Article

Use of the gluteus maximus muscle as the neosphincter for restoration of anal function after abdominoperineal resection

Department of General Surgery, Universidad Pontificia Bolivariana, Clínica de Las Américas, Diagonal 75B #2A-80/308, Medellín, Colombia, .
Techniques in Coloproctology (Impact Factor: 2.04). 12/2012; 17(4). DOI: 10.1007/s10151-012-0961-z
Source: PubMed

ABSTRACT

Background:
Our aim was to evaluate complications and long-term functional outcome in patients who had sphincter reconstruction using the gluteus maximus muscle as the neosphincter after abdominoperineal resection for rectal cancer treatment.

Methods:
Seven patients underwent reconstruction from 2000 to 2010. First, the sigmoid colon was brought down to the perineum as a perineal colostomy, with the procedure protected by a loop ileostomy. Reconstruction of the sphincter mechanism using the gluteus maximus took place 3 months later, and after another 8-12 weeks, the loop ileostomy was closed. We studied the functional outcome of these interventions with follow-up interviews of patients and objectively assessed anorectal function using manometry and the Cleveland Clinic Florida (Jorge-Wexner) fecal incontinence score.

Results:
The mean follow-up was 56 months (median 47; range 10-123 months). One patient had a perianal wound infection and another had fibrotic stricture in the colocutaneous anastomosis that required several digital dilatations. Anorectal manometry at 3-month follow-up showed resting pressures from 10 to 18 mm Hg and voluntary contraction pressures from 68 to 187 mm Hg. Four patients had excellent sphincter function (Jorge-Wexner scores ≤5).

Conclusions:
Our preliminary results show that sphincter reconstruction by means of gluteus maximus transposition can be effective in restoring gastrointestinal continuity and recovering fecal continence in patients who have undergone APR with permanent colostomy for rectal cancer. Furthermore, the reconstruction procedure can be performed 2-4 years after the APR.

Full-text

Available from: Rodrigo Castano, Dec 25, 2013
ORIGINAL ARTICLE
Use of the gluteus maximus muscle as the neosphincter
for restoration of anal function after abdominoperineal resection
J. D. Puerta
´
az
R. Castan
˜
o Llano
L. J. Lombana
J. I. Restrepo
G. Go
´
mez
Received: 22 July 2012 / Accepted: 30 November 2012 / Published online: 15 December 2012
Ó Springer-Verlag Italia 2012
Abstract
Background Our aim was to evaluate complications and
long-term functional outcome in patients who had sphinc-
ter reconstruction using the gluteus maximus muscle as the
neosphincter after abdominoperineal resection for rectal
cancer treatment.
Methods Seven patients underwent reconstruction from
2000 to 2010. First, the sigmoid colon was brought down to
the perineum as a perineal colostomy, with the procedure
protected by a loop ileostomy. Reconstruction of the
sphincter mechanism using the gluteus maximus took place
3 months later, and after another 8–12 weeks, the loop
ileostomy was closed. We studied the functional outcome
of these interventions with follow-up interviews of patients
and objectively assessed anorectal function using
manometry and the Cleveland Clinic Florida (Jorge-Wex-
ner) fecal incontinence score.
Results The mean follow-up was 56 months (median 47;
range 10–123 months). One patient had a perianal wound
infection and another had fibrotic stricture in the colocu-
taneous anastomosis that required several digital dilata-
tions. Anorectal manometry at 3-month follow-up showed
resting pressures from 10 to 18 mm Hg and voluntary
contraction pressures from 68 to 187 mm Hg. Four patients
had excellent sphincter function (Jorge-Wexner scores B5).
Conclusions Our preliminary results show that sphincter
reconstruction by means of gluteus maximus transposition
can be effective in restoring gastrointestinal continuity and
recovering fecal continence in patients who have under-
gone APR with permanent colostomy for rectal cancer.
Furthermore, the reconstruction procedure can be per-
formed 2–4 years after the APR.
Keywords Abdominoperineal resection Colostomy
Fecal incontinence Gluteus maximus transposition
Introduction
Important progress has been made in the treatment of
colorectal cancer in recent decades. Total mesorectal
excision [1] has been accepted and is now widely used,
even by laparoscopic surgeons [2]. The administration of
neoadjuvant therapy [3] has made possible preservative
sphincter surgery as the first choice for treatment of
tumors of the upper and middle thirds of the rectum. In
addition, coloanal anastomosis allows patients with
tumors located in the lower third of the rectum to avoid
abdominal colostomy and improves their quality of life
[4, 5].
J. D. Puerta
´
az (&)
Department of General Surgery, Universidad Pontificia
Bolivariana, Clı
´
nica de Las Ame
´
ricas,
Diagonal 75B #2A–80/308, Medellı
´
n, Colombia
e-mail: puerta58@gmail.com
R. Castan
˜
o Llano
Department of Gastrointestinal Surgery and Endoscopy,
Universidad de Antioquia and Universidad Pontificia
Bolivariana, Hospital Pablo Tobo
´
n Uribe, Medellı
´
n, Colombia
L. J. Lombana
Department of General Surgery, Pontificia Universidad
Javeriana, Hospital Universitario San Ignacio, Bogota
´
, Colombia
J. I. Restrepo
Departments of General Surgery and Coloproctology,
Universidad CES, Hospital Pablo Tobo
´
n Uribe, and Clı
´
nica las
Vegas, Medellı
´
n, Colombia
G. Go
´
mez
Clı
´
nica Saludcoop, Medellı
´
n, Colombia
123
Tech Coloproctol (2013) 17:425–429
DOI 10.1007/s10151-012-0961-z
Page 1
A small proportion, 5–30 %, of patients diagnosed with
rectal cancer still need abdominoperineal resection (APR)
of the rectum [68]. This procedure is performed to obtain
a tumor-free margin with resection of tumors situated less
than 2 cm above the dentate line. Permanent colostomy,
as a consequence of APR, causes psychological trauma,
diminishes the quality of life, and considerably affects the
lifestyle of patients; hence, the restoration of anal function
is a major challenge for the colorectal surgical team
[9, 10].
Charles Chetwood [11] performed the first transposition
of gluteus muscle to reinforce the sphincter muscles and
restore function in 1902. Since then, various modifications
of gluteus maximus transposition for treatment of fecal
incontinence have been described [1215]. In 1930, Chit-
tenden used gluteal muscle flaps for anal reconstruction
after APR [16]. However, most studies using muscle as the
neosphincter after colon descent have used the gracilis
muscle [17, 18]. The technique has been modified by
adding electrostimulation to the graciloplasty [19, 20].
Perineal colostomy has been used [10], and smooth muscle
tissue grafts have been implanted as the neosphincter [9].
Artificial sphincters have also been used [21].
There are certain theoretical advantages to using the
gluteus maximus as a neosphincter instead of other striated
muscles and this is of interest for anal reconstruction after
APR. We published our initial experience with bilateral
transposition of the gluteus muscles for sphincter recon-
struction after APR in 2001 [22]. The aim of the present
study was to evaluate complications and long-term func-
tional outcome after descent of the sigmoid colon and
gluteus transposition in patients who had been previously
treated for rectal cancer with APR and permanent
colostomy.
Materials and methods
From July 2000 through March 2010, we performed anal
reconstruction in 7 patients who had undergone APR with a
permanent colostomy for carcinoma situated in the lower
third of the rectum. The reconstruction was performed
2–10 years after the. Of the 7 patients treated, five had
radiotherapy.
The patients were highly motivated to undergo the
reconstruction procedure and were willing to modify their
lifestyle, including dietary habits. All patients were free of
local or systemic recurrence, and the residual colon was
examined to determine whether its length was sufficient to
carry out the anastomosis with the perianal skin. The sur-
gical team clearly explained the procedures and the pos-
sible adverse effects to the patients. All patients signed an
informed consent form for each surgical procedure.
Surgical technique
Our surgical technique consisted of the following steps: (1)
descent of the sigmoid colon to the perineum as a perineal
colostomy, with the procedure protected by a loop ileos-
tomy; (2) reconstruction of the sphincter mechanism using
the gluteus maximus; and (3) closure of the loop ileostomy.
To prepare the colon for the perineal colostomy, poly-
ethylene glycol was used, and metronidazole was admin-
istered as a prophylactic antibiotic. A laparotomy was
performed by following the APR incision. The peritoneal
cavity was exhaustively reviewed to eliminate any tumoral
recurrence or metastasis. The left colon, the splenic flexure,
and—in a few cases—the transverse colon were freed to be
able to bring the colon down to the perineal skin. The
previous colostomy was then released, preserving the sur-
rounding skin. The pelvis was always dissected following
the median line and very close to the sacrum, until the
perineal skin was reached. Great care was taken to avoid
injuring the urinary bladder and the ureter. The colon was
brought down and an anastomosis was established with the
skin preserved from the previous colostomy. The entire
procedure was protected with a loop ileostomy (Fig. 1).
Reconstruction of the sphincter mechanism was per-
formed 3 months after the colostomy procedure. Bilateral
transposition of the gluteus maximus was carried out by
making an incision, bilaterally, extending from the coccyx
toward the greater trochanter, freeing it from its insertion at
the sacrococcygeal level. The muscle was dissected fol-
lowing the direction of its fibers and conserving its apo-
neurosis. We were very careful to preserve the vascular and
nerve structures situated in the lower half of the muscle,
which exit the pelvis through the greater sciatic foramen.
Enough muscle must be released to ensure that it reaches
the anus without significant tension. Two identical curved
and lateral incisions were made 2 cm from the anus to
Fig. 1 Perineal colostomy
426 Tech Coloproctol (2013) 17:425–429
123
Page 2
avoid laceration of the mucocutaneous fold when closing
the incisions. More than 2.5 cm of skin was needed
between the 2 incisions to avoid necrosis around that area.
These 2 incisions were then joined by a subcutaneous
tunnel, which was made from the incision located in the
gluteus region to the one situated in the perianal area. The
gluteus maximus, previously dissected, was then extracted
from this second incision. The end of the exposed gluteus
was divided into 2 segments, following the direction of its
fibers and leaving enough muscle to poke out from the skin
border. One segment passed in front of, and the other
behind, the anal canal. The segments were then extracted
from the contralateral anal incision and finally sutured on
the opposite side. The identical procedure was performed
with the other gluteus muscle. After 8–12 weeks, the ile-
ostomy was closed (Fig. 2).
Postoperative care
All patients received instructions to perform contraction
and relaxation exercises (Kegel exercises) to train the
neosphincter after the surgery. Patients were asked to
perform the exercise routine every day for 15 min at a
convenient time that did not interfere with their daily
activities or work.
Assessments
Anorectal manometry using 8-channel equipment was
performed 3 months after surgery on all patients. Follow-
up visits and assessments were conducted 2–3 months after
the reconstruction surgery, then at 6 months, and then
every year. A final evaluation was made in 2011 in all
patients except patient number 3, who was evaluated in
2008 and was then lost to follow-up. The Cleveland Clinic
Florida fecal incontinence score (CCF-FIS) (Jorge-Wexner
score) [13] was used to assess incontinence at the last
follow-up visit.
Results
From July 2000 to March 2010, 7 patients underwent anal
reconstruction with gluteus muscle transposition. Table 1
summarizes their demographic characteristics, comorbidi-
ties, and the year the reconstruction procedure was
performed. The mean follow-up was 56 months (median,
47; range, 10–123 months).
Every patient received instructions as to how to carry
out the Kegel exercises of the neosphincter. Three patients
attended a pelvic floor retraining program; the others
reported that the function of their neosphincter was
adequate and did not attend the program.
Anorectal manometry in the 7 patients showed resting
pressures ranging from 10 to 18 mm Hg and voluntary
contraction pressures ranging from 68 to 187 mm Hg. The
values of the pressure obtained adequately correlated with
the function of the sphincter.
Perianal sepsis occurred in 1 patient and abscess drain-
age was performed in both ischiorectal fossas. Another
patient had fibrotic stricture in the colocutaneous
Fig. 2 Right gluteus maximus muscle sutured to the left of the anus
Table 1 Patient characteristics
Patient Date Sex Age Comorbidities Follow-up
(months)
1 2001 M 40 Obesity 123
2 2004 M 30 None 84
3 2005 F 38 Chronic diarrhea 47*
4 2006 M 38 None 54
5 2007 F 66 Diabetes 40
6 2007 M 50 Coronary artery disease 39
7 2010 M 43 None 10
* Lost to follow-up
Table 2 Cleveland Clinic Florida fecal incontinence scores at final
follow-up
Patient Incontinence of Uses
diaper
Lifestyle Total
score
Solids Liquids Gases
100 001 1
200 000 0
303 322 10
402 300 5
503 322 10
600 100 1
701 231 7
Tech Coloproctol (2013) 17:425–429 427
123
Page 3
anastomosis that required several digital dilatations. None
of the patients had tumor recurrence.
Table 2 shows the individual CCF-FIS for the 7 patients
included in the present study. Four patients had excellent
sphincter function, 3 patients used diapers occasionally,
and just 1 used a diaper frequently. In 2 patients, bowel
function was controlled with enemas every 2 days, thus
allowing them to work and have a normal social life. The
four patients with excellent sphincter function could defe-
cate without difficulty and at will. None of the patients
wanted a colostomy again.
Although the gluteus maximus muscle is important for
walking up stairs, none of our patients complained of
difficulties in performing this activity.
Discussion
Our goal is to restore anal function and improve the quality
of life in patients who have had a permanent colostomy
after APR. However, before we propose anal reconstruc-
tion, patients need to be highly motivated to achieve this
goal. Patients with advanced stage cancer or those who
have undergone noncurative resections should not be
considered candidates for reconstruction.
Since the first attempts by Chittenden [16], anorectal
reconstruction after APR has been a major challenge for
colorectal surgical teams, and various methods have been
used. The advantages of the gluteus maximus muscle are
that it is a powerful voluntary muscle, its vascular and
nerve structures can be preserved after liberation from its
origin at the level of the sacrum, and it can be dissected
following the direction of its fibers with a length sufficient
to reach the anal canal. Despite these considerations, the
neosphincter produced by transposition of the gluteus has
received little attention, and only a few sporadic reports
on its use in reconstruction after APR have been pub-
lished [12, 15, 22]. We did not perform electrostimulation
of the gluteoplasty in our patients, although others [23]
have used electrostimulation for fecal incontinence treated
with gluteoplasty. In contrast, a number of reports on the
use of the gracilis muscle have appeared [14]. Simonsen
et al. [17] first described the technique with unstimulated
gracilis muscle in perineal colostomy for restoration of
anal function after APR. Williams et al. [24] and Baeten
et al. [25] used low-frequency chronic electrostimulation
by an implanted pulse generator to change easily fatigued
muscle fibers into resistant muscle by inducing a struc-
tural and metabolic transformation of the fiber from type
II to type I. Cavina et al. [18, 19] then made great pro-
gress in this field: first in a long-term study using a
nonstimulated gracilis muscle in 81 patients and in a
further study using the low-frequency stimulated muscle
in 31 patients. The results of these studies motivated
several groups to use the electrostimulated gracilis as the
neosphincter for total anorectal reconstruction after APR
[26, 27].
The use of an artificial anal sphincter seems promising
[28]. Romano et al. [21] reported good results in 8 patients.
Devesa et al. [29] described a patient who underwent a
perineal colostomy with a coloplasty, internal sphincter
reconstruction using smooth muscle, and placement of an
artificial sphincter with excellent results for continence and
quality of life.
The effectiveness of anorectal reconstruction is difficult
to measure because success depends not only on the pro-
cedure but also on how much the patient exercises the
neosphincter. At the beginning, it is more difficult to
control defecation, but with the Kegel exercises and
retraining of the pelvic floor, continence begins to improve.
Anorectal sensitivity substantially changes but the patients
get used to this situation with time. Changes in dietary
habits and drug use should be implemented to modify the
frequency of defecation and consistency of each stool. The
final outcome in regard to continence is obtained only some
months after surgery.
Assessment of neosphincter function with the CCF-FIS
and anorectal manometry gives us only general idea of
sphincter performance. Although anorectal manometry is a
tool frequently used to monitor sphincter function, resting
pressure correlates only weakly with incontinence [30].
Thus, manometry should only be used as a complementary
tool in the analysis of incontinence.
Our previous experience using the gluteus maximus
transposition technique in 22 patients with fecal inconti-
nence due to various causes resulted in a success rate of
approximately 70 % [15]. The present study group was
too small to draw conclusions, but 4 of the 7 patients
were judged to have excellent sphincter function, and all
stated that they preferred the sphincter reconstruction to
the previous colostomy. The success of anorectal recon-
struction after APR may be influenced by a myriad of
factors that could interfere with the delicate balance
among anatomy, sensitivity mechanisms, and muscular
groups that is responsible for the function of normal
continence [12]. Every part of the reconstruction—descent
of the colon, construction of the neosphincter, and closure
of the protective ileostomy—presents inherent risks. Per-
ianal sepsis, the most frequent complication of such
procedures, occurred in only 1 patient in the present
series. Owing to the comprehensive diagnostic studies we
performed before the procedure, no local or regional
recurrence of cancer was observed in any patient who
underwent reconstruction.
428 Tech Coloproctol (2013) 17:425–429
123
Page 4
Conclusions
Our preliminary results show that sphincter reconstruction
by means of gluteus maximus transposition can be effec-
tive in restoring gastrointestinal continuity and recovering
fecal continence in patients who have undergone APR with
permanent colostomy for rectal cancer. Furthermore, the
reconstruction procedure can be performed 2–10 years
after the APR.
Conflict of interest None.
References
1. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in
rectal cancer surgery–the clue to pelvic recurrence? Br J Surg
69:613–616
2. Breukink S, Pierie J, Wiggers T (2006) Laparoscopic versus open
total mesorectal excision for rectal cancer. Cochrane Database
Syst Rev: CD005200
3. Latkauskas T, Paskauskas S, Dambrauskas Z et al (2010) Pre-
operative chemoradiation vs radiation alone for stage II and III
resectable rectal cancer: a meta-analysis. Colorectal Dis 12:1075–
1083
4. Parks AG, Percy JP (1982) Resection and sutured colo-anal
anastomosis for rectal carcinoma. Br J Surg 69:301–304
5. Drake DB, Pemberton JH, Beart RW Jr, Dozois RR, Wolff BG
(1987) Coloanal anastomosis in the management of benign and
malignant rectal disease. Ann Surg 206:600–605
6. Altomare DF (2005) Total anorectal reconstruction with dynamic
graciloplasty. In: Delaini GG (ed) Rectal cancer: new frontiers in
diagnosis, treatment, and rehabilitation. Springer, Milan
7. Tilney HS, Heriot AG, Purkayastha S et al (2008) A national
perspective on the decline of abdominoperineal resection for
rectal cancer. Ann Surg 247:77–84
8. Marwan K, Staples MP, Thursfield V, Bell SW (2010) The rate of
abdominoperineal resections for rectal cancer in the state of
Victoria, Australia: a population-based study. Dis Colon Rectum
53:1645–1651
9. Hirche C, Mrak K, Kneif S et al (2010) Perineal colostomy with
spiral smooth muscle graft for neosphincter reconstruction fol-
lowing abdominoperineal resection of very low rectal cancer:
long-term outcome. Dis Colon Rectum 53:1272–1279
10. Kirzin S, Lazorthes F, Nouaille de Gorce H, Rives M, Guimbaud R,
Portier G (2010) Benefits of perineal colostomy on perineal mor-
bidity after abdominoperineal resection. Dis Colon Rectum
53:1265–1271
11. Chetwood C (1902) Plastic operation for restoration of the
sphincter ani with report of a case. Med Rec 61:529–531
12. Devesa JM, Vicente E, Enriquez JM et al (1992) Total fecal
incontinence–a new method of gluteus maximus transposition:
preliminary results and report of previous experience with similar
procedures. Dis Colon Rectum 35:339–349
13. Jorge JM, Wexner SD (1993) Etiology and management of fecal
incontinence. Dis Colon Rectum 36:77–97
14. Cera SM, Wexner SD (2005) Muscle transposition: does it still
have a role? Clin Colon Rectal Surg 18:46–54
15. Puerta J, Castan
˜
o R, Hoyos S (1998) Transposicio
´
n del glu
´
teo
mayor en el manejo de la incontinencia fecal. Rev Colomb
Gastroenterol 13:9–18
16. Chittenden AS (1930) Reconstruction of anal sphincter by muscle
slips from the glutei. Ann Surg 92:152–154
17. Simonsen OS, Stolf NA, Aun F, Raia A, Habr-Gama A (1976)
Rectal sphincter reconstruction in perineal colostomies after
abdominoperineal resection for cancer. Br J Surg 63:389–391
18. Cavina E (1996) Outcome of restorative perineal graciloplasty
with simultaneous excision of the anus and rectum for cancer. A
ten-year experience with 81 patients. Dis Colon Rectum 39:
182–190
19. Cavina E, Seccia M, Banti P, Zocco G (1998) Anorectal recon-
struction after abdominoperineal resection. Experience with
double-wrap graciloplasty supported by low-frequency electr-
ostimulation. Dis Colon Rectum 41:1010–1016
20. Altomare DF, Rinaldi M, Pannarale OC, Memeo V (1997)
Electrostimulated gracilis neosphincter for faecal incontinence
and in total anorectal reconstruction: still an experimental pro-
cedure? Int J Colorectal Dis 12:308–312
21. Romano G, La Torre F, Cutini G, Bianco F, Esposito P, Montori
A (2003) Total anorectal reconstruction with the artificial bowel
sphincter: report of eight cases. A quality-of-life assessment. Dis
Colon Rectum 46:730–734
22. Puerta J, Castan
˜
o R, Hoyos S (2001) Reconstruccio
´
n del me-
canismo esfinteriano con la transposicio
´
n del glu
´
teo mayor, luego
de reseccio
´
n abdominoperineal. Rev Colomb Cir 16:225–227
23. Madoff RD, Rosen HR, Baeten CG et al (1999) Safety and
efficacy on dynamic mucle plasty for anal incontinence: lessonjs
from a prospective, multicenter trial. Gastroenterology 116:
549–556
24. Williams NS, Hallan RI, Koeze TH, Watkins ES (1990) Resto-
ration of gastrointestinal continuity and continence after
abdominoperineal excision of the rectum using an electrically
stimulated neoanal sphincter. Dis Colon Rectum 33:561–565
25. Baeten C, Spaans F, Fluks A (1988) An implanted neuromuscular
stimulator for fecal continence following previously implanted
gracilis muscle. Report of a case. Dis Colon Rectum 31:134–137
26. Ho KS, Seow-Choen F (2005) Dynamic graciloplasty for total
anorectal reconstruction after abdominoperineal resection for
rectal tumour. Int J Colorectal Dis 20:38–41
27. Violi V, Boselli AS, De Bernardinis M et al (2004) Surgical
results and functional outcome after total anorectal reconstruction
by double graciloplasty supported by external-source electrosti-
mulation and/or implantable pulse generators: an 8-year experi-
ence. Int J Colorectal Dis 19:219–227
28. Marchal F, Doucet C, Lechaux D, Lasser P, Lehur PA (2005)
Secondary implantation of an artificial sphincter after abdomi-
noperineal resection and pseudocontinent perineal colostomy for
rectal cancer. Gastroenterol Clin Biol 29:425–428
29. Devesa JM, Lopez-Hervas P, Vicente R, Rey A, Die J, Fraile A
(2005) Total anorectal reconstruction: a novel technique. Tech
Coloproctol 9:149–152
30. Bordeianou L, Lee KY, Rockwood T et al (2008) Anal resting
pressures at manometry correlate with the Fecal Incontinence
Severity Index and with presence of sphincter defects on ultra-
sound. Dis Colon Rectum 51:1010–1014
Tech Coloproctol (2013) 17:425–429 429
123
Page 5
  • [Show abstract] [Hide abstract] ABSTRACT: Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed. A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis. Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy. Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.
    No preview · Article · Nov 2014 · International Journal of Colorectal Disease
  • [Show abstract] [Hide abstract] ABSTRACT: Surgical treatment of low rectal malignancies may necessitate an abdominal colostomy. The dream of most patients is to avoid a permanent colostomy. To this end, total anorectal reconstruction offers a possibility for the patient to avoid a permanent colostomy while having a potentially functional quality of life. This chapter provides an overview of the indications, limitations, technique, and outcomes of anorectal reconstruction.
    No preview · Article · Jan 2015