The Interventional Procedures Advisory Committee (IPAC) reconsidered this procedure in light of the HTA Programme-funded evaluation of the National Specialist Commissioning Advisory Group (NSCAG) service. The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on stimulated graciloplasty for faecal incontinence.
This procedure is used to treat otherwise intractable faecal incontinence.
Stimulated graciloplasty involves the creation of a new anal sphincter using transposed gracilis muscle. The muscle is moved from the thigh and implanted with electrode from an electric pulse generator. The continuous current of the pulse generator gradually converts the skeletal muscle fibres of the gracilis into smooth muscles fibres, thus allowing sustained contraction of the new anus and producing continence to faeces.
The procedure can be performed in stages, or all at once. Generally it involves mobilising one or both gracilis muscles by detaching the muscles from the knee ligament. The muscle remains fastened to its pelvic attachments with the blood supply intact, but is brought up into the abdomen, where it is placed around the anus, which may be pre-existing but not functioning, or be created from other tissues such as colon pulled through after an operation such as abdominoperineal resection. The 'knee-end' of the gracilis is fastened to the contralateral pelvis. A pulse generator is implanted in the abdomen and electrodes are implanted in the gracilis.
Training of the gracilis begins some weeks after the operation, with the periods that the pulse generator is switched on gradually increasing until the conversion of the gracilis fibres from skeletal to smooth muscle is largely completed.
The standard intervention for otherwise intractable faecal incontinence is colostomy.
Depending on the details of the procedure performed one of the following OPCS-4 codes is utilised:
H57.4 Creation of graciloplasty sphincter
H57.5 Placement of dynamic graciloplasty sphincter
H57.6 Maintenance of dynamic graciloplasty sphincter
H57.7 Removal of dynamic graciloplasty sphincter