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Background: We undertook a prospective longitudinal study of patients with end-stage fecal incontinence who were undergoing transposition of the gracilis muscle as a neo-anal sphincter with external low-frequency electrical stimulation of the nerve to the gracilis combined with biofeedback., Methods: A total of 31 patients (21 male, 10 female: median age: 22 years; range: 4-77 years) underwent this procedure for treatment of traumatic disruption (11 patients, 35%), congenital atresia (11 patients, 35%), iatrogenic injury (6-20%), and perineal sepsis (3 patients, 10%). The gracilis muscle was transposed at operation in an alpha or gamma configuration. Low-frequency (7 Hz) transcutaneous electrical stimulation commenced 2 weeks after operation and was continued for up to 12 weeks. Biofeedback therapy, which consisted of supervised neosphincter squeeze exercises, commenced simultaneously and continued for up to 28 weeks. Outcome was assessed by clinical examination, anal manometry, the Cleveland Clinic Florida continence score (CCFS), and the Rockwood quality of life scale (FIQL). Successful outcome was defined by improvement in clinical outcome, patient satisfaction, a positive result on anal manometry, and/or CCFS < 9, or FIQL > or = 4., Results: At median follow-up of 67 months, overall improvement was seen in 22 (71%). Maximum resting pressure (MRP) and maximum squeeze pressure (MSP) improved significantly after operation [MRP pre versus post, mean (SD), cm water-13.8 (9.6) versus 20.9 (11.3); P = 0.01; and MSP 36.6 (22.4) versus 95.4 (71.2), P = 0.001]. In a subset of 18 patients who showed improvement after operation, the CCFS score (mean, SD) improved from 19.2 (3.4) to 5.2 (5.6); P = 0.0001. FIQL (mean, SD) showed significant improvement in all four domains in 14 patients who reported improvement since the year 2000., Conclusions: A modified dynamic gracilis neoanal sphincter for end-stage fecal incontinence helps restore and sustain continence with improvement in quality of life in the majority of patients. The procedure was most effective as augmentation in those who had suffered a traumatic injury, when compared with patients with congenital atresia and sepsis that had resulted in loss of the native anal sphincter.

Introduction: Fecal incontinence (FI) impairs quality of life. We performed an audit of biofeedback (BFB) in management of patients with FI., Methods: Fifty patients (median [range] age 30 [4-77] years; 28 men) who received BFB for median (range) of 15 weeks (4-28), either postoperatively (n=39), or as the sole treatment (n=11) were evaluated. Cleveland continence score (0-good, 20-poor), anorectal manometry parameters, and patient satisfaction (assessed by Fecal Incontinence Quality of Life Scale [FIQLS]) were evaluated at baseline and after the BFB therapy in all patients., Results: Continence scores improved after intervention. In the surgery + BFB group, mean (SD) continence scores baseline vs. postsurgery + BFB (post-treatment) were 18.2 (3.9) vs. 6 (5.9; p< 0.01). In the BFB alone group, scores were similar at baseline 11.7 (5.9) and 6.1 (5.2) post BFB (p=0.08). Maximum resting anal pressure (MRP) improved from preoperative 12.6 (9.8) mmHg to: vs. 21.1 (11.9) mmHg post-treatment (p< 0.01). In patients who received BFB alone, MRP did not change significantly (pre vs post BFB 22.9 (11.7) mmHg vs. 29.6 (12.1) mmHg [p=0.08]). Maximal squeeze pressure improved significantly (preoperative vs. post-treatment: 46.3 (41.2) mmHg vs. 78.3 (33.9) mmHg [p< 0.01]; pre vs. post BFB alone: 72.4 (34.8) mmHg vs. 114.5 (43.1) mmHg [p< 0.01]). In 29 patients (19 surgery + BFB; 10 BFB alone), maximal tolerable volume in saline continence improved from baseline 47.9 (27.4) mL to 152.6 (87) mL after surgery + BFB (p< 0.01); pre vs. post BFB: 98 mL (95.9) vs. 205 (134.3) p< 0.02]. There was significant improvement in all parameters of FIQLS in both groups: lifestyle (p< 0.02), coping/behavior (p< 0.02), depression/self perception (p< 0.02) and embarrassment (p< 0.02)., Conclusion: BFB therapy with or without surgical reconstruction of the damaged anal sphincter improves maximum squeeze pressure, saline retention capacity, quality of life and is a useful first line treatment for fecal incontinence.