Complications

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landmarktoidentifythelateralborderofthedissection.Careshouldbe takennottodissecttoofarlaterallyduetotheriskofpotentially disruptingpudendalinnervation.

Thescartissueisdividedthroughthemidlineifthesphincterhalvesare joinedbyscar.Itisimportanttopreserveallscartissuetoanchorthe

sutures.Iftherepairisperformedearly,priortoscartissuedeveloping, themuscleedgesretractlaterally.TheedgesaregraspedwithAllis clamps.Themoremobilesideofthesphincterisplacedastheexternal layer,andthelessmobilesideistheinnerlayer(Fig.15-2).

p.111

p.112

FIGURE15-2Sphincterscardividedbutnot

excised.

Afteradequatemobilization,anenblocoverlappingrepairoftheEAS– IAScomplexisperformedusingverticalmattresssuturesof2.0

polydioxanonemonofilamentdelayedabsorptionsutures(PDS). Whereaswepreferthissuture,somesurgeonspreferapermanentsuture (Fig.15-3).

FIGURE15-3Internalanalsphincterimbricated

whenalayeredrepairisperformed.

Ifthesurgeonpreferstheanteriorlevatorplasty,IASimbrication,and overlappingEASrepair,theinitialincisionanddissectionarethesameas above.

Theintersphinctericspaceisthenmobilizedfromlateraltomedialtothe areaofthemidlinescar,andexternalandIASsareseparated.

Therepairstartswithappositionofthelevatormuscleswiththree interruptedsuturesof2.0PDS.

Theinternalmusclefibersareidentifiedandimbricatedwiththree,3.0 PDSmattresssutures(Fig.15-4).

FIGURE15-4Overlappingrepairoftheanal

sphincterwithmattresssutures..

TheEASisoverlapped,andmattresssuturesof2.0PDSareusedto approximatetheends(Fig.15-5).

FIGURE15-5Externalanalsphincteroverlapped.

Thetapesareloosenedpriortoskinclosure. TheedgesofthewoundareapproximatedinaV-shapeorlongitudinally

withinterrupted3.0absorbablemattresssutures. Thecenterofthewoundcanbeleftopen,asmalldraininserted,orthe

woundcanbeclosed(Fig.15-6).

p.112

p.113

FIGURE15-6Edgesofthewoundapproximated

inaV-shapeorlongitudinallywithinterrupted3-0 absorbablemattresssutures.Thecenterofthewound isleftopenfordrainage.Theperinealbodyisbulkier thanitwaspreoperatively.

POSTOPERATIVEMANAGEMENT

Postoperativemanagementrequireskeepingthestoolssoft,thearea clean,andpaintolerable.Patientsareretainedovernight1–2days.There isnoconsensusontheroutineadministrationofpostoperativeoral antibioticsatdischarge.Twosmall,randomizedcontrolledtrials,onein primaryrepairofanalsphincterinjuryandtheotherfordelayedrepair, showedthatmaintainingthepatientnothingbymouthandconstipated doesnothaveanyprovenbenefit.However,wefeelthatitiscrucialto ensurethatthepatientdoesnotpassahardstoolintheimmediate postoperativeperiodasthatcandisruptthefreshrepair.Thus,attention tobowelhabitsisimportant,andthepatientistypicallydischargedona stoolsoftener.Onerandomizedcontrolledtrialshowednoadvantageto postoperativebowelconfinement.

COMPLICATIONS

Asreportedintheliterature,complicationratesrangefrom8%to31%of patients.Earlycomplicationsmayincludetheformationofahematoma orseromathatcanbetreatedbyopeningthewoundandevacuatingthe hematomaorseroma,andfecalimpaction,whichcancausedisruptionof therepair.Latecomplicationsincludeabscessformation,fistulas,and woundbreakdown.Abscessesrequiredrainage,woundbreakdown usuallyhealssecondarily,andrarelydoesthisrequiresecondary suturing.Thepatient’smaincomplaintafterthesurgeryispainfromthe perinealwound.Othercomplicationsreportedintheliteratureinclude urinarytractinfection(UTI),urinaryretention,bleeding,andotherrare complicationssuchasdeepvenousthrombosis(DVT)andpneumonia.

RESULTS

Earlysymptomimprovement(upto90%)isnotedaftersphincteroplasty. However,5-and10-yearfollow-upsrevealadeclineincontinenceand increasingfecalaccidentswithareturntobaseline.Itisdifficultto compareamongseriesbecausemanyareretrospective,surgical techniquevaries,andthepatientpopulationisheterogeneousasdepicted inTable15-1.

p.113

p.114

TABLE15-1 SphincteroplastySeries

References N

Ageat

surgery,

mean

(ranges)

FU,mean

(ranges) Long-termoutcomes

Gibbsand Hooks(1993)

33 47(20–74) 43(4–114)

Good/excellent(73%) 10/33Reliablecontrolofliquid andsolidstool 14/33Occasionallossofliquid stoolorgas

Karouietal. (2000)

74 52.9(21–

85)

21/74(28%)Totallycontinent 17/74(23%)Incontinentofgas 36/74(49%)Incontinentoffeces

Maloufetal. (2000)

46 43(26–67) 77(60–96)

23/46(50%)Eithernoneor monthlyorless-frequenturge fecalincontinence 4continentofsolidandliquid

stool

Nopatientfullycontinent

Buieetal. (2001)

158 36(20–74) 43(6–120)

97/158(61%)Excellentorgood results 36/158Completelycontinent 61/158Gasincontinenceormild stain 42/158(27%)Pador incontinencelessthanonceper

month 19/158(12%)Incontinence greaterthanoncepermonth

Halversonand Hull(2002)

44 38.5(22–

80)

62.5(47–

141)

6/44(14%)Completely continent 18/44(41%)Continentofliquid andsolidstool 16/44(36%)Bestpossible quality-of-lifescore

Barisicetal. (2006)

56 35.9(18–

64)

80.1(26–

154)

27/56(48%)Excellentorgood outcomes 7/56(13%)Fairoutcomes 22/56(39%)Pooroutcomes

Bravo Gutierrezet al.(2004)

130 37 120(84–

192)

8/130(6%)Completely continent 21/130(16%)Incontinentofgas only 25/130(19%)Soiling 74/130(57%)Incontinentof solidstool

Zorcoloetal. (2005)

73 56(27–

80)

73(48–

112)

2/73(3%)Completelycontinent 50/73(68%)Incontinentofgas 21/73(29%)Incontinentof liquidstool 18/73(25%)Incontinentofsolid stool Note,somepatientshave numerousformsofincontinence 11/73(22%)Failureleadingto gracilisneosphincteror colostomy

Greyetal. (2007)

47 46(22–80) 60+

28/47(60%)Improved continence 17/47(36%)Initiallyimproved, butsincedeteriorated 2/47(4%)Unchanged

Zutshi(2009) 31 44(22–80) 129(113–

208)

Nopatientscompletely continent Nopatientscontinentofliquid andsolidstool

Oometal. 120 58(30– 111(12–

44/120(37%)Excellentorgood

(2009) 85)

*,†

207) outcomes 7/120Excellentoutcomes 37/120Goodoutcomes 28/120(23%)Moderate outcomes 48/120(40%)Pooroutcome— lessthan50%reductionof incontinentepisodesandnot satisfiedwiththeirsituation

Johnsonetal. (2010)

33 36(22–

75)

103(62–

162)

19/33(58%)Excellentorgood outcomes 3/33(9%)Fullycontinent 16/33(49%)Improved 14/33(42%)Incontinence unchangedorworse

Lehtoetal. (2013)

34 51.6(30–

79)

††

89.3(74.6–

104.2)

MedianWexnerscore Preop11.8 Shortterm9.5 Longterm12.0 Lessthan30%reported improvementinsymptomsof solid,liquid,andflatus incontinence

Lamblinetal. (2014)

20 52(36–

67)

87(54.2–

117.8)

Nopatientscontinentforgas Initialresults: 85%continentforsolidstool 70%continentforliquidstool Only48%maintained continenceat84months

Resultsreportedasmedian.

†

Ageatfollow-up.

††

Unknownifageatsurgeryorfollow-up.

CONCLUSIONS

Overlappingsphincterrepairremainsthetreatmentofchoiceforpatients withEASdefects.Itisimportanttocounselpatientsthatforoverlapping sphincterrepairandallotherinterventionsforFI,itisraretoachieve perfectcontinence.Inaddition,thereisadeclineincontinenceovertime thatmayoccurbecauseoftheweakeningofthemuscleduetonormal agingorbreakdownoftherepair.Whenpatientshaverecurrent symptomsofFIafteraninitialsuccessfulrepair,reevaluationisbeneficial andoptionssuchasredosphincteroplastyandSNSorradiofrequency tissueremodelingmaybeoffered.

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