Total anorectal reconstruction with the artificial bowel sphincter: report of eight cases. A quality-of-life assessment

Laparoscopic sphincter reconstruction after abdominoperineal resection: feasibility and technical aspects

BACKGROUND

Abdominal colostomy has been reported as an option with good quality of life for patients requiring abdominoperineal resection (APR) for very low rectal cancer. Some young, compliant patients, nevertheless, are very motivated to avoid abdominal colostomy following APR. Spiral smooth muscle cuff perineal colostomy as neosphincter reconstruction can be a reasonable alternative. We have published before the results of a series of sphincter reconstruction in the conventional technique following APR. As we developed our technique for colorectal resection sphincter reconstruction, we also changed to a laparoscopic approach.
 The aim of the present study was to evaluate the feasibility of laparoscopic neosphincteric reconstruction and outline the aspects of the technique.

METHODS

This retrospective study was conducted on 15 patients treated at our institution during a 6 year period for low rectal cancer by laparoscopic APR and spiral smooth muscle cuff perineal colostomy as sphincter reconstruction. At follow-up at a median time of 3.7 years (range 3-9 years) after surgery, patients underwent functional evaluation which included the modified Holschneider continence score (0-16), assessing consistency of stool, frequency, impulse, discrimination, warning period, incontinence for formed or fluid feces, soiling, wearing pads, drugs, enema where a score of 13-16 is associated with normal continence, as well as neosphincter manometry.

RESULTS

Laparoscopic sphincter reconstruction was feasible in all 15 patients. Two of the fifteen patients (13%) required secondary colostomy in the long term due to neosphincter malfunction and neosphincter perforation after enema. Four of the remaining thirteen patients (30%) were partially continent according to the Holschneider continence score (HCS) with a score of 7-12. The other 9 (70%) were continent (HCS: 13-16). Neosphincter manometry showed a median resting pressure of 33 cm H₂O (range 30-41 cm H₂O) and a median squeeze pressure of 95 cm H₂O (range 84-150 cm H₂O).

CONCLUSIONS

Laparoscopic sphincter reconstruction following APR is a feasible option offering an alternative to abdominal colostomy for selected patients.

Challenges faced in the clinical application of artificial anal sphincters

Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials.

Current aspects and future prospects of total anorectal reconstruction--a critical and comprehensive review of the literature

PURPOSE

Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed.

METHODS

A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis.

RESULTS

Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy.

CONCLUSIONS

Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.

Vascularized anal autotransplantation model in rats: preliminary report

Ostomy has served as an effective surgery for various anorectal disfunctions. However, it must also be noted that those patients suffered greatly from stresses caused by their stoma. Many alternative therapies have been developed, but none have solved this critical issue. Meanwhile, due to the improvements in operative methods and immunosuppressive therapy, allotranplantation has gained great popularity in recent years. Therefore, we began development of an anal transplantation model. The operation was performed in six adult Wistar rats that were divided into two groups. Group 1 underwent vascular anastomoses, while group 2 did not Group 1 grafts survived, fully recovering anal function. However, many of the group 2 grafts did not survive; those that did survive showed major defects in their anus, never recovering anal function. We succeeded in establishing the rat anal transplantation model utilizing super-microsurgery. While research in anal transplantation was behind compared to that in other fields, we hope that this model will bring significant possibilities for the future.

Anorectal autotransplantation in a canine model: the first successful report in the short term with the non-laparotomy approach

Colostomy is conventional treatment for anal dysfunction. Recently, a few trials of anorectal transplantation in animals have been published as a potential alternative to colostomies; however, further development of this technique is required. In this study, we utilized a canine model of anorectal transplantation, evaluated the patency of our microsurgical anastomoses, and assessed the perfusion of the transplanted anus. We designed a canine anorectal transplantation model, wherein anorectal autotransplantation was performed in four healthy beagle dogs by anastomoses of the lower rectum, the bilateral pudendal arteries (PAs) and veins (PVs), and pudendal nerves (PNs). Postoperative graft perfusion was measured by indocyanine green (ICG) angiography and histological examination. The length of the anorectal graft including perianal skin, anal sphincter muscle, bilateral PAs, PVs, and PNs was 4.9 ± 0.3 cm. All diameters of the PAs, PVs, and PNs were large enough to be microscopically anastomosed. Both ICG angiography and histological examination demonstrated good graft perfusion, except for one case that lead to venous congestion. These results show that anastomosis of the bilateral PAs, PVs, and PNs is required for anorectal transplantation. This is the first successful report of canine anorectal autotransplantation.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be 'dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Current status: new technologies for the treatment of patients with fecal incontinence

Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. Treatment is often challenging and needs to be individualized. During the last several years, new technologies have been developed, and others are emerging from clinical trials to commercialization. Although their specific roles in the management of fecal incontinence have not yet been completely defined, surgeons have access to them and patients may request them. The purpose of this project is to put into perspective, for both the patient and the practitioner, the relative positions of new and emerging technologies in order to propose a treatment algorithm.

Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

BACKGROUND

Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

DISCUSSION

Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Use of the gluteus maximus muscle as the neosphincter for restoration of anal function after abdominoperineal resection

BACKGROUND

Our aim was to evaluate complications and long-term functional outcome in patients who had sphincter reconstruction using the gluteus maximus muscle as the neosphincter after abdominoperineal resection for rectal cancer treatment.

METHODS

Seven patients underwent reconstruction from 2000 to 2010. First, the sigmoid colon was brought down to the perineum as a perineal colostomy, with the procedure protected by a loop ileostomy. Reconstruction of the sphincter mechanism using the gluteus maximus took place 3 months later, and after another 8-12 weeks, the loop ileostomy was closed. We studied the functional outcome of these interventions with follow-up interviews of patients and objectively assessed anorectal function using manometry and the Cleveland Clinic Florida (Jorge-Wexner) fecal incontinence score.

RESULTS

The mean follow-up was 56 months (median 47; range 10-123 months). One patient had a perianal wound infection and another had fibrotic stricture in the colocutaneous anastomosis that required several digital dilatations. Anorectal manometry at 3-month follow-up showed resting pressures from 10 to 18 mm Hg and voluntary contraction pressures from 68 to 187 mm Hg. Four patients had excellent sphincter function (Jorge-Wexner scores ≤5).

CONCLUSIONS

Our preliminary results show that sphincter reconstruction by means of gluteus maximus transposition can be effective in restoring gastrointestinal continuity and recovering fecal continence in patients who have undergone APR with permanent colostomy for rectal cancer. Furthermore, the reconstruction procedure can be performed 2-4 years after the APR.

Combination of pseudocontinent perineal colostomy and appendicostomy: a new approach in the treatment of low rectal cancer

BACKGROUND

Abdominal perineal resection (APR) with applied colostomy remains the standard treatment for low rectal cancer; however, to date, a very high morbidity rate has been reported.

AIMS

The aims of this study were to assess fecal continence, persistence of disease-related symptoms, and quality of life in patients with low rectal cancer after APR and pseudocontinent perineal colostomy and concomitant appendicostomy.

METHODS

We included 17 patients with low rectal cancer who underwent APR at our hospital in this cross-sectional study. Following APR, pseudocontinent perineal colostomy and concomitant appendicostomy were performed. Patients then underwent antegrade colonic enema with tap water. Patients' symptoms, fecal continence, and quality of life were evaluated at regular time intervals.

RESULTS

After a median follow-up of 12 months, 15 of 17 patients completed the study period. All patients were able to perform an antegrade enema by themselves. Mean continence score was 7 (out of 20) based on the Wexner Scale scoring system. Mean global health status score was 78, physical function was 93, and emotional function was 88. Minor morbidity was observed in 6 patients (40%).

CONCLUSION

Pseudocontinent perineal colostomy with appendicostomy provides an acceptable level of continence and functional and emotional improvement in patients with low rectal cancer undergoing APR. Hence, this combinative method could be considered as an alternative for abdominal colostomy in selected patients.

The development of a canine anorectal autotransplantation model based on blood supply: a preliminary case report

Colostomy is conventionally the only treatment for anal dysfunction. Recently, a few trials of anorectal transplantation in animals have been published; however, further development of this technique is required. Moreover, it is crucial to perform this research in dogs, which resemble humans in anorectal anatomy and biology. We designed a canine anorectal transplantation model, wherein anorectal autotransplantation was performed by anastomoses of the rectum, inferior mesenteric artery (IMA) and vein, and pudendal nerves. Resting pressure in the anal canal and anal canal pressure fluctuation were measured before and after surgery. Graft pathology was examined three days after surgery. The anal blood supply was compared with that in three beagles using indocyanine green (ICG) fluorescence angiography. The anorectal graft had sufficient arterial blood supply from the IMA; however, the graft's distal end was congested and necrotized. Functional examination demonstrated reduced resting pressure and the appearance of an irregular anal canal pressure wave after surgery. ICG angiography showed that the pudendal arteries provided more blood flow than the IMA to the anal segment. This is the first canine model of preliminary anorectal autotransplantation, and it demonstrates the possibility of establishing a transplantation model in dogs using appropriate vascular anastomoses, thus contributing to the progress of anorectal transplantation.

Perineal colostomy with spiral smooth muscle graft for neosphincter reconstruction following abdominoperineal resection of very low rectal cancer: long-term outcome

BACKGROUND

To avoid abdominal colostomy and improve quality of life, several types of anorectal reconstruction following abdominoperineal resection have been proposed. The aim of this study was to assess functional results and the quality of life of patients with very low rectal cancer after abdominoperineal resection and neosphincter reconstruction by perineal colostomy with a colonic muscular cuff.

PATIENTS AND METHODS

Twenty-seven patients who had undergone neosphincter reconstruction with a perineal spiral cuff plasty after abdominoperineal resection were included in a retrospective study to evaluate long-term outcome. The functional results were analyzed using anal manometry and the continence score. The quality of life was measured with the global and disease-specific questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 and C38.

RESULTS

Median follow-up time was 105 months (range, 18-185 mo). The median Holschneider continence score of the study sample was 13 (continent), with a range of 10 (partially continent) to 16 (continent), thus demonstrating satisfactory functional results. The functional assessment was completed by neosphincter manometry which revealed a median resting vs compression pressure of 40 vs 96 cmH2O with a range of 5 to 81 cmH2O vs 49 to 364 cmH2O. The quality-of-life analyses showed an above-average score for both global health and disease-specific status.

CONCLUSION

Spiral cuff colostomy with reconstruction after abdominoperineal resection of very low distal rectal cancer offers a surgical option for a selective group of patients with reasonable functional long-term results and an improved quality of life.

The current status of the Acticon Neosphincter

Severe fecal incontinence is a very debilitating condition with a tremendous impact on an individual's life. In the past if a patient was not amenable to a tissue repair or failed a tissue repair, a colostomy was his or her only surgical option. New innovations have emerged giving patients more options to regain continence. The Acticon Neosphincter, which is an artificial bowel sphincter, is one of those newer options. The device is reserved for patients with severe fecal incontinence that is not amenable to lesser forms of therapy. Because it is an artificial device, the risk of infection is of particular concern. With experience, however, the infection rate has declined and the artificial bowel sphincter has become a good option for patients with severe fecal incontinence. The results are quite impressive with a significant number of patients obtaining complete continence.

Abdominoperineal resection: how is it done and what are the results?

Abdominoperineal resection (APR) for many years was the treatment of choice for most patients with rectal cancer. Recent advances in surgical technique and other treatment modalities have led to a marked increase in the rate of sphincter-sparing operations, with a concomitant decrease in APR. However, it is still necessary in selected patients, especially those with very distal tumors or poor sphincter function. This review will cover the history of APR, current operative strategy and complications, oncologic and quality of life results, as well as potential future advances.

Perineal colostomy with appendicostomy as an alternative for an abdominal colostomy: symptoms, functional status, quality of life, and perceived health

PURPOSE

Abdominoperineal rectum resection with perineal colostomy and appendicostomy for antegrade continence enema has been developed as an alternative for abdominal colostomy or total anal reconstruction in patients with low rectal cancer. This present study was designed to compare symptoms, functional status, quality of life, and perceived health after perineal colostomy and appendicostomy with that after abdominal colostomy.

METHODS

Twenty-seven patients, 14 with abdominal colostomy and 13 with perineal colostomy and appendicostomy, were included. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR38 were used to investigate functional status and symptoms. Quality of life was measured by using a Linear Analog Scale and the Satisfaction with Life Scale. Self-perceived health was assessed by using a Linear Analog Scale.

RESULTS

Patients with perineal colostomy and appendicostomy were younger and more frequently female. They experienced better physical functioning (93.3 vs. 73.3 P = 0.048), a slightly better role functioning (100 vs. 83.3 not significant), body image (77.8 vs. 66.7 not significant), and sexual functioning (33.3 vs. 0; not significant) than patients with abdominal colostomy. Stoma-related problems were substantial in patients with abdominal colostomy (38.1) and very limited in patients with an appendicostomy (8.7). Fecal loss did not occur one hour or more after antegrade continence enema in 11 patients with perineal colostomy and was limited in the others. Quality of life and self-perceived health were comparably good in both groups.

CONCLUSIONS

Perineal colostomy with appendicostomy for antegrade continence enema is a valid and acceptable alternative for a permanent abdominal colostomy in selected patients, with a comparable functional and quality of life outcome.

[Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]

Dynamic graciloplasty (DGP) and the Acticon Neosphincter (artificial bowel sphincter, ABS) are well-established therapeutic instruments in patients with severe fecal incontinence. However, the success rates in the literature must be interpreted with caution. The report presented here presents firstly a critical analysis of 1510 patients in 52 studies (29 DGP vs 23 ABS). The evidence of these studies was assessed using the Oxford EBM criteria. All data were statistically analysed. Up to 94% of the studies analysed show EBM levels of only >3b. Both procedures show significant improvements in postoperative continence scores (p<0.001) and a significant advantage of ABS over DGP. Nevertheless, they are associated with a high incidence of morbidity in the long term (infection rate ABS vs DGP 21.74% vs 35.1%, revision rate ABS vs DGP 37.53% vs 40.64%, and ABS explantation rates of 30%). Presently no therapeutic recommendation can be expressed based on the few data available. Furthermore, therapy should be performed in specialized centers and patients should be given a realistic picture of the critical outcome of both surgical techniques.

Functional results and quality of life for patients with very low rectal cancer undergoing coloanal anastomosis or perineal colostomy with colonic muscular graft

BACKGROUND

The aim of this study was to compare functional results and quality of life (QoL) of two salvage techniques: coloanal anastomosis (CAA) or perineal reconstruction after abdominoperineal resection for very low rectal cancer.

METHODS

Between 1991 and 2001, 50 patients were operated for a very low rectal adenocarcinoma and analyzed after a follow-up greater than one year and because there was no relapse or no treatment, they were included in the analysis. Thirty-eight patients had a CAA, including: straight anastomosis (n=23), J pouch (n=10), coloplasty (n=2) and intersphincteric resection (n=3). Twelve patients underwent a PC.

RESULTS

Vaizey's incontinence score was equivalent for the two groups: CAA 12 (0-22) versus PC 11 (8-13). The only differences were more frequent fractioned stools for the CAA group and increased pad soiling for the PC group. Overall QoL scores (QLQ C-30) were equivalent for CAA and PC.

CONCLUSIONS

For very low rectal tumors, the choice of surgical technique must be based on oncologic rather than future functional or QoL criteria, because both approaches seem to provide similar results.

Neosphincter surgery for fecal incontinence: a critical and unbiased review of the relevant literature

Up until about 15 years ago the only realistic option for end-stage fecal incontinence was the creation of a permanent stoma. There have since been several developments. Dynamic graciloplasty (DGP) and artificial bowel sphincter (ABS) are well-established surgical techniques, which offer the patient a chance for continence restoration and improved quality of life; however, they are unfortunately associated with high morbidity and low success rates. Several trials have been done in an attempt to clarify the advantages and disadvantages of these methods and define their place in the second-line treatment of severe, refractory fecal incontinence. This review presents a critical and unbiased overview of the current status of neosphincter surgery according to the available data in the world literature.

Técnicas novedosas en el tratamiento de la incontinencia anal

Fecal incontinence can negatively affect the patient's occupational and social life. Until recently, most patients with severe anal incontinence unresponsive to conservative medical and/or surgical treatments underwent colostomy. Currently, these patients can benefit from one of the innovative techniques that have recently been developed. Thus, the artificial anal sphincter and dynamic graciloplasty are now available, each with specific indications. Both procedures achieve good functional results but complication and reintervention rates are not inconsiderable. Sacral neuromodulation represents an important advance due to its relative simplicity and because, through a period of test stimulation, patients who can definitively benefit from its application can be identified. Other techniques, such as injectable bulking agents or radiofrequency ablation are so recent that experience is limited and their role remains to be defined. Since these techniques are so novel and their economic cost is high, their use should be restricted to study groups with an anorectal physiology laboratory and within the context of clinical trials until experience shows whether or not their application can become widespread.

Secondary implantation of an artificial sphincter after abdominoperineal resection and pseudocontinent perineal colostomy for rectal cancer

INTRODUCTION

Fecal continence with a perineal colostomy performed after abdominoperineal resection (APR) is not always satisfactory despite retrograde colonic enemas. Functional improvement is currently examined using artificial sphincters. Preliminary results are disclosed.

PATIENTS

In 3 female patients, 45, 59 and 68 years old, curative APR and perineal colostomy were performed after radiotherapy in 2, for T1-2N0 cancer of the lower rectum. Due to occasional leaks, need for strict diet and fear of incontinence, an Acticon Neosphincter (AMS) was implanted consecutively at a mean 4.5 years after APR.

RESULTS

Device implantation was feasible and uneventful. In one case, a superficial hematoma was drained and healed by second intention. Devices were activated 3 months after implantation. At a mean 2.5 years follow-up, the 3 patients had an activated and functional artificial sphincter. Leaks and fecal urgency significantly decreased but colonic enemas were maintained. Dietary restrictions were less and quality of life improved. All 3 considered the device as a useful adjunct.

CONCLUSION

In this limited experience, implantation of artificial sphincter around a perineal colostomy following APR for rectal cancer appeared feasible and safe even in case of previous radiotherapy. Mid-term tolerance was satisfactory. Continence and quality of life significantly improved.

A review of contemporary surgical alternatives to permanent colostomy

OBJECTIVES

To review the options available to patients with faecal incontinence with failed conservative treatment and/or failed anal sphincter repair and assessing the current indications and results of these options.

METHODS

A literature search of MEDLINE, EMBASE and Cochrane databases was performed using the relevant search terms.

RESULTS

Continent options for patients with severe or end stage faecal incontinence include the creation of a form of an anal neosphincter and more recently sacral nerve stimulation. Over half the patients, who are candidates, may benefit from these procedures, although long term results of sacral nerve stimulation are unknown. Dynamic graciloplasty improves the continence in 44-79% of the patients. The complications include frequent reoperations, high incidence of infection and obstructive defaecation. The success rates of artificial bowel sphincter vary between 24% and 79%. Once functional, the artificial bowel sphincter seems to improve the continence in the majority of the patients. Device removal due to infection, obstructive defaecation and pain is a frequent problem. Sacral nerve stimulation is claimed to result in improvement in continence in 35-100% of patients. The main risks in this procedure are infection, electrode displacement and pain.

CONCLUSIONS

All these procedures have high complication rates and have moderate success rates only. A major proportion of patients will need reoperations and hence high motivation is necessary for patients who undergo these procedures. A uniform standard for measurement of success is also necessary so that these procedures can be compared with each other.