w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Deoti
surgical
flap
and
sphincteroplasty
for
treatment
of
severe
perineal
deformity
Beatriz
D.S.
Rodrigues
a,b,∗,
Kelly
Cristine
de
Lacerda
Rodrigues
Buzatti
a,
Igor
G.N.
Reis
a,
Flávio
C.
Barros
a,
Vinícius
R.T.
Nunes
b,
Rodrigo
G.
da
Silva
aaUniversidadeFederaldeMinasGerais(UFMG),FaculdadedeMedicina,DepartamentodeCirurgia,BeloHorizonte,MG,Brazil bUniversidadeFederaldeMinasGerais(UFMG),HospitaldasClínicas,BeloHorizonte,MG,Brazil
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Articlehistory:
Received3November2016 Accepted18December2016 Availableonline2February2017
Keywords:
Colorectalsurgery Surgicalflaps Fecalincontinence Treatmentoutcome
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Purpose:Analincontinenceisaverystigmatizingcondition,whichaffectsbiopsychosocially thepatient.Itisaneglected,butquitecommoncomplicationofobstetricandanorectal surgery,howeverithastreatmentoptions.Noneofthetreatmentoptionshaveexceptional efficacyratesandstillassociatedwithriskofrecurrence.Thesurgerytechniquesknown are:anteriorandposteriorshorteningprocedure;post-analrepair;anteriorelevatorplasty andexternalsphincterplication;totalpelvicfloorrepairandsphincterrepair.Noneofthem useaflaprotationofadiposetissue.Thepurposeistoproposeanewsurgerytechnique ofanalsphincteroplasty,whichusesflaprotation,forsevereperinealdeformityassociated withanalincontinence.
Methods:Patientwithsevereperinealdeformityandanalincontinencetreatedwithanew surgerytechniqueofsphincteroplastywithflaprotation.
Results:The severeperineal deformitywascorrectedwith bothestheticandfunctional results.AnalcontinencemeasuredbyWexnerandJorgeassessmentinafollow-upperiod of2yearsaftertheintervention.Picturesandvideoshowestheticandfunctionalaspects.
Conclusion: Thisis the firsttime thata flap rotationis used totreat a severe perineal deformity.Andthetechniquepresentedpromisingoutcomes,whichallowsperineum recon-structionthatissimilartotheoriginalanatomy.Therefore,thistechniqueisjustifiedto betterevaluateitsefficiencyandtheimpactonpatients’prognosis.
©2017SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:bdeoti@gmail.com(B.D.Rodrigues).
http://dx.doi.org/10.1016/j.jcol.2016.12.002
Retalho
cirúrgico
de
Deoti
mais
esfincteroplastia
para
tratamento
de
deformidade
perineal
grave
Palavraschave:
Cirurgiacolorretal Retalhoscirúrgicos Incontinênciafecal Resultadodotratamento
r
e
s
u
m
o
Objetivo:Aincontinênciaanaléumacondic¸ãomuitoestigmatizante,queafeta biopsicosso-cialmenteopaciente.Éumacomplicac¸ãonegligenciada,masbastantecomumdacirurgia obstétricaeanorretal,noentanto,temopc¸õesdetratamento.Nenhumadasopc¸õesde trata-mentotemtaxasdeeficáciaexcepcionaiseaindaestáassociadaaoriscoderecorrência.As técnicascirúrgicasconhecidassão:procedimentodeencurtamentoanterioreposterior; reparac¸ãopós-anal;plásticadoelevadoranterioreplicaturaexternadoesfíncter;reparo totaldoassoalhopélvicoereparodoesfíncter.Nenhumdelesutilizaumarotac¸ãoderetalho detecidoadiposo.Oobjetivoéproporumanovatécnicacirúrgicadeesfincteroplastiaanal, queutilizaarotac¸ãoderetalho,paradeformidadeperinealgraveassociadaàincontinência anal.
Métodos: Pacientecomdeformidadeperinealgraveeincontinênciaanaltratadacomnova técnicacirúrgicadeesfincteroplastiacomrotac¸ãoderetalho.
Resultados:Adeformidadeperinealgravefoicorrigidacomresultadosestéticosefuncionais. Continênciaanalmedidapelaavaliac¸ãodeWexner&Jorgeemumperíododeseguimento de2anosapósaintervenc¸ão.Imagensevídeomostramaspectosestéticosefuncionais.
Conclusão: Estaéa primeiravezqueumarotac¸ãoderetalho éusadaparatrataruma deformidadeperinealgrave.Eatécnicaapresentouresultadospromissores,oquepermitea reconstruc¸ãodoperíneosemelhanteàanatomiaoriginal.Portanto,estatécnicaéjustificada paramelhoravaliarsuaeficiênciaeoimpactonoprognósticodospacientes.
©2017SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Anal incontinence isthe lackof abilitytovoluntarily con-trol flatulenceand feces.Thisisasymptomwhich reflects aneglectedbutquitecommoncomplicationofobstetricand anorectal surgery. It is a very stigmatizing condition and causesimmeasurablenegativeimpactonqualityoflife,such asdisturbanceofemotional balance,ofsocialrelations, of laborrelations,totallossofself-esteemanddepression.The patienthides thissocialembarrassmentand faces asocial isolation,whichworsenswiththeperinealdeformity.Being ashamedtotalkaboutitandignorantofthetreatment pos-sibility,onedoes notseekcare. Thepatient presents three maincomplaints:“soiling”(dirt),whichisaconstantperianal humidity;theunconsciousincontinence(passive),whenthe patientrealizesthattherehasbeenalossofcontentthrough smell,itching,discomfortormoisture;andincontinenceasa matterofurgency,whenthepatientisunabletoinhibitthe willingnesstoevacuate.1,2
Theclinical treatmentistheprimaryoption for manag-inganalincontinence,whilethesphincteroplastyisasurgical option and there is hesitation to indicate this procedure. Firstly,becausetheclinicaltreatmentpresents goodresults and50–70%ofthepatientshaveanalfunctionrecoveryand lifequalityimprovement.Secondly,becausethe aimofthe surgeryistorestoretheanatomy,notthefunction.Thirdly, thisisaverydelicateandcomplexprocedure.Andfourthly,the surgicaltreatmentofthisconditionisstillassociatedwiththe riskofrecurrenceormaintenanceofincontinence.Theanal
sphincteroplastyisoftenoneoftheonlytreatmentsavailable. Showsgoodresultsintheshortterm,butthereisadecline overtime.2
The purpose of this article is to propose a surgical technique forreconstruction ofperianal severe anatomical deformities.
Methods
Themethodisanexperimentalsurgerytechniqueof sphinc-teroplasty with flap rotation for severe perineal deformity associatedwithanalincontinenceinafemalepatientwith severefecalincontinence.Thisnewtechniquewasdeveloped atthetimeofsurgeryandaninformedconsentprovidedbythe patientapprovedtheprocedureandthephotographstaken. Thephotographsandvideosdonotallowthepatient’s identi-fication.
Patient
prolactinoma.Previoussurgeries:oophorectomyforteratoma, c-sectionaftergoingintolabor(firstpregnancy).Family his-toryisnegativeforcolorectalcancerandinflammatorybowel disease.Acolonoscopywasmadeandit wasnormal. Mag-neticresonanceimagingofthepelvisshoweddistortionand asymmetry of the anus lifter muscle, with presence of a cyst (1.5cm×1.2cm), located posterior to the rectus, 3cm far from anal edge.Theanorectal manometry showedlow restpressures,satisfactorycontractionpressures,radial con-tractionasymmetryandgoodtolerancetoballooninflation. Endorectalultrasound identified a residual cyst in soaring musclesofthe anus (rightposterolateral position),atrophy oftheleft lateralpillarofpuborectalismuscle,withdiffuse hypocontractility,externalsphinctermusclestotallychanged, withareasofgreaterandlesserthickness,withmore signif-icanttaperingontheleftside,withlossofupto80%ofthe thickness. Theremainder offiberspresentedloss of paral-lelismandhypocontractility.Noexamrevealedactivefistula orCrohn’sdisease.Theproposedtreatmentwasthe sphinc-teroplastywithskinflaprotation.
Technique
Preoperativemechanicalbowelpreparationwasconductedon theoperation’seve.Theadministrationofantibiotics prophy-lacticallywasmadeaccordingtotheProtocoloftheHospital InfectionControlCommittee(HICC).Thesurgerywasmade withthepatientunderspinalanesthesia.Onthedayofthe procedure,thepatientwassubmittedtourethral catheteriza-tionwithafoleycatheterandpositionedinprone-jackknife position.Thebuttocksweredisplaced.Theincisionwas pos-teriorperianal,heldincircularmanner,respectingthelimitof 180◦to200◦,inordertoavoidinjuryoftheterminalbranchesof thepudendalnerveasintheelectronicsupplementary mate-rial (Video1).Atthis point the mucosaiswithout support andacertaindegreeofprolapseoccurs.Themucosawasthen releasedfromtheinternalsphincterandfromthe surround-ingfibrosis.Theperianalskinwasliftedasthenextstepand afterthattheintegratesphincterwasidentifiedlaterallytothe fibrotictissue.Thesphincterwasseparatedfromthefibrosis withextracarenottodissecttoolaterally,becausethe ner-voussupplytotheexternalanalsphinctermusclecomesin atthispoint.Anervestimulationmaybeusedtoidentifythe terminalportionofthepudendalnerveifanextensive dissec-tionisnecessary.Thislateraldissectionallowedreachingthe externalanalsphincter(EAS)withagoodbloodsupply.The planbetweenthetwosphincters(externalandinternal)was achievedandpenetratedbilaterallyuntilreachingthefibrotic tissueinthemiddleline,separatingcompletelytheEASofthe internalanalsphincter(IAS).Inthispatient,acystwas curet-tedandthepuborretalmusclewasreleasedfromthefibrosis towhich itwasadhered.Oncethe mucosawascompletely dissectedfromthefibrotic tissue,itwasenabledextremely carefuldissectionofthelateralaspectofthehealthymuscle toprovideafreeflapofabout1.5cm.Duringthedissection,it isfoundtwoarmsofthesubcutaneousportionofEAS.
Firstly,theIASwassutured.Thesectionedendoftheinner faceofthefibrotictissueissuturedtotheinnerfaceofthe muscle,and the mostsuperficialfibrosis faceissutured to themoresuperficialmuscleface.Allpointsareknottedafter
thepassageofwiresinanterior–posteriordirectioninorderto reduceitsdiameter,whichisapproximatelyenoughtofirmly positionthesurgeon’sindexfinger.Itwasusedsimpleknots andapolyglactin910wire(surgeon’spreference).Thegoalis todoarepairthatisnottootight.Following,theoverlapping of the EASsubcutaneous portion,including the superficial portion,isperformed.
Afterfinishingthesphincterrepair,themucosamustbe suturedtotheANODERMAtoavoidtheanalmucosa retrac-tion.Themucousmembraneshouldnotbedirectlysutured totheskintoavoidectropionandchronichumidity.Thenthe skinisnotapproximatedbyprimarysuture,becauseunder itthereisthesuturedmuscleandanemptyspacewherea big importantfibrosis canarise.Thescartissuewastotally removed,formingadefectwithlargediameter(seeVideo1, whichshowsthestepbystepofthesurgerytillthescartissue removal,beforeflaprotationplanning).
Aflapofskinaccompaniedbylush subcutaneoustissue wasmade.Afterrotatingandadvancingtheflap,itsskinwas suturedwiththebordersofthewoundand,thesubcutaneous filledall theemptyspaceandcoveredthe suturedmuscles andtheoverlapping.Inaddition,thepointsweremade sepa-ratedtoenabledrainage,avoidingaccumulationofsecretions. APenrosedrainwasplacedforanyseromathatmightcollect (seeVideo2,whichdescribestheprinciples,theplanningand thestepbystepoftheflaprotation).
Results
The post-op period developed properly as expected. The perceivedcomplicationswere:inthesecondpost-opday(POD) localpainoccurredanddifficultytoevacuate;inthethird,the patientreportedasensationofblockedevacuation,but the digitalrectalexaminationrevealednoobstructionor steno-sis;inthefourthPOD,wasabletoevacuate,butitwaspainful. Therewerenomorecomplaintsonthefollowingdayand,at the8thPOD,patientwasdischarged.Aftertwoyearsof follow-up(seeVideo3,whichshowstheoutcomeofthesurgeryafter 6monthsoffollow-upandthesphinctercontractionafter two-year-follow-up), thepatient remainswell withWexner and Jorge3of7.
Discussion
Sphincteroplastyisaneffectiveproceduretotreatanal incon-tinence.Since1971,whenParksetal.4describedthetechnique for the first time, efforts have been made to improve it, whichwasaccomplished bySladeetal.in1977.5 Thisnew technique hasasatisfactory short-termsuccessrate. How-ever, whenmonitoringiscarried outforalonger periodof time,abouttenyearsafterthesurgery,thefunctionalresult declinesconsiderably.2Despitethecontinenceisnottotal,the patientisstillsatisfiedwiththeprocedure’sresult,because thereisclinicalimprovementcomparedtothepreoperative condition.4,5
Isthecurrentlyusedcriteria(itvaryalotintheworks pub-lisheduntilnow)idealtodefinethesuccessoftheprocedure? Isitjustifiabletoconductanoperation,whichdoesnotsustain long-termresults?
A survey of 182 patients who underwent conventional sphincteroplasty showed that in the first three years after surgery, 18% of the patients did not present anal inconti-nence,25%reportedincontinenceonlyforgas,19%claimonly dirtand36%havesolidstoolincontinence.Thosenumbers, whenmeasuredonaten-yearmonitoring,fallto6%,16%,19% and 57%,respectively.These resultsconfirmthat the tech-niquecurrentlyusedpresentsadropineffectivenesswhen thefollow-upperiodislonger.1Ontheotherhand,an interest-ingfactconcernsthelifequalityofpatientsafterthesurgical procedure.Despitetheprobleminkeepinggoodresultsafter longpost-optime,whentheFIQLSquestionnaire(Fecal Incon-tinenceQualityofLifeScale)isapplied,thepatientsclaimthat thecontinenceisbetterthanitwasbeforetheprocedureand about75%ofpatientsfeelsatisfiedwiththesurgery.Thisresult isveryrelatedtothelifequalitypriortotheprocedure,which wasverybad,makinganyprogressonpatient’scontinence a considerable improvementin quality oflife. In addition, thepatients’responsetothisquestionnaireprovedthatanal incontinencehasalargenegativeeffectonthequalityoflife.1 Thereisstillnoexplanationforthislongtermfailureto occur,however, twofactors havebeenidentified as predic-torsoffailure:theworsefunctionalresultintheshortterm andage.Itwasshownthatpatientswhopresentedabetter resultatshorttermwerelesslikelytoevolvetoincontinence. Similarly,olderpatientshadgreaterchancetobecome incon-tinentagain.Thereasonforthisassociationisstillunknown, butitisbelievedthatthelossofmusclestrengthbyagingof thetissueisthemainfactor.1Studiesdifferabouttherelation ofpreoperativephysiology, i.e.assessmentofthe pudendal nervefunctionandsphinctercontractionforce,onpredicting long-termcontinenceresults.6,7
Inthestudiesthatlinkthesepredictors,thereisno ques-tioning about a possible relationship between the surgical techniqueandthesuddendropoflong-termefficiency.The surgicaltechniqueusedisthesamesince1977,thereforethere isnobasisforcomparison.
Thesphincteroplastyhasacceptablefunctionalresultsas longasthelocationoftheoperationdoesnotinfect.Itisthe procedure ofchoicefor the partialor complete damageof theexternalanalsphincter.Webelievethattheflaprotation shouldbedoneincasesofsevereperinealdeformity,i.e.poor perinealbody,presenceoflargeemptyspaceaftersphincter repairandexcessivelossofskinorextensivedevitalizedscar skin.
Intheplasticsurgery,thegreatertheanaldefectthe big-gertheemptyspace,whichisreplacedbyalargeamountof fibrosis.4,5
Theformationofscar tissueiscrucialtothe successof thesurgery,becauseitisnecessarytopreventsuture dehis-cence,whichisthereasonwhythepredecessorsofParksetal. failed.4However,anextensivefibroticformationtakesaspace thatshouldbeoccupiedbymuscle,causingreducedstrength inlocalcontraction,possiblybeingonemorereasonforthe long-termfailure.Anotherfactorforthisdecreasedabilityto contractistheadherenceofthefibrosisintothemuscletissue.
Theformationoffibrotictissuenaturallyoccursaspartofthe healingprocessafterproceduressuchasepisiotomyandthis fibrosismaycausefunctionimpairmentofpelvicfloor mus-cles.Despitethevastmajority,skeletalmuscleinjuryrecover withoutthis harmfulfibrosisformation,theproliferationof myofibroblastsmaybeexcessiveinlargeorrepeatedtrauma, suchasrepeatedepisiotomiesandsurgicaltreatmentofanal fistulas,resultingintheformationofdensescartissuethat restrictstheregenerationofmyofibrils.8
In recent years, researchhas shown that subcutaneous fat contains many stem and regenerative cells, which are importantforrevascularizationandsurvivalofthedamaged tissue.9,10Untilrecently,thestemcellsweremostcommonly harvestedfromthebonemarroworbloodofadults,butitwas necessarytocarryoutthecultureofthesecellsduetothelow frequencyoftheminthesesources.Inthe otherhand,the regenerativecellsderivedfromadiposetissueareabundant andhavetheabilitytodifferentiateintodifferentcelltypes.In addition,thereisnoneedtomakeacultureofthiscells,being possibletoremoveanduseitduringtheprocedure.8,11–14
Themajorindicationofthistechniqueisbasedonthese studies.Oncethemusclerepairisincontactwithahealthy subcutaneoustissue,themuscledoesnotadheretoskinand thereisnoemptyspace,whichallowsalaminarscartissue. Also,thismuscle–fatcontactcanstimulatetheregeneration ofmyofibrilsassubcutaneoustissueisasourceofstemcells. Likewise,theregenerationofmyofibrilscanoccur,and conse-quentlybettermusclecontractionfunctioncanbeobtained. Webelievethatthistechniqueisindicatedincasesofsevere perinealdeformities,inwhichthesphincteroplastywillcause largevoids. Inadditiontoallthis,thesutureissteady and sustained.8–15
Theskinthatcoversthedefectishealthyandatthelate post-opitgetsanconcentricanalfoldingthathelpstoimprove thecontinence.Additionally,thereisnotagreatlossofmuscle tissue,whichfavorsagreatercontraction forceforalonger periodforthepatient.
Anotherkeyissueistohaveaccesstothecompletepre-op propaedeuticinordertoassessthecausesthatledto incon-tinencebeforetheoperation,onceitispossibletoassociate differenttreatmentsfordifferentcauses.Thisisvery impor-tant becauseweknow thatthe successoftheoperationis greaterwhenyoudonothaveanothercause.Astudyshows thatthesuccessoftheoperationis62.7%withoutpudendal nerveinjuryandfallsto16.7%whenthisinjuryispresent.The knowledgeoftheassociatedcausesfortheanalincontinence would also be important to correctly indicate the surgery andwouldavoidproscribingatechniquethathasacceptable resultsandrebuildstheanatomyofafunctionallyimportant area.6
Currentlymostpatientsare coveredbyasingletherapy, usuallyonethatisavailableontheservicewithoutbeingable toconsidermultipletreatment.
totheSNS,biofeedbacktechniqueshouldalsobeconsidered. Studieshaveshownthat,onaverage,biofeedbackshows sig-nificantreductionofanalincontinencein62.77%ofpatients.16 Althoughimprovingtreatment isneeded, itis also nec-essary to invest in prevention. The biggest cause of anal sphincterinjuryisthebirthinjury.However,theconstipation hasbeenshownasothermajorcause.10Therefore,pelvicfloor injuryisapreventableproblem,forwhichtherearemeasures tobetaken.Thus,identification andtreatmentof constipa-tionareofutmostimportancetopreventtheoccurrenceof analincontinence.Concerningnaturalchildbirth,apossible preventionmethodistheperinealmassagetechnique.This techniquewasproventoavoidpelvicinjuriesinnulliparous women,whoperformedtheperinealmassage.Thereisa16% reductionintheincidenceofsuturerequiringpelvictrauma.9 Itiscomplextomeasuretheseverityofanalincontinence, itsimpactonqualityoflifeandpost-opfunctionaloutcome. So far, no instrument of severityscore or QoL assessed is universallyaccepted.Anin-depthdiscussionoftheavailable classificationsystemsisbeyondthefocusofthisarticle.The differenceofopinioninthismatterstemsfromanabsenceof levelIevidence,fromalackoflong-termfollow-upandfrom theinconsistentresultsanddifferentmethodsinpublished studies.However,theratesofoccurrenceandrecurrenceof incontinence has prompted the search for more effective methods.
Conclusion
Thedeclineineffectivenessofcontinenceafter sphinctero-plastypointstothe needofimproving patient’s diagnostic approach and operative technique before abandoning this treatment.Combiningdifferenttechniques,thelongandthe short-termresultscanbeimproved,makingpossibleagreater qualityoflifeforthepatientforagreaterperiodoftime.
Acaseseriesiscurrentlyonfollow-upforlaterpublication. Thistechniquepresentspromisingoutcomesthatneedtobe furtherevaluatedandjustifiesthecontinuityofitsuseinorder tostudyitsefficiency.Itallowsaperineumreconstructionthat issimilartotheoriginalanatomyandthisfactaloneisenough tojustifyitsapplication.Additionally,theassociationof dif-ferenttreatmentapproaches(beforeorafterthesurgery)is necessaryincasesofmultipleetiologies.Thus,thequalityof lifeofpatientssufferingwithincontinencemayhaveabetter prognosis.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgments
TheauthorsthankthesupportfromHospitaldasClínicas– UFMG,directionand,thesupportfromtheColoproctologists teamoftheGastroenterologyAlfaInstitute(AIG),Hospitaldas
Clínicas–UFMGand,BárbaraDeotiSilvaRodriguesformaking the surgeryandanatomydrawingsand providingthemfor publicationinthisarticle.
Appendix
A.
Supplementary
data
Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.jcol.2016.12.002.
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