Perineal Antropylorus Transposition for End-Stage Fecal Incontinence in Humans

Abstract

Antropyloric valve transposition can be used effectively for a selected group of patients with end-stage fecal incontinence. Patients undergoing anal sphincter augmentation have better outcomes in comparison with those having an excised sensate anorectum.

Dynamic Article

“…9 We have shown that the antropylorus, a smooth muscle segment, when surgically removed from gastroduodenal continuity and transposed to the perineum, provides a continuous tone and functions as an effective anal sphincter. [12][13][14] We have also reported that patients in whom the anorectum was excised (as in an aPR operation) functionally do not fare as well as patients in whom the native anal sphincter was preserved (traumatic anal sphincter damage) after the aPV transposition procedure, primarily because of inadequate voluntary control. 12 this prompted us to reinnervate the transposed segment by pudendal nerve branch in an attempt to provide sensory neural control.…”

“…one patient had undergone aPV transposition following aPR, but without neural (anterior vagus to inferior rectal nerve) anastomosis. 12 all patients with rectal malignancy received short-course neoadjuvant radiation of 25 Gray (Gy) in 5 fractions. after surgery, 50 Gy of radiation was given in 27 fractions followed by 6 cycles of chemotherapy (oxaliplatin with 5-fluorouracil and folinic acid regimen).…”

“…the voluntary hold in these patients was lacking. 12,13,15 to circumvent this problem, we decided to place a gracilis muscle wrap (a skeletal muscle under voluntary control) around the perineally transposed antropyloric smooth muscle segment. the combination of smooth muscle (aPV segment providing a continuous tone) and a striated muscle (gracilis wrap providing short voluntary control) closely simulates normal anorectal sphincter anatomy.…”

“…a disease-specific personal questionnaire was used along with the continence scale (supplemental Digital Content 2, http://links.lww.com/DCR/a174) to objectively assess patient satisfaction levels following surgery. 12 all patients were followed up telephonically in addition to their routine outpatient visits. Patients were enquired in detail about their continence status (including bowel urgency, episodes of leakage/incontinence, and lifestyle changes) in each follow-up.…”

“…[9][10][11] We have recently reported the technical feasibility and initial outcomes of perineal transposition of antropyloric valve (aPV), a smooth muscle segment, for neoanal reconstruction. [12][13][14] subsequent technical modification involving pudendal innervation of this transposed segment had also been attempted to improve neoanal sensation and provide neural control, although without much difference in outcomes. 15, 16 We hereby describe wrapping the gracilis muscle around the perineally transposed segment of aPV to improve voluntary fecal control in these patients.…”