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Mongardini FM, Cozzolino G, Karpathiotakis M, Cacciatore C, Docimo L. Short- and long-term outcomes of sphincteroplasty for anal incontinence related to obstetric injury: a systematic review. Updates Surg 2023; 75:1423-1430. [PMID: 37516713 DOI: 10.1007/s13304-023-01609-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
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.
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Affiliation(s)
- Federico Maria Mongardini
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giovanni Cozzolino
- Department of Advanced Medical and Surgical Sciences, University of Campania L. Vanvitelli, 80138, Naples, Italy
| | - Menelaos Karpathiotakis
- Department of Surgical Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Chiara Cacciatore
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ludovico Docimo
- Division of General, Oncological, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
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Burkett LS, Canavan TP, Glass Clark SM, Giugale LE, Artsen AM, Moalli PA. Reducing pelvic floor injury by induction of labor. Int Urogynecol J 2022; 33:3355-3364. [PMID: 35976420 PMCID: PMC9383672 DOI: 10.1007/s00192-022-05296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor. METHODS Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion. RESULTS Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL. CONCLUSIONS Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.
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Affiliation(s)
- Linda S Burkett
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
- Virginia Commonwealth University Health System, 1250 East Marshall Street, Richmond, VA, 23298, USA
| | - Timothy P Canavan
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Stephanie M Glass Clark
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Lauren E Giugale
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Amanda M Artsen
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Pamela A Moalli
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA.
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA.
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Stride SL, Hundley VA, Way S, Sheppard ZA. Identifying the factors that influence midwives' perineal practice at the time of birth in the United Kingdom. Midwifery 2021; 102:103077. [PMID: 34252652 DOI: 10.1016/j.midw.2021.103077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/31/2021] [Accepted: 06/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Obstetric Anal Sphincter Injuries (OASI) Care Bundle is designed to reduce the incidence of obstetric anal sphincter injuries. However, introducing behavioural change requires an understanding of current practice. This study aims to establish midwives practise at the time of birth, and the factors that influence this. DESIGN Quantitative research - a national online survey. SETTING Nationwide - United Kingdom (UK). Participants 563 midwives from across the UK. METHODS An online survey of midwives' practice. Midwives were invited to participate through the Supervisor of Midwives network. Consent was sought on the landing page. Data analysis using descriptive and inferential statistics, with sub group analyses were used to explore variations in practice. Measurements Number of midwives using "hands on" the perineum and the influences on midwives' perineal practice at the time of birth. FINDINGS Most midwives preferred to use "hands on" the perineum at the time of birth (61.4%). "Hands on" practise was significantly associated with where midwives worked (p<0.001), risk factors for OASI (p<0.001), and the approach that they were taught in their midwifery training (p<0.01). Midwives expressed lack of confidence in some areas with a third unsure that they could identify the third degree tear category b (38.2%) or c (34.3%). KEY CONCLUSIONS There has been a growth in the number of midwives using "hands on" at the time of birth but midwives feel that they require additional training in regards to identifying an OASI. The study should be repeated following the roll out of the OASI care bundle, to identify its impact on midwives' perineal practice. IMPLICATIONS FOR PRACTICE The study identified that there needs to be an improvement in the recognition of OASI by midwives, and in future repeating the study would identify whether the OASI care bundle has influenced midwives' practice.
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Affiliation(s)
- Sara L Stride
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth Gateway Building, St Paul's Lane, Bournemouth, Dorset. BH8 8AJ.
| | | | | | - Zoë A Sheppard
- Research and Innovation, Dorset County Hospital, Williams Avenue, Dorchester, Dorset. DT1 2JY (present address)
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Haug HM, Carlsen E, Johannessen HO, Johnson E. Short-, long-, and very long-term results of secondary anterior sphincteroplasty in 20 patients with obstetric injury. Int J Colorectal Dis 2021; 36:2775-2778. [PMID: 34528117 PMCID: PMC8589817 DOI: 10.1007/s00384-021-04026-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE More long-term follow-up studies beyond 10 years after secondary sphincteroplasty for obstetric damage are warranted. This prospective study aimed to compare reported data on incontinence and satisfaction in a cohort of such patients examined at short-, long-, and very long-term follow-up. METHODS Twenty out of 33 obstetric patients (61%) operated with secondary anterior overlapping sphincteroplasty during February 1996 to April 2004 were evaluated preoperatively and at short-, long-, and very long-term follow-up. Anal incontinence was scored by a combination of Wexner's and St. Mark's incontinence scores. The patients also reported degree of treatment satisfaction. RESULTS Twenty patients were examined preoperatively and after a median (range) of 5 (2-62), 102 (64-162), and 220 (183-278) months. Corresponding incontinence scores were 11.5 (5-18), 5.5 (1-17) (p < 0.01), 10.0 (0-18) (p > 0.05), and 12.0. (1-18) (p > 0.05). With increasing follow-up times, patients reporting a better outcome were 75%, 65%, and 45%. At very long-term follow-up patients, reports were more dismal than expected in those also reporting improved incontinence cores. Incontinence scores did not improve in patients with neuropathy (n = 5) or patients (n = 5) with more than 10 years of symptoms. CONCLUSION Initial improvement of anal incontinence attenuated with time, in particular from short- to long-term follow-up. Patients with neuropathy experienced no improvement of incontinence. Beyond stoma formation, in compliant patients, one should consider other treatment options like sacral nerve stimulation and neosphincter formation.
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Affiliation(s)
- Helene Marie Haug
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P. O. Box 4956, 0424 Nydalen, Oslo Norway
| | - Erik Carlsen
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P. O. Box 4956, 0424 Nydalen, Oslo Norway
| | - Hans-Olaf Johannessen
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P. O. Box 4956, 0424 Nydalen, Oslo Norway
| | - Egil Johnson
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P. O. Box 4956, 0424 Nydalen, Oslo Norway ,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Kumar S, Medappil N, Singh SK, Chandra A. Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition. Ann Coloproctol 2020; 36:58-61. [PMID: 32146790 PMCID: PMC7069671 DOI: 10.3393/ac.2018.08.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/21/2018] [Indexed: 11/30/2022] Open
Abstract
Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient’s neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark’s incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.
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Affiliation(s)
- Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Noushif Medappil
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Sunil Kumar Singh
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
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