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Techniques in Coloproctology

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01-03-2020 | Fecal Incontinence | Original Article

Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life

Authors: M. Barbosa, M. Glavind-Kristensen, P. Christensen

Published in: Techniques in Coloproctology | Issue 3/2020

Abstract

Background

An early secondary repair of the anal sphincter may be necessary if primary repair of obstetric anal sphincter injury (OASIS) is complicated by wound rupture or severe infection. The objective of this study was to assess the long-term functional outcomes, morbidity, and impact on quality of life (QoL) following an early secondary repair of OASIS.

Methods

This retrospective cohort study was conducted at Aarhus University Hospital, Denmark. All women having a secondary repair of the anal sphincter within 21 days of delivery from February 1991 to February 2017 were included (n = 51). Complications were assessed by reviewing medical records. The patient-reported outcomes were assessed in 2018 by questionnaires. Primary outcome was Wexner score and St. Mark’s score. Impact on QoL was assessed using the Fecal Incontinence Quality of Life Scale (FIQLS).

Results

After a median follow-up time of 6.7 years (IQR 3.3–16.6), 34 women completed the questionnaire. The mean (SD) Wexner score was 5.2 ± 4.7 and the mean (SD) St. Mark’s score was 6.8 ± 5.7. Women with a Wexner score ≥ 9 had a significantly lower QoL score in all domains of the FIQLS compared to women with a Wexner score < 9 (p < 0.001). Postoperative complications were experienced by 37%. Ten women developed a fistula of which nine required surgical treatment.

Conclusions

An early secondary repair of the anal sphincter can be performed within 21 days of delivery with functional long-term outcomes comparable to those following a late sphincter repair. However, there is an imminent risk of complications, mainly fistulas, which should be taken into consideration when choosing the ideal timing of the repair.

Linneberg S, Leenskjold S, Glavind K (2016) A five year follow-up of women with obstetric anal sphincter rupture at their first delivery. Eur J Obstet Gynecol Reprod Biol 203:315–319. https://doi.org/10.1016/j.ejogrb.2016.06.018 CrossRefPubMed

Dudding TC, Vaizey CJ, Kamm MA (2008) Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 247(2):224–237. https://doi.org/10.1097/SLA.0b013e318142cdf4 CrossRefPubMed

Friedman AM, Ananth CV, Prendergast E, D'Alton ME, Wright JD (2015) Evaluation of third-degree and fourth-degree laceration rates as quality indicators. Obstet Gynecol 125(4):927–937. https://doi.org/10.1097/aog.0000000000000720 CrossRefPubMed

Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN (2010) An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 21(1):5–26. https://doi.org/10.1007/s00192-009-0976-9 CrossRefPubMed

Kirss J, Pinta T, Bockelman C, Victorzon M (2016) Factors predicting a failed primary repair of obstetric anal sphincter injury. Acta Obstet Gynecol Scand 95(9):1063–1069. https://doi.org/10.1111/aogs.12909 CrossRefPubMed

Stock L, Basham E, Gossett DR, Lewicky-Gaupp C (2013) Factors associated with wound complications in women with obstetric anal sphincter injuries (OASIS). Am J Obstet Gynecol 208(4):327.e321–327.e326. https://doi.org/10.1016/j.ajog.2012.12.025 CrossRef

Cunningham FGW, Whitridge J (1993) Puerperal infection. In: Gary Cunningham F et al (eds) Williams obstetrics, 19th edn. Appleton and Lange, Norwalk

Fang DT, Nivatvongs S, Vermeulen FD, Herman FN, Goldberg SM, Rothenberger DA (1984) Overlapping sphincteroplasty for acquired anal incontinence. Dis Colon Rectum 27(11):720–722CrossRef

Abrams PC (ed) (2009) Incontinence, 4th edn. Health Publications Ltd

10.

Hauth JC, Gilstrap LC 3rd, Ward SC, Hankins GD (1986) Early repair of an external sphincter ani muscle and rectal mucosal dehiscence. Obstet Gynecol 67(6):806–809CrossRef

11.

Soerensen MM, Bek KM, Buntzen S, Hojberg KE, Laurberg S (2008) Long-term outcome of delayed primary or early secondary reconstruction of the anal sphincter after obstetrical injury. Dis Colon Rectum 51(3):312–317. https://doi.org/10.1007/s10350-007-9084-4 CrossRefPubMed

12.

Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36(1):77–97CrossRef

13.

Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999) Prospective comparison of faecal incontinence grading systems. Gut 44(1):77–80CrossRef

14.

Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43(1):9–16 (discussion 16-17) CrossRef

15.

Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381. https://doi.org/10.1016/j.jbi.2008.08.010 CrossRefPubMed

16.

Arona AJ, al-Marayati L, Grimes DA, Ballard CA (1995) Early secondary repair of third- and fourth-degree perineal lacerations after outpatient wound preparation. Obstet Gynecol 86(2):294–296CrossRef

17.

Lewicky-Gaupp C, Tavathia M, Mueller M, Collins S, Kenton K (2019) 60: obstetric anal sphincter injury breakdown: is early repair successful? Am J Obstet Gynecol 220(3):S747. https://doi.org/10.1016/j.ajog.2019.01.090 CrossRef

18.

Hankins GD, Hauth JC, Gilstrap LC 3rd, Hammond TL, Yeomans ER, Snyder RR (1990) Early repair of episiotomy dehiscence. Obstet Gynecol 75(1):48–51PubMed

19.

Buie WD, Lowry AC, Rothenberger DA, Madoff RD (2001) Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty. Dis Colon Rectum 44(9):1255–1260CrossRef

20.

Gibbs DH, Hooks VH 3rd (1993) Overlapping sphincteroplasty for acquired anal incontinence. South Med J 86(12):1376–1380CrossRef

21.

Grey BR, Sheldon RR, Telford KJ, Kiff ES (2007) Anterior anal sphincter repair can be of long term benefit: a 12-year case cohort from a single surgeon. BMC Surg 7:1. https://doi.org/10.1186/1471-2482-7-1 CrossRefPubMedPubMedCentral

22.

Halverson AL, Hull TL (2002) Long-term outcome of overlapping anal sphincter repair. Dis Colon Rectum 45(3):345–348CrossRef

23.

Oom DM, Gosselink MP, Schouten WR (2009) Anterior sphincteroplasty for fecal incontinence: a single center experience in the era of sacral neuromodulation. Dis Colon Rectum 52(10):1681–1687. https://doi.org/10.1007/DCR.0b013e3181b13862 CrossRefPubMed

24.

Barbosa M, Glavind-Kristensen M, Moller Soerensen M, Christensen P (2019) Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up. Colorectal Dis. https://doi.org/10.1111/codi.14792 CrossRefPubMed

25.

Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA (2000) Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet (Lond, Engl) 355(9200):260–265CrossRef

26.

Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN (2004) Long-term results of anterior sphincteroplasty. Dis Colon Rectum 47(5):727–731. https://doi.org/10.1007/s10350-003-0114-6(discussion 731-722) CrossRefPubMed

27.

Zorcolo L, Covotta L, Bartolo DC (2005) Outcome of anterior sphincter repair for obstetric injury: comparison of early and late results. Dis Colon Rectum 48(3):524–531. https://doi.org/10.1007/s10350-004-0770-1 CrossRefPubMed

28.

Engel AF, Kamm MA, Sultan AH, Bartram CI, Nicholls RJ (1994) Anterior anal sphincter repair in patients with obstetric trauma. Br J Surg 81(8):1231–1234CrossRef

29.

Browning GG, Motson RW (1984) Anal sphincter injury. Management and results of parks sphincter repair. Ann Surg 199(3):351–357CrossRef

30.

Maslekar S, Gardiner AB, Duthie GS (2007) Anterior anal sphincter repair for fecal incontinence: good longterm results are possible. J Am Coll Surg 204(1):40–46. https://doi.org/10.1016/j.jamcollsurg.2006.10.008 CrossRefPubMed

31.

Lo J, Osterweil P, Li H, Mori T, Eden KB, Guise JM (2010) Quality of life in women with postpartum anal incontinence. Obstet Gynecol 115(4):809–814. https://doi.org/10.1097/AOG.0b013e3181d4160d CrossRefPubMed

32.

Samarasekera DN, Bekhit MT, Wright Y, Lowndes RH, Stanley KP, Preston JP, Preston P, Speakman CT (2008) Long-term anal continence and quality of life following postpartum anal sphincter injury. Colorectal Dis 10(8):793–799. https://doi.org/10.1111/j.1463-1318.2007.01445.x CrossRefPubMed

33.

Smith TM, Menees SB, Xu X, Saad RJ, Chey WD, Fenner DE (2013) Factors associated with quality of life among women with fecal incontinence. Int Urogynecol J 24(3):493–499. https://doi.org/10.1007/s00192-012-1889-6 CrossRefPubMed

34.

Heymen S (2004) Psychological and cognitive variables affecting treatment outcomes for urinary and fecal incontinence. Gastroenterology 126(1 Suppl 1):S146–S151CrossRef

35.

Rydningen MB, Dehli T, Wilsgaard T, Lindsetmo RO, Kumle M, Stedenfeldt M, Norderval S (2017) Sacral neuromodulation for faecal incontinence following obstetric sphincter injury—outcome of percutaneous nerve evaluation. Colorectal Dis 19(3):274–282. https://doi.org/10.1111/codi.13472 CrossRefPubMed

36.

Seong MK, Jung SI, Kim TW, Joh HK (2011) Comparative analysis of summary scoring systems in measuring fecal incontinence. J Korean Surg Soc 81(5):326–331. https://doi.org/10.4174/jkss.2011.81.5.326 CrossRefPubMedPubMedCentral

37.

Vaizey CJ (2014) Faecal incontinence: standardizing outcome measures. Colorectal Dis 16(3):156–158. https://doi.org/10.1111/codi.12566 CrossRefPubMed

38.

Scheer I, Andrews V, Thakar R, Sultan AH (2008) Urinary incontinence after obstetric anal sphincter injuries (OASIS)—is there a relationship? Int Urogynecol J Pelvic Floor Dysfunct 19(2):179–183. https://doi.org/10.1007/s00192-007-0431-8 CrossRefPubMed

39.

Mous M, Muller SA, de Leeuw JW (2008) Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG 115(2):234–238. https://doi.org/10.1111/j.1471-0528.2007.01502.x CrossRefPubMed

40.

Signorello LB, Harlow BL, Chekos AK, Repke JT (2001) Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 184(5):881–888. https://doi.org/10.1067/mob.2001.113855(discussion 888-890) CrossRefPubMed

41.

Fodstad K, Staff AC, Laine K (2016) Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecol J 27(10):1513–1523. https://doi.org/10.1007/s00192-016-3015-7 CrossRefPubMed

42.

Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Oian P (2014) Anal incontinence, urinary incontinence and sexual problems in primiparous women—a comparison between women with episiotomy only and women with episiotomy and obstetric anal sphincter injury. BMC Women’s Health 14:157. https://doi.org/10.1186/s12905-014-0157-y CrossRefPubMedPubMedCentral

43.

Rothbarth J, Bemelman WA, Meijerink WJ, Buyze-Westerweel ME, van Dijk JG, Delemarre JB (2000) Long-term results of anterior anal sphincter repair for fecal incontinence due to obstetric injury/with invited commentaries. Dig Surg 17(4):390–393 (discussion 394) CrossRef

44.

Rothbarth J, Bemelman WA, Meijerink WJ, Stiggelbout AM, Zwinderman AH, Buyze-Westerweel ME, Delemarre JB (2001) What is the impact of fecal incontinence on quality of life? Dis Colon Rectum 44(1):67–71CrossRef

45.

Kuismanen K, Nieminen K, Karjalainen K, Lehto K, Uotila J (2018) Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment. Tech Coloproctolog 22(3):209–214. https://doi.org/10.1007/s10151-018-1770-9 CrossRef

Title: Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life
Authors: M. Barbosa
M. Glavind-Kristensen
P. Christensen
Publication date: 01-03-2020
Publisher: Springer International Publishing
Keyword: Fecal Incontinence
Published in: Techniques in Coloproctology / Issue 3/2020
Print ISSN: 1123-6337
Electronic ISSN: 1128-045X
DOI: https://doi.org/10.1007/s10151-019-02146-z

At a glance: The STEP trials

Springer Medicine

Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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