Distal feeding-bowel stimulation to treat short-term or long-term pathology: a systematic review.

BACKGROUND: Distal feeding (DF) describes the insertion of a feeding tube into a fistula or stoma to administer a liquid feed into the distal bowel. It is currently used clinically in patients who are unable to absorb enough nutrition orally. This systematic review investigates DF as a therapeutic measure across a spectrum of patients with stomas and fistulae. METHODS: A total of 2825 abstracts and 44 full-text articles were screened via OVID. Fifteen papers were included for analysis. Randomised controlled trials, cohort and observational studies investigating DF as a therapeutic measure were included. RESULTS: Three feeds were used across the studies-reinfusion of effluent, infusion of prebiotic or a mixture. The studies varied the length of feeding between 24 hours and 61 days, and the mode of feeding, bolus or continuous varied.DF was demonstrated to effectively wean patients from parenteral nutrition in two papers. Two papers demonstrated a significant reduction in stoma output. Three papers demonstrated improved postoperative complication rates with distal feeding regimens, including ileus (2.85% vs 20% in unfed population, p=0.024). One paper demonstrated a reduction in postoperative stool frequency. CONCLUSIONS: This review was limited by study heterogeneity and the lack of trial data, and in the patient groups involved, the variability in diet and length of regimen. These studies suggest that DF can significantly reduce stoma output and improve renal and liver function; however, the mechanism is not clear. Further mechanistic work on the immunological and microbiological action of DF would be important.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery.

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review.

INTRODUCTION: There is a paucity of data on incidence and mechanisms of long-term gastrointestinal consequences after chemoradiotherapy for anal cancer. Most of the adverse effects reported were based on traditional external beam radiotherapy whilst only short-term follow-ups have been available for intensity-modulated radiotherapy, and there is lack of knowledge about consequences of dose-escalation radiotherapy. METHOD: A systematic literature review. RESULTS: Two thousand nine hundred and eighty-five titles (excluding duplicates) were identified through the search; 130 articles were included in this review. The overall incidence of late gastrointestinal toxicity was reported to be 7-64.5%, with Grade 3 and above (classified as severe) up to 33.3%. The most commonly reported late toxicities were fecal incontinence (up to 44%), diarrhea (up to 26.7%), and ulceration (up to 22.6%). Diarrhea, fecal incontinence and buttock pain were associated with lower scores in radiotherapy specific quality of life scales (QLQ-CR29, QLQ-C30, and QLQ-CR38) compared to healthy controls. Intensity-modulated radiation therapy appears to reduce late toxicity. CONCLUSION: Late gastrointestinal toxicities are common with severe toxicity seen in one-third of the patients. These symptoms significantly impact on patients' quality of life. Prospective studies with control groups are needed to elucidate long-term toxicity.

Assessment and management of patients with intestinal failure: a multidisciplinary approach.

Intestinal failure (IF) is a condition characterized by the inability to maintain a state of adequate nutrition, or fluid and electrolyte balance due to an anatomical or a physiological disorder of the gastrointestinal system. IF can be an extremely debilitating condition, significantly affecting the quality of life of those affected. The surgical management of patients with acute and chronic IF requires a specialist team who has the expertise in terms of technical challenges and decision-making. A dedicated IF unit will have the expertise in patient selection for surgery, investigative workup and planning, operative risk assessment with relevant anesthetic expertise, and a multidisciplinary team with support such as nutritional expertise and interventional radiology. This article covers the details of IF management, including the classification of IF, etiology, prevention of IF, and initial management of IF, focusing on sepsis treatment and nutritional support. It also covers the surgical aspects of IF such as intestinal reconstruction, abdominal wall reconstruction, and intestinal transplantation.

Combined Laparoscopic and Perineal Approach to Omental Interposition Repair of Complex Rectovaginal Fistula.

INTRODUCTION: Surgical repair of rectovaginal fistula remains a challenge. Complex and recurrent rectovaginal fistula repairs often fail because of scarring and devascularization of the surrounding tissue. Omental interposition may promote healing by introducing bulky vascularized tissue into the rectovaginal septum. TECHNIQUE: With the patient in the lithotomy position, the rectovaginal septum was dissected transperineally up to the fistula tract and the openings on both vaginal and rectal sides were closed using interrupted, absorbable sutures. The dissection was continued cranially to meet the laparoscopic dissection from above. The laparoscopic surgeon detached the omentum from the colon, then the anastomotic arterial branches between the Barlow's arcade and the gastroepiploic arcade were divided and the greater omentum was mobilized, retaining blood supply from the left gastroepiploic artery. The rectum was then mobilized commencing on the right lateral side of the mesorectum and then proceeding anteriorly. The peritoneum between the rectum and the vagina was incised and the anterior mobilization was continued to connect with the perineal dissection. The mobilized omentum was pulled down between the rectum and the vagina.The perineal operator secured the omentum around the rectal closure and at skin level with absorbable sutures. All of the patients had a defunctioning ileostomy or colostomy before omental repair. RESULTS: Patients underwent repair for complex or recurrent rectovaginal fistulas with this novel approach. Fistula healing was evaluated during examination under anaesthesia. All of the patients had completely healed at the latest follow-up (median = 15 mo; range, 8-41 mo). Postoperative complications included 1 superficial wound infection that was treated conservatively and 1 rectovaginal hematoma, which required CT-guided aspiration. CONCLUSIONS: Combined laparoscopic omental interposition with perineal rectovaginal fistula repair is a safe and effective treatment for complex rectovaginal fistulas.

A Systematic Review and Meta-analysis of Timing and Outcome of Intestinal Failure Surgery in Patients with Enteric Fistula.

BACKGROUND: The timing of intestinal failure (IF) surgery has changed. Most specialized centers now recommend postponing reconstructive surgery for enteric fistula and emphasize that abdominal sepsis has to be resolved and the patient's condition improved. Our aim was to study the outcome of postponed surgery, to identify risk factors for recurrence and mortality, and to define more precisely the optimal timing of reconstructive surgery. METHODS: PubMed, Embase, and the Cochrane Library were systematically reviewed on the outcomes of reconstructive IF surgery (fistula recurrence, mortality, morbidity, hernia recurrence, total closure, enteral autonomy). If appropriate, meta-analyses were performed. Optimal timing was explored, and risk factors for recurrence and mortality were identified. RESULTS: Fifteen studies were included. The weighted pooled fistula recurrence rate was 19% (95% CI 15-24). Lower recurrence rates were found in studies with a longer median time and/or, at the minimum of the range, a longer time interval to surgery. Overall mortality was 3% (95% CI 2-5). Total fistula closure rates ranged from 80 to 97%. Enteral autonomy after reconstructive surgery, mentioned in four studies, varied between 79 and 100%. CONCLUSIONS: Postponed IF surgery for enteric fistula is associated with lower recurrence. Due to the wide range of time to definitive surgery within each study, optimal timing of surgery could not be defined from published data.

Management of Intestinal Failure: The High-Output Enterostomy and Enterocutaneous Fistula.

This article provides an overview of the pathophysiology, causes, investigations, and management of high-output enterostomy and enterocutaneous fistula. High-output stoma and enterocutaneous fistula can result in intestinal failure and this is often fatal if not managed properly. The management involves reducing fluid losses, providing nutrients with fluids, and treating the underlying cause and sepsis. A multidisciplinary approach is required for successful management of patients with high-output enterostomy and enterocutaneous fistula.

Pilot study of immunological factors in non-inflammatory bowel disease enterocutaneous fistulas.

BACKGROUND: Tumour necrosis factor alpha (TNF-α) is a cytokine elevated in inflammatory bowel disease enterocutaneous fistula (IBD ECF). Dendritic cells are antigen presenting cells that orchestrate the immune responses and regulate the production of cytokines by immune cells including T cells. No study to date has assessed the level of TNF-α or the presence of dendritic cells in non-IBD ECF. The aim of this study was to assess the inflammatory activity, with a particular emphasis on TNF-α in non-IBD ECF when compared with control small bowel tissue. METHODS: Tissue biopsies were obtained from ECF at operation from non-IBD patients and from terminal ileum in normal colonoscopy control patients. After overnight culture, accumulation of intracellular TNF-α was measured by flow cytometry in cells treated with monensin to assess the on-going cytokine production. Data were acquired using FACS Canto II. Unpaired Student's t-test was used to compare variables between groups and p < 0.05 was regarded as significant. RESULTS: The on-going production of TNF-α from dendritic cells (p = 0.0007), putative monocyte and B cell populations (p = 0.04) and CD3+ T cells (p = 0.04) was significantly higher in non-IBD ECF tissue than that from control tissue. CONCLUSIONS: This study reveals results which provide evidence for the potential use of anti-TNF-α agents in the treatment of non-IBD ECF. A pilot study to evaluate this treatment as an alternative option in an already surgically challenging group of patients is planned. Positive findings would be a major medical advance with a new use for anti-TNF-α agents.

Quality of Life After Ostomy Surgery in Muslim Patients: A Systematic Review of the Literature and Suggestions for Clinical Practice.

PURPOSE: To determine factors that influence health-related quality of life (HRQOL) after ostomy surgery in Muslim patients. METHODS: A systematic literature review of published data was carried out using MeSH terms ("Muslim" OR "Islam") AND ("stoma" OR "ostomy" OR "colostomy" OR "ileostomy") AND "quality of life" AND "outcomes." RESULTS: Twelve studies enrolling 913 subjects were deemed suitable for inclusion in the review. HRQOL was found to be particularly impaired in Muslims; this impairment went beyond that experienced by non-Muslim patients. Factors associated with this difference included psychological factors, social isolation, underreporting of complications, and sexual dysfunction leading to breakdown of marital relations as well as diminished religious practices. CONCLUSION: Muslims requiring ostomies should receive preoperative counseling by surgeons and ostomy nurses. These discussions should also include faith leaders and/or hospital chaplains. Ongoing support after surgery can be extended into the community and encompass family doctors and faith leaders. Additional research exploring HRQOL after surgery in Muslims living in Western societies is indicated.

Mesenteric Infarction: Clinical Outcomes After Restoration of Bowel Continuity.

INTRODUCTION: Patients who have a bowel resection for mesenteric infarction may require parenteral nutrition (PN). This study primarily aimed to determine the aetiological factors for a mesenteric infarction and the effects of restoring bowel continuity on the long-term PN requirements. METHODS: A retrospective review of data on patients treated for mesenteric infarction from 2000 to 2010. RESULTS: A total of 113 patients (61 women, median age 54 years) were identified. Seventy-four (65%) had a superior mesenteric artery thromboembolism, 25 (22%) had a superior mesenteric vein thrombosis, and 4 (3%) had superior mesenteric artery stricture or spasm. Patients younger than 60 years most commonly had a clotting abnormality (n = 23/46, 50%), whereas older patients had a cardiological risk factor (n = 11/17, 65%). All patients with a jejunostomy required long-term PN. Fifty-seven (49%) patients had restoration of bowel continuity (colon brought into circuit). After this, PN was stopped within 1 year in 20 (35%), within 2 years in 29 (50%) patients and within 5 years in 44 (77%) patients (P = 0.001). CONCLUSIONS: A thrombotic tendency is the main etiological factor in most patients younger than 60 years. An anastomosis of the remaining jejunum to the colon can allow PN to be stopped.

Pudendal nerve stimulation for bowel dysfunction in complete cauda equina syndrome.

OBJECTIVE: Pudendal nerve stimulation (PNS) aims to maximize afferent or efferent stimulation from the sacral plexus. BACKGROUND: We hypothesized this may be a promising new treatment for patients with bowel dysfunction in complete cauda equina syndrome (CES). METHODS: Thirteen patients with complete CES [8 constipation predominant (group 1) and 5 incontinence predominant (group 2)] had a 3-week trial of PNS. Patients who showed a 50% or more improvement in symptoms during the trial phase proceeded to permanent neurostimulator implantation. RESULTS: Five (63%) of the 8 patients in group 1 showed a 50% or more improvement in bowel symptoms during the trial phase and were permanently implanted. The mean Cleveland Clinic constipation score, sense of incomplete evacuation (%), and straining during defecation (%) improved from 17 ± 3.2 to 10 ± 4.5, 94 ± 18% to 30 ± 35%, and 81 ± 23% to 44 ± 38%, respectively. All 5 patients in group 2 showed a 50% or more reduction in incontinent episodes during the trial phase. The mean St Mark's score, ability to defer defecation, and the number of incontinent episodes per week improved from 18 ± 1.0 to 3.8 ± 2.5, 2.2 ± 1.8 to 11 ± 5.5 minutes, and 9.4 ± 10.7 to 0.4 ± 0.5 episodes, respectively, per week. During a median follow-up of 12 (10-22) months of permanent implantation, one patient lost efficacy at 6 months due to lead migration and another required removal and reimplantation of the neurostimulator due to wound infection. CONCLUSIONS: PNS is an effective treatment in the short term for bowel dysfunction in some patients with complete CES.

A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas.

OBJECTIVE: Several randomized control trials (RCTs) have compared somatostatin and its analogues versus a control group in patients with enterocutaneous fistulas (ECF). This study meta-analyzes the literature and establishes whether it shows a beneficial effect on ECF closure. METHODS: We searched MEDLINE, EMBASE, CINAHL, Cochrane, and PubMed databases according to PRISMA guidelines. Seventy-nine articles were screened. Nine RCTs met the inclusion criteria. Statistical analyses were performed using Review Manager 5.1. RESULTS: Somatostatin analogues versus control. Number of fistula closed: A significant number of ECF closed in the somatostatin analogue group compared to control group, P = 0.002.Time to closure: ECF closed significantly faster with somatostatin analogues compared to controls, P < 0.0001.Mortality: No significant difference between somatostatin analogues and controls, P = 0.68.Somatostatin versus control. Number of fistula closed: A significant number of ECF closed with somatostatin as compared to control, P = 0.04.Time to closure: ECF closed significantly faster with somatostatin than controls, P < 0.00001.Mortality: No significant difference between somatostatin and controls, P = 0.63 CONCLUSIONS: Somatostatin and octreotide increase the likelihood of fistula closure. Both are beneficial in reducing the time to fistula closure. Neither has an effect on mortality. The risk ratio (RR) for somatostatin was higher than the RR for analogues. This may suggest that somatostatin could be better than analogues in relation to the number of fistulas closed and time to closure. Further studies are required to corroborate these apparent findings.

Long-term MRI-guided combined anti-TNF-α and thiopurine therapy for Crohn's perianal fistulas.

BACKGROUND: Anti-tumor necrosis factor (TNF) therapy heals many Crohn's disease (CD) anal fistulas clinically but the rate, extent, and durability of deep tissue healing and factors influencing long-term outcome are unknown. METHODS: Consecutive patients with CD-related perianal (anal, rectovaginal, anolabial) fistulas treated with infliximab or adalimumab were monitored prospectively both clinically and radiologically using magnetic resonance imaging (MRI). RESULTS: Forty-one consecutive patients with CD-related perianal fistulas were treated with infliximab (n = 32) or adalimumab (n = 9; following infliximab failure) in combination with a thiopurine (unless intolerant). Fifty-eight percent of all patients, comprising 66% and 43% of infliximab and adalimumab-treated patients, respectively, demonstrated remission or response at 3 years. Thirty-three percent of infliximab treated patients maintained clinical remission at 3 years. Radiological healing lagged behind clinical remission by a median of 12 months. The likelihood of clinical remission at any time was five times greater in patients who had early clinical response within 6 weeks than those without. A higher number of fistula tracts was associated with reduced clinical remission. All patients who achieved radiological healing maintained healing on infliximab treatment, while only 43% maintained healing after cessation of anti-TNF therapy. CONCLUSIONS: Combination anti-TNF and thiopurine therapy provides sustained benefit in patients with perianal CD fistula. Early clinical response is associated with subsequent clinical remission. Radiological healing is slower than clinical healing. Radiologically healed fistula tracts maintain healing on infliximab but can recur after cessation of therapy.

Prospective study of immunological factors in non-inflammatory bowel disease enterocutaneous fistulas.

BACKGROUND: Enterocutaneous fistulas (ECF) are debilitating and usually result following complex abdominal surgery. While there is an association with inflammatory bowel disease (IBD), a large number of fistulas occur after surgery not related to IBD. The consequences of ECF include short bowel syndrome and the need for long term parenteral nutrition.ECF can heal spontaneously and in the case of IBD can be cured by medical therapy in some instances. Those that do not resolve spontaneously have to be cured by surgery which is complex and associated with a high morbidity. It is not considered traditional treatment to use the same medical therapy as in IBD to cure ECF caused by other conditions.A small case series has reported three patients with persistent ECF not related to IBD to have healed following use of Infliximab which is the treatment commonly used for ECF caused by IBD. Infliximab acts by inhibiting the activity of the inflammatory cytokine TNF- alpha. It is not known if this cytokine is present in ECF tissue in the absence of IBD.The aim of this study is to demonstrate the presence of inflammatory markers in tissue surrounding non-IBD ECF and in particular to quantify the presence of the cytokine TNF- alpha. We hypothesise that TNF - alpha levels are raised in non-IBD ECF. METHODS/DESIGN: Tissue and serum from ECF of IBD and non-IBD patients will be prospectively collected at St. Mark's Hospital Intestinal Failure Unit. The control group will consist of patients undergoing colonoscopy for bowel cancer screening, with normal findings. Biopsies of the terminal ileum will be obtained from this group during colonoscopy. The fistula tract and serum cytokine profiles of interleukins (IL)-1a, IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, TNF- alpha, IFN-y, MCP-1, EGF and VEGF will be assessed. DISCUSSION: This study aims to assess the presence or absence of TNF- alpha expression in the ECF tissue in non-IBD origin. If our hypothesis is correct we would then be able to study the use of the TNF- alpha inhibitor Infliximab as a therapeutic option in the treatment of non-IBD ECF. Secondary aims include assessing the spectrum of inflammatory cytokines and markers present in tissue and serum of non-IBD ECF when compared with IBD ECF and normal controls. TRIAL REGISTRATION: ISRCTN44000447.

Prospective evaluation of anti-tumor necrosis factor therapy guided by magnetic resonance imaging for Crohn's perineal fistulas.

OBJECTIVES: Anti-tumor necrosis factor (TNF) therapy heals Crohn's fistulas clinically, but the rate, extent, and duration to achieve fistula track healing are unknown. METHODS: We sought to monitor deep healing, as indicated by magnetic resonance imaging (MRI), and to use this to determine treatment duration. Clinical and MRI fistula healing (at 6, 12, and 18 months), Crohn's Disease Activity Index (CDAI), Perianal Crohn's Disease Activity Index (PDAI), and the Inflammatory Bowel Disease Questionnaire were prospectively assessed. RESULTS: Thirty-four consecutive patients with perineal fistulas were treated with infliximab (19), adalimumab (7; all infliximab failures) and thalidomide (8). Median follow-up was 110 weeks (range, 74-161). Baseline MRI: 38% >or=2 tracks, 21% anolabial/rectovaginal. At latest follow-up, clinical fistula 'response' and 'closure' were seen in 50 and 46% of antibody-treated patients, respectively. All patients stopped thalidomide early due to side effects. Of 26 antibody-treated patients, at 6 (n=25), 12 (n=25), and 18 (n=20) months, respectively, MRI showed complete healing (20, 28, and 30%, respectively), improvement (68, 72, and 65%), no change (12, 0, and 0%) or worsening (0, 0, and 5%). MRI healing at 6 months (n=5) persisted at 12 and 18 months, including in two patients who stopped treatment at 6 months. Fistula history length and complexity did not influence the outcome. The only surgical intervention was seton insertion in one patient. The PDAI and CDAI scores decreased, and quality of life improved significantly at last follow-up. CONCLUSIONS: MRI fistula resolution was variable and slower than clinical healing. Prolonged treatment is often required for internal track resolution. Preliminary data suggest once MRI healing has occurred fistulas remain healed, while remaining on, or stopping anti-TNFalpha therapy. The use of a second antibody is clinically valuable.

Sacral nerve stimulation for fecal incontinence related to obstetric anal sphincter damage.

PURPOSE: Sphincter repair is the standard treatment for fecal incontinence secondary to obstetric external anal sphincter damage; however, the results of this treatment deteriorate over time. Sacral nerve stimulation has become an established therapy for fecal incontinence in patients with intact sphincter muscles. This study investigated its efficacy as a treatment for patients with obstetric-related incontinence. METHODS: Fecally incontinent patients with external sphincter defects who would normally have undergone overlapping sphincter repair as a primary or repeat procedure were included. Eight consecutive women (median age, 46 (range, 35-67) years) completed temporary screening; all eventually had permanent implantation. RESULTS: Six of eight patients had improved continence at median follow-up of 26.5 (range, 6-40) months. Fecal incontinent episodes improved from 5.5 (range, 4.5-18) to 1.5 (range, 0-5.5) episodes per week (P = 0.0078). Urgency improved in five patients, with ability to defer defecation improving from a median of <1 (range, 0-5) minute to 1 to 5 (range, 1 to >15) minutes (P = 0.031, all 8 patients). There was no change in anal manometry or rectal sensation. There was significant improvement in lifestyle, coping/behavior, depression/self-perception, and embarrassment as measured by the American Society of Colon and Rectal Surgery fecal incontinence quality of life score. CONCLUSIONS: Sacral nerve stimulation is potentially a safe and effective minimally invasive treatment for fecal incontinence in patients with de novo external anal sphincter defects or defects after unsuccessful previous external anal sphincter repair, although numbers remain small.

Obstetric anal sphincter injury: incidence, risk factors, and management.

BACKGROUND AND AIMS: Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management. METHOD: This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists. RESULTS: A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality. CONCLUSIONS: Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

Long-term results of repeat anterior anal sphincter repair.

PURPOSE: Anterior anal sphincter repair for obstetric trauma sometimes fails because of breakdown of the repair. The long-term results of repeating the overlapping repair are not known. METHODS: Twenty-three patients with repeat obstetric-related anterior sphincter repair had previously been assessed at a median of 20 months follow-up, at which time 13 patients (65 percent) felt 50 percent or greater improvement compared with their preoperative symptoms. Patients were reassessed at a median of 5 years (range, 48-86 months) using a questionnaire, an incontinence score, and telephone interview to determine current bowel function, continence, and restriction in activities of daily life and overall satisfaction with the results of surgery. RESULTS: Twenty-one of 23 patients (median age, 47 (range, 27-66) years) were contacted. One patient was lost to follow-up and one had died of an unrelated cause. Of 21 patients, one was fully continent and 12 more reported symptom improvement of 50 percent or more compared with preoperatively. Four were unchanged, and of the four whose symptoms had deteriorated, two had undergone further surgery for incontinence. Compared with the 20-month assessment, there was no significant change in continence scores (median, 12/20 (range, 1-20) vs. 7/20 (range, 2-19); 20 vs. 60 months), rating of improvement (median, 50 (range, 0-100) percent) at 20 and 60 months), or satisfaction (7/10 (range, 0-10) at 20 and 60 months). CONCLUSIONS: Repeat anterior sphincter repair results in improved continence for the majority of patients, with no substantial change between the short-term and long-term follow-up.