Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life.

BACKGROUND: An early secondary repair of the anal sphincter may be necessary if primary repair of obstetric anal sphincter injury (OASIS) is complicated by wound rupture or severe infection. The objective of this study was to assess the long-term functional outcomes, morbidity, and impact on quality of life (QoL) following an early secondary repair of OASIS. METHODS: This retrospective cohort study was conducted at Aarhus University Hospital, Denmark. All women having a secondary repair of the anal sphincter within 21 days of delivery from February 1991 to February 2017 were included (n = 51). Complications were assessed by reviewing medical records. The patient-reported outcomes were assessed in 2018 by questionnaires. Primary outcome was Wexner score and St. Mark's score. Impact on QoL was assessed using the Fecal Incontinence Quality of Life Scale (FIQLS). RESULTS: After a median follow-up time of 6.7 years (IQR 3.3-16.6), 34 women completed the questionnaire. The mean (SD) Wexner score was 5.2 ± 4.7 and the mean (SD) St. Mark's score was 6.8 ± 5.7. Women with a Wexner score ≥ 9 had a significantly lower QoL score in all domains of the FIQLS compared to women with a Wexner score < 9 (p < 0.001). Postoperative complications were experienced by 37%. Ten women developed a fistula of which nine required surgical treatment. CONCLUSIONS: An early secondary repair of the anal sphincter can be performed within 21 days of delivery with functional long-term outcomes comparable to those following a late sphincter repair. However, there is an imminent risk of complications, mainly fistulas, which should be taken into consideration when choosing the ideal timing of the repair.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up.

AIM: Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury. METHOD: This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale. RESULTS: Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001). CONCLUSION: At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

Pelvic organ function before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study.

OBJECTIVE: To assess urinary, sexual, and bowel function before and after laparoscopic bowel resection for rectosigmoid endometriosis. DESIGN: Prospectively collected data regarding the function of the pelvic organs. SETTING: Tertiary endometriosis referral unit, Aarhus University Hospital. SAMPLE: A cohort of 128 patients who underwent laparoscopic bowel resection for endometriosis. METHODS: The International Consultation on Incontinence Questionnaire (ICIQ), Sexual Function-Vaginal Changes Questionnaire (SVQ), and the Low Anterior Resection Syndrome (LARS) questionnaire were answered before and after surgery. Non-invasive urodynamic testing was performed. MAIN OUTCOME MEASURES: Pre- and postoperative function of the pelvic organs was compared, and risk factors for improved/impaired function were identified. RESULTS: A total of 96.1% of the women completed the 1-year follow-up. A significant decrease (P = 0.002) in bladder filling problems (F-score) was observed 1 year after surgery, primarily caused by a significant decrease in bladder pain (P = 0.0001). No change for urodynamic parameters was observed. A significant increase in overall sexual satisfaction (P = 0.0001) and decrease in worries about sexual life (P = 0.001) was seen 1 year after surgery. Frequency of defecation was significantly increased 1 year after surgery (P = 0.0001), but the overall bowel function measured by LARS score was unchanged. Patients with anastomotic leakage had a significantly higher risk (odds ratio, OR 5.40; P = 0.002) of increased incontinence problems (I-score) 1 year after surgery. CONCLUSION: A significant and clinically relevant improvement in urinary and sexual function 1 year after laparoscopic bowel resection for endometriosis was found. Except for anastomotic leakage, this could be observed independent of any patient- or treatment-related factor. Apprehension about impairment of urinary and sexual function should not be a contraindication for bowel resection in endometriosis patients. TWEETABLE ABSTRACT: Rectal resection for endometriosis does not impair urinary and sexual function 1 year after surgery.

Subjective and objective results of anterior vaginal wall repair in an outpatient clinic: a 5-year follow-up.

INTRODUCTION AND HYPOTHESIS: This prospective follow-up study evaluates long-term subjective and objective outcome of conventional anterior vaginal wall repair in an outpatient setting. METHODS: Eighty-two women were operated. At 5-year follow-up anatomical results were evaluated by clinical examination. Furthermore, the women filled in a validated symptom and quality of life questionnaire. RESULTS: Seventy (85%) women attended the follow-up visit. Eleven percent of these had been reoperated for anterior vaginal wall prolapse and was considered a separate group in the analysis. Thirty-four percent had no pelvic organ prolapse (POP). Twenty-nine percent had stage 1 POP whereas 24% had stage 2 and 2% stage 3 at follow-up. Seventy-eight percent of the women had no bulge symptoms, and 73%of the women considered their condition improved. CONCLUSIONS: At 5-year follow-up 78 % was relieved from their bulge symptoms by an operation using local anesthesia. Eleven percent of the women had been reoperated.

Pulmonary endothelial dysfunction after cardiopulmonary bypass in neonatal pigs.

BACKGROUND: In neonatal pigs cardiopulmonary bypass (CPB) is associated with endothelial dysfunction in isolated large pulmonary arteries. It is, however, of great importance if this functional change extends to the small pulmonary resistance arteries, which are the key regulators of pulmonary flow and pressure. The aim of this study was to assess changes in pulmonary microvascular function after CPB using a clinically relevant pediatric procedure. METHODS: From three groups of neonatal pigs (CPB-, sham- and control group) pulmonary resistance arteries and systemic resistance arteries (from skeletal muscle) were isolated and mounted as ring preparations in wire myographs. Vessel diameters were less than 500 microm. Concentration-response curves were constructed for norepinephrine (NA), vasopressin (Vp), and the thromboxane A2-analog U46619, while the endothelium-dependent and -independent vasodilator functions were assessed as responses to acetylcholine and nitric oxide (NO). RESULTS: Maximum pulmonary vasodilator response to acetylcholine was attenuated after CPB compared with sham-operated and control animals (P=0.04). NO-induced relaxation, and contractile responses to NA, Vp, and U46619 were not influenced by CPB. In systemic arteries no changes in contractile or relaxant responses were seen after CPB. CONCLUSION: CPB seems to induce pulmonary endothelial dysfunction in pulmonary but not peripheral resistance arteries in neonatal piglets.

Effects of ouabain on the isolated human uteroplacental vasculature.

OBJECTIVE: We sought to describe the effects of ouabain on the human uteroplacental vasculature. STUDY DESIGN: Stem villous vessels and intramyometrial arteries isolated from placental and myometrial biopsy specimens at term were mounted in organ baths. Moreover, isolated human placental cotyledons were perfused. RESULTS: Contractions induced by the thromboxane A2 analog U46619 were unaffected by pretreatment with ouabain 10(-10) to 10(-6) mol/L. In fetal vessels nitric oxide (10(-8) to 3 x 10(-5) mol/L) induced relaxation of vascular tonus induced by U46619 and potassium. This relaxation was inhibited by pretreatment with ouabain 10(-7) to 10(-6) mol/L. These associations were unaffected by removal of the endothelium. In maternal arteries ouabain (10(-6) mol/L) failed to significantly affect nitric oxide-induced relaxation. Ouabain (10(-9) mol/L) significantly affected pressure-flow relationships in perfused cotyledons. CONCLUSIONS: Ouabain impairs nitric oxide-induced relaxation of human stem villous arteries and veins, which may explain the changes induced by therapeutically relevant concentrations of the drug on pressure-flow relationships in the perfused cotyledon. Thus treatment with cardiac glycosides in pregnancy may impair uteroplacental blood flow.