Introduction: For patients with severe fecal incontinence, who have failed medical therapy, surgical reconstruction of the anal sphincter, by dynamic gluteoplasty, may provide symptomatic relief and improve quality of life. However, donor site morbidity may be significant, and long-term results are largely unknown. The purpose of this study is to report technical refinements with gluteoplasty, to assess donor-site morbidity, and to determine functional outcome.

Methods: We performed a retrospective analysis of 22 consecutive patients undergoing gluteoplasty for fecal incontinence, at a university teaching hospital. Charts were reviewed for patient demographics, past medical history, management of complications, and long-term outcome. During the study period, our operative technique evolved and now includes the following caveats: 1) sigmoid incision at the inferior gluteal fold, 2) sparing of the posterior femoral cutaneous nerve, 3) harvest of the lower third of the gluteus maximus muscle, including its insertion on the femur, 4) identification and preservation of the inferior gluteal neuro-vascular pedicle, 5) splitting of the flap for anterior transposition of the superior slip and posterior transposition of the inferior slip, 6) tendon-type repair of the flap to the contralateral ischial tuberosity, and 7) advancement of the remaining gluteus for coverage of the sciatic nerve.

Results: From October 1996 to February 2003, 22 patients (19 female, 3 male; mean age 43 years, range 23-65 years) underwent dynamic unilateral gluteoplasty for reconstruction of the anal sphincter. All patients had severe fecal incontinence, refractory to aggressive medical therapy, documented by manometry and endorectal ultrasound. Etiology of incontinence was as follows: obstetrical injury (n=11), irritable bowel syndrome (n=3), previous rectal surgery (n=3), Crohn’s disease (n=2), impalement (n=1), rectocele (n=1), and idiopathic (n=1). Gluteoplasty was successful in restoring continence in 17 patients (77.3%), was partially successful in 3 patients (13.6%), and was not successful in 2 patients (9.1%), both of whom ultimately required permanent ostomy. Of note, biofeedback improved functional outcome in 5 of 6 patients who initially had partial or no continence after gluteoplasty. Donor site morbidity was observed in 13 patients (59.1%) and included posterior thigh numbness (n=7), dysthesias (n=5), cellulitis (n=4), irregular contour (n=2), and seroma (n=1), but no hip dysfunction or altered gait. Perirectal complications were noted in 11 patients (50%) and included delayed wound healing (n=2), flap dehiscence (n=2), cellulitis (n=2), perirectal abscess requiring temporary fecal diversion (n=2), recurrent fistula (n=1), rectal prolapse (n=1), and chronic pelvic pain (n=1). Mean length of follow-up was 22 months.

Conclusions: Dynamic gluteoplasty to reconstruct the anal sphincter was successful or partially successful in restoring fecal continence in the vast majority of carefully selected patients (19/22, 86.4%). Perineal complications and donor site morbidity were frequent, but permanent, severe sequelae were uncommon. Refinements in surgical technique, such as preservation of the posterior femoral cutaneous nerve and improved tendon fixation, may reduce morbidity while further optimizing functional outcome.
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