The Electrically Stimulated Gracilis Neosphincter Incorporated as

ANNALS OF SURGERYVol. 224, No. 6, 702-711©D 1996 Lippincott-Raven Publishers

The Electrically Stimulated GracilisNeosphincter Incorporated as Partof Total Anorectal ReconstructionAfter Abdominoperineal Excision ofthe RectumB. James Mander, B.Sc., F.R.C.S., John F. Abercrombie, F.R.C.S.,Bruce D. George, M.S., F.R.C.S., and Norman S. Williams, M.S., F.R.C.S.

From the Academic Department of Surgery, St. Bartholomew's and the Royal LondonHospital School of Medicine and Dentistry, Whitechapel, London, England

ObjectiveThe authors investigated the feasibility and effectiveness of combining electrically stimulatedgracilis neoanal (ESGN) sphincter and a coloperineal anastomosis in selected patients afterabdominoperineal excision of the rectum (APER).

Summary Background DataThe ESGN is effective in the treatment of idiopathic fecal incontinence.

MethodsBetween March 1989 and September 1993, 12 patients (9 men, 3 women) with a medianage of 59.25 years (range, 45-70) underwent the procedure. The underlying disease wasadenocarcinoma in 10, anal malignant melanoma in 1, and a sweat gland tumor in theother. In all patients, a sphincter saving resection was contraindicated. The procedure wasperformed in stages. Stage 1 involved a conventional APER with the formation of a perinealstoma. Eleven patients underwent a vascular delay procedure. All patients weredefunctioned. In stage 2, the gracilis was mobilized, transposed around the anal canal, andthe electrodes and hardware needed for electrical stimulation were implanted. Once muscleconversion was complete, the defunctioning stoma was closed.

ResultsEight patients were closed successfully. In seven of the eight patients, complete physiologicmeasurements were taken. Median basal and maximum neosphincter pressures were 30and 122 cm H20, respectively, at the start of electrical stimulation and 22.5 and 76.2 cmH20, respectively, after 1 year. Median functioning neosphincter pressure was 36 cm H20at 1 year. All of the patients whose stomas were closed experienced episodes ofincontinence to solid stool and wore pads for persistent fecal soiling. They all reporteddifficulty in evacuation. Despite imperfect continence, no patient wished to go back to lifewith a stoma.

702

Electrically Stimulated Gracilis Neosphincter as Part of Total Anorectal Reconstruction After APER

ConclusionsThe incorporation of ESGN as part of total anorectal reconstruction is technically feasible.The majority of patients are satisfied with their function and pleased to avoid a permanentstoma.

The electrically stimulated gracilis neoanal sphincter(ESGN) has been shown to be effective in the treatment ofidiopathic fecal incontinence.`'5 Chronic low frequencyelectrical stimulation effects the conversion of the musclefrom fast to slow twitch phenotype6 and provides a meansof patient control over sphincter function. There is goodevidence that the psychologic morbidity associated withan abdominal stoma is lessened if a perineal stoma isfashioned after abdominoperineal excision of the rectum(APER).7 However, patients with a perineal colostomylack the normal sensory8 and motor functions of the intactanorectum and are unable to control fecal passage.We thought that the incorporation of the ESGN in pa-

tients with a perineal stoma might improve their func-tional outcome. We have described previously the feasi-bility of incorporating the procedure in total anorectalreconstruction (TAR), both after APER9 and restorativeproctocolectomy.'0 In this study, we report the clinicalresults and functional outcome of using this technique aspart of TAR in patients observed for a minimum of 24months.

PATIENTS AND METHODSTwelve patients (9 men, 3 women; median age, 59.25

years; range, 45-70) underwent TAR, incorporating agracilis neoanal sphincter between March 1989 and Sep-tember 1993. The underlying disease was adenocarci-noma in 10 patients (Dukes' A, 6; B, 3; C, 1), anal malig-nant melanoma in 1, and a sweat gland tumor in the other.The median length of follow-up was 53.8 months (range,3-79).The procedure was performed in stages. All patients

had tumors within 5 cm of the anal margin, and sphinctersaving resection was contraindicated. Patients were onlyoffered this procedure if their underlying prognosis wasexcellent and they expressed resistance to the formationof a traditional stoma. In addition, patients needed to bemedically fit and highly motivated. Before surgery, allpatients were counseled by a specialized stoma nurse andat least two surgeons. The experimental nature of theprocedure was explained. They then were given time toreflect and, where possible, to meet another patient who

had undergone the procedure before their final decisionswere made.

Stage 1A conventional APER was performed (Miles 1908";

Keighley and Williams 199312) in 10 patients. The colonwas mobilized to the transverse colon and transected inthe proximal sigmoid using a transverse stapling instru-ment. The transected end of the colon was drawn gentlydown to the perineum, ensuring correct orientation andthe absence of tension. The remaining muscles of thepelvic floor then were repaired around the pulled-throughcolon, the serosa being sutured circumferentially to themuscles. The staple line of the proximal colon then wasexcised, and the mucosa was sutured to the perineal skinusing interrupted 2.0 polyglactin 910 sutures. The serosaof the proximal colon then was sutured to the sacral peri-osteum with two or three interrupted sutures to preventsubsequent neorectal prolapse.

In two patients, a colonic J-pouch was fashioned from6 cm lengths of colon using a linear staple cutter. Theapex of the pouch was sutured to the perineal skin. Intwo patients, additional procedures were performed. Onepatient, who had a low grade skin appendage tumor invad-ing the rectum, underwent a simultaneous total abdominalhysterectomy. Another presented with hematuria frombladder involvement, and a cystectomy with ileal loopurinary diversion was performed in addition to the APER.In a third patient, approximately one third of his externalsphincter and anal mucosa was preserved. All patientswere defunctioned with a loop ileostomy fashioned in theright iliac fossa.

In 11 patients, the procedure was performed simultane-ously with an APER and approximately 22 months laterin the 12th patient. All patients had ostensibly curativeprocedures. Eleven of the 12 patients underwent a vascu-lar delay procedure on the distal end of the gracilis mus-cle. This involves the ligation of the two or three distalperforating vessels to the gracilis several weeks beforetransposition. These are inevitably sacrificed during trans-position of the muscle. Ligation results in the opening ofcommunicating arterioarterial channels from the proximalmajor vascular pedicle'3 and is thought to reduce the riskof distal muscle ischemia after transposition.

Stage 2The electrically stimulated gracilis neosphincter proce-

dure was performed when all the wounds and perineal

Address replint requests to B. J. Mander, B.Sc., F.R.C.S., AcademicDepartment of Surgery, Royal London Hospital, Whitechapel, Lon-don El lBB.

Accepted for publication June 20, 1996.

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704 Mander and Others

Figure 1. Transposition of the gracilis muscle. The muscle is pulledthrough into the perneum and transposed around the anal canal. Thedistal tendon is attached to the ipsilateral ischial tuberosity.

colostomy had healed, approximately 8 to 12 weeks afterstage 1. The development and operative details of theprocedure are described in detail elsewhere.'4",5 In brief,the gracilis (left 1 1, right 1) was mobilized and transposedaround the neoanal canal through surgically created tun-nels (Fig. 1). During the period of these 12 procedures, wewere assessing different configurations of the transposedgracilis muscle. The configurations used were gamma 6,alpha 5, and epsilon 1 (Fig. 2). An electrode was suturedover a branch of the nerve to the gracilis (two patients)or over the main nerve itself.'" The electrode was con-nected to a totally implantable stimulator (Itrel 6, Med-tronic, Inc., Minneapolis, MN; NICE 6, Nice Technology,Inc., Ft. Lauderdale, FL), which then was placed in asubcostal subcutaneous pocket. All patients received sys-temic amoxicillin, gentamicin, and metronidazole periop-eratively. Once all the wounds had satisfactorily closed,electrical stimulation was commenced. The stimulatorswere programmed by telemetry and initially were set tostimulate intermittently. The duty cycle was increasedgradually every 2 weeks during the training period untilapproximately 12 weeks later, when the muscle was stim-ulated continuously. This pattern of stimulation is knownto effect the phenotypic transformation of the gracilisfrom a fast to a slow twitch type.'6 Muscle conversion isan integral part of the procedure because it enables theneosphincter to contract continuously without fatigue.

Stage 3The defunctioning loop ileostomy was closed. Once

bowel activity returned, the patient was instructed to at-

tempt to evacuate at regular intervals. Initially, this wasevery 3 to 4 hours, but gradually this interval was in-creased. To effect neorectal emptying, the patientswitched the neosphincter off by placing a small magnetover the device.

Physiologic Measurements

All physiologic measurements were made with a water-filled microballoon 6 mm in diameter connected to a pres-sure transducer, amplifier, and chart recorder. The micro-balloon was inserted into the anal canal and the pressurerecorded at 1-cm intervals from the anal verge. All pa-tients were assessed before surgery and at regular inter-vals after surgery. During electrical stimulation, measure-ments were recorded at the site of maximum contractionwithin the neoanal canal. The following measurementswere made:

1. Basal pressure. The pressure within the neoanal ca-nal before muscle transposition.

2. Basal neosphincter pressure. The pressure recordedat the site of the neosphincter when the stimulatorwas switched off.

3. Maximum neosphincter pressure. The pressure re-corded when the muscle was stimulated at tetany.

4. Functioning neosphincter pressure. The pressuregenerated at the site of the neosphincter when it wasactivated continuously at 10 to 12 Hz for at least 1hour. This is a measure of the constant neosphincterpressure.

Complete physiologic data were obtained from sevenof the eight patients who had their defunctioning stomasclosed. Measurements were made at various times aftersurgery. We have tabulated the results recorded beforesurgery, at the start of electrical stimulation, and at 1 year(or the time of last follow-up) (Table 1).

Statistical Analysis and Presentation of ResultsResults are expressed as median with 95% confidence

intervals. Comparisons between measurements weremade using the Wilcoxon signed rank test for paired data.

Figure 2. Configurations of gracilis muscle around the neoanal canal.Left, gamma; middle, alpha; right, epsilon.

Ann. Surg. * December 1996


Table 1.

Median Pressure(cm H20)

(95% confidenceinterval) (n = 7)

Preoperative basal pressure (BP)Basal neosphincter pressure

(BNP) (at start of electricalstimulation)

Basal neosphincter pressure(BNP) (after 1 yr of electricalstimulation)

Maximum neosphincter pressure(MNP) (at start of electricalstimulation)

Maximum neosphincter pressure(MNP) (after 1 yr of electricalstimulation)

Functional neosphincterpressure (FNP) (after 1 yr ofstimulation) (n = 6)*

15.0 (7.5-22.5)

30.0 (10.0-45.0)

22.5 (15.0-35.0)

122.0 (65.0-185.0)

76.2 (42.5-127.5)

36.0 (30.0-90.0)

Preoperative basal pressure versus basal neosphincter pressure (p not signifi-cant). BNP (start) vs. BNP (1 yr) (p not significant). BNP start vs. MNP start(p < 0.05). BNP (1 yr) vs. MNP (1 yr) (p < 0.05). MNP (start) vs. MNP (1 year)(p < 0.05). BNP (1 yr) vs. FNP (1 yr) (p < 0.05).

RESULTS

Mortality

There was no postoperative mortality. One patient diedof a myocardial infarction during the training program 10weeks after the second stage.

Morbidity

Systemic Complications

Acute renal failure developed in one patient after stage1. This was caused by severe Candida oesophagitis andoesophageal perforation. Despite this, this patient madea full recovery.

Local Complications

There were no complications specifically related to thedelay procedure. Local recurrence has not developed inany of the patients with adenocarcinoma, although thepatient with the Dukes' C lesion has presented recentlywith pulmonary metastases. Pelvic lymph node metasta-ses developed in the patient with melanoma 22 monthsafter closure, for which this patient received radiationtherapy.

Perineal sepsis developed in two patients after stage 2,which led to neoanal stenosis, requiring anoplasty in one.

A perineal hernia developed in one patient, which ulti-mately necessitated neorectal excision to effect repair.

Hardware Complications

Two patients required repositioning of the electrodeafter it migrated away from the nerve. There were twocases of neuropraxia to the nerve. One stimulator failed.Sepsis developed in one patient, which localized aroundhis stimulator, necessitating its removal.

In two of the patients in whom the gracilis was wrappedin an alpha configuration, the pressure generated was in-sufficient to occlude the neoanal canal. In both of thesecases, a graciloplication procedure was undertaken totighten up the muscle.

Physiologic Results

The threshold voltage of contraction increased withtime, a previously reported finding with the ESGN.16Changes in the fusion frequency and twitch velocity char-acteristics indicated conversion of the muscle phenotypein all patients.

There was no significant increase in basal pressurewithin the neoanal canal after the wrap. The applicationof electrical stimulation increased markedly neoanal canalpressure (Fig. 3). Despite conversion of the muscle beingassociated with a decrease in the maximum-generated

200

150

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00

C" 100

0Z

0 EQc -

0

0

0

BNP MNP-startFigure 3. Effect of tetanic stimulation on neosphincter occlusion pres-sures at the start of electrical stimulation (basal neosphincter pressurewithout stimulation, maximum neosphincter pressure). p = 0.018 (Wil-coxon signed rank test).

n=7

p = 0.018

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200

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150

100

50

0MNP - start MNP -l year

Figure 4. Changes in maximum neosphincter pressure after 1 yearof continuous electrcal stimulation. p = 0.018 (Wilcoxon signed ranktest).

pressure (Fig. 4), the muscle still was capable of generat-ing considerable pressures 1 year after the commencementof stimulation (Fig. 5).

perfect continence with only minimal fecal soiling. Thiswas despite the development of a neuropraxia, which set-tled, leaving a relatively weak gracilis wrap. Hardwaresepsis eventually necessitated the removal of his stimula-tor, but he continues to have an excellent quality of lifewith near-normal continence despite the loss of stimula-tion.

All the patients who were closed successfully admittedto occasional episodes of incontinence to solid stool andthe persistent inability to prevent the leakage of liquidstool or flatus. They needed to wear pads to cope withtheir persistent fecal soiling. They all reported difficultyin evacuation. Patients achieved satisfactory continenceby the use of constipating agents and by neorectal irriga-tion. All patients experienced a defunctioning stoma dur-ing the course of their TAR. Despite objectively subopti-mal function, not one of the patients wished to go backto life with a stoma if it were avoidable.

DISCUSSIONMethods of Reconstruction

A variety of techniques have been described for TAR.Neosphincters have been fashioned from intestinalsmooth muscle,'7 unstimulated skeletal muscles (e.g., ad-ductor longus,'8 gluteus maximus,19 and gracilis20) andstimulated skeletal muscles."5 The muscle of choice for

160Functional Outcome

Eight patients had their defunctioning stomas closed.The reasons for nonclosure were death in one, perinealhernia in one, neoanal stenosis in one, and inability totolerate electrical stimulation in one. Severe perineal sep-sis developed in two of the eight patients in the earlypostoperative period, which ultimately necessitated theformation of a definitive abdominal stoma. The other sixpatients were closed uneventfully and have all been ob-served for at least 18 months. One returned abroad imme-diately after surgery, but on inquiry 2 years later wassatisfied with his function. Another was lost to follow-up20 months after closure but had acceptable function upto that time.One patient was observed for 22 months with minor

fecal soiling. He consistently was satisfied with the func-tion of his reconstruction at every assessment. Local re-currence of his original disease (melanoma) required radi-ation therapy. Radiation colitis associated with mucousdischarge and severe perianal excoriation subsequentlydeveloped in this patient, which required the formationof a definitive stoma. One patient, who had some analmucosa and external sphincter preserved, achieved near-

140

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0.o 600z

40

20

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BNP MNPFigure 5. Effect of tetanic stimulation on neosphincter occlusion pres-sures after 1 year of electrical stimulation (basal neosphincter pressurewithout stimulation, maximum neosphincter pressure). p = 0.018 (Wil-coxon signed rank test).

n = 7

p = 0.018

n = 7

p = 0.018



an electrically stimulated neosphincter is the gracilis mus-cle.The combination of a neoanal sphincter with a perineal

stoma has been used for TAR in more than 100 patientsafter APER.9"0'9-25 The perineal colostomy is formedsimilarly in most series, although in one, an absorbablemesh is used to prevent perineal hernia. The anatomicarrangement of the transposed muscle varies between se-

ries. Simonsen et al.20 and Santoro et al.25 used one un-

stimulated gracilis, whereas Cavina et al.22 and Mercatiet al.23 used both. One was placed posteriorly to the neo-

rectum to mimic the puborectalis, whereas the other waswrapped in a gamma configuration around the anal canal.Recently, Cavina et al.22 reported their early experiencewith continuous electrical stimulation. Most authors, in-cluding ourselves, have elected to fashion a stoma pro-

phylactically to defunction the reconstruction.Our technique differed from most reported series in

that we used chronic long-term electrical stimulation totransform the muscle phenotype, rendering it capable ofsustained contraction without fatigue. Throughout the pe-

riod of these procedures, we audited our results critically.This led to a number of modifications in an effort tooptimize the procedure, which explains the heterogeneityof the group with regard to muscle configuration, type ofstimulator, and the presence or absence of a colonic Jpouch.

There have been 3 reported deaths of the 136 patientsfor whom data are available. The incidence and severity ofpostoperative morbidity vary enormously between series.Mercati et al.23 describe no perioperative morbidity,whereas the experience of Cavina et al.22 is "character-ized by the high cumulative frequency of early and latecomplications . . . which contrasted with generally goodfunctional outcome." Nine of the first 32 patients in theseries by Cavina et al.22 required revision of their neoanusand 4 needed perineal reconstruction (3 associated withperineal herniae and 1 for mucosal prolapse). Ischemicnecrosis of the distal colon and perineal sepsis were themajor causes of failure in this series. We have had fewcomplications associated with the formation of the peri-neal colostomy.

Muscle transposition itself has been associated withsignificant problems of perineal suppuration and anal ste-nosis. There are three reported cases of the gracilis tendonbecoming separated from its bony attachment. In our own

series, there was one case of anal stenosis at the level ofthe graciloplasty and two cases of perineal sepsis second-ary to tendon erosion into the neorectum. It is likely thatthe cause of these complications was an unnecessarilytight gracilis wrap around the neorectum. These threecases all occurred relatively early in the series. The tech-nique has undergone a continuous process of evolutionand refinement, which largely has eliminated these techni-

707

cal problems. It is not surprising that the complicationrate using the electrically stimulated graciloplasty as partof total anorectal reconstruction is considerably higherthan when it is used to treat fecal incontinence arisingfrom other etiologies.3 There is a steep learning curve

associated with the technique. Careful patient selectionand meticulous surgical technique are integral compo-

nents in the procedure.There is no reason to suggest that TAR after APER

should result in a poorer outcome from an oncologic pointof view than after APER alone. In only one of our pa-

tients, with an amelanotic malignant melanoma, did localrecurrence develop, after a median follow-up of 23months. However, absolute determination of the onco-

logic safety of the procedure requires more patients andlonger follow-up.

Comparison with Results of OtherGroupsThe mean pressures generated by our graciloplasties

are slightly lower than those achieved by the two othergroups who use a similar technique.424 This may be a

consequence of wrapping the gracilis in an alpha configu-ration in five of the patients. This configuration generateslower pressures than does the gamma. Our experiencewith the procedure in patients with incontinence has ledus to abandon the alpha configuration in favor of thesuperior gamma.

The wrap itself did not significantly increase basal neo-

anal canal pressure (Fig. 6) In all patients, the applicationof electrical stimulation markedly increased the pressure

produced within the anal canal (Fig. 3), and this was

sustained at 1 year (Fig. 5). In all patients, there was

physiologic evidence of muscle conversion. The conver-

sion of the muscle is associated with some drop in themaximum pressure generated (Fig. 4). The applicationof chronic long-term electrical stimulation provides themeans of producing a truly dynamic neosphincter. In ad-dition, it enables muscle transformation to occur, whichovercomes the problem of muscle fatigue and, thus, maxi-mizes the sphincteric potential of the muscle.

Six of our 12 patients achieved a level of continencewith which they were satisfied. In the large series byCavina et al.,24 30 (71%) of the unstimulated patientsand 9 (100%) of the stimulated patients had good results(defined as continent all the time to formed and liquidstool, use of pads for mucous leakage, and use of enemasto effect colonic voiding). By any standard, these resultsare impressive. Baeten reports 8 (61%) of 13 patients hada successful outcome (continent to liquid and solid stool,occasional fecal soiling).26 Elias et al.2' (using a smoothmuscle neosphincter) had 10 patients incontinent of gasand 11 with occasional soiling. All seven patients in the

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60

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Ocm

- E 30Cu00z*i 200(U

10

0'

Pre-wrap Post-wrapFigure 6. Changes in neoanal canal pressures after transposition ofthe gracilis muscle. p = 0.11 (Wilcoxon signed rank test).

series by Mercati et al.23 (who had unstimulated gracil-oplasties) had a satisfactory outcome, although they ac-

knowledged this included episodes of incontinence tosolid feces.We have not managed to achieve complete continence

in our patients despite being able to generate sustainedneosphincter pressures of a magnitude sufficient to main-tain continence in the majority of patients with fecal in-continence. In contrast to others,20'22 none of our patientscan defer the defecation of liquid feces or be continentof flatus. Differences in technique, care in questioningpatients, and observer bias may explain the differencesbetween our results and others. We think that there are a

number of reasons why the results of ESGN are not as

good when used in TAR than when used to treat idiopathicfecal incontinence.

All the series of TAR have concentrated on recon-

structing a satisfactory neosphincter to achieve conti-nence. Normal continence does not arise merely as a resultof the anal sphincters preventing the passage of fecesthrough a conduit of excretion. Patients after APER havelost not only normal sphincteric function but also are

without the normal sensory apparatus, reservoir capacity,and evacuatory function of the excised anorectum.Most of the reports on TAR do not comment on pa-

tient's sensory function efter reconstruction. Most of thepatients are reconstructed with a neosphincter that willonly contract on volition. A sense of neorectal filling or

impending evacuation clearly is essential to the successful

maintenance of continence in these patients. Seccia etal.22 report that 10 of 25 patients could perceive solidstool in the neorectum and 12 could discriminate amonggas, liquid, and solid. They attribute the poor results infour patients to the failure to perceive the urge to defecate.Simonson et al.20 acknowledged that although most oftheir patients had some sense of neorectal filling, in only5 of their 22, was it "similar to normal." These subjectiveresults are surprising because anorectal sensory functioninevitably is disturbed by APER. We have performed anobjective assessment on the sensory function of six ofour patients after TAR.8 We showed the complete absenceof any physiologic anorectal sensation after surgery. Al-though it is acknowledged that new and repeatable sensa-tions may develop in patients that will alert them to im-pending defecation, we think that claims of normal dis-criminatory capacity need to be treated with caution. Itis our belief that the loss of normal anorectal sensationafter TAR is an important contributory factor to limitingthe success of the procedure.

After APER, patients also lose their reservoir capacityof the rectum. This also is the case after SSR and inchildren undergoing pull-through procedures. In the for-mer group, despite normal sphincteric action, some pa-tients experience varying degrees of defecatory fre-quency, urgency, and incontinence. The colonic J-pouchwas introduced in 1986 to recreate the reservoir functionof the excised rectum.2728 The incorporation of a pouchhas reduced the problems of frequency and urgency, butmay be associated with the development of evacuatorydifficulties.29 We incorporated a colonic pouch in two ofour patients as part of TAR. One died before closure ofthe stoma, and in the other patient, there was no obviousfunctional benefit.Our functional results indicate that the major problem

for our patients is difficult and incomplete evacuation ofthe neorectum. A neorectum that cannot empty com-pletely will leak feces persistently, even in the presenceof an active neosphincter. Evacuatory function after TARis not discussed directly in other series, although manyacknowledge the problem of soiling. Cavina et al.22 andElias et al.21 acknowledge that their patients require dailyirrigation to effect colonic voiding. It is likely that theirsatisfactory outcome is a consequence of maintaining anempty colon.

Chiotasso et al.7 have reported a series of 41 patientsin whom a coloperineal anastomosis was constructed afterAPER without a neosphincter. The patients performeddaily irrigation. All 18 patients observed for at least ayear were satisfied with their perineal stoma, and nonerequested a conversion to an abdominal stoma. This sug-gests that a neosphincter may not be essential to a success-ful outcome after TAR. It still is further evidence of how

p = 0.11


Vol. 224 * No. 6 Electrically Stimulated Gracilis Neosphincter as Part of Total Anorectal Reconstruction After APER 709

distressing many patients view the prospect of an abdomi-nal stoma.

Recognizing the problem of evacuation, we now havemodified our technique of TAR to incorporate a continentcolonic conduit fashioned in the proximal colon.30'3' Thisconduit is intubated regularly so that the neorectum canbe evacuated by antegrade colonic lavage. Our early re-sults are encouraging, and it remains to be seen if bothan ESGN and a conduit are required.

After APER, the reconstruction of a neoanorectum witha neosphincter is technically feasible. The majority ofpatients are satisfied with the results and pleased to avoida permanent abdominal stoma. Although physiologicallyseductive, ESGNs do not fully restore continence afterAPER. Refinements in operative techniques and improve-ments in hardware should reduce the high morbidity ratesand significant expense of the procedure. We think thatefforts to overcome the loss of anorectal sensation andrectal evacuatory function that follow the procedure willimprove the functional results.

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Discussion

DR. JACK COLLIN (Oxford, United Kingdom): This is a veryinteresting paper. I have three questions: You did not mentionhow the patients actually evacuated feces, but you said they

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The Electrically Stimulated Gracilis Neosphincter Incorporated as