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R D Madoff

Publications and source records attributed to R D Madoff.

At least 19 recordsLinked to original sources
PubMed2001

Pelvic wall involvement denotes a poor prognosis in T4 rectal cancer.

PURPOSE: An aggressive surgical approach with en bloc resection of involved structures is often possible with anterior rectal cancers that invade adjacent visceral organs, but is rarely possible in tumors that invade the pelvic wall. However, most staging systems include both situations in the same group of T4 rectal cancers. We performed a retrospective study of patients with stage T4 rectal cancer undergoing surgery to assess the influence of different organ involvement on resectability and survival. METHODS: A retrospective review was conducted of 84 patients with T4 rectal cancer treated at the University of Minnesota and affiliated hospitals over a ten-year period. Forty-seven patients (56 percent) were staged for local invasion on the basis of final pathology, 19 (23 percent) on the basis of operative findings, and 18 (21 percent) on the basis of ultrasound images. Patients were divided into two groups, those with or without pelvic wall involvement. Resectability, local control, and overall survival were compared between groups. Survival curves were estimated by the Kaplan-Meier method and compared by log-rank test. Multivariate analysis was performed with Cox proportional and logistic regression. RESULTS: Thirty-one patients (37 percent) had involvement of the pelvic wall, whereas 53 patients (63 percent) had visceral involvement only. All 29 patients with distant metastasis died of their disease. Forty-seven of the 55 patients without distant metastasis underwent tumor resection. Age and pelvic wall involvement were the only two factors independently associated with the probability of resection in logistic regression analysis (P = 0.0067 and P = 0.037, respectively). The only factor that affected median survival in patients without distant metastasis was tumor resection (49.1 months for resection vs. 6.1 months for no resection, P = 0.017). Patients with visceral involvement had a longer median survival (49.2 months) than those with pelvic wall involvement (13.2 months), but the difference did not reach statistical significance (P = 0.058). CONCLUSION: Rectal cancers with pelvic and visceral involvement have different rates of resectability and median survival. These differences should be reflected in the TNM classification system.

Adult↗
PubMed2001

Treatment of locally recurrent rectal cancer.

PURPOSE: This study was designed to analyze the outcome for patients with isolated local recurrence after radical treatment of rectal cancer and to identify predictors of curative resection. METHODS: The medical records of 87 patients who developed isolated local recurrence after curative radical surgery for primary rectal cancer were retrospectively reviewed. Survival rates from the time of recurrence were calculated using the Kaplan-Meier method. Tumor stage and histology, patient characteristics, and treatment variables were analyzed using logistic regression to identify predictors of curative surgery. RESULTS: Symptomatic treatment alone or chemotherapy and/or radiation therapy was provided to 23 patients (26 percent), and surgical exploration was performed in 64 patients. In 22 patients (25 percent), the tumor was considered unresectable at surgery (n = 13) or was resected for palliation with gross or microscopic positive margins (n = 9). In 42 patients (48 percent), curative-intent resection was performed. The only independent predictors of resectability were younger age at diagnosis, earlier stage of the primary tumor, and initial treatment by sphincter-saving procedure. There was no difference in survival between patients who had no surgery and those who had palliative surgery. The estimated five-year survival rate for patients who had curative-intent resection was better than for those who had no surgery or palliative surgery (35 vs. 7 percent; P = 0.01). Of the 42 patients who underwent curative-intent resection, 14 (33 percent) developed a second recurrence at a mean of 15 +/- 11 months after reoperation. Twenty-five percent of patients developed major complications. CONCLUSIONS: Salvage surgery for locally recurrent rectal cancer may be helpful in a selected group of patients. The stage and treatment of the primary tumor may help to identify patients with the best chance for curative-intent resection.

Chi-Square Distribution↗
PubMed2001

Complications of dynamic graciloplasty: incidence, management, and impact on outcome.

PURPOSE: Dynamic graciloplasty can improve continence in patients with severe refractory fecal incontinence, but associated morbidity is high. The purpose of this study was to identify complications associated with dynamic graciloplasty and to characterize their treatment and impact on patient outcome. METHODS: In 121 patients enrolled in a prospective trial of 20 centers and eligible for safety analysis, all complications of dynamic graciloplasty were recorded at the time of their occurrence and followed up until resolution. Severe treatment-related complications were defined as those requiring hospitalization or surgical intervention. RESULTS: In 93 patients, 211 complications occurred. Of these, 89 (42 percent) in 61 patients were classified as severe treatment-related complications and resulted from the following: major infection, 19; minor infection, 10; thromboembolic events, 3; device performance and use, 13; pain, 16; noninfectious gracilis problems, 8; noninfectious wound-healing problems, 3; other surgery-related complications, 3. In addition, severe treatment-related complications resulted from constipation in ten and stoma creation or closure in ten. The recovery rate (full or partial) was 87 percent overall, and for severe treatment-related complications, was 92 percent. Of the types of complications, only major infections had an adverse effect on outcome. CONCLUSION: Severe complications occur frequently after dynamic graciloplasty, but are usually treatable. They often require one or more reoperations and can lead to significant delays in completion of therapy. In most cases therapy can be salvaged.

Anal Canal↗
PubMed2001

Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty.

PURPOSE: Preoperative anorectal physiology studies have become part of the standard evaluation of fecal incontinence. This study was undertaken to see whether anorectal physiology results predicted surgical outcome after anterior sphincteroplasty. METHODS: Between 1985 and 1994, 191 females with a mean age of 37 (range, 20-74) years underwent anterior sphincteroplasty for anal sphincter disruption. A follow-up questionnaire was sent to all patients, and there were 158 respondents (83 percent). Mean follow-up was 43 (range, 6-120) months. Obstetric injuries accounted for incontinence in 91 percent of the 158 patients who responded to the questionnaire. Mean duration of incontinence was 4.2 years (range, 3 months-51 years) before surgery. Preoperatively, patients were incontinent to solid stool (53 percent), liquid stool (33 percent), gas (3 percent), and unspecified (11 percent). RESULTS: Subjectively, the results were as follows: 129 patients (82 percent) improved, 17 (11 percent) were initially improved but subsequently deteriorated, 7 (4 percent) were unchanged, and 5 (3 percent) were worse. Objectively, postoperative continence was classified as follows: excellent (normal) in 23 percent, good (incontinent to gas or minor stain) in 39 percent, fair (incontinent to stool an average of less than once per month) in 26 percent, and poor (incontinent to stool an average of greater than once per month) in 12 percent. Preoperative continence level (incontinent to solid vs. liquid stool) was predictive of postoperative continence classification. Preoperative anorectal manometry was not predictive of clinical outcome (n = 128). There was no significant difference in postoperative continence classification among patients with normal, unilaterally abnormal, and bilaterally abnormal pudendal latency (n = 89). CONCLUSIONS: Clinical rather than manometric assessment predicts continence after anterior sphincteroplasty.

Adult↗
PubMed2001

Rectal prolapse.

Explore the source record for details and available documents.

Defecography↗
PubMed2000

Is local excision adequate therapy for early rectal cancer?

PURPOSE: Radical surgery of rectal cancer is associated with significant morbidity, and some patients with low-lying lesions must accept a permanent colostomy. Several studies have suggested satisfactory tumor control after local excision of early rectal cancer. The purpose of this study was to compare recurrence and survival rates after treating early rectal cancers with local excision and radical surgery. METHODS: One hundred eight patients with T1 and T2 rectal adenocarcinomas treated by transanal excision were compared with 153 patients with T1N0 and T2N0 rectal adenocarcinomas treated with radical surgery. Neither group received adjuvant chemoradiation. Mean follow-up time was 4.4 years after local excision and 4.8 years after radical surgery. RESULTS: The estimated five-year local recurrence rate was 28 percent (18 percent for T1 tumors and 47 percent for T2 tumors) after local excision and 4 percent (none for T1 tumors and 6 percent for T2 tumors) after radical surgery. Overall recurrence was also higher after local excision (21 percent for T1 tumors and 47 percent for T2 tumors) than after radical surgery (9 percent for T1 tumors and 16 percent for T2 tumors). Twenty-four of 27 patients with recurrence after local excision underwent salvage surgery. The estimated five-year overall survival rate was 69 percent after local excision (72 percent for T1 tumors and 65 percent after T2 tumors) and 82 percent after radical surgery (80 percent for T1 tumors and 81 percent for T2 tumors). Differences in survival rate between local excision and radical surgery were statistically significant in patients with T2 tumors. CONCLUSIONS: Local excision of early rectal cancer carries a high risk of local recurrence. Salvage surgery is possible in most patients with local recurrence, but may be effective only in patients with T1 tumors. When compared with radical surgery, local excision may compromise overall survival in patients with T2 rectal cancers.

Adenocarcinoma↗
PubMed2000

Standards for anal sphincter replacement.

PURPOSE: Anal sphincter replacement offers a new treatment option for patients with severe refractory fecal incontinence or for those who require abdominoperineal resection for localized malignancy. The purpose of this study was to review the current status of anal sphincter replacement, formulate a consensus statement regarding its current use, and outline suggestions for future development. METHODS: Four areas of interests were selected: indications for sphincter replacement, continence scoring and quality of life, choice of therapy, and dissemination of new technology. A questionnaire regarding these issues was developed and circulated to working party members; its results served as the basis for this consensus document. RESULTS: Both electrically stimulated skeletal muscle neosphincter and artificial anal sphincter are options for patients with end-stage fecal incontinence. Electrically stimulated skeletal muscle neosphincter is also appropriate for reconstruction after surgical excision of the anorectum in selected cases. Avoidance of complications requires strict attention to sterile technique, prophylactic antibiotics, and deep venous thrombus prophylaxis. A standardized scoring system is proposed that evaluates both continence and evacuation. Quality of life is a critical endpoint for assessing sphincter replacement, and use of The American Society of Colon and Rectal Surgeons incontinence-specific quality-of-life instrument is recommended. As the efficacy of sphincter replacement becomes proven, dissemination of the technique should occur in a controlled manner to ensure adequate surgeon training, minimization of complications, and optimization of results. CONCLUSIONS: Sphincter replacement by electrically stimulated skeletal muscle neosphincter and artificial anal sphincter provide a continent option for patients with end-stage fecal incontinence and those requiring abdominoperineal resection. The guidelines offered in this document are intended to facilitate the controlled and safe development and acceptance of these new techniques.

Anal Canal↗
PubMed2000

Safety and efficacy of dynamic graciloplasty for fecal incontinence: report of a prospective, multicenter trial. Dynamic Graciloplasty Therapy Study Group.

PURPOSE: Dynamic graciloplasty has been used for intractable fecal incontinence, and good results have been reported. The aim of this study was to assess prospectively the safety and efficacy of dynamic graciloplasty for intractable fecal incontinence in a prospective, multicenter trial. METHODS: A total of 123 adults were treated with dynamic graciloplasty at 20 institutions. Continence was assessed preoperatively and postoperatively by use of 14-day diaries. RESULTS: There was one treatment-related death. One hundred eighty-nine adverse events occurred in 91 patients (74 percent). Forty-nine patients (40 percent) required one or more operations to treat complications. One hundred seventy (90 percent) events were resolved. Sixty-three percent of patients without pre-existing stomas recorded a 50 percent or greater decrease in incontinent events 12 months after dynamic graciloplasty, and an additional 11 percent experienced lesser degrees of improvement. Twenty-six percent were not improved, worsened, or exited. In patients with pre-existing stomas, 33 percent achieved successful outcomes at 12 months. This number increased to 60 percent at 18 months. Seventy-eight percent of patients had increased enema retention time, and mean anal canal pressures improved significantly at 12 months. Significant changes in quality of life were also observed. CONCLUSIONS: Objective improvement can be demonstrated in the majority of patients with end-stage fecal incontinence treated with dynamic graciloplasty. Reduction in incontinence episodes can be correlated with improved quality of life. Adverse events are frequently encountered, but most resolve with treatment.

Adolescent↗
PubMed2000

Local excision of rectal cancer without adjuvant therapy: a word of caution.

OBJECTIVE: To evaluate the results of local excision alone for the treatment of rectal cancer, applying strict selection criteria. BACKGROUND DATA: Several retrospective studies have demonstrated that tumor control in properly selected patients with rectal cancer treated locally is comparable to that observed after radical surgery. Although there is a consensus regarding the need for patient selection for local excision, the specific criteria vary among centers. METHODS: The authors reviewed 82 patients with T1 (n = 55) and T2 (n = 27) rectal cancer treated with transanal excision only during a 10-year period. At pathologic examination, all tumors were localized to the rectal wall, had negative excision margins, were well or moderately differentiated, and had no blood or lymphatic vessel invasion, nor a mucinous component. End points were local and distant tumor recurrence and patient survival. RESULTS: Ten of the 55 patients with T1 tumors (18%) and 10 of the 27 patients with T2 tumors (37%) had recurrence at 54 months of follow-up. Average time to recurrence was 18 months in both groups. Seventeen of the 20 patients with local recurrence underwent salvage surgery. The survival rate was 98% for patients with T1 tumors and 89% for patients with T2 tumors. Preoperative staging by endorectal ultrasound did not influence local recurrence or tumor-specific survival. CONCLUSION: Local excision of early rectal cancer, even in the ideal candidate, is followed by a much higher recurrence rate than previously reported. Although most patients in whom local recurrence develops can be salvaged by radical resection, the long-term outcome remains unknown.

Aged↗
PubMed2000

Evidence for colorectal cancer micrometastases using reverse transcriptase-polymerase chain reaction analysis of MUC2 in lymph nodes.

Poor survival in patients following resection for early stage colorectal cancer is thought to be due in part to the presence of occult micrometastases at the time of surgery. The MUC2 mucin gene is highly expressed in the colon and associated colorectal tumors and may be a candidate marker for colorectal cancer micrometastases. We have used RT-PCR to detect expression of MUC2 mRNA transcripts in order to identify possible lymph node micrometastases in node negative (Stage I and II, or Dukes A and B) colorectal cancer patients. A total of 396 nodes (histologic stage N0) from 34 colon and nine rectal cancers were studied by RT-PCR analysis with nested primers for MUC2 (an average of 7.6 nodes per case). In the primary tumors, 42/43 (98.1%) were positive for MUC2 by RT-PCR. Evidence of the presence of MUC2 was demonstrated in nodes from 0 of 10 (0%) patients with Tis or T1, one of six (16.7%) from T2, 10 of 25 (40.0%) from T3, and one of two (50%) from T4 tumors. MUC2 RT-PCR was negative in six nodes from three patients with non-malignant colon disease and positive in histologically positive lymph nodes from six of six (100%) stage III colon cancers. In this study, using RT-PCR to detect the presence of MUC2 transcripts, we have found preliminary evidence for possible micrometastatic disease in approximately a third of histologically negative N0 colorectal cancer patients. The increased presence of MUC2 expression also correlated with more advanced T stage. We conclude that MUC2 RT-PCR may be a sensitive and specific marker for occult micrometastases. This technique has the potential to identify a group of colorectal cancer patients at risk for early cancer recurrence.

Biomarkers, Tumor↗
PubMed1999

Malignant tumors of the anal canal: the spectrum of disease, treatment, and outcomes.

BACKGROUND: Cancers of the anal canal are a rare and diverse group of tumors of the gastrointestinal tract currently managed most often with surgery, chemoradiotherapy, or both. Previous investigations of cancer of the anal canal have reported on small numbers of patients, included only squamous histology, or included a select group of patients. The current study reviewed a large consecutive series of patients with cancer of the anal canal, including all histologies, who received chemoradiotherapy as the primary treatment modality. METHODS: The spectrum of pathology, treatment, and outcomes for 192 patients with malignant tumors of the anal canal over a 10-year period, from 1984 to 1994, was analyzed. Patient charts were reviewed for diagnosis, staging, treatment, survival, and recurrence rates. RESULTS: The pathologies of 192 patients (mean age, 58 years; 119 females and 73 males) included 143 (74%) with squamous cell carcinoma, 36 (19%) with adenocarcinoma, and 7 (4%) with melanoma. The remaining 6 patients (3%) were diagnosed with neuroendocrine tumors (2), carcinoid tumor (1), Kaposi sarcoma (1), leiomyosarcoma (1), or lymphoma (1). T classification distributions were T1 (3%), T2 (46%), T3 (28%), and T4 (12%). The overall crude 5-year survival and recurrence rates were 53% and 34%, respectively. Five-year survival rates were 57% for squamous cell carcinoma, 63% for adenocarcinoma, and 33% for melanoma. Five-year survival rates by T classification were T1 (62%), T2 (57%), T3 (45%), and T4 (17%). Twenty-one (15%) of the patients with squamous cell carcinoma underwent surgical therapy only, with a 5-year survival rate of 60% and a recurrence rate of 23% at 5 years. The remaining 122 patients (85%) with squamous cell carcinoma received chemoradiotherapy only, with a 5-year survival rate of 55% and a recurrence rate of 34% at 5 years. Salvage abdominal perineal resection for recurrent or persistent squamous cell carcinoma after chemoradiotherapy was performed on 13 patients, with 8 (62%) of them alive at a mean follow-up of 32 months. Twenty-two patients (61%) with adenocarcinoma of the anal canal were treated with surgery, and 14 patients (39%) underwent surgery with adjuvant chemoradiation therapy. The 5-year survival and recurrence rates were 63% and 21%, respectively. CONCLUSIONS: Chemoradiotherapy for patients with squamous cell carcinoma offers survival rates equivalent to surgical therapy and preserved sphincter function. Adenocarcinoma managed with surgery, with adjuvant therapy for selected patients, gives good results. Melanoma continues to be associated with a poor prognosis.

Adenocarcinoma↗
PubMed1999

Complete rectal prolapse: evolution of management and results.

UNLABELLED: Optional treatment for complete rectal prolapse remains controversial. PURPOSE: We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. METHODS: We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64: range, 12-231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). RESULTS: Median age of patients was 64 (11-100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineal rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61 vs. 30 percent, P = 0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomy vs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8 vs. 5 days, P = 0.001). Perineal procedures, however, had a higher recurrence rate (16 vs. 5 percent, P = 0.002). Functional improvement was not significantly different, and most patients were satisfied with treatment and outcome. CONCLUSIONS: We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate.Patient satisfaction]

Colon, Sigmoid↗
PubMed1999

Effect of delivery on anal sphincter morphology and function.

PURPOSE: Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States. METHODS: Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients. RESULTS: Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P < 0.05), and manometric results were reduced. Three of these seven patients had a third-degree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section. CONCLUSIONS: The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.

Adult↗
PubMed1999

Colorectal cancer in inflammatory bowel disease: a continuing problem.

PURPOSE: Because of the increased risk of colorectal cancer in patients with inflammatory bowel disease, surveillance colonoscopy with mucosal biopsies for dysplasia has been advocated to prevent malignancy or permit its early diagnosis. However, despite adoption of colonoscopic surveillance programs by many clinicians, we have noted a pattern of continued referrals for inflammatory bowel disease-associated malignancy. This study was undertaken in an effort to characterize this cohort of patients. METHODS: We reviewed the operative records of a large metropolitan colorectal practice from 1983 to 1995. During this period 40 large-bowel resections were performed for patients with documented inflammatory bowel disease and concomitant carcinoma. A retrospective analysis was conducted with emphasis on clinical presentation, pathologic description, and most recent follow-up. RESULTS: Mean age at the time of diagnosis of cancer was 48 years with an average inflammatory bowel disease duration of 19 years. Seven patients had documented inflammatory bowel disease for less than eight years before their cancer diagnosis. Carcinomas were identified preoperatively by colonoscopy in 92 percent of patients. One-half of these patients had the colonoscopy to investigate a recent change in inflammatory bowel disease symptoms or signs, whereas the other half underwent endoscopy as routine surveillance. For the remaining 8 percent of patients, operated on for worsening symptoms, the carcinoma was detected in the pathological specimen only. The majority of patients (68 percent) did not have a preoperative diagnosis of dysplasia. Twenty-five percent of tumors were mucinous, 20 percent were multicentric, and 70 percent were located distal to the splenic flexure. Among the seven patients who died, four had pancolitis, six had a recent worsening of symptoms, and all had cancer involving the rectum. CONCLUSION: Cancer occurs at a younger age in patients with long-standing inflammatory bowel disease. The tumors are often mucinous, multiple, and located in the left colon. Despite increasing acceptance of surveillance colonoscopy as a recommended strategy in cancer prevention, almost one-half of the patients in this study had their cancer diagnosed because increased colitis symptoms led to colonoscopic examination. Eighteen percent of patients developed cancer with less than an eight-year history of inflammatory bowel disease. These data call into question the effectiveness of dysplasia surveillance as a population-based strategy to decrease the colorectal cancer mortality in inflammatory bowel disease patients.

Adult↗
PubMed1999

Techniques and complications of ileostomy takedown.

OBJECTIVE: We use a loop ileostomy for temporary fecal diversion because of ease of technical construction and assumed low complication rate. Here, we review our complications of loop ileostomy and takedown using three techniques of closure. METHODS: We reviewed charts of all patients who had temporary ileostomies constructed during 1987 to 1995 (n = 366). Ileostomy takedown was performed in 339 patients using one of three closure techniques: enterotomy suture (65%), resection with handsewn anastomosis (20%), and stapled anastomosis (15%). Complications were recorded for pre-takedown and 30-day post-takedown intervals. RESULTS: Overall complication rate was 28%. Pre-takedown complications occurred in 21 patients (5.7%), including small bowel obstruction (2.5%) and dehydration/electrolyte derangement (2.2%). Post-takedown complications occurred in 83 patients (24.5%), including wound infection (14.2%), small bowel obstruction (5%), anastomotic leak (2.9%), and 1 death from a cardiac event. Post-takedown obstruction was higher for closure using resection with sutured anastomosis (12%) compared with enterotomy suture (2.3%), P < or = 0.003. Stapled anastomosis had an intermediate rate of obstruction (7.7%). Anastomotic leak was similar between closure techniques. CONCLUSIONS: Loop ileostomy and takedown are associated with low rates of serious complications (5% or less). As such, we continue to advocate use of loop ileostomy as a diversion procedure. Closure by enterotomy suture is preferred over resection. However, if resection is required, closure by stapled anastomosis is preferred over suture anastomosis.

Adolescent↗
PubMed1999

Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial.

BACKGROUND & AIMS: Dynamic muscle plasty has been advocated as therapy for refractory fecal incontinence and for anorectal reconstruction to avoid colostomy after abdominoperineal resection. This study evaluates the results of a multicenter experience with dynamic muscle plasty in the treatment of fecal incontinence and total anal reconstruction. METHODS: One hundred thirty-nine patients were enrolled at 12 centers between June 1992 and November 1994 and followed up through June 1996. Intramuscular leads and neurostimulators were implanted to stimulate transposed gracilis or gluteus muscle. Success was defined as 70% reduction in solid stool incontinence for patients with baseline incontinence and zero incontinence to solid stool for patients with baseline stomas and for patients undergoing total anal reconstruction. RESULTS: Overall, 85 of 128 graciloplasty patients (66%) achieved and maintained a successful outcome over the follow-up period. By etiology, these proportions were 71%, 50%, and 66% for patients with acquired fecal incontinence, congenital incontinence, and total anal reconstruction, respectively. One third of graciloplasty patients experienced a major wound complication, with therapy failing in 41%. Experienced centers had better outcomes and lower complication rates than inexperienced centers. Of the 11 gluteoplasty patients, 5 (45%) achieved and maintained a successful outcome. CONCLUSIONS: Dynamic graciloplasty may be an effective procedure for patients with refractory, end-stage fecal incontinence as well as for patients who require anorectal excision for low-lying malignancy. However, the procedure has significant morbidity that can lead to functional failure. Outcome after dynamic graciloplasty appears to correlate with surgical experience. In contrast to graciloplasty, the use of dynamic gluteoplasty should be limited to investigational purposes.

Adolescent↗