Introduction
Fecal incontinence is a devastating condition in which patients have extremely poor quality of life, with limitations in social interaction, physical activ- ity, and employability. Defined as incomplete con- trol of the fecal stream, fecal incontinence may be due to a number of factors, such as increased stool production, decreased rectal vault capacitance, diminished rectal distension sensibility, and anal sphincter disruption. Despite such medical thera- pies as motility inhibitors, stool-bulking agents, biofeedback, and Kegel exercises, these interven- tions may only provide limited relief from this dis- abling condition [1].
Disruption of the anal sphincter may be due to trauma, obstetrical injury, or iatrogenic rectal sur- gery, and therefore, the sphincter may be amenable to primary repair or secondary surgical reconstruc- tion. Patients with partial sphincter function and mild to moderate symptoms may benefit from ante- rior overlapping sphincteroplasty, especially young women with perineal lacerations or stretch injury from childbirth [2]. If considerable damage has occurred to the pelvic floor or sphincter mechanism, functional transfer of the gracilis or gluteus muscles should be considered [3].
Introduced by Chetwood in 1902 [4], rediscov- ered by Bruining in 1981 [5], and further described by Guelinckx in 1996 [6], functional myoplasty with the gluteus maximus may provide adequate control of the fecal stream, improving the quality of life in carefully screened patients. Successful outcomes can be achieved, especially in patients with severe fecal incontinence (greater than one episode per day) who have good voluntary control of the recon- structed sphincter. With some training, the trans- ferred muscle is taught to contract when the patient senses distension or filling of the rectal vault.
Because the gluteus is a skeletal muscle with the potential for fatigue, patients must locate a bath- room expeditiously, as continence duration is lim- ited.
Gracilis versus Gluteus
No randomized, controlled trials exist to compare the efficacy of the gluteus maximus muscle to the gracilis muscle in creating a neosphincter. Certain factors, such as anatomy and function, as well as the primary reason for fecal incontinence, dictate deci- sion making. At our institution, the gluteus muscle is preferred in patients who require considerable mus- cle bulk, who need moderate resting tones with high squeeze pressures, who would benefit from a com- plete rectum wrap, and who have minimal rectovagi- nal scarring. Alternately, the gracilis muscle is cho- sen in patients who have a deficient perineal body, who have extensive scarring of the rectovaginal sep- tum (requiring an anterior approach), who have some native sphincter function with moderate incon- tinence, and who have minimal needs for high squeeze pressures [7–22].
Anatomy and Function
The gluteus maximus muscle arises from the outer surface of the os ileum, sacrum, coccyx, and sacro- tuberous ligament and inserts into the iliotibial tract and gluteal tuberosity of the femur. Motor innerva- tion is derived from the inferior gluteal nerve, which is composed of nerve roots L5, S1, and S2; therefore, fecal incontinence secondary to spina bifida or myelomeningocele are absolute contraindications to gluteoplasty [23]. The superior and inferior gluteal arteries supply blood to the muscle at its proximal origin, making gluteoplasty contraindicated in those with Leriche syndrome [6]. Because the neurovascu- lar bundle is proximal, distal muscle transposition has little or no adverse effect [23].
Running, climbing stairs, and standing up from a sitting position are all actions facilitated by the glu- teus maximus. Thus, the gluteus as opposed to the gracilis, which plays a supportive role in thigh adduc- tion and hip flexion, is more amenable to reeducation [6]. A natural synergy exists between the gluteus and
Gluteoplasty for the Treatment of Fecal Incontinence
Lindsee E. McPhail, C. Scott Hultman
20
the external anal sphincter; contracting the gluteus is a reflexive action in response to rectal distention, and hip adduction is not [6]. Furthermore, gluteus muscle bulk generates significantly higher squeeze pressures than the gracilis muscle and provides a generous amount of tissue in which to implant electrodes and seal rectal microperforations [6].
Despite the reported success of gluteoplasty for fecal incontinence, graciloplasty is more frequently performed, for reasons that include ease of harvest, anterior approach, and patient positioning [7–22].
Minimal donor-site morbidity can be achieved via endoscopic harvest or through minimal–access inci- sions [22]. Disadvantages of the gracilis flap include early muscle fatigue, difficulty training them to con- tract (which is accomplished via thigh adduction), incomplete rectum wrap, inability to generate a high squeeze pressure, and frequent constipation due to distortion of the anorectal angle. The gracilis may, in fact, serve as a static sling with some contractile properties, whereas the gluteus can generate signifi- cant sustained squeeze pressures and add consider- able bulk to the perirectal space.
History
In 1902, Chetwood first described the use of the glu- teus maximus muscle as an anal neosphincter. Trans- posing the gluteus muscles by crossing them under- neath the ligamentous connection between the anus and the coccyx, Chetwood successfully treated a patient who developed fecal incontinence secondary to trauma [4]. Today, some argue that his reported results are a product of fibrosis as opposed to func- tionality [5]. In 1944, Bistrom also utilized the glu- teus muscle in treating fecal incontinence. He creat- ed a hole in the detached origin of the muscle, through which he brought the rectal stump [24].
Over the next half century, attention turned from the gluteus maximus muscle as a potential neosphincter and focused on the gracilis muscle. In 1981, Bruining reintroduced the gluteus, describing a technique in which this muscle is detached from the femur and elevated to the level of the proximal neu- rovascular pedicle. Both muscles are then wrapped around the rectum, after splitting the distal ends, to form a “scissors-like” neosphincter [5]. An alternate method was described by Hentz in 1982 in which the gluteus is detached at its sacral origin, split, and wrapped around the rectum [25]. Also in 1982, Prochiantz and Gross published a series of 15 patients with fecal incontinence who underwent glu- teoplasty with a proximally based muscle flap that functioned as a contractile sling [26].
In 1985, Orgel and Kucan introduced the tech-
nique utilized at our institution–the right inferior double-split gluteus maximus muscle procedure. For this operation, the inferior half of one gluteus muscle (typically the right, which is technically easier to har- vest for right-handed surgeons) is mobilized at its insertion at the iliotibial band and posterior gluteal tubercle of the femur, divided longitudinally in the direction of its fibers, tunneled around the sphincter, and attached to the contralateral ischial tuberosity.
This method, which involves mobilizing only one muscle, has the advantage of decreasing the potential for hip instability [27].
Since 1985, several more studies were conducted investigating the use of gluteoplasty. The vast major- ity–Yuli in 1987 [28], Pearl in 1991 [23], Devasa in 1992 [29], Christiansen in 1995 [30], Meehan in 1997 [31], and Yoskioka in 1999 [32]–employed the tech- nique first introduced by Hentz: bilateral distally based muscle flap fashioned in a contractile sling about the rectum. Only Guelinckx in 1996 deviated from this majority [6]. His unilateral, proximally based muscle flap, which is tunneled around the rec- tum and attached to the contralateral ischial tuberos- ity, resulted in an 82% continence rate, and this pro- cedure is employed at our institution today [6].
A comprehensive review of published cases reveals a limited number of studies with large sample size and objective assessment of long-term outcomes [3–6, 23, 25–35]. Combined data from 17 reports identified 149 patients who underwent functional gluteoplasty for fecal incontinence. This procedure was successful or partially successful in 73% of patients, with a combined major and minor compli- cation rate of 38%. These results are comparable with those of our institution, where we demonstrated a success rate or partial success rate of 88%. Our com- plication rate, though, was notably higher than that of the combined series, at 64% [36]. However, these studies represent a diverse group of patients in terms of operative technique, with three series using unilat- eral flaps and 14 using bilateral flaps. Six reports described proximally based flaps, while nine described distally based flaps. Regarding flap fixa- tion, 12 series noted the creation of a sling without boney anchoring, and four reported the use of the ischial tuberosity to secure the gluteal slips.
Surgical Approach and Operative Technique
At our institution, preoperative evaluation includes assessment by a multidisciplinary team that compris- es members from general surgery, plastic surgery, urogynecology, and gastroenterology. Workup involves a combination of sigmoidoscopy, endorectal ultrasound, rectal manometry, and pudendal nerve
studies. The information provided by these studies helps identify patients with fecal incontinence who are suitable operative candidates, specifically those individuals with good rectal vault capacitance, intact sensibility with rectal distension, and favorable anatomy for transposition of the gluteus muscle.
Selected patients may benefit from preoperative biofeedback and training of the gluteus.
After obtaining informed consent and providing discussion of the potential benefits and risks, patients receive a mechanical bowel preparation and are kept on clear liquids for several days prior to their proce- dure. Temporary diverting colostomy should be strongly considered in high-risk patients with recto- vaginal or perirectal fistulas, inflammatory bowel dis- ease, or severe perirectal scarring with perineal defi- ciency. Topographic landmarks, including the sacrum, infragluteal crease, and borders of the gluteus, are marked in the preoperative holding area (Fig. 1a).
Following intubation and induction of general anes- thesia, the patient is transferred to the prone, jack-knife position (Fig. 1b). Perirectal incisions are made later- ally at the junction of the skin and anoderm, exposing the contralateral ischial tuberosity (usually the left), which is marked with a braided, permanent suture that is anchored in periosteum and later attached to the ten- don of the transferred muscle Anterior and posterior rectal tunnels are developed with blunt and sharp dis- section, avoiding rectal perforation. The lower third of the gluteus maximus muscle is then harvested through a sigmoid incision placed near the infragluteal crease.
Effort is made to preserve the posterior cutaneous nerve of the thigh. The gluteus is detached from its insertion on the posterior gluteal tubercle of the femur, saving a strip of tendon and periosteum for later fixa- tion to the ischial tuberosity (Fig. 1c)
After identifying and preserving the inferior gluteal nerve and vascular pedicle (Fig. 1d), the infe-
a
b
c
d
Fig. 1a–g.A 48-year-old woman with severe fecal incontinence (greater than one episode/day) from an obstetrical stretch injury who had a previously failed anterior overlapping sphincteroplasty. She underwent reconstruction of the anal sphincter with a proximally based, unilateral, split gluteus muscle as a functional transfer. She is now able to maintain continence long enough to get to a bathroom, by contracting the gluteus neosphincter when she senses rectal vault dis- tension. a Marks in the preoperative holding area. b Jack-knife position. c The gluteus is detached. d Identifying and pre- serving the inferior gluteal nerve and vascular pedicle (continued)
rior gluteal flap is elevated from lateral to medial and subsequently split with bipolar cautery. This maneu- ver creates a slightly longer inferior slip, which is transposed through the posterior tunnel around the rectum, and a shorter superior slip, which is trans- posed through the anterior tunnel in the rectovaginal septum (Fig. 1e). After transposition and balancing, the gluteal slips are brought to the contralateral ischial tuberosity and secured with a modified Kessler tendon repair. If mobile and available, the lower edge of the remaining gluteus muscle is advanced inferiorly over the sciatic nerve to provide coverage (Fig. 1f). The gluteal donor site is closed in multiple layers over a fluted drain, and the perirectal incision is similarly closed, with vaginal packing placed.
Postoperatively, the patient is maintained on a low-residue diet and given narcotics for analgesia to help decrease gastrointestinal motility. Prophylactic oral antibiotics, covering enteric flora, are prescribed for approximately 1 week. The patient is allowed to ambulate on the second day after the procedure but is not permitted to sit for 2 weeks, thus avoiding pressure on the perineum and ischial tuberosity (Fig. 1g). Within 4 weeks, most patients can perform voluntary contraction of the gluteus, although biofeedback has been necessary in a minority of our
patients to guide contraction of the neosphincter and improve fecal continence.
University of North Carolina Clinical Experience
From 1996 to 2004, we performed functional unilat- eral gluteoplasty in 25 patients with severe fecal incontinence. Using a modified Pescatori grading system to assess continence for solid stool [37], we determined that gluteoplasty was successful in 18 patients (72%) and partially successful in four (16%).
Gluteoplasty was defined as successful if patients had less than one episode of incontinence per week, par- tially successful if one to three episodes per week, and not successful if greater than three per week.
Etiology of incontinence included obstetrical injury (13), irritable bowel syndrome (3), previous rectal surgery (3), Crohn’s disease (3), traumatic impalement (1), rectocele (1), and idiopathic (1). Five patients with a primary diagnosis of obstetrical injury also had a secondary diagnosis of irritable bowel syndrome. Gender distrtibution was 22 women and three men, with a mean age of 42 years and a range of 23–65 years. Mean length of follow-up was 20.6 months, with a range of 3–68 months.
Although gluteoplasty was efficacious in improv- Fig. 1.(continued) e Transposition and balancing. f The gluteal slips are brought to the contralateral ischial tuberosity and secured. g The patient is allowed to ambulate on the second day but is not permitted to sit for 2 weeks; thus avoiding pres- sure on the perineum and ischial tuberosity
e
f g
ing continence in 22/25 patients (88%), significant morbidity was observed. Two patients required per- manent colostomy for refractory incontinence. In terms of donor-site complications, 16/25 patients (64%) developed a combination of posterior thigh numbness (7), dysesthesias (5), cellulitis (5), irregu- lar contour (3), abscess (2), severe chronic pain (2), and hematoma (1), but there was no altered gait or hip dysfunction. Regarding perirectal complications, 14/25 patients (56%) had sinus tract formation (3), flap dehiscence requiring reoperation (2), perirectal abscess requiring temporary fecal diversion (2), chronic pelvic pain (2), vaginal perforation with delayed healing (1), recurrent fistula (1), and rectal prolapse (1). Six patients required readmission for wound care, intravenous antibiotics, or operative intervention.
Despite this high incidence of donor-site and perirectal complications, we concluded that the risk–benefit profile for functional gluteoplasty remains favorable. Although a continence rate of 88% was observed in our series, patients must be ade- quately counseled and prepared for significant potential morbidity. We believe that careful patient selection, preoperative education, biofeedback, and surgical technique refinement are important deter- minants of successful outcome.
Future surgical approaches to the management of fecal incontinence include the development of mechanical artificial sphincters [38, 39] and the exploration of alternative muscle flaps, such as the sartorius and rectus femoris, with the goal of improv- ing efficacy and reducing morbidity [40–42]. Fur- thermore, dynamic stimulation of the muscle flap via implantable electrodes (to help decrease muscle fatigue and by recruiting slow-twitch fibers), shows considerable promise in clinical trials [6, 13–21].
Finally, randomized clinical trials comparing the results of graciloplasty and gluteoplasty would be of considerable value in terms of guiding patient selec- tion and elucidating the efficacy of these two proce- dures in anal sphincter reconstruction for fecal incontinence.
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