Dynamic graciloplasty in the treatment of patients with faecal incontinence

Abstract

Background: Dynamic graciloplasty is a recent innovation in the surgical management of faecal incontinence. This study reports further experience with this procedure in a series of consecutive patients. Methods: Between July 1994 and February 1998, 21 dynamic graciloplasties were performed in 18 patients with total faecal incontinence. The two most recent patients were excluded because of follow-up less than 6 months. Continence scores and manometric data were collected before operation and 6 months afterwards. Subsequent clinical data were obtained at regular outpatient review. Seven patients had a three-stage procedure (vascular delay and stoma creation; gracilis transposition and implantation of stimulator and leads; stoma closure), four patients had a two-stage procedure (stoma, with transposition and implantation; stoma closure) and five underwent a one-stage procedure without defunctioning stoma. Results: Mean(s.d.) follow-up was 20(10·2) months, and was complete in all patients. Eight of the 16 patients had postoperative morbidity. Thirty-three subsequent admissions and 23 reoperations were required to treat complications, to correct technical problems or to manage outcome failures. A defunctioning stoma did not protect wounds from infection (P= 0·6) or reduce the postoperative morbidity rate (P= 0·14). Continence scores were improved by the procedure (P< 0·001) and anal canal pressure increased with stimulation (mean increase 35·9 cmH2O, P< 0·001). Two patients required revisional surgery for perielectrode fibrosis. Five patients had revisional surgery for electrical device failure. Thirteen of the 16 patients were either improved or fully continent after operation, and satisfied with the result of the procedure. Ultimate failure (n = 3) occurred in patients with chronic preoperative constipation or diarrhoea, or abnormal rectal sensitivity. Conclusion: Dynamic graciloplasty is an effective procedure in selected cases of end-stage faecal incontinence. Patient motivation is essential given the necessity for close follow-up.