DYNAMIC GRACILOPLASTY - COMPLICATIONS AND MANAGEMENT

PURPOSE: Patients with intractable fecal incontinence, in whom all oth er treatment failed, can be treated by dynamic graciloplasty. Good res ults have been reported, but this technique involves specific problems . All problems that occurred over an eight-year period are presented, and management is discussed. METHODS: Dynamic graciloplasty was perfor med in 67 patients with a mean follow-up of 2.7 years. All patients we re monitored by physical examination, anal manometry, defecography, an d electromyography at fixed intervals. All complications were noted an d treated. Continence was defined as being continent to solid and liqu id stools. RESULTS: The technique was successful in 52 patients (78 pe rcent), whereas failures occurred in 15 patients (22 percent). Complic ations resulted from technical problems, problems with infection, and problems attributable to an abnormal physiology of the muscle or an an orectal functional imbalance. In total, 53 complications were identifi ed in 36 patients. Most technical problems, concerning the transpositi on and stimulation of the gracilis muscle, could be treated. Failures were attributable to a bad contraction of the distal part of the muscl e (n = 4) and perforation of the anal canal during stimulation (n = 1) . In eight patients, infection of the stimulator and leads required ex plantation. Three patients did not regain continence after reimplantat ion. Apart from moderate constipation, physiologic complications were very hard to treat and resulted in failures in five patients because o f overflow incontinence, soiling, a nondistending rectum, strong peris talsis, and strong constipation. In two patients, the technique failed despite a well-contracting graciloplasty; no clear reason for the fai lure was found. CONCLUSION: Complications associated with the techniqu e of dynamic graciloplasty such as loss of contraction infection, bad contraction in the distal part of the muscle, and constipation can oft en be prevented or treated. Difficulties related to an impaired sensat ion and/or motility, attributable to a congenital cause or degeneratio n, are impossible to treat, and this signifies that a good selection o f patients is essential to prevent disappointment.