Authors’ reply re: Cesarean section in the second delivery to
prevent anal incontinence after asymptomatic obstetrical anal sphincter
injury: the EPIC multicenter randomized trial
Dear editor,
We thank Sultan et al (1), whose pioneering work is a source of
inspiration, for their interest in our EPIC study and their relevant
questions (2). We started our project more than ten years ago with the
hypothesis than cesarean section is protective in case of anal sphincter
lesions to prevent anal incontinence, and like them we were quite
surprised by the results showing that a cesarean section for the
subsequent delivery failed to prevent anal incontinence 8 months after
delivery. We agree of course that long term follow-up should be
performed.
We agree that the difference between a scar and a sphincter defect is
sometime difficult to distinguish. We also agree that the use of a
validated ultrasound score may be useful but none was available when we
designed our study 14 years ago. We did not plan an independent review
of ultrasound interpretation because we previously showed 98.9%
inter-observer concordance in our center in a previous study you
mentioned (3). A large number of sub-group analyses was not planned in
order to avoid inflation of type 1 error. We do however agree that the
description of anal sphincter lesions must be detailed, which it is why
we evaluated the levator muscle, internal and external sphincter (deep
and superficial fibers) according to their angulation defect as well as
their depth and length. Levator muscle and internal anal sphincter
lesions were too rare to deserve statistical test. Nonetheless, our
analysis did not show a benefit of cesarean section, even in case of
severe anal sphincter lesions with more than 90° angulation, more than
50% height and 50% thickness (p=0.78).
The statement that 85% of forceps deliveries had an undiagnosed OASI is
an overstatement. Anal sphincter lesions were diagnosed by ultrasound in
231 of 391 patients (59%) with a first delivery by forceps, of which
159 (69%) were undiagnosed at delivery. These findings are consistent
with those we reported in 2000 (3).
We did not perform anorectal manometry according to practice guidelines
(4), since it is not well correlated with sphincter defects and because
manometric results are less relevant than anal symptoms. Treating a low
level of pressure, particularly with surgery such as cesarean section
would not be recommended, whereas treating a symptom would be justified.
The randomized controlled design avoided recruitment biases between the
2 groups, and failed to show that systematic cesarean section in case of
asymptomatic sphincter lesions was protective from anal incontinence 8
month after the second delivery.
[Authors] Laurent Abramowitz, Laurent Mandelbrot, Florence Tubach,
Carine Roy.
References:
- Okeahialam NA et al. Re:
Cesarean section in the second delivery to prevent anal incontinence
after asymptomatic obstetrical anal sphincter injury: the EPIC
multicenter randomized trial. (First comment letter. Reference to be
added).
- Abramowitz L, Mandelbrot L, Bourgeois Moine A, Le Tohic A, de Carne
Carnavalet C, Poujade O, et al.
Cesarean section in the second
delivery to prevent anal incontinence after asymptomatic obstetrical
anal sphincter injury: the EPIC multicenter randomized trial. BJOG:
Int J Obstet Gy. 2020 Aug 8;1471-0528.16452.
- Abramowitz L, Sobhani I, Ganansia R, Vuagnat A, Jean Louis Benifla JL,
Darai E, et al. Are sphincter defects the cause of anal incontinence
after delivery. Results of a prospective study. Dis Colon and Rectum.
2000;43:590-8.
- Vitton V, Soudan D, Siproudhis L, Abramowitz L, Bouvier M, Faucheron
JL, et al. Treatments of faecal incontinence: recommendations from the
French National Society of Coloproctology. Colorectal Dis. 2014
Mar;16(3):159-66.