Composite Antropyloric Valve and Gluteus Maximus Muscle Wrap for Neoanal Reconstruction: Initial Results

Abstract

BACKGROUND: Severe fecal incontinence has a significant negative impact on patient well-being. Current surgical methods of total anorectal reconstruction to substitute a colostomy have suboptimal results. A composite graft using antropyloric valve transposition and gracilis wrap has been described with good outcomes. However, this procedure requires extensive training of patients. Gluteus maximus, an accessory muscle for continence, may be better suited for this purpose. OBJECTIVE: The purpose of this study was to evaluate the outcomes of composite antropylorus–gluteus graft for intractable fecal incontinence. DESIGN: Patients underwent a 3-stage procedure: antropyloric transposition with diversion stoma followed by gluteus wrap. Stoma was closed after ensuring the anatomic and functional integrity of the graft. SETTINGS: This study was conducted at a single tertiary care institution. PATIENTS: Patients who were on permanent colostomy for intractable incontinence or would have had one after abdominoperineal resection were included. MAIN OUTCOME MEASURES: Endoultrasonography, MRI, loopogram, saline holding test, anal manometry, St. Mark’s fecal incontinence score, and personal interviews were used for measurement. RESULTS: Eleven patients underwent the procedure with a median follow-up of 16 months (range, 13–34 mo). Digital rectal examination revealed a resting tone with a distinct squeeze provided by the composite graft. Radiological imaging confirmed healthy grafts. There was a significant improvement in mean anal manometry values (resting pressure: preoperative = 10.25 mm Hg vs postoperative = 20.45 mm Hg; squeeze pressure: preoperative = 22.63 mm Hg vs postoperative = 105.18 mm Hg) and mean incontinence score postprocedure (preoperative = 22.8 vs postoperative = 8.6). On personal interview, majority of the patients were continent and expressed satisfaction with the procedure. LIMITATIONS: The study was limited by its small sample size with no control group. CONCLUSIONS: Composite graft in patients with intractable fecal incontinence can serve as a viable novel method for total anorectal reconstruction. However, it should only be recommended for a highly select group of individuals in a surveillance setting. Its long-term outcomes remain to be determined as well as its risk versus benefit.