2.135 盆底失弛缓所致便秘患者肛直肠动力和感觉功能改变

目的我们将出口梗阻型便秘中存在排便时盆底失弛缓的患者,与不存在盆底失弛缓而是由于其他功能性原因,如直肠粘膜脱垂、会阴下降或是直肠壁前突等导致便秘的患者分组,从肛管直肠的神经感觉及反射功能,肛管直肠压力状况和盆底形态功能状况等多种角度进行对照研究,以期发现盆底失弛缓(anismus)的实验室检查和临床症状特征,从而进一步了解anismus所致便秘患者的肛管直肠功能形态特点及其在便秘发生中的作用.方法患者均为1998年～2001年间南京中医院门诊及住院病人.所有便秘患者根据盆底肌电图检查结果进行分组.凡肛门随意肌(耻骨直肠肌或外括约肌)在排便时活动电位大于静息电位的,即耻直肌弛缓系数(=耻骨肌排便动作电位/耻直肌静息电位)或外括约肌弛缓系数(=外括约肌排便动作电位/外括约肌静息电位)大于1的患者被列在anismus组;两系数均小于1的患者被列在非anismus组中.同时测得的数据还包括耻直肌收缩系数(=大力收缩时耻直肌动作电位/耻直肌静息电位)和外括约肌收缩系数(=大力收缩时外括约肌动作电位 /外括约肌静息电位).根据以上分组方法分组后,分析两组患者一般资料.Anismus组患者共52例,其中男性患者24例,女性28例;年龄42.7±6.5岁;病程10.4±6.2年.非anis mus组中患者共56例,其中男性22例,女性34例;年龄41.8±6.3岁;病程12.2±7.2年 .两组一般临床资料比较除助解方式中开塞露运用比例外,患者年龄、病程、其他助解方式情况均无显著差异,具可比性.所有患者进行1.肛管肌电功能测定;2.直肠感觉功能测定 ;3.肛管直肠压力动功能测定;4.肛管直肠形态功能测定;5.临床症状观察.结果 1.直肠神经感觉功能两组患者对照,初始感觉,初始便意和直肠最大耐受的压力阈值无显著差异,而初始感觉,初始便意和最大耐受的容积阈值有显著性差异 ,非anismus组的容量阈值要高于anismus组.2.直肠壁顺应性肠壁顺应性反映了直肠壁的弹性状况.两组患者对照,非anismus组直肠顺应性要明显低于anismus组.3.肛管括约肌动力状况反映了内外括约肌的动力功能状况.两组患者比较anismus组患者的静息压和收缩压水平明显高于非anismus组,但两组患者的肛门抑制反射和收缩反射压差相近,两组患者肛管功能长度无明显差异.4.排便时肛管压力梯度状况反映了排便时肛缘6cm以上的压力梯度.anismus组患者排便时肛管高压区的压力梯度呈上升趋势,而非anismus组患者排便时肛管高压区的压力梯度呈下降趋势.5.排便时肛管直肠形态影像对照anismus组患者在X线影像诊断上以搁架征为主要表现,其中部分患者伴发了盆底直肠弛缓状况.而非anism us组则以直肠前突,直肠粘膜脱垂和直肠粘膜内套叠为主征.6.临床症状积分对照anism us组患者临床症状以粪便至肛门口,解出和排便不尽感为主征.非anismus组则以解便周期延长和排便不尽感为主要症状.结论盆底的肌电图和压力测定的异常结果是诊断anismus的"金标准",即排便时盆底肌群的弛缓系数大于1,肛管压力梯度呈上升趋势.除此而外,排粪造影能够使我们了解anismus患者肛门直肠功能受损的严重程度及其伴发的盆底其他症状,有助于全面了解患者盆底的功能状况.     

女性盆底有限元力学分析的研究进展

女性盆底功能障碍性疾病(pelvic floor dysfunction,PFD)是指盆底支持组织因损伤或退化等原因所致松弛而引发的疾病.主要包括压力性尿失禁(stress urinary incontinence,SUI)和盆腔器官脱垂(pelvic organ prolapse,POP).有研究发现盆腔脏器脱垂是一种缘于盆底支持组织生物力学性能进行性减退的疾病[1].有实验发现,盆腔器官脱垂患者盆底组织成纤维细胞对应力的反应性降低,阴道壁组织的生物力学性能明显低于非脱垂患者,认为盆底支持组织力学性能的降低或许是导致盆腔器官脱垂的原因[2].因此,迫切需要对盆底器官组织之间的力学关系进行分析和评估,才能设计出完善的治疗方案.本文就PFD发病机制有限元力学研究进展综述如下.     

自适应式生物反馈训练联合腹部穴位按摩对糖尿病合并出口梗阻型便秘患者肛直肠功能与精神心理因素的影响

目的:分析糖尿病合并出口梗阻型便秘患者应用自适应式生物反馈训练联合腹部按摩对肛直肠功能与精神心理因素的影响.方法:择取2021年2月至2022年2月期间我院收治的95例糖尿病合并出口梗阻型便秘患者作为研究对象,以抽签的方法将其分组.两组患者均给予常规治疗,对照组47例给予腹部穴位按摩,联合组48例在此基础上增加自适应式生物反馈训练.6 w后,对比两组患者便秘症状、肛直肠功能、精神心理因素.结果:联合组粪便性状、排便次数、排便阻塞感、盆底松弛度分值均低于对照组(P<0.05);联合组直肠肛管压差、力排时肛管残余压均低于对照组,直肠静息压、肛门直肠缩榨压均高于对照组(P<0.05);联合组抑郁自评量表(Self-rating depression scale,SDS)评分、焦虑自评量表(Self-rating anxiety scale,SAS)评分均低于对照组(P<0.05).结论:自适应式生物反馈训练联合腹部穴位按摩可有效改善糖尿病合并出口梗阻型便秘患者便秘症状,减轻不良心理状态,提高肛直肠功能,在临床中有一定应用价值。     

围绝经期盆底康复联合中药及雌激素治疗盆底器官脱垂的临床疗效分析

目的分析围绝经期盆底康复联合中药及雌激素治疗盆底器官脱垂的临床疗效。方法研究对象选取本院2011年10月~2013年9月收治的98例围绝经期盆底器官脱垂患者,随机方法分组。对照组患者接受盆底康复联合雌激素治疗,实验组患者接受盆底康复联合中药治疗。治疗8w后,对比分析两组患者临床疗效、不良反应的差异性。结果经过治疗后实验组总有效率明显高于对照组,经字2检验分析发现组间差异有统计学意义(P<0.05)。治疗期间实验组不良反应发生率明显低于对照组,经字2检验分析发现组间差异有统计学意义(P<0.05)。结论围绝经期盆底康复联合中药及雌激素治疗盆底器官脱垂均具有一定的疗效,其中盆底康复联合中药疗效更好,不良反应更小,具有更大的临床优势。     

从腔镜解剖视角看分析肠脱垂嵌顿Altemeier手术治疗策略

<正>成人完全直肠脱垂在多数情况下可自行还纳或手法还纳，只有2.0%～4.0%的患者会出现直肠脱垂嵌顿^[1]需急诊手术。Altemeier手术是嵌顿性直肠脱垂急诊手术的常用术式之一^[2]，其手术原理包括：(1)切除脱出肛门外的直肠肠管和冗长的乙状结肠；(2)切除肛门外多余的盆底腹膜，抬高并重建盆底腹膜；(3)折叠修补肛提肌，部分改善肛门括约肌松弛^[3]。本文以腹腔镜视角和TME手术过程结合经会阴手术特点解读直肠脱垂嵌顿Altemeier手术，便于理解其手术相关解剖和技术特点，有利于临床开展。     

648例产后女性盆底康复疗效分析

目的:探讨盆底康复治疗对产后女性盆底肌力的改善情况.方法:分别对2015-2017年我院产后门诊就诊的177例剖宫产患者及471例顺产患者进行盆底肌力测试,制定1个疗程连续10次的盆底康复治疗方案,比较盆底康复实施前后盆底肌力评分改变.结果:盆底康复治疗前的剖宫产及顺产患者盆底肌力无明显差异(P>0.05),经过盆底康...     

脑卒中后便秘的护理体会

目的：探讨脑卒中患者住院期间便秘的护理方法。方法将我院2012年1月~2013年12月收治的72例脑卒中后便秘患者进行针对性的护理，综合评价护理效果。结果本组72例患者经过综合护理后1 d排便者17例(23.6%)、2 d排便者32例(44.4%)、3 d排便者11例(15.3%)、3 d以上排便者12例(16.7%)，其中最长者为7 d。在住院期间未发生再次脑卒中。结论加强脑卒中便秘患者的护理，可有效减轻患者痛苦，促进疾病康复。     

2.162 慢性特发性便秘肛门直肠动力学的研究

目的研究慢性特发性便秘(CIC)患者肛门直肠动力学特征,探讨便秘的病因和发病机制.方法采用多导单囊肛门直肠功能测定仪检测24例(CIC)患者的肛门直肠压力、直肠容量感知、疼痛阈值、耐受阈值及排便功能等指标,并与12例健康人做对照.结果 CIC组直肠静息压,肛管括约肌静息压、最大缩窄压及肛管长度与对照组无显著性差异,但CIC患者的初始感觉阈值、疼痛阈值、排便阈值、引起肛门直肠抑制反射的最低充气量和肛管内括约肌松弛压均高于正常对照组.模拟排便时,CIC组30%(8/24)的患者在直肠收缩时伴有肛管括约肌的矛盾收缩.结论 CIC患者直肠粘膜对容量刺激的反应性降低和排便时肛管括约肌的反向矛盾收缩可能是形成便秘的原因之一.     

生物反馈式括约肌控制装置

针对肛门失禁患者的排便控制问题,在前人工作的基础上改进生物反馈式肛门括约肌装置.根据正常人排便控制原理及内括约肌松弛反射过程,系统分为体内模块和体外模块:体内模块利用压力传感器对肠道压力进行测量,并将信号通过nRF401传到体外模块,实现生物反馈;体外模块通过nRF401控制体内模块完成排泄的整个生理过程,装置采用MSP430F1232单片机进行控制.     

桥式手术在女性盆底功能障碍性疾病的研究（附60例病例分析）

目的探讨阴道“桥式”修补术治疗女性盆底功能障碍性疾病的效果。方法采用回顾性分析我院行阴道后壁“桥式”修补术患者60例,采用美国Bump教授提出并被国际尿控协会制定的盆腔器官脱垂定量（POP-Q）分度法,本研究60例患者中阴道后壁膨出26例（43.3%）为Ⅰ度,25例（41.7%）为Ⅱ度,9例（15.0%）为Ⅲ度及以上。平均随访36个月,比较手术前后POP-Q分度BP点的变化,以了解“桥式”修补术后患者的解剖学恢复情况。通过性生活问卷评价患者手术前后的性生活质量,并评价患者手术前后的排便功能失调的改善情况。结果单纯行“桥式”缝合的平均手术时间15-20min,出血约10-20ml,无手术并发症。60例患者术前POP-Q分度BP点-1.2±1.9cm;术后-2.9±0.33cm,经统计学分析,二者差异有显著性（P〈0.05）随访36个月,治愈率98%;术后有1例慢性便秘患者阴道后壁膨出复发。BP点术后18个月为0,复发率〈2%。60例患者术前有16例（26.6%）存在便秘或排便不尽感,术后有8例患者自觉排便情况有改善;60例患者中术前有19例性生活不活跃,单纯性阴道后壁局部修补（桥式手术）9例术后性生活质量得到改善。对于复合手术如增加TOT-O或AVP或TVT者,手术前后性生活经统计分析无差异P〉0.05。结论桥式手术对重建女性盆底功能十分重要,无论单纯行“桥式”缝合还是“桥式”手术复合修补盆底其他器官对重建女性泌尿生殖器官的完整性有现实意义,建议进一步推广应用。     

Retroperitoneal pelvic lipoma

A patient with a retroperitoneal pelvic lipoma is presented. Preoperative assessment with computed axial tomography led to the presumptive diagnosis of a fat-containing tumor. Management and differential diagnosis of retroperitoneal tumors are described.     

聚丙烯补片在改良盆底重建修复盆腔脏器脱垂中的应用

背景：合成补片是重要的盆底组织替代物,能够替代薄弱受损的盆底筋膜组织,己被广泛应用于盆底薄弱组织的修补重建中。 目的：观察补片在改良盆底重建修复盆腔脏器脱垂的疗效及并发症,探讨其安全性及有效性。 方法：纳入45例女性盆腔脏器脱垂患者,根据患者意愿分两组治疗,试验组25例经阴道植入聚丙烯补片进行改良盆底重建修复,对照组20例采用传统经阴道全子宫切除联合阴道壁修补治疗,记录两组围手术期情况,随访评价两组子宫脱垂分期、并发症、盆底功能及盆底不适情况,以及客观治愈率。 结果与结论：与对照组比较,试验组手术时间短、出血量小、感染轻、恢复快(P均 < 0.05)。随访6个月时,试验组子宫脱垂分期评分高于对照组;随访12个月时,试验组并发症发生率、盆底功能影响评分及盆底不适情况评分均低于对照组(P < 0.05),客观治愈率高于对照组(P < 0.05)。表明采用聚丙烯补片进行盆底重建修复盆腔脏器脱垂具有手术时间短、出血量小、恢复快、裸露率低等特点,同时能显著提高盆底功能,改善盆底不适情况,降低术后并发症的发生,提高客观治愈率,短期随访安全有效。中国组织工程研究杂志出版内容重点：生物材料;骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性;组织工程全文链接：     

选择性髂内动脉插管灌注对盆腔恶性肿瘤介入性治疗的手术研究与探索

本文旨在探讨盆腔恶性肿瘤的介入性治疗问题。对45例患有盆腔恶性肿瘤的患者,采用Seldinger法,经双侧股动脉插管,先端选择性导入对侧髂内动脉;或一侧导入肠系膜下动脉,另侧导入髂内动脉,留置导管12小时,使用突击剂量持续灌注化疗药物。并经手术、B超、CT、内窥镜及指检等方法进行化疗前后的对比观察。结果:其中病灶消失持续1个月以上者9例、病灶缩小50％以上并持续超过一个月者23例、缩小不足50％且增大未达25％者9例、增大超过25％以上者4例,总有效率为71.1％。10例患者出现了脱发及皮肤色素沉着,1例患者出现下肢动脉栓塞,10例出现了不同程度的消化道反应等。结论:本法损伤小,操作简便安全,可多次重复术式:选择性强,药效持久均衡且毒副作用小;可提高手术切除率,也为不能手术的癌肿提供一种较理想的治疗手段。     

A life of pelvic pain

Pelvic pain associated with menstruation, i.e., dysmenorrhea, is a chronic pelvic pain that not only interferes with a woman's wellbeing for a large part of her life but also often co-occurs with other chronic painful conditions such as interstitial cystitis and irritable bowel syndrome and others. Little has been known about mechanisms underlying these chronic pelvic pains. This paper reviews 37 years of research in my laboratory at Florida State University on such mechanisms. Our research, mostly on rats, has contributed to the following findings: (1) Female reproductive organs are innervated in a topographic fashion by afferents in the pelvic (vagina/cervix) and hypogastric (cervix/uterine horn) nerves. (2) The input contributes to uterine and vaginal perceptions (nociception) that are modified by reproductive status. (3) Throughout the CNS, neurons responsive to stimulation of the reproductive tract also respond to stimulation of skin and other internal organs, in a manner modifiable by reproductive status and peripheral pathophysiology. (4) This dynamic physiological convergence may reflect extensive anatomical divergence of and interconnections between pathways entering the CNS via gateways through the spinal cord, dorsal column nuclei, and solitary nucleus. (5) The convergence also indicates the existence of extensive cross-system, viscero-visceral interactions within the CNS, that, while organized for coherent bodily functioning, serves as a substrate by which pathophysiology in one organ can influence physiology and responses to pathophysiology in other organs. (6) Some cross-system effects observed so far include: (a) Bladder inflammation reduces the rate of uterine contractions and the effects of drugs on the uterus. (b) Colon inflammation produces signs of inflammation in the otherwise healthy bladder and uterus. (c) A surgical model of endometriosis produces vaginal hyperalgesia, exacerbates pain behaviors induced by a ureteral stone, and reduces volume voiding thresholds if the bladder. These cross-system effects, which likely involve CNS mechanisms, likely also underlie co-occurrence of painful clinical conditions. Research continues on details of these mechanisms and their relevance for clinical diagnosis and therapy. None of this work could have been done without collegial support of colleagues and technical staff at Florida State University.     

Three-dimensional visualization of pelvic vascularity

The aim of this study was to establish a 3D digitized model of pelvic vasculature for anatomic study, preoperative planning, and virtual reality. Three adult fresh cadavers were perfused with carboxymethyl cellulose/lead oxide mixture to mark blood vessels, and subjected to multilayer spiral computed tomography scanning to obtain a series of thin sections. Then, the 2D images of the pelvis and pelvic blood vessels were transformed into 3D digitized models using Mimics 11.0. The 2D images of carboxymethyl cellulose/lead oxide filled arteries had the features of entire outline and few constructed defects. The 3D digitized models of the pelvis and pelvic artery system displayed spatial location and the adjacent relationship of arteries with the pelvis. Not only the well-known arteries but also the tiny blood vessels in the reconstructed structures were well demonstrated and observed interactively. The reconstructed tissue flaps, including a lobulated skin flap with the pedicle of superficial epigastric artery, and an iliac flap with the pedicle of deep iliac circumflex artery, demonstrated their blood supply area. This indicated that the modified technique of vascular perfusion with carboxymethyl cellulose/lead oxide and reconstitution with Mimics 11.0 software contributed to 3D digitized model of pelvic vasculature.     

A comparison of different pelvic reconstruction surgeries using mesh for pelvic organ prolapse patients

This study was carried out in order to compare the effects in different surgeries using mesh in pelvic organ prolapse patients whose leading points were C. Thirty-nine patients were categorized into 3 groups: group A pelvic reconstruction with hysterectomy; group B hysterectomy prior to pelvic reconstruction; and group C pelvic reconstruction with uterus preserved. At first visit, POP-Q stage was determined, and age, BMI, admission days, operation time, post-operative stage and complications were observed and results were analyzed and compared. All patients who were operated upon converted to stage one month following the operation, and no further change was observed except in one patient. Group admission days were not significantly different, but tended to be lower in group C. Group average operation times between 'group A and B' and 'group A and C' were statistically different. No significant difference was observed in post-operative complications between the groups, but 3 members of group A developed erosion, whereas no erosion occurred in groups B and C. Pelvic reconstruction using mesh is a highly efficient method of treating pelvic organ prolapse. Improvements in stage and post-operative complications were not significantly different in the groups. However, uteropexy showed a shorter operation time, fewer admission days, and less erosion due to mesh than conventional pelvic reconstruction with hysterectomy.     

Anterior pelvic plating and sacroiliac joint fixation in unstable pelvic ring injuries

Purpose

To analyze the effectiveness of anterior pelvic plating and subsequent percutaneous sacroiliac joint screw fixation in patients with unstable pelvic ring injuries.

Materials and Methods

Thirty-two patients were included with twenty-one males and eleven females. The mean age was 41 years (range, 19-76). The mean follow-up period was 51 months (range, 36-73). According to AO-OTA classification, there were 11 cases of B2 injuries, 8 cases of B3 injuries, 9 cases of C1 injuries, 2 cases of C2 injuries and 2 cases of C3 injuries. In the posterior lesions, there were 20 cases of sacral fractures and 12 cases of sacroiliac joint disruptions or dislocations. Anterior pelvic plating and subsequent percutaneous sacroiliac joint fixation were performed.

Results

The clinical results were 16 cases of excellent, 10 cases of good, 4 cases of moderate and 2 cases of poor functional results. The 2 cases out of 7 moderate reductions had poor functional results with residual neurologic symptoms. The radiological results were 16 cases of anatomic, 9 cases of nearly anatomic and 7 cases of moderate reduction. All patients were healed except 3 cases of nonunion at the pubic ramus. The complications encountered were 3 cases of screw loosening, 2 cases of anterior plate breakage and 1 case of postoperative infection.

Conclusion

In patients with unstable pelvic ring injuries, anterior pelvic plating and subsequent percutaneous sacroiliac joint screw fixation may be a useful surgical option. The radiological results and residual neurologic symptoms had effects on its functional results.