Imperforate Anus and Graciloplasty
Question: What are the chances of Graciloplasty success to treat and repair an imperforate anus?
My daughter was born in 1982 with a high imperforate anus. She had a colostomy from her birth to 1984, when she had surgery to establish continuity of the anus. The surgery had no effect on her continence, and when she was 12 years old, the repair of the anus failed because it was made without colostomy.
Six months later, the last attempt at repair was not very successful, and she is still incontinent. She is having difficulty coping with the situation, does not want enemas, and has asked us to seek intervention.
Graciloplasty with electrical stimulation has been proposed. What are the chances of success for this procedure, and has it been used successfully on people who have imperforate anus and several attempts at repair?
Answer: Cautiously skeptical about the results of graciloplasty in this case
The concept of "high imperforate anus" in a female is a conflicting, controversial one. The great majority of female patients classified as having "high imperforate anus" in the past, in reality, suffered from a persistent cloaca. The urethra, vagina and rectum were fused together, opening in a single orifice in the perineum.
Often, the rectal part was repaired, leaving the patient with a common opening for the vagina and urethra together. In such cases, the patients remained asymptomatic until puberty, when it became obvious that the vagina was still attached to the urethra and the patient needed another operation.
Your daughter needs an examination under anesthesia to rule out that condition. Otherwise, there is no explanation for such a diagnosis as "high imperforate anus."
Graciloplasty is an old operation and uses a long thigh muscle called the gracilis to surround the lower rectum. The patient is trained to try to contract that muscle to simulate the function of a new sphincter. That operation was abandoned because it didn't usually work.
Recently, the procedure has been revived by a number of surgeons who believe that by connecting an electrical current to that new sphincter, it may develop a tone that will be able to prevent fecal incontinence. That procedure is known as dynamic graciloplasty.
Skepticism remains, however, about the results of that treatment. First, the results presented by authors still report a significant number of patients in which the procedure doesn't work. Second, the long-term effects of such operations remain unknown. Patients undergoing this operation have a foreign body (electrical device), which can cause problems later in life.
Keep in mind that bowel control depends on three factors:
- Sensation
- Sphincter
- Colonic motility
Dynamic graciloplasty only addresses the sphincter problem, but not the other two conditions. If a patient has no sensation, a sphincter is usually useless. More important, perhaps, is the fact that there are two types of patients who suffer from fecal incontinence:
- Those who suffer from incontinence and constipation
- Those who suffer from incontinence and a tendency to diarrhea
Creating a new functional sphincter without identifying the type of incontinence that the patient has, may have severe secondary effects.
In a patient who suffers from constipation, the activation of the sphincter may hold the stool inside the rectum, but the deactivation (relaxation) of the sphincter doesn't mean that the patient will be able to empty the rectum and the patient may need an enema to empty the rectum.
Using enemas, however, can keep patients completely clean without the need of a new sphincter.
All these reasons argue for remaining cautiously skeptical about the results of graciloplasty.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
