Graciloplasty for Anal Incontinence—Is Electrical Stimulation Necessary?

Abstract

Introduction Anal incontinence brings lot of social embarrassment, mental distress, dignity loss, anxiety, low confidence, and eventually a low self-esteem with a restricted social life to the affected person. Surgical repair is the mainstay of treatment for anal incontinence. However, some patients need additional procedures such as gluteoplasty, graciloplasty (adynamic and dynamic), artificial bowel sphincter, and sacral nerve stimulation, which help to reinforce or augment the anal sphincter. Methods A retrospective analysis of 17 patients who underwent adynamic graciloplasty for reconstruction of anal sphincter from January 2008 to December 2017 was done. Demographic profile, fecal incontinence scores (Wexner score and KAMM score), and anal manometric findings were recorded pregraciloplasty and postgraciloplasty. Results Of the total 17 patients, 9 were males and 8 were females. Satisfactory continence was achieved in 13 patients out of 17 (76.47%). Continence was defined as satisfactory for patients having a postoperative Wexner score of 2 or less and KAMM score of 4 or less. It was considered to be poor if the Wexner score was greater than 6 and KAMM score was greater than 8 in the follow-up period or if the stoma was not reversed. Conclusions Unstimulated or adynamic graciloplasty is a relatively safe procedure, has a short learning curve, is affordable, and avoids the additional implant-related complications. We feel that the unstimulated graciloplasty still has a significant role in the management of anal incontinence.

Dynamic Reconstruction of Anal Sphincter with Camera Shutter Style Double-Opposing Gracilis Flaps

“…In the past, electrostimulation is commonly used after the graciloplasty to transform the gracilis muscle from type II to type I (slow-twitching fatigue-resistant fibers), which allows the gracilis muscle to work as a new sphincter and maintain a sustained contraction. 7 However, in most of these cases, they only achieved partial continence at best, with continued fecal leakage requiring diapers still. The success of conventional graciloplasty has been less than 50% mainly due to muscle fatigue and the inability of patients to voluntarily contract the transposed muscle.…”

“…Gohil et al described the use of a single gracilis muscle wrapped around the anus in an “alpha,” “epsilon,” and “gamma” configuration, and showed that satisfactory continence was achieved in 76.4% of the patients in adynamic gracilis reconstruction. 7 The disadvantage of wrapping around the anus completely, was that it would exert a pulley effect, where the resultant force generated is centrifugal and could not collapse the anus to enforce continence. Rouanet et al used a gamma configuration for each gracilis muscle, and fixed both muscles to each other to create a double gracilis wrap.…”

Dynamic reconstruction of anal sphincter with camera shutter style double-opposing gracilis flaps and biofeedback training

“…In the past, electrostimulation is commonly used after the graciloplasty to transform the gracilis muscle from type II to type I (slow-twitching fatigue-resistant bers), which allows the gracilis muscle to work as a new sphincter, and maintain a sustained contraction [7]. However, in most of these cases, they only achieved partial continence at best, with continued faecal leakage requiring diapers still, The success of conventional graciloplasty has been less than 50% mainly due to muscle fatigue and the inability of patients to voluntarily contract the transposed muscle 5 .Gohil et al described the use of a single gracilis muscle wrapped around the anus in a "alpha", "epsilon", and "gamma" con guration, and showed that satisfactory continence was achieved in 76.4% of the patients in adynamic gracilis reconstruction [7]. Rouanet et al used a gamma con guration for each gracilis muscle, and xed both muscles to each other to create a double gracilis wrap.…”

Fecal Incontinence: Evaluation and Treatment

“…This induces contractions, and the initial fast-twitch fatigable muscle is retrained to become a slowtwitch, fatigue-resistant muscle. The technique demonstrated good effect in some patients, but complications were common [56][57][58]. Complications included surgical site infection, pain, device problems, erosion, and outlet obstruction.…”