Reply to “Comment on anatomic sphincteroplasty with combined reconstruction of internal and external anal muscles in the anal incontinence surgical treatment'”

Dear Editor,

Response to the comment made by Dr. Fernando de la Portilla.

First of all, we would like to thank Dr. de la Portilla for his comment on our article, which we read with interest.

In our experience, the immediate outcomes of classic sphincteroplasty rarely achieved an excellent degree of continence, even if this improved compared to the preoperative one, its fine control, particularly of gases, was exceptional. This, the well-known fact of functional deterioration over time, led us, other authors to reflect on how to improve them.

The classic repair reconstructs a very short anal canal, mainly in obstetric injuries. Our modification, learned from anatomical dissections on the cadaver, aims to obtain a greater pressive length with the repair of the internal anal sphincter, but this is not the only technical variation. Dissection in height of the anovaginal space and skin inversion plasty, gestures not included in other series, we believe may be decisive in its increase and precision, as indicated by the commentator.

The technique, as the article¹ shows, is not particularly complex and dissection of both sphincters can always be performed by surgeons with experience in coloproctology, after basic training and attention to detail.

We also endorse the comments on the application to pure, isolated defects of the internal anal sphincter, where, in our modest experience, anatomical repair has given better results than with bulking agents.

Obviously, further casuistry and multicentre studies are needed to validate the technique as a paradigm shift in anal sphincter reconstruction. The present article is only a technical description and the results of our prospective series are in the process of being published, but suffice it to say that in a medium-term follow-up (median 30 months), 70% are excellent and 25% good compared to the 46% and 23% respectively, also obtained prospectively by our group using classic sphincteroplasty.² The fact that such a marked improvement has been obtained in patients with similar characteristics and operated on by the same surgeons makes it difficult for us to consider, even from an ethical point of view, a comparative study with respect to classic sphincteroplasty.

We would like to thank Dr. Fernando de la Portilla once again for his comments and advice.

Funding

The authors did not receive any support grants for this study.

Conflict of interests

The authors have no conflict of interests to declare.