Shafik A.
New concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. II. Anatomy of the levator ani muscle with special reference to puborectalis.
Invest Urol 1975; 513(3):175-82.
A study of the surgical anatomy of the levator ani muscles, with special stress on the puborectalis, was performed on 22 cadaveric specimens. The study comprised dissection and microscopic examination. The levator ani was found to consist of two portions only: pubococcygeus and iliococcygeus, the puborectalis being a part of the external anal sphincter. Both levatores decussate at the anococcygeal raphe, which represents a "decussation line" and not a site of insertion for the muscle fibers. A "digastric" pattern of the levator is demonstrated, which is    responsible for the harmonic nature of the function of the muscle bundles on each side of the pelvis. The levator hiatus was found to be formed of the medial borders of the pubococcygeus, , and not the puborectalis. A "hiatal ligament" was identified, stretched between the edges of the levator hiatus and the intrahiatal viscera. The role of the pubococcygeus in anal fixation is discussed, and a new concept that the puborectalis does n ot belong to the levator ani but constitutes na integral portion of the external and sphincter. The puborectalis and the deep external anal sphincter were found to be fused together and identical from the morphologic, histologic, and functional points of view as well as with respect to innervation. Both form a single U-shaped loop which is given the name "top loop."
 

Shafik A.
A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. The external anal sphincter: a triple-loop system.
Urol 1975;12(5):412-9.
Since anal sphincters are used as the continent sphincters in some urologic operations, a study of their anatomic structure and function seems necessary. The anatomy of the external anal sphincter has been studied in 18 cadavers by dissection and serial histologic sections. The muscle has been found to consist of a series of U-shaped loops which are distinguishible as three main "loops": top, intermediate, and base. The puborectalis and the deep portion of the external sphincter have been found to be one muscle which is given the name "top loop." No concentric circular muscle bundles could be detected at any level of the external sphincter except in the base loop. A new concept of the mechanism of action of the external sphincter in anal continence and during defecation is   presented. An air-tight occlusion of the anal canal could be achieved by the "triple-loop system" of the external sphincter which compresses opposed alternating anal segments. An incomplete anal occlusion by a single loop contraction is completed and potentiated by the succeeding loop action. The last fecal portion is dispelled from the anal canal by a process of "vermicular contractions" which is the result of the loop arrangement of the muscle bundles. Single-loop continence has been discussed. It is suggested that unless all three of the loops are destroyed, any single loop can act as a sphincter which maintains continence to solid stools but not to fluid ones or flatus.

Shafik A.
A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. III. The longitudinal anal muscle: anatomy and role in anal sphincter mechanism.
Invest Urol 1976;13(4):271-7.
A study of the longitudinal anal muscle was performed in 16 cadaveric specimens. The study comprised dissection and microscopic examination. The bundles of the longitudinal were found arranged in three layers: medial, intermediate, and lateral; each has a different origin and is separated from the other by a fascial septum. Four fascial septa related to the longitudinal muscle could be identified. They split and decussate below the lower end of the longitudinal muscle to form the "central tendon." The central tendon lies between the base loop of the external anal sphincter and the longitudinal muscle. It gives rise to multiple small fibrous septa in different directions; those
which penetrate the base loop split and decussate to form the corrugator ani cutis. A mechanism of action of the corrugator is presented. The role of the longitudinal muscle in the anal sphincter mechanism and during defecation is discussed. The muscle plays its major role during defecation. The part played by the muscle in anal fixation is considered. It helps to fix the anal canal to the side wall of the pelvis during defecation, thus preventing anal prolapse.
 

Hakelius L, Gierup J, Grotte G, Jorulf H.
A new treatment of anal incontinence in children: free autogenous muscle transplantation.
J Pediatr Surg 1978;13(1):77-82.
A new method is presented for the treatment of anal incontinence in children, including free autogenous muscle transplantation. The primary step is denervation of a skeletal muscle, which 2 wk later is transplanted and placed as a U-sling around the rectum, imitating the position and function of the puborectalis muscle. The transplant is placed in close contact with innervated muscles, which act as reinnervation sources. The results in five consecutive patients are highly promising. An early sign of improvement is the occurrence of a sensation of rectal fullness. All the patients reached an acceptable degree of continence, including abandonment of the use of napkins, 4-12 mo after surgery.
 

Beersiek F, Parks AG, Swash M.
Pathogenesis of ano-rectal incontinence. A histometric study of the anal sphincter musculature.
J Neurol Sci 1979;42(1):111-27.
Type 1 fibre predominance was found in the external anal sphincter, puborectalis and levator ani muscles of 17 control subjects, and of 16 patients with ano-rectal incontinence. In the external anal sphincter and puborectalis muscles of the control subjects the mean diameter of Type 2 fibres was slightly greater than that of Type 1 fibres, but in the levator ani muscles of control female subjects the mean diameter of Type 1 fibres was much greater than that of Type 2 fibres. In the patients with anorectal incontinence there was marked hypertrophy of fibres of both histochemical types. This was most marked in the puborectalis and external anal sphincter muscles. In 12 of the 16     incontinent patients there were histological and statistical features consistent with a neurogenic disorder. These histometric studies provide a quantitative basis for physiological and pathological studies of these muscles in incontinence and other anorectal disorders.

Shafik A.
A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. IX. Single loop continence: a new theory of the mechanism of anal continence.
Dis Colon Rectum 1980;23(1):37-43.
The role of the external and internal anal sphincters in the mechanism of anal continence is presented. The external sphincter induces continence by 1) preventing internal sphincter relaxation, what I have called the "voluntary inhibition action," and 2) mechanical compression of the rectal neck and anal canal proper. The mechanism of both actions is described. The internal sphincter plays a significant role not only in involuntary, but also in voluntary, continence. The importance of this role in the correction of anal incontinence is clarified. "Stress defecation," a condition which follows internal sphincter damage, is discussed. A "single loop continence" theory is presented, based on the fact that each of the three loops of the external sphincter has its own innervation, attachment, and direction of muscle bundles; each loop thus acts as a separate sphincter. The clinical application of this theory is presented.
 

Leigh RJ, Turnberg LA.
Faecal incontinence: the unvoiced symptom.
Lancet 1982;1(8285):1349-51.
76 patients with diarrhoea due to a variety of causes and seen consecutively in the gastrointestinal clinic were questioned about the frequency of faecal incontinence. 51% (39) of these patients had incontinence but of these fewer than half (19) volunteered the information spontaneously. Only 4 patients provided clear evidence of a possible predisposing cause. Anal-sphincter pressures, particularly the maximum squeeze pressures, were significantly lower than normal in the incontinent patients, and their ability to retain saline infused into the rectum was significantly impaired. All but 7 of 42 continent subjects could retain more than 500 ml before leaking, whereas      19 of 22 frequently incontinent subjects leaked after infusion of less than 500 ml. These results suggest that incontinence is a common but frequently unvoiced symptom in patients with diarrhoea. It should be actively sought since it may be the prime reason for the patient to seek help with a complaint of "diarrhoea". The saline-infusion test is a simple method of measuring this disturbance of anorectal function.
 

Keighley MR, Fielding JW.
Management of faecal incontinence and results of surgical treatment.
Br J Surg 1983;70(8):463-8.
Ninety-five patients have been referred for the assessment and treatment of faecal incontinence. Incontinence was associated with previous anal trauma in 49 cases: 13 occurred after vaginal delivery, 32 were associated with anal operations and in 4 severe perineal trauma occurred after road accidents. Other causes were: idiopathic incontinence in 18, persistent incontinence despite successful rectopexy for prolapse in 10, diabetic neuropathy in 5 and in 13 the cause was not identified. Conservative treatment by control of diarrhoea, physiotherapy or electrical therapy was often successful in patients with minor incontinence. Fifty-six patients have been treated surgically.     Complete continence was achieved in 67 per cent of patients treated by postanal repair and in 61 per cent by sphincter reconstruction. We believe that postanal repair is the treatment of choice for idiopathic incontinence and incontinence after rectopexy or anal dilatation. Sphincter repair should only be performed with a covering colostomy and is the treatment of choice for recent or long standing division of the external sphincter ring.
 

Husemann B, Hager T.
Experience with the Erlangen magnetic ring colostomy-closure system.
Int Surg 1984;69(4):297-300.
The Erlangen magnetic ring for colostomy closure was used in 240 patients. Forty-five rings were explanted because of infection, pressure necrosis, parastomal hernia, invagination, prolapse and stenosis. Although continence was obtained in 68% of patients, only 43% of surviving patients are still using the system. Reasons given for not using the cap were pain and weight. Increased use of deep anterior resections and the introduction of irrigation and improved stoma bags have limited the indications for the use of the magnetic ring.
 

Shafik A.
A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Reversion to normal defecation after combined excision operation and end colostomy for rectal cancer.
Am J Surg 1986;151(2):278-84.
Twenty-one patients with combined excision operation for rectal cancer were subjected to electromyographic study of the levator ani muscle, the puborectalis muscle, and the external anal sphincter. Myoelectric activity of the puborectalis and levator ani muscles was detected in 12 patients, 6 of whom had normal activity of both muscles. Of the remaining six patients, there was reduced activity of the levator ani muscle in four and of the puborectalis muscle in all six. These patients underwent training and electric stimulation of these muscles. To verify the myoelectric findings, 15 specimens removed at combined excision operation were examined grossly and   microscopically for the muscles removed at operation. Eight specimens were found to be free of the levator and puborectalis muscles, which indicated that these muscles were not excised. The 12 patients with myoelectrically active levator and puborectalis muscles were operated on to restore defecation by way of the normal perineal route. The technique comprises freeing of the colostomy and mobilization of the entire left side of the colon. The perineal scar is then excised and the colonic end fixed to the perineal skin and thus is controlled by the levator and puborectalis muscles. Full fecal control was achieved in seven patients and incomplete control in five. It is  concluded that excision of the levator ani muscle, the puborectalis muscle, and the external anal sphincter should not be considered a standard part of the radical operation for cancer of the lower or middle third of the rectum, and that a combined excision operation has no place in the treatment of rectal cancer.
 

Christiansen J, Lorentzen M.
Implantation of artificial sphincter for anal incontinence.
Lancet 1987;2(8553):244-5.
The implantation of an artificial anal sphincter in a man with severe anal incontinence an myasthenia gravis is described. The prosthesis used, an "AMS 800' artificial urinary sphincter, gave the patient complete control of defecation. The technique offers the possibility of curing anal incontinence of neuromuscular origin, for which there has been no treatment until know.
 
 

Christiansen J.
Place of abdominoperineal excision in rectal cancer.
J R Soc Med 1988;81(3):143-5.
In an attempt to elucidate if and when there is a place for abdominoperineal excision in rectal cancer, we have evaluated survival, risk of local recurrence and functional results of alternative procedures. There seems to be no difference in survival rate after intended curative surgery for rectal cancer between rectal excision and sphincter-saving resection. This is also true with respect to risk of local recurrence, except in patients with poorly differentiated Dukes’ C tumours, where the risk of significant distal intramural spread is increased. Functional results are satisfactory after low anterior resection with colorectal anastomosis, whereas colo-anal anastomosis is followed by less satisfactory results especially in elderly patients. In these patients rectal excision with a permanent colostomy is probably preferable.
 
 

Fedorov VD, Shelygin YA.
Treatment of patients with rectal cancer.
Dis Colon Rectum 1989;32(2):138-45.
During a 20-year period (1965 to 1985), 4673 patients with rectal cancer underwent surgical treatment, with 3500 of them being subjected to radical surgery. Postoperative mortality was 6.1 percent. During the last five years, the mortality rate decreased dramatically down to 4.9 percent, despite an increase in the group of elderly patients (35.7 percent) and performance of a considerable percentage of simultaneous, extensive, and combined operations (33.7 percent). The trend of employing sphincter-saving operations (in more than 60 percent of patients, the anterior resection and abdominoanal resection with a pull-through were performed) accounts for the favorable five-year survival rate (62 to 69 percent) and results in a good functional outcome in 80 percent of patients. The use of a combination of conservative and operative methods of rehabilitation contributes to the professional readaptation of 75 to 80 percent of patients after surgery with construction of a stoma. In 223 cases, a Soviet magnetic occlusive device was implanted, while in 67 patients an artificial sphincter mechanism was constructed from the flap of the adductor longus femoris muscle. It should be emphasized that surgical methods of rehabilitation are used both in primary and reconstructive operations. The experience with management of 124 patients with recurrent cancer after resection and extirpation of the rectum shows that local excision or repeated resections of the rectum cure 20 to 29 percent of those operated on.
 

Yoshioka K, Keighley MR.
Critical assessment of the quality of continence after postanal repair for faecal incontinence
Br J Surg 1989;76(10):1054-7.
One hundred and twenty-four patients had a postanal repair for the treatment of faecal incontinence between January 1976 and July 1987. One hundred and sixteen of these patients have been followed up for more than 1 year with a median follow-up of 5 years. Incontinence was improved in 81 per cent of patients. Furthermore, bowel frequency fell: 58 per cent had more than four bowel movements before operation compared with 19 per cent after operation. However, 60 per cent of patients still claimed urgency, 76 per cent still leaked faeces and 52 per cent continued to wear pads after the operation. Maximum resting anal pressure and maximum squeeze pressure did not change significantly after operation either in patients whose bowel control was improved or in those who were not. The results indicate that the quality of continence after postanal repair is poor.

Ma S, Leu SY, Fang RH.
Reconstruction of anorectal angle after abdominoperineal resection of rectum and anus--an animal model.
Ann Plast Surg 1989;23(6):519-22.
Voluntary control of the bowel movements is a social necessity. Lack of control relegates one to psychological debility and the possible need for a permanent colostomy. Anorectal angle plays an important role in fecal continence. In the normal individual, this angle lies in the range of 60 to 105 degrees. Perineal colostomy, once proposed for patients who had received abdominoperineal resection (APR), has been abandoned because of frank incontinence. This study used a canine     model. The anorectal angle, external sphincter, internal sphincter, and the puborectalis were all destroyed after APR. The colon was pulled through the perineal defect. Enteropexy, gracilis muscle transfer, and perineal colostomy were performed to restore the anorectal angle. Barium enema was performed preoperatively and postoperatively. The anorectal angle was reconstructed within normal ranges after abdominoperineal resection of the rectum and anus.
 

Frigell A, Ottander M, Stenbeck H, Pahlman L.
Quality of life of patients treated with abdominoperineal resection or anterior resection for rectal carcinoma.
Ann Chir Gynaecol 1990;79(1):26-30.
The functional results of surgery for rectal carcinoma were evaluated in 68 patients, 37 treated with anterior resection and 31 with abdominoperineal resection. The patients answered a questionnaire 8-84 months after surgery regarding bowel habits, urgency, incontinence and quality of life. Those who had undergone anterior resection had significantly more frequent bowel movements per day than those treated with abdominoperineal resection, and problems with urgency and flatus. Significantly more patients treated with anterior resection used medication to achieve normal bowel function. Despite the problems of frequent bowel movement, urgency, flatulence and the need for frequent medication, the patients who had undergone sphincter-saving procedures seemed to have a better quality of life than those treated with abdominoperineal resection.
 

Enck P, Eggers E, Koletzko S, Erckenbrecht JF.
Spontaneous variation of anal "resting" pressure in healthy humans.
Am J Physiol 1991;261:G283.
To investigate anal sphincter performance during sleep and after a meal, a two-channel micro-transducer probe was used for 12-h stationary recording of basal anal pressure overnight in eight healthy male volunteers. It was shown that the basal anal pressure ("resting" pressure) exhibits three distinct patterns of cyclic activity changes in all subjects: a long-term rhythm with a prominent decrease of pressure during which sleep was approximately circadian, an ultradian rhythm of approximately 20 to 40 min in length that was more prominent at night, and spontaneous relaxations of the sphincter tone occurring between 3 and 20 times per hour with the maximum frequency after breakfast. These data indicate that the anal sphincter is a dynamic structure not often at rest. Long-term anorectal manometry may be supplementary to short-term clinical evaluation of anal sphincter performance in healthy subjects as well as in patients with defecation disorders.
 

Pearl RK, Prasad ML, Nelson RL, Orsay CP, Abcarian H.
Bilateral gluteus maximus transposition for anal incontinence.
Dis Colon Rectum 1991;34(6):478-81.
Seven patients (five men and two women) ranging in age from 26 to 65 years (means = 44) underwent bilateral gluteus maximus transposition for complete anal incontinence. The indications for operation were sphincter destruction secondary to multiple fistulotomies (n = 4), bilateral pudendal nerve damage (n = 2), and high imperforate anus (n = 1). The procedure is performed without the use of a diverting colostomy. The inferior portion of the origin of each gluteus maximus is detached from the sacrum and coccyx, bifurcated, and tunneled subcutaneously to encircle the anus. The ends are then sutured together to form two opposing slings of voluntary muscle. Postoperatively, six patients regained continence to solid stool, two to liquid stool as well, and only one patient in this group was able to control flatus. Although resting pressures remained unchanged, voluntary squeeze pressures were restored by this operation. In addition, rectal sensation was markedly improved, which helps make this a worthwhile procedure for properly selected patients.
 

Rintala R, Mildh L, Lindahl H.
Fecal continence and quality of life in adult patients with an operated low anorectal malformation.
J Pediatr Surg 1992;27(7):902-5.
Fecal continence and quality of life were evaluated by a questionnaire in 83 adult patients (mean age, 35 years; 53 women, 30 men) who underwent surgery for a low anorectal anomaly between 1947 and 1963. Fecal continence was assessed by a score described by Holschneider. Seventy-eight healthy people with similar age and sex distributions were used as controls. All controls had good fecal continence, 76% with completely normal bowel function. The aberrations in anal function found in 24% of the controls were minor, such as constipation or occasional slight smearing. Only 60% of the patients who had a low anorectal anomaly had good continence and completely normal bowel function was observed in 15%. Male patients had a slightly better outcome than females. Social problems related to deficient fecal control were reported by 39% of the patients. In addition, 13% of the patients had difficulties in sexual functions. Other health problems were reported by 52% of the patients. Social or sexual problems associated with anal function were not reported by the control population; 6% of them had other health problems. The present controlled study shows that at the adult age, a significant proportion of patients with low anorectal anomalies suffer from deficient fecal control and a diminished qualit y of life.
 

Christiansen J, Sparso B.
Treatment of anal incontinence by an implantable prosthetic anal sphincter [see comments]
Ann Surg 1992;215(4):383-6.
Twelve patients with anal incontinence due to neurologic disease or failure of previous incontinence surgery underwent implantation of an artificial anal sphincter. The system used was a modification of the AMS 800 artificial urinary sphincter. In two patients, infection necessitated removal of the system, and in four patients, eight revisional procedures had to be performed because of mechanical failure. After various modifications of the system, especially reinforcement of the closing mechanism of the cuff, only one case of mechanical failure has occurred. Erosion through the anal canal did not occur. Among 10 patients with the system in function for more than 6 months, the result was considered excellent in 5, with only occasional leakage of flatus, good in 3, who occasionally leaked liquid feces and flatus, and acceptable in 2, in whom the cuff obstructed defecation. It is concluded that implantation of an artificial anal sphincter is a valid alternative to permanant colostomy in patients with anal incontinence due to neurologic disorders and in patients in whom other types of incontinence surgery have failed.
 

Devesa JM, Vicente E, Enriquez JM, Nuno J, Bucheli P, de Blas G, Villanueva MG.
Total fecal incontinence--a new method of gluteus maximus transposition: preliminary results and report of previous experience with similar procedures.
Dis Colon Rectum 1992;35(4):339-49.
Since 1986, different procedures of gluteus maximus transposition have been performed, by one of the authors, in 10 patients with total anal incontinence not amenable to sphincter repair, due to congenital anomalies (four), sphincteric denervation (three) or after severe trauma (three). Variable degrees of long-lasting fecal control were obtained in all but one patient, with great improvement in six. Difficulties for achieving a closed anus without muscular tension of the neosphincter, together with the morbidity associated with anal wound infection, determined the reasons for the successive use of different techniques (Bistrom, Hentz, Schoamaker) until the authors, in 1990, designed a new procedure (Devesa). Although the reported experience with this technique described here is limited to only four patients, our impression is that the method is easier, has less morbidity, and achieves better short-term functional results, derived from a thick, tension-free neosphincter.
 

George BD, Williams NS, Patel J, Swash M, Watkins ES.
Physiological and histochemical adaptation of the electrically stimulated gracilis muscle to neoanal sphincter function.
Br J Surg 1993;80(10):1342-6.
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.
 

Simmang C, Birnbaum EH, Kodner IJ, Fry RD, Fleshman JW.
Anal sphincter reconstruction in the elderly: does advancing age affect outcome?
Dis Colon Rectum 1994;37(11):1065-9.
PURPOSE: This study was designed to determine whether advancing age affects outcome after anal sphincter reconstruction. METHOD: Anal sphincter reconstruction, performed on patients 55 years of age and older, was reviewed to determine if functional outcome was adversely affected by advancing age. A subgroup of patients was studied with anal manometry before and after repair and with pudendal nerve terminal motor latency (PNTML) before surgery. Results were compared with a younger group of patients. RESULTS: Between July 1986 and July 1991, 14 patients, ages ranging from 55 to 81, underwent anal sphincter reconstruction using an overlapping muscle repair. Ten patients were incontinent of solid stool and four of liquid stool. Improvement was seen in 13 of 14 patients: 7 (50 percent) complete control, 3 (21 percent) incontinent to flatus, and 4 (29 percent) incontinent to liquid stools (including the patient who failed to improve). Ten patients were studied with a continuous pull-out manometric technique and PNTML: one was not improved. There was minimum change in mean maximum resting pressure (35.0-37.9 mmHg). Mean maximum squeezing pressure increased from 66 to 75 mmHg overall. Patients with complete control had a mean maximum squeezing pressure of 81 mmHg compared with 60 mmHg in patients with residual incontinence. Mean anterior anal sphincter length increased from 2.92 cm to 3.31 cm. PNTML was normal (2.0 +/- 0.2) on one or both sides in all nine patients who improved (average, 2.1). The patient who failed to improve had abnormal nerve function bilaterally (2.4, 2.7). CONCLUSION: Anal sphincter reconstruction can be performed in elderly patients with improvements in the majority of patients. Total control can be achieved by restoring maximum squeezing pressure in a patient with normal pudendal nerve function.
 
 
 

Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP.
Permanent electrostimulation of sacral spinal nerves with an implantable neurostimulator in treatment of fecal incontinence.
Chirurg 1995;66(8):813-7.
Functional deficits of the striated muscular anal sphincter frequently result in faecal incontinence. The therapeutic options for patients without a defined muscular defect are limited. Our patient without defined lesion, but with a clinically relevant reduction of the voluntary force of the anal sphincter resulting in daily loss of stool, underwent an electrostimulation procedure of the sacral spinal nerves. The procedure was divided in three steps: acute percutaneous testing, temporary percutaneous nerve evaluation and permanent electrostimulation phase with an implantable neurostimulation device. In all three phases electrostimulation of the third sacral spinal nerve resulted in a positive clinical effect and an increase of the anal canal closure pressure. By application of permanent electrostimulation of the third sacral spinal nerve the patient became completely continent.

Fengler SA, Nelson RL, Pearl RK, Abcarian H, Orsay CP.
Pull-through procedures performed months to years after permanent proctectomy.
Dis Colon Rectum 1995;38(3):294-6.
PURPOSE: Patients who have undergone proctectomy without concomitant rectal reconstruction or coloanal anastomosis were not normally considered candidates for re-establishment of anal continuity until a case report published in 1985. With the addition of nine patients, reported herein is a series of ten patients who have undergone delayed pull-through procedures months to years after permanent proctectomy. PATIENTS: Ten patients (including the single case reported in 1985) have undergone delayed pull-through procedures up to 24 years after permanent proctectomy and ostomy formation. Delayed ileal pouch-anal anastomoses were performed in nine patients, and delayed coloanal anastomosis was performed in one patient. There were four males and six females, each of whom had evidence of external sphincter contraction on physical examination. Average age was 33 (range, 24-51) years at the time of reconstruction. Average duration of follow-up is 32 (range, 1-96) months. RESULTS: One patient is awaiting ileostomy closure. Five of nine patients use constipating agents. Two patients are constipated and use enemas to aid in evacuation. None are wearing protective undergarments. One patient had his ileostomy reconstructed eight years after delayed pull-through for uncontrollable diarrhea associated with chemotherapy for multiple myeloma and recently died. Postoperative complications included wound infection (3), enterocutaneous anastomotic stricture requiring anoplasty (2), small bowel obstruction (1), pneumonia (1), presacral abscess (1), and pouchitis (1). CONCLUSIONS: Delayed pull-through procedures performed months to years after permanent proctectomy can be performed in selected patients, with results comparable to rectal reconstruction done at the time of proctectomy.
 

Matzel KE, Stadelmaier U, Hohenfellner M, Gall FP.
Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence [see comments]
Lancet 1995;346(8983):1124-7.
Functional deficits of the striated anal sphincteric muscles without any apparent gross defect often result in a lack of ability to postpone defaecation by intention or in faecal incontinence in response to increased intra-abdominal or intra-rectal pressure. We applied electrostimulation to the sacral spinal nerves to increase function of the striated muscles of the anal sphincter. Of three patients followed for 6 months, two gained full continence and one improved from gross incontinence to minor soiling. Closure pressure of the anal canal increased in all. Preliminary data indicate that anal closure pressure increases with the duration of stimulation. Continuous stimulation of sacral spinal nerves can help some patients with faecal incontinence. It may be possible to promote continence with intermittent stimulation.

Christiansen J, Hansen CR, Rasmussen O.
Bilateral gluteus maximus transposition for anal incontinence.
Br J Surg 1995;82(7):903-5.
Seven patients (five women and two men) with anal incontinence in whom previous surgery had failed, were treated by bilateral gluteus maximus transposition. All patients were incontinent to solid stool. Previous surgery was postanal repair in four women and secondary overlapping suture for obstetric tear in one. The two men were treated in childhood for anal atresia. No covering stoma was used. Wound infection occurred in three patients, requiring surgical drainage in two. After follow-up of more than 1 year three patients experienced improved continence but in four continence was unchanged. Anorectal physiology studies showed moderately increased resting and squeeze pressures in patients who were improved by the operation, but none could retain more than 200 ml of viscous fluid instilled into the rectum. No change in rectal sensitivity or volume tolerance was found. This preliminary series does not indicate that better results are obtained by gluteus maximus transposition than by unstimulated graciloplasty.
Heesakkers JP, Jianguo W, Geerdes BP, Baeten CG, Janknegt RA.
Electrical stimulated graciloplasty in the male goat: an animal model for urethral pressure measurement.
Neurourol Urodyn 1996;15(5):545-553
The feasibility of dynamic urinary graciloplasty as a treatment for incontinence is currently investigated. Therefore an animal model is developed to improve the technique of dynamic urinary graciloplasty. This article is a report of the urethral pressure measurements in the male goat. This study compares the graciloplasty around the bulbous urethra with the graciloplasty around the bladderneck. The male goat as an animal model of urethral pressure measurements is discussed. Under anaesthesia in ten male goats the penile shaft outside the pelvis was dissected. Urethral pressure profilometry was performed. The bulbous urethra was dissected and a split sling graciloplasty was performed around the bulbous urethra. The contralateral gracilis was used for bladderneck graciloplasty. Urethral pressure profilometry was done without and with electrical muscle stimulation. The highest native urethral pressure was 136 cm water at the pelvic outrance. Without stimulation the bladderneck graciloplasty pressure was 97 cm water. The bulbous urethra graciloplasty pressure was 122 cm water. These pressures were not significantly different from the pelvic outrance pressure. With stimulation the highest bladderneck and bulbous urethra graciloplasty pressures were 183 cm water and 294 cm water respectively. The stimulated bulbous urethra graciloplasty pressure was significantly higher than the highest native urethral pressure. In conclusion, the male goat is a suitable animal model for urethral pressure measurement. The highest native urethral pressure is located at the pelvic outrance. A non-stimulated graciloplasty acts like a sling with regard to generated urethral pressure. With stimulation sphincterlike activity of the graciloplasty can be observed. In male goats the graciloplasty around the bulbous urethra is superior to the bladderneck graciloplasty.

Guelinckx PJ, Sinsel NK, Gruwez JA.
Anal sphincter reconstruction with the gluteus maximus muscle: anatomic and physiologic considerations concerning conventional and dynamic gluteoplasty.
Plast Reconstr Surg 1996;98(2):293-302.
Myoplasties have acquired an important place in anal sphincter repair. The use of the gluteus maximus muscle for sphincterplasty was reported initially in 1902. However, in 1952, the gracilis sphincterplasty became more popular because of the accessibility of this muscle. Unfortunately, continence rates, especially after graciloplasty, remained unpredictable because of inability to maintain muscle contraction despite training programs. Training should induce a shift in muscle fiber type distribution toward a more fatigue-resistant composition, with predominance of type I fibers. In order to obtain a more pronounced adaptation in the contractile, histochemical, and metabolic properties of muscle fibers, postoperative intermittent long-term stimulation of the graciloplasty was performed. As these results and the results of dynamic cardiomyoplasty with an implantable myostimulator proved to be successful, implantable pulse generators were used after graciloplasty. Subsequently, continence rates after graciloplasties improved significantly. These data encouraged us to perform dynamic gluteoplasties for anal sphincter repair. This paper presents the results in 7 patients treated by conventional and 4 patients treated by dynamic gluteoplasty. Advantages and disadvantages of gluteoplasty were compared with those of graciloplasty. The neurovascular pedicle of the gluteoplasty underwent less traction after transposition compared with the graciloplasty based on cadaver studies. Gluteus muscle transfer far exceeded the amount of muscle tissue of a normal anal sphincter despite muscle atrophy after transposition. This guaranteed a contractile muscle cuff around the anal canal in contrast to the tendinous sling after graciloplasty. Because of the excellent vascularization of the muscle, microperforations of the rectal mucosa caused by submucosal dissection were sealed, and implantation of electrodes and a pulse generator in one surgical intervention was well tolerated. The myoplasty induced a double curvation of the anal canal in contrast to the graciloplasty, which enhanced the natural anorectal angle. Patient evaluation revealed continence for stool in 9 of the 11 patients; 7 of the 11 patients also were continent for liquids, among them all of the patients who had undergone dynamic gluteoplasties. Mean basal pressure after dynamic gluteoplasty was 49 mmHg, which is lower than the reported mean basal pressure (62 mmHg) during stimulation after dynamic graciloplasty. Squeeze pressure after gluteoplasty, with or without stimulation, proved to be similar to or higher than that obtained in dynamic graciloplasty. Comparing our results of conventional gluteoplasty with the results of graciloplasty prior to stimulation, higher pressures were obtained by the gluteoplasty, especially in squeeze pressures. In the last 5 patients intraoperative pressure measurements were used to restore the optimal resting length of the muscle after transposition. An intraluminal pressure of at least 40 mmHg during rest and 80 to 120 mmHg during stimulation should be obtained to guarantee a future continent sphincter.
 

Velitchkov NG, Kirov GK, Losanoff JE, Kjossev KT, Grigorov GI, Mironov MB, Klenov IS. Abdominoperineal resection and perineal colostomy for low rectal cancer. The Lazaro da Silva technique.
Dis Colon Rectum 1997;40(5):530-3.
PURPOSE: We sought to evaluate a new technique for creation of a continent perineal colostomy following abdominoperineal resection (APR) of the rectum for low rectal cancer. METHODS: Nine selected patients with low rectal cancer (two males; median age, 55.6 years; classified as Dukes A, 6 patients and as Dukes B, 3 patients) underwent APR. Following this, the original Lazaro da Silva technique was used as follows: 1) for performance of three circular myotomies in the distal sigmoid with a distance between each couple of no more than 8 cm; 2) repair of the myotomies, thus creating three circular colonic valves, the most distal of which remained extraperitoneally; 3) for construction of a perineal colostomy lying flush with the perineal skin; 4) after the patient starts consuming a regular diet, enemas through the perineal stoma are done, usually twice per week, to achieve defecation. Functional outcome was assessed by evaluation of bowel movements and neoanal continence. RESULTS: There were no deaths. From January 1994 until October 1995, no tumor recurrence has occurred, and fecal continence has been good. Four of the patients were able to defecate without enemas (2-4 times per week), and in five patients the self-administration of enemas (2-4 times a week) were necessary to accomplish defecation. CONCLUSION: Initial results with the Lazaro da Silva technique have been encouraging.
 

Gilliland R, Heymen JS, Altomare DF, Vickers D, Wexner SD.
Biofeedback for intractable rectal pain: outcome and predictors of success.
Dis Colon Rectum 1997;40(2):190-196
PURPOSE: A number of modalities have been used for the treatment of intractable rectal pain, with varying degrees of success. Electromyography (EMG)-based biofeedback therapy has been used in the treatment of this condition during the past six years. MATERIALS AND METHODS: Medical records of 86 patients who completed at least one session of biofeedback for rectal pain between February 1989 and August 1995 were retrospectively reviewed. All sessions were one-hour outpatient encounters with a trained biofeedback therapist. There were 31 male and 55 female patients with a median age of 68 (range, 12-96) years. Surgery (19.8 percent) or stress (15.1 percent) were frequently cited as precipitating factors for the development of rectal pain. Eleven patients completed only one session of biofeedback and were excluded from further analysis. Of the remaining patients, 28 complained of concomitant constipation. Assessment of the benefit of therapy was based on the patients' subjective reports of the level of symptoms, aided by a linear analog scale. RESULTS: Twenty six patients (34.7 percent) reported an improvement in symptoms. Outcome was not influenced by patients' ages (P = 0.63), duration of symptoms (P = 1.0), or a prior history of surgery (P = 0.14). Alleviation of symptoms was not significantly related to the presence of paradoxical puborectalis contraction demonstrated on either EMG (P = 1) or defecography (P = 0.12). Importantly, outcome was significantly improved in patients who completed the treatment schedule compared with those who self-discharged (P < 0.001). CONCLUSIONS: Although idiopathic rectal pain is difficult to treat, EMG-based biofeedback can produce alleviation of symptoms. However, success depends on patients' willingness to pursue a full course of therapy.
 

Matzel KE, Stadelmaier U, Muehldorfer S, Hohenberger W.
Continence after colorectal reconstruction following resection: impact of level of anastomosis.
Int J Colorectal Dis 1997;12(2):82-87.
In 48 patients who had undergone anterior resection for rectal cancer with straight colorectal reconstruction, clinical and manometric results were correlated with the level of anastomosis. Patients were divided into four groups by anastomotic level: < or = 3, 4-6, 7-9, and > or = 10 cm. Functional outcome with regard to frequency of bowel movements, minor leakage, fecal incontinence. ability to defer stool and to differentiate consistency showed increasing impairment the lower the anastomotic level. Frequency, leakage owing to the inability to defer stool, incontinence for solid stool, inability to discriminate flatus from stool, and incomplete emptying were significantly different (P < 0.05) between the patients with an anastomotic level between 3-6 cm and between 7-9 cm. Manometric data revealed no trend or significant differences among the groups with regard to anal resting pressure and maximal and median squeeze pressure. Rectoanal inhibitory reflex was abolished in 60% of the patients. Clear changes, with a trend toward reduced function with lower anastomotic levels, were seen in the volume that produced a feeling of urgency, maximal tolerable volume, and neorectal compliance (between anastomotic levels 7-9 and > or = 10 cm the differences were significant; P < 0.05). Analysis by length of residual rectum (< 1.5, 1.5-4.0, 4.1-6.5, > 6.5 cm) demonstrated similar findings, suggesting that impaired function after rectal resection is due to reduced function of the neorectum. Thus, as much residual rectum as possible should be preserve without risking cure. If the level of the anastomosis is expected to be below 6 cm, or if the residual rectum is less than 4 cm, the construction of a colon pouch to increase neorectal capacity should be considered.
 

Korsgen S, Deen KI, Keighley MR.
Long-term results of total pelvic floor repair for postobstetric fecal incontinence.
Dis Colon Rectum 1997;40(7):835-839.
PURPOSE: This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD: Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18-78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS: Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION: Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.
 

Heesakkers J, Jianguo W, de Bruine A, van den Bogaard A, Janknegt R.
Dynamic urinary graciloplasty in male goats: a study on histology and urethral pressures.
Neurourol Urodyn 1997;16(2):117-123
The purpose of this study was to investigate the feasibility of dynamic bulbous urinary graciloplasty with respect to graciloplasty histology and urethral pressures. Two adult male goats underwent a pulled-through bulbous urethral graciloplasty with implant of electrodes and a pulse stimulator. Afterwards, a stimulation protocol was applied to have the fatiguable type II fibers replaced by fatigue-resistant type I fibers. Urethral pressure profilometry as well as analysis of histology was performed afterwards and compared with preoperative biopsies and preoperative recorded urethral
pressures. Successful conversion from type II into type I muscle fibers was observed; the percentage of type I fibers increased from 29% to 83%. The percentage of connective tissue increased from 8% to 16%. No stricturing of the bulbous urethra was observed. The urethral pressures before stimulation increased from a mean of 107 cm H2O without stimulation, to 187 cm H2O with stimulation for the two goats. After training, the urethral pressure increased from a mean of 85 cm H2O without stimulation, to 118 cm H2O with stimulation. In male goats, successful dynamic urinary graciloplasty at the bulbous urethra is feasible. The achieved muscle fiber conversion guarantees fatigue-resistance, necessary for a continuous sphincteric muscle contraction. The maximal urethral pressures, however, are lower than those without stimulation.
 

Chancellor MB, Hong RD, Rivas DA, Watanabe T, Crewalk JA, Bourgeois I.
Gracilis urethromyoplasty--an autologous urinary sphincter for neurologically impaired patients with stress incontinence.
Spinal Cord 1997;35(8):546-549
PURPOSE: To investigate the effect of a neurovascularly intact gracilis muscle urethral wrap, to be used to restore urinary continence as a transposed urinary sphincter graft, in patients with neurogenic lower urinary tract dysfunction. METHODS: Five neurologically impaired men with a denervated and damaged urinary sphincter mechanisms were treated. The etiology of sphincteric insufficiency included sphincter denervation in three patients, external sphincterotomy in one, and urethral trauma due to a chronic indwelling catheter in one. All patients underwent gracilis urethromyoplasty sphincter reconstruction. Two patients also underwent concomitant ileocystoplasty and one patient ileocystostomy because of poor bladder compliance and a bladder capacity of < 200 ml. RESULTS: The gracilis urethromyoplasty functioned as a new autologous sphincter with follow-ups ranging from 6-35 months. The surgery was successful in four patients. Three of the four patients were managed with intermittent catheterization, and one managed by ileocystostomy. The fifth patient continued to require an indwelling urethral catheter. CONCLUSION: Gracilis urethromyoplasty achieves compression of the urethra using a neurovascularly intact muscle graft. The functional urethral closure, obtained from the gracilis muscle wrap, assures dryness, and permits intermittent self-catheterization. It also avoids the risks of infection, erosion, or malfunction associated with the artificial urinary sphincter. The potential exists for electrical stimulation of this muscle graft to allow volitional control of the neo-sphincter mechanism, and voluntary voiding.