Dynamic graciloplasty: a small and salutary experience

The Colorectal Unit at the King Faisal Specialist Hospital and Research Centre was one of 12 centers involved in the first international multicenter trial of dynamic graciloplasty. Some complications and problems related to the procedure were specific to Saudi Arabia, and this paper documents this experience in more detail.

Patients with a generalized anal sphincter weakness were offered dynamic graciloplasty. Prior to surgery, patients underwent manometric examination of their sphincters. A right gracilis transposition was undertaken. After six weeks, a pulse generator was implanted and electrodes were inserted. The stimulation program commenced four weeks later. The neosphincter was magnetically controlled to allow defecation. Patients were followed at 3-monthly intervals to assess clinical progress.

Five patients (3 males and 2 females) were considered to be suitable for the procedure. One patient developed an infection of the thigh wound which resolved without drainage. There was no other surgical morbidity. Mean resting (26.4 mm Hg) and "squeeze" (51.4 mm Hg) pressures prior to surgery were low. Following implantation, mean resting and "squeeze" pressures rose during training in 4 patients (48.5 and 100.8 mm Hg, respectively). Two patients maintained satisfactory clinical and manometric function at 6 and 5 years' follow-up. One patient ceased to have any function in the transposed muscle and refused a further graciloplasty four years after graciloplasty. Another patient avulsed the leads and the transposed tendon on two occasions, and failed to heed advice given regarding posture and sitting. The final patient had an unsatisfactory wrap because of massive peri-rectal fibrosis. There was a 50% reduction in bowel frequency in the two patients in whom the procedure was successful.

The technique requires a high level of patient cooperation, but should be available in specialized centers for the management of patients with refractory anal incontinence.