The magnetic anal sphincter versus the artificial bowel sphincter: a comparison of 2 treatments for fecal incontinence.

BACKGROUND: Fecal incontinence is a debilitating ailment, and surgery offers the only recourse for the patients in whom conservative treatment fails. OBJECTIVE: This study aims to report the first matched comparison between patients implanted with the magnetic anal sphincter and the artificial bowel sphincter. PATIENTS AND INTERVENTIONS: From December 2008 to June 2010, 10 female patients, median age 64.5 years (range, 42-76), with severe fecal incontinence for a median of 7.5 years (range, 1-40), were implanted with the magnetic anal sphincter. Ten female patients implanted with the artificial bowel sphincter were identified. Both groups were matched for age, etiology, duration of incontinence, and preoperative functional scores. MAIN OUTCOME MEASURES: Outcomes measures included length of hospitalization, complications, and changes in functional scores (anorectal physiology, incontinence, and quality of life). RESULTS: Patients with the magnetic anal sphincter had a shorter median operative time (62 vs 97.5 min, P = .0273), length of hospitalization(4.5 vs 10 days, P < .001), and follow-up duration (8 vs 22.5 mo, P = .0068), without a statistically significant difference in 30-day complications (4 vs 2, P = .628) and revision/explantation (1 vs 4, P = .830). Both groups achieved significant improvements in preoperative incontinence (P < .0002) and quality-of-life scores (P < .009). In a comparison of baseline resting anal pressures, patients with the artificial bowel sphincter had significantly higher pressures with the cuff inflated (P = .0082), and those with the magnetic anal sphincter had a significant increase as well (P = .0469). At the latest review, both groups had similar quality-of-life scores (P = .374); patients with the artificial bowel sphincter had higher (median) closed-cuff anal pressures compared with the anal resting pressure of those with a magnetic anal sphincter (89 vs 58.5 cmH2O, P = .0147), together with more constipation (4 vs 1, P = .830) and a trend toward better incontinence scores (P = .0625). LIMITATIONS: This was a nonrandomized study with small patient numbers. CONCLUSION: In the short term, the magnetic anal sphincter is as effective as the artificial bowel sphincter in restoring continence and quality of life.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited.

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.