Long-term outcome of sphincteroplasty with separate suturing of the internal and the external anal sphincter

Anatomical sphincteroplasty as a surgical treatment for faecal incontinence: proposal for a global anatomical reconstructive surgical procedure and results from a case series

The aim of this study is to describe the technical details and clinical and functional results of anatomical sphincteroplasty as a global reconstructive surgery for the treatment of faecal incontinence caused by anal sphincter lesions. This was a prospective, longitudinal study that included patients who underwent the anatomical sphincteroplasty procedure described here to treat complete sphincter damage. We have described the different technical steps in detail. We evaluated the intraoperative and postoperative complications rate, Cleveland Clinic Score (CCS), a modification of the CCS that included soiling (mCCS), the Faecal Incontinence Quality of Life Scale (FIQLS), and patient satisfaction. An endoanal ultrasound and anorectal manometric study were performed in all the patients. Forty-four patients were included with a mean of 40.5 months follow-up. The CCS reduced from 15 to 3.3 points and the mCCS from 18.5 to 4.5 points over the study period; p < 0.001. Excellent or good results were achieved in 93% of cases. Endoanal ultrasounds showed a good sphincter repair in 66% of the cases. Anorectal manometry showed an increase in the mean maximal resting pressure from 27.6 mmHg to 41.7 mmHg and of the maximal squeeze pressure from 57.9 to 93 mmHg (p < 0.001) with respect to the preoperative values. Anatomical sphincteroplasty is a surgical proposal for the global anatomical reconstruction of anal sphincter lesions, even in cases of very severe damage. The procedure is safe and produced excellent clinical and functional results after a medium-term follow-up.

Short- and long-term outcomes of sphincteroplasty for anal incontinence related to obstetric injury: a systematic review

Anal incontinence is a frequent pathological condition with devastating impact on quality of life. The prevalence is approximately 15% of the population, with higher incidence reported in the elderly and multiparous women, and several factors have a major role in its pathogenesis, such as anatomical sphincter defects (Glasgow and Lowry in Dis Colon Rectum 55(4): 482-490, 2012), delivery injuries, and colorectal, uro-gynecological, and perineal surgery. The direct surgical approach is the gold standard treatment for fecal incontinence, especially through anterior sphincteroplasty, although a permanent defect of continence persists over time. The aim of our study is to evaluate, throughout a systematic review of the literature, the short- and long-term outcomes of sphincteroplasty performed for obstetric injuries anal incontinence. A systematic review of the studies published in the literature from January 2000 to December 2021 was performed in accordance with the PRISMA guidelines. Of the 2543 studies extrapolated, only eight fulfilled the inclusion criteria and were admitted represented by retrospective and prospective studies. The data analyzed from the included studies were number and mean age of the female population, and incontinence improvement with preoperative and postoperative short- and long-term outcomes, as reported by QoL questionaries and incontinence scores. Overall 355 patients with obstetric sphincter damage underwent sphincteroplasty with an anterior external sphincter overlapping procedure. A consistent improvement in fecal incontinence at short-term follow-up with relative improvement in QoL was reported. In 7 of 8 studies, the authors found a progressive worsening of the incontinence symptoms on the long-term follow-up. However, it is not clear whether the decrease in long-term continence results is parallel to a simultaneous decrease in QoL scores. Nevertheless, compared to the preoperative findings, the improvement was maintained in the long-term follow-up. Despite the limited data in the literature, a properly performed sphincteroplasty can guarantee a consistent improvement of the continence in short term with encouraging outcomes, especially for solid stool continence, in long time. We believe that anterior sphincteroplasty, as a low cost, feasible, and safe procedure, still has a role in the treatment of fecal incontinence for obstetric injury. Further large cohort randomized clinical trials are necessary to validate these results.

Long-term functional results of transvaginal anal sphincter repair for faecal incontinence; a retrospective case series

INTRODUCTION AND HYPOTHESIS

We report our experience with a transvaginal approach with overlapping anal sphincter repair. The aim of this cohort study was to evaluate long-term functional outcomes. Women who had undergone transvaginal anal sphincteroplasty for anal incontinence from July 2005 to July 2020 and attended a multidisciplinary team of urogynaecologists and colorectal surgeons at the Mercy Hospital Perineal clinic were included.

METHODS

One hundred seven women were included in the study with a median follow-up of 57.5 months. We analysed outcomes by comparing patient's St Mark's score difference before and after surgery. Meaningful clinical difference (MID) was set at 5 points; complications and patient demographics were recorded along with a question about whether they would recommend this treatment to a friend.

RESULTS

An improvement was seen in 69.3% of women with a marked improvement in 46.5%. Furthermore, 70% said they would recommend the procedure to a friend, if they were in a similar situation. Wound infection or partial perineal breakdown was reported in 45% of women but did not have a significant impact on outcomes.

CONCLUSION

Transvaginal anal sphincter repair is associated with significant improvements in patients' St. Mark's score. Our data show that the long-term success rate of transvaginal/perineal AS repair may be better than previously reported in the literature with 70% of women satisfied at 57 months. Another benefit of the transvaginal route is the possibility of performing a pelvic floor and perineal repair at the time of surgery.

Multimodal Management of Fecal Incontinence Focused on Sphincteroplasty: Long-Term Outcomes from a Single Center Case Series

The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985−2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60−173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS > 15 vs. 2.5% postoperatively; p < 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair.

Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature

INTRODUCTION AND HYPOTHESIS

Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6 months, early secondary repair of the anal sphincter can be completed within 14 days. Our aims were to review the literature and to describe experiences in our unit.

METHODS

This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019.

RESULTS

Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n = 10)], infection [5.2% (n = 5)] and fistula formation [8.2% (n = 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n = 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in those who also underwent secondary repair (Starck score 2.1 vs. 5.7, p = 0.01).

CONCLUSION

Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.

CAN Stryphnodendron adstringens EXTRACT IMPROVE THE RESULTS OF FISTULOTOMY FOLLOWED BY PRIMARY SPHINCTEROPLASTY IN THE TREATMENT OF TRANSSPHINCTERIC FISTULAE?

BACKGROUND

There is still a need for progress in the treatment of transsphincteric anal fistulae and the use of herbal medicines seems promising.

AIM

To evaluate the efficacy of Stryphnodendron adstringens associated with fistulotomy and primary sphincteroplasty in the treatment of transsphincteric fistulae in rats.

METHODS

Thirty Wistar rats were used, which were submitted to transsphincteric fistulas with steel wire 0; after 30 days a treatment was performed according to the group. Group A (n=10) was submitted to fistulotomy; group B (n=10), fistulotomy followed by primary sphincteroplasty with "U" stitch with polyglactin 911 4-0; group C(n=10) , similar to group B, but with the interposition between the muscular stumps of hemostatic sponge soaked in Stryphnodendron adstringens extract. Euthanasia was performed after 14 days, resecting a segment of the anal canal for histological analysis, which aimed to evaluate the closure of the fistula, the area of separation of the muscle cables, the inflammatory process and the degree of fibrosis.

RESULTS

No animal had a remaining fistulous tract. About the spacing between the muscle cables, an average of 106.3 µm2 was observed in group A, 82.8 µm2 in group B and 51.8 µm2 in group C (p<0.05). There was no difference between the groups regarding the inflammatory process and, in relation to fibrosis, in group A there was a mean of 0.6, in group B 0.7 and in group C 0.2 (p<0.05).

CONCLUSIONS

Stryphnodendron adstringens extract was able to allow less spacing between muscle cables in rats submitted to fistulotomy followed by primary sphincteroplasty, in addition to providing less local fibrosis.