ELECTROSTIMULATED GRACILIS NEOSPHINCTER FOR FECAL INCONTINENCE AND INTOTAL ANORECTAL RECONSTRUCTION - STILL AN EXPERIMENTAL PROCEDURE

The possibility of converting an easily fatiguable muscle like the gra cilis muscle into a fatigue-resistant one using chronic electrostimula tion has renewed interest in Pickrell's procedure. Between July 1991 a nd June 1996, 9 patients (2 M; 7 F) mean age=45 y (range 14-72) underw ent dynamic graciloplasty using Medtronic electrostimulators. Five pat ients had faecal incontinence (2 congenitally anomaly, 1 neurological, 2 post-operative) and 4 had a perineal colostomy performed either sim ultaneously (two cases) or at 3 to 4 years after abdominoperineal exci sion of the rectum. Early post-operative complications included distal tendon necrosis [1], perineal colostomy breakdown [1], detachment of the gracilis tendon [2] and seroma in the thigh [1]. Long-term complic ations included rectocele with faecal impaction in one patient with im perforate anus, anal stricture in one patient who had refashioning of a perineal colostomy, and displacement of the lead from the main nerve in 3 with external expulsion in 2. The patient with anal stricture wa s successfully treated with anoplasty but subsequently returned to an abdominal colostomy due to stricture recurrence 2 years later. The rec tocele was successfully treated using a transvaginal approach. Electri cal conversion of the muscle was completed in all patients but long te rm functional results an available for only 5 cases. Manometry reveale d a significant improvement in anal pressure under electro-stimulation and the continence grading scale score significantly improved in 4 pa tients. The technique is applicable to a very selected group of patien ts with no other options but is still in the experimental phase and sh ould not be performed outside controlled trials. Repeated hospitalisat ion and reoperations are often required although the complication rate may diminish and improve with experience.