Sphincter Reconstruction Research Articles

Bilateral simultaneous free gracilis muscle transfer: A realistic option in management of bilateral facial paralysis

Objectives Bilateral facial paralysis patients have oral incompetence, poor articulation, and dental caries. This problem is frequently addressed by performing staged gracilis transplants without specific oral sphincter reconstruction. The purpose of this study is to describe the technique of bilateral simultaneous free gracilis muscle transfer with oral sphincter reconstruction, for one-stage facial reanimation in patients with bilateral facial paralysis. Study Design Case series. Methods/Results One-stage bilateral gracilis transfer was performed in three patients with bilateral facial paralysis. Muscle transplants produced a meaningful smile in all transferred muscles. All patients reported improved speech and decreased drooling. Conclusions Bilateral gracilis transplants with reconstruction of the oral commissure is a realistic option in management of the bilaterally paralyzed face. In this small series, it appears to improve oral competence, restore smiling, and contribute favorably to lower lip support. This technique has been made more feasible because the operative time for free tissue transfer has continuously declined with the use of two-team surgery, improved microsurgical techniques, and the advent of venous coupling devices.

Duplicated proctodeum

A 3-month-old female infant was noted to have two near mirror image anal openings: an anterior, normally sited, anus and a posterior duplicated proctodeum. Ultrasound and X-rays were normal. Contrast X-ray showed 2-cm long non-communicating proctodeal duplication. She underwent EUA, proctoscopy, stimulation of sphincter and transproctodeal excision of the duplication and external sphincter reconstruction with excellent cosmetic and functional results.

Primary repair of advanced obstetric anal sphincter tears: should it be performed by the overlapping sphincteroplasty technique?

Advanced obstetric anal sphincter tears are often associated with a high incidence of fecal and flatus incontinence. We aimed to assess the clinical outcome of these repairs when done by the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. Between August 2005 and December 2006, all grades 3 and 4 obstetric anal sphincter tears in our department were repaired by a reconstructive pelvic surgeon, primarily using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. All women were followed every 6 months using the Colorectal Anal Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, a physical examination of the anal sphincter, anal manometry, and transperineal anal sonography. There were 3,478 deliveries of which 22 (0.63%) anal sphincter tears were repaired in women aged 22-41 years. Two women were diagnosed with Royal College of Obstetricians and Gynecologists grade 3a, eight with grade 3b, nine with grade 3c, and three with grade 4 anal sphincter tears. Postoperatively, 21 patients attended the outpatient clinic, with an average follow-up time of 9.2+/-1.4 months. Only two women (9.5%) complained of flatus incontinence and fecal urgency and had mildly decreased anal sphincter squeeze pressure and a small sonographic anal sphincter defect. None of the women complained of fecal incontinence. Two women (9.5%) reported on transient perineal pain and one (4.8%) on transient dyspareunia. All other women were asymptomatic and had normal anal manometry and sonographic evaluation. Repair of obstetric anal sphincter tears using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum seems to carry favorable clinical outcome and reduced risk for anal incontinence, perineal pain, and sexual dysfunction.

Long-Term Outcome of Delayed Primary or Early Secondary Reconstruction of the Anal Sphincter after Obstetrical Injury

Traditionally sphincter repair has not been performed during the puerperium. This prospective study was designed to determine the long-term outcome of delayed primary or early secondary sphincteroplasty in the puerperium. Between 1991 and 2005, 22 females underwent delayed primary or early secondary repair after third-degree or fourth-degree anal sphincter rupture. Delayed primary reconstruction was performed more than 72 hours after delivery. Early secondary reconstruction was performed within 14 days postpartum. The reconstruction of the anal sphincter was performed without a covering stoma, in all cases. A control group of 19 age-matched and parity-matched females, without known anal sphincter injury after vaginal delivery, were included. Current degree of continence and associated quality of life were determined by a fecal incontinence severity questionnaire and a quality of life questionnaire. None of the females had complications postoperatively. Mean follow-up was 50 (range, 2-155) months in the case group and 60 (range, 12-132) months in the control group. At time of follow-up, the Wexner score was 4.1 (range, 0-13) in females with delayed primary or early secondary reconstruction and 1.1 (range, 0-8) in the control group (P<0.01). The inconvenience of incontinence after reconstruction was significantly higher (P<0.01) compared with the control group, but the quality of life was not significantly affected (P=0.75). It is safe to perform a delayed primary or early secondary reconstruction without a covering stoma in females who have sustained a third-degree or fourth-degree obstetric tear. The long-term functional outcome is acceptable.

Overlap Technique Improves Results of Primary Surgery after Obstetric Anal Sphincter Tear

This study was designed to evaluate prospectively the results of the overlap technique in primary sphincter reconstruction after obstetric tear. Obstetric tears in 44 women were operated on with primary overlap reconstruction. These women were investigated six to nine months after the operation. Results were compared with those of a historical control group of 52 women whose obstetric sphincter rupture had been treated with the end-to-end technique. The overlap group had significantly more incontinence symptoms after delivery and repair of the sphincter tear than before delivery (P < 0.0001); however, their incontinence symptoms were significantly fewer than those of the end-to-end group (P = 0.004). The prevalence of persistent rupture of the external anal sphincter was significantly lower in the overlap group (6/44, 13.6 percent) than in the end-to-end group (39/52, 75 percent; P < 0.0001). Internal anal sphincter rupture occurred in 5 patients (11.4 percent) in the overlap group and in 40 patients (76.9 percent) in the end-to-end group (P < 0.0001). The overlap technique should be adopted as the method of choice for primary sphincter repair after obstetric tear.

Experimental study on reconstruction of pyloric sphincter with pedicle ileocecal valve

目的 利用回盲瓣重建胃幽门括约肌预防胃大部切除术后的反流性胃炎.方法 小型猪21只,随机分为假手术组、Billroth Ⅰ组(B-Ⅰ)及实验组.术后2、4、6个月测定胃液的pH值、胆酸浓度、菌群变化及胃黏膜的病理改变.结果 术后2～4个月B-Ⅰ组和实验组的pH值、胆酸、细菌数高于假手术组;6个月,实验组与假手术组pH值、胆酸比较差异无统计学意义,且细菌数量明显减少,而B-Ⅰ组仍较高.病理证实实验组吻合口愈合良好,胃黏膜正常.结论 回盲瓣可预防胃大部切除术后可能引起的反流性胃炎。

MP-02.20: Midline scroto-perineal approach for innervation preserving sphincteroplasty and penile lengthening: a technique to improvise functional outcome of single stage reconstruction of exstrophy-epispadias

Current multistage and complete primary repair of exstrophy epispadias do not describe the specific reconstruction of external urethral sphincter. We describe a new approach for sphincteric reconstruction and penile lengthening.

Leiomyoma of the Perineum

In Brief Leiomyomas occur in the pelvis and urogenital tract. Most clinicians' experience with leiomyomas comes from managing uterine leiomyomas. Scattered case reports describe rare vaginal, urethral, paraurethral, and bladder leiomyomas. We report on a 60-year-old female presenting with a 6-month history of perineal discomfort and a mass situated in the perineum. Magnetic resonance imaging helped characterize the lesion preoperatively. The perineum was explored, and the mass was identified and excised. The tumor did not arise from the posterior vaginal wall or the rectum. The pathology demonstrated a 4 × 4 × 3 cm leiomyoma of the perineum. We report on a 60-year-old female with a history of posterior compartment repair and anal sphincter reconstruction with a 6-month history of pelvic pain.

Martius flap: an adjunct for repair of complex, low rectovaginal fistula

Background Complex, rectovaginal fistula (RVF) are uncommon but difficult therapeutic problems. Local repair and flap advancement techniques have a high incidence of recurrence with poor functional outcomes. Transperineal repair with anal sphincter reconstruction, when indicated, and placement of a Martius flap (bulbocavernosus pedicled transplant) result in improved rates of repair and better functional outcomes. Methods A consecutive series of patients were retrospectively reviewed from a prospective database between 2002 and 2006. Data were gathered from 2 colon- and rectal-specialty practices. Patient demographics and operative and functional outcomes were documented. Results Sixteen patients with a mean age of 39.5 years (17–62) were treated. Etiology of the fistula was obstetric (9), cryptoglandular (5), and Crohn’s disease (2). They had undergone a mean of 1.5 (0–4) prior repairs, and 6 had a preexisting diverting stoma before repair. Preoperatively, anal sphincter disruption was identified in 11 patients, and fecal incontinence was identified in 5 patients all with anal sphincter disruption. Dyspareunia was identified in 1 of 13 sexually active patients preoperatively. At a mean follow-up of 75 weeks (24–190), 1 recurrent fistula was identified (6.2%). Stomas were reversed in all patients. Two patients complained of fecal incontinence postoperatively. Five patients had dyspareunia postoperatively (5/16, 31%). One patient had a labial wound complication requiring local wound care. Conclusion Selected complex RVF can be reliably repaired with good functional outcomes using the Martius flap with anal sphincter reconstruction. Persistent or recurrent fecal incontinence and dyspareunia are common sequela of the underlying perineal injury and repair. No acute or delayed morbidity related to the Martius flap was identified.

Cerclage sphincter pharyngoplasty: A new technique for velopharyngeal insufficiency

Several surgical techniques are available for the treatment of velopharyngeal insufficiency (VFI). Each method has its own complications and non-dynamic roles. So the aim of this study was to present a novel physiological surgical technique designed by the author for reconstruction of the velopharyngeal sphincter in VFI. This prospective study included six patients with VFI (two males and four females) with ages from 5 to 20 years (mean: 12.50 years). Speeches, nasopharyngeal and oral endoscopies for velopharyngeal valve closure were measured according to a 5-point scale where 0 was equivalent to normal and 4 meant a severe (constant) deviation. They were scheduled for cerclage sphincter pharyngoplasty after failure of appropriate speech therapy. Under general anaesthesia and the patient in semiflower's position; two level cerclages (1-0 polypropylene suture materials) were inserted behind the muscles of the velopharynx. The first at the level of junction of posterior and middle one-thirds of the soft palate passing through soft palate, left lateral pharyngeal wall, posterior pharyngeal wall, right lateral pharyngeal wall and the soft palate. The second was at 3mm in front of the latter. The surgical technique was described in details. Before surgery five patients (83.3%) had sever hypernasality (rating scale 3). After the cerclage operation and speech therapy four patients (66.6%) significantly improved to normal nasality (rating scale 0) and the remaining two patients improved to mild and moderate hypernasality (rating scale 1 and 2), respectively (p<0.05). By endoscopy the closing activity was (rating scale 3) in five patients (83.3%) and (rating scale 2) in one patient (18%). After the cerclage operation and speech therapy five patients (83.3%) changed significantly to complete closure (rating scale 0) and to (rating scale 1) in one patient (p<0.05). Cerclage sphincter pharyngoplasty is a new procedure designed by the author in VFI. It helps the velopharynx to function physiologically in three-dimensional patterns without dependency on the type of closure. Also it is an easy technique; without tissue flaps transfer, upper airway obstruction or hyponasality.

Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano

Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano

Surgical Treatment of Rectovaginal Fistulas

Rectovaginal fistulas account for less than 5% of all anorectal fistulas. They may occur as a result of obstetrical injuries, inflammatory bowel diseases, or pelvic cancer irradiation. The aim of the study was to describe the results of different methods of surgical treatment according to the etiology and localization of rectovaginal fistulas. Material and methods. The study included 23 female patients who underwent operations for rectovaginal fistulas within the period of 1995 to 2006. The age of patients ranged from 18 to 64 years, with an average age of 41 years. 14 patients received radical treatment according to the etiology and localization of the fistulas: four were treated with abdominal approach, six with a local excision of the rectovaginal fistula involving layer closure of rectal and vaginal openings and interposition of musculomucosal flaps, and four with a simple fistulectomy involving the removal of inflamed tissue and the reconstruction of the perineal body, anal sphincters, and all layers of the rectal and vaginal walls. In nine cases, patients received a palliative surgical treatment to address extensive tissue destruction resulting from radiotherapy for uterine cervix cancer or advanced rectal cancer. Results. Complete recovery occurred in patients who underwent laparotomy for rectovaginal fistulas following inflammatory bowel disease or complicating anterior resection of the rectum. Patients operated on using rectal and vaginal approaches displayed positive results, as did those who underwent. fistulectomy with perineal body and anal sphincter reconstruction. Conclusions. Various surgical techniques are available for the management of rectovaginal fistulas depending on their etiology, size, and location. The best results of low rectovaginal fistula treatment occurred using fistulectomy with layer closure and both-sided covering of the tissue defect with advancement vaginal and rectal flaps.

The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction

The middle third defects of the face following total or partial oncologic maxillectomy include very important facial structures, both for esthetical and for functional reasons. Among the outcomes, large oronasal or oromaxillary fistulas due to destruction of big bone segments and soft tissues have long been the consequences of such extensive surgical ablations. In the last few years, immediate reconstruction of maxillary bones and soft tissues has proved to be a reliable morphofunctional reconstruction technique following surgery for large oncological defects or the late effects of radiation therapy. Among other free flaps such as composite fibula, composite scapula, or composite radial, the use of vascularized iliac crest with the internal oblique flap has become our flap choice for morphofunctional maxillary reconstruction for bone segments within 6-15 cm of length, and when there is no need for overlying facial skin or oral sphincter reconstruction. The advantages of this composite bone flap are its available large and resizable bone stock; the quality of the bone for transfer (optimal height, depth, and contour to maintain a good facial profile); and the possibility to properly reconstruct the oral lining, orbital content; and maxillary soft tissues with a portion of the internal oblique muscle flap raised with the same pedicle. In addition, this flap's soft tissue will epithelialize during the healing stages.

Perineal endometriosis in episiotomy scar with anal sphincter involvement: report of two cases and review of the literature

Perineal endometriosis with anal sphincter involvement is a rare occurrence with only nine cases reported so far. Two such cases are presented, and the literature is reviewed. In presented cases, diagnosis was suspected at clinical exam. Anal manometry was performed in both cases and endoanal ultrasound in one case. Wide surgical excision of endometriotic mass together with part of external anal sphincter was carried out in both cases. The procedure was followed by anal sphincter reconstruction in an "overlapping" fashion in the first and "apposition" technique in the second case. Histopathologic tests confirmed endometriosis. The recovery was uneventful in both cases with excellent functional results. Two years after the operation, patients are asymptomatic and fully continent. According to the literature and our own experience, wide excision of endometrioma with primary sphincteroplasty seems to be the best chance of cure with satisfactory functional results and should be recommended.

Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano

Background The goal of this study was to compare the outcomes of advancement flap (AF) versus fistulotomy with sphincter reconstruction (FSR) for primary complex fistula-in-ano in terms of recurrence and anal function. Methods A randomized clinical trial was conducted to compare AF with FSR. Preoperative and postoperative evaluation included physical examination, anal ultrasonography, and anal manometry, with a minimum follow-up period of 24 months. Anal continence was evaluated using the Wexner Continence Grading Scale (scale, 0–20). Results Sixty patients were randomized to AF (group 1, N = 30) or FSR (group 2, N = 30). Three patients from group 1 and 2 patients from group 2 were excluded from the study because of active sepsis at surgery. Fistulas were classified as high transsphincteric in 44 patients (80%) and suprasphincteric in 11 patients (20%). Demographic and clinical features showed no differences between the 2 groups. The mean Wexner Continence Grading Scale did not vary significantly after surgery in either group, and there was no difference between the groups. On anal manometry there was a significant decrease in the maximum resting pressure after surgery in both groups, and in the maximum squeeze pressure in the AF group, but neither the maximum resting pressure nor the maximum squeeze pressure differed significantly between groups, either before or after surgery. Two fistulas from each group recurred after surgery (7.4% and 7.1%, respectively). The mean follow-up period was 36 months (range, 24–52 mo). Conclusions FSR compares with AF in terms of postoperative continence and recurrence. Anal continence and manometric values are not jeopardized in either technique.

A modified procedure for velopharyngeal sphincteroplasty in primary cleft palate repair and secondary velopharyngeal incompetence treatment and its preliminary results

During cleft repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve the surgical treatment for cleft palate and secondary velopharyngeal incompetence (VPI), a carefully designed modified procedure for primary palatoplasty and secondary VPI was presented. Fifty-six patients (48 for primary cleft palate repair and eight for secondary VPI of previously repaired clefts) underwent this procedure from 1988 to 2001. The modified procedure is a combination of the tunnelled palatopharyngeus myomucosal flap for dynamic circular reconstruction of the pharyngeal element of the velopharyngeal sphincter and the double-reversing Z-plasty with levator velo palatini muscles reposition in the velar element of the sphincter. The satisfactory velopharyngeal competence (complete velopharyngeal closure and marginal velopharyngeal closure) was achieved in 23 of 25 patients with primary cleft palate repair examined by nasendoscopy and the nasality, speech articulation and intelligibility are also assessed in 25 primary cleft palate repaired patients with 92% satisfactory result (normal speech and speech with mild VPI) in single word test and 88% in continuous speech evaluation. Based on our experience, we believe that this modified procedure is a reasonable choice for primary cleft repair and secondary VPI treatment because it is in accord with normal physiology and anatomy of the velopharyngeal sphincter, can lengthen the soft palate, decrease the enlarged velopharynx, augment the posterior pharyngeal wall, and enhance the relationship between the muscles of velopharyngeal sphincter which results in a dynamic neo-sphincter in palatopharyngoplasty. Further study of the procedure is needed. The theoretical basis, operative highlights, velopharyngeal function, advantages and disadvantages of the modified procedure were discussed.

Restoration of Fecal Continence After Functional Gluteoplasty

For patients with severe fecal incontinence, reconstruction of the anal sphincter, via gluteoplasty, may improve quality of life, but little is known about long-term functional results. We present our comprehensive experience with gluteoplasty, highlighting technical refinements, donor-site morbidity, and functional outcomes. We performed a retrospective analysis of 25 consecutive patients (22 female, 3 male; mean age 42 years, range 23-65) undergoing gluteoplasty for fecal incontinence at a university teaching hospital from 1996-2004. Etiology of incontinence was as follows: obstetrical injury (n = 13), irritable bowel syndrome (n = 3), previous rectal surgery (n = 3), Crohn disease (n = 3), impalement (n = 1), rectocele (n = 1), and idiopathic (n = 1). Gluteoplasty was successful in restoring fecal continence in 18 patients (72%) and was partially successful in 4 patients (16%). Two patients required permanent ostomy because of refractory incontinence. Donor-site morbidity and perirectal complications were observed in 16 patients (64%) and included dysthesias (n = 7), cellulitis (n = 5), irregular contour (n = 3), abscess (n = 2), seroma (n = 2), fistula (n = 1), but no hip dysfunction or altered gait. Mean length of follow-up was 20.6 months (range: 3-68 months). Despite a high incidence of donor-site and perirectal complications, unilateral functional gluteoplasty was successful in restoring long-term fecal continence in most patients.

Management of faecal incontinence and results of surgical treatment.

Ninety-five patients have been referred for the assessment and treatment of faecal incontinence. Incontinence was associated with previous anal trauma in 49 cases: 13 occurred after vaginal delivery, 32 were associated with anal operations and in 4 severe perineal trauma occurred after road accidents. Other causes were: idiopathic incontinence in 18, persistent incontinence despite successful rectopexy for prolapse in 10, diabetic neuropathy in 5 and in 13 the cause was not identified. Conservative treatment by control of diarrhoea, physiotherapy or electrical therapy was often successful in patients with minor incontinence. Fifty-six patients have been treated surgically. Complete continence was achieved in 67 per cent of patients treated by postanal repair and in 61 per cent by sphincter reconstruction. We believe that postanal repair is the treatment of choice for idiopathic incontinence and incontinence after rectopexy or anal dilatation. Sphincter repair should only be performed with a covering colostomy and is the treatment of choice for recent or long standing division of the external sphincter ring.

Anal endosonographic findings in the follow-up of primarily sutured sphincteric ruptures.

Twenty-four women with primary suture of an obstetric tear of the anal sphincter were examined with anal endosonography a median of 12 (range 3-18) months after delivery. Endosonography was normal in ten patients, of whom one was incontinent. The examination showed a defect in the external anal sphincter in 13 patients; six of these were incontinent, two of whom had normal findings on palpation. An isolated internal sphincter defect was found in a continent patient. Since anal endosonography causes no more discomfort than digital examination, it may be useful to identify patients who would benefit from surgical reconstruction of the anal sphincter.

Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano

The aim of this study was to assess the results of fistulotomy with sphincter reconstruction in the management of recurrent complex fistula-in-ano in terms of recurrence and continence. Prospective study of 16 patients undergoing fistulotomy with sphincter reconstruction for recurrent complex fistula-in-ano was done. Preoperative and postoperative evaluation included physical examination, anal ultrasonography and anal manometry, with a 40-month follow-up. The Wexner Continence Grading Scale (0-20) was used to assess faecal continence. Fistulas were classified as high transsphincteric in 13 patients (81.3%), suprasphincteric in 2 (12.5%) and extrasphincteric in 1 patient (6.2%). Four patients (25%) had recurred twice or more. Eight patients (50%) complained of varying degrees of prior faecal incontinence. Their mean score decreased from 8.5 to 1.875 after surgery, and all the patients improved except for one whose score remained the same. On anal manometry, the differences between continent and incontinent patients before surgery [maximum resting pressure (MRP) 86.3 vs 57.6 mmHg, maximum squeeze pressure (MSP) 196.5 vs 138.6 mmHg] decreased after surgery (MRP 81.9 vs 63.7 mmHg, MSP 179.8 vs 159.3 mmHg). In fully continent patients, both the clinical score and manometric values were quite similar after surgery. Two fully continent patients (25%) developed occasional flatus incontinence and soiling, scoring two and three points, respectively. One patient recurred (6.25%) 6 months after surgery. Fistulotomy with sphincter reconstruction seems to be an effective resource in the management of recurrent complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.