Muscle Transposition: Does It Still Have a Role?

Abstract

Since the early 1900s, skeletal muscle transpositions have been employed for complicated cases of fecal incontinence to augment or replace the anal sphincter. Multiple techniques have evolved that vary with the type and configuration of muscle used in the reconstruction. Transposition of the gluteus maximus muscle was popular in the early stages of development but was replaced by techniques involving transposition of the gracilis muscle. Within the past 16 years, electrical stimulators have been applied to the transposed muscle flaps to create a dynamic reconstruction improving the efficacy of these neosphincters over their static counterparts. However, the stimulated versions are technically demanding with a high rate of morbidity secondary to complications of the multiple components and variations in technique. The stimulator used in this procedure has been removed from the US market, although it is still available in other countries. Currently in the United States, gracilis transposition is still employed in the absence of an electrical stimulator as an adjunct to the artificial bowel sphincter (Acticon Neosphincter TM , American Medical Systems, Minnetonka, MN), such as in cases of severe muscle loss and congenital atresia. In European countries, the stimulated graciloplasty continues to evolve, leading to expansion of its use in total anorectal reconstruction for anal atresia and after abdominoperineal resection. KEYWORDS: Fecal incontinence, muscle transposition, graciloplasty, gluteoplasty, neosphincter constructionObjectives: Upon completion of this article, the reader should be able to: (1) list current therapeutic options for failed overlapping sphincteroplasty; and (2) evaluate the results of each of these procedures.Patients with severe fecal incontinence unresponsive to conservative measures can be divided into two broad categories of surgical approach. The first group includes those patients with an identifiable anatomic sphincter defect who can expect a 40 to 60% long-term surgical success rate with overlapping sphincteroplasty.1 The absence of pudendal neuropathy yields the best outcome in these patients. 2 The second group includes those patients with extensive sphincter damage, muscle loss, or pudendal neuropathy not amenable to direct sphincter repair. With the widespread prevalence of fecal incontinence and development of newer surgical techniques, the patient with severe fecal incontinence is seldom obligated to a permanent stoma. Neosphincter

Management of fourth degree obstetric perineal tear without colostomy using non - stimulated gracilis - our experience over eleven years

“…Striated muscle is unable to maintain a contraction for a prolonged period[ 18 ] and this problem has been addressed by implantation of a neuromuscular stimulator after gracilis transposition. [ 25 26 ] The literature on gracilis reconstruction for faecal incontinence is dominated by the use of this technique in children, after trauma and after bowel surgery. In our series, we have not used stimulator for gracilis and all these cases are post-delivery recto-vaginal fistulae.…”

Clinical Challenges of Fecal Incontinence in the Elderly

“…Studies found up to 60 % of patients who had graciloplasty still benefited after 2 years in addition to improvements in quality of life and social functioning [80,81]. However, dynamic graciloplasty is associated with a high rate of complications including fibrosis, seroma of incision site, excoriation of skin at nerve stimulation site, fecal impaction, post operative infection, rupture of tendon, muscle detachment, and electrode displacement [82]. Due to the high rates of complications, dynamic graciloplasty is not approved in the USA for fecal incontinence.…”

Fecal Incontinence: Etiology, Diagnosis, and Management

“…The gracilis muscle is easier to mobilize and is more superficial in location. 37 Additionally, the single long muscle belly of the gracilis muscle allows unilateral dissection as opposed to bilateral dissection of the gluteus maximus muscle to encircle the anus. The drawbacks of graciloplasty include its inability to maintain a resting tone and quick fatigability with chronic contraction to maintain anal tone.…”