PURPOSE
Conservative anal surgery, with maximum preservation of the anal sphincters and continence, is becoming increasingly possible with the emergence of new sphincter-sparing treatments. Many surgeons remain skeptical, however, of the nature and impact of incontinence after anal surgery. We aimed to characterize the patterns of anal sphincter injury in patients with fecal incontinence after anal surgery.
METHODS
We reviewed our fecal incontinence database and studied a subset develo** incontinence after anal surgery. Maximum resting and squeeze pressures and the distal high-pressure zone to mid–anal canal resting pressure gradient were evaluated. Anal ultrasounds were evaluated and specific postoperative lesions were characterized.
RESULTS
Patterns of sphincter injury in 93 patients with fecal incontinence after manual dilation, internal sphincterotomy, fistulotomy, and hemorrhoidectomy were studied. The internal sphincter was almost universally injured, in a pattern specific to the underlying procedure. One-third of patients had a related surgical external sphincter injury. Two-thirds of women had an unrelated obstetric external sphincter injury. The distal resting pressure was typically reduced, with reversal of the normal resting pressure gradient of the anal canal in 89 percent of patients. Maximum squeeze pressure was normal in 52 percent.
CONCLUSION
Incontinence after anal surgery is characterized by the virtually universal presence of an internal sphincter injury, which is distal in the high-pressure zone, resulting in a reversal of the normal resting pressure gradient in the anal canal. These data support concerns that non–sphincter-sparing anal surgery leads to fecal incontinence and is increasingly difficult to justify given the availability of modern sphincter-sparing approaches.
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REFERENCES
IT Khubchandani JF Reed (1989) ArticleTitleSequelae of internal sphincterotomy for chronic fissure-in-ano Br J Surg 76 431–4 Occurrence Handle1:STN:280:BiaB1cjmsFA%3D Occurrence Handle2736353
DC Nyam JH Pemberton (1999) ArticleTitleLong-term results of lateral sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence Dis Colon Rectum 42 1306–10 Occurrence Handle1:STN:280:DyaK1Mvls1SgtQ%3D%3D Occurrence Handle10528769
V Usatoff A Polglase (1997) ArticleTitleThe longer term results of lateral anal sphincterotomy ANZ J Surg 67 45–6 Occurrence Handle1:STN:280:ByiC1crmvFE%3D
CT Speakman SJ Burnett MA Kamm CI Bartram (1991) ArticleTitleSphincter injury after anal dilatation demonstrated by anal ultrasonography Br J Surg 78 1429–30 Occurrence Handle1:STN:280:By2C38jjvFY%3D Occurrence Handle1773315
MB Nielsen Oø Rasmussen JF Pedersen J Christiansen (1993) ArticleTitleRisk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano: an endosonographic study Dis Colon Rectum 36 677–80 Occurrence Handle1:STN:280:ByyA2M7ltVw%3D Occurrence Handle8348852
AH Sultan MA Kamm RJ Nicholls CI Bartram (1994) ArticleTitleProspective study of the extent of internal anal sphincter division during lateral sphincterotomy Dis Colon Rectum 37 1031–3 Occurrence Handle1:STN:280:ByqD3cbitFw%3D Occurrence Handle7924711
R Farouk JR Monson GS Duthie (1997) ArticleTitleTechnical failure of lateral sphincterotomy for the treatment of chronic anal fissure: a study using anal ultrasonography Br J Surg 84 84–5 Occurrence Handle1:STN:280:ByiC1MnivVY%3D Occurrence Handle9043463
PJ Lunniss MA Kamm RK Phillips (1994) ArticleTitleFactors affecting continence after surgery for anal fistula Br J Surg 81 1382–5 Occurrence Handle1:STN:280:ByqD2c7it1Q%3D Occurrence Handle7953425
WH Isbister N Sanea ParticleAl (2001) ArticleTitleThe cutting seton: an experience at King Faisal Specialist Hospital Dis Colon Rectum 44 722–7 Occurrence Handle1:STN:280:DC%2BD3M3msVehuw%3D%3D Occurrence Handle11357036
K-P Hamalainen AP Sainio (1997) ArticleTitleCutting seton for anal fistulas: high risk of minor control defects Dis Colon Rectum 40 1443–7 Occurrence Handle1:STN:280:DyaK1c%2FmvFyksA%3D%3D Occurrence Handle9407983
WF Tets Particlevan HC Kuijpers (1994) ArticleTitleContinence disorders after anal fistulotomy Dis Colon Rectum 37 1194–7 Occurrence Handle7995143
J Garcia-Aguilar C Belmonte WD Wong SM Goldberg RD Madoff (1996) ArticleTitleAnal fistula surgery: factors associated with recurrence and incontinence Dis Colon Rectum 39 723–9 Occurrence Handle1:STN:280:BymB1M%2FlsFM%3D Occurrence Handle8674361
JR Cintron JJ Park CP Orsay et al. (2000) ArticleTitleRepair of fistulas-in-ano using fibrin adhesive: long-term follow-up Dis Colon Rectum 43 944–50 Occurrence Handle1:STN:280:DC%2BD3czmsFKisg%3D%3D Occurrence Handle10910240
L Patrlj B Kocman M Martinac et al. (2000) ArticleTitleFibrin glue-antibiotic mixture in the treatment of anal fistulae: experience with 69 cases Dig Surg 17 77–80 Occurrence Handle10.1159/000018804 Occurrence Handle1:STN:280:DC%2BD3c7ovVSrtQ%3D%3D Occurrence Handle10720836
SM Sentovich (2001) ArticleTitleFibrin glue for all anal fistulas J Gastrointest Surg 5 158–61 Occurrence Handle10.1016/S1091-255X(01)80028-7 Occurrence Handle1:STN:280:DC%2BD3Mzjt1Cltw%3D%3D Occurrence Handle11331478
I Lindsey MM Smilgin-Humphreys C Cunningham NJ Mortensen BD George (2002) ArticleTitleRandomized, controlled trial of fibrin glue vs. conventional treatment for anal fistulas Dis Colon Rectum 45 1608–15 Occurrence Handle10.1007/s10350-004-6287-9 Occurrence Handle12473883
TJ O’Kelly AF Brading NJ Mortensen (1993) ArticleTitleNerve mediated relaxation of the human internal anal sphincter: the role of nitric oxide Gut 34 689–93 Occurrence Handle1:CAS:528:DyaK3sXlslyhu74%3D Occurrence Handle7684992
JN Lund JH Scholefield (1997) ArticleTitleA randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in the treatment of anal fissure Lancet 349 11–4 Occurrence Handle10.1016/S0140-6736(96)06090-4 Occurrence Handle1:CAS:528:DyaK2sXltVaqug%3D%3D Occurrence Handle8988115
EA Carapeti MA Kamm PJ McDonald SJ Chadwick D Melville RK Phillips (1999) ArticleTitleRandomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate Gut 44 727–30 Occurrence Handle1:CAS:528:DyaK1MXjtF2kt74%3D Occurrence Handle10205213
G Brisinda G Maria AR Bentivoglio E Cassetta D Gui A Albanese (1999) ArticleTitleA comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure N Engl J Med 341 65–9 Occurrence Handle10.1056/NEJM199907083410201 Occurrence Handle1:CAS:528:DyaK1MXks1GlsLc%3D Occurrence Handle10395629
I Lindsey OM Jones BD George C Cunningham NJ Mortensen (2003) ArticleTitleBotulinum toxin therapy for chronic anal fissure: second-line therapy after failed GTN Dis Colon Rectum 46 361–6 Occurrence Handle10.1007/s10350-004-6556-7 Occurrence Handle12626912
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Recipient of the Colon and Rectal Disease Research Foundation prize for best poster.
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Lindsey, I., Jones, O., Smilgin-Humphreys, M. et al. Patterns of Fecal Incontinence After Anal Surgery. Dis Colon Rectum 47, 1643–1649 (2004). https://doi.org/10.1007/s10350-004-0651-7
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DOI: https://doi.org/10.1007/s10350-004-0651-7