surgical management of fecal incontinence surgical management of fecal incontinence in fecal incontinence (fi), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. there are many surgical options described for fi, and they can be considered in 4 general groups. restoration and improvement of residual sphincter function sphincteroplasty (sphincter repair) correction of anorectal deformities that may be contributing to fi sacral nerve stimulation replacement / imitation of the sphincter or its function narrowing of anal canal to increase the outlet resistance without any dynamic component anal encirclement (thiersch procedure) radiofrequency ablation ("secca procedure") nondynamic graciloplasty ("bio-thiersch") implantation/injection of microballoons, carbon-coated beads, autologous fat, silicone, collagen. dynamic sphincter replacement implantation of artificial bowel sphincter (neosphincter) dynamic graciloplasty antegrade continence enema (ace)/ antegrade colonic irrigation fecal diversion (stoma creation) surgical management of fecal incontinencespecialtygastroenterology the relative effectiveness of surgical options for treating fecal incontinence is not known. a combination of different surgical and non-surgical therapies may be optimal. a surgical treatment algorithm has been proposed for fi, although this did not appear to include some surgical options. isolated sphincter defects may be initially treated with sphincteroplasty and if this fails, the patient can be assessed for sacral nerve stimulation. functional deficits of the external anal sphincter (eas) and/or internal anal sphincter (ias), i.e. where there is no structural defect, or only limited eas structural defect, or with neurogenic incontinence, may be assessed for sacral nerve stimulation. if this fails, neosphincter with either dynamic graciloplasty or artificial anal sphincter may be indicated. substantial muscular and/or neural defects may be treated with neosphincter initially. sphincteroplasty (sphincter repair) this operation aims to repair sphincter defects (which may be of unknown cause) or damage from trauma (usually caused by obstetric damage). where the sphincter has separated from a tear, this procedure brings these ends back together. primary sphincteroplasty is repair carried out soon after the trauma has occurred, whilst other repairs may be carried out years after the original trauma (secondary or delayed sphincter repair), usually because the trauma went unrecognised. usually, sphincter defects are in the anterior position on the sphincter, when an anterior sphincteroplasty may be carried out. where the sphincter defect is laterally or posteriorly placed, this carries a less successful outcome. overlapping anterior sphincteroplasty is preceded by a bowel preparation and possibly antibiotics. once the patient is under anesthesia, an incision is made in front of the anus (the anterior perineum). scar tissue is removed and the mucosa of the anal canal separated from the damaged sphincter. the sphincter is cut and its ends overlapped and then stitched back together. the exact method of the procedure varies, e.g. the cut sphincter may be stitched back end to end, rather than overlapped, or the ias and eas may be repaired as separate stages. sphincter repair may sometimes be combined with an anterior levatorplasty (an operation to tighten the pelvic floor). a surgical drain is left to prevent buildup of fluid. after the operation, sitz baths are recommended to maintain hygiene during healing, and laxatives prescribed to avoid hard stool. overlapping anterior sphincteroplasty improves fi symptoms in the short term in most (50-80%) patients with sphincter defects. thereafter, continence deteriorates. most who undergo this operation are incontinence again after 5 years. poor results with this procedure may be related to pelvic floor denervation (nerve damage). primary sphincter repair is inadequate in most women with obstetric ruptures following vaginal delivery. residual sphincter defects remain in most and around 50% remain incontinent. residual sphincter defect following the operation (as demonstrated by endoanal ultrasonography) then the procedure may be repeated. postanal repair this procedure aims to improve fi by restoring the anorectal angle and lengthen the anal canal. the main indication is denervation of the pelvic floor (e.g. descending perineum syndrome). after the patient is anesthetized, an incision is made posterior to (behind) the anus and a space between the eas and ias is opened up. this plane is followed, freeing the rectum from its attachment to the pelvic floor. puborectalis and pubococcygeus are folded and held with stitches. these folds will lengthen the anal canal. it is safe and simple, but long term improvements in fi are poor (30-40%). total pelvic floor repair refers to a procedure combining postanal and anterior anal repair. perianal injectable bulking agents these procedures aim to inject bio-compatible material into the walls of the anal canal, aiming to bulk out these tissues. this may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and reducing fi. originally, this technique was described for urinary incontinence, but has since been used for fi, especially passive soiling due to ias dysfunction. this measure has many advantages over more invasive surgery, since there are rarely any serious complications and the procedure can be carried out under local anesthetic on an out patient basis. many different materials have been used as perianal injectable bulking agents, including: autologous fat (fat tissue transferred from elsewhere in the body), teflon, bovine glutaraldehyde cross-linked collagen (collagen from cows), carbon-coated zirconium beads, polydimethylsiloxane elastomer, dextranomer/non-animal stabilised hyaluronic acid, hydrogel cross-linked with polyacrylamide, porcine dermal collagen (collagen from pig skin), and synthetic calcium hydroxylapatite ceramic microspheres. dextranomer in stabilised hyaluronic acid improves continence for a little over half of patients in the short term. however, future trials are required. dextranomer is marketed as solesta, bio-compatible silicone is also referred to as a ptq implant and carbon coated beads as durasphere. the bulking material can be introduced as either intersphincteric (into the space between the ias and the eas) or submucosal (under the mucosal layer) injections. ultrasound guidance may be used during the injections, which may be more effective than the surgeon simply palpating (feeling) where to inject. a cochrane systematic review of the efficacy of this type of treatment for fi reported that ptq implants were the most widely used material, but that there was currently insufficient evidence to be considered to assess the effectiveness of injectable bulking agents. a randomized trial by dehli et al. compared perianal injectable bulking agents to sphincter training and biofeedback, and found the former to be superior. both methods lead to an improvement of fi, but comparisons of st mark's scores between the groups showed no difference between treatments. sacral nerve stimulation