Stimulated graciloplasty for treatment of intractable fecal incontinence -Critical influence of the method of stimulation

INTRODUCTION: Patients with end-stage fecal incontinence, in whom all stand ard medical and surgical treatment has failed or is not expected to be effe ctive, can be treated by stimulated graciloplasty. The aim of the present s tudy was to assess the efficacy of stimulated graciloplasty by both direct nerve and intramuscular perineural stimulation techniques and to evaluate v arious parameters relative to outcome. METHODS: A prospective analysis of a ll patients who underwent this procedure was undertaken. All patients were preoperatively investigated by anal manometry, electromyography, pudendal n erve terminal motor latency assessment, endoanal ultrasound, and an enema r etention test. They were further assessed with an incontinence scoring syst em and a Quality of Life Questionnaire. Postoperative evaluation included a norectal manometry, incontinence store registry, and a Quality of Life Ques tionnaire. In our initial experience the stimulation system electrodes were fixed directly to the nerve (direct nerve stimulation graciloplasty); late r in the study the stimulation system electrodes were fixed intramuscularly close to the nerve branches (intramuscular perineural stimulation gracilop lasty). RESULTS: From May 1993 to February 1998, 27 patients underwent 33 g racilis transpositions for fecal incontinence, 30 of which were stimulated. Six of the patients with direct nerve stimulation graciloplasty eventually had the direct nerve stimulator removed and replaced with an intramuscular electrode stimulator. After an mean follow-up (until the time of exit from study) of 12.5 (range, 1-23) months for direct nerve stimulation gracilopl asty and 21 (range, 8-27) months for intramuscular perineural stimulation g raciloplasty, 13 graciloplasties (43 percent) were successful. There was no correlation between outcome of surgery and age, duration or cause of sympt oms, body habitus, manometric or electromyographic parameters, prior sphinc ter repair, the presence of a pre-existing stoma, or any immediate postoper ative complications. However, the number of patients with intramuscular per ineural stimulation graciloplasty who had a successful outcome (continent, 69 percent; improved but not fully continent, 23 percent; incontinent, 8 pe rcent) was significantly higher than patients with direct nerve stimulation graciloplasty (improved but not fully continent, 10 percent; incontinent, 90 percent). CONCLUSION: The success of stimulated graciloplasty is depende nt on the method of nerve stimulation, whereas surprisingly, none of the ma ny other factors assessed influenced outcome.