Surgical repair of traumatic cloacal deformity - a video vignette

Clinical and functional outcome of surgery for posttraumatic cloacal deformity

AIM

Cloacal deformity is a disabling condition that severely affects a patient's quality of life. Surgery to repair cloacal deformity remains the mainstay of treatment. The aim of this study is to assess the clinical and functional outcome of patients treated for traumatic cloacal deformity by three different techniques.

METHOD

A retrospective multicentre study was carried out using data from women operated on for cloacal deformity between 2015 and 2019. Demographic characteristics, the presence of urinary and/or faecal incontinence and manometric findings were collected. The main outcome measures were represented by St Mark's and Rockwood faecal incontinence quality of life scores.

RESULTS

Thirty eight women with a median age of 34 years [interquartile range (IQR) 31-39 years] were enrolled. Perineoplasty was performed in 23 patients by direct suture of the rectovaginal septum, in five using the X-flap and in 10 by the Singapore flap. Median resting and squeezing pressures increased significantly from 28.15 (IQR 23-32.7) cmH₂ O to 45 (IQR 31-60.7) cmH₂ O (p = 0.0001) and from 47 (IQR 41.2-54.7) cmH₂ O to 97.2 (IQR 80-118) cmH₂ O (p = 0.0001), respectively. Maximum tolerable volume improved from 120 (IQR 90-137.5) ml to 137.5 (IQR 120-150) ml (p = 0.002). The St Mark's score decreased from 18 (IQR 14-20) to 4.5 (IQR 2-8) after 20 months (p = 0001). Sexual activity was confirmed by 16 patients preoperatively and by 27 postoperatively. A diverting stoma was performed in three patients after X-flap perineoplasty and in 14 treated by direct closure. No significant differences were found pre- and postoperatively between the three groups.

CONCLUSION

Regardless of the technique used, surgical repair significantly improves both clinical and functional outcomes irrespective of the presence of a covering stoma.

Traumatic deficient perineum: surgical management and outcome from a single center

INTRODUCTION AND HYPOTHESIS

Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair.

METHODS

Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS.

RESULTS

There were 20 patients (median age 55.5 years; range 29-81 years) with a median duration of incontinence symptoms of 174 (range 1-540) months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322) months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients.

CONCLUSIONS

Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.