VA100 - 2026 ASCRS Barton Hoexter, MD, Best Video Award Fluorescence Enhanced Composite Antropyloric Gluteus Maximus Transposition for Neoanal Reconstruction.

Purpose/Background: End stage fecal incontinence requiring permanent stoma has a significant negative impact on physical, mental and social well-being of the patient. Besides affecting the quality of life, it imparts a considerable economic burden to the patient in our part of the world. We had earlier described Composite Antropyloric (AP) Gluteus Maximus Transposition as a novel method of Neoanal Reconstruction, AP valve being smooth muscle segment provides resting tone and gluteus as skeletal muscle giving voluntary squeeze. We now describe its modification using ICG enhanced Intraoperative Navigation to improve vascularity and survival of the perineally transposed graft.

Methods/Interventions: 5 consecutive patients requiring permanent colostomy following failed conventional treatments (3 with perineal trauma, 2 congenital anorectal malformation) were included. Patients were evaluated for anatomic integrity (using MRI pelvis, 3D ultrasonography, sigmoidoscopy), Functional status (using Saline retention test, High definition Manometry to measure resting and squeeze sphincter pressures) and subjective assesment using SIMS and locally validated Qol score. In the first stage, the patients underwent transposition of AP valve to the perineum. During this procedure, ICG was used to deliniate gastroepiploic arcade and preserve the infrapyloric vessels and objectively determine the vascularity of APV graft before its perineal transposition. As a second stage, inferior half of the Gluteus maximus was wrapped around the perineally transposed AP graft based on the inferior gluteal artery visualised by ICG. Finally, bowel continuity was restored. Three months thereafter the procedure we assessed the continence of the patient using the above mentioned criteria.

Results/Outcomes: Between January 2022 to June 2024, 5 patients underwent the procedure. Intraop completeness of GE arcade and preservation of infrapyloric vessels were accomplished in all 5 patients using ICG. Use of ICG helped optimise graft vascularity obviating the need for supercharging. There was significant improvement in the SMIS scores (22 vs 8), post-operative mean resting (12.25 vs 22.45 mmHg) and squeeze (20.63 vs 110.18 mmHg) pressures. On personal interview all patients were satisfied with their quality of life. One patient had wound infection at the pylorus transposed site and one patient had wound infection at the colostomy site which were managed conservatively.

Conclusion/Discussion: ICG navigation aids the surgeon intraoperatively to define the pedicle, optimize the vascularity of the transposed graft which may improve outcomes. Fluorescence Enhanced Composite Antropyloric/ GM reconstruction could be a more reliable alternative for patients with end stage fecal incontinence for neoanal reconstruction.