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Zentralbl Chir 2012; 137(4): 340-344
DOI: 10.1055/s-0032-1315109
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Der künstliche Sphinkter zur Therapie der Stuhlinkontinenz

The Artificial Sphincter: Therapy for Faecal Incontinence
U. Baumgartner
  Allgemein- und Viszeralchiurgie, Kreiskrankenhaus Emmendingen, Emmendingen, Deutschland
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Publication History

Publication Date:
29 August 2012 (online)

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Zusammenfassung

Einleitung: Die Stuhlinkontinenz stellt einen gravierenden Lebenseinschnitt für den Patienten dar und führt fast regelhaft zu sozialer Entfremdung und persönlicher Desintegration. Wird die innere Emigration aufgrund des Leidensdrucks überwunden und ist der Patient schließlich zur Therapie bereit, so steht an erster Stelle die konservative Behandlung (diätetische Maßnahmen, motilitätshemmende Medikamente, Beckenbodengymnastik, Elektrostimulationstherapie, Biofeedback-Training, Irrigation).

Diskussion: Wann besteht die Indikation für einen künstlichen Analsphinkter? Wenn die konservative Therapie, ein Sphinkter-Repair (falls indiziert), die Rekonstruktion eines insuffizienten Beckenbodens und die Sakralnervenstimulation zu keiner Kontinenzverbesserung führen, dann ist als Ultima Ratio die Implantation eines künstlichen Analsphinkters indiziert. Auf dem Markt gibt es 2 etablierte künstliche anale Sphinktersysteme, den „Artificial Bowel Sphincter®“ (ABS) (Fa. A. M. S.; Minnetonka, MN, USA) und das Analband (Fa. A. M. I.; Feldkirch, Österreich). Wie wird der künstliche Analsphinkter implantiert? Bei beiden Systemen wird unter absolut aseptischen Bedingungen (in Steinschnittlage über perianale Inzisionen) eine befüllbare Silikonmanschette in den sublevatorischen Raum implantiert, die zirkulär den Analkanal umgreift. Eine Beeinträchtigung der Beckenbodennerven erfolgt dabei nicht. Über einen Silikonschlauch ist die Analmanschette mit einem wassergefüllten Reservoir verbunden, aus dem über eine Pumpe im Skrotum/Labie (ABS) oder durch Auspressen des Ballonreservoirs (unterhalb des Rippenbogens) die Analmanschette befüllt wird, sodass sich der Analkanal verschließt bzw. durch Entleeren der Analmanschette wieder öffnet. Beide Systeme werden subkutan platziert, je nach Produkt an unterschiedlichen anatomischen Positionen. Schlussfolgerung: Beide Systeme verbessern signifikant die anale Kontinenzleistung. Beide haben relativ hohe Revisionsraten, deren Ursachen aber sehr unterschiedlich sind. Der ABS hat hohe Infektions- und Penetrationsraten in den Analkanal und damit Explantationsraten bis zu 60 %. Diese scheinen beim Analband um ein Vielfaches niedriger zu liegen; Probleme bietet beim Analband eher das Ventil, das gelegentlich gewechselt werden muss. Trotz dieser Probleme stellen beide Systeme eine sehr effiziente Methode dar, die Stuhlinkontinenz signifikant zu verbessern und damit die Lebensqualität der Betroffenen.

Abstract

Introduction: Faecal incontinence (FI) challenges a patientʼs professional, social and sexual life. Often the patient becomes depressive and socially isolated. If able to break open for therapy the patient should receive as first line a conservative treatment (like dietary measures, pelvic re-education, biofeedback, bulking agents, irrigation).

Discussion: When is the time to implant an artificial anal sphincter? If conservative therapy fails as well as surgical options (like a sphincteroplasty – if indicated a reconstruction of the pelvic floor if insufficient, or a sacral nerve stimulation) an ultimo surgical procedure should be offered to appropriate and compliant patients: an artificial anal sphincter. Worldwide, there are two established devices on the market: the artificial bowel sphincter® (ABS) from A. M. S. (Minnetonka, MN, USA) and the soft anal band® from A. M. I. (Feldkirch, Austria). How to implant the artificial anal sphincter? Both devices consist of a silicon cuff which can be filled with fluid. Under absolute aseptic conditions this cuff is placed in the lithotomy position by perianal incisions around the anal canal below the pelvic floor. A silicon tube connects the anal cuff with a reservoir (containing fluid) which is placed either behind the pubis bone in front of the bladder (ABS) or below the costal arch (anal band). With a pump placed in the scrotum/labia (ABS) or by pressing the balloon (anal band) in both types operated by the patient the fluid is shifted forth and back between the anal cuff and the reservoir closing or opening the anal canal. Both systems are placed completely subcutaneously.

Conclusions: Both devices improve significantly the anal continence. Both systems have a high rate of reoperations. However, the causes for the redos are different. The ABS is associated with high infection and anal penetration rates of the cuff leading to an explantation rate to up to 60 % of the implants. This kind of complication seems to be much lower with the anal band. The major problem in the anal band is a defunctioning valve which occasionally has to be replaced. Despite these problems both types of artificial anal sphincters improve faecal incontinence significantly and, thus, quality of life of incontinent patients.

Schlüsselwörter

Stuhlinkontinenz - künstlicher Analsphinkter - Soft Anal Band® - Artificial Bowel Sphincter® - Beckenbodeninsuffizienz

Key words

faecal incontinence - artificial anal sphincter - soft anal band® - artificial bowel sphincter® - pelvic floor insufficiency
 

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