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Six patients incapacitating faecal incontinence, in whom conventional treatment had either failed or was contraindicated, were treated by a new technique. A neonanal sphincter was constructed by transposing the gracilis muscle around the anal canal. Chronic neuromuscular stimulation via an implanted electrical stimulator was then used in an attempt to convert the muscle to a slow twitch fatigue resistant muscle. Physiological measurements suggested that this conversion had begun, enabling the neosphincter to mount a sustained contraction. Five patients had their covering stomas closed, and continence was improved in all of them. However, one patient could not cope psychologically with the stimulator, and another patient was continent for long periods only when the neosphincter was used in conjunction with a silastic plug. This new technique may benefit selected patients with incontinence whose only alternative would be a permanent stoma.
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PMID:Construction of a neoanal sphincter by transposition of the gracilis muscle and prolonged neuromuscular stimulation for the treatment of faecal incontinence. 233 92

The feasibility of skeletal muscle transposition and electrical stimulation (dynamic myoplasty) for treatment of fecal incontinence has been shown in adults. It might be attractive to use such a technique in pediatric patients. Therefore, the influence of growth on skeletal muscle transposition and stimulation was studied in five puppies. In each dog, two neosphincters were constructed around a Thiry-Vella loop by using a dissected sartorius muscle with the neurovascular supply intact. In each of these five puppies, one of these muscles was electrically stimulated during a mean of 19 weeks (one puppy died during the first postoperative week). Muscle biopsies showed an increase in the percentage type I, fatigue-resistant muscle fibers from 61 to 94 in electrically stimulated sartorius neosphincters, but also an increase from 57 to 67 percent in transposed nonstimulated sartorius muscles. The diameter of these type I fibers during growth increased 36% in eletrically stimulated sartorius neosphincters and 55% in nonstimulated sphincters. Function of the neosphincters was tested with the inflow of saline in the Thiry-Vella loop. It was shown that the stimulated neosphincters were capable of inhibiting flow (which corresponded to manometric pressure registrations), but the nonstimulated sphincters were unable to inhibit flow. The experiments were complicated by infection and necrosis around the implanted stimulators in four puppies (which required reimplantation). We conclude that a dynamic myoplasty for fecal incontinence is feasible in growing puppies but that the technique is unacceptable during rapid growth because of the risks of infection and dislocation of the implanted device.
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PMID:Dynamic myoplasty in growing dogs as a feasibility study for treatment of fecal incontinence. 759 39

The purpose of this prospective study was to see if pretreatment anorectal motility can predict successful correction of faecal incontinence with biofeedback. Forty-seven consecutive children, aged 5 to 18 years, were treated. They had been treated for idiopathic constipation with faecal impaction, but had remained incontinent (n = 15), had been operated for congenital anorectal malformations of high (n = 19) or low (n = 2) type, or had a number of organic congenital pelvic abnormalities (n = 11). This consecutive series represents our entire experience with biofeedback for faecal incontinence, in the period from January 1 1983 to December 31 1989. In each patient, at the first session, anorectal manometry was performed. Resting pressures in the rectum, upper anal canal and lower anal canal were measured. The threshold of rectal sensation during distension, the maximal pressure during voluntary sphincteric contraction and the time to half decrease of sphincteric pressure because of muscular fatigue were also noted. The patient was then asked to make a voluntary sphincteric contraction, while the rectum was being distended with the volume at threshold for rectal sensation. In subsequent sessions, the rectum was also distended but without warning the patient, who was congratulated when he or she contracted the sphincter immediately after onset of rectal distension. Full continence was the criterion used to classify re-education as a success. Improvement or no change in continence was considered as failure of the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Biofeedback re-education of faecal continence in children. 781 85

A neosphincter was successfully created around each end of a Thiry-Vella loop in five dogs using transposed sartorius muscle to study new treatments for faecal incontinence. One of these dynamic neosphincters in each dog was electrically trained for 8 weeks while the other served as a control. Muscle biopsies demonstrated an increase in type 1 fatigue-resistant fibres from a median of 49 (range 37-54) per cent before electrical stimulation to 78 (range 53-99) per cent 8 weeks later in the stimulated sartorius neosphincters (P < 0.05), whereas the percentage of type 1 fibres in control neosphincters increased only slightly. Retention times of saline increased from a median of 10 (range 5-50)s before to 340 (range 100-470)s after electrical stimulation (P < 0.05) but also increased in control neosphincters (to 370 (range 330-1200)s); this may indicate that electrical stimulation immediately increases acute retention times. It is concluded that construction of a neosphincter is technically feasible with preservation of muscle morphology and that stimulation induces morphological and functional changes towards the characteristics of the external anal sphincter.
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PMID:Canine model for treatment of faecal incontinence using transposed and electrically stimulated sartorius muscle. 817 34

The physiological and histochemical characteristics of the gracilis muscle were studied in 19 patients undergoing electrically stimulated gracilis neosphincter construction. Indications for surgery were faecal incontinence (n = 11) and reconstruction following sphincter excision or congenital absence (n = 8). Transposition of the gracilis muscle around the anal canal followed by chronic low-frequency electrical stimulation was associated with a shift in the frequency-response curve and a prolongation of the time-course of individual muscle twitches suggestive of transformation to a slow-twitch fatigue-resistant type. Temporary cessation of electrical stimulation resulted in a reversal of the frequency-response changes. Muscle biopsies taken before and a median of 80 (range 49-137) days after transposition and low-frequency electrical stimulation indicated a significant increase in the proportion of type 1 fibres and a significant decrease in their diameter. These results show that the human gracilis muscle is capable of physiological and histochemical adaptation to long-term neosphincter function.
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PMID:Physiological and histochemical adaptation of the electrically stimulated gracilis muscle to neoanal sphincter function. 824 19

Dynamic graciloplasty for fecal incontinence includes gracilis muscle transposition around the anal canal as a new sphincter and subsequent electrical stimulation. The aim of electrical stimulation is to transform the gracilis fast-twitch, "fatigue-prone" fibers into slow-twitch, "fatigue-resistant" fibers to achieve a sustained tonic contraction. The latter is considered essential for sphincter function. Therefore, the following features of transposed gracilis muscle morphology were studied in nine patients before and after electrical stimulation: 1) the percentage of Type I fibers, 2) the lesser diameter of these fibers, and 3) the positive collagen staining area. Furthermore, the external and sphincter and gracilis muscle histology was investigated in six autopsy cases. The mean percentage of Type I, slow-twitch, fatigue-resistant fibers in transposed gracilis muscle increased from 46 percent before electrical stimulation to 64 percent (P < 0.01, paired Student's t-test) after electrical stimulation. The mean lesser diameter of these fibers did not change significantly (from 32 to 29 microns), and the mean percentage of collagen increased from 4 percent before electrical stimulation to 7 percent (P < 0.01) afterward. The external sphincter in cadavers demonstrated a predominance of Type I fibers (80 percent) with a lesser diameter of 23 microns and a high percentage (12 percent) of collagen. Gracilis muscle histology was uniform at six different sample sites in these cadaver dissections. We conclude that electrical stimulation induces histologic changes in transposed gracilis muscle, allowing this muscle to function as an external anal sphincter.
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PMID:Morphology of dynamic graciloplasty compared with the anal sphincter. 850 Mar 73

Dynamic myoplasty combines muscle transfer with electrical stimulation to provide contractile function that augments or replaces impaired organ function. Dynamic cardiomyoplasty was the first clinical application in which a skeletal muscle, latissimus dorsi, was transferred and stimulated to provide cardiac assistance, a function different from its original one. The problem of early muscle fatigue that was encountered in the initial implementation of the method was solved by training the muscle with electrical stimulation and thus changing its fiber composition. With intramuscular electrodes, the conditioned latissimus dorsi is stimulated in synchrony with the heart muscle. Safeguards are built into the two-channel implanted stimulator to avoid excessively high pulse rates. Clinicians report that 80% of patients with moderate to severe heart failure prior to operation showed a clinical improvement of 1.6 New York Heart Association classes. Alternative methods of providing cardiac assistance that are also being investigated include wrapping the muscle around the aorta, creating a skeletal muscle ventricle, and using the muscle to power an implantable pump. These latter techniques are still under preclinical investigation. Compared with heart transplant, cardiomyoplasty has the great advantage of not being subject to tissue rejection. The second principal application of dynamic myoplasty is treatment of fecal incontinence through creation of an electrically stimulated skeletal muscle neosphincter (ESMNS). The gracilis muscle of the leg is mobilized, wrapped around the anal canal, and conditioned with electrical stimulation to become more fatigue resistant. To achieve continence, the muscle is continuously stimulated except when the patient wishes to defecate. Overall success rates in achieving continence are 60-65%. Both cardiomyoplasty and the ESMNS technique, and their associated devices, are being refined through ongoing clinical trials.
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PMID:Dynamic myoplasty: surgical transfer and stimulation of skeletal muscle for functional substitution or enhancement. 872 69

The stimulated gracilis neosphincter is a viable procedure in selected patients with fecal incontinence. The aim of this paper is to review the technique of this staged operative procedure and review the problems and complications. Stage 1 consists of the vascular "delay" of the gracilis muscle and the creation of a temporary stoma. Stage 2 consists of transposition of the muscle around the anus with implantation of the stimulator. Low-frequency electrical stimulation is applied to the muscle for 12 weeks, after which stage 3 (stoma closure) is undertaken. From March of 1993 to March of 1995, 14 patients (9 females and 5 males) with a mean age of 44 years (range 20 to 67 years) underwent the procedure. Two patients died within 1 year of the operation from unrelated causes. Two patients developed anal stenosis and required permanent stomas. Other complications noted during ascent of the learning curve included seroma, excoriation of the skin above the stimulator, transposition of the stimulator, premature battery discharge, wound infection, rupture of the gracilis tendon, fatigue during programming sessions, and electrode displacement or fibrosis from the nerve. However, 8 of the 10 eligible patients had stoma reversal; the manometric results showed an average mean squeeze pressure that increased from 43 mmHg prior to surgery to 151 mmHg after the operation (p < 0.01). Based on an objective functional questionnaire, 60 percent of the patients who could be evaluated reported improvement in continence, social interactions, and the quality of their life. In conclusion, despite a steep learning curve, the stimulated gracilis operation is a viable operation for selected patients with severe incontinence.
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PMID:The stimulated gracilis neosphincter for fecal incontinence: a new use for an old concept. 877 92

It is estimated that 10-20% of patients with multiple sclerosis (MS) have a chronic progressive (CP) course characterized by an insidious onset of neurological deficits followed by steady progression of disability in the absence of symptomatic remission. To date no therapeutic modality has proven effective in reversing the clinical course of CP MS although there are indications that prolonged treatment with picotesla electromagnetic fields (EMFs) alters the clinical course of patients with CP MS. A 40 year-old woman presented in December of 1992 with CP MS with symptoms of spastic paraplegia, loss of trunk control, marked weakness of the upper limbs with loss of fine and gross motor hand functions, severe fatigue, cognitive deficits, mental depression, and autonomic dysfunction with neurogenic bladder and bowel incontinence. Her symptoms began at the age of 18 with weakness of the right leg and fatigue with long distance walking and over the ensuing years she experienced steady deterioration of functions. In 1985 she became wheelchair dependent and it was anticipated that within 1-2 years she would become functionally quadriplegic. In December of 1992 she began experimental treatment with EMFs. While receiving regularly weekly transcortical treatments with AC pulsed EMFs in the picotesla range intensity she experienced during the first year improvement in mental functions, return of strength in the upper extremities, and recovery of trunk control. During the second year she experienced the return of more hip functions and recovery of motor functions began in her legs. For the first time in years she can now initiate dorsiflexion of her ankles and actively extend her knees voluntarily. Over the past year she started to show signs of redevelopment of reciprocal gait. Presently, with enough function restored in her legs, she is learning to walk with a walker and is able to stand unassisted and maintain her balance for a few minutes. She also regained about 80% of functions in the upper limbs and hands. Most remarkably, there was no further progression of the disease during the 4 years course of magnetic therapy. This patient's clinical recovery cannot be explained on the basis of a spontaneous remission. It is suggested that pulsed applications of picotesla EMFs affect the neurobiological and immunological mechanisms underlying the pathogenesis of CP MS.
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PMID:Treatment with electromagnetic fields reverses the long-term clinical course of a patient with chronic progressive multiple sclerosis. 935 26

The possibility of converting an easily fatiguable muscle like the gracilis muscle into a fatigue-resistant one using chronic electrostimulation has renewed interest in Pickrell's procedure. Between July 1991 and June 1996, 9 patients (2 M; 7 F) mean age = 45 y (range 14-72) underwent dynamic graciloplasty using Medtronic electrostimulators. Five patients had faecal incontinence (2 congenitally anomaly, 1 neurological, 2 post-operative) and 4 had a perineal colostomy performed either simultaneously (two cases) or at 3 to 4 years after abdominoperineal excision of the rectum. Early post-operative complications included distal tendon necrosis [1], perineal colostomy breakdown [1], detachment of the gracilis tendon [2] and seroma in the thigh [1]. Long-term complications included rectocele with faecal impaction in one patient with imperforate anus, anal stricture in one patient who had refashioning of a perineal colostomy, and displacement of the lead from the main nerve in 3 with external expulsion in 2. The patient with anal stricture was successfully treated with anoplasty but subsequently returned to an abdominal colostomy due to stricture recurrence 2 years later. The rectocele was successfully treated using a transvaginal approach. Electrical conversion of the muscle was completed in all patients but long term functional results are available for only 5 cases. Manometry revealed a significant improvement in anal pressure under electro-stimulation and the continence grading scale score significantly improved in 4 patients. The technique is applicable to a very selected group of patients with no other options but is still in the experimental phase and should not be performed outside controlled trials. Repeated hospitalisation and reoperations are often required although the complication rate may diminish and improve with experience.
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PMID:Electrostimulated gracilis neosphincter for faecal incontinence and in total anorectal reconstruction: still an experimental procedure? 940 48


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