Nuevas alternativas en el tratamiento quirúrgico de la incontinencia fecal grave.

OBJECTIVE: To establish real utility of artificial bowel sphincter, dynamic graciloplasty and sacral nerve stimulation for the treatment of severe fecal incontinence. METHOD: Thirty fecally incontinent patients were included. Group I: 17 patients with median age 46 years with artificial bowel sphincter implantation during November 1996-2002. Group II: 5 patients with median age 42 years with dynamic graciloplasty between January-October 1998. Group III: 8 women with median age 62 years with sacral neuromodulation during February 2001October 2003. RESULTS: Group I: Mean follow-up 42 months. Morbidity in 94% of patients. After first implant 9 devices were explanted (53%), with reimplantation in 5 of these. Wexner score, quality of life and anal pressures with cuff closed improved significantly after implant. Group II: Median follow-up 72 months. Morbidity in 80% of patients. After standard stimulation, 4 new programmings and 3 pacemaker replaces by battery discharge were performed. In one tendon detachment surgical revision was needed. In a descriptive way, Wexner score and quality of life didn´t improve after surgery but did postoperative anal pressures. Group III: Fecal incontinence significantly improved after subchronic test stimulation. Five patients (62,5%) received a definitive implantation. With a mean follow-up of 24 months morbidity was minor and one device was explanted. In a descriptive way, fecal incontinence and Wexner scores decreased and quality of life and anal pressures increased after permanent implant. CONCLUSIONS: Artificial bowel sphincter implantation is a simple procedure with high morbidity and explants but significantly improves anal continente, quality of life and anal resting pressures. Dynamic graciloplasty is a complex procedure with high morbidity. In a descriptive way, it increases anal pressures but didn´t improve neither fecal incontinence nor quality of life. Sacral neuromodulation is a simple procedure with minor morbidity. During subchronic stimulation a significant improvement in anal continence occurs that is maintained with permanent stimulation but the small sample in this phase didn´t allow obtaining definitive conclusions. The three analyzed techniques are useful alternatives for treatment of severe fecal incontinence, but in our experience the functional result with dynamic graciloplasty is worse.