Living 20 years with perineal colostomy and dynamic graciloplasty - a case report discussing the role of this approach.

backgroundDespite advances in neoadjuvant therapies and surgical techniques, abdominoperineal excision of the rectum (APER) is still necessary in a considerable number of cases, often requiring the creation of a permanent colostomy, which can significantly impact a patient's quality of life (QOL). Total anorectal reconstruction (TAR) with dynamic graciloplasty has emerged as a reconstructive option for patients undergoing APER, aiming to restore continence by avoiding a permanent abdominal colostomy and improving quality of life. However, this approach presents several challenges, including technical complexity and variable long-term outcomes. CASE REPORT: We present the case of a 34-year-old female patient who underwent APER with extended resection (rectum and vaginal wall) due to low rectal adenocarcinoma infiltrating the posterior vaginal wall. Following a prolonged postoperative course and the decision against living with an abdominal colostomy, the patient underwent secondary TAR with reconstruction of the posterior vaginal wall and dynamic graciloplasty in 2001. The procedure included creating a neorectum using a myocutaneous flap for vaginal reconstruction and a gracilis muscle wrap with neurostimulation as a neosphincter. Despite early postoperative complications, the patient achieved satisfactory continence with regular transanal irrigation and lived with the reconstruction for over 20 years. In 2024, the patient returned for management due to the obsolescence of her neurostimulator, which was subsequently removed without deterioration in her continence function.

conclusionThis case highlights the complex and prolonged management challenges associated with TAR and dynamic graciloplasty for patients with severe anorectal dysfunction following APER. While dynamic graciloplasty has been shown to offer some level of continence in patients with faecal incontinence, the need for additional interventions, such as regular irrigation, is often required to maintain quality of life after TAR following APER. The durability of this reconstructive approach and the patient's long-term satisfaction underline its potential as a viable, though technically demanding, alternative to conventional colostomy in selected patients. However, the role of electrically induced muscle fiber transformation ("dynamic graciloplasty") needs to be discussed.