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Numerous proven surgical therapies now exist to compensate for loss of anal sphincter function or loss of rectal reservoir capacity. Fecal incontinence that results from the combined loss of rectal reservoir and anal sphincter tone remains a surgical challenge. This case describes what may be the first successful treatment of a patient with imperforate anus and familial adenomatous polyposis using an ileal J-pouch and artificial bowel sphincter. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Anorectal malformations are among the various etiologic factors causing fecal incontinence. Patients with imperforate anus are difficult to treat, specifically those with high lesions. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence. The aim of this study was to evaluate the results of these technologies in the treatment of patients with chronic fecal incontinence due to imperforate anus. METHODS: All patients with imperforate anus who had fecal incontinence and underwent either the artificial bowel sphincter procedure or the gracilis neosphincter procedure between February 1995 and December 2000 were evaluated. Preoperative and postoperative incontinence score (Cleveland Clinic Florida Incontinence Score; 0 = perfect continence; 20 = complete incontinence), quality of life, (Fecal Incontinence Quality of Life Scale, 29 items forming 4 scales), and manometric sphincter pressure results were compared. RESULTS: Eleven patients had artificial bowel sphincter and five had the gracilis neosphincter (one nonstimulated) procedure. There were 11 males and 5 females of a mean age of 25.3 (range, 15–45) years. The mean follow-up time was 1.7 years (5 months to 5.7 years). Eight (50 percent) complications occurred in six patients, including three with fecal impaction (all artificial bowel sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and two patients with concomitant wound infection (one gracilis neosphincter, one artificial bowel sphincter); no patients had the devices explanted. Fourteen patients had manometric data (10 artificial bowel sphincter and 4 gracilis neosphincter) available. The overall incontinence score decreased from a preoperative mean of 18.5 to a postoperative mean of 7.5 in the artificial bowel sphincter group (P < 0.01) and from 17.4 to 9.4 in the gracilis neosphincter group (P = 0.06). All four Fecal Incontinence Quality of Life scales increased in both the artificial bowel sphincter (lifestyle and depression/self-perception, P = 0.02; coping/behavior and embarrassment, P = 0.03) and the gracilis neosphincter (lifestyle and coping, P = 0.06; depression and embarrassment, P = 0.05) patients. As well, the mean resting and squeeze pressures increased with both techniques (artificial bowel sphincter: P = 0.008 and P = 0.02, respectively; gracilis neosphincter: P = 0.4 and P = 0.1, respectively). All results were statistically significant in the artificial bowel sphincter group. CONCLUSIONS: Artificial bowel sphincter and gracilis neosphincter are efficient methods to treat patients with imperforate anus. These techniques should be considered for patients with imperforate anus and severe fecal incontinence. [ABSTRACT FROM AUTHOR]

Posterior sagittal anorectoplasty, regarded as a standard surgical primary repair for anorectal malformations in infancy, was evaluated for effectiveness when performed as a secondary operation for establishing continence in the adult. The purpose of this review was to evaluate our results of performing posterior sagittal anorectoplasty in adult patients and to emphasize the extensive evaluation required to perform proper patient selection.From January 1, 1992, to December 31, 1996, eight patients with Grade 3 incontinence underwent posterior sagittal anorectoplasty. The ages ranged from 13 to 40 (mean, 26) years.All patients had diverting stomas at the time of repair and all but one had restoration of intestinal continuity. Of eight patients who underwent posterior sagittal anorectoplasty, one failed secondary to rectal ischemia and retained a diverting stoma. Six patients had restoration of continuity. Five patients were continent and one had incontinence only to gas.We have established that posterior sagittal anorectoplasty can effectively be used to establish continence as a secondary procedure for a select group of adult patients. [ABSTRACT FROM AUTHOR]

We are interested in the way patients, who underwent surgery for high anorectal atresia, control their defecation. Considering that some patients, despite newer operative techniques, always will suffer from minor or major soiling we attempted to find some guidelines for postoperative support for future patients.Fifty-eight patients (median age, 26 (range, 18.1-56.9) years) were personally interviewed.Regulating defecation is done in five different modes: 16 patients have stools after urge, 15 control their stools mainly by going to the toilet at regular times, 18 perform bowel-irrigations or use enemas, 2 have loss of feces continuously, and 7 patients have an ileostomy or colostomy. More than one-half of patients influence their defecation by diet. Of the patients with anal defecation, 6 never soil, 39 sometimes soil small amounts, and 6 often soil seriously. Eighteen patients occasionally suffer from constipation. There is no mode of defecation regulation outstanding in preventing soiling or constipation. However, patients who do not regulate defecation somehow suffer from serious soiling. Most patients are content with their level of cleanliness.Irrespective of the mode of defecation regulation, many patients soil sometimes small amounts and a few often soil seriously. In view of the fact that most patients had to find the current control of defecation regulation by themselves rather late and lacked professional support, it is questionable whether the chosen mode of defecation regulation is the most optimal mode for each patient. We assume that a stepwise protocol under professional support, starting by the most natural mode of defecation, will improve defecation regulation in a more efficient way (earlier and better). [ABSTRACT FROM AUTHOR]

Posterior sagittal anorectoplasty was used for the first time in 1980 to treat anorectal malformations. This approach includes a wide exposure, through a midline posterior incision, to determine the limits of the sphincteric mechanism and to place the rectum within its limits. This approach has been used to treat children with anorectal malformations, who underwent conventional procedures that failed. The management of anorectal malformations with this approach rendered significantly better results in terms of bowel control. However, there is still a large number of patients suffering from fecal incontinence and for them a bowel management program was designed to improve their quality of life. The posterior sagittal approach was also used for the treatment of acquired conditions including tumors, post-trauma and postradiation fistulas, and other postoperative complications. A historic review of the posterior approach disclosed that Cripps, a British surgeon, published his experience with a posterior transsphincteric approach to the rectum nine years before Kraske, a German surgeon, whose name has been traditionally associated with the leadership in this approach. Kraske actually approached the rectum through a paramedian incision and never performed a real transsphincteric incision. An experimental study done in dogs by the author demonstrated that it is not harmful to divide the sphincteric mechanism. The posterior sagittal approach represents a useful alternative to treat many pelvic conditions and, therefore, it must be a part of the armamentarium of colorectal surgeons. Finally, a series of clinical experiences convinced the author that coordinated rectosigmoid motility is the most important single factor in fecal continence and, therefore, our efforts to help patients suffering from fecal incontinence must be aimed at the manipulation of bowel motility. [ABSTRACT FROM AUTHOR]

Sphincter reconstruction using the gluteus maximus muscle was attempted in a 9-year-old boy who had been incontinent following surgery for the high type of anorectal malformation. Anorectal function following this procedure was assessed by anorectal manometry, defecogram, and electromyography. Postoperative function improved from Kelly 1 (poor) to Kelly 3 (fair). Adequate anorectal pressure difference and good voluntary contraction were documented one year after surgery. A defecogram one month postoperatively showed the presence of an empty segment which had not been noted before. Tonic activity at rest, which had not been present before, was found both one month and one year after surgery. These results indicate that the gluteus maximus muscle maintains some function as a newly created anorectal sphincter. In the present study, the patient was examined periodically for one year after surgery. Further follow-up studies are necessary. [ABSTRACT FROM AUTHOR]

The role of anal sensation in fecal control is well established. A new operative method of creating a skin-lined anal canal using the patient's foreskin, as a secondary procedure, in patients with anal (colonic) prolapse following surgery for high anorectal anomalies, is described. The results in five patients treated between 1967 and 1979 are presented. A sixth patient, treated in 1983, is not included due to the short follow-up period. [ABSTRACT FROM AUTHOR]

A case of an adult patient with the anorectal malformation of a rectovestibular fistula successfully repaired by performing a posterior sagittal anorectoplasty is reported. This case should increase the awareness of both primary and secondary anorectal malformations in the adult patient.Management and outcome of an adult patient who presented with a rectovaginal fistula and underwent primary operative correction of her anorectal malformation using posterior sagittal anorectoplasty is reviewed.Total continence was achieved in an adult patient undergoing primary repair of a rectovaginal fistula using posterior sagittal anorectoplasty.Posterior sagittal anorectoplasty can be successfully performed in the adult patient for a primary repair of anorectal malformations. This operation should be considered in patients who have undergone another prior operative procedure with less than optimum function and now desire a secondary corrective procedure. [ABSTRACT FROM AUTHOR]

The stimulated gracilis neosphincter is accepted as a viable option in select patients with fecal incontinence. The aim of this study was to review the initial problems and complications.A prospective analysis of all patients who underwent this procedure was undertaken. Stage I consisted of the distal vascular delay of the muscle and creation of a temporary stoma. Stage II was the transposition of the muscle and implantation of the stimulator and electrodes. Low frequency electrical stimulation was applied to the muscle for 12 weeks, after which Stage III (stoma closure) was undertaken.From March 1993 to December 1995, 17 patients (9 females and 8 males) with a mean age of 42.2 (range, 19-72) years underwent the procedure. One patient died from pancreatitis and another from small-bowel adenocarcinoma, three and six months after the procedure, respectively. Two patients (one with Crohn's disease) required permanent stomas. One additional patient required a permanent stoma because of lead fibrosis. Other complications noted during ascent of the learning curve included seroma of the thigh incision, excoriation of the skin above the stimulator, fecal impaction, anal fissure, parastomal hernia, rotation of the stimulator, premature battery discharge, fracture of the lead, perineal skin irritation, perineal sepsis, rupture of the tendon, tendon erosion, muscle fatigue during programming sessions, and electrode displacement from the nerve or fibrosis around the nerve. However, ultimately after rectification of these problems, 13 of the 15 eligible patients had stoma reversal. Manometric results showed an average basal pressure of 43 mmHg and an average maximum squeeze pressure that increased from 36 mmHg before surgery to 145 mmHg by stimulation (P <0.01). Based on objective functional questionnaires, 9 of 15 (60 percent) evaluable patients reported improvement in continence, social interactions, and quality of life. Three of these nine patients require daily use of enemas.Although the stimulated gracilis operation is a feasible procedure for selected patients with severe incontinence, the learning curve is steep. Although the ultimate outcome in a selected group of patients can be very gratifying, major technical modifications are required before use beyond a research protocol setting. Furthermore, patients must have the psychological strength, emotional commitment, and financial resources that may be necessary for multiple revisional surgeries or ultimate device failure. [ABSTRACT FROM AUTHOR]