Overlapping sphincteroplasty: is it the standard of care?
Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have altera...
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| Published in: | Clinics in colon and rectal surgery Vol. 18; no. 1; p. 22 |
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| Main Authors: | , |
| Format: | Journal Article |
| Language: | English |
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United States
01.02.2005
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| ISSN: | 1530-9681, 1530-9681 |
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| Abstract | Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition. |
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| AbstractList | Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition. Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition.Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition. |
| Author | Goetz, Laura H Lowry, Ann C |
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| Keywords | obstetric trauma anal sphincter injury Fecal incontinence overlapping sphincteroplasty |
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| References_xml | – reference: 8416784 - Dis Colon Rectum. 1993 Jan;36(1):77-97 – reference: 5131253 - Proc R Soc Med. 1971 Dec;64(12):1187-9 – reference: 8969660 - Dis Colon Rectum. 1996 Dec;39(12):1356-60 – reference: 10211495 - Dis Colon Rectum. 1999 Feb;42(2):193-5 – reference: 12004213 - Dis Colon Rectum. 2002 May;45(5):635-40 – reference: 8173367 - BMJ. 1994 Apr 2;308(6933):887-91 – reference: 9106697 - Dis Colon Rectum. 1997 Apr;40(4):462-7 – reference: 10859083 - Dis Colon Rectum. 2000 Jun;43(6):813-20 – reference: 832558 - Dis Colon Rectum. 1977 Jan-Feb;20(1):33-5 – reference: 11084569 - Am J Obstet Gynecol. 2000 Nov;183(5):1220-4 – reference: 9075757 - Dis Colon Rectum. 1997 Feb;40(2):197-200 – reference: 9556246 - Dis Colon Rectum. 1998 Feb;41(2):209-14 – reference: 10613469 - Dis Colon Rectum. 1999 Dec;42(12):1525-32 – reference: 10826416 - Dis Colon Rectum. 2000 May;43(5):590-6; discussion 596-8 – reference: 11711725 - Dis Colon Rectum. 2001 Nov;44(11):1567-74 – reference: 15129307 - Dis Colon Rectum. 2004 Jun;47(6):858-63 – reference: 12847369 - Dis Colon Rectum. 2003 Jul;46(7):937-42; discussion 942-3 – reference: 7956570 - Dis Colon Rectum. 1994 Nov;37(11):1065-9 – reference: 2704499 - Obstet Gynecol. 1989 May;73(5 Pt 1):732-8 – reference: 11584195 - Dis Colon Rectum. 2001 Sep;44(9):1255-60 – reference: 10232879 - Scand J Gastroenterol. 1999 Mar;34(3):315-8 – reference: 10675072 - Lancet. 2000 Jan 22;355(9200):260-5 – reference: 10910243 - Dis Colon Rectum. 2000 Jul;43(7):961-4; discussion 964-5 – reference: 1555052 - Br J Surg. 1992 Feb;79(2):104-6 – reference: 10711565 - Obstet Gynecol. 2000 Mar;95(3):464-71 – reference: 3167529 - Br J Surg. 1988 Aug;75(8):786-8 – reference: 8064190 - Int J Colorectal Dis. 1994 May;9(2):110-3 – reference: 10027362 - Br J Surg. 1999 Jan;86(1):66-9 – reference: 7953372 - Br J Surg. 1994 Aug;81(8):1231-4 – reference: 9360815 - Curr Opin Obstet Gynecol. 1997 Oct;9(5):320-4 – reference: 15037931 - Dis Colon Rectum. 2004 May;47(5):727-31; discussion 731-2 – reference: 10426237 - Br J Obstet Gynaecol. 1999 Apr;106(4):318-23 – reference: 15094271 - Lancet. 2004 Apr 17;363(9417):1270-6 – reference: 11053947 - Dig Surg. 2000;17(4):390-3; discussion 394 – reference: 8831535 - Dis Colon Rectum. 1996 Oct;39(10):1164-70 – reference: 10211515 - Dis Colon Rectum. 1999 Jan;42(1):16-23 – reference: 12068192 - Dis Colon Rectum. 2002 Mar;45(3):345-8 – reference: 7907036 - Int J Gynaecol Obstet. 1993 Dec;43(3):263-70 – reference: 8689168 - Br J Surg. 1996 Feb;83(2):218-21 – reference: 9860332 - Dis Colon Rectum. 1998 Dec;41(12):1516-22 – reference: 9514430 - Dis Colon Rectum. 1998 Mar;41(3):344-9 – reference: 11432241 - Acta Chir Iugosl. 2000;47(4 Suppl 1):37-41 – reference: 7561433 - Int J Colorectal Dis. 1995;10(3):152-5 – reference: 8665241 - Br J Surg. 1996 Apr;83(4):502-5 – reference: 10525809 - Abdom Imaging. 1999 Nov-Dec;24(6):569-73 – reference: 12794572 - Dis Colon Rectum. 2003 Jun;46(6):722-9 – reference: 2361431 - Dis Colon Rectum. 1990 Jul;33(7):606-9 – reference: 8646958 - Dis Colon Rectum. 1996 Jun;39(6):686-9 – reference: 10813117 - Dis Colon Rectum. 2000 Jan;43(1):9-16; discussion 16-7 – reference: 10613471 - Dis Colon Rectum. 1999 Dec;42(12):1537-43 – reference: 14598410 - Br J Surg. 2003 Nov;90(11):1333-7 |
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| Title | Overlapping sphincteroplasty: is it the standard of care? |
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