Artificial Options

Professor Norman Williams, Royal London Hospital

Powerpoint File

The combination of the electrically stimulated gracilis neoanal sphincter and continent colonic conduit: a way forward for total anorectal reconstruction?

Purpose: Patients undergoing total anorectal reconstruction for anorectal atresia or following abdominoperineal resection of the rectum do not fare as well after an electrically stimulated gracilis neoanal sphincter as do patients with incontinence alone. This retrospective study reports the outcome for the combination of a continent colonic conduit or Antegrade Continence Enema procedure to an electrically stimulated gracilis neoanal sphincter in patients with atresia or following an abdominoperineal resection of the rectum as part of total anorectal reconstruction, to overcome combined incontinence and evacuatory dysfunction.

Methods: Between September 1994 and September 1999, 11 continent colonic conduits were fashioned in 11 patients with an electrically stimulated gracilis neoanal sphincter as part of total anorectal reconstruction for end stage faecal incontinence. In addition, three patients had an Antegrade Continence Enema procedure in situ, one of which was converted to a colonic conduit at a later stage. Five patients had a colonic conduit fashioned subsequent to an electrically stimulated gracilis neoanal sphincter, four had both procedures in a combined operation and five had a conduit formed before an electrically stimulated gracilis neoanal sphincter (including the three with an Antegrade Continence Enema procedure).

Results: Median follow-up was for 53 (range 7-98) months up until July 2002 or up until exit from this study group because of end stoma formation (n = 6). Seven patients (50 percent) had a successful outcome, defined as continent to solid and liquid stool. Overall, eight patients (57 percent) reported some degree of improvement in their bowel function and were successfully managed by this combination of procedures. An end stoma was formed in 6 patients (43 percent).

Conclusion: The combination of antegrade irrigation via a colonic conduit or an Antegrade Continence Enema procedure provides a successful outcome for some patients when incorporated into total anorectal reconstruction, provided that sepsis is avoided, thus avoiding permanent stoma formation. The combination of such procedures may represent a way forward for total anorectal reconstruction and warrants further clinical trial.

The Colorectal Development Unit – Impact on functional outcome for the electrically stimulated gracilis neoanal sphincter

Background: A Colorectal Development Unit (CDU) was established to treat patients with end stage faecal incontinence with the electrically stimulated gracilis neoanal sphincter (ESGN). The aim of this study was to investigate the impact of the CDU on functional outcome and complications.

Methods: From March 1997 to March 2003 53 patients underwent ESGN formation. Results were compared with 65 patients undergoing ESGN surgery prior to the unit (Pre-CDU) between 1988 and 1997, which were similar with regard to age, sex, aetiology and follow-up.

Results: Thirty-three CDU patients (70%) had a good functional outcome defined as continence to solid and liquid stool, a significant improvement when compared to the Pre-CDU group, successful in 29 (45%) (P=0.01). Episodes of technical complications leading to stimulator replacement were significantly reduced, from 25 to three over time (P<0.001). Severe septic episodes were significantly reduced from 21 to four (P=0.003) but there was no significant change in the incidence of postoperative evacuatory dysfunction.

Conclusion: Since the setting up of a CDU, a successful outcome has been achieved in 33 of 47 patients (70%) undergoing ESGN surgery, which represents a significant improvement over time. This is probably related to improved patient assessment and selection, more reliable equipment and increased operative and perioperative experience that come with a multidisciplinary team approach.