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Britto C, Pfalzgraf D, Lima R, Medeiros P, Rebouças R, Passerotti C. Video-Endoscopic Mobilization of the Gracilis Muscle for Rectourinary Fistula Repair. Urol Int 2021; 105:1123-1127. [PMID: 34120106 DOI: 10.1159/000515614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/28/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis. METHOD We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail. RESULTS Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60-145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula. DISCUSSION The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access. CONCLUSION Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.
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Affiliation(s)
- Cesar Britto
- Hospital Universitário Onofre Lopes, UFRN, Natal, Brazil
| | - Daniel Pfalzgraf
- University Medical Mannheim, Mannheim, Germany.,Heilig Geist Hospital Bensheim, Bensheim, Germany
| | | | - Paulo Medeiros
- Hospital Universitário Onofre Lopes, UFRN, Natal, Brazil
| | - Rafael Rebouças
- Hospital da Policia Militar Edson Ramalho, João Pessoa, Brazil.,Universidade de João Pessoa, UNIPE, João Pessoa, Brazil
| | - Carlo Passerotti
- Laboratório de Investigação Médica-Urologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Alemão Oswaldo Cruz, Centro de Cirurgia Robótica, São Paulo, Brazil
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Ecker KW, Baars A, Töpfer J, Frank J. Necrotizing Fasciitis of the Perineum and the Abdominal Wall-Surgical Approach. Eur J Trauma Emerg Surg 2008; 34:219-28. [DOI: 10.1007/s00068-008-8072-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Accepted: 05/07/2008] [Indexed: 01/22/2023]
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Plastic Surgery. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ruthmann O, Fischer A, Hopt UT, Schrag HJ. [Dynamic graciloplasty vs artificial bowel sphincter in the management of severe fecal incontinence]. Chirurg 2007; 77:926-38. [PMID: 16896900 DOI: 10.1007/s00104-006-1217-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- O Ruthmann
- Abteilung für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Hugstetter Strasse 55, 79106 Freiburg im Breisgau
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Zmora O, Tulchinsky H, Gur E, Goldman G, Klausner JM, Rabau M. Gracilis muscle transposition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 2006; 49:1316-21. [PMID: 16752191 DOI: 10.1007/s10350-006-0585-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE This study was designed to assess the efficacy of gracilis muscle transposition in repairing rectovaginal and rectourethral fistulas. METHODS Data were retrieved from a retrospective chart review of patients who underwent gracilis muscle transposition for fistulas between the rectum and urethra/vagina. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Follow-up data were gathered from outpatient clinic visits. Success was defined as a healed fistula after stoma closure. RESULTS Six females and three males, aged 30 to 64 years, underwent gracilis muscle transpositions from 1999 to 2005. One pouch-vaginal, three rectourethral, and five rectovaginal fistulas were repaired. The etiologies were Crohn's disease (n = 2), iatrogenic injury to the rectum during radical prostatectomy (n = 2), previous pelvic irradiation for rectal cancer (n = 2) or for cervical cancer (n = 1), recurrent perianal abscesses with fistulas (n = 1), and obstetric tear (n = 1). Seven patients underwent previous medical and surgical repair attempts. There were no intraoperative complications. Postoperative complications included perineal wound infection (n = 1) and at the colostomy closure (n = 2). There were no long-term sequelae. At a median follow-up period of 14 (range, 1-66) months since stoma closure, the fistula healed in seven patients. One patient refused ileostomy closure. One patient with severe Crohn's proctitis has a persistent rectovaginal fistula. CONCLUSIONS Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina, and the rectum, especially after failed perineal or transanal repairs. It is associated with low morbidity and a good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.
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Affiliation(s)
- Osnat Zmora
- Colorectal Unit, Division of Surgery B, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel
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Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Chapman AE, Geerdes B, Hewett P, Young J, Eyers T, Kiroff G, Maddern GJ. Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2002.02018.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
The aim of this systematic review was to compare the safety and efficacy of dynamic graciloplasty with colostomy for the treatment of faecal incontinence.
Methods
Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase and Cochrane Library databases up until November 1999. Inclusion of papers depended on a predetermined protocol, independent assessments by two reviewers and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials and case series. Forty papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance.
Results
No high-level evidence was available and there were no comparative studies. Mortality rates were around 2 per cent for both graciloplasty and colostomy. Morbidity rates reported for graciloplasty appear to be higher than those for colostomy. Dynamic graciloplasty was clearly effective at restoring continence in between 42 and 85 per cent of patients, whereas colostomy is, by its design, incapable of restoring continence. However, dynamic graciloplasty is associated with a significant risk of reoperation.
Conclusion
While dynamic graciloplasty appears to be associated with a higher rate of complications than colostomy, it is clearly a superior intervention for restoring continence in some patients. It is recommended that a comparative, but non-randomized, study be undertaken to evaluate the safety of dynamic graciloplasty in comparison to colostomy, and that the procedure should be performed only in centres where it is carried out routinely.
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Affiliation(s)
- A E Chapman
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, Australia
| | - B Geerdes
- Department of Surgery, Queen Elizabeth Hospital, Woodville, Australia
| | - P Hewett
- Department of Surgery, Queen Elizabeth Hospital, Woodville, Australia
| | - J Young
- Department of Surgery, Lyell McEwan Hospital, Elizabeth Vale, Australia
| | - T Eyers
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - G Kiroff
- Department of Surgery, Geelong Hospital, Geelong, Victoria, Australia
| | - G J Maddern
- Department of Surgery, University of Adelaide, Queen Elizabeth Hospital, Woodville, Adelaide, South Australia, Australia
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Plastic Surgery. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
BACKGROUND Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition. METHODS A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts. RESULTS The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the artificial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the artificial sphincter. Both of the above operations have been associated with implant-related infection and impaired evacuation. CONCLUSION Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres. Patients are likely to benefit from a plan that incorporates preoperative counselling and a selective approach.
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Affiliation(s)
- D A Niriella
- Academic Department of Surgery, North Colombo General Hospital and University of Kelaniya, Sri Lanka
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Mavrantonis C, Billotti VL, Wexner SD. Stimulated graciloplasty for treatment of intractable fecal incontinence: critical influence of the method of stimulation. Dis Colon Rectum 1999; 42:497-504. [PMID: 10215051 DOI: 10.1007/bf02234176] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Patients with end-stage fecal incontinence, in whom all standard medical and surgical treatment has failed or is not expected to be effective, can be treated by stimulated graciloplasty. The aim of the present study was to assess the efficacy of stimulated graciloplasty by both direct nerve and intramuscular perineural stimulation techniques and to evaluate various parameters relative to outcome. METHODS A prospective analysis of all patients who underwent this procedure was undertaken. All patients were preoperatively investigated by anal manometry, electromyography, pudendal nerve terminal motor latency assessment, endoanal ultrasound, and an enema retention test. They were further assessed with an incontinence scoring system and a Quality of Life Questionnaire. Postoperative evaluation included anorectal manometry, incontinence score registry, and a Quality of Life Questionnaire. In our initial experience the stimulation system electrodes were fixed directly to the nerve (direct nerve stimulation graciloplasty); later in the study the stimulation system electrodes were fixed intramuscularly close to the nerve branches (intramuscular perineural stimulation graciloplasty). RESULTS From May 1993 to February 1998, 27 patients underwent 33 gracilis transpositions for fecal incontinence, 30 of which were stimulated. Six of the patients with direct nerve stimulation graciloplasty eventually had the direct nerve stimulator removed and replaced with an intramuscular electrode stimulator. After an mean follow-up (until the time of exit from study) of 12.5 (range, 1-23) months for direct nerve stimulation graciloplasty and 21 (range, 8-27) months for intramuscular perineural stimulation graciloplasty, 13 graciloplasties (43 percent) were successful. There was no correlation between outcome of surgery and age, duration or cause of symptoms, body habitus, manometric or electromyographic parameters, prior sphincter repair, the presence of a pre-existing stoma, or any immediate postoperative complications. However, the number of patients with intramuscular perineural stimulation graciloplasty who had a successful outcome (continent, 69 percent; improved but not fully continent, 23 percent; incontinent, 8 percent) was significantly higher than patients with direct nerve stimulation graciloplasty (improved but not fully continent, 10 percent; incontinent, 90 percent). CONCLUSION The success of stimulated graciloplasty is dependent on the method of nerve stimulation, whereas surprisingly, none of the many other factors assessed influenced outcome.
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Affiliation(s)
- C Mavrantonis
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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Affiliation(s)
- Hajivassiliou
- University of Glasgow and Royal Hospital for Sick Children, Glasgow, UK, Department of Coloproctology, Royal Infirmary, Glasgow, UK
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Ramakrishnan V, Southern S, Hart NB, Tzafetta K. Endoscopically assisted gracilis harvest for use as a free and pedicled flap. BRITISH JOURNAL OF PLASTIC SURGERY 1998; 51:580-3. [PMID: 10209458 DOI: 10.1054/bjps.1998.0179] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endoscopic assistance in soft tissue surgery may prove to greatly aid in the improvement of cosmesis and reduction of morbidity in certain procedures. The scar produced from open gracilis harvest is the most common complaint following surgery. We present five cases of endoscopically assisted gracilis harvest for use as a neosphincter and in foot reconstruction. The operative technique is described.
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Affiliation(s)
- V Ramakrishnan
- Department of Plastic and Reconstructive Surgery, Kingston General Hospital, Hull, UK
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van Aalst VC, Werker PM, Stremel RW, Perez Abadia GA, Petty GD, Heilman SJ, Palacio MM, Kon M, Tobin GR, Barker JH. Electrically stimulated free-flap graciloplasty for urinary sphincter reconstruction: a new surgical procedure. Plast Reconstr Surg 1998; 102:84-91. [PMID: 9655411 DOI: 10.1097/00006534-199807000-00013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In electrically stimulated (dynamic) graciloplasty for urinary incontinence, the gracilis muscle is transposed into the pelvis, and the distal part is used to reconstruct a neosphincter. Clinical outcomes using this technique have been disappointing due to stricture of the urethra caused by ischemia in the distal part of the gracilis and limited gracilis length available for neosphincter construction. Furthermore, the urethra is twisted by the contracting gracilis, rather than circumferentially squeezed. The purpose of the present study was to test the anatomical and functional feasibility of a new surgical approach to reconstruct a urinary sphincter, using the gracilis muscle as a free flap. In 12 human cadavers, the anatomical feasibility for creating a neosphincter by using the gracilis free flap was determined. In all cases, transfer of the gracilis muscle into the pelvis as a free flap (with the nerve intact) was feasible, and ample muscle was available to construct a neosphincter around the bladder neck. Gracilis neosphincter function was studied in seven dogs. The left gracilis muscle was subjected to transfer into the pelvis as an innervated free flap to create a neosphincter around the urethra. The right (control) gracilis muscle was lifted as a single pedicle flap, remained in situ, and was wrapped around a stent to mimic the urethra. Function (expressed as peak pressure generation and fatigue rate) and surface perfusion were determined for all gracilis muscles. In each dog, both sides were compared using the paired Student's t test for statistical analysis, and no significant difference was measured for the two groups. In conclusion, an innervated gracilis free flap can be used to create a neosphincter around the bladder neck. In an acute study in dogs, function and perfusion of the innervated gracilis free flap are not compromised.
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Affiliation(s)
- V C van Aalst
- Department of Surgery, School of Medicine, University of Louisville, KY, USA
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Girsch W, Rab M, Mader N, Kamolz LP, Hausner T, Schima W, Gruber H. Considerations on stimulated anal neosphincter formation: an anatomic investigation in search of alternatives to the gracilis muscle. Plast Reconstr Surg 1998; 101:889-95; discussion 896-8. [PMID: 9514319 DOI: 10.1097/00006534-199804040-00001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Electrically stimulated anal neosphincter formation with transposed gracilis is performed clinically in an increasing number of patients. The use of a stimulated gluteus maximus in this application has been reported also. The question arises whether or not an optimal design for such a procedure has already been ascertained. An anatomic study was performed on 30 human cadavers to evaluate the semitendinosus muscle and its suitability for construction of a stimulated anal neosphincter. Semitendinosus fulfilled requirements for transposition around the anal canal in all cases. The muscle length was found adequate for transposition; nerve and vascular supply provided a suitable arc of rotation. The pattern of innervation might allow selective stimulation of that particular part of the muscle, which is intended to restore sphincter function. For clinical application, a vascular delay procedure is strongly recommended.
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Affiliation(s)
- W Girsch
- Department of Plastic and Reconstructive Surgery, the Institute of Anatomy, Medical School at the University of Vienna, Austria
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Considerations on Stimulated Anal Neosphincter Formation: An Anatomic Investigation in Search of Alternatives to the Gracilis Muscle. Plast Reconstr Surg 1998. [DOI: 10.1097/00006534-199804040-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wexner SD, Gonzalez-Padron A, Rius J, Teoh TA, Cheong DM, Nogueras JJ, Billotti VL, Weiss EG, Moon HK. Stimulated gracilis neosphincter operation. Initial experience, pitfalls, and complications. Dis Colon Rectum 1996; 39:957-64. [PMID: 8797641 DOI: 10.1007/bf02054681] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The stimulated gracilis neosphincter is accepted as a viable option in select patients with fecal incontinence. The aim of this study was to review the initial problems and complications. METHODS A prospective analysis of all patients who underwent this procedure was undertaken. Stage I consisted of the distal vascular delay of the muscle and creation of a temporary stoma. Stage II was the transposition of the muscle and implantation of the stimulator and electrodes. Low frequency electrical stimulation was applied to the muscle for 12 weeks, after which Stage III (stoma closure) was undertaken. RESULTS From March 1993 to December 1995, 17 patients (9 females and 8 males) with a mean age of 42.2 (range, 19-72) years underwent the procedure. One patient died from pancreatitis and another from small-bowel adenocarcinoma, three and six months after the procedure, respectively. Two patients (one with Crohn's disease) required permanent stomas. One additional patient required a permanent stoma because of lead fibrosis. Other complications noted during ascent of the learning curve included seroma of the thigh incision, excoriation of the skin above the stimulator, fecal impaction, anal fissure, parastomal hernia, rotation of the stimulator, premature battery discharge, fracture of the lead, perineal skin irritation, perineal sepsis, rupture of the tendon, tendon erosion, muscle fatigue during programming sessions, and electrode displacement from the nerve or fibrosis around the nerve. However, ultimately after rectification of these problems, 13 of the 15 eligible patients had stoma reversal. Manometric results showed an average basal pressure of 43 mmHg and an average maximum squeeze pressure that increased from 36 mmHg before surgery to 145 mmHg by stimulation (P < 0.01). Based on objective functional questionnaires, 9 of 15 (60 percent) evaluable patients reported improvement in continence, social interactions, and quality of life. Three of these nine patients require daily use of enemas. CONCLUSION Although the stimulated gracilis operation is a feasible procedure for selected patients with severe incontinence, the learning curve is steep. Although the ultimate outcome in a selected group of patients can be very gratifying, major technical modifications are required before use beyond a research protocol setting. Furthermore, patients must have the psychological strength, emotional commitment, and financial resources that may be necessary for multiple revisional surgeries or ultimate device failure.
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Affiliation(s)
- S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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