Cost-effectiveness of dynamic graciloplasty in patients with fecal incontinence.

Department of Health, Organization, Policy and Economics, Faculty of Health Sciences, University of Maastricht, The Netherlands. PURPOSE: This study evaluates the cost-effectiveness of dynamic graciloplasty for intractable fecal incontinence. PATIENTS AND METHODS: The costs and effects of dynamic graciloplasty were measured in a prospective, longitudinal study and in a clinical trial. Forty-three patients with intractable fecal incontinence were evaluated before and after dynamic graciloplasty. Costs were obtained from the hospital information system and from patient-oriented questionnaires. We compared the costs of a dynamic graciloplasty with the costs of a colostomy. Colostomy costs were evaluated using a group of seven patients who had a stoma in place for incontinence for several years. Sensitivity analyses were included. RESULTS: Total direct costs of lifelong dynamic graciloplasty were $31,733 (United States dollars), costs of lifelong conventional treatment were$12,180 (United States), and costs of colostomy, including lifelong stoma care, were $71,576 (United States). The clinical success rate of dynamic graciloplasty was 74 percent. Quality of life after successful dynamic graciloplasty was better than with conventional treatment. CONCLUSION: We found that dynamic graciloplasty was more expensive than conventional treatment but resulted in a significantly higher quality of life. Stoma treatment was the least attractive alternative regarding both costs and effects. The Dutch Health Insurance Executive Board recommended reimbursement for the dynamic graciloplasty procedure

Secondary coloperineal pull-through and double dynamic graciloplasty after Miles resection--feasible, but with a high morbidity.

Department of Surgery, University Hospital Maastricht, The Netherlands. PURPOSE: Until recently, patients who underwent abdominoperineal resections had to cope with a colostomy for the rest of their lives. For some of these patients this colostomy was a terrible burden, physically and mentally. Publications about abdominoperineal pull-through and double dynamic graciloplasty immediately after a Miles resection showed good results. The purpose of this study was to investigate the procedure as a secondary approach after abdominoperineal resections. METHODS: In this study seven patients were evaluated. All had had an abdominoperineal resection and proved to have unbearable problems with their stoma. All had a secondary pull-through and double dynamic graciloplasty, a mean of 8.5 (range, 1.1-34.8) years after the Miles resection. RESULTS: In five patients continence was regained; two were reversed to colostomy because of several complications. Patients who had a successful outcome also suffered from numerous complications, with a total mean hospital stay of 73.8 (range, 27-167) days, a mean of 3.1 (range, 1-6) additional operations, and 1.8 (range, 0-4) readmissions. CONCLUSION: Secondary anorectal reconstruction after abdominoperineal resection is a feasible option, but with a high morbidity. Because of this the procedure was stopped at the beginning of 199

Dynamic graciloplasty. Complications and management.

Dynamic graciloplasty. Complications and management. Geerdes BP, Heineman E, Konsten J, Soeters PB, Baeten CG. Department of Surgery, University Hospital Maastricht, The Netherlands. PURPOSE: Patients with intractable fecal incontinence, in whom all other treatment failed, can be treated by dynamic graciloplasty. Good results have been reported, but this technique involves specific problems. All problems that occurred over an eight-year period are presented, and management is discussed. METHODS: Dynamic graciloplasty was performed in 67 patients with a mean follow-up of 2.7 years. All patients were monitored by physical examination, anal manometry, defecography, and electromyography at fixed intervals. All complications were noted and treated. Continence was defined as being continent to solid and liquid stools. RESULTS: The technique was successful in 52 patients (78 percent), whereas failures occurred in 15 patients (22 percent). Complications resulted from technical problems, problems with infection, and problems attributable to an abnormal physiology of the muscle or an anorectal functional imbalance. In total, 53 complications were identified in 36 patients. Most technical problems, concerning the transposition and stimulation of the gracilis muscle, could be treated. Failures were attributable to a bad contraction of the distal part of the muscle (n = 4) and perforation of the anal canal during stimulation (n = 1). In eight patients, infection of the stimulator and leads required explantation. Three patients did not regain continence after reimplantation. Apart from moderate constipation, physiologic complications were very hard to treat and resulted in failures in five patients because of overflow incontinence, soiling, a nondistending rectum, strong peristalsis, and strong constipation. In two patients, the technique failed despite a well-contracting graciloplasty; no clear reason for the failure was found. CONCLUSION: Complications associated with the technique of dynamic graciloplasty such as loss of contraction, infection, bad contraction in the distal part of the muscle, and constipation can often be prevented or treated. Difficulties related to an impaired sensation and/or motility, attributable to a congenital cause or degeneration, are impossible to treat, and this signifies that a good selection of patients is essential to prevent disappointment

Electrical stimulated graciloplasty in the male goat: an animal model for urethral pressure measurement.

Electrical stimulated graciloplasty in the male goat: an animal model for urethral pressure measurement. Heesakkers JP, Jianguo W, Geerdes BP, Baeten CG, Janknegt RA. Department of Urology, University Hospital Maastricht, The Netherlands. 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

Electrical stimulated graciloplasty in the male goat: an animal model for urethral pressure measurement.

Electrical stimulated graciloplasty in the male goat: an animal model for urethral pressure measurement. Heesakkers JP, Jianguo W, Geerdes BP, Baeten CG, Janknegt RA. Department of Urology, University Hospital Maastricht, The Netherlands. 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

Total anorectal reconstruction with a double dynamic graciloplasty after abdominoperineal reconstruction for low rectal cancer.

Department of Surgery, University Hospital Maastricht, The Netherlands. PURPOSE: Total anorectal reconstruction with a double dynamic graciloplasty was performed after abdominoperineal reconstruction (APR) for low rectal cancer. In four patients an additional pouch was constructed to improve neorectal motility and capacity. The aim of this study was to evaluate the results in the first 20 patients and to report on the preliminary results of patients with an additional pouch. METHODS: Twenty patients with a mean age of 52 (range, 25-71) years and a rectal tumor at a mean of 3 (range, 0-5) cm from the anal verge were treated. In 14 patients the Miles resection, colon pull-through, and construction of a neosphincter were performed in one session. Six patients had the double graciloplasty at an average of 4.1 (range, 1.1-8.8) years after APR. In four patients a pouch was constructed with an isolated segment of distal ileum. RESULTS: After a mean follow-up of 24 (range, 1-60) months after APR, none of the patients developed local recurrence, whereas four patients developed distant metastasis. Fifteen of 20 patients were available for evaluation, and 5 patients were still in training. Of these 15 patients, 8 patients were continent (53 percent), 2 patients were incontinent, and in 5 patients the perineal stoma was converted to an abdominal stoma. Failures were attributable to necrosis of the colon stump (n = 2) and incontinence (n = 3). At 26 weeks mean resting pressure was 44 (standard deviation (SD), 28) mmHg, and mean pressure during stimulation was 90 (SD, 46) mmHg at a mean of 3.5 (SD, 1.2) volts at 52 weeks. Mean defecation frequency was three times per day (range, 1-5). Of the eight patients who were continent, six used daily enemas. Mean time to postpone defecation was 11 (range, 0-30) minutes. CONCLUSION: In experienced hands, the double dynamic graciloplasty is an oncologically safe procedure that can have an acceptable functional outcome in a well-selected group of patients. However, to improve the outcome, further modifications will be necessary. So far, the addition of a pouch has not resulted in improved outcome