Neosphincters in the management of faecal incontinence D. A. Niriella and K. I. Deen Academic Department of Surgery, North Colombo General Hospital and University of Kelaniya, Sri Lanka Correspondence to: Professor K. I. Deen, Department of Surgery, Faculty of Medicine, PO Box 6, Talagolla Road, Ragama, Sri Lanka Background: Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition. Methods: A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts. Results: The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the arti®cial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the arti®cial sphincter. Both of the above operations have been associated with implant- related infection and impaired evacuation. Conclusion: Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be con®ned to specialist colorectal centres. Patients are likely to bene®t from a plan that incorporates preoperative counselling and a selective approach. Paper accepted 27 June 2000 British Journal of Surgery 2000, 87, 1617±1628 Introduction Continence of gas and stool is the ability to retain and expel gas and faeces at a socially appropriate place and time. Continencedependsonanumberoffactors,notablynormal anatomy and function of the internal and external anal sphincters and of the pelvic ¯oor muscles, and normal anal and rectal sensation. Other variables that play a part in preserving continence are stool volume and consistency, intestinal transit and normal mental function. The com- munity prevalence of faecal incontinence in Europe and the United States is approximately 2 per cent 1,2 . Comparable data are not available for developing countries. Previously published data suggest a global incontinence rate of 5 per cent 3 . In older individuals the prevalence is reported to approach60percent 4 .Anumberofindependentfactorsare known to predict faecal incontinence 1,3 . The social and personal stigmas associated with the condition cause silent suffering and deterioration in quality of life. This is unfortunate in the presence of novel methods of treatment, some albeit still in an experimental stage. Treatment of faecal incontinence requires a multi- disciplinary approach; surgical intervention is one of many therapeutic options. A comprehensive history and clinical examination in the initial assessment of patients is essential, but it is insuf®cient by itself 5,6 , and must be supplemented by other special investigations. The use of anal manometry, pudendal nerve terminal motor latency, electromyo- graphy 7 , endoanal ultrasonography 8 , defaecography and proctography 9 offers a better understanding of the problem and provides guidelines for deciding the optimal thera- peutic approach. Patient selection is important to avoid disappointment 10 ; only some forms of faecal incontinence are amenable to neosphincter reconstruction undertaken in Review ã 2000 Blackwell Science Ltd British Journal of Surgery 2000, 87, 1617±1628 1617