anal submucosal carbon bead injection for treatment of idiopathic fecal incontinence: a preliminary report. Dis Colon Rectum. 2009;52:293–8.

    Article  PubMed  Google Scholar 

  62. Aigner F. Injectables with special regard to Durasphere for the treatment of fecal incontinence. Colorectal Dis. 2007;9:13–60.

    Article  Google Scholar 

  63. Beggs A, Irukulla S, Sultan AH, Ness W, Abulafi A. A pilot study of ultrasound guided Durasphere injection in the treatment of Fecal Incontinence. Colorectal Dis. 2010;12:935–40.

    Article  PubMed  CAS  Google Scholar 

  64. Jorge JM, Yusuf S, Alvarenga C, Habr-Gama A, Kiss DR, Gama-Rodrigues JJ. Transsphincteric injection of silicone biomaterial in the treatment of fecal incontinence due to internal anal sphincter defects. Dis Colon Rectum. 2004;47:565–660.

    Article  Google Scholar 

  65. Oliveira LC, Neves Jorge JM, Yussuf S, Habr-Gama A, Kiss D, Cecconello I. Anal incontinence improvement after silicone injection may be related to restoration of sphincter asymmetry. Surg Innov. 2009;16:155–61.

    Article  PubMed  Google Scholar 

  66. Chan MK, Tjandra JJ. Injectable silicone biomaterial (PTQ) to treat fecal incontinence after hemorrhoidectomy. Dis Colon Rectum. 2006;49:433–9.

    Article  PubMed  Google Scholar 

  67. Van der Hagen SJ, van Gemert WG, Baeten CG. PTQ implants in the treatment of fecal soiling. Br J Surg. 2007;94:222–3.

    Article  PubMed  Google Scholar 

  68. Gaj F, Trecca A, Crispino P. Efficacia dell’agente PTQ nel trattamento dell’incontinenza fecale. Chir Ital. 2007;59:355–9.

    PubMed  Google Scholar 

  69. Maeda Y, Vaizey CJ, Kamm MA. Long-term results of perianal silicone injection for fecal incontinence. Colorectal Dis. 2007;9:357–61.

    Article  PubMed  CAS  Google Scholar 

  70. de la Portilla F, Fernandez A, Leon E, Rada R, Cisneros N, Maldonado VH, et al. Evaluation of the use of PTQTM implants for the treatment of incontinent patients due to internal anal sphincter dysfunction. Colorectal Dis. 2008;10:89–94.

    PubMed  Google Scholar 

  71. Soerensen MM, Lundby L, Buntzen S, Laurberg S. Intersphincteric injected silicone biomaterial implants: a treatment for fecal incontinence. Colorectal Dis. 2009;11:73–6.

    Article  PubMed  CAS  Google Scholar 

  72. Bartlett L, Ho YH. PTQ anal implants for the treatment of fecal incontinence. Br J Surg. 2009;96:1468–75.

    Article  PubMed  CAS  Google Scholar 

  73. Graf W, Danielsson J, Sonesson AC. Results after submucous bulking therapy with NASHA/Dx for anal incontinence in relation to pretreatment clinical characteristic. Poster no. 280. In: 37th annual meeting of the International Continence Society, Rotterdam, 2007.

    Google Scholar 

  74. Dehli T, Lindsetmo RO, Mevik K, Vonen B. Anal incontinence assessment of a new treatment. Tidsskr Nor Laegeforen. 2007;127:2934–6.

    PubMed  Google Scholar 

  75. Stojkovic SG, Lim M, Burke D, Finan PJ, Sagar PM. Intra-anal collagen injection for the treatment of fecal incontinence. Br J Surg. 2006;93:1514–8.

    Article  PubMed  CAS  Google Scholar 

  76. Luo C, Samaranayake CB, Plank LD, Bissett IP. Systematic review on the efficacy and safety of injectable bulking agents for passive fecal incontinence. Colorectal Dis. 2010;12:296–303.

    Article  PubMed  CAS  Google Scholar 

  77. Ratto C, Parello A, Donisi L, Litta F, De Simone V, Spazzafumo L, Giordano P. Novel bulking agent for faecal incontinence. Br J Surg. 2011;98:1644–53.

    Article  PubMed  CAS  Google Scholar 

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  1. Coloproctology Section, Department of Surgery, Virgen del Rocio University Hospital, Avda. Manuel Siurot s/n, Seville, 41013, Spain

    Fernando de la Portilla M.D., Ph.D., MAECP, EBSQ-C

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  1. Fernando de la Portilla M.D., Ph.D., MAECP, EBSQ-C
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Correspondence to Fernando de la Portilla M.D., Ph.D., MAECP, EBSQ-C .

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    Andrew P. Zbar

  2. Delware Street 420, Minneapolis, 55455, Minnesota, USA

    Robert D. Madoff

  3. , Dept. Colorectal Surgery, Cleveland Clinic, Florida, Cleveland Clinic Blvd. 2950, Weston, 33331, Florida, USA

    Steven Wexner

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de la Portilla, F. (2013). Approaches to Internal Anal Sphincter Augmentation. In: Zbar, A., Madoff, R., Wexner, S. (eds) Reconstructive Surgery of the Rectum, Anus and Perineum. Springer, London. https://doi.org/10.1007/978-1-84882-413-3_33

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