盆底松弛直肠脱垂的微创治疗

目的探讨直肠黏膜脱垂及直肠前突导致排便障碍的微创治疗方法。方法回顾性分析我院2003年12月-2005年12月收治的直肠黏膜脱垂、直肠黏膜脱垂合并直肠前突及单纯直肠前突共200例的临床资料。结果本组有194例（97％）行一次直肠黏膜环形切除（PPH）手术后排便障碍得到了缓解；有6例（3．0％）症状缓解不明显，其中，行2次PPH手术者4例，术后排便障碍缓解。结论PPH手术在治疗时恢复了肛管的通畅性，安全、迅速，住院时间短，恢复快，相对传统术式复发少，对于重度脱垂的病人可重复手术，效果好。     

Rectocele repair by anterolateral rectopexy: long‐term functional outcome

Introduction Rectoceles are frequently associated with feelings of pelvic discomfort and symptoms of obstructed defaecation (OD). Repair by a transvaginal or transanal approach might result in de novo dyspareunia in up to approximately 40% of the cases. This study was designed to investigate whether anterolateral rectopexy provides an adequate rectocele repair without dyspareunia as a side effect. Method A consecutive series of 33 women (median age 55 years; range: 37–73) with a symptomatic rectocele (depth > 3 cm) underwent anterolateral rectopexy. Before the operation, all patients underwent evacuation proctography (EP), which was repeated 6 months after the repair in all but three patients. A standardized questionnaire concerning pelvic discomfort, OD and dyspareunia was used to assess the long‐term effect of rectocele repair. The response rate was 91%. Results Six months after the procedure, EP revealed a recurrent or persistent rectocele in six patients (20%). However, in four of these six patients, the depth of the rectocele was < 3 cm. The median duration of follow‐up was 74 months (range: 2–96). Among the patients with an adequate repair, signs of OD persisted in 55%. None of the patients encountered de novo dyspareunia after the procedure. Conclusion Anterolateral rectopexy provides an effective tool for anatomical correction of rectoceles and does not result in dyspareunia as a side effect. However, despite adequate repair, OD persist in the majority of patients.     

经肛吻合器直肠切除术在治疗直肠前突中的应用

目的 评价经肛吻合器直肠切除(STARR)术在治疗直肠前突的临床疗效及安全性.方法 采用PPH吻合器作半环型直肠下端黏膜切除治疗92例直肠前突患者,观察手术时间、手术效果、并发症及复发率.结果 手术全部成功完成,平均手术时间(25±8)min,总有效率达100%,术后出现下腹不适及胀痛32例(34.7%),尿潴留9例(9.8%),肛门部疼痛5例(5.4%),出血3例(3.3%),术后住院时间1.0～5.0 d.平均(2.2±0.9)d;随访4～40个月未见复发病例.结论 STARR术治疗直肠前突,具有手术安全,恢复快,近期疗效满意和复发率低等优点.

Abstract：

Objective To evaluate the clinical curative effect and safety of the stapled transanal rectal resection (STARR) in treatment rectocele. Methods Ninety-two cases suffering from rectocele were treated with rectal inferior extremity half circum mucosectomy by PPH stapler. The operative time, operation effect,complication and recurrence rate were studied. Results All cases were operated successfully. The mean operation time was (25 ±8)min,The totol effective rate was 100% ,postoperative complication included inferior abdomen discomfort and pain (32 cases,34. 7%),urinary retention(9 cases,9. 8%) ,anal anus pain(5 cases, 5. 4%) and bleeding(3 cases,3. 3%). The average length of postoperative stay was 1-5 days (average[2. 2 ±0. 9]days). The follow-up period ranged from 4 to 40 months and no recurrence was observed. Conclusion The stapled transanal rectal resection (STARR) has several advantages,such as safety,rapid recovery,good recent therapeutic effect and lower recurrence in treating rectocele.     

经阴道补片修补术联合消痔灵注射黏膜固定术治疗直肠前突的疗效评价

目的评价经阴道补片修补术联合消痔灵注射黏膜固定术治疗直肠前突的疗效。方法 60例直肠前突患者,分成观察组和对照组。对照组采用经阴道补片修补术治疗;观察组采用经阴道补片修补术联合消痔灵注射黏膜固定术治疗。结果观察组总有效率为93.33%,高于对照组总有效率70.00%,差异有统计学意义(P<0.05)。结论经阴道补片修补术联合消痔灵注射黏膜固定术治疗直肠前突疗效可靠。     

PPH加硬化剂注射术及部分残留疝囊修补术治疗直肠前突的临床研究

为提高直肠前突的治疗效果,减少并发症,根据其发病机理及病理特点,采用PPH加硬化剂注射术及部分残留疝囊修补术的综合术式治疗中、重度直肠前突50例,其中中度39例,重度11例。50例均采用直肠指诊及排粪造影确诊。结果显示,痊愈24例（48．0%）,显效20例（40．0％）,有效6例（12．0％）,有效率100％。术后随访6个月至3年,复发3例。无并发症。结果表明,该法治疗中、重度直肠前突,疗效确切,无后遗症及并发症。     

A novel technique for rectocele repair in elderly women

We have developed a transvaginal technique for rectocele repair which we believe to be particularly suitable for older woman. A transverse incision was made in the mucocutaneous border of the vaginal introitus. The rectal wall was separated from the rectovaginal septum. The vaginal wall was divided in the middle. The first flap was sewn to the second and this onto the first. This intervention permits the contemporary correction of other pathologies frequently found in older women, such as cystocele and prolapse of the uterus. Twenty-two elderly women underwent operations using this technique; the mean follow-up period was 48 months (range, 24–84 months). The need to assist evacuation digitally disappeared in all patients.     

109例便秘患者的排粪造影分析

目的:通过便秘患者的排粪造影资料显示其肛管直肠形态及功能,寻找便秘原因.方法:109倒排粪造影,其中13例行结肠传输试验.结果:由于肛管直肠形态功能异常所致的排粪功能障碍者91例,其中女性病例占80.22%.而女性异常病例中又以直肠前突多见.排粪造影及结肠传输试验均异常者7例.外科单纯手术纠正者2例,术后随访造影表现正常.结论:排粪造影对于便秘患者病因分析及诊疗方案的制定有重要的意义.     

Anal Continence After Rectocele Repair

INTRODUCTION: Rectocele may be associated with both chronic constipation and anal incontinence. Several different surgical procedures have been advocated for rectocele repair. The aim of the present study was to evaluate anorectal function and clinical outcome in a consecutive series of patients who underwent selected endorectal or transperineal surgery for rectocele for whom operative treatment was determined by clinical and proctographic features. Attention was paid to the cohort of rectocele patients presenting with incontinence as a leading symptom. METHODS: Sixty consecutive patients with symptomatic rectocele underwent surgical treatment at our institution. Fifty-eight of the patients were female (mean age 56; range, 21–70 years). Incontinence was graded according to a previously reported scoring system that accounts for the type and frequency of incontinence episodes. Preoperative anorectal manometry was performed using an open perfused polyethylene probe. Rectal sensation was recorded by balloon distention. Endoanal ultrasonography was performed with a 7.5-MHz probe. Preoperative defecography was performed at rest and on maximal squeeze and straining. Patients with obstructed defecation as their principal symptom, with associated mucosal rectal prolapse, underwent an endorectal procedure. For patients with associated anal incontinence (Grade B2 or greater), and without a rectal mucosal prolapse, a transperineal approach was performed with either an anterior external overlapping sphincteroplasty or levatorplasty. The median follow-up was 48 (range, 9–122) months. RESULTS: There was no operative mortality. Postoperative complications occurred in 18 patients (30 percent). Of 43 patients with incontinence, 34 (79 percent) were available for postoperative evaluation. None were fully continent. However, in 25 patients (73.5 percent), continence improved after surgery; half had only mucus soiling or loss of gas. Incontinence scores decreased (i.e., improved) from 4.8 ± 0.9 to 3.9 ± 0.9 (P = 0.002). A significant improvement was found both after transanal and perineal procedures. Only ten initially continent patients were available for postoperative assessment. All patients stated that they had clinical improvement in constipation. Their preoperative mean anal resting pressure was 62.5 ± 3.9 (standard error of the mean) mmHg, with a postoperative mean of 75.5 ± 7 mmHg. The preoperative mean squeeze pressure was 83.1 ± 8.5 mmHg, with a mean postoperative squeeze pressure of 88.5 ± 7.9 mmHg (P = not significant). The maximal tolerable volumes were all within normal limits, confirming the proctographic evidence that there were no cases of megarectum in our patient series. The pudendal nerve terminal motor latency was abnormal in all but two patients with incontinence (mean pudendal nerve terminal motor latency = 3.1; range, 1.2–4 milliseconds). Rectoceles recurred in six patients (10 percent): five after a Block procedure and one after a Sarles-type operation. The postoperative endosonographic appearance varied according to the nature of the procedure performed. CONCLUSION: There are few data concerning patients with rectocele who have associated anal incontinence, however, surgical decision analysis resulted in improvement in both constipation and incontinence in the majority of our patients with rectocele. Nevertheless, because none of the patients gained full continence postoperatively, pelvic floor rehabilitation might be also needed to achieve better sphincter function in patients with incontinence.     

Which surgical approach for rectocele? A multicentric report from Italian coloproctologists

The most effective surgical technique for rectocele has not yet been clearly established. A retrospective multicentric study was carried out to compare the long-term results of 3 endorectal techniques (Block, Sarles and stapled) and the perineal levatorplasty, alone and in association, in a series of patients with symptomatic rectocele. From January 1992 to December 1999, 2212 patients with defecation disorders were referred to 5 Italian coloproctology units. An anterior rectocele was clinically diagnosed in 1045 patients and confirmed with defecography. On the basis of clinical and radiological parameters, 317 patients (312 women; mean age, 52.4±20.1 years) were selected for surgery. Group 1 consisted of 141 patients (136 women; mean age, 50.4±18.8 years) who were submitted to endorectal operations. Group 2 consisted of 126 women (mean age, 52.5±19.7 years) who received perineal levatorplasty. Finally, 50 women (mean age, 54.3±21.9 years) in Group 3 received endorectal operations associated with perineal levatorplasty. A total of 269 patients were followed postoperatively (mean period, 24.2±3.1 months, 27.5±5.4 months and, 22.8±2.8 months, respectively) with the same questionnaire and clinical examination. Three months after surgery, a defecography examination and anorectal manometry were performed in 136 and 132 patients, respectively. Operative time, hospital stay and time to return to work were significantly higher in Group 3 (p<0.001). There was one death in Group 3 due to severe sepsis. Main postoperative complications were: in Group 1, hemorrhage (7.8%, all Sarles), dehiscence of the endorectal suture (5.0%, all Block), distal rectal stenosis (2.1%, 1 stapled, 2 block), and rectovaginal fistula (1.4%, all Sarles); in Group 2, delayed healing of the perineal wound (16.4%); in Group 3 delayed healing of the perineal wound (22.0%), hemorrhage (6%, all Sarles), dehiscence (4.0%), stenosis (2.0%). 17.3% of patients of Group 2 and 22.5% of Group 3 complained of dyspareunia. Postoperative defecography showed a complete absence of the rectocele in 44.1% of patients and reduction of size in the others, without significant differences among the three groups. Manometric pattern was not significantly modified by surgery. Significant symptoms recurred in 5.9% of the patients in Group 1, 6.4% in Group 2, and 5.0% in Group 3. Perineal levatorplasty did not significantly improve obstructed defecation, as it did not allow to excise the rectal mucosal prolapse, and was followed by an high incidence of delayed healing of the perineal wound and dyspareunia. Sarles procedure achieved better control of mucosal prolapse but carried a higher complication rate compared to the others. The association of the perineal levatorplasty with an endorectal technique required significantly longer operative time, and led to a longer hospital stay and time to return to work. In conclusion, the investigated techniques showed different patterns of postoperative complications: bleeding after Sarles, dehiscence after Block, dyspareunia after perineoplasty and fatal gangrene after stapled, but non of them showed a clear superiority over the others in term of clinical or functional results 2 years after surgery. Received: 28 September 2001 / Accepted in revised form: 16 November 2001