Therapeutische Optionen bei Stuhlinkontinenz. Alternativen zur definitiven Kolostomie?

Transkript

1 Therapeutische Optionen bei Stuhlinkontinenz. Alternativen zur definitiven Kolostomie? K. E. Matzel Department Chirurgie, Universität, Germany Bern, 23. April 2009

2 Ja, etliche

3 Begriffsklärung klinisch etablierte operative Techniken Indikationsspektrum Ergebnisse Therapiealgorithmus

4 International Counsultation on Incontinence, ICI 2008 Patient presents with FI Basic assessment (e.g. history, examination, medication and diet review) Take out of pathway: Alarm signals: referral for investigation Impaction: treat then evaluate Surgical evaluation needed: e.g. rectal prolapse, recent sphincter injury, fistula Address reversible risk factor e.g. Medication; toilet access; loose stools Patient and / or carer education C Bowel habit and training C Manage constipation C (E I) Diet (e.g. soluble fibre for loose stool) B (E II) Medication (e.g. loperamide for loose stool) C PFMT / anal sphincter exercises C If initial management fails to achieve adequate symptom relief consider: Diagnostic testing; Biofeedback; Irrigation C (E I) Surgical evaluation or symptom management if adequate relief not obtained from conservative management, depending on symptom severity and patient preference

5 Candidate for surgery for FI Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Colostomy

6 Diagnostik der Stuhlinkontinenz

7 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect International Consultation on Incontinence, 2008

8 EAUS: Ventraler Defekt

9 EAUS: Ventraler Defekt

10 EAUS: Sphinkter Defekt: EAS

11 EAUS: Sphinkter Defekt: EAS Oberer Mittlere Untere

12 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect < 180 International Consultation on Incontinence, 2008

13 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect < 180 Sphincter Repair International Consultation on Incontinence, 2008

14 Begriffsklärung Sphinkterrepair: Sphinkteroplastik: primärer, zeitnahe Rekonstruktion nach Trauma sekundäre, zeitversetzte Rekonstruktion nach Trauma

15 Sphinkterrekonstruktion

16 Sphinkterrekonstruktion Überlappende oder Stoß-auf-Stoß- Naht ebenbürtig (RCT) - sofern adäquat mobilisiert und Analring rekonstruiert - Ausgeprägte Denervation/verlängerte PNTML: Ergebnis schlechter Tjandra JJ, et al.. Dis Col Rect 46: , 2003

17 Sphinkteroplastik: Ergebnisse N umber of Follow -up Con tinen t % A uthors (ref) Y ear pat ien ts (months ) (exc e llen t / good) Fles h man e t a l [41] Enge l e t a l [42] Londono -Schim m er e t al [43] Oli v eir a e t al [44] * 71 Gi llilan d e t a l [45] * 55 $ Young et al [46] * 86 $ M alouf e t a l [1] Karoui e t a l [47] Oster b erg e t al [48] Morren e t a l [49] Tan e t a l [50] Halve r son and H u ll [2] Bra vo G u tierr e z e t al [51] Nor d erval e t a l [52] Zorcolo e t a l [53] * 55 Trowbridge e t a l [54] Ba r is ic e t a l [55] * 48 M adoff [56] # m e tan a lysis * M ed ian fo llow -up + 130/190 av a ilab le for 10 y e ar fo llow -up $ defined a s Ņsuc c essf u lól

18 Sphinkteroplastik: Ergebnisse CONTINENCE: EXCELLENT/ GOOD N umber of Follow -up Con tinen t % A uthors (ref) Y ear pat ien ts (months ) (exc e llen t / good) Fles h man e t a l [41] Enge l e t a l [42] Londono -Schim m er e t al [43] Oli v eir a e t al [44] * 71 Gi llilan d e t a l [45] * 55 $ Young et al [46] * 86 $ M alouf e t a l [1] Karoui e t a l [47] Oster b erg e t al [48] Morren e t a l [49] Tan e t a l [50] Halve r son and H u ll [2] Bra vo G u tierr e z e t al [51] Nor d erval e t a l [52] Zorcolo e t a l [53] * 55 Trowbridge e t a l [54] Ba r is ic e t a l [55] * 48 M adoff [56] # m e tan a lysis * M ed ian fo llow -up + 130/190 av a ilab le for 10 y e ar fo llow -up $ defined a s Ņsuc c essf u lól

19 Sphinkteroplastik: Ergebnisse CONTINENCE: EXCELLENT/ GOOD N umber of Follow -up Con tinen t % A uthors (ref) Y ear pat ien ts (months ) (exc e llen t / good) Fles h man e t a l [41] Enge l e t a l [42] Londono -Schim m er e t al [43] Oli v eir a e t al [44] * 71 Gi llilan d e t a l [45] * 55 $ 18 Monate Young et al [46] * 86 $ M alouf e t a l [1] Karoui e t a l [47] Oster b erg e t al [48] Morren e t a l [49] Tan e t a l [50] Halve r son and H u ll [2] Monate Bra vo G u tierr e z e t al [51] Nor d erval e t a l [52] Zorcolo e t a l [53] * 55 Trowbridge e t a l [54] Ba r is ic e t a l [55] * 48 M adoff [56] # m e tan a lysis * M ed ian fo llow -up + 130/190 av a ilab le for 10 y e ar fo llow -up $ defined a s Ņsuc c essf u lól

20 Sphinkteroplastik: Langzeitergebnisse N=69 Fwup: 62.5 M. (47-141) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% IK: Stuhl IK: Gas, Schleim kontinent Monate Halverson A et al, DCR, 45,335-8,2002

21 Sphinkteroplastik: Langzeitergebnisse

22 Sphinkteroplastik Indikation: klinisch relevante Lücke des externen analen Sphinkters < 180 Grad,> 90 Grad - Trauma: Entbindung, Operationen Versagen konservativer Therapie

23 Sphinkteroplastik Bei symptomatischen Patienten mit definiertem Defekt des EAS - meist anteriorer Defekt - Kurzzeiteffekt: gut - exzellent: 31-86%: - Langzeiteffekt: kontinent nach 5 J: 10-14%: Patientenzufriedenheit 10 J: 40 %

24 Sphinkteroplastik Bei symptomatischen Patienten mit definiertem Defekt des EAS - meist anteriorer Defekt - Kurzzeiteffekt: gut - exzellent: 31-86%: - Langzeiteffekt: kontinent nach 5 J: 10-14%: Patientenzufriedenheit 10 J: 40 % - additives Biofeedback möglicherweise wirkungvoll - Ergebnis anhand einzelner manometrischer und physiologischer (PNTML) Parameter nicht vorhersagbar

25 Sphinkteroplastik Wiederholter Sphinkterepair bei Symptom- und Lückenpersistenz - Repair vs. ReRepair: gutes Ergebnis: 50% vs. 58 % - Langzeiteffekt: mässig, vergleichbar zu 1. Repair

26 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect < 180 Sphincter Repair International Consultation on Incontinence, 2008

27 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect < 180 >180 or perineal tissue loss Sphincter Repair International Consultation on Incontinence, 2008

28 Dammriss Grad IV

29 Behandlungskonzepte Sphinkterrepair / Sphinkteroplastik: Rekonstruktion der Anatomie führt zu Funktionswiederherstellung Sphinkterersatzverfahren: Ersatz der Anatomie führt zu Funktionswiederherstellung

30

31 Evidenz: Sphinkterersatz: DGP Published results of dynamic graciloplasty: since 1999, including series with 40 or more patients, general measures of continence Authors Year Number of Percentage Follow-up patients continent* Madoff et al [49 ] months (median) 66 Mander et al [50 ] months (median) 69 Baeten et al [51] months (mean) 74 Wexner et al [52 ] months 53 Rongen et al [53 ] months (median) 72 Pennickx et al [54] months (median) 55 Tillin et al [55] months (median) 70 Table adapted from [30] * variable definitions; does not necessarily denote perfect continence

32 Evidenz: Sphinkterersatz: DGP Published results of dynamic graciloplasty: since 1999, including series with 40 or more patients, general measures of continence Authors Year Number of Percentage Follow-up patients continent* Madoff et al [49 ] months (median) 66 Mander et al [50 ] months (median) 69 Baeten et al [51] months (mean) 74 Wexner et al [52 ] months 53 Rongen et al [53 ] months (median) 72 Pennickx et al [54] months (median) 55 Tillin et al [55] months (median) 70 Table adapted from [30] Percentage * variable definitions; does not necessarily denote perfect continence continent 53-74

33 Evidenz: Sphinkterersatz: DGP Bei irreparablem Sphinkterdefekten in Betracht zu ziehen - Alternative zur Stomaanlage - Erhebliche postoperative Morbidität - Variable Ergebnisse: 55 % - 74 % - gut in Zentren mit Volumen - Lernkurve

34 Artificial Bowel Sphincter

35 Evidenz: Sphinkterersatz: ABS Published results of artifical bowel sphincter: since 1999, including series with 10 or more patient, general measures of continence Authors Year Number of patients Mean or median follow-up (months) Number (%) of functioning devices "Success" in patients with a functioning device "Success" in intention to treat Lehur et al [46 ] (83%) 90% 75% O'Brien et al [56] ns 10 (77%) 90% 69% Malouf et al [57] (39%) ns 39% Altomare et al [58] (75%) 67% 50% Devesa et al [59] (49%) 65% 53% Wong et al [60] (65%) 85% 54% Ortiz et al [61] (68%) 60% 41% Lehur et al [62] (75%) 92% 69% Parker et al [63] (46%) 49% 47% Michot et al [64] (80%) 79% 60% Casal et al [65] (90%) 44% 40% Altomare et al [66] ns: long-tem 6 (24%) 50% 12%

36 Evidenz: Sphinkterersatz: ABS Published results of artifical bowel sphincter: since 1999, including series with 10 or more patient, general measures of continence Authors Year Number of patients Mean or median follow-up (months) Number (%) of functioning devices "Success" in patients with a functioning device "Success" in intention to treat Lehur et al [46 ] (83%) 90% 75% O'Brien et al [56] ns 10 (77%) 90% 69% Malouf et al [57] (39%) ns 39% Altomare et al [58] (75%) 67% 50% Devesa et al [59] (49%) 65% 53% Wong et al [60] (65%) 85% 54% Ortiz et al [61] (68%) 60% 41% Lehur et al [62] (75%) 92% 69% Parker et al [63] (46%) 49% 47% Michot et al [64] (80%) 79% 60% Casal et al [65] (90%) 44% 40% Altomare et al [66] ns: long-tem 6 (24%) 50% 12% Functioning device 24% - 83%

37 Evidenz: Sphinkterersatz: ABS Published results of artifical bowel sphincter: since 1999, including series with 10 or more patient, general measures of continence Authors Year Number of patients Mean or median follow-up (months) Number (%) of functioning devices "Success" in patients with a functioning device "Success" in intention to treat Lehur et al [46 ] (83%) 90% 75% O'Brien et al [56] ns 10 (77%) 90% 69% Malouf et al [57] (39%) ns 39% Altomare et al [58] (75%) 67% 50% Devesa et al [59] (49%) 65% 53% Wong et al [60] (65%) 85% 54% Ortiz et al [61] (68%) 60% 41% Lehur et al [62] (75%) 92% 69% Parker et al [63] (46%) 49% 47% Michot et al [64] (80%) 79% 60% Casal et al [65] (90%) 44% 40% Altomare et al [66] ns: long-tem 6 (24%) 50% 12% Success 24% - 90%

38 Evidenz: Sphinkterersatz: ABS Published results of artifical bowel sphincter: since 1999, including series with 10 or more patient, general measures of continence Authors Year Number of patients Mean or median follow-up (months) Number (%) of functioning devices "Success" in patients with a functioning device "Success" in intention to treat Lehur et al [46 ] (83%) 90% 75% O'Brien et al [56] ns 10 (77%) 90% 69% Malouf et al [57] (39%) ns 39% Altomare et al [58] (75%) 67% 50% Devesa et al [59] (49%) 65% 53% Wong et al [60] (65%) 85% 54% Ortiz et al [61] (68%) 60% 41% Lehur et al [62] (75%) 92% 69% Parker et al [63] (46%) 49% 47% Michot et al [64] (80%) 79% 60% Casal et al [65] (90%) 44% 40% Altomare et al [66] ns: long-tem 6 (24%) 50% 12% ITT 12% - 75%

39 Evidenz: Sphinkterersatz: ABS Bei irreparablem Sphinkterdefekten in Betracht zu ziehen - Alternative zur Stomaanlage - Erhebliche postoperative Morbidität, Revisionsrate 46% - Explantationsrate 20 % - 37 % - Revisionsrate mit Erfahrung sinkend - Variable Ergebnisse: 33 % - 79 %

40 Sphinkterersatz: Patientenselektion Sphinkterersatzverfahren EMG: M. grazilis + - Dynamische Graziloplastik Artificial Bowel Sphincter

41 Sphinkterersatz: Patientenselektion Sphinkterersatzverfahren Z.n. perianaler Sepsis, Erhöhtes Infekt- Risiko, TrophischeΔ Perineum, z.b. Radiation, Analatresie EMG: M. grazilis + - Dynamische Graziloplastik Artificial Bowel Sphincter

42 Sphinkterersatz: Patientenselektion Sphinkterersatzverfahren Z.n. perianaler Sepsis, Erhöhtes Infekt- Risiko, TrophischeΔ Perineum, z.b. Radiation, Analatresie EMG: M. grazilis + - Herzschrittmacher, Z.n. Beinamputation, FunktionsΔ Bein Dynamische Graziloplastik Artificial Bowel Sphincter

43 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect <180 >180 or perineal tissue loss Sphincter Repair Repeat EAUS Dynamic Graciloplasty Artificial Bowel Sphincter International Consultation on Incontinence, 2008

44 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect None <180 >180 or perineal tissue loss Sphincter Repair Repeat EAUS Dynamic Graciloplasty Artificial Bowel Sphincter International Consultation on Incontinence, 2008

45 Behandlungskonzepte Sphinkterrepair / Sphinkterersatz: Rekonstruktion / Ersatz der Anatomie führt zu Funktionswiederherstellung Neurostimulation / Sakralnervstimulation:

46 Behandlungskonzepte Sphinkterrepair / Sphinkterersatz: Rekonstruktion / Ersatz der Anatomie führt zu Funktionswiederherstellung Neurostimulation / Sakralnervstimulation: Aktivierung funktioneller Reserven durch Stimulation peripherer Nerven (sakrale Spinalnerven)

47 Neurostimulation: Sakralnerven Indikation: - morphologisch intakter externen analen Sphinkters - zumindest residuale Innervation des externen analen Sphinkter - Versagen konservativer Therapie

48

49 SNS

50 Niederfrequenz Stimulation: 15 Hz, 210 μsec, an/aus : 5sek/1sek, Stromstärke rke nach Perzeption

51 SNS: Test Schritt 1 & 2 Screening: Tage 1 2 Wochen Erfolg: 50% Reduktion: Anzahl der IK Tage mit IK Hetzer et al., Tech Coloproctol 2005

52 SNS %IC pre

53 SNS %IC pre PNE Stim

54 SNS %IC pre PNE Stim

55 SNS: Test Schritt 1 & 2 Screening: Tage 1 Wochen 2 Schritt 3 Follow-up Hetzer et al., Tech Coloproctol 2005

56 SNS %IC pre PNE Implant Stim

57 SNS %IC pre PNE Implant 12m 45m Stim

58 SNS Reproduzierbarkeit des Testergebnis durch permanente Stimulation 90 % %IC pre PNE Implant 12m 45m Stim

59 SNS Pragmatischer Zugang basierend auf Teststimulation Stuhlinkontinenz (Stuhltagebücher) Keine spezielle anatomischen / physiologischen Bedingungen Existenz eines Zielorgans (Ultraschall, MRI) Existenz neuro-muskuläre Verbindung Versuch und Irrtum

60 SNS Stuhlinkontinenz (Stuhltagebücher) Existenz eines Zielorgans (Ultraschall, MRI) Existenz neuro-muskuläre Verbindung

61 SNS Residuale Willkürfunktion (beim Pressen) Reflex Aktivität des EAS/PR (Niesen, Pinbrick) Reaktion auf direkte Pudendus Stimulation (St.Marks Elektrode, PNTML irrelevant)

62 Permanente SNS: Ergebnisse Published results of sacral nerve stimulation since 1999, including series with 10 or more patients, general indications, no subgroups Incontinent episodes per week Incontinence-score (CCIS) Authors (ref) Year Number of patients Follow-up (months) Before SNS (baseline) After SNS (last FU) Before SNS (baseline) Rosen et al [17] * 6 2 ns ns Ganio et al [18] ,5 5,8 0 ns ns Matzel et al [15] ns ns 16 2 Altomare et al [20] * Matzel et al [21] * 16,4 2,0 ns ns Jarrett el al. [22] * Rasmussen et al [23] ns ns 18 7 Leroi et al [24] * 3,5* 0,5* 16* 10* Kenefick et al [25] * 12 0 ns ns Holzer et al [26] * 2,3 0,67 ns ns Hetzer et al [27] ns ns 14 5 Tan et al [28] ,5 3,1 16 1,2 Melenhorst et al [29] ,5 10,4 1,5 ns ns After SNS (last FU) 62

63 Permanente SNS: Ergebnisse Published results of sacral nerve stimulation since 1999, including series with 10 or more patients, general indications, no subgroups Authors (ref) Year Number of patients Follow-up (months) Incontinence episodes/ week Incontinent episodes per week Before SNS (baseline) After SNS (last FU) Incontinence-score (CCIS) Before SNS (baseline) Rosen et al [17] * 6 2 ns ns Ganio et al [18] ,5 5,8 0 ns ns Matzel et al [15] ns ns Incontinence score CCS Score Altomare et al [20] * Matzel et al [21] * 16,4 2,0 ns ns Jarrett el al. [22] * Rasmussen et al [23] ns ns 18 7 Leroi et al [24] * 3,5* 0,5* 16* 10* Kenefick et al [25] * 12 0 ns ns Holzer et al [26] * 2,3 0,67 ns ns Hetzer et al [27] ns ns 14 5 Tan et al [28] ,5 3,1 16 1,2 Melenhorst et al [29] ,5 10,4 1,5 ns ns After SNS (last FU) 63

64 Permanente SNS: Verbesserung # pts Follow up (Monate) 100% 75-99% 50-74% <50% Ganio et al (DCR 01) 5 14 (5-37) Leroi et al (DCR 01) 6 2 (1-7) Rosen et al (Gastroenterology 01) (3-26) >3 Durchschnitt 67% Rasmussen et al (Ugeskr Laeger 02) (1-12) Uludag et al (Ned Tijdschr Geneeskd 02) 27 6 Durchschnitt 86% Kenefick et al (BJS 02) (3-60) Matzel et al (Chirurg 03) (3-99)

65 Permanente SNS: Verbesserung # pts Follow up (Monate) 100% 75-99% 50-74% <50% Ganio et al (DCR 01) 5 14 (5-37) Leroi et al (DCR 01) 6 2 (1-7) Rosen et al (Gastroenterology 01) (3-26) >3 Durchschnitt 67% Rasmussen et al (Ugeskr Laeger 02) (1-12) Uludag et al (Ned Tijdschr Geneeskd 02) % Durchschnitt 86% Kenefick et al (BJS 02) (3-60) Matzel et al (Chirurg 03) (3-99)

66 Permanente SNS: Verbesserung # pts Follow up (Monate) 100% 75-99% 50-74% <50% Ganio et al (DCR 01) 5 14 (5-37) Leroi et al (DCR 01) 6 2 (1-7) Rosen et al (Gastroenterology 01) (3-26) >3 Durchschnitt 67% Rasmussen et al (Ugeskr Laeger 02) Uludag et al (Ned Tijdschr Geneeskd 02) (1-12) % 2 Durchschnitt 86% 1 3 Kenefick et al (BJS 02) (3-60) Matzel et al (Chirurg 03) (3-99)

67 Verbesserung Follow-up: Multicenter n: 34, FU: median 23.9 m (1-36) 20 # Patienten % 24% 20% 15% % 99-75% 74-50% < 50% Matzel et al. Lancet, 1240,2004

68 Verzögerung der Defäkation Vollständige Entleerung Baseline (N=34) Last Follow up (N=34) # Pati e nten Nicht <1 min 1-5 min 5-15 min >15 min 0 Nie Manchmal Oft Immer p < p = Matzel et al. Lancet, 1240,2004

69 ASCRS-FIQL + : Lebensqualitätsindex n: 34, FU: median 23.9 (1-36) 5 Scala Score Lifestyle Coping/ Behaviour Depression/ Self Perception Embarrassment p < Baseline Last FU + FI QoL Scale, DCR, Jan 2000, Rockwood et al Matzel et al. Lancet, 1240,2004

70 SNS IK: Langzeit: Initiales Konzept Frequenz Inkontinenz (flüssig/fest) in 7 Tagen N:9: Fwup: Jahre Baseline Letztes FWup 8 9 mean

71 Geburtshilflich Trauma Normaler Sphinkter Kongenital Diarrhoe Postoperativ IAS Schwäche Rektum Prolaps 42 8 Neurologisch IAS degeneration CJ Vaizey, SNS for Bowel Dysfunction, London, 2001

72 Geburtshilflich Normaler Sphinkter 21 Postoperativ IAS Schwäche Rektum Prolaps Neurologisch IAS degeneration %

73 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect None <180 >180 or perineal tissue loss Sphincter Repair Repeat EAUS Dynamic Graciloplasty Artificial Bowel Sphincter SNS International Consultation on Incontinence, 2008

74 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect None <180 Geburtshilfliches Trauma: n=19/20: CCS (Maslekar et al., ASCRS, 2006) SNS Sphincter Repair Repeat EAUS >180 or perineal tissue loss Dynamic Graciloplasty Artificial Bowel Sphincter International Consultation on Incontinence, 2008

75 SNS vs. Sphinkteroplastik Baeten et al. (ESCP 2006): Inkontinenz Episoden Primärer Repair & SNS

76 SNS vs. Sphinkteroplastik Baeten et al. (ESCP 2006): Inkontinenz Episoden Primärer Repair & SNS SNS, kein Repair

77 SNS bei Sphinkterlücken 30 o -90 o FI: Baseline: 1.3/Woche FU: 0.3/Woche p=0.03 CCS: p< p< p<0.001 p< FU:12-97m Ratto et al. ESCP All IAS EAS IAS+EAS

78 SNS in Sphincter Gaps no gap vs. < 90 o vs. 90 o -120 o Improvement in continence Wexner s Score P=0.796* Sphincter lesions no vs. < 90 o vs. 90 o -120 o Incontinent episodes/w P=0.525* Incontinent days/w Days with staining/w Days using pads/w P=0.717* P=0.814* P=0.407* Intact external anal sphincter External sphincter defect< 90 External sphincter defect 90 Tjandra et al. 2007

79 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect None <180 >180 or perineal tissue loss Sphincter Repair Repeat EAUS Dynamic Graciloplasty Artificial Bowel Sphincter SNS International Consultation on Incontinence, 2008

80 Candidate for surgery for FI Evaluation EAUS+/- Manometry, EMG, MRI, Defecography Persistent FI Surgical treatment for anatomical abnormality Complete spinal cord impairment Rectal prolapse, Cloaca, Rectovaginal fistula ACE Colostomy Sphincter defect None <180 >180 or perineal tissue loss SNS Colostomy Sphincter Repair Repeat EAUS Dynamic Graciloplasty Artificial Bowel Sphincter International Consultation on Incontinence, 2008

81 Therapieoptionen bei Stuhlinkontinenz Repair: Traditionelles Konzept Repair: Akzeptable Kurz-, mäßige Langzeitresultate

82 Therapieoptionen bei Stuhlinkontinenz Repair: Traditionelles Konzept Repair: Akzeptable Kurz-, mäßige Langzeitresultate DGP, ABS: Invasiv, komplikationsträchtig ABS, DGP: akzeptable Kurz- und Langzeit-Ergebisse

83 Therapieoptionen bei Stuhlinkontinenz SNS: Konzeptioneller Therapiewandel SNS: Patientenselektion durch Behandlungsversuch SNS: Akzeptable Kurz-, vielversprechende Langzeitresultate

84 Therapieoptionen bei Stuhlinkontinenz SNS: Konzeptioneller Therapiewandel SNS: Patientenselektion durch Behandlungsversuch SNS: Akzeptable Kurz-, vielversprechende Langzeitresultate Sphinkerrepair vs. SNS??

85