We interviewed Professor Carlo Ratto who will be presenting 'Traumatic sphincter injury: repair now or later' at ESCP Virtually Vilnius.

Carlo Ratto MD FASCRS is Associate Professor in General Surgery at the Catholic University in Rome, and the Chair of the Proctology Unit, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, Rome, Italy.

Traumatic sphincteric injuries can occur due to delivery, iatrogenic trauma, blunt or penetrating trauma and cause morbidity and mortality.

Obstetric Anal Sphincter Injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. One tenth of obstetric claims involve perianal trauma including anal sphincter injury.

Obstetric anal sphincter damage and related fecal incontinence are common and can cause long-term sequelae if not detected and corrected. They represent the major cause of fecal incontinence in women. The majority of negligence claims were related to missed and inaccurate diagnosis of anal sphincter injury after delivery, or to persistent sphincter defects and incontinence symptoms even after primary repair.

Traditionally, obstetric anal sphincter tear repair is performed by obstetricians with an end-to-end surgical technique. However, such a procedure does not always restore the normal anatomy or function. New techniques have been suggested, such as the overlapping, normally practiced by colorectal surgeons.

Traditionally, anal sphincter repair has been performed immediately after vaginal birth within 24h (primary repair). Some studies show that the sphincter repair can be deferred due to any inconvenient causes without deteriorating functional outcomes. Furthermore, some authors found that long-term functional outcomes were comparable between delayed primary repair and early secondary repair.

What do you think about the role of the surgeon in sphincteric injuries, especially in the OASIS?

The most helpful role played by a general surgeon (in particular a colorectal surgeon) should be to cooperate with obstetricians in the management of OASIS. Severe OASIS (3rd-4th degrees) involve anal sphincters but, paradoxically, they are observed, diagnosed, and, most times, primarily treated by the obstetricians who could be not sufficiently trained to identify and repair the sphincter(s) tears. The coloproctologist himself/herself should be appropriately trained both in primary and secondary repair, late repair, and alternative therapies. Availability of the coloproctologist in assessing possible (and, unfortunately, frequent) failure of a sphincter repair can try to recover the anal continence and quality of life, and, so, avoiding the severe psychological consequences of this severe dysfunction.

Is the therapeutic choice influenced by the timing of the correction of the defect?

Yes, of course, but I think that also the possible different evolution of the sphincter repair should be taken in consideration to choose the timing of the operation. There are evidences and consensus that the 'primary repair' is the best to ensure good functional outcomes. However, a short delay (within three days) does not worsen the outcome. Following a primary repair, although the operation could seem technically well done, there is a substantial risk of residual defects and functional failure; in these cases, a secondary repair shows not encouraging results. Finally, a late repair (years after the delivery or a failed primary repair) could obtain satisfying results in the short-medium term, but fecal incontinence reappears in the majority of patients in the long-term.

What will be the focus of your presentation?

Sphincter repair has been performed in OASIS since many decades ago, by both obstetricians and surgeons. This technique seems still indispensable, at least when an early operation is necessary. The best outcome can be obtained when expert hands manage both the diagnosis and the surgical procedure. Moreover, obstetricians are called to prevent the perineal damages, identify a sphincter lesion as soon as possible when occurred, and correctly repair it immediately, thereafter follow the patients in the future. Collaboration with coloproctologists in a 'perineal clinic' is the key to offer the best management to the patient.

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