Physiological anorectal reconstruction with pudendal nerve anastomosis and a colonic S-pouch after abdominoperineal resection: report of 2 successful cases

Perineal colostomy: an alternative to avoid permanent abdominal colostomy: operative technique, results and reflection

BACKGROUND

The most common injury to indicate definitive stoma is rectal cancer. Despite advances in surgical treatment, the abdominoperineal resection is still the most effective operation in radical treatment of malignancies of the distal rectum invading the sphincter and anal canal. Even with all the effort that surgeons have to preserve anal sphincters, abdominoperineal amputation is still indicated, and a definitive abdominal colostomy is necessary. This surgery requires patients to live with a definitive abdominal colostomy, which is a condition that modify body image, is not without morbidity and has great impact on the quality of life.

AIM

To evaluate the technique of abdominoperineal amputation with perineal colostomy with irrigation as an alternative to permanent abdominal colostomy.

METHOD

Retrospective analysis of medical records of 55 patients underwent abdominoperineal resection of the rectum with perineal colostomy in the period 1989-2010.

RESULTS

The mean age was 58 years, 40 % men and 60 % women. In 94.5% of patients the indication for surgery was for cancer of the rectum. In some patients were made three valves, other two valves and in the remaining no valve at all. Complications were: mucosal prolapse, necrosis of the lowered segment and stenosis.

CONCLUSION

The abdominoperineal amputation with perineal colostomy is a good therapeutic option in the armamentarium of the surgical treatment of rectal cancer.

Anal sphincter reconstruction using a transposed gracilis muscle with a pudendal nerve anastomosis: a preliminary anatomic study

PURPOSE

Few studies have demonstrated the feasibility of cross innervating a skeletal muscle neosphincter with the pudendal nerve in an animal model. This study was designed to evaluate in humans the technical feasibility of anastomosing the nerve of the gracilis muscle and the pudendal nerve when the gracilis muscle is transposed around the anus.

METHODS

Anatomic assessment was made in 30 cases. The gracilis muscle and its principal neurovascular pedicle were dissected and the nerve to the gracilis divided at its origin. The gracilis muscle, accompanied by its nerve, was then transposed around the anus. The pudendal nerve was dissected in its extrapelvic portion and divided at its termination. Gracilis reinnervation was considered feasible when the proximal end of the nerve to the gracilis muscle and the distal end of the pudendal nerve were able to be placed into tension-free contact.

RESULTS

The mean lengths of the nerve to the gracilis and the pudendal nerve were 126.5 +/- 20.6 mm and 57.5 +/- 16.3 mm. Anastomosing the nerve of the gracilis muscle and the pudendal nerve was possible in 28 cases. There was a total mean surplus nerve length of 25.1 +/- 20.9 mm. In 26 cases, the distal end of the pudendal nerve (mean, 3.3 +/- 1.1 mm) was similar or larger than the end of the nerve to the gracilis (mean, 3 +/- 0.8 mm).

CONCLUSIONS

Anal sphincter reconstruction using transposed gracilis muscle with pudendal nerve anastomosis is anatomically achievable in cadavers, and supports the potential applications of this technique for perineal reconstruction in clinical practice.

Anatomic bases of graciloplasty using end-to-side nerve pudendal anastomosis

The objective of this study was to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve using an end-to-side nerve anastomosis. This study was carried out in 14 cases (7 adult human cadavers bilaterally). The gracilis muscle and its vascular-nervous bundle have been dissected and the nerve innervating the gracilis muscle has been cut at its origin. The gracilis muscle, accompanied by its nerve, has then been transposed around the anus. The pudendal nerve has been dissected from its extrapelvic part. The reinnervation using an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension-free contact with the extrapelvic part of the pudendal nerve. The extrapelvic part of the pudendal nerve has a common trunk in 12 cases. The width of the extrapelvic part of the pudendal nerve was 2.6+/-0.7 mm, range 1-3.5. The width of the proximal endings of the nerve innervating the gracilis muscle was 2.3+/-0.5 mm, range 2-3. The reinnervation of the gracilis muscle by the pudendal nerve has been possible in 14 cases. An average supplementary length of 17.4+/-15.4 mm was available (range 5-52). These results suggest an eventual practical aspect of this technique for the reconstruction of a functional sphincter using the gracilis muscle transposed around the anus.

Long-term outcomes of a neo-anus with a pudendal nerve anastomosis contemporaneously reconstructed with an abdominoperineal excision of the rectum

BACKGROUND

Pudendal nerve innervation can transform a neo-sphincter into an original anal sphincter-like muscle in animal studies. The results led us to clinical trials of a neo-anus with a pudendal nerve anastomosis (NAPNA). No long-term results in a series have been reported.

METHODS

From 1995 to 2003, a neo-anus was reconstructed by using an inferior portion of the gluteus maximum muscle with a pudendal nerve anastomosis contemporaneously with an abdominoperineal excision of the rectum (APER) in 19 patients (17 men, 2 women; median age, 62.0 years; range, 46-73) with low-lying malignancy. The long-term (<2 years) clinical results were evaluated.

RESULTS

The neo-sphincter began contracting (n = 15) at 6.6 +/- 1.8 months after surgery; then the ileostomy was closed (n = 14) at 9.1 +/- 2.6 months. The long-term results were studied in 10 patients (40.9 +/- 14.1 months after ileostomy closure). All patients (100%) defecated at 4.8 +/- 2.6 times/day without irrigation. Pads were used every day in 9 patients (90%). The Cleveland Clinic Florida incontinence score was 12.2 +/- 3.3 points. No patients lost their occupation. Eight patients (80%) answered that their life with a NAPNA was better than with an ileostomy. The average World Health Organization Quality of Life-BREF in patients with NAPNAs was significantly better than that in those patients who underwent conventional APERs in our hospital (n = 27, 66.4 +/- 0.8 years old) ( P = .0402). Four patients (40%) experiencing the need to defecate got significantly better continence score (mean +/- SD).

CONCLUSIONS

The sensitivity to recognize the need to defecate may be a key to success in NAPNAs. A NAPNA can be a practical option for selected patients wishing to avoid a stoma after an APER.