Reconstruction of rectal sphincter by transposition of gluteus muscle for fetal incontinence

Adynamic and dynamic muscle transposition techniques for anal incontinence

Gracilis muscle transposition is well established in general surgery and has been the main muscle transposition technique for anal incontinence. Dynamization, through a schedule of continuous electrical stimulation, converts the fatigue-prone muscle fibres to a tonic fatigue-resistant morphology with acceptable results in those cases where there is limited sphincter muscle mass. The differences between gluteoplasty and graciloplasty, as well as the techniques and complications of both procedures, are outlined in this review. Overall, these techniques are rarely carried out in specialized units with experience, as there is a high revision and explantation rate.

Restoration of fecal continence after functional gluteoplasty: long-term results, technical refinements, and donor-site morbidity

PURPOSE

For patients with severe fecal incontinence, reconstruction of the anal sphincter, via gluteoplasty, may improve quality of life, but little is known about long-term functional results. We present our comprehensive experience with gluteoplasty, highlighting technical refinements, donor-site morbidity, and functional outcomes.

METHODS

We performed a retrospective analysis of 25 consecutive patients (22 female, 3 male; mean age 42 years, range 23-65) undergoing gluteoplasty for fecal incontinence at a university teaching hospital from 1996-2004. Etiology of incontinence was as follows: obstetrical injury (n = 13), irritable bowel syndrome (n = 3), previous rectal surgery (n = 3), Crohn disease (n = 3), impalement (n = 1), rectocele (n = 1), and idiopathic (n = 1).

RESULTS

Gluteoplasty was successful in restoring fecal continence in 18 patients (72%) and was partially successful in 4 patients (16%). Two patients required permanent ostomy because of refractory incontinence. Donor-site morbidity and perirectal complications were observed in 16 patients (64%) and included dysthesias (n = 7), cellulitis (n = 5), irregular contour (n = 3), abscess (n = 2), seroma (n = 2), fistula (n = 1), but no hip dysfunction or altered gait. Mean length of follow-up was 20.6 months (range: 3-68 months).

CONCLUSIONS

Despite a high incidence of donor-site and perirectal complications, unilateral functional gluteoplasty was successful in restoring long-term fecal continence in most patients.

Surgical treatment of constipation and fecal incontinence

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Factors predictive of outcome after surgery for faecal incontinence

BACKGROUND

Surgical treatment of faecal incontinence may be categorized into procedures that either repair or augment the native sphincter mechanism or, alternatively, require construction of a neosphincter using either autologous tissue or an artificial device.

METHODS

This article reviews the currently available surgical options for the treatment of faecal incontinence, discusses factors predictive of outcome, and includes an algorithm for treatment.

RESULTS AND CONCLUSION

Procedures such as postanal repair, direct sphincter repair and reefing are seldom used. Overlapping repair has become the operation of choice in incontinent patients with isolated anterior defects in the external anal sphincter muscle, particularly in postobstetric trauma. Pudendal neuropathy seems to be a predictive factor of success, although this is not universally accepted. Total pelvic floor repair has been offered as a recent alternative. Neosphincter procedures include a gluteoplasty, non-stimulated and stimulated unilateral or bilateral graciloplasty and artificial bowel sphincter. The success and morbidity rates with the stimulated graciloplasty and artificial bowel sphincter appear similar. The newest alternative, sacral nerve stimulation, seems promising. In the final analysis, case selection and surgical judgement are probably the most important factors influencing the success of surgery for faecal incontinence. Presented as the Edinburgh Royal College of Surgeons invited lecture to the Association of Coloproctology of Great Britain and Ireland, Southport, UK, June 1999

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.

The posterior sagittal approach: implications in adult colorectal surgery. Harry E. Bacon Lectureship

Posterior sagittal anorectoplasty was used for the first time in 1980 to treat anorectal malformations. This approach includes a wide exposure, through a midline posterior incision, to determine the limits of the sphincteric mechanism and to place the rectum within its limits. This approach has been used to treat children with anorectal malformations, who underwent conventional procedures that failed. The management of anorectal malformations with this approach rendered significantly better results in terms of bowel control. However, there is still a large number of patients suffering from fecal incontinence and for them a bowel management program was designed to improve their quality of life. The posterior sagittal approach was also used for the treatment of acquired conditions including tumors, post-trauma and postradiation fistulas, and other postoperative complications. A historic review of the posterior approach disclosed that Cripps, a British surgeon, published his experience with a posterior transsphincteric approach to the rectum nine years before Kraske, a German surgeon, whose name has been traditionally associated with the leadership in this approach. Kraske actually approached the rectum through a paramedian incision and never performed a real transsphincteric incision. An experimental study done in dogs by the author demonstrated that it is not harmful to divide the sphincteric mechanism. The posterior sagittal approach represents a useful alternative to treat many pelvic conditions and, therefore, it must be a part of the armamentarium of colorectal surgeons. Finally, a series of clinical experiences convinced the author that coordinated rectosigmoid motility is the most important single factor in fecal continence and, therefore, our efforts to help patients suffering from fecal incontinence must be aimed at the manipulation of bowel motility.

Total fecal incontinence--a new method of gluteus maximus transposition: preliminary results and report of previous experience with similar procedures

Since 1986, different procedures of gluteus maximus transposition have been performed, by one of the authors, in 10 patients with total anal incontinence not amenable to sphincter repair, due to congenital anomalies (four), sphincteric denervation (three) or after severe trauma (three). Variable degrees of long-lasting fecal control were obtained in all but one patient, with great improvement in six. Difficulties for achieving a closed anus without muscular tension of the neosphincter, together with the morbidity associated with anal wound infection, determined the reasons for the successive use of different techniques (Biström, Hentz, Schoamaker) until the authors, in 1990, designed a new procedure (Devesa). Although the reported experience with this technique described here is limited to only four patients, our impression is that the method is easier, has less morbidity, and achieves better short-term functional results, derived from a thick, tension-free neosphincter.