Overlapping Sphincteroplasty: Lower Expectations.

SCOTTSDALE, ARIZ. - Until recently Dr. Dee E. Fenner told incontinent patients with a chronically ruptured anal sphincter that an overlapping sphincteroplasty would provide a 75% chance of regaining continence, at least of solid stool.

But a recent study downgraded those odds. Now she cautions them that the surgery offers only a 50% chance of long-term success, she said at a urogynecology conference sponsored by the Mayo Clinic Scottsdale.

The earlier optimism was based on a 1998 review of 16 studies on sphincteroplasty, which included 757 patients and represented almost all of the studies published on the topic since 1955. The review found an average success rate of about 75% over follow-up periods that ranged from 10 to 59 months with a mean of 27 months. Success was defined as continence, at least of solid stool, and some improvement of continence of liquid stool and gas (Dis. Colon Rectum 41[12]:1516-22, 1998).

More recently, however, a long-term study of 55 consecutive women with obstetric anal sphincter damage showed that the results of overlapping sphincter repair deteriorated over time. All were continent of solid and liquid stool at a median of 15 months after the repair, said Dr. Fenner of the University of Washington, Seattle.

Investigators were able to track 47 of the patients for a minimum of 5 years. Over all, 23 (49%) of the 47 reported long-term success, defined as no need for further surgery and fecal incontinence occurring no more than once a month (Lancet 355[9200]:260-65, 2000).

Nine patients required further surgery for incontinence or other bowel and colon problems.

Of the 38 patients who had no further surgery after overlapping sphincteroplasty, none could control both stool and flatus. Only four (11%) were totally continent of both solid and liquid stool. Twenty (53%) still wore a pad for incontinence, and 25(66%) reported lifestyle restrictions due to incontinence. "It's really important to be honest and let our patients know that we're going to do the best we can, but even with the most successful surgery ...