Table 3.

Summary of the main indications and recommendations for different surgical treatments for fecal incontinence in the analysed guidelines

	ICS	NICE	ASCRS	Italian	French
Treatment indication is based on:	Three groups: 1. spinal cord; 2. structural defects; 3. all the others: based on EAS integrity	EAS defect and patient willingness	No algorithm defined	No algorithm defined	Four groups: 1. significant and recent sphincter tear; 2. external rectal prolapse; 3. neurological disease 4. all other patients
SNM indications	Patients without defect; or < 120° defect; second line if sphincteroplasty fails	When sphincter surgery is deemed inappropriate: no defect, sphincter disruption, or sphincter defect + atrophy, denervation, a small defect, absence of voluntary contraction, fragmentation of the sphincter or a poor-quality muscle	First-line surgical option for FI with and without sphincter defects	Intact but weak anal sphincter; Sphincter disruption up to 120 degrees; After rectal surgery or rectal prolapse surgery; Double incontinence; Selected patients with neurogenic FI	In the algorithm: all patients after the specific treatment failure: 1. sphincteroplasty in recent sphincter tear; 2. rectopexy in rectal prolapse; 3. TAI for neurologic patients, or 4.-biofeedback for the rest of patients
					Inclusion criteria: idiopathic anal incontinence; old sphincter defect even when extensive; scleroderma; central or incomplete peripheral non-progressive neurological lesion;, concomitant urinary incontinence with overactive bladder
					It is not recommended in patients with Crohn’s disease owing to the paucity of published data
Sphincter repair indications	Symptomatic patients with a defined defect in the EAS: first option if lesion 120–180°; after SNM if lesion < 120°; adding vaginoplasty if lesion > 180°	Full-length EAS defect that is 90° or greater (with or without an associated internal anal sphincter defect)	Symptomatic patients with a defined defect of the EAS	Highly symptomatic patients with a defect of the EAS	Defect of 60° to 120° and is especially recommended if the lesion is recent
	Patients option when deciding whether sphincter repair vs SNM
Redo-sphincteroplasty	Recommended after an EUS that confirms the lesion	Not mentioned	No recommended unless other treatment modalities are not possible or have failed	Recommended for persistent or relapsing EAS defect	Not mentioned
Biomaterial injection (bulking agents) indications	After sphincteroplasty or SNM when minimal defect remains	No consistent results. Just used in the context of a clinical trial or formal audit protocol	They state that may help to decrease episodes of passive FI	Passive FI, post-defecatory leakage and involuntary gas escape. It can be used in damaged or degenerated IAS with very limited evidence	Weakly recommended when SNM fails, at the same level than ABS of PTNS
Stimulated Graciloplasty (SG) indications	Selected patients who have failed other modalities of treatment particularly where there has been loss of native sphincter tissue	For carefully selected patients in whom other treatments have failed or are contraindicated. Should be performed in by clinicians with specific training and experience	Not mentioned	To replace the anal sphincter when extensive sphincter damage, muscle loss and pudendal neuropathy are involved. Final rescue solution before colostomy	It is not possible to make specific recommendations
Artificial Bowel Sphincter (ABS) indications	For patients who have failed other modalities of treatment. Neurological patients after failure of TAI	For carefully selected patients in whom other treatments have failed or are contraindicated. Less recommended than SG	In patients in whom all other treatments have failed, or those with extensive sphincter destruction (> 180 degrees), congenital malformations, neurogenic incontinence from spinal cord injury, or postsurgical significant bowel dysfunction with intact anal canal anatomy	Same indications as graciloplasty	Weakly recommended as a third-line treatment once SNM fails, at the same level as bulking agents or PTNS
Other treatment indications	PTNS: remains an investigational treatment protocol which cannot currently be recommended for clinical practice MAS: a novel treatment for patients who have failed other modalities of treatment Puborectal sling remains unproven but may be of value in selected patients Vaginal bowel control system remains to be established Secca: long-term results are disappointing Stem cell therapy remains experimental and should only be offered as part of a well-designed research trial	PTNS: if conservative management failures MAS: limited evidence MACE, neo-appendicostomy or continent colonic conduit: in selected people with constipation and colonic motility disorders associated with FI Other novel treatments with limited evidence: Transabdominal artificial bowel sphincter implantation; Endoscopic radiofrequency of the anal sphincter	PTNS, SECCA and MAS: weak recommendation	PTNS: it could offer a relatively affordable treatment in patients who have failed conservative treatment SECCA: not recommended MAS: limited evidence MALONE*: considered to give pseudocontinence in selected patients with associated constipation or neurogenic bowel	PTNS: weakly recommended after SNM fails in the algorithm. Also stated as a potential alternative to be use with the same indications as SNM being a less invasive option SECCA: not recommended MAS: it is not possible to make specific recommendations MALONE*: in case of TAI failure

ICS International Continence Society, NICE National Institute for Health and Care Excellence, ASCRS American Society of Colon and Rectal Surgeons, FI Fecal Incontinence, IAS Internal Anal Sphincter, EAS External Anal Sphincter, SNM Sacral Neuromodulation, EUS Endoanal Unltrasound, TAI Transanal Irrigation, PTNS Posterior Tibial Nerve Stimulation, MAS Magnetic Anal Sphincter, MACE Malone Antegrade Continence Enema, SECCA Secca System (radiofrequency)