EP870 - Complex anorectal reconstruction for benign end stage fecal incontinence.

Purpose/Background: Complex benign anorectal pathologies with end stage fecal incontinence include congenital anorectal malformations (ARM) and perineal trauma often requiring a stoma, pose significant reconstructive challenges. Traditional surgical approaches for neoanal reconstruction are suboptimal eventually ending in a permanent stoma. We describe anal transposition with sphincter reconstruction and Composite antropyloric valve /gluteus maximus transposition as promising alternative for restoration of incontinence in such cases.

Methods/Interventions: A retrospective analysis of 15 patients undergoing complex anorectal reconstruction was performed. The cohort included 10 patients with congenital ARM (7 with absent anal canal and sphnctyer , 3 with ectopic anus) and 5 patients with end stage perineal trauma resulting in anal canal and sphincter injury. Comprehensive preoperative evaluation including MRI pelvis, anorectal manometry, and sigmoidoscopy Surgical approach: (1) Antropyloric valve/ Gluteus maximus transposition was performed in 7 ARM cases with absent anal canal and sphincter, and in 5 perineal trauma cases with anal canal stricture and sphincter injury (n=12); (2) Transposition of anal canal with overlapping sphincteroplasty was performed in 3 ARM cases with ectopic anus(n=3). Postoperative outcomes were assessed using saline holding test, anorectal manometry, St. Mark's Incontinence Score (SMIS) and Quality of life questionnaire.

Results/Outcomes: Over follow-up duration of 40 months,15 patients (median age 26 years) underwent complex anorectal reconstruction. In the antropyloric valve/ Gluteus maximus transposition group (n=12), postoperative SMIS scores improved significantly from preoperative values of 20-24 (complete incontinence) to a mean of 8.2 ± 2.4, indicating achievement of functional continence. Anorectal manometry showed mean resting pressures of 34 ± 8 mmHg and mean squeeze pressures of 94 ± 12 mmHg at final follow-up. In anal canal transposition with sphincteroplasty group (n=3), mean postoperative SMIS was 4.1 ± 1.2 mmhg, with resting pressures of 52 ± 6 mmHg and squeeze pressures of 103 ± 10 mmHg. Early complications included wound infection in 2 patients and anastomotic leak in 1 patient, both managed conservatively. Average Saline holding time was 2 min in postoperative follow up.One patient had necrosis of APVT graft requiring graft excision and permanent stoma. Patient satisfaction was intermediate , with 10/15 patients (66.6%) reporting significant improvement in quality of life.

Conclusion/Discussion: Antropyloric valve/ Gluteus maximus transposition and anal canal transposition with sphincteroplasty provide viable surgical options for complex anorectal reconstruction in patients with congenital anorectal malformations and traumatic perineal injuries. Our series demonstrates the importance of tailoring the surgical approach based on anatomical findings, with valve transposition reserved for cases with absent sphincter mechanism and sphincteroplasty for cases with salvageable sphincter complex. The comprehensive preoperative assessment including MRI and manometry is crucial for appropriate patient selection and surgical planning. These techniques offer hope for patients with previously limited reconstructive options, though careful patient selection and meticulous surgical technique remain paramount for optimal outcomes.