Abstract
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.
Keywords
end-stage fecal incontinence - colostomy - free antropyloric valve flap
