Dynamic graciloplasty in the treatment of patients with faecal incontinence

Background: Dynamic graciloplasty is a recent innovation in the surgical ma nagement of faecal incontinence. This study reports further experience with this procedure in a series of consecutive patients. Methods: Between July 1994 and February 1998, 21 dynamic graciloplasties we re performed in 18 patients with total faecal incontinence. The two most re cent patients were excluded because of follow-up less than 6 months. Contin ence scores and manometric data were collected before operation and 6 month s afterwards. Subsequent clinical data were obtained at regular outpatient review. Seven patients had a three-stage procedure (vascular delay and stom a creation; gracilis transposition and implantation of stimulator and leads ; stoma closure), four patients had a two-stage procedure (stoma, with tran sposition and implantation; stoma closure) and five underwent a one-stage p rocedure without defunctioning stoma. Results: Mean(s.d.) follow-up was 20(10.2) months, and was complete in all patients. Eight of the 16 patients had postoperative morbidity. Thirty-thre e subsequent admissions and 23 reoperations were required to treat complica tions, to correct technical problems or to manage outcome failures, defunct ioning stoma did not protect wounds from infection (P = 0.6) or reduce the postoperative morbidity rate (P = 0.14). Continence scores were improved by the procedure (P < 0.001) and anal canal pressure increased with stimulati on (mean increase 35.9 cmH(2)O, P < 0.001). Two patients required revisiona l surgery for perielectrode fibrosis. Five patients had revisional surgery for electrical device failure. Thirteen of the 16 patients were either impr oved or fully continent after operation, and satisfied with the result of t he procedure. Ultimate failure (n = 3) occurred in patients with chronic pr eoperative constipation or diarrhoea, or abnormal rectal sensitivity. Conclusion: Dynamic graciloplasty is an effective procedure in selected cas es of end-stage faecal incontinence. Patient motivation is essential given the necessity for close follow-up.