Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1010 - файл
.pdf
Chapter 19 Sphincteroplasty
Halverson AL, Hull TL (2002) Long-term outcome of overlapping anal sphincter repair. Dis Co-
lon Rectum 45: 345–348
Hasegawa H,Yoshioka K, Keighley MRB (2000) Randomized trial of fecal diversion for sphinc-
ter repair.Dis Colon Rectum 43: 961–965
Hool GR, Lieber ML, Church JM (1999) Postoperative anal canal length predicts outcome in pa-
tients having sphincter repair for fecal incontinence. Dis Colon Rectum 42 :313–318
Jorge JMN,Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum
36: 77–97
Keighley MRB (1993) Faecal incontinence. In: Keighley MRB, Williams NS (eds) Surgery of the
anus, rectum and colon. Saunders, London, pp 516–608
Laurberg S, Swash M,Henry MM (1988) Delayed external sphincter repair for obstetric tear. Br J
Surg 75: 786–788
Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ et al (1994) Overlapping anal sphincter
repair for faecal incontinence due to sphincter trauma: five-year follow-up functional results.
Int J Colorect Dis 9: 110–113
Malouf AJ, Norton CS, Engel AF et al (2000) Long-term results of overlapping anterior anal-
sphincter repair for obstetric trauma. Lancet 355: 260–265
Nessim A,Wexner SD, Agachan F, Alabaz O, Weiss Eg, Nogueras JJ et al (1999) Is bowel confine-
ment necessary after anorectal reconstructive surgery? A prospective, randomized,surgeon-
blinded trial. Dis Colon Rectum 42: 16–23
Parks AG, McPartlin JF (1971) Late repair of injuries of the anal sphincter. Proc R Soc Med 64 :
1187–1189
Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, Kamm MA (1999) Results of repeat anal
sphincter repair.Br J Surg 86: 66–69
Rosenberg J,Kehlet H (1999) Early discharge after external anal sphincter repair. Dis Colon Rec-
tum 42: 457–459
Rothbarth J, Bemelman WA, Meijerink WJHJ et al (2000) Long-term results of anterior anal
sphincter repair for fecal incontinence due to obstetric injury.Dig Surg 17 :390–394
Scott A, Hawley PR, Phillips RKS (1989) Results of external sphincter repair in Crohn’s disease.
Br J Surg 76:959–960
Sitzler PJ, Thomson JPS (1996) Overlap repair of damaged anal sphincter.A single surgeon’s se-
ries. Dis Colon Rectum 39:1356–1360
Simmang C, Birnbaum EH, Kodner IJ, Fry RD, Fleshman JW (1994) Anal sphincter reconstruc-
tion in the elderly: does advancing age affect outcome? Dis Colon Rectum 37:1065–1069
Slade MS, Goldberg S, Schottler JL, Balcos EG, Christenson CE (1977) Sphincteroplasty for ac-
quired anal incontinence.Dis Colon Rectum 20: 33–35
Soffer EE, Hull T (2000) Fecal incontinence: a practical approach to evaluation and treatment.
Am J Gastroenterol 95:1873–1880
Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999) Prospective comparison of faecal incontinence
grading systems. Gut 44 : 77–80
Young CJ, Mathur MN, Eyers AA, Solomon MJ (1998) Successful overlapping anal sphincter re-
pair.Relationship to patient age, neuropathy, and colostomy formation. Dis Colon Rectum 41:
344–349
287
Chapter 20
Dynamic Graciloplasty
Cor G.M.I. Baeten, Jarno Melenhorst
Chapter 20 Dynamic Graciloplasty
289
20
Contents
20.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 290
20.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . 290
20.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
20.4 Stimulation of the Gracilis Muscle . . . . . . . . . . . . . 292
20.5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
20.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . 294
20.7 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
20.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 295
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
290
Cor G.M.I. Baeten, Jarno Melenhorst
20
20.1 Introduction
Fecal incontinence is a socially incapacitating condition that generates high treatment
costs. It can be treated with numerous therapies. The usual conservative treatments
and operations are able to help a high rate of patients, but there are always problems
that cannot be solved. Patients who have an absent or a nonfunctional anal sphincter
could benefit from a dynamic graciloplasty.Dynamic graciloplasty means a musculus
gracilis transposition, which is electrically stimulated.
Almost 60 years ago, Pickrell (Pickrell et al.1952) described the method to bring a
gracilis muscle around the anus in children with anal atresia.With this graciloplasty it
was thought that these patients could control their incontinence. In reality it functioned less than was hoped for. The reason for this was that the patients had to contract
the gracilis muscle voluntarily. The muscle could sustain this contraction only for a
few minutes. Therefore this procedure became obsolete. It took many years before a
solution was found.
First physiologists, and later thoracic surgeons (Salmons and Henriksson 1981;
Pette and Vrbova 1992; Chachques et al.1986; Malek and Mark 1989) discovered that a
normal skeletal muscle,which consists in the majority of fatigue-prone type II fibers,
could change its fiber-pattern by electrical stimulation. This principal applied to the
gracilis muscle meant that it was possible to create a nonfatigable neosphincter predominantly consisting of type I fibers. The electrical stimulation also forced the
gracilis wrap to contract independent of will. Many surgeons have used this dynamic
graciloplasty successfully since 1986 (Baeten et al. 1988, 1991, 1995;Williams et al. 1991;
Cavina et al. 1998; Penninckx 2004).
20.2 Indications
Dynamic graciloplasty is indicated for patients with a sphincter defect that cannot be
treated by a conventional sphincter repair. This means a defect with such a loss of
sphincter muscle that no overlapping Parks repair is possible or in case of a defect in
which the muscle remnant is denervated.Also in patients who had anal repair in the
past that proved to be non-functional, dynamic graciloplasty can give a solution.
Another indication forms the group of patients with an anatomically intact sphincter but with severe neuropathy. It is possible to treat these patients with sacral nerve
stimulation, but when this treatment fails dynamic graciloplasty is an option.Central
neurological disorders such as meningomyelocele or cauda equina syndrome also
form an indication.
A third group is made up of patients who have no sphincter because of a congenital defect (anal atresia) or an abdominoperineal resection. In these cases one or two
gracilis wraps can replace the sphincters and pelvic floor.
20.3 Technique
The technique of dynamic graciloplasty is described by various authors and is in principle almost the same. The patient’s skin is prepared at the donor leg, the perineum
and the lower abdomen. They receive antibiotic prophylaxis and general anesthesia
without muscle relaxants.Epidural anesthesia is also possible.
Chapter 20 Dynamic Graciloplasty
Then the patients are positioned in lithotomy with the donor leg in a movable stirrup. The draping allows free access to the leg, perineum and lower abdomen.
The gracilis muscle is exposed through an incision in the medial aspect of the
upper leg.
At the distal third part of the gracilis, there is overlap of the sartorius muscle, which
can act as a reference point.Normally there are one to four peripheral arteries. These
are divided and the distal insertion of the gracilis can be freed by blunt dissection
under the sartorius below the knee. The tendon can be cut close to its insertion at the
tuberositas tibiae.At this stage it can be helpful to make an auxiliary incision below the
knee.
The outstretched muscle is then freed of connective tissue, working towards the
main artery and nerve. This is invariably found at 8 cm from the origin of the muscle
at the frontolateral aspect. Care must be taken not to damage the nerve and vascularization.
Proceeding with the next step in the operation, which is the creation of the tunnel
around the anus. Two incisions are made lateral of the anus at approximately 5 cm
from the anal verge. Through these incisions one can make the tunnel dorsally from
the anus by digital dissection. The reference point of the posterior aspect of the tunnel
is the tip of the os coccyx. The frontal tunnel can give problems with blunt dissection.
When excessive scar tissue from previous surgery is encountered,an auxiliary incision
can be made posterior in the vagina, preventing unintentional perforation of the anorectum.
When the anus is encircled, one has to make a subcutaneous connection between
the perineum and the wound in the upper leg. The tunnel created by blunt dissection
must be wide enough to allow an unobstructed passage of the biggest part of the gracilis muscle. An entrapment of the muscle is possible, when the passage is too narrow.
This will lead to necrosis of the distal part of the gracilis.
To determine which loop configuration will be used; the gracilis muscle must be
brought through the tunnels to encircle the anus. When the muscular part is long
enough, an epsilon or gamma loop is preferable,in which there is a 360-degree coverage around the anal canal.In case of a short muscular part, one has to settle for an alpha loop (Geerdes et al.1996).
The distal tendon of the muscle is attached to the contralateral side of the pubic
bone if it is a gamma or epsilon loop.An alpha loop is the result of attaching the tendon to the ipsilateral side.Thus,a gamma loop passes the anus first at the frontal,then
at the dorsal and again at the frontal side.An epsilon loop goes first dorsally then frontally and again dorsally of the anus, and an alpha loop passes first frontally and then
dorsally of the anus.
It is important that the tendon of the gracilis will be attached to the periost of the
ramus inferior of the pubic bone, behind the bulk of the muscle and not in front because this would produce an entrapment of the gracilis.
At this stage one has to make a choice whether to proceed with the implant of the
electrodes and the implantable stimulator immediately or to delay the implant to a later date. In the latter case,the tendon of the gracilis can be sutured to the periost with
a nonresorbable suture and the wounds can be closed.
When the implant is done immediately, it is best to retract the gracilis muscle again
into the wound in the upper leg.
Two electrodes, one positive and one negative, are implanted in the outstretched
muscle near the side of the entrance of the main pedicle nerve and are connected to a
temporary stimulator. The most optimal location of the electrode placement is found
291
20
292
Cor G.M.I. Baeten, Jarno Melenhorst
at the location where the muscle contracts firmly with stimulation at a very low voltage. When this spot is found both electrodes can be fixed to the epimysium of the
muscle.
Now the gracilis can be brought again in the chosen way around the anus and the
tendon is sutured to the periosteum of the ramus inferior of the pubic bone.
The electrodes can now be tunneled to a pocket in the lower abdomen at the same
side as where the gracilis was taken. This pocket is made through an incision in the
lower abdomen and created underneath the fascia of the musculus rectus abdominis.
Both electrodes can now be connected to an implantable stimulator (IPG) and the
stimulator is placed in the pocket,which is closed after irrigating the wound with antibiotics.All skin wounds can now be closed and the operation is completed.
An alternative for the electrode implant is to use one epineural electrode. For this,
the nerve leading to the gracilis has to be freed over several centimeters and a quadripolar electrode is sutured over the nerve to the fascia of the underlying muscle.
As mentioned before, the implant can also be done at a later phase. The gracilis
muscle then has to be freed again at the spot where the gracilis is plicated in the upper
leg. The implant of the electrodes is the same as is described above but now not in the
outstretched but in the plicated gracilis. The contractions of the muscle can be seen in
the wound or felt around the anus.
During the creation of the tunnel, if an unintentional perforation of the anal canal
is made a two-staged operation rather than a single-phase operation should be done.
The risk of infecting foreign material is high after a perforation. This is a serious
problem,often requiring re-operations. It must be avoided in all cases.
It is also possible to do this procedure after abdominoperineal resection for patients with rectal cancer. The resection has to be followed immediately by a pullthrough of the descending colon to the perineal skin. It is important to do this pullthrough in the same operation as the resection because a secondary procedure could
lead to many complications. The distal end of the colon (neorectum) can now be encircled by one or two gracilis muscles.Both muscles can be stimulated by implantation
of one electrode in each muscle. And both electrodes are connected to one stimulator
(Geerdes et al. 1997).
20.4 Stimulation of the Gracilis Muscle
The stimulation period should not be commenced immediately.After the operation it
is best to rest the gracilis muscle some for 2–4 weeks and leave the stimulator switched
off.After this rest period, the muscle should be trained. The stimulator can be switched
on in a frequency of 2.1 Hz. This will give intermittent contractions of the muscle and
is felt by the patient as a twinkling but not unpleasant feeling. The voltage can be programmed so that an increase in anal pressure is measured of at least 20 cm Hg. The
programming of the implanted stimulator is done telemetrically and can be done in an
outpatient department. After the first 2 weeks of stimulation, the frequency is increased to 5.2 Hz and after 2 weeks again to 10 Hz.Every time anal manometry is performed one must be sure that a sufficient pressure increase is found. Over time it is
likely that the voltage will have to be increased to provide the desired pressure, while
the muscle changes gradually from type 2 into type 1 fibers. The type 1 fibers are nonfatigable but also less forceful than the type 2 fibers and need a higher voltage to result
in the same contraction force of the whole muscle.Another reason for the necessity to
increase the voltage is the fibrosis formed around the tip of the electrodes, leading to
Chapter 20 Dynamic Graciloplasty
higher resistance at the side of muscle contact.This demands a higher voltage to give
the same effect on the muscle contraction. This increase in voltage will continue over
about 6 months and then reaches a plateau that will probably remain for a lifetime
(Rongen et al.2001).
Experience in hundreds of patients has shown that with this training program the
muscle really changes into a predominantly type 1 muscle that is able to contract without fatigue.The changes in the muscle can be proven with a simple test: a normal skeletal muscle will show a flat contraction with a stimulation frequency of 25 Hz.A stimulation-changed muscle shows a flat contraction with only 10 Hz.The changes were also proven by biopsies of the muscle,which showed an enormous decrease of type 2 fibers and an increase in type 1 fibers (Baeten et al. 1988). The stimulation of a gracilis
muscle changes the fiber pattern into a fiber composition that can give a nonfatigable
long-term contraction independent of brain input.In this way, it replaces the function
of the original anal sphincters.
The muscle contraction is maintained by the stimulation and results in a closure of
the anus. To open the anus the stimulator can be switched off with a handheld programmer by the patient. This results in a relaxation of the gracilis and enables defecation. After passage of stool, the stimulator can be switched on again to close the anal
canal.
20.5 Results
It is difficult to compare the results of dynamic graciloplasty since various authors use
different criteria for success. Most of them define success as reaching a level of continence of 1 or 2 on the Williams scale. This means normal continence or occasional loss
of flatus. Others define success as a more then 50% reduction in incontinence events.
In one fairly large multicenter study (Baeten et al.2002), in which all the data from
different clinics were obtained in a prospective matter, the overall success rate was
62%.The success rates of single-center studies vary from 56% to 74% and are shown in
Table 20.1.
293
Table 20.1. Success rates for dynamic graciloplasty
Author Year Number Success (%) Infection (%)
1. Baeten et al. 1995 52 73 12
2. Wexner et al. 1996 17 60 –
3. Cavina et al. 1998 31 85 –
4. Mander et al. 1999 64 56 –
5. Rongen et al. 1999 7 71 –
6. Madoff et al. 1999 128 66 32
7. Baeten et al. 2000 123 63 15
8. Rongen et al. 2001 26 72 5
9. Konsten et al. 2001 81 57 15
10. Konsten et al. 2001 200 74 4
11. Penninckx et al. 2004 60 72 15
294
Cor G.M.I. Baeten, Jarno Melenhorst
20
20.6 Complications
Although the results are good for the majority of the patients, it is obtained at the cost
of several problems that had to be solved (Geerdes et al. 1996). One of the most frequently mentioned complications is infection. This is a combination of inflammatory
problems at several sites of the operation.There are infections reported at the donorleg wound. These can be treated in a conservative way, and have no influence on the
functional outcome of the dynamic graciloplasty. Infections around the anus are frequently seen and can be treated by drainage and irrigation of the wounds and do not
interfere with success unless they are caused by a perforation of the anorectum.Infections at the site of the pocket always require removal of the stimulator,since it is an infected foreign body. This is not the end of the procedure because the IPG and electrodes can be reimplanted again when the infection is healed.A vital muscle normally
survives an infection.
No contraction or insufficient contraction of the gracilis can have several causes,
grossly divided in two subgroups. The first group consists of patients who are not capable of voluntarily contracting the gracilis muscle. This is a problem of the muscle itself.
One of the causes is a detachment of the distal tendon. Reattaching the tendon to
the pubic bone can easily solve this.It can also be caused by fibrosing or necrotizing of
the distal end of the gracilis. In this case, this gracilis can no longer be used and the
only solutions are a graciloplasty of the other side or an artificial bowel sphincter implant.
The second group consists of patients whose gracilis muscle contracts voluntarily,
but this contraction cannot be obtained with stimulation. This must be a problem of
the stimulation. One of the reasons for such a problem could be an empty stimulator.
Replacement is the solution.Another cause is the dislodgement of the electrode out of
the muscle. The electrode should be reimplanted to solve this problem. In a very few
cases, the electrode breaks; this can also be solved by renewal of the electrode.
In several patients, incontinence changes into constipation after dynamic graciloplasty at the same rate as we see also after sphincteroplasties or artificial bowel sphincters. The reason for this constipation is almost never a narrowing of the anus, and the
cause remains unclear. Dietary modifications and medications together with retrograde colonic irrigation facilitate the passage of stool.
A serious complication is an erosion or perforation through the anorectum. This always causes a serious infection.The best way to proceed in such a case is to give the patient a protective colostomy and to close the defect in the rectum. Care must be taken
during preparation and suturing of the tendon.This should not be too tight; otherwise
there is a higher risk of perforation due to erosion.
All in all the number of complications is high, but almost all of them are treatable.
20.7 Discussion
Dynamic graciloplasty is a good treatment for patients with incontinence who have no
other options.One has to keep in mind that this therapy only restores sphincter function, but has no influence on other reasons for incontinence. For instance, patients
with an extreme urge or a nondistending rectum or neorectum or those with nontreatable diarrhea will probably not benefit from a dynamic graciloplasty alone. It can be
Chapter 20 Dynamic Graciloplasty
Fig. 20.1. Success rate after dynamic graciloplasty
difficult to evaluate patients with multiple causes for incontinence, and restoring one
of the causes will not automatically lead to the solution of the problem of incontinence. Many operations such as anal repair, artificial bowel sphincter and dynamic
graciloplasty are considered to be a failure when the patient is not continent, but one
has to look for other causes.The function of the sphincter or neosphincter should only
be judged after carefully observing all of the problems, before one says that the operation has really failed.
295
20.8 Conclusion
For the group of patients with severe fecal incontinence due to sphincter malfunction,
dynamic graciloplasty forms a good alternative. It is successful in the majority of patients (Table 20.1, Fig. 20.1).Therefore, colostomy is no longer the endpoint of fecal incontinence.
References
Baeten CG, Bailey HR, Bakka A, Belliveau P, Berg E, Buie WD, Burnstein MJ, Chachques JC,
Grandjean PA, Carpentier A (1986) Dynamic cardiomyoplasty: experimental cardiac wall re-
placement with a stimulated skeletal muscle. In: Chiu RCJ (ed) Cardiomyoplasty and muscle-
powered devices. Futura Publishing, New York, pp 59–84
Baeten C, Spaans F, Fluks A (1988) An implanted neuromuscular stimulator for faecal continence
following previously implanted gracilis muscle.Dis Colon Rectum 31: 134–137
Baeten CGMI, Konsten J, Spaans F,Visser R, Hebaets AMMC, Bourgeois IM,Wagenmakers AJM,
Soeters PB (1991) Dynamic graciloplasty for treatment of faecal incontinence. Lancet 338:
1163–1165
Baeten CG, Geerdes BP, Adang EM,Heineman E, Konsten J, Engel GL,Kester AD, Spaans F, Soet-
ers PB (1995) Anal dynamic graciloplasty in the treatment of intractable fecal incontinence.
N Engl J Med 332: 1600–1605
20
296
Cor G.M.I. Baeten, Jarno Melenhorst
Christiansen J, Coller JA, Galandiuk S,LaFontaine LJ, Lange J,Madoff RD, Matzel KE,Pahlman L,
Parc R, Reilly JC, Seccia M, Thorson AG,Vernava AM 3rd,Wexner S (2000) Safety and effica-
cy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial,
Dynamic Graciloplasty Therapy Study Group. Dis Colon Rectum 43: 743–751
Cavina M, Seccia M, Banti P, Zocco G (1998) Anorectal reconstruction after abdominoperineal
resection. Experience with double-wrap graciloplasty supported by low-frequency electrical
stimulation. Dis Colon Rectum 41 :1010–1016
Geerdes BP, Heineman E,Konsten J,Soeters PB, Baeten CG (1996) Dynamic graciloplasty.Com-
plications and management.Dis Colon Rectum 39 : 912–917
Geerdes BP, Zoetmulder FA, Heineman E,Vos EJ, Rongen MJ, Baeten CG (1997) Total anorectal re-
construction with a double dynamic graciloplasty after abdominoperineal reconstruction for
low rectal cancer. Dis Colon Rectum 40:698–705
Konsten J, Rongen MJ,Ogunbiyi OA,Darakhshan A, Baeten CG,Williams NS (2001) Comparison
of epineural or intramuscular nerve electrodes for stimulated graciloplasty. Dis Colon Rec-
tum 44 : 581–586
Madoff RD,Rosen HR, Baeten CG,LaFontaine LJ, Cavina E,Devesa M, Rouanet P,Christiansen J,
Faucheron JL, Isbister W, Kohler L, Guelinckx PJ, Pahlman L (1999) Safety and efficacy of
dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial.
Gastroenterology 116: 549–556
Malek AM, Mark RG (1989) Functional electrical stimulation of the latissimus dorsi for use in
cardiac arrest. IEEE Transbiomed Eng 36: 781–788
Mander BJ,Wexner SD,Williams NS, Bartolo DC,Lubowski DZ,Oresland T, Romano G, Keighley
MR (1999) Preliminary results of a multicentre trial of the electrically stimulated gracilis neo-
anal sphincter.Br J Surg 86: 1543–1548
Penninckx F, Belgian Section of Colorectal Surgery (2004) Belgian experience with dynamic gra-
ciloplasty for fecal incontinence.Br J Surg 91: 872–878
Pette D, Vrbova G (1992) Adaptation of mammalian skeletal muscle fibres to chronic electrical
stimulation. Rev Biochem Pharmacol 120 :115–202
Pickrell KL,Broadbent TR, Masters FW, Metzger JT (1952) Construction of a rectal sphincter and
restoration of anal incontinence by transplanting the gracilis muscle: report of four cases in
children.Ann Surg 135: 853–862
Rongen MJ,Dekker FA,Geerdes BP, Heineman E,Baeten CG (1999) Secondary coloperineal pull-
through and double dynamic graciloplasty after Miles resection – feasible, but with a high
morbidity.Dis Colon Rectum 42 :776–780; discussion 781
Rongen MJ,Adang EM, van der Hoop AG, Baeten CG (2001) One-step vs two-step procedure in
dynamic graciloplasty.Colorectal Dis 3 :51–57
Salmons S, Henriksson J (1981) The adaptive response of skeletal muscle to increase use.Muscle
Nerve 4: 9–105
Wexner SD, Gonzalez-Padron A,Rius J, Teoh TA, Cheong DM,Nogueras JJ,Billotti VL,Weiss EG,
Moon HK (1996) Stimulated gracilis neosphincter operation. Initial experience, pitfalls, and
complications.Dis Colon Rectum 39: 957–964
Williams NS, Patel J, George RD, Hallan RI, Watkins ES (1991) Development of an electrically
stimulated neoanal sphincter.Lancet 338 :1166–1169
Соседние файлы в папке @xirurgi_2025