Fernando Ruwan J, Sultan Abdul H, Kettle Christine, Thakar Ranee
Department of Urogynaecology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, UK, W2 1NY.
Cochrane Database Syst Rev. 2013 Dec 8;2013(12):CD002866. doi: 10.1002/14651858.CD002866.pub3.
Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair.
To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies.
Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS.
Trial quality was assessed independently by all authors.
Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women).
AUTHORS' CONCLUSIONS: The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.
分娩期间的肛门括约肌损伤——产科肛门括约肌损伤（OASIS）——与严重的产妇发病相关，包括会阴疼痛、性交困难（性交疼痛）和肛门失禁，这可能导致心理和身体后遗症。许多女性因尴尬而未寻求医疗帮助。公认的两种修复受损肛门外括约肌（EAS）的方法是端端（近似）修复和重叠修复。
比较OASIS后重叠修复与端端修复在减少后续肛门失禁、会阴疼痛、性交困难以及改善生活质量方面的有效性。
我们检索了Cochrane妊娠与分娩组试验注册库（2013年9月30日）以及检索到的研究的参考文献列表。
比较OASIS后EAS即时一期修复不同技术的随机对照试验。
所有作者独立评估试验质量。
纳入了6项质量各异的合格试验，涉及588名女性。结局测量、时间点和报告结果存在相当大的异质性。荟萃分析表明，12个月时，两种修复技术在会阴疼痛（风险比（RR）0.08，95%置信区间（CI）0.00至1.45，1项试验，52名女性）、性交困难（平均RR 0.77，95%CI 0.48至1.24，2项试验，151名女性）、排气失禁（平均RR 1.14，95%CI 0.58至2.23，3项试验，256名女性）方面无统计学显著差异。然而，重叠组的便急发生率在统计学上显著较低（RR 0.12，95%CI 0.02至0.86，1项试验，52名女性），肛门失禁评分较低（标准化均差（SMD）-0.70，95%CI -1.26至-0.14，1项试验，52名女性）。重叠技术还与12个月内肛门失禁症状恶化的风险在统计学上显著较低相关（RR 0.26，95%CI 0.09至0.79，1项试验，41名女性）。生活质量无显著差异。在36个月随访时，排气失禁（平均RR 1.12，95%CI 0.63至1.99，1项试验，68名女性）或大便失禁（平均RR 1.01，95%CI 0.34至2.98，1项试验，68名女性）无差异。
现有数据表明，在一年随访时，与即时一期端端修复相比，肛门外括约肌即时一期重叠修复似乎与便急和肛门失禁症状发生风险较低相关。在36个月时，两种技术在排气或大便失禁方面似乎无差异。然而，由于该证据仅基于两项小型试验，需要更多的研究证据来证实或反驳这些发现。
