Int J Colorectal Dis (2006) 21: 795–801DOI 10.1007/s00384-006-0101-1 ORIGINAL ARTICLE

Charles EvansKathy DavisDevinder Kumar

Accepted: 12 January 2006Published online: 7 March 2006# Springer-Verlag 2006

Overlapping anal sphincter repair and anteriorlevatorplasty: effect of patient’s ageand duration of follow-up

Abstract Background and aims:Anal sphincter repair can improvefunction in patients with faecal in-continence but it is unclear whichbenefit and its long-term efficacy hasbeen questioned. This study aims toassess the functional outcome of asingle surgeon series of overlappinganal sphincter repairs with anteriorlevatorplasty. Method: A retrospec-tive study of 66 patients’ case notesand anorectal physiology combinedwith an interview to assess theircurrent continence and associatedquality of life after surgery. Results:Sixty-six female patients, mean age62.8 years, mean follow-up45.2 months, were assessed. Func-tional improvement in continence wasseen in 77.1% of patients, whichmirrored their subjective rating ofsurgery (62.7% —good/excellent).Continence grading scores improved

from a mean (SD) 9.71 (4.82) pre-surgery to 5.55 (4.11) post-surgery.There was no statistical difference infunctional results when stratified byage (<63 years or ≥63 years) or byfollow-up [long-term (43–78 months)vs short-term (14–42 months)]. Post-surgical physiology data were notstatistically improved compared topre-surgery. Conclusions: Overlap-ping anal sphincter repair with ante-rior levatorplasty is an effectivetreatment for faecal incontinence. Pa-tient age does not correlate withoutcome, and symptoms do notdeteriorate over time. Anorectalphysiology results don’t predict forsymptomatic improvement in patientswith faecal incontinence.

Keywords Faecal incontinence .Surgery . Anal sphincter .Levatorplasty . Follow-up

Introduction

Faecal incontinence has been defined as “any incontinenceof flatus, liquid stool or solid stool that impacts on qualityof life” [1]. Its prevalence is measured at 11–15% withinthe community when looking at studies that have beenregarded to have minimised bias [1]. However, itsincidence is known to be age-dependent and is found inmore than 50% of nursing home residents [2]. Thepreservation of faecal continence is multifactoral, depend-ing primarily on the normal anatomy and physiology of thecolon and anorectum. Stool consistency, personal mobilityand individual’s mental status are also critical [3].Consequently, there is a diverse aetiology for incontinence

making treatment a challenging and complex issue.Treatment options include conservative management, bio-feedback therapy and surgery.

It has been shown that in persistent faecal incontinencesecondary to damage to the structural integrity of the analsphincter complex, reconstructive surgical intervention canrestore satisfactory functional improvement [4]. Over-lapping anal sphincter repair is a well-described procedure[5, 6] and is generally considered to be the principal, first-line surgical therapy with various studies showingapproximately two-thirds of patients gaining substantialbenefit [4]. Anterior levatorplasty can be performed at thesame time and has been shown to improve sphincterpressures and upper anal canal sensation [7]. There are,

C. Evans . K. Davis . D. Kumar (*)Colorectal Surgery Unit,St James Wing (Level III),St George’s Hospital,Blackshaw Road,London SW17 0QT, UKe-mail: dkumar@sghms.ac.ukTel.: +44-208-7251302Fax: +44-208-7253611

however, doubts over the long-term efficacy of thisprocedure with reports [8–11] of poor functional resultsafter extended periods of time.

The aim of this study was to assess the clinical andfunctional results after overlapping anal sphincter repaircombined with anterior levatorplasty on a group of patientsperformed by one surgeon (DK), using the same technique,over an extended period of time.

Patients and methods

Between January 1997 and December 2003, 101 patients(all female) underwent overlapping anal sphincter repairand anterior levatorplasty at St George’s Hospital by onesurgeon (DK). All patients had incontinence to liquid and/or solid stool. None had undergone any previous analsphincter surgery for incontinence, and all had failedconservative treatment previously, including dietary andfluid manipulation, anti-diarrheal medication and stoolbulking.

Of the 101 patients, 66 were successfully contacted andrecruited to a retrospective study. Ethical approval for thestudy was obtained from the local ethical committee, andall patients gave informed consent before inclusion. Themean (SD) age of the patients was 62.4 (12.29) years, range32–83 years. The mean (SD) length of time post-surgerywas 45.2 (18.68) months, range 14–78 months. All patientsunderwent a structured interview to assess their currentdegree of continence and associated quality of life, using avalidated continence grading scale [12], concomitantsymptomatology and subjective assessment of overallsatisfaction of surgical outcome. A single investigator,who had not performed the surgery, conducted allinterviews over a period of 2 years. Each interview lasteda mean of 45 min, range 10–60 min.

Continence status was classified in accordance with ascoring scale (0 = perfect continence to 20 = completeincontinence) dependent upon the frequency and type ofincontinence, pad usage and associated lifestyle alteration,thus giving global assessment of the patient’s continence.The patient’s perception of functional improvement and asubjective rating of the surgical result were recorded usingtwo Likert designed scales scored to reflect the best(score 1) and the worst (score 5) outcome. A visualanalogue scale was also constructed to assess the patient’soverall satisfaction with the surgical result (0 = not satisfiedto 10 = very satisfied).

Endoanal ultrasound and anorectal manometry wereperformed on all patients preoperatively, with completedata obtained in 59/66 patients and repeated in 38/66 (57%) ata mean (SD) 12.82 (6.65), range 5–36 months after surgery.

Surgery

Before surgical operation, all patients received bowelpreparation, and prophylactic antibiotics were given oninduction of general anesthetic. Patients were placed in thelithotomy position. A circumlinear anal incision wasperformed exposing the extra-sphincteric plane. Afterdissection and identification of both external and internalsphincters, an anterior overlapping sphincter repair usinginterrupted non-absorbable sutures and levatorplasty usingabsorbable sutures was performed. To prevent dyspareunia,care was taken not to place the two sutures of thelevatoplasty too high up the rectovaginal septum. Scartissue was left in place to provide additional support. Theskin was closed in a longitudinal configuration with thecentral portion left open for drainage. None had a divertingcolostomy and drains were not used. All were prescribedwith 1 week of oral antibiotics and lactulose.

Endoanal ultrasound

Endoanal ultrasound was performed using a 7.5-MHztransducer providing a 360° view of both internal andexternal anal sphincters. The lower, middle and upper analcanal was imaged, and an identifiable defect was found inall patients. Postoperative ultrasound was used to assess theintegrity of the overlapping sphincter repair and thepresence of recurrent or residual anal sphincter defects.

Anorectal manometry

Anorectal physiology using a water-filled microballoonsystem and the stationary ‘pull through’ technique wasperformed. Resting and squeeze pressures were measuredin the left lateral position. The normal reference for the StGeorge’s laboratory are ≤80 and ≥120 cm H2O for meanresting and squeeze pressures, respectively.

Measures of rectal volume threshold and constant andmaximum tolerable sensation were made. The first sensa-tion observed being representative of threshold volume, theconstant sensation in the rectum and the urge to defecatebeing representative of the constant volume and maximumtolerable volume. Normal reference values of 40 ml forthreshold, 150–160 ml for constant and 200–220 ml formaximum tolerable were used.

Anal canal mucosal electro-sensitivity was also mea-sured in the lower, mid- and upper anal canal by passing adirect current through an electrode positioned in the analcanal. Up to 16 mAwas used as a normal reference value.

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Analysis

Statistical analysis

Data was analysed using SPSS Version 11.0 (SPSS,Chicago, IL, USA). Results are noted as mean, SD andrange. In all statistical tests, p values were two-tailed andsignificance was 5%. Relationships between subjectiveassessments of functional outcome were calculated usingPartial and Pearson’s correlation coefficients. Differenceswithin groups were compared using the independent t testandWilcoxon’s signed-rank test. The MannWhitneyU testand paired t test were used to compare physiologicalpre- and post-sphincter repair data. Functional outcomewas defined by recoding postoperative continence gradingscores into good (0–5), fair (6–10) or poor (11–20) inaccordance with the study by Rothbarth et al. whichproposed that continence scores greater than 9 impacts onquality of life [13].

Age-specific analysis

To look more specifically at what effect the age of thepatient had upon the success rates of the surgery, patientswere split into two subgroups. Patients were categorisedinto either a younger or older group. The younger groupwas classified as aged 32–62 years old which included 32patients with mean (SD) age 52.5 (8.97) years. The mean(SD) (range) time since surgery was 47.31 (18.80)(18–78) months. In this group, 19 patients had hadpostoperative physiology tests at a mean (SD) (range)11.37 (6.07) (5–32) months. The older group was classifiedas aged 63–83 years old with 34 patients of mean (SD) ageof 71.65 (6.26) years. The mean (SD) (range) time sincesurgery was 43.112 (18.60) (14–76) months. Nineteenpatients had undergone postoperative physiology at a mean(SD) (range) of 14.26 (7.04) (5–36) months.

Follow-up specific analysis

To assess what effect an increased length of time post-surgery had upon results, the 66 patients were re-categorised into those having short-term follow-up andthose having long-term follow-up. Thirty-three wereclassified as having short-term with a range of 14–42 months post-surgery and the other 33 long-term witha range of 43–78 months post-surgery. The age of thepatients within these groups was not felt to be relevantowing to the similar age-specific results.

Results

Clinical data

Collective results

All patients were incontinent to liquid and/or solid stoolpreoperatively. Post-surgery, at the time of interview, 14(21.2%) were now continent to flatus, liquid and solid stoolover the previous year. Twenty-one (31.8%) were continentto liquid and solid stool but rarely/occasionally incontinentto flatus. Twenty-two (33.3%) were continent to solid stoolonly, and 9 (13.6%) had multiple symptoms of inconti-nence to flatus, liquid and solid stool (Fig. 1).

Postoperative continence grading scores were a mean(SD) value of 5.55 (4.11). Thirty-four patients were able torecall enough information for preoperative continencegrading scores to be made with a mean (SD) 9.71 (4.82).

The patients’ perception of continence compared topreoperative status revealed that 51 (77.1%) felt faecalcontinence had improved. Eleven (16.6%) of the patientsfelt there was no change and four (6.1%) felt it got worse.These results were mirrored by the patient’s subjectiverating of the surgical result in that 41 (62.7%) felt theoutcome was excellent or good; 11 (16.7%) fair; five(7.6%) poor and nine (13.6%) perceived that surgery hadfailed. On the visual analogue satisfaction scale, the mean(SD) score was 6.27 (2.96) (range: 0, not satisfied to 10,very satisfied).

Age-specific results

Comparing the two age groups (older and younger) showedsimilar results with regard to postoperative continence. Themean (SD) continence grading score in the younger groupwas 5.59 (4.36) whereas in the older group, it was 5.50(3.93). The younger patients’ perception of continence

Fig. 1 Collective continence

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compared to preoperative status revealed that 23 (71.9%)felt faecal continence had improved, seven (21.9%) of thepatients felt there was no change and two (6.3%) felt it gotworse. These results were matched with the older group inwhom 28 (82.4%) reported an improvement, four (11.8%)felt there was no change and two (5.9%) felt that there wasa worsening of their condition (Fig. 2). The patient’ssubjective rating of the surgical result was also similarbetween the two groups (Fig. 3). On the visual analoguesatisfaction scale, the mean (SD) score was 6.20 (3.17) inthe younger group and 6.34 (2.80) in the older group. Therewas no statistical difference found between the youngerand older groups when comparing continence gradingscores and visual analogue scales.

Duration of follow-up specific results

There was no difference in the levels of continencebetween those with short- or long-term follow-up. Themean (SD) continence grading score in the short-termfollow-up group was 6.36 (4.36) whereas in the long-termgroup, it was 4.73 (3.74). This difference was notstatistically significant. In the short-term follow-up, pa-tients’ perception of continence compared to preoperativestatus revealed that 26 (78.8%) felt faecal continence hadimproved, four (12.1%) of the patients felt there was nochange and three (9.1%) felt it got worse. These results

were similar in the long-term group in whom 25 (75.8%)felt there was an improvement, seven (21.3%) felt therewas no change and one (3%) reported a worsening of hersymptoms (Fig. 4). The patient’s subjective rating of thesurgical result was also similar between the two groups(Fig. 5). On the visual analogue satisfaction scale, the mean(SD) score was 6.23 (3.11) in the short-term follow-upgroup and 6.32 (2.87) in the long-term group, which wasnot of statistically significant difference.

Physiological data

Preoperative physiological data showed that in mostcategories, patients had parameters below normal values(Table 1). Of the 38 patients who had postoperative testing,there was seen to be an improvement in resting and squeezepressures. There were almost identical results with regardto rectal volume threshold, rectal volume constant and analelectro-sensitivity (Table 1). No improvement in anycategory was found to be of statistical significance.

When postoperative results were separated into the twoage categories, it was shown that the younger group (n=19)showed a general improvement in physiological param-eters. Anal resting pressure (p=0.004 Wilcoxon’s signed-rank test or t test p=0.003) and anal squeeze pressure(Wilcoxon p=0.005 or t test p=0.001) were however theonly ones that reached statistical significance. Mean (SD)pre- and post-resting pressures 56.65 (20.96) to 73.39

Fig. 2 Age-specific symptom improvement

Fig. 3 Age-related subjective assessment of surgery

Fig. 4 Lenght of follow-up-specific symptom improvement

Fig. 5 Subjective assessment of surgery depending upon length offollow-up

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(23.61) cm H2O, and mean (SD) pre- and postoperativesqueeze pressures 109.15 (39.79) to 128.11 (44.91) cmH2O. In the older group (n=19), all physiologicalparameters changed very little with none reachingstatistical significance.

It was also noted that preoperative physiologicalmeasurements did not predict functional outcome in anygroup.

Preoperative endoanal ultrasound demonstrated 49 pa-tients to have combined internal and external sphincterdefects and 10 to have only external defects. Postoperativeresults confirmed an intact overlap repair in 37 of 38. Aninternal anal sphincter defect was identified in six patients,and one patient had a persistent external anal sphincterdefect with a rectocele observed.

Discussion

The surgical treatment for faecal incontinence, at thepresent time, is not limited to one standard procedure. Thismay suggest that an ideal treatment does not exist [14] andprobably reflects a complex, multi-factorial aetiology.However, it is generally agreed that overlapping analsphincter repair should be offered as the first-line surgicaltherapy. In this study, we looked at the results of thisprocedure performed by only one surgeon. This eliminatedsurgeon and surgery-related variability. Thus, differencesdirectly attributable to patient-related factors and the lengthof time from surgery were evaluated. We acknowledge thatthis is a retrospective analysis, using recall to establishpreoperative incontinence that has the risk of leading tobias. However, preoperative continence scores were onlycalculated if adequate information could be recalled, andwhilst subjective data was used, this was always matchedwith more specific objective results.

In accordance with other studies, there appeared to besubstantial benefit from surgery in over two-thirds of thepatients [4]. Subjective improvements to faecal inconti-nence were corresponded to objective improvements seenin continence grading scores (9.71 pre-surgery to 5.55 post-surgery). Rothbarth et al. [13] used the same continencescore as in this study and found that a continence scorehigher than 9 was reflective of a greater frequency of

incontinence to stool requiring the use of protective padsand had a restricting impact on everyday life. A placeboeffect could not be ruled out entirely; however, in the lowfunctional continence grading scores calculated throughthis validated scoring system, they suggest it is unlikely,especially when neither the time post-repair nor an ageeffect significantly influenced the improvement in symp-toms and perception data.

Our study found no correlation between the age of apatient and the success of surgery. There were matchingresults in the two age categories in terms of incontinencescoring and subjective assessment, despite physiologyresults showing only the younger age group to have animprovement in anal resting pressure and anal squeezepressure. This inconsistency between symptomatic im-provement and physiological data has been seen in otherstudies. Osterberg et al. [14] gave a possible explanationstating that the stenosing effect of surgery within the analcanal, a ‘biological’ Thiersch effect, causes increasedresistance to flow through the anus which may not bedetected in pressure measurements.

There is a conflicting evidence regarding the effect of apatient’s age upon the outcome of surgery. Studiesperformed by Bravo et al. [11], Morren et al. [15] andSitzler and Thomson [16] found that increasing ageresulted in poorer results. In contrast, Oliveira et al. [17],Simmang et al. [18] and this research found no suchcorrelation. One possible explanation for the poorer resultsin the elderly patients may be that their aetiology has aneurogenic or myogenic component as well as structuralsphincter deficit [16]. This study showed no statisticallysignificant differences in electro-sensitivity between thetwo age groups which may explain our results. However,when assessing the literature, it is clear that no one specificaetiological component can be linked to the success orfailure of surgery, and whilst neurogenic or myogenicproblems may be more prevalent in elderly patients withincontinence, it has not been confirmed that they lead topoorer surgical results. Our data suggest that all aspects,including physiological, anatomical and psychologicalassessment, need to be investigated to achieve a successfulsurgical outcome rather than rely on individual factors suchas the patient’s age.

Table 1 Anorectal physiology pre- and post-overlapping anal sphincter repair and anterior levatorplasty

Patients Basalpressure(cm H2O)

Squeezepressure(cm H2O)

Rectalvolumethreshold (ml)

Rectalvolumeconstant (ml)

Rectalvolumemaximum (ml)

Electro-sensitivitylow (mA)

Electro-sensitivitymiddle (mA)

Electro-sensitivityhigh (mA)

Mean (SD)preoperative n=59

53.60(21.52)

100.09(35.20)

40.22(27.98)

119.66(64.83)

183.27(86.40)

12.48(5.77)

16.93(5.13)

19.10(3.74)

Mean (SD)postoperative n=38

62.98(24.30)

111.43(41.32)

41.18(20.81)

127.24(64.28)

176.79(67.85)

14.05(5.32)

17.26(4.34)

19.97(2.29)

Normal values ≥80 ≥120 40 150–160 200–220 16 16 16

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When looking at the effect of the duration of follow-upon the results of sphincter repair, we found a morefavourable outcome than in previous studies [8–11]. Thereappeared to be a sustained improvement regardless of agein comparison to the reports of deterioration in continencefunction in up to two-thirds of the patients. There is noclear explanation as to why this study found morepromising results. One possible explanation may be thatan overlapping sphincter repair combined with an anteriorlevatorplasty was used in contrast to the others that usedonly an overlapping sphincter repair. The levatorplasty,through plicating the anterior limbs of the levator muscle,has been shown to increase the length of the anal sphincter,high-pressure zone consistently [19]. This may prevent orat least delay any suggested progressive deterioration insphincter function over time [8, 11].

Although the overlapping anal sphincter repair is themost widely used technique in the primary anatomicalreconstruction of a damaged sphincter complex, a numberof different techniques are described in other series. Studieshave used end to end anastomsis, imbrication or plicationof the internal and/or external sphincter at the site of thegap [15, 20, 21], differing operating positions, for example,prone jackknife rather than lithotomy [22]; and if indicated,a temporary colostomy has also been performed. It may beargued that the choice of technique is operator-dependent,and studies comparing techniques, e.g. Buie et al. [22] andMorren et al. [15], have reported no difference in functionaloutcome. However, our study used the one technique,overlapping anal sphincter repair and combined levator-plasty, with the additional benefit of being performed byonly one operator. It provided encouraging results in bothsymptom improvement and patient’s perception of out-come, correlating to objective data, whatever the age of thepatient and however long the time period after surgery. This

may be due to the standardization of the treatment providedin this series, and it would seem logical that if there wassuch standardization throughout, the overall outcomewould improve.

Although complete continence was only obtained in21.2% of the patients, there was a significant symptomaticbenefit for 62.7% of the patients and an improvement in thequality of their lives which we believe is the main aim ofthe surgery. It is important that when discussing preoper-atively the outcome of surgery, a realistic approach is takenand not over expectations. It must also be remembered thatthe decision to intervene surgically for a disorder such asfaecal incontinence is based solely on the patient’sperception of bother caused by the symptoms. Anyassessment of results of surgery, therefore, must similarlybe based on change in the symptoms and on the patient’sperception of outcome [8] which in our study is generallyfavourable regardless of the age of the patient or theduration post-surgery.

Conclusion

Overlapping anal sphincter repair combined with anteriorlevatorplasty is an effective treatment for faecal inconti-nence in terms of symptomatic improvement and objectiveresults. Anorectal physiology results do not predict symp-tomatic improvement in faecal incontinence. There appearsto be no correlation between age of the patient and thelikelihood of a successful clinical outcome, and we foundno significant deterioration in symptoms with increasedlength of follow-up. We recommend that a standardtreatment should be put in place to improve the overalloutcome of surgery and enable a meaningful comparison ofresults between different units.

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