Morbidity and functional outcome after double dynamic graciloplasty for anorectal reconstruction

Background:After abdominoperineal resection (APR), anorectal reconstruction with dynamic graciloplasty has been proposed to avoid abdominal colostomy and improve quality of life. Graciloplasties involving one or two gracilis muscles with various configurations have been described. The aim of this st udy was to evaluate morbidity and functional results in a homogeneous serie s of patients undergoing double dynamic graciloplasty following APR for rec tal cancer. Patients and methods: From Map 1995 to May 1998, 15 patients (ten men and f ive women; mean age 54 (range 39-77) pears) underwent anorectal reconstruct ion with double dynamic graciloplasty after APR for low rectal carcinoma. A ll patients had preoperative radiotherapy (45 Gy), 11 with concomitant chem otherapy, eight had intraoperative radiotherapy (15 Gy) and ten received ad juvant chemotherapy for 6 months. The surgical procedure was performed in t hree stages: APR with coloperineal anastomosis and double graciloplasty (do uble muscle wrap); implantation of the stimulator 2 months later; and ileos tomy closure after a training period. Results: There was no operative death. At a mean of 28 (range 3-48) months of follow-up, there was no local recurrence; two patients had lung metastas es. Early and late morbidity occurred in 11 patients, mainly related to the neosphincter (12 of 16 complications). The main complication was stenosis of the neosphincter (n = 6), which developed with electrical stimulation. O f 12 patients available for functional outcome, seven were continent, two w ere incontinent and three had an abdominal colostomy (two for incontinence, one for sepsis). Compared with patients without stenosis, patients with ne osphincter stenosis required major reoperations (four versus zero) and had a poor outcome (two of six versus five of six with a good result). Conclusion: The double dynamic graciloplasty is associated with a high risk of neosphincter stenosis, which may entail morbidity, reintervention and p oor functional results. The stenosis is a heterogeneous feature of the neos phincter induced by asymmetrical traction of both gracilis muscles. It is s uggested that single dynamic graciloplasty should be used for anorectal rec onstruction after APR.