Short- and Long-Term Outcomes of Overlap Anal Sphincter Repair for Fecal Incontinence Following Sphincter Injury

Lakmal, Kasun; Basnayake, Oshan; Jayarajah, Umesh; Samarasekera, Dharmabandhu N

doi:10.1055/s-0041-1724061

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Journal of Coloproctology (Rio de Janeiro)

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Sumário

Original Article • J. Coloproctol. (Rio J.) 41 (01) • Jan-Mar 2021 • https://doi.org/10.1055/s-0041-1724061 copy

Short- and Long-Term Outcomes of Overlap Anal Sphincter Repair for Fecal Incontinence Following Sphincter Injury

Resultados em curto e longo prazos do reparo por sobreposição do esfíncter anal para incontinência fecal após lesão esfincteriana

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Several techniques are used to repair the anal sphincter following injury. The aim of the present study is to comprehensively analyze the short- and long-term outcomes of overlap repair following anal sphincter injury.

Methods

A search was conducted in the PubMed, Medline, Embase, Scopus and Google Scholar databases between January 2000 and January 2020. Studies that described the outcomes that are specific to overlap sphincter repair for fecal incontinence with a minimum follow-up period of one year were selected.

Results

A total of 22 studies described the outcomes of overlap sphincter repair. However, 14 studies included other surgical techniques in addition to overlap repair, and were excluded from the analysis. Finally, data from 8 studies including 429 repairs were analyzed. All studies used at least one objective instrument; however, there was significant heterogeneity among them. Most patients were female (n=407; 94.87%) and the mean age of the included individuals was 44.6 years. The majority of the procedures were performed due to obstetric injuries (n=384; 89.51%). The eight included studies described long-term outcomes, and seven of them demonstrated statistically significant improvements regarding the continence; one study described poor outcomes in terms of overall continence. The long-term scores were significantly better compared with the preoperative scores. However, compared with the shortterm scores, a statistically significant deterioration was noted in the long-term.

Conclusion

The majority of the studies described good long-term outcomes in terms of anal continence after overlap sphincter repair. However, further studies are needed

Keywords:
overlap anal sphincter repair; overlap repair; outcome; fecal incontinence; anal incontinence; sphincter injury

	Author	Location	Study design	N	Demographics	Injury pattern	Timing of the surgery	Preoperative investigations	Type of surgery	Short-term outcome (less than 1 year)	Long-term outcome (more than 1 year)
1	Maldonado et al.,¹²12 Maldonado PA, Mcintire D, Corton MM. Long-Term Outcomes After Overlapping Sphincteroplasty for Cloacal- Like Deformities. Female Pelvic Med Reconstr Surg 2019;25 (04):271-2782019	United States	Retrospective study	29	All-female sample (mean age: 31.8 years)	fourth-degree lacerations (cloacal-like deformities)	Mean: 68.1 months	Presenting symptoms and physical examination	EAS OLR	NA	53.8% reported complete continence at amean follow-up of 7.0 ± 3.6 years
2	Khafagy et al.,⁹9 Khafagy WW, El-Said MM, Thabet WM, et al. Evaluation of anatomical and functional results of overlapping anal sphincter repair with or without the injection of bone marrow aspirate concentrate: a case-control study. Colorectal Dis 2017;19(01):O66-O742017	Egypt	Case-controlstudy	Total -40ORLs in 20 patients	M = 11 (55%); F = 9 (45%); mean age: 30.6 ± 17.5 years	anal fistula (n = 19; 47.5%); perineal trauma (n = 6; 15%); obstetric trauma – third degree perineal tear (n = 5; 12.5%); perianal necrotizing fasciitis (n = 5; 12.5%); hemorrhoidectomy (n = 3; 7.5%); stricturotomy for anal stenosis (n = 2; 5%)	1.01 ± 0.35 years	Wexner continence score, anorectal manometry, Endoanal US	EAS OLR +/-BMAC	6 months to 12 months; mean Wexner score changes from 7.7 to 7.4	NA
3	El-Gazzaz et al.,¹¹11 El-Gazzaz G, Zutshi M, Hannaway C, Gurland B, Hull T. Overlapping sphincter repair: does age matter? Dis Colon Rectum 2012;55(03):256-2612012	United States	Retrospective study	197	All-female sample; 146(74.1%) patients in group A (< 60 yearsold); 51 (25.9%) patients in group B (> 60 years old);overall mean age at surgery: 50.4 years	obstetric injuries	NA	FIQL;FISI	EAS OLR	NA	The mean FISI score changed from 27.2 to 29.8 over an average of 7.7 years of follow-up
4	Zutshi et al.,¹⁰10 Zutshi M, Tracey TH, Bast J, Halverson A, Na J. Ten-year outcome after anal sphincter repair for fecal incontinence. Dis Colon Rectum 2009;52(06):1089-10942009	United States	Prospective	N =44 at the 5-year follow-up, and n = 31 at the 10-year follow-up	Median age at surgery:5-year follow-up group -38.5 years;10-year follow-up group - 44 years	Obstetric trauma: 70.4%;iatrogenic: 15.9%;trauma: 6.8%;not reported: 6.8%	NA	FIQL; FISI; Bristol Stool Form Scale	EAS OLR	NA	Changes in scores from 5 years to 10 years of follow-up:a) mean patient-related FISI – from 21 to 39.39;b) mean surgeon-related FISI – from 20 to 39.97;c) mean FIQL – from 12 to 10.82
5	Dobben et al.,⁸8 Dobben AC, Terra MP, DeutekomM, et al. The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence. AJR Am J Roentgenol 2007;189(02):W70-7 2007	Netherlands	Prospective	30	97% of females; mean age: 50Years (±12 years)	Obstetric trauma: 97%	Median: 6.5years (0.5–22 years)	Vaizey incontinence scoreand Endoanal US, and MRI	EAS ORL	After surgery, the mean Vaizey score improved from 18 to 13 (p < 0.001)	NA
6	Barisic et al.,⁷7 Barisic GI, Krivokapic ZV, Markovic VA, Popovic MA. Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months. Int J Colorectal Dis 2006;21(01):52-562006	Serbia	Prospective	65	Females: 55 (84.61%); males: 10 (15.38%); mean age: 35.9 years (range: 18–64 years).	Obstetric trauma: 72.3%;fistulotomy: 13.8%; non-specificTrauma: 9.2%; war injury:4.6%.	Range: 0.5 to 20 years	Wexner score; Browning–Parks scale; analManometry; electromyography;defecography	EAS OLR	Wexner score improved from 17.8 preoperatively to 3.6 three months after the operation	Wexner deteriorated over time to 6.3 after an average of 80.1 months of follow-up
7	Tjandra et al.,¹⁴14 Tjandra JJ, Han WR, Goh J, Carey M, Dwyer P. Direct repair vs. overlapping sphincter repair: a randomized, controlled trial. Dis Colon Rectum 2003;46(07):937-942, discussion 942-943 2003	Australia	Randomized controlled trial	Total -23;OLR -11direct end-to-end repair -12	all female; DR 47y (32–71), OLR 45y (31–68);	Obstetric trauma	1 year	Endoanal US; anorectal manometry; neurophysiologic; Cleveland Clinic Continence Score	DR ; OLR	Mean Cleveland score changed from17 to 3 postoperatively;maximum squeeze pressure changed from 80 mm Hg to 130 mm Hg postoperatively	Median follow-up of 18 months -improvement in continencescores (p < 0.05).
8	Malouf et al.,¹³13 Malouf AJ, Norton CS, Engel AF, Nicholls RJ, KammMA. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000;355(9200):260-265 2000	United Kingdom	Retrospective	38	All-female sample; mean age: 43 years (26–67 yeaus)	Obstetric-related trauma	NA	Modified Park's continenceScores; resting anal pressure; maximum squeeze anal pressure;sphincter length; pudendal nerve latencies; Endoanal US	OLR	NA	Outcome assessed at a median of 15 and 77 months;at 15 months,median Modified Park's score preoperatively: 4;15 months post operatively: 2; and 77 months postoperatively: 3

	Author	Objective preoperative assessment	Objective postoperative assessment	Short-term outcome	Long-term outcome	Tools
1	Maldonado et al.¹²12 Maldonado PA, Mcintire D, Corton MM. Long-Term Outcomes After Overlapping Sphincteroplasty for Cloacal- Like Deformities. Female Pelvic Med Reconstr Surg 2019;25 (04):271-278	No	No	Yes	Yes	Fecal Incontinence Severity Index
2	Khafagy et al.⁹9 Khafagy WW, El-Said MM, Thabet WM, et al. Evaluation of anatomical and functional results of overlapping anal sphincter repair with or without the injection of bone marrow aspirate concentrate: a case-control study. Colorectal Dis 2017;19(01):O66-O74	Yes	Yes	No	Yes	Wexner Continence Score
3	El-Gazzaz et al.¹¹11 El-Gazzaz G, Zutshi M, Hannaway C, Gurland B, Hull T. Overlapping sphincter repair: does age matter? Dis Colon Rectum 2012;55(03):256-261	No	No	No	Yes	Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index
4	Zutshi et al.¹⁰10 Zutshi M, Tracey TH, Bast J, Halverson A, Na J. Ten-year outcome after anal sphincter repair for fecal incontinence. Dis Colon Rectum 2009;52(06):1089-1094	No	No	No	Yes	Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, Bristol Stool Form Scale
5	Dobben et al.⁸8 Dobben AC, Terra MP, DeutekomM, et al. The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence. AJR Am J Roentgenol 2007;189(02):W70-7	Yes	No	No	Yes	Vaizey Incontinence Score
6	Barisic et al.⁷7 Barisic GI, Krivokapic ZV, Markovic VA, Popovic MA. Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months. Int J Colorectal Dis 2006;21(01):52-56	Yes	No	Yes	Yes	Wexner Score, Browning-Park's Scale
7	Tjandra et al.¹⁴14 Tjandra JJ, Han WR, Goh J, Carey M, Dwyer P. Direct repair vs. overlapping sphincter repair: a randomized, controlled trial. Dis Colon Rectum 2003;46(07):937-942, discussion 942-943	Yes	Yes	Yes	Yes	Cleveland Clinic Continence Score
8	Malouf et al.¹³13 Malouf AJ, Norton CS, Engel AF, Nicholls RJ, KammMA. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000;355(9200):260-265	Yes	No	No	Yes	Modified Park's Scores

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[1] Address for correspondence Dharmabandhu Nandadeva Samarasekera, MD FRCS Eng & Edin, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Western Province, P.O. Box 271, Sri Lanka (e-mail: samarasekera58@yahoo.co.uk).