Endoscopic full-thickness dissection (EFTD) in the rectum: a case series.

BACKGROUND: Rectal endoscopic full- thickness dissection (EFTD) using a flexible colonoscope is an alternative to the well-established trans-anal endoscopic microsurgery (TEM) and the trans-anal minimally invasive surgery (TAMIS) techniques for resecting dysplastic or malignant rectal lesions. This study evaluated EFTD safety by analyzing outcomes of the first patients to undergo rectal EFTD at the University Hospital of North-Norway. METHODS: The first 10 patients to undergo rectal EFTD at the University Hospital of North-Norway April, 2016 and January, 2021, were included in the study. The procedural indications for EFTD were therapeutic resection of non-lifting adenoma, T1 adenocarcinoma (AC), recurrent neuroendocrine tumor (NET) and re-excision of a T1-2 AC. RESULTS: EFTD rectal specimen histopathology revealed three ACs, five adenomas with high-grade dysplasia (HGD), one NET and one benign lesion. Six procedures had negative lateral and vertical resection margins and in three cases lateral margins could not be evaluated due to piece-meal dissection or heat damaged tissue. Two patients experienced delayed post-procedural hemorrhage, one of whom also presented with a concurrent post-procedural infection. No serious complications occurred. CONCLUSION: Preliminary results from this introductory trial indicate that EFTD in the rectum can be conducted with satisfactory perioperative results and low risk of serious complications.

Transanal total mesorectal excision for rectal cancer has been suspended in Norway.

BACKGROUND: Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates. METHODS: Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan-Meier estimates were used to compare local recurrence. RESULTS: In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent. CONCLUSION: Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.

ANTECEDENTES: La resección total del mesorrecto transanal (transanal total mesorectal excision, TaTME) para el cáncer de recto se ha propuesto como una alternativa al abordaje abdominal tradicional. Sin embargo, la recidiva local (local recurrence, LR) después de este procedimiento es motivo de preocupación. El objetivo de este estudio fue evaluar la LR en pacientes operados mediante TaTME. Los objetivos secundarios incluyeron la mortalidad postoperatoria, las fugas anastomóticas y el porcentaje de estomas. MÉTODOS: Se registraron los datos de todos los pacientes operados mediante TaTME y se compararon con las cohortes nacionales del Registro Noruego de Cáncer Colorrectal (Norwegian Colorectal Cancer Registry, NCCR) y del Registro Noruego de Cirugía Gastrointestinal (Norwegian Registry for Gastrointestinal Surgery, NoRGast) utilizando estimaciones de Kaplan-Meier y la prueba de log-rank para comparar curvas de LR. RESULTADOS: En Noruega, 157 pacientes se sometieron a TaTME por cáncer de recto entre octubre de 2014 y octubre de 2018. Tres de siete hospitales abandonaron el TaTME después de un total de cinco procedimientos. La LR observada fue 12/157 (7,6%), siendo ocho de ellas multifocales o extensas. La tasa estimada de LR a 2,4 años fue de 11,6 % (i.c. del 95% 6,6 a 19,9) versus 2,4 % (1,4 a 4,3) en el NCCR (log rank P < 0,001). El cociente de riesgos instantáneos (hazard ratio, HR) ajustado fue 6,7 (i.c. del 95% 2,9 a 15,3). Las fugas anastomóticas que precisaron una reintervención después de TaTME ocurrieron en un 8,4% versus 4,5% en el registro NoRGast (P = 0,047). Cincuenta y seis pacientes (35,7%) tenían un estoma en el último seguimiento; 39 (24,8%) eran permanentes. CONCLUSIÓN: Las tasas de fuga anastomótica tras una TaTME fueron más altas que los datos nacionales con tasas de LR y patrones de crecimiento desfavorables.

Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast.

BACKGROUND: To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome. METHODS: An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat. RESULTS: Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001). CONCLUSIONS: Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome.

The New National Registry for Gastrointestinal Surgery in Norway: NoRGast.

BACKGROUND AND AIMS: There is an increasing demand for high-quality data for the outcome of health care. Diseases of the gastro-intestinal tract involve large patient groups often presenting with serious or life-threatening conditions. Complications may affect treatment outcomes and lead to increased mortality or reduced quality of life. A continuous, risk-adjusted monitoring of major complications is important to improve the quality of health care to patients undergoing gastrointestinal resections. We present the development of the Norwegian Registry for Gastrointestinal Surgery, a national registry for colorectal, upper gastrointestinal, and hepato-pancreato-biliary resections in Norway. MATERIALS AND METHODS: A narrative and qualitative presentation of the development and current state of the registry. RESULTS: We present the variables and the analysis tools and provide examples for the potential in quality improvement and research. Core characteristics include a strictly limited set of variables to reflect important risk factors, the procedure performed, and the clinical outcomes. CONCLUSION: A registry with the potential to present complete national cohort data is a powerful tool for quality improvement and research.

Sacral neuromodulation for combined faecal and urinary incontinence following obstetric anal sphincter injury.

AIM: The aim of this study was to investigate the efficacy of sacral neuromodulation (SNM) in the treatment of faecal incontinence and concomitant urinary incontinence in women with a history of obstetric anal sphincter injury (OASIS). METHOD: In this prospective study, consecutive women with faecal incontinence following OASIS accepted for SNM were screened for concomitant urinary incontinence. The primary outcome was the change in urinary incontinence score on the International Consultation on Incontinence Questionnaire for Urinary Incontinence, Short Form (ICIQ-UI-SF), between baseline and 12 months. Secondary outcomes included the change in St Mark's score, sexual function and quality of life, change in grade of urinary incontinence and disappearance of urgency. RESULTS: From March 2012 to September 2014, 39 women with combined faecal incontinence and urinary incontinence received SNM. Thirty-seven women were available for analysis after 12 months. The mean reduction in the ICIQ-UI-SF score between the baseline and 12 months was 5.8 (95% CI 3.7-8.0, P < 0.001). ICIQ-UI-SF was reduced in 29 (78%) women, urinary incontinence resolved in 13/37 (35%, 95% CI 20%-50%) patients, and urgency disappeared in 14/33 (42%, 95% CI 26%-59%). The mean reduction in the St Mark's score was 10.6 (95% CI 8.6-12.7, P < 0.001). Disease-specific quality of life, Euroqual 5-dimension visual analogue scale (EQ-5D VAS) and several areas of sexual function changed significantly for the better. CONCLUSION: More than three-quarters of the women with combined faecal and urinary incontinence following OASIS reported a successful outcome with reduction in ICIQ-UI-SF at 12 months after SNM.

Efficacy of autologous fat graft injection in the treatment of anovaginal fistulas.

BACKGROUND: Injection of autologous fat is an established method within plastic surgery for soft tissue augmentation. The aim of the present study was to determine whether transperineal fat graft injection could promote healing of anovaginal fistulas. METHODS: The procedures were performed at the University Hospital of North Norway, Tromsø, Norway, and at Aarhus University Hospital, Aarhus, Denmark, between May 2009 and September 2016. After abdominal liposuction, fat was injected around the fistula tract that was finally transected percutaneously with a sharp cannula and fat injected between the cut parts. The internal opening was closed with a suture. Patients had a minimum follow-up of 6 months after last fat graft injection. RESULTS: Twenty-seven women underwent 48 procedures. The cause of fistula was obstetric (n = 9), abscess (n = 9), Crohn's disease (n = 7), radiation for anal cancer (n = 1) and endoscopic surgery after radiation for rectal cancer (n = 1). The mean amount of injected fat was 73 ml (SD ± 20 ml), and operating time was 63 min (SD ± 21 min). At median follow-up of 20 months (range 6-87 months) after the last injection, fistulas were healed in 21 women (77%), in 8 women after just one procedure. Healing was achieved in 6 of 7 women (86%) with Crohn's disease and in both women who had undergone radiation therapy. One woman developed an abscess and additional trans-sphincteric fistula 8 weeks after injection. CONCLUSIONS: Fat graft injection for anovaginal fistulas is effective and safe.

Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial.

AIM: The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS). METHOD: This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores. RESULTS: Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77). CONCLUSION: SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.

Sacral neuromodulation for faecal incontinence following obstetric sphincter injury - outcome of percutaneous nerve evaluation.

AIM: The purpose of this study was to assess the efficacy of percutaneous nerve evaluation (PNE) in women with faecal incontinence (FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect. METHOD: This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score. RESULTS: Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) (P < 0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence (P = 0.04), body mass index (BMI) (P = 0.03) and pain during PNE (P = 0.046) but not to the extent of the sphincter defect (P = 0.1). Responders had a higher St Mark's score than nonresponders (P = 0.046). CONCLUSIONS: The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect.

Novel treatment for recalcitrant rectovaginal fistulas: fat injection.

INTRODUCTION AND HYPOTHESIS: The treatment of recurrent rectovaginal fistula (RVF) is a challenge for the surgeon. Within plastic surgery fat harvesting and subsequent transplantation by injection is an established method for soft tissue augmentation. We hypothesized whether soft tissue augmentation by transperineal injection of autologous fat could stimulate fistula healing in women with recalcitrant RVF. MATERIALS AND METHODS: Six patients with a recalcitrant RVF, 4 due to obstetric injury and 2 associated with Crohn's disease, were included in the pilot study. The fat graft from the lower abdomen was injected transperineally around the fistula tract. At the end of the injection procedure the fistula tract was transected transversely. RESULTS: In 1 patient the fistula healed after a single treatment, while the other 5 required two treatments with a 6-week interval. In the patients with an RVF due to obstetric injury no recurrence occurred during follow-up, mean 41 months (range 4-53). In the 2 patients with Crohn's disease a new fistula developed after 23 and 25 months respectively. CONCLUSION: We describe fat injection as a new and promising method for the treatment of a recalcitrant RVF where previous attempts had failed to heal the fistula. This method does not include wide dissection, thereby reducing the risk of injury to important neurovascular structures. The method is minimally invasive and causes minimal donor site morbidity. More advanced techniques can still be used in cases of recurrence.

Efficacy of cyclic sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) is an established treatment option for faecal incontinence. Cyclic stimulation will improve the longevity of the implanted stimulator, but little is known about its efficacy. The aim of this retrospective clinical study was to assess the efficacy of cyclic SNS for faecal incontinence. METHODS: Sixty-three patients underwent percutaneous nerve evaluation (PNE) test with a 2-week period of continuous SNS. The PNE test was deemed positive in 42 patients (67 %) who underwent implantation with permanent stimulator. All 42 patients were initially stimulated in a cyclic manner with stimulation for 20 s followed by 8 s without. During follow-up, the stimulator was explanted in 2 patients and permanently turned off in one due to the loss of effect. A postal questionnaire including the Wexner score, a general quality of life (Qol) score, and a bowel habit diary was distributed to 39 patients. RESULTS: The questionnaire was returned by 29/39 (74 %) of the patients. Median duration of follow-up was 16 (range 3-34) months. The Wexner score and the general QoL score were significantly improved compared to pre-treatment values. Some 18 patients (62 %) were still treated with cyclic stimulation at follow-up, reporting more frequent episodes of urgency without incontinence (p = 0.020) compared to symptoms during the PNE test. Patients who had changed to continuous stimulation due to a suboptimal effect during follow-up reported more frequent episodes of urgency with incontinence (p = 0.034), minor soiling (p = 0.045) and days wearing pads (p = 0.027) compared with symptoms during the PNE test. CONCLUSIONS: Cyclic stimulation seems effective for most patients treated with SNS for faecal incontinence.

Novel treatment of a rectourethroperineal fistula after perineal prostatectomy using autologous fat transplantation.

We describe a novel approach for treatment of a rectourethroperineal fistula after perineal prostatectomy using autologous fat transplantation. Unlike other procedures, this technique does not include a wide dissection in scar tissue, thereby reducing the risk of injury to important neurovascular structures. Donor site morbidity is minimal and more advanced techniques can still be used in case of recurrence.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND: This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS: Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS: For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS: Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study.

OBJECTIVE: To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed. METHODS: Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score. RESULTS: Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007). CONCLUSION: Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair.

Three-dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classification of anal sphincter defects.

OBJECTIVES: To determine the degree of intraobserver and interobserver agreement for an experienced and an inexperienced sonologist using two scoring systems for ultrasonographic assessment of anal sphincter defects. METHODS: The study sample comprised the datasets of all women aged between 20 and 40 years who had attended our outpatient clinic and undergone a complete three-dimensional (3D) endoanal ultrasound (EAUS) examination in the period from January 2003 to December 2005. The EAUS datasets were assessed twice independently by two sonologists: one with experience of > 400 3D EAUS assessments and one inexperienced sonologist who had performed approximately 50 assessments before the study. Cases with intraobserver disagreement were resolved by a third (final) assessment. The final assessment from each observer was used to determine the degree of interobserver agreement. Sphincter defects were classified according to our EAUS defect score and the Starck score. RESULTS: EAUS datasets of 55 women were included. Based on first vs. second assessments, intraobserver agreement for the experienced sonologist was good for our EAUS defect score (weighted kappa, 0.75) and the Starck score (weighted kappa, 0.73). Intraobserver agreement for the inexperienced sonologist was moderate for our EAUS defect score (weighted kappa, 0.58) and good for the Starck score (weighted kappa, 0.62). Interobserver agreement was good for both our EAUS defect score (weighted kappa, 0.65) and the Starck score (weighted kappa, 0.74). CONCLUSIONS: Intraobserver and interobserver agreement was acceptable for both scoring systems. The experienced sonologist obtained a higher degree of intraobserver agreement than did the inexperienced sonologist.

Long-term results after anterior sphincteroplasty for anal incontinence.

OBJECTIVE: To assess the long term incontinence and quality of life (Qol) results after elective anterior sphincteroplasty for anal incontinence. MATERIALS AND METHODS: Short and long term follow-up included respectively 28 and 25 of the 29 patients who were operated between 1989 and 1998 in our institution. Qol was assessed with gastro intestinal quality of life index (GIQLI). Incontinence was graded according to Parks score supplied with St Mark's score at long term follow-up. RESULTS: 21 (73%) patients had a history of obstetric sphincter tears. Mean age at operation was 45 years (range 6-77). Median time from operation to short term follow-up was 26 months (mean 38 months, range 2-113) and 84 months (mean 105, range 74-185) to long term follow-up. At short term follow-up 19 of 28 patients (68%) were continent for stool compared with nine of 25 patients (36%) at long term follow-up. Nine of 17 (53%) who were continent for stool at short term follow-up remained continent for stool at long term follow-up. Patients with a history of obstetric sphincter tear had less severe incontinence at long term follow-up compared to women with other causes of incontinence (St. Mark's score 8 and 16 respectively, p = 0,015). Patients with no incontinence or gas incontinence only, had higher quality of life score at both follow-ups than those who where incontinent for stool (p = 0,007 and p= 0,014 respectively). CONCLUSION: More than half of the patients remained continent for stool at long term follow-up. Continence for stool was associated with high Qol score.

Introducing an asymmetric cleft lift technique as a uniform procedure for pilonidal sinus surgery.

BACKGROUND AND AIMS: Asymmetric techniques for surgery in pilonidal sinus disease (PSD) have been reported to provide better results than simple excision and closure in the midline. The aim of this retrospective study was to evaluate the results after introducing the Bascom asymmetric cleft lift procedure in our hospital on a day care basis. MATERIAL AND METHODS: From a total of 33 patients operated from April 2002 to September 2004 with the Bascom asymmetric cleft lift technique, we were able to contact 29 who were invited to a follow up study. Eighteen (62%) of these patients accepted a consultation in the outpatient clinic while 11 (38%) were interviewed by phone. RESULTS: At follow up mean 17 (range 10-27) months after the operation 24 (83%) of the wounds were healed while recurrences were present in 5 (17%) of the patients. In two of the patients with recurrences errors in the procedures were identified. Further results related to pre-, per- and postoperative conditions are discussed in this paper. CONCLUSION: Early results after surgery for PSD with the Bascom asymmetric cleft-lift technique are promising. The technique has now become our standard procedure for treating chronic, symptomatic PSD.

Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects.

OBJECTIVE: To determine if there is a correlation between the sonographic extent of anal sphincter defects revealed by three-dimensional endoanal sonography (EAUS) and the degree of anal incontinence following primary repair of obstetric sphincter tears. METHODS: This was a follow-up study of women who had suffered anal sphincter tearing during vaginal delivery at Aalesund Hospital between January 2002 and July 2004. Incontinence was assessed by St Mark's score. The anal canal was assessed with three-dimensional endoanal sonography (EAUS). Sphincter defects were classified according to the Starck score and our new EAUS defect score. The EAUS images were interpreted by an observer blinded to other patient data. RESULTS: Sixty-one women were included in this study. Incontinence was reported by 32 (52%) women at a median of 21 (range, 9-35) months after delivery. Three-dimensional EAUS datasets were obtained in 55 women. There was a significant correlation between St Mark's score and our EAUS defect score (P = 0.034), and correlation approached but did not reach significance between St Mark's score and the Starck score (P = 0.053). There was a strong correlation between our EAUS defect score and the Starck score (P < 0.001). CONCLUSIONS: There is a positive correlation between the extent of sphincter defects and the degree of anal incontinence following primary repair of obstetric sphincter tears. Our findings highlight the importance of adequate reconstruction of the anal sphincters during primary repair.