Keywords
overlap anal sphincter repair - overlap repair - outcome - fecal incontinence - anal
incontinence - sphincter injury
Palavras-chave
reparo por sobreposição do esfíncter anal - reparo por sobreposição - desfecho - incontinência
fecal - incontinência anal - lesão esfincteriana
Introduction
Fecal incontinence is defined as the involuntary evacuation of feces. It is a debilitating
problem that causes physical, social and psychological impairments, with a considerable
effect on the quality of life.[1] This condition affects 2% to 17% of the overall population, and almost half of all
nursing home residents.[2] The etiology of fecal incontinence is multifactorial, and the most common factors
are injury to the sphincter or neuronal damage associated with vaginal injuries, anorectal
surgical procedures, and neurological conditions.[3]
The outcome following the repair of an anatomical defect of the anal sphincter depends
on several factors, including the age of the patient, the cause of the injury, the
length of time between the injury and the repair, and the type of repair.[4]
[5] Overlap and end-to-end are two widely-used techniques among several used to repair
the anal sphincter following injury. The overlap repair is used for external anal
sphincter defects, and it was described by Parks and McPartlin.[6] Several studies have assessed both the short- and long-term outcomes following overlap
sphincteroplasty after various types of sphincter injuries using different tools to
assess fecal incontinence.
The objective of the present review is to analyze the short- and long-term outcomes
of overlap repair for patients presenting with fecal incontinence.
Materials and Methods
A systematic review of the literature was performed including all observational and
experimental studies on overlap sphincter repair, in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The
primary objective of the systematic review iwa to determine the short- and long-term
outcomes and the success rates of the overlap sphincter repair. The secondary outcome
was to identify the associated factors such as clinical and demographic parameters,
and injury patterns in relation to the outcome.
Search Strategy
We searched the PubMed, Medline, Google Scholar, Embase and Scopus databases for articles
published between January 2000 and January 2020 using the search terms anal sphincter OR fecal incontinence OR anal incontinence AND overlap repair OR overlap surgery in the title or abstract fields. A non-English language database known as APAMED
Central was searched using the same criteria to reduce publication bias. The search
was limited only to human studies. The reference list provided in full papers were
was also used to identify additional papers to be review. The last search date was
January 31, 2020. Both experimental and observational studies that considered the
outcome of overlap sphincter repair were included in the qualitative analysis.
The initial screening for eligibility was performed by two investigators based on
the titles, abstracts, and keywords of the citations from the electronic databases.
Thereafter, the full texts of all relevant records were assessed based on the inclusion
criteria. In cases of doubt, the opinion of senior investigators was sought. Studies
with elective surgical treatments with a minimum follow-up period of one year were
defined as eligible. Studies including immediate primary repair following injury were
excluded, as the objective improvement in the sphincter function could not be assessed
in them. Studies including other interventions in addition to overlap sphincter repair
and those without objective assessment tools were excluded to minimize the bias and
the confounding factors. The list eligible studies was then decided by consensus between
two investigators.
Data from individual studies were tabulated, including study design, basic demographic
and clinical parameters of the patients, injury pattern, timing of the surgery, preoperative
investigations, postoperative short- and long-term outcomes, and complications. Finally,
a qualitative analysis was performed with the available data. A meta-analysis could
not be performed due to the heterogeneity in: the methodology of the studies, the
treatment options, and the description of the outcomes. The assessment of the risk
and bias of the eligible studies was performed using standard risk-assessment tools.([Supplementary Table S1])
Results
The initial search revealed 571studies. After excluding the duplicates and the articles
that were not relevant, a total of 22 studies describing the outcomes of overlap sphincter
repair were selected ([Fig. 1]). However, 14 studies used other surgical techniques in addition to overlap repair;
therefore, they were excluded from the analysis. Data from 8 studies including 429
repairs were used in the final analysis; there were 4 were prospective studies,[7]
[8]
[9]
[10] 3 retrospective studies,[11]
[12]
[13] and 1 randomized control trial.[14] The majority of the patients were female (n = 407; 94.87%), and the mean age of the included individuals was 44.6 years. The
most common etiology for sphincter damage was obstetric injuries (n = 384; 89.51%). Every study used at least one validated tool for the pre- and postoperative
assessment of the continence. In total, 5 studies[8]
[9]
[12]
[13]
[14] (n = 164; 38.22%) used endoanal ultrasound and/or manometry for the preoperative assessment.
Only 2 studies[9]
[14] (n = 31; 7.22%) used endoanal ultrasound and/or manometry for the assessment postoperatively.
Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.
All included studies described long-term outcomes, and seven[7]
[8]
[9]
[10]
[11]
[12]
[13] of them described statistical significant improvements in the continence. However,
1 study[14] (n = 11; 2.56%) described a poor outcome in terms of overall continence. Two studies[7]
[14] mentioned both short- and long-term outcomes. The long-term scores were significantly
better compared with the preoperative scores. However, compared with the short -erm
scores, a statistically significant deterioration was noted in the long-term ([Table 1]).
Table 1
Summary of the findings of studies included in the systematic review
|
Author
|
Location
|
Study design
|
N
|
Demographics
|
Injury pattern
|
Timing of the surgery
|
Preoperative investigations
|
Type of surgery
|
Short-term outcome (less than 1 year)
|
Long-term outcome (more than 1 year)
|
|
1
|
Maldonado et al.,[12]2019
|
United States
|
Retrospective study
|
29
|
All-female sample (mean age: 31.8 years)
|
fourth-degree lacerations (cloacal-like deformities)
|
Mean: 68.1 months
|
Presenting symptoms and physical examination
|
EAS OLR
|
NA
|
53.8% reported complete continence at a
mean follow-up of 7.0 ± 3.6 years
|
|
2
|
Khafagy et al.,[9]2017
|
Egypt
|
Case-control
study
|
Total -40
ORLs in 20 patients
|
M = 11 (55%); F = 9 (45%); mean age: 30.6 ± 17.5 years
|
anal fistula (n = 19; 47.5%); perineal trauma (n = 6; 15%); obstetric trauma – third degree perineal tear (n = 5; 12.5%); perianal necrotizing fasciitis (n = 5; 12.5%); hemorrhoidectomy (n = 3; 7.5%); stricturotomy for anal stenosis (n = 2; 5%)
|
1.01 ± 0.35 years
|
Wexner continence score, anorectal manometry, Endoanal US
|
EAS OLR +/-BMAC
|
6 months to 12 months; mean Wexner score changes from 7.7 to 7.4
|
NA
|
|
3
|
El-Gazzaz et al.,[11]2012
|
United States
|
Retrospective study
|
197
|
All-female sample; 146
(74.1%) patients in group A (< 60 years
old); 51 (25.9%) patients in group B (> 60 years old);
overall mean age at surgery: 50.4 years
|
obstetric injuries
|
NA
|
FIQL;
FISI
|
EAS OLR
|
NA
|
The mean FISI score changed from 27.2 to 29.8 over an average of 7.7 years of follow-up
|
|
4
|
Zutshi et al.,[10]2009
|
United States
|
Prospective
|
N =44 at the 5-year follow-up, and n = 31 at the 10-year follow-up
|
Median age at surgery:
5-year follow-up group -38.5 years;
10-year follow-up group - 44 years
|
Obstetric trauma: 70.4%;
iatrogenic: 15.9%;
trauma: 6.8%;
not reported: 6.8%
|
NA
|
FIQL; FISI; Bristol Stool Form Scale
|
EAS OLR
|
NA
|
Changes in scores from 5 years to 10 years of follow-up:
a) mean patient-related FISI – from 21 to 39.39;
b) mean surgeon-related FISI – from 20 to 39.97;
c) mean FIQL – from 12 to 10.82
|
|
5
|
Dobben et al.,[8] 2007
|
Netherlands
|
Prospective
|
30
|
97% of females; mean age: 50
Years (±12 years)
|
Obstetric trauma: 97%
|
Median: 6.5years (0.5–22 years)
|
Vaizey incontinence score
and Endoanal US, and MRI
|
EAS ORL
|
After surgery, the mean Vaizey score improved from 18 to 13 (p < 0.001)
|
NA
|
|
6
|
Barisic et al.,[7]2006
|
Serbia
|
Prospective
|
65
|
Females: 55 (84.61%); males: 10 (15.38%); mean age: 35.9 years (range: 18–64 years).
|
Obstetric trauma: 72.3%;fistulotomy: 13.8%; non-specific
Trauma: 9.2%; war injury:
4.6%.
|
Range: 0.5 to 20 years
|
Wexner score; Browning–Parks scale; anal
Manometry; electromyography;
defecography
|
EAS OLR
|
Wexner score improved from 17.8 preoperatively to 3.6 three months after the operation
|
Wexner deteriorated over time to 6.3 after an average of 80.1 months of follow-up
|
|
7
|
Tjandra et al.,[14] 2003
|
Australia
|
Randomized controlled trial
|
Total -23;
OLR -11
direct end-to-end repair -12
|
all female; DR 47y (32–71), OLR 45y (31–68);
|
Obstetric trauma
|
1 year
|
Endoanal US; anorectal manometry; neurophysiologic; Cleveland Clinic Continence Score
|
DR ; OLR
|
Mean Cleveland score changed from
17 to 3 postoperatively;
maximum squeeze pressure changed from 80 mm Hg to 130 mm Hg postoperatively
|
Median follow-up of 18 months -
improvement in continence
scores (p < 0.05).
|
|
8
|
Malouf et al.,[13] 2000
|
United Kingdom
|
Retrospective
|
38
|
All-female sample; mean age: 43 years (26–67 yeaus)
|
Obstetric-related trauma
|
NA
|
Modified Park's continence
Scores; resting anal pressure; maximum squeeze anal pressure;
sphincter length; pudendal nerve latencies; Endoanal US
|
OLR
|
NA
|
Outcome assessed at a median of 15 and 77 months;
at 15 months,
median Modified Park's score preoperatively: 4;
15 months post operatively: 2; and 77 months postoperatively: 3
|
Abbreviations: BMAC, bone marrow aspirate concentrate; DR, direct repair; EAS OLR, external anal
sphincter overlap repair; F, female; FIQL, Fecal Incontinence Quality of Life Scale;
FISI, Fecal Incontinence Severity Index; M, male; MRI, magnetic resonance imaging;
NA, not available; ORL, overlap repair; US, ultrasound.
Discussion
The objective of the present review was to analyze the short- and long-term outcomes
of overlap anal sphincter repair for patients presenting with fecal incontinence.
There was considerable heterogeneity in terms of study designs, pre- and postoperative
assessment methods, and tools used for the assessment of the outcome. Most of the
data available in the present systemic review came from prospective studies. [Table 2] shows the availability of information in the respective studies in relation to the
objective of the study. In the present study, we were able to combine the relevant
data regarding the overlap as the sole surgical technique. The continence was assessed
through validated questionnaires and other assessment tools.
Table 2
Availability of information in the studies included in relation to the objective of
the systematic review
|
Author
|
Objective preoperative assessment
|
Objective postoperative assessment
|
Short-term outcome
|
Long-term outcome
|
Tools
|
|
1
|
Maldonado et al.[12]
|
No
|
No
|
Yes
|
Yes
|
Fecal Incontinence Severity Index
|
|
2
|
Khafagy et al.[9]
|
Yes
|
Yes
|
No
|
Yes
|
Wexner Continence Score
|
|
3
|
El-Gazzaz et al.[11]
|
No
|
No
|
No
|
Yes
|
Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index
|
|
4
|
Zutshi et al.[10]
|
No
|
No
|
No
|
Yes
|
Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, Bristol
Stool Form Scale
|
|
5
|
Dobben et al.[8]
|
Yes
|
No
|
No
|
Yes
|
Vaizey Incontinence Score
|
|
6
|
Barisic et al.[7]
|
Yes
|
No
|
Yes
|
Yes
|
Wexner Score, Browning-Park's Scale
|
|
7
|
Tjandra et al.[14]
|
Yes
|
Yes
|
Yes
|
Yes
|
Cleveland Clinic Continence Score
|
|
8
|
Malouf et al.[13]
|
Yes
|
No
|
No
|
Yes
|
Modified Park's Scores
|
The present review included studies that analyzed anal sphincter injuries of different
etiologies. However, most of the traumas were associated with obstetric injuries.
Previous reviews[15]
[16] mainly analyzed only obstetric anal sphincter injuries. The study conducted by Khafagy
et al.[9] has the most diverse etiologies, including anal fistula, perineal necrotizing fasciitis,
trauma after hemorrhoidectomy, and injuries following stricturotomy for anal stenosis.
As the etiology for the majority of the cases of anal sphincter injury was obstetric
trauma in the present review, most patients included in the studies reviewed were
female. Even though there are several techniques for anal sphincter repair, the two
mainly accepted techniques are end-to-end anastomosis and overlap sphincter repair.[14] A previous review[17] included studies using both methods of repair; therefore, the authors were unable
to assess the outcomes of the individual techniques. In the present review, we considered
the studies that used the overlap technique as the sole method of repair. A previous
review[18] comparing the two techniques in patients with anal incontinence secondary to obstetric
anal sphincter injuries concluded that there was no significant difference between
them in terms of symptomatic outcomes after one year of follow-up. The studies included
in the current review[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14] had different objectives in terms of outcome.
The present study was limited by the heterogeneity of outcomes and the paucity of
level-1 data precluding a meta-analysis. In the included studies,[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14] the measurements used to assess the outcome were heterogeneous, with poor utilization
of pre- and postoperative imaging modalities. Less than 50% of the patients underwent
preoperative imaging exams to identify the sphincter defect. Less than 10% of the
patients underwent postoperative imaging exams or physiological assessments. These
findings reveal the need for proper pre- and postoperative assessments in future studies.
Conclusion
Most of the included studies good long-term outcomes in terms of anal continence after
overlap sphincter repair. However, further studies are needed to identify the factors
associated with poor outcomes to assist in patient selection for overlap repair. In
future researches, preoperative and postoperative assessments with imaging exams and
physiology studies will be necessary.
