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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 104 | Long-Term Follow-Up of Dynamic Graciloplasty for Fecal Incontinence [2003년 6월 DCR] | 2011-11-17 | 4837 |
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Mart-Jan G. M. Rongen, M.D., O¨ zenc¸ Uludag, M.D.,Kadri El Naggar, M.D.,a Bas P. Geerdes, M.D., Ph.D.,Joop Konsten, M.D., Ph.D., Cor G. M. I. Baeten, M.D., Ph.D.
From the Department of Surgery, University Hospital Maastricht, Maastricht, the Netherlands
PURPOSE: Graciloplasty has been used as a treatment for end-stage fecal incontinence since 1946. Electric stimulation with an implantable pulse generator has existed for 15 years. The gracilis muscle is wrapped around the anal canal and stimulated by intramuscular electrodes connected with an implantable pulse generator. Initial reports have been promising, but long-term results have not been presented to date.
METHODS: Data of 200 consecutive patients with a follow-up of at least two years were analyzed in a prospective manner from 1986 until 1999.
RESULTS: The overall success rate was 72 percent. In patients with fecal incontinence caused by
trauma, the rate was 82 percent. Once continent, patients remained continent after a median follow-up of 261 (standard deviation, 132) weeks. Median survival of the implantable pulse generator until battery expiration was 405 weeks. Disturbed evacuation remained a problem in 16 percent of all patients. Complications were frequent but treatable. CONCLUSION: Dynamic graciloplasty is a good, cost-effective treatment for fecal incontinence with results lasting for a median of more than five years.
Since 1986, dynamic graciloplasties (DGPs) have been performed for end-stage fecal incontinence.
Many reports were written about the outcome and pitfalls of this procedure and its many variations. Results were maintained for most of the groups involved in this technique, but long-term efficacy has not been reported yet, certainly not for a great number of patients. Discrepancies between functional and clinical results in some patients also emphasize the need for a closer look at the overall results. DISCUSSION
The success rate of DGP after a median of five years was 72 percent, which is better than the long-term
results of anal repair. Although DGP was technically functional in 91 percent of the cases, the presence of a (neo)sphincter is only partially responsible for continence. Insufficient forming of stool led to leakage in 17 patients. The lower success rates in the congenital and pudendopathy group give support to the conclusion that besides sphincter function, sensation,distention,
evacuation, anocortical integration, or stool consistency might be impaired in these groups. It is remarkable that the lower motor neuron lesion group, which also had diminished sensation and evacuation problems, were better off in terms of success. One might argue that presently, patients’ diaries are considered the best way to determine continence. At the start of the present study, this technique was not incorporated in the data collection, except in a small (n = 15) subset of patients as part of a multicenter study. Morbidities associated with this procedure are numerous in frequency but generally manageable without major interventions.
Disturbed evacuation was primarily a temporary problem, and when this problem remained, diet advice
and bulk laxatives resolved the problem. In some patients, biofeedback therapy led to resolution of the problems. The observation that initial evacuation difficulty frequently was present might be explained by the fact that during their years of incontinence, there was no evacuation mechanism active in these patients. Infections were initially a major problem but diminished significantly after a change in infection prevention. Even if an infection occurs, with subsequent removal, implantation can be done repeatedly provided the gracilis muscle is vital and produces a voluntary contraction.
Anal perforation is a problem that might be prevented by use of a vaginal incision during the preparation
of the perianal tunnel in patients with extensive scarring in the perineum anterior of the anus. Care must be taken during preparation that the tendon is not sutured too tightly around the anal canal to prevent it eroding through the anus. Because the IPG life is a median of 7.8 years, cost-effectiveness of the therapy appears to be better
than calculated previously. Recent multicenter studies show lower success rates, high morbidity, and even mortality. However, many of these centers had little experience in the procedure and a relatively small number of patients enrolled in these studies. Given the learning curve of this procedure, these results can be explained. Other studies from more experienced centers show results comparable to those of the present study. In the treatment of intractable fecal incontinence,sacral nerve stimulation is a promising new therapy.
Patients with gross sphincter defects are not likely to benefit from this treatment and will continue to depend on the creation of neosphincters. A recently presented multicenter study on the artificial bowel sphincter does not show better success rates and morbidity than achieved with DGP. An accurate predictor of successful outcome remains to be found. To date, neither sensation, capacity,
nor any other preoperative investigation has provided a clear prospect of outcome in individual cases. The present study emphasizes that incontinence is not just a mechanical problem. With the development of sacral nerve modulation and the ability to evaluate the effect of modulation, patients with incontinence who do not respond to this treatment will be selected. This group might be better candidates for DGP, with an increased chance of success. Regardless, DGP has paved the way for sacral nerve modulation, because we have gained experience with implanted electric devices for fecal incontinence. |
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