Total anorectal reconstruction by double graciloplasty: experience with delayed, selective use of implantable pulse generators

This study reports our experience with total anorectal reconstruction (TAR) , supported at a later phase, whenever necessary, by an implantable pulse g enerator. Thirteen patients underwent total anorectal reconstruction by dou ble graciloplasty, diverting loop colostomy, and implantation of temporary electrodes. External-source, short-term, intermittent electrostimulation an d biofeedback were used for neosphincter voluntary control training. After abdominal stoma closure, 6 months after initial surgery in disease-free pat ients, functional results were evaluated by a scoring system and anomanomet ry A pulse generator was implanted whenever continence was judged unsatisfa ctory. After continuous electrostimulation training, neosphincter function was reassessed. Major graciloplasty complications (partial muscle necrosis and perineal colostomy necrosis) were treated successfully by surgery. One death of myocardial infarction occurred after discharge. Three patients ref used further surgery. One patient did not undergo abdominal stoma closure b ecause of early hepatic metastases. Functional evaluation after closure (ei ght patients) showed the following results: two "excellent" (no pulse gener ator implanted), three "good" (two stimulator implantations, with an "excel lent" result), two "fair", and one "poor" (3 implantations, with a "good" r esult). In addition to improving clinical results (P=0.042), resting anal p ressures were also increased significantly by active an implantable pulse g enerator (P=0.043). Although stimulators, whenever implanted, improved the neosphincter function, delayed, selective use of these in some cases render ed an implantable pulse generator either unnecessary from a functional view point or redundant because of cancer recurrence or infectious complications . Drawbacks to the procedure were poor patient complicance to neosphincter training and to multiple surgical procedures, and excessive wasting of huma n resources during training for intermittent electrostimulation and biofeed back.