Dynamic Graciloplasty

Autor: Harald R. Rosen - Wien

Anal sphincter reconstruction by means of electrically stimulated (dynamic) graciloplasty offers a new treatment option for patients with severe fecal incontinence or for those who require abdominoperineal resection (APR) for cancer.

In the 90’s, Baeten (4) and Williams (5) introduced dynamic graciloplasty as an anal sphincter substitute for congenital or acquired fecal incontinence. Dynamic graciloplasty is a new and promising modality for patients with therapy-refractory incontinence. The use of the gracilis muscle as the neosphincter after successful transformation of the muscle fibers by means of electric stimulation has made it possible to use this method  for the purpose  of  anal sphincter reconstruction  for the treatment of fecal incontinence following extensive sphincter trauma (surgery for cancer, trauma, etc.) After transposition of the gracilis muscle (at our department usually from the left leg), a muscle sling (neosphincter) is placed around the anus or rectum. In this step of the operation, we use the previously described split-sling technique for placement of the muscle sling (7,8). The tendon of the gracilis muscle is fixed by making a stab incision in the skin, with nonabsorbable sutures which remain in position for 6 weeks and ensure stable fixation of the tendon in the subcutaneous tissue. Stimulation of the gracilis muscle is achieved by implanting two neuro-muscular stimulation electrodes in the proximal nerve-vessel bundle  (model SP5566 Medtronic, Maastricht, Netherlands), and a stimulation generator (Interstim, Medtronic) which is introduced into a generator-bed pouch in the left portion of the lower abdomen after subcutaneous pullthrough of the electrodes.

Muscle transformation was started in all patients after 14 to 41 days (median, 20 days) by means of telemetry. Based on our animal experiments (9,10), we use the following muscle fiber transformation protocol .  

During a period of eight years (1992-2000) 29 patients were treated by graciloplasty for either acquired (trauma, surgery) or congenital incontinence (anal atresia, meningomyelocele). 35 out of a total of 64 patients received dynamic graciloplasty for  total anorectal reconstruction (TAR)  following total removal of the anus for cancer. 

The most prominent complication was an injury or arrosion of the neorectum or neoanus (n:9) following TAR (compared to only one patient in the group of fecal incontinence) which could be avoided by increasing experience with this method . Defecation disorders with consecutive incontinence were observed as the major functional problem in cancer patients and could be overcomed by periodical irrigations.  

Although sphincter replacement by TAR following  cancer surgery revealed worse functional results (60% of patients reached a continence score I or II according to Williams) compared to patients treated with dynamic graciloplasty for fecal incontinence (80  - 90% score I or II) and must, therefore,  be regarded only as a compromise it is a treatment option which can be offered to selected patients in order to achieve a life style without permanent colostomy.

1. Renner K, Rosen HR, Novi G, Hölbling N, Schiessel R. Quality of life after surgery for rectal cancer. Do we still need a permanent colostomy ? Dis Colon Rectum 1999;42:1160-1167

2. Leo E, Belli F, Baldini MT, et al. New perspectives in the treatment of low rectal cancer: total rectal resection and coloendoanal anastomosis. Dis Colon Rectum 1994; 37 (suppl):S62-68

3. Schiessel R, Karner-Hanusch J, Herbst F, Wunderlich M. Intersphincteric resection for low rectal tumours. Br J Surg 1994;81:1376-1378

4. Baeten CGM, Konsten J, Spaans F, Habets AMMC, et al. Dynamic graciloplasty for treatment of fecal incontinence. Lancet 1991; 338:1163

5. Williams NS, Patel J, George BD, Hallan RI, Watkins ES. Development of an electrically stimulated neoanal sphincter. Lancet 1991; 338:1166

6. Cavina E, Secchia M, Evangelista G, Chiarugi M, et al.  Perineal colostomy and electrostimulated gracilis “neosphincter” after abdomino-perineal resection of the colon and anorectum: a surgical experience and follow-up study in 47 cases. Int J Colorectal Dis 1990; 5:6-10

7. Rosen HR, Feil W, Novi G, Zoech G, et al. The electrically stimulated (dynamic) graciloplasty for faecal incontinence – first experiences with a modified muscle sling. Int J Colorectal Dis 1995; 9:184-186

8. Rosen HR, Novi G, Zöch G, Feil W, Urbarz C, Schiessel R. Restoration of anal sphincter function by single-stage dynamic graciloplasty with a modified (split sling) technique. Am J Surg 1998;175:187-193

9. Rosen HR, Dorner G, Renner K, Seitel A, et al.  Muscle transformation of the sartorius muscle in a canine model – clinical impact for electrodynamic graciloplasty as a “neosphincter”. Dis Colon Rectum 1997;40:1321-1327

10. Rosen HR, Ausch C, Novi G, Zöch G, Feil W, Schiessel R. Analer Schließmuskelersatz mittels dynamischer Grazilisplastik-Ergebnisse der Anwendung an 50 Patienten. Chirurg 1999;70:469-475

11. Baeten CGMI, Geerdes BP, Adang EMM, Heineman E, et al. Anal dynamic graciloplasty in the treatment of intractable fecal Incontinence. N Engl J Med 1995; 332:1600-1605

12.  Madoff RD, Baeten CGMI, Christiansen J,  et al. Standards for anal sphincter replacement. Dis Colon Rectum 2000; 43:135-141

13.  Mander JB, Abercrombie JF, George BD, Williams NS. The electrically stimulated gracilis neosphincter incorporated as part of total anorectal reconstruction after abdominoperineal excision of the rectum. Ann Surg 1996; 224:702-706