Post Operative Complications

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Electrostimulated graciloplasty for TAR after Miles is still affected by a worrying percentage of post-operative complications which can affect the overall success rate (Table 1). The number of complications per patient after dynamic graciloplasty for faecal incontinence or total anorectal reconstruction was 2.9 (range 1-9) in Sielezneff et al.'s [26] experience and the total complications numbered 138 in 128 patients and 68 in 27 patients in Madoff et al.'s [27] and Wexner et al.'s [28] experiences, respectively.

The more sophisticated the procedure, the more likely the occurrence of complications. In this operation complications can be related to:

1. Neo-sphincter construction. The most frequent complication is perineal infection, which occurs in about 10-30% of cases but can usually be managed conservatively with abscess drainage and antibiotics. Other, less frequent complications include tendon detachment from the ischiatic tuberosity and tendon necrosis. In the first type re-attachment of the tendon is usually feasible, whereas in the second the transposed muscle is no longer serviceable. Perineal colostomy may also be complicated by stricture [29], often requiring further surgery.

Another possible complication can occur at the site of muscle mobilisation with seroma formation in the thigh or persistent pain.

2. Electronic device-related complications. The most fearful complication is infection. As with all foreign bodies implanted in the human body, the occurrence of prosthesis infection is possible, difficult to manage, and often requires complete removal of the

9 100 Double gracilis 8 67 Single gracilis 8 64 Double gracilis 2 50 Single gracilis

10 56 Single gracilis 12 75 Double gracilis 10 58 Single gracilis device itself. Electrode displacement, sometimes with external expulsion, was a relatively common complication using the four-plate electrode for direct nerve stimulation [30].

Skin erosion by the pacemaker can also occur if it is implanted too superficially, or close to bone protuberances, or if the patient loses weight. Implanting the pacemaker at the level of the waistband or too close to bones can cause pain. Albeit rarely, failures of the electronic devices have been described including electrode breakdown, early battery rundown and accidental deactivation of the pacemaker.

3. Functional complications. The occurrence of faecal incontinence or obstructed defecation can be considered functional complications after this operation. Although some degree of both may be well tolerated by patients, excessive incontinence or constipation may severely affect their quality of life, sometimes dictating a return to an abdominal colostomy. Soiling is a common finding due to the mucosal exposure in the perineum, but true faecal incontinence may result from insufficient increase of neoanal pressure during muscle stimulation. On the contrary, obstructed defecation may be a consequence of neo-anal stricture or rectocele, but most commonly of a combination of factors due to the anatomical and functional changes induced by the surgical procedure in the perineum, including the loss of fine pro-prioceptive and somatic (anal) sensitivity [31], the loss of the rectal ampulla and part of the pelvic floor muscles, and the reduced propulsion motility of the transposed colon compared to the rectum [32]. To overcome these problems, in addition to the perineal colostomy, Saunder et al.'s [33] proposed a defunc-tioned colonic conduit for antegrade enemas or, more recently, a Malone antegrade continent enema even without a neo-anal sphincter mechanism [34].

Evaluation of the results of electrostimulated graciloplasty for total anorectal reconstruction after Miles' operation is extremely unreliable because almost all the reports deal with small series of patients, retrospectively analysed with significant variations in the technique used (double vs. single gracilis, nerve vs. muscle stimulation, the use of dif ferent devices, different electrodes and protocols for muscle conversion) but, most importantly, there is no universally accepted definition of the outcome. Perfect continence and defecation are virtually impossible to achieve in these patients, so that some degree of incontinence or the need for regular use of enemas to empty the neorectum are still considered successful outcomes. Only a few recent papers have adopted scoring systems to define the severity of incontinence and no purpose-designed quality of life (QoL) index has yet been introduced. Improvement of QoL should be the real aim of this operation.

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