Annals of Coloproctology

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Case Report

Benign proctology

Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition: Saket Kumar, Noushif Medappil, Sunil Kumar Singh, Abhijit Chandra; Ann Coloproctol. 2020;36(1):58-61. Published online February 29, 2020; DOI: https://doi.org/10.3393/ac.2018.08.21

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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.

Citations

Citations to this article as recorded by

Is It a Refractory Disease?- Fecal Incontinence; beyond Medication
Chungyeop Lee, Jong Lyul Lee
The Ewha Medical Journal.2022;[Epub] CrossRef

Original Articles

Sphincter Repair for Fecal Incontinence after Obstetric Injury.: Ahn, Kwang Woo , Lee, Sang Jeon , Park, Jin Woo; J Korean Soc Coloproctol. 1999;15(1):9-19.

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Abstract PDF: PURPOSE
We designed this study to evaluate efficacy of sphincter repair and factors influencing in patients with postobstetric fecal incontinence.
METHODS
Twenty-one patients (mean age 42 years; range 23~67) undergoing sphincter repair for postobstetric fecal incontinence (mean duration 12 years; range 6 months~46 years) were evaluated prospectively. Preoperatively, standardized interviews, anorectal manometry and measurement of pudendal nerve terminal motor latency (PNTML) were performed. Incontinence was graded according to the Parks' classification: Grade 1 - continence to stool and flatus; Grade 2 - incontinent to flatus, some urgency to stool present but no incontinence; Grade 3 - incontinent to liquid stool; Grade 4 - incontinent to formed stool. Sphincter repair methods were overlap repair of external anal sphincter (EAS) in 4 patients, overlap repair of EAS with anterior levatorplasty in 15 patients, and overlap repair of EAS with anterior levatorplasty and postanal repair in 2 patients. Anorectal manometry at 3 months, and interviews at 3 months and 6 months after sphincter repair were performed again. Patients' satisfaction was classified as excellent, good, fair, and no improvement.
RESULTS
Difficulty in first delivery was noticed in 18 patients and history of previous sphincter repair was noticed in 5 patients. Preoperatively, most patients showed high grade incontinence (grade 3 in 13 and grade 4 in 8 patients). After sphincter repair, 18 patients (85.7%) became grade 1 or 2, and 16 patients (76.2%) replied their functional satisfaction excellent or good. There were no difference between the results at 3 months and 6 months. Poor functional outcome was in 2 of 3 patients with bilaterally prolonged preoperative PNTML. Short duration of incontinence and young age at the time of repair favored good results. Previous sphincter repair did not influence the outcome. Postoperatively both anal pressure and high pressure zone length were significantly increased in patients with improved continence Postoperative complications were wound infection in 2 patients and necrosis at the apex of the advancement skin flap in 1 case but these did not influence the outcome.
CONCLUSIONS
Most postobstetric fecal incontinence can be successfully treated with sphincter repair. Excellent results are expected when the duration of incontinence is short and the patients are young. Pudendal neuropathy seemed to be related to poor outcome.

Outcome and Preoperative Predictive Factor after Complete Anatomical Repair in Perineal Obstetric Injury.: Park, Duk Hoon , Yoon, Seo Gue , Lee, Jong Ho , Yoon, Jong Seop , Rhou, Jai Hyun , Lee, Jong Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(4):222-228.

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Abstract PDF: PURPOSE
To assess the outcome of complete anatomical repair (sphincteroplasty, rectal wall plication, rectovaginal septum plication, perineal body repair, levatoroplasty) and to identify the preoperative factors influencing the outcome for the perineal obstetric injury.
METHODS
Eighteen, consecutive female patients who had undergone complete anatomical repair with chronic fecal incontinence due to perineal injury during 13 months were evaluated. Mean age was 48.9+/-10.1 years, mean duration of symptom was 18.9 (range: 1-33) years, mean delivery numbers were 2.8 +/-1.2 times, and mean follow up was 11.9 +/- 4.7 months. The predictive factors were age, manometry, PNTML (pudendal nerve terminal motor latency), rectal sensation, RAIR (rectoanal inhibitory reflex), duration of symptom, angle of sphincter defect, vaginal delivery numbers, hospital stay, follow-up period, wound healing period, and Wexner's incontinence score.
RESULTS
The anatomical success rate via endoanal ultrasonography was 100%, complication rate was 5.5%, and functional success rate (Wexners' score < or =5) was 88.9%. The patients showed lower maximal resting pressure, maximal squeezing pressure, maximal voluntary contraction, mean resting pressure, mean squeezing pressure, and maximal tolerable volume than the normal control group (p<0.05). The median incontinence score was significantly decreased after surgery (pre op=12.2 vs post op=2.9) (p<0.05). Among the preoperative predictive factors, the incontinence score correlated significantly with postoperative functional success (r=0.552, P=0.017).
CONCLUSIONS
Complete anatomical repair showed an excellent anatomical result and a good functional outcome. Patient with high preoperative incontinence score had a tendency for postoperative residual incontinence.

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