We welcome the findings from the prospective randomized controlled trial by Farrell et al. This trial has a rigorous study design and a sufficient enough sample size to demonstrate a clinically significant benefit from overlap repair, if one existed. As the authors state, prior evidence of superiority of the overlap repair came from only one randomized controlled trial, which formed part of the latest Cochrane systematic review. This trial, by Fernando et al, had demonstrated benefit only in terms of fecal urgency and anal incontinence scores with overlap repair. The latest trial by Farrell et al challenges this view by demonstrating higher flatal incontinence at 6 months postpartum with overlap technique (unadjusted odds ratio OR 2.44, confidence interval CI 1.18-5.04). Interestingly, this finding also is corroborated in the prior study by Fernando et al, where a similar effect at 6 months (OR 2.00, CI 0.51-7.80) did not reach statistical significance. A simple meta-analysis of the data sets from those two studies gives an odds ratio of 2.33 (CI 1.23-4.43) for flatal incontinence with overlap compared with end-to-end repair at 6 months postpartum. This raises an important question: is overlap repair truly inferior to end-to end repair with regard to continuing bowel morbidity?
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