Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition

Abstract

Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient's neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark's incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.

Keywords: Anal sphincter; Fecal incontinence; Obstetric injury; Rectovaginal fistula.

Fig. 1.

A preoperative image of the perineum in the lithotomy position showing a fistulous communication between the lower rectum and vagina along with a thinned rectovaginal septum.

Fig. 2.

Three-dimensional endoanal ultrasound examination performed in the lithotomy position showing extensively damaged (arrows) anal sphincter in the anterolateral position.

Fig. 3.

Schematic diagram of the abdominal and perineal procedures (left panel) abdominal and (right panel) perineal. A, left gastroepiploic arterial pedicle; B, antropyloric segment; C, gastrocolic omentum; D, descending colon.

Fig. 4.

Manometry tracing showing the constant resting tone of the transposed antropyloric segment (yellow).

Fig. 5.

(A) Preoperative distal colon loop barium study showing the rectovaginal fistulous connection. (B) Postoperative film showing retention of contrast (arrow) proximal to the perineal antropyloric valve.