THE STIMULATED GRACILIS NEOSPHINCTER FOR FECAL INCONTINENCE - A NEW USE FOR AN OLD CONCEPT

The stimulated gracilis neosphincter is a viable procedure in selected patients with fecal incontinence. The aim of this paper is to review the technique of this staged operative procedure and review the proble ms and complications. Stage 1 consists of the vascular ''delay'' of th e gracilis muscle and the creation of a temporary stoma. Stage 2 consi sts of transposition of the muscle around the anus with implantation o f the stimulator. Low-frequency electrical stimulation is applied to t he muscle for 12 weeks, after which stage 3 (stoma closure) is underta ken. From March of 1993 to March of 1995, 14 patients (9 females and 5 males) with a mean age of 44 years (range 20 to 67 years) underwent t he procedure. Two patients died within 1 year of the operation from un related causes. Two patients developed anal stenosis and required perm anent stomas. Other complications noted during ascent of the learning curve included seroma, excoriation of the skin above the stimulator, t ransposition of the stimulator, premature battery discharge, wound inf ection, rupture of the gracilis tendon, fatigue during programming ses sions, and electrode displacement or fibrosis from the nerve. However, 8 of the 10 eligible patients had stoma reversal; the manometric resu lts showed an average mean squeeze pressure that increased from 43 mmH g prior to surgery to 151 mmHg after the operation (p < 0.01). Based o n an objective functional questionnaire, 60 percent of the patients wh o could be evaluated reported improvement in continence, social intera ctions, and the quality of their life. In conclusion, despite a steep learning curve, the stimulated gracilis operation is a viable operatio n for selected patients with severe incontinence.