ABSTRACT
The external anal sphincter (EAS) is a skeletal muscle capable of voluntary contraction to prevent accidental defecation. Current reconstructive options for a severely damaged EAS using local muscle flaps are not always adequate for functional repair. The present preliminary experimental model was designed to assess the feasibility of a neuromicrovascular latissimus dorsi muscle transfer for functional external spincter muscle reconstruction. In nine mongrel dogs, the anal sphincter muscles were totally resected, leaving a mucosal canal in place. A segmental latissimus dorsi muscle was shaped around the anal canal in a circular fashion, with coaptation to the pudendal nerve, and vessel anastomosis at the ischiorectal fossa. Functional evaluation was performed using electromyogram, sphincter manometry, video documentation, and histologic examination with standard and immunohistochemical staining. After 8 months, the remaining three eligible dogs were continent. Muscle function was verified by means of electromyogram, sphincter manometry, and a video record. Histologic and immunohistochemical examination confirmed the functional results, showing only minor zones of fatty and fibrous degeneration.
Transplantation of a segmental latissimus dorsi muscle with vascular anastomosis and coaptation to the pudendal nerve has proved to be successful in restoring (voluntary) anal continence experimentally in dogs. Its feasibility for perfect orientation as a neosphincter seems to be superior to any pedicled muscle flap. However, these preliminary results deserve further investigation prior to considering application in humans.
KEYWORDS
Anal sphincter muscle repair - neuromicrovascular muscle transplantation - latissimus dorsi
REFERENCES
1
Madoff R D, Baeten C G, Christiansen J et al..
Standards for anal sphincter replacement.
Dis Colon Rectum.
2000;
43
135-141
2
Pickrell K L, Broadbent T R, Masters F W, Metzger J T.
Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle: a report of four cases in children.
Ann Surg.
1952;
135
853-862
3
Thompson N.
Autogenous free grafts of skeletal muscle.
Plast Reconstr Surg.
1971;
48
11-27
4
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
77-82
5
Hakelius L, Olsen L.
Free autogenuous muscle transplantation in children. Long term results.
Eur J Pediatr Surg.
1991;
1
353-357
6
Holle J, Freilinger G.
Improvement of continence by myoplasty of the pelvic floor.
Prog Pediatr Surg.
1984;
17
123-130
7
Holschneider A M, Hecker W C.
Flapped and free muscle transplantation in the treatment of anal incontinence.
Z Kinderchir.
1981;
32
244-258
8
Belloli G P, Campobasso P, Girardi G F, Termini C.
Free autogenous muscle grafts in nine children with total anal incontinence.
Pediatr Med Chir.
1981;
3
481-485
9
Cavina E, Seccia M, Evangelista G et al..
Construction of a continent perineal colostomy by using electrostimulated gracilis muscles after abdominoperineal resection: personal technique and experience with 32 cases.
Ital J Surg Sci.
1987;
17
305-314
10
Williams N S, Hallan R I, Koeze T H, Pilot M A, Watkins E S.
Construction of a neoanal sphincter by transposition of the gracilis muscle and prolonged neuromuscular stimulation for the treatment of fecal incontinence.
Ann R Coll Surg Engl.
1990;
72
108-113
11
Baeten C G, Konsten J, Spaans F et al..
Dynamic gracilioplasty for treatment of fecal incontinence.
Lancet.
1991;
338
1163-1165
12
Baeten C G, Geerdes B P, Adang E M, Heineman E, Konsten J, Engel G L et al..
Anal dynamic graciloplasty in the treatment of intractable fecal incontinence.
N Engl J Med.
1995;
332
1600-1605
13
Guelinckx P J, Sinsel N K, Gruwez J A, Lammens M, Bourgeois Jr I.
Neurovascular intact muscle transposition for anal sphincter repair. Experimental model and experience with dynamic pacing.
Dis Colon Rectum.
1995;
38
878-885
14
Guelinckx P J, Sinsel N K, Gruwez J A.
Anal sphincter reconstruction with the gluteus maximus muscle: anatomic and physiologic considerations concerning conventional and dynamic gluteoplasty.
Plast Reconstr Surg.
1996;
98
293-304
15
Wexner S D, Gonzales-Padron A, Rius J et al..
Stimulated gracilis neosphincter operation. Initial experience, pitfalls, and complications.
Dis Colon Rectum.
1996;
39
957-964
16
Rosen H R, Novi G, Zoech G, Feil W, Urbarz C, Schiessel R.
Restoration of anal sphincter function by single-stage dynamic graciloplasty with a modified (split sling) technique.
Am J Surg.
1998;
175
187-193
17
Hajivassiliou C A, Carter K B, Finlay I G.
Assessment of a novel implantable artificial anal sphincter.
Dis Colon Rectum.
1997;
40
711-717
18
Christiansen J, Rasmussen O O, Larsen K L.
Long-term results of artificial anal sphincter implantation for severe anal incontinence.
Ann Surg.
1999;
230
45-48
19
Wong W D, Congliosi S M, Spencer M P et al..
The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study.
Dis Colon Rectum.
2002;
45
1139-1153
20
Congilosi S M, Johnson D R, Medot M et al..
Experimental model of pudendal nerve innervation of a skeletal muscle neosphincter for fecal incontinence.
Br J Surg.
1997;
84
1269-1273
21
Sato T, Konishi F.
Functional perineal colostomy with pudendal nerve anastomosis following anorectal resection: an experimental study.
Surgery.
1996;
119
641-651
22
Sato T, Konishi F, Kanazawa K.
End-to-side pudendal nerve anastomosis for the creation of a new reinforcing anal sphincter in dogs.
Surgery.
2000;
127
92-98
23
Shono T, Nagasaki A, Goto S, Ikeda K.
Experimental free muscle transplantation to the anus using microsurgical technique-a new treatment for anal incompetence.
Z Kinderchir.
1989;
44
352-356
24 Schwabegger A H, Kronberger P, Obrist P, Brath E, Miko I. Functional sphincter ani externus substitute using free innervated latissimus dorsi muscle (LDM) flap: an experimental study in dogs. In: Proceedings of the Inaugural Congress, World Society of Reconstructive Microsurgery, Taipei, Taiwan, October 23-November 3, 2001. Bologna, Italy; Monduzzi Editore 2001: 43-44
25
Ninkovic M, Stenzl A, Hess M, Feichtinger H, Schwabegger A, Colleselli K et al..
Functional urinary bladder wall substitute using free innervated latissimus dorsi muscle (LDM) flap.
Plast Reconstr Surg.
1997;
100
402-414
26
Stenzl A, Ninkovic M, Willeit J et al..
Free neurovascular transfer of latissimus dorsi muscle to the bladder. I. Experimental studies.
J Urology.
1997;
157
1103-1108
27
Stenzl A, Ninkovic M, Kölle D, Knapp R, Anderl H, Bartsch G.
Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle.
Lancet.
1998;
16;351
1483-1485
28
Millesi H.
Invited discussion of Wintsch K, Helaly P. Free flap of gliding tissue.
J Reconstr Microsurg.
1986;
2
151-152
29
Schwabegger A H, Hussl H, Rainer C, Anderl H, Ninkovic M.
Clinical experiences and indications of the free serratus fascia flap, a report of 21 cases.
Plast Reconstr Surg.
1998;
102
1939-1946
30
Wintsch K, Helaly P.
.
Free flap of gliding tissue J Reconstr Microsurg.
1986;
2
143-151
31
Frey M, Gruber H, Freilinger G.
The importance of the correct resting tension in muscle transplantation: experimental and clinical aspects.
Plast Reconstr Surg.
1983;
71
510-518
32
Kadi F, Waling K, Ahlgren C et al..
Pathological mechanisms implicated in localized female trapezius myalgia.
Pain.
1998;
78
191-196
33
Geerdes B P, Kurvers H A, Konsten J, Heineman E, Baeten C G.
Assessment of ischemia of the distal part of the gracilis muscle during transposition for anal dynamic graciloplasty.
Br J Surg.
1997;
84
1127-1129
34
Starke J, Braun J, Gruwez J, Schumpelick V.
Transposition of the gluteus maximus muscle for sphincter replacement in anal incontinence.
Chirurg.
1992;
63
56-60
Univ.-Prof. Dr. Anton H SchwabeggerM.Sc.
Univ. Klinik für Plastische und Wiederherstellungschirurgie
Anichstrasse 35, A-6020 Innsbruck, Austria