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Electrically Stimulated Gracilis Neosphincter for End-stage Fecal Incontinence: The Long-term Outcome

Boyle, Derek J. M.D., F.R.C.S.; Murphy, Jamie B.Chir., Ph.D.; Hotouras, Alexander M.Sc., M.R.C.S. (Engl.); Allison, Marion E. R.G.N., M.Sc.; Williams, Norman S. M.S., F.R.C.S.; Chan, Christopher L. Ph.D., F.R.C.S.

doi: 10.1097/DCR.0b013e3182a4b55f
Original Contributions: Anorectal Disease

BACKGROUND: Electrically stimulated gracilis neosphincter is an established treatment for patients with end-stage fecal incontinence. Few data, however, describe its long-term efficacy.

OBJECTIVE: This study aimed to assess the long-term functional outcome associated with this procedure.

DESIGN: Patients who underwent gracilis neosphincter construction between1989 and 2001 were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiologic data were available for all patients.

SETTINGS: This study was conducted at an academic colorectal unit in a tertiary center.

PATIENTS: Sixty patients (median age, 42 years; 46 females) with fecal incontinence and a Williams continence score ≥5 were recruited to the study. The causes of incontinence included obstetric injury (n = 22), anal surgery (n = 17), atresia (n = 7), idiopathic incontinence (n = 6), anorectal excision (n = 4), and ileoanal pouch incontinence (n = 4).

MAIN OUTCOME MEASURE: The primary outcomes measured were the Williams continence score and the proportion of patients with a Williams score ≤3 who avoided permanent stoma formation.

RESULTS: Continence improved for the cohort postoperatively at 2 years (2(2–5); p < 0.001) but no significant difference was found between continence scores preoperatively and at 13 years (5(3–6); p = not significant). However, a sustained improvement at 13 years was noted for patients in the anal surgery (3(2–5);p < 0.001) and obstetric injury groups (4.5(3–6); p = 0.001). Twenty-six patients (43%) had a Williams score ≤3 and avoided permanent stoma after 13 years. Eighteen patients developed postoperative rectal evacuatory disorder; 10 of them required a conduit to facilitate colonic irrigation. Postoperative evacuatory disorder was more frequent in patients with a history of obstetric injury (p = 0.008).

LIMITATIONS: This study was limited by the lack of bowel diaries and quality-of-life scores.

CONCLUSION: Gracilis neosphincter is associated with clinically significant and sustained symptom improvement in patients with end-stage fecal incontinence secondary to obstetric injury or anal surgery. These data support the continued use of this procedure in highly selected patients.

Academic Surgical Unit, National Centre for Bowel Research and Surgical Innovation, Barts Health NHS Trust, London, United Kingdom

Financial Disclosure: None reported.

Drs Boyle and Murphy contributed equally to this work.

Correspondence: Alexander Hotouras, B.Sc., M.Sc., M.B.B.S.(Lond.), M.R.C.S.(Engl.), Academic Surgical Unit, National Centre for Bowel Research and Surgical Innovation, 2 Newark St, London, E1 2AT United Kingdom. E-mail:

© 2014 The American Society of Colon and Rectal Surgeons