J. Coloproctol. (Rio J.) vol.37 número1

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w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Sphincteroplasty

and

perineoplasty

with

skin

advancement

flap

in

management

of

traumatic

cloacal

defect

Fakhrolsadat

Anaraki

a

_,

_Omid

_Etemad

b,∗

a_Shahid_Beheshti_University_of_Medical_Sciences,_Colorectal_Division_of_Surgery_Ward,_Taleghani_Hospital,_Tehran,_Iran

b_Shahid_Beheshti_University_of_Medical_Sciences,_Surgery_Ward,_Taleghani_Hospital,_Tehran,_Iran

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Articlehistory:

Received6August2016 Accepted31August2016

Availableonline28September2016

Keywords:

Traumaticcloacadefect Sphinctroplasty Prinealreconstruction Skinadvancementflap

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b

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Background:Traumaticcloacaldefect(TCD)istheconditionthatoccursin0.3%ofwomen whohaveexperiencedthethird/fourth-degreeperineallacerationduringtraumaticNatural VaginalDelivery(NVD).Thisconditionhasmanyundesirableeffectsintheirlives.Surgery isthebestwaytorepairthisdeformityandwillimprovethequalityoflifeinthesepatients.

Design:Inthisstudy,weprospectivelystudied19patientswhowerereferredtothehospital withsymptomsofTCDwithinyears2011and2015withthemeanof2.6-yrsfollow-up.They allunderwentsphincteroplastyandperineoplastywithskinadvancementflap.

Results:Ofall19patients,incontinencetosolidfaecesin16patients(84%),incontinenceto liquidstoolin15patients(78%)andincontinencetoflatusin4patients(21%)were com-pletelyresolved.TheFIscorewasdecreasedfromthemeanof12.7to2.6.Sexualfunction wassignificantlyimprovedinallofthemanddyspareuniawascompletelydisappearedin 9patients(50%).Thequalityoflifescorewasincreasedfromthemeanof45to95. Post-operationcomplicationswereoccurredin3ofpatients(woundinfectionin2-casesand recto-vaginalfistulainanother).

Conclusion:Ourfindingsshowthatsphincteroplastyandperineoplastywithskin advance-mentflapisaneffectivesurgicaltechniquetorepairtheperinealbodyduetoitsbenefits andfewcomplications.Inthisstudy,therewassignificantimprovementinqualityoflifeof almostallpatientsafterthisreconstructivesurgery.Consultingwithacolorectalsurgeonis recommendedforthesecases.

licenses/by-nc-nd/4.0/).

∗ _{Corresponding}_author_.

E-mail:[email protected](O.Etemad).

http://dx.doi.org/10.1016/j.jcol.2016.08.002

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Esfincteroplastia

e

perineoplastia

com

retalho

cutâneo

de

avanc¸o

no

tratamento

de

defeito

cloacal

traumático

Palavras-chave:

Defeitocloacaltraumático Esfincteroplastia

Reconstruc¸ãoperineal Retalhocutâneodeavanc¸o

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e

s

u

m

o

Experiência: Defeitocloacaltraumático(RCT)éacondiçãoqueocorreem0,3%dasmulheres quesofreramlaceraçãoperinealdeterceiro/quartograuduranteumpartovaginalnatural (PNV)traumático.Essacondiçãocausamuitosefeitosindesejáveisemsuasvidas.Acirurgia éamelhorformaderepararessadeformidade,emelhoraráaqualidadedevidanessas pacientes.

Modelo: Nesseestudo,estudamos prospectivamente 19 pacientesqueforam encamin-hadasaohospitalcomsintomasdeRCTentre2011e2015,comumamediade2,6anosde seguimento.Todasforamsubmetidasaumaesfincteroplastiaeperineoplastia,comretalho cutâneodeavanc¸o.

Resultados:Datotalidadede19pacientes,aincontinênciaparafezessólidasem16pacientes (84%),aincontinênciaparafezeslíquidasem15pacientes(78%)eaincontinênciaparaflatos emquatropacientes(21%)foramcompletamenteresolvidas.OcorreureduçãonoescoreFI, deumamediade12,7para2,6.Afunçãosexualmelhorousignificativamenteemtodasas pacientes,eadispareuniadesapareceucompletamenteemnovepacientes(50%).Oescore paraqualidadedevidamelhorou,damediade45para95.Ocorreramcomplicações pós-operatóriasemtrêspacientes(infecçãodaferidaemdoiscasosefistularetovaginalnocaso restante).

Conclusão: Nossosachadosdemonstramqueaesfincteroplastiaeaperineoplastiacom retalhocutâneodeavançoétécnicacirúrgicaefetivaparaoreparodocorpoperineal,graçasa seusbenefícioseàspoucascomplicações.Nesseestudo,foiobservadamelhorasigana qual-idadedevidadepraticamentetodasaspacientesemseguidaaessacirurgiareconstrutiva. Parataiscasos,érecomendávelumaconsultacomumcirurgiãocolorretal.

licenses/by-nc-nd/4.0/).

Background

Cloacaldeformityistheconditionthatoccursin0.3%ofthe patients with the third or fourth-degree laceration during (NVD).1–4_This_injury_is_{characterized}_by_disruption_of_the

peri-nealbodyanddistalportionofrecto-vaginalseptum.1

Patients with cloacal deformity invariably suffer from severe incontinence to flatus, liquid and solid stool and severeurinaryandvaginalinfections.5_Difficulties_during

sex-ualfunctionsuchasdyspareuniainthesepatientsare also annoying.1–5 _These_problems_may_lead_to_{psychological}_and

physicaldisorderssuchassocialisolationandsexual dysfunc-tionwhichcoulddecreasethequalityoflife.1–5_For_patients

withhistoryofTCDandsuccessfulsurgicalrepair,Caesarean sectionseemsreasonableforthenextdelivery.5

Todiagnosethisdeformityweshouldhaveacareful obstet-ric history and detailed physical examination of perineal area.1_Diminution_or_absence_of_prineal_body_and_the

anovagi-nal/rectovaginalseptuminwomenwithhistoryoftraumatic NVDaretheevidencesofcloacaldeformity.

There are also additional diagnostic tests including endoanal ultrasound, manometry and pudendal nerve stimulation.6

SeveralsurgicaltechniquesareavailabletotreatTCDand reconstructperinealbody.Inthisstudy,wewillstudythe con-ditionsof19patientswhowereunderwentsphincteroplasty

andperineoplastywithskinadvancementflaptorepairthe perinealbodybetween2011and2015atthe follow-upplan between3-monthsand4-yrswiththemeanof2.6-yrs.

Objective

Thesphincteroplastyand perineoplastywithskin advance-ment flap were performed for all patients. All data are gatheredformean2.6-yrs offollow-up. Thedatarelatedto incontinencescoreandqualityoflifewerecollectedbyusing WextnerFaecalIncontinenceScore(FIScore)andQualityof Life (QoL) form which are available in Appendix 1 and 2, respectively.

Other data including pre- and post-operation dyspareu-nia,sexualfunctionsatisfaction,satisfactionoftheresultsof surgery,andalsopost-operationcomplicationswerecollected throughinterviewswitheachpatient.

Fig.1showsTCDinoneofthepatients.

Design

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Fig.1–Traumaticcloacadefectinoneofthepatients.

• Identifyingtheskinflapwithapproximatelengthof8–10cm (Fig.2B).

• Separationofano-rectumfromthevaginabydissectingthe recto-vaginalseptum(Fig.3A).

• Performanceofsphincteroplastyinordertooverlappingthe internalandexternalsphincter(Fig.3B).

• Reconstructionofperinealbodybyapproximatingthe bul-bocavernosus,externalsphincterand transverseperineal muscles.

• Reconstruction ofperineal skinwith advancement flaps (Fig.4).

Overlappingsphincteroplastywasperformedbyusing2/0 vicryl separated sutures. Perineal body was reconstructed byapproximatingbulbocavernosus,transverse perinealand externalsphinctermuscles.Finallyskinreconstructionwas donewithadvancementflapandhemovacdrainwasplaced under the flap. The patienst left NPO for three days and loperamidewasadministeredforthemandthewoundwas dresseddaily.Thedrainwasremovedafter3–4days.

Outcome

measures

WeconsideredthenumberofNVDs,BMI,ageandthe inter-valbetweenthetraumaticNVDandreconstructiveoperation. ThisinformationistabulatedinTable1.

Alsoasyou canfindfrom Table2,wecollectedthedata

ofall19patientsincludingtheFaecalIncontinence(FI)score (accordingtotheWexnerFIscoreinAppendix1),Qualityof Life(QoLforminAppendix2),dyspareunia,lifesatisfaction in pre- and post-operation, post-op complicationssuch as woundinfection,recto-vaginalfistulaandflapnecrosisand satisfactionbytheresultsofthesurgery.Foreasyanalyzing, weallocatedanumbertoeachpatient.

Results

AccordingtoTable1,themeanageofpatientsatthetimeof surgerywas35-yrs-oldandthemeanintervalyearsbetween thetraumaticNVDandthereconstructivesurgerywas5.9-yrs. ThemeanBMIofthepatientsatthetimeofsurgerywas26.63. AsitcanbefoundfromTable2,of19patientswhosuffered from faecalincontinence,3ofthem(15%)were completely curedwiththepost-opscoreof0/20,andthereisasignificant improvementinothers.Incontinencetothe solidstoolwas treatedin16patients(84%)and4patients(21%)stillsuffered fromincontinencetotheliquidstool.Theincontinencetothe gaswascompletelycuredin3patients(15%).Consequently thefaecalincontinencescorewassignificantlydecreasedin

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Fig.3–(A)Separationofano-rectumfromthevaginabydissectingtherecto-vaginalseptum;(B)performanceof sphincteroplastyinordertooverlappingtheinternalandexternalsphincter.

Fig.4–Reconstructionofperinealskinwithadvancement flaps.

allpatients.ThemeanFIscorewasdecreasedfrom12.7/20to 2.6/20(Fig.5).

Of18patientswhohadsexualfunctionaftersurgery,sexual functiondissatisfactioninallofthepatientswascompletely resolved(Fig.6A).

Of18patientswhohadsexualfunction,thedyspareunia was cured in 9 patients. The score of this parameter was decreasedfromthemeanof5tolessthan1(Fig.6B).

Pre-and post-Op FI score (Wextner)

Pre-Op FI score Post-Op FI score

25 20 15 10 5 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Fig.5– Comparisonofpre-andpost-opfaecalincontinence score.

Thequalityoflifehadasignificantimprovementandwas increasedfromthemeanof45/119to95/119(Fig.7).

17patients(89.47%)weresatisfiedand2patients(10.52%) wererelativelysatisfiedfromtheresultsofsurgery(Fig.8).

Asit canbe foundfromFig. 9, recto/vaginalfistulawas occurredinonepatient(5%)andwoundinfectionin2patients (10%)whichallofthemweremanagedconservatively.There wasnocomplicationreportedintheothers.

Alsowehaveinvestigatedifthereareanysignificant dif-ferencesbetweenthepre/postopvaluesofthegivenvariables byusingSPSSver.20.

Table1–Patientsdata.

Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Age 25 29 33 30 71 58 20 37 32 39 42 33 41 27 27 30 33 38 32

BMI 25 23 29 27 30 20 25 31 23 27 26 28 30 34 26 30 22 27 25

Interval(-yrs) 4 2 4 1.5 20 10 8 5 2 1 20 3 10 4 1 10 3 3 2

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Pre-and post -Op sexual function satisfaction Pre-and post -Op dyspareunia

Pre-Op Post-Op Pre-Op dyspareunia Pre-Op dispareunia

6 5 4 3 2 1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 0

6 5 4 3 2 1 0

A

B

Fig.6–Changesinpre-opandpost-opsexualfunctionsatisfaction(A)anddyspareunia(B).

Table2–Dataofpre-andpost-op.

Patients Pre-op FI

Post-op FI

Pre-op dyspareunia

Post-op dyspareunia

Pre-opsexual function satisfaction

Post-opsexual function satisfaction

Pre-op QoL

Post-op QoL

Complication Satisfaction

1 8/20 3/20 5/5 2/5 0/5 4/5 48/119 100/119 Wound

infection Yes

2 4/20 1/20 5/5 0/5 2/5 5/5 81/119 116/119 – Yes

3 4/20 1/20 5/5 1/5 2/5 5/5 87/119 100/119 – Yes

4a _15/20 _0/20 _5/5 _1/5 _0/5 _5/5 _34/119 _98/119 _– _Yes

5 10/20 7/20 – – – – 37/119 79/119 – Relatively

6 4/20 0/20 5/5 0/5 0/5 5/5 82/119 102/119 Wound

infection Yes

7 16/20 5/20 5/5 3/5 0/5 4/5 36/119 87/119 – Relatively

8 16/20 4/20 5/5 3/5 0/5 4/5 36/119 72/119 – Yes

9 20/20 11/20 5/5 0/5 0/5 5/5 34/119 60/119 – Yes

10 10/20 4/20 5/5 0/5 0/5 5/5 36/119 72/119 – Yes

11 16/20 2/20 5/5 2/5 0/5 4/5 38/119 99/119 – Yes

12 16/20 3/20 5/5 0/5 0/5 5/5 38/119 85/119 – Yes

13 10/20 1/20 5/5 1/5 0/5 5/5 43/119 98/119 – Yes

14 20/20 0/20 5/5 0/5 0/5 5/5 38/119 108/119 R.V.F.b _Yes

15 12/20 1/20 5/5 0/5 0/5 5/5 45/119 98/15 – Yes

16 13/20 2/20 5/5 0/5 0/5 4/5 47/119 106/119 – Yes

17 15/20 2/20 5/5 1/5 0/5 5/5 43/119 95/119 – Yes

18 16/20 1/20 5/5 1/5 0/5 5/5 49/119 98/119 – Yes

19 15/20 2/20 5/5 0/5 0/5 5/5 38/119 105/119 – Yes

a _The_patient_whose_husband_is_dead_and_did_not_have_sexual_activity.

b _{Recto-Vaginal}_Fistula.

By assuming that the acceptable ofthe (sig.) p-value is

p<0.05,theresultsshowasignificantdifferencebetween pre-andpostopFIscore,pre-andpostopdyspareunia,pre-and post opsexual functionsatisfaction,and pre- and post op qualityoflife.p-valuerangeofeach parameteristabulated

inTable3.

Quality of life score

140 120 100 80 60 40 20 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Pre-Op Post-Op

Fig.7–Post-surgicalimprovementofqualityoflife.

Discussion

TCD is a rare complication of traumatic NVD which may lead to faecal incontinence, stress, social isolation and

10.53

89.47

Satisfied Relatively satisfied Dissatisfied

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10.50 5.30

Wound infection

Recto/Vaginal fistula

No complications 1

2

3

84.20

Fig.9–Post-opcomplications.

physiologicaldamagesinapatient.Repairandreconstruction ofperineal bodyanddeformedorgans forthesepatientsis efficient.Thevitalpartofsuchtheseproceduresisprecision whiledissectingand dividingthe ano-vaginal/recto-vaginal septum.There are several surgical techniques totreat the TCD and almost all of them have a significant impact to improve the physical and physiological conditions of the patients.

Thereareseveralarticlesinwhichthedeformityofcloaca hasbeentreatedbyusingdifferenttechniquesof reconstruc-tivesurgery.3,7–9_In_order_to_analyze_the_outcomes_of_the_other

surgeonswithours, wehavecompared ourmainvariables withtheothersasfollows.

Pre/postopFIscore

Inthisstudy,faeces,liquidstoolandgasincontinencywas resolvedin84%,78%and15%ofthepatients,respectively.Also themeanFIscorewasdecreasedfrom12.7to2.6.

In the Spanos’sstudy on 4patients, the mean FIscore was decreased from 18 to 1.5 _In _the _{Hollingshead’s} _study

on 29 patients, incontinence to faeces, liquid stool and gas was resolved in 100%, 50% and 40% of the patients, respectively.2

Pre/postopdyspareunia

Inourstudy,fromall18patientswhohadsexualfunctionafter thesurgery,dyspareuniawascompletelyresolvedin9ofthem (50%).Thisparameterwasdecreasedfromthemeanof5to0.8 aftertherepairsurgery.

InSpanos’sstudyon4patients,onepatientsufferedfrom dyspareunia afterthe repairsurgery.5 _In_{Venkatesh’s} _study

on44patients,27%ofthemstillsufferedfromdyspareunia.4

InAbcarian’sstudyon43patients,dyspareuniawasresolved

Table3–p-Valueofeachvariable.

Variable p-Value

Pre-andpost-opFI <0.05

Pre-andpost-opQoL <0.05

Pre-andpost-opdyspareunia <0.05

Pre-andpost-opsexualfunctionsatisfaction <0.05

in15%ofthem.1 _In_{Hollinshead’s}_study_on₂₉_patients,

dys-pareuniawasresolvedin9patients.2_In_Valente’s_study,_this

parameterwasresolvedinall4patientswhowereunderwent thestudy.8

Pre/postopsexualfunctionsatisfaction

Inourstudy,thesexualfunctionsatisfactionwasimproved fromthemeanscoreof0.2to4.7.

Hollingshead reported the improvementofsexual func-tion satisfactionscorein9patients from29patientsinhis study.2_Spanos_reported_the_improvement_of_sexual_function

satisfactioninall4patientsofhisstudy.5

Pre/postopqualityoflife

Inourstudy,thequalityoflifescorewasincreasedfromthe meanof45to95.

InValenete’sstudyon4patients,thequalityoflifeinall patientswassignificantlyimproved.8 _In_Altomar’s_study _on

onepatientwith20-yrsfollow-upplan,therewasreporteda significantimprovementinqualityoflife.10

Post-opcomplications

Wereportedcomplicationsin3patientsincludewound infec-tion intwo patients (10%) and recto/vaginal fistulain one patient(5%).All3patientswerecuredbyconservative treat-ment.

InHarjeet’sstudy,woundinfection wasreportedinall4 patients.7_In_Kaiser’s_study_on₁₂_patients,_there_was_reported

therecto/vaginalfistulain5patients.3_In_Spanos’s_study_on

4 patients, there was no complication reported.5

Holling-sheadreportedtherecto/vaginalfistulain3patients(10%)and woundinfectionin4patients(14%)ofall29patients.2

Conclusion

Wehavestudied19 patientswhowerereferredtothe hos-pital with symptoms of TCD between 2011 and 2015 at 3-monthsto4-yrswiththemeanof2.6-yrsfollow-up.They allunderwentsphincteroplastyandperineoplastywithskin advancementflap.Accordingtothesignificantimprovements ofFIscore,dyspareunia,sexualfunctionsatisfactionand qual-ityoflifeandalsominimalcomplicationsinallpatientsofour study,thistechniqueisrecommendedasaneffectivesurgical methodtotreattheTCDinsuchpatients.Forpatientswith successfulsurgicalrepairofTCD,Caesarseansectionseems reasonableforthenextdelivery.

Insuchthesecases,consultingwithacolorectalsurgeon mayimprovequalityoflifeofthepatients.

Conflicts

of

interest

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Acknowledgements

ThisarticlehasbeenextractedfromthethesiswrittenbyDr. OmidEtemadinSchoolofMedicineShahidBeheshti Univer-sityofMedicalSciences(RegistrationNo.:467).

Appendix

A. Supplementary

data

Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.jcol.2016.08.002.

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