Free Antropyloric Valve Flap for End-Stage Fecal Incontinence as a Substitute to Permanent Colostomy.

BACKGROUND: Surgical removal of the anal canal and sphincter for carcinoma results in end-stage fecal incontinence (ESFI) and requires a permanent colostomy resulting in significant impact on quality of life. Presently, there are limited options for EFSI. The successful use of pedicled antropyloric valve (APV) based on left gastroepiploic artery as an alternative to permanent colostomy has previously been described. It is based on a long omental pedicle which at times is risky and is difficult to perform. A free APV flap could be the only solution in such cases. We assessed the vascular anatomy for the technical feasibility of a free APV flap, and report the first ever clinical application of free APV flap.

METHODS: Bench dissection of 10 pancreaticoduodenectomy specimens was done to delineate the vessels of APV flap. It showed the consistent presence of right gastroepiploic and infrapyloric vessels in all specimens with sufficient diameters. After the technical feasibility, a free APV Flap transposition to perineum was done in a patient, where pedicled transposition was not feasible.

RESULTS: The free APV flap with vagus nerve branch was harvested without extensive dissection along the greater curvature of stomach. A tension free anastomosis was achieved between the epiploic and left colic vessels. The flap survived well and had a definite tone on digital examination. It was evaluated by radiological and manometric methods.

CONCLUSIONS: APV flap for EFSI can be done as a free flap with distinct advantages and it has the potential of becoming popular options for EFSI.