STIMULATED GRACILIS NEOSPHINCTER OPERATION - INITIAL EXPERIENCE, PITFALLS, AND COMPLICATIONS

PURPOSE: The stimulated gracilis neosphincter is accepted as a viable option in select patients with fecal incontinence. The aim of this stu dy was to review the initial problems and complications. METHODS: A pr ospective analysis of all patients who underwent this procedure was un dertaken. Stage I consisted of the distal vascular delay of the muscle and creation of a temporary stoma. Stage II was the transposition of the muscle and implantation of the stimulator and electrodes. Low freq uency electrical stimulation was applied to the muscle for 12 weeks, a fter which Stage III (stoma closure) was undertaken. RESULTS: From Mar ch 1993 to December 1995, 17 patients (9 females and 8 males) with a m ean age of 42.2 (range, 19-72) years underwent the procedure. One pati ent died from pancreatitis and another from small-bowel adenocarcinoma , three and six months after the procedure, respectively. Two patients (one with Crohn's disease) required permanent stomas. One additional patient required a permanent stoma because of lead fibrosis. Other com plications noted during ascent of the learning curve included seroma o f the thigh incision, excoriation of the skin above the stimulator, fe cal impaction, anal fissure, parastomal hernia, rotation of the stimul ator, premature battery discharge, fracture of the lead, perineal skin irritation, perineal sepsis, rupture of the tendon, tendon erosion, m uscle fatigue during programming sessions, and electrode displacement- from the nerve or fibrosis around the nerve. However, ultimately after rectification of these problems, 13 of the 15 eligible patients had s toma reversal. Manometric results showed an average basal pressure of 43 mmHg and an average maximum squeeze pressure that increased from 36 mmHg before surgery to 145 mmHg by stimulation (P < 0.01). Based on o bjective functional questionnaires, 9 of 15 (60 percent) evaluable pat ients reported improvement in continence, social interactions, and qua lity of life. Three of these nine patients require daily use of enemas . CONCLUSION: Although the stimulated gracilis operation is a feasible procedure for selected patients with severe incontinence, the learnin g curve is steep. Although the ultimate outcome in a selected group of patients can be very gratifying, major technical modifications are re quired before use beyond a research protocol setting. Furthermore, pat ients must have the psychological strength, emotional commitment, and financial resources that may be necessary for multiple revisional surg eries or ultimate device failure.