结肠慢通过便秘的外科治疗(附11例报告)

分析了11例结肠慢通过性便秘手术情况。男性1例为巨乙状结肠伴扭转,女性10例中9例为全结肠通过缓慢,1例为乙状结肠缓慢。2例乙状结肠缓慢者作该肠段切除,而9例全结肠通过缓慢者作全或次全结肠切除。此外术前排粪造影及盆腔造影及手术中10例病人均发现有直肠内脱垂,盆底下降、子宫内脱垂及后倒等。故10例伴有盆底变化者分别作了直肠悬吊、盆底抬高和子宫固定及后倒纠正等手术。术后一个月内均恢复正常排便,无坠胀及排出困难。仅一例术后有梗阻症状。切除结肠病理大部分有肌间神经丛变性等变化。根据上述发现认为本病除少数有解剖因素外,大部分有出口性便秘的盆底变化,推测本病多数为出口梗阻基础上应用大量刺激性泻剂,引起结肠肌间神经丛损伤而最终发生结肠通过性便秘,并提出预防措施。     

Analysis of the causes for increases in the length of stay in the Recovery Unit of La Paz Maternity Hospital in 2008

ObjectiveTo establish the spectrum of diseases in the obstetric patient that involves an increase in the length of stay in the Recovery Unit of a specialist Maternity Hospital. To analyse the severity of these conditions as regards the means required for their resolu-tion, as well as to identify the factors that influence on post-operative morbidity in the obstetric patient.Material and methodsAll the case histories of all the patients admitted to the Maternity Hospital Recovery Unit during the year 2008 were reviewed. Those who required a lon-ger stay than usual were selected, which included, those with more than 6 hours after a caesarean, and all admissions made during pregnancy, or after dilation and curettage or partum.ResultsOut of a total of 10419 births delivered in 2008, 3000 obstetric patients were ad-mitted to the Maternity Hospital Recovery Unit, of which 285 (9.5%) required critical care. The most frequent cause of increased length of stay was obstetric haemorrhage, followed by hypertensive states of pregnancy. No patients died in this Unit in the year 2008.ConclusionsThe number of patients who had an increased length of stay in the Mater-nity Hospital Recovery Unit is similar to the percentage of patients who are admitted to Intensive Care Units in countries such as Canada or the United Kingdom, but our Unit had a lower death rate in the year evaluated. The main causes are obstetric haemorrhage and hypertensive states of pregnancy, thus patients with risk factors for developing these complications must be observed closely and monitored.     

Effect of obesity on esophageal transit

Esophageal transit time as measured by radionuclide scintigraphy using a swallowed technetium sulfur colloid bolus was measured in obese patients with gastroesophageal reflux, lean patients with reflux, and lean volunteers without reflux. The esophageal transit time was significantly prolonged in the obese group compared with both lean groups (p less than 0.001). Esophageal manometric measurement also confirmed that obese patients have an elevated gastroesophageal pressure gradient, presumably caused by increased intraabdominal pressure resulting from the mechanical burden of excess fat. The esophageal transit time is significantly related to the gastroesophageal pressure gradient. This finding, coupled with those in previous manometric investigations showing that esophageal muscle has a decreased maximum velocity with increasing afterload, explains in part why obese patients have delayed esophageal transit time. Therapy for reflux in obese patients should be aimed at improving esophageal transit.     

Does surgery correct esophageal motor dysfunction in gastroesophageal reflux.

The high incidence of dysphagia in patients with symptomatic gastroesophageal reflux (GER) but no evidence of peptic stricture suggests esophageal motor dysfunction. Conventional methods for detecting dysfunction (radiologic and manometric examinations) often fail to detect abnormality in these patients. Radionuclide transit (RT), a new method for detecting esophageal motor dysfunction, was used to prospectively assess function in 29 patients with symptomatic GER uncomplicated by stricture before and three months after antireflux surgery (HILL). The preoperative incidence of dysphagia and esophageal dysfunction was 73% and 52%, respectively. During operation (Hill repair), intraoperative measurement of the lower esophageal sphincter pressure was performed and the LESP raised to levels between 45 and 55 mmHg. The preoperative lower esophageal sphincter pressure was raised from a mean of 8.6 mmHg, to mean of 18.5 mmHg after operation. No patient has free reflux after operation. Postoperative studies on 20 patients demonstrated persistence of all preoperative esophageal dysfunction despite loss of dysphagia. RT has demonstrated a disorder of esophageal motor function in 52% of patients with symptomatic GER that may be responsible for impaired esophageal clearance. This abnormality is not contraindication to surgery. The results indicate that construction of an effective barrier to reflex corrects symptoms of reflux, even in the presence of impaired esophageal transit. Radionuclide transit is a safe noninvasive test for assessment of esophageal function.     

Dynamic urethral pressure measurements in the diagnosis of incontinence in women

Summary A group of 72 female patients whose incontinence had persisted despite various therapies was selected for an extensive urodynamic study. Overt neuropathy was absent in the patient group. An objectified history was taken and the patients were categorized accordingly. Filling cystometry and flow studies were performed in supine and standing positions, combined with continuous measurement of urethral pressure from three points within the urethra and EMG of the urethral and anal sphincters. Urethral pressure profiles were taken at rest and under stress conditions. The history indicated stress incontinence in 23 patients, urge incontinence in 33 and mixed incontinence in 16. Cystometry and urethral profile measurement alone confirmed the history in 80% of the stress and urge patients. Urethral pressure registration during filling, however, showed that a pathologic urethral function was involved in 40 patients (14 stress, 16 urge and 10 mixed incontinents) and, as a result, changed the therapeutic approach in these cases. This pathology was not clear from the EMG recordings or the urethral pressure profiles. Continuous measurement of the urethral pressure dynamics during cystometry can unveil pathology of the urethral function as the basic cause of incontinence and thus prevent inadequate therapies from being used for these patients.     

Care of obstetric patients during the immediate postanesthesia period

STUDY OBJECTIVE: To determine the level of care available to obstetric patients during the immediate postanesthesia period. DESIGN: Mail and telephone survey of members of anesthesia departments in Michigan. SETTING: All Michigan hospitals with licensed obstetric beds. PATIENTS: Patients recovering from general or major regional anesthesia following an operative delivery. INTERVENTIONS: The factors determining patient care were the physical suitability of the recovery site, skills and experience of personnel providing care in postanesthesia care units (PACUs), and adjustments in care patterns by anesthesia personnel. MEASUREMENTS AND MAIN RESULTS: Most obstetric PACUs are staffed by labor and delivery nurses whose assignment to the unit is only part of their overall patient care responsibilities within the labor and delivery area (88.2% of hospitals with more than 2,000 annual births and performing cesarean deliveries in the obstetric suite; 92.3% of hospitals with 500 to 1,999 annual births and performing cesarean deliveries in the obstetric suite). Obstetric PACUs in the remaining hospitals in either group are staffed by dedicated nurses who are permanently assigned to these units. Preparation of labor and delivery nurses for PACU duties varies greatly, but 60.0% of hospitals with more than 2,000 annual births and 30.8% of hospitals with 500 to 1,999 annual births provide no special training. Concern about the level of expertise available in obstetric PACUs staffed by labor and delivery nurses was expressed by almost every respondent and has led to a practice pattern followed by most anesthesia personnel of transferring patient care responsibility only after patients have regained consciousness, cardiovascular stability, and ventilatory adequacy. Several institutions also allow anesthesia personnel to summon nurses from the surgical PACU or to transfer patients to alternate recovery sites, such as the surgical PACU or the intensive care unit (ICU). CONCLUSIONS: In many obstetric PACUs, the level of expertise of personnel needs to be upgraded to ensure the safety of patients recovering from general or major regional anesthesia and to comply with existing care standards.     

Neurocardiogenic syncope in the obstetric patient

We report two patients who presented to our obstetric unit with a diagnosis of neurocardiogenic syncope. The first patient presented to the obstetricians in the second trimester having had two episodes of syncope during her pregnancy. The second patient had a pacemaker fitted prior to conceiving. We present the peri-partum management of both these patients.     

智能胶囊结肠压力测定对慢传输型便秘手术方式选择的临床意义

目的探讨智能胶囊结肠压力测定对慢传输便秘术式及疗效的评价作用。方法符合罗马III诊断标准、排除器质性便秘、内科治疗3年以上不缓解、有强力手术意愿的慢传输便秘患者31例,术前及术后半年同步口服智能胶囊结肠压力测定和结肠运输试验。术前检查结果决定手术方式：80%的不透X线颗粒在左半结肠停留超过72 h,或大于总时间的50%,结肠脾曲综合征,智能胶囊结肠压力测定左半结肠停留时间长、压力低幅传输波（low amplitude propagated contractions,LAPCs）及高幅传输波（high amplitude propagated contractions,HAPCs）少于右半结肠50%者行左半结肠切除;80%的不透X线颗粒在右半结肠停留超过72 h,或大于总时间的50%,LAPCs及HAPCs少于左半结肠的50%者行右半结肠切除;结肠运输试验时间〉120 h,消化道压力测定为全结肠压力波明显减少,HPACs少于6次/d者行结肠次全切除;结肠运输时间〉168小时,小肠通过时间〉24 h,消化道压力测定为全结肠压力波明显减少,HAPCs〈2次者行全结肠切除＋回肠直肠切除;16例行传统剖腹手术,15例行腹腔镜手术。结果 31例均恢复出院,术后便秘改善明显改善,术后半年与术前比较智能胶囊的在体总时间、结肠通过时间及群发HAPCs、平均收缩幅度及生理相应比差异有统计学意义,但HAPCs及LAPCs数差异无统计学意义,结肠传输时间术后显著少于术前。腹腔镜手术组和传统手术组相比,术后肠粘连及肠梗阻发生率明显减少,3例全结肠切除术者术后早期腹泻明显。结论智能胶囊结肠压力波测定对手术方式选择有一定的指导意义,腹腔镜较传统手术创伤小、并发症少,有望成为慢传输便秘治疗的标准术式。     

Videofluorographic evaluation of dysphagia before and after modification of the flap and scar in patients with oral cancer

Dysphagia is an important postoperative problem in patients with oral cancer. We evaluated the usefulness of a technique to modify the flap and scar for the alleviation of swallowing disorders. The modifications were made while tongue pressure was being measured to improve excursion of the residual tongue in nine patients. They had been operated on for oral cancer and reconstruction was with a forearm free flap, or the wound was closed primarily. After a 5 ml bolus of liquid barium had been given orally, lingual movement, barium inflow into the pharynx before swallowing, stasis in the epiglottic valleculae, and stasis in the oral cavity after swallowing, were evaluated by videofluorography before and after modification. Oral transit time, pharyngeal transit time, and total transit time were also measured. Lingual movement improved in eight patients. Barium inflow into the pharynx before swallowing improved slightly in all patients. Stasis in the epiglottic valleculae was improved in six patients. Stasis in the oral cavity improved in all patients. Oral transit time and total transit time were significantly shorter after modification of the flap and scar than before operation. Pharyngeal transit time was unchanged. We conclude that our technique for modification of the flap and scar can alleviate postoperative swallowing dysfunction in patients with oral cancer.     

Gastroesophageal reflux after esophageal surgery--evaluations based on esophageal transit scintigram

By means of esophageal transit scintigram using 99mTc-DTPA, 15 patients (13 esophageal carcinomas and 2 cardia carcinomas) were studied, in whom esophagogastric anastomosis was done according to the posterior invagination anastomosis technique we had devised. In all 8 patients with anastomosis at cervical region, gastroesophageal reflux was not seen on both scintigrams before and after meals, and the average pressure gradient of high pressure zone at anastomosis was 39.8 cmH2O. In 2 of 7 patients with intrathoracic anastomosis, the scintigram before meals showed severe reflex, and the endoscopic findings showed diffuse and moderate erosion in the esophageal mucosa. The average pressure gradient across the anastomosis was 6.5 cmH2O. In these 2 patients, the new fornix with a sharp angle of His was not formed. In the remaining 5 patients with intrathoracic anastomosis, reflux was not seen on the scintigram before meals. However, in 2 of them, the scintigram after meal and endoscopic examination revealed mild reflux and mild esophagitis respectively. Furthermore in one patient very mild reflux was observed only on the scintigram after meals but the endoscopic findings showed the normal esophageal mucosa. In these 5 patients, the average pressure gradient across the anastomosis was 17.0 cmH2O, which was significantly higher (p less than 0.01) than that in 2 patients with severe reflux and was significantly lower (p less than 0.01) than the mean value of high pressure zone in 8 patients with cervical anastomosis. In conclusion, it is presumed that the formation of a large fornix enough to store food and a sharp angle of His are important factors in maintaining an anti-reflux mechanism. The esophageal transit scintigram was proved to be an excellent technique in detecting and evaluating quantitatively gastroesophageal reflux.     

Informed consent for obstetric anesthesia research: factors that influence parturients' decisions to participate

Patients who are approached to participate in clinical studies just before delivery may have insufficient time to make an informed decision and/or may feel pressured into participation. This study was designed to examine factors that influence parturients to consent or decline participation in an anesthesia study related to their delivery. Parturients who had been approached to participate in a continuing clinical obstetric anesthesia study were subsequently given a questionnaire that documented their reasons for consenting or declining participation. There were no demographic differences among the consenters (n = 166) and nonconsenters (n = 109). The most important factors in the patient's decision to consent were related to their understanding and perceived importance of the study and the potential benefit to other women. Forty-one (40. 6%) nonconsenters strongly considered their pain/discomfort a factor in declining participation. Only one patient felt some pressure to consent, suggesting that the overall environment was noncoercive. Logistic regression analysis demonstrated that patients who read the consent form completely, those who had participated in a previous research study, and those who were less anxious about participating were more likely to consent. Implications: Obtaining informed consent for obstetric anesthesia studies presents a challenge to the anesthesiologist. Results from this study suggest that the environment in which consent for obstetric studies is sought is not coercive. However, it is important that the anesthesiologist ensures that the patient fully understands the study and develops a rapport with the patient to allay any anxiety associated with her participation as a potential research subject.     

Anorectal physiology in relation to clinical subgroups of patients with severe constipation

OBJECTIVE: The aim of this study was to evaluate anorectal physiology in relation to clinically defined subgroups of patients with idiopathic constipation and to analyse relationships between anorectal physiology and rectal evacuation. SUBJECTS AND METHODS: One hundred consecutive patients with idiopathic constipation were clinically categorized as slow transit (n=19), outlet obstruction (n=52) and a group with mixed symptoms (n=29). They were examined by recording anal pressures and also rectal volumes in response to stepwise increases in rectal pressure (5-60 cm H2O). The manovolumetric results were compared with 28 sex and aged matched controls. Rectal evacuation was measured by computer-based image analysis of rectal emptying rate in defaecography. RESULTS: The rectal pressure thresholds for filling, urge and pain did not differ between the groups but there were proportionally more patients in the slow transit and mixed group with thresholds for filling exceeding 25 cm H2O (P=0.04). In total, 18% of patients had impaired sensitivity which was associated with long duration of symptoms (P < 0.05). Patients with grossly impaired rectal sensitivity (filling threshold > 40 cm H2O) had impaired rectal evacuation (P < 0.05). The rectal compliance was increased in the slow transit and mixed group (P < 0.01-0.05) in the pressure interval 5-15 cm H2O. Anal resting and squeeze pressures did not differ between the groups although 7/19 in the slow transit group had values around the lower limit of controls. Slow wave frequency was lower in all patient groups (P < 0.001 vs. controls). Rectal evacuation was not related to sphincter function or to rectal compliance. CONCLUSIONS: Clinical categorization of constipated patients defines groups where altered anorectal physiology is not uncommon. Constipation with symptoms of infrequent defaecation may be associated with impaired rectal sensitivity and increased rectal compliance whereas outlet obstruction symptoms are not clearly related to changes in anorectal physiology.     

Cisapride for Constipation in Spinal Cord Injured Patients: A Preliminary Report

Abstract

Chronic constipation in patients with spinal cord injury (SCI) has significant impact on quality of life. To measure baseline clinical functioning, colonic transit time and anorectal manometry and the effect of cisapride on these clinical and physiological parameters, we studied 12 SCI patients. Patients initially received baseline clinical scoring, measurement of colonic transit time and anorectal manometry. Patients then received cisapride 20 mg orally three times each day. After one and three months of cisapride therapy, all measurements were repeated. The mean duration of cisapride treatment was 5.2 months. Six of 12 (50 percent) reported that symptoms of constipation improved. No patient had worsening of symptoms. Prior to cisapride treatment, 23 percent of patients passed colonic transit markers by day five and 57 percent by day seven; baseline anal manometry revealed variable resting and squeeze pressures. After treatment, 33 percent of patients passed their colonic transit markers by day five and 71 percent by day seven. Six of 12 (50 percent) demonstrated a 10 percent or more increase in resting anal canal pressures. We conclude that about 50 percent of SCI patients have subjective improvement in constipation after cisapride therapy. Cisapride appears to improve both colonic and anorectal function. (J Spinal Cord Med, 8:240–244)     

Prospective study of the effect of rectopexy on colonic motility in patients with rectal prolapse

BACKGROUND: Patients with rectal prolapse have abnormal hindgut motility. This study examined the effect of rectal prolapse surgery on colonic motility. METHODS: Twelve patients undergoing sutured rectopexy were studied before and 6 months after surgery by colonic manometry, colonic transit study and clinical assessment of bowel function. The results were compared with those from seven control subjects. RESULTS: Before surgery colonic pressure was greater in patients than controls (P < 0.050). Controls responded to a meal stimulus by increasing colonic pressure; this increase was absent in patients. After rectopexy, colonic pressure reduced towards control values and patients' colonic pressure response to a meal returned. High-amplitude propagated contractions (HAPCs) were seen in all controls but in only three patients before and two patients after surgery. Three patients had prolonged colonic transit before and eight after rectopexy. CONCLUSION: Patients with rectal prolapse have abnormal colonic motility associated with reduced HAPC activity. Rectopexy reduces colonic pressure but fails to restore HAPCs, reduce constipation or improve colonic transit. These observations help explain the pathophysiology of constipation associated with rectal prolapse.     

Reproducibility of non-invasive urodynamics,using the cuff-uroflow,for the diagnosis of bladder outlet obstruction in males

OBJECTIVE: To determine the repeatability of the parameters obtained from non-invasive urodynamics, using the cuff-uroflow, for the diagnosis of bladder outlet obstruction. MATERIAL AND METHODS: The study was carried out in a consecutive series of 34 males with functional urinary tract symptoms. The test-retest reproducibility of isometric pressure, flow in response to isovolumetric pressure and the energy transfer ratio obtained at two different times using the cuff-uroflow method was determined. RESULTS: Very good agreement for the flow in response to isovolumetric pressure measurement (intraclass correlation coefficient 0.96) and good agreement for the isovolumetric pressure measurement (intraclass correlation coefficient 0.87) and the energy transfer ratio (intraclass correlation coefficient 0.84) were demonstrated. The patients were classified into three groups according to the value of the energy transfer ratio, and it was found that there was very good agreement between the groups into which patients were classified as a result of the first and second measurements (kappa index 0.81). CONCLUSIONS: The parameters obtained with the cuff-uroflow are reliable and the energy transfer ratio allows one to classify patients into reproducible groups.     

Diagnostic evaluation of patients with faecal incontinence at a specialist institution

BACKGROUND: Evaluation of the anorectal function, clinically, structurally, and functionally, in patients with faecal incontinence should ensure appropriate and individual treatment. METHODS: Two hundred and twenty-six patients with faecal incontinence were reviewed regarding disease history and results of anorectal physiological tests and anal ultrasonography. RESULTS: The mean age was 54 years, and 191 patients (85%) were female. Sixty-two patients had passive faecal incontinence only, 49 had urge faecal incontinence only, and 115 had both passive and urge faecal incontinence. Patients with passive faecal incontinence only had a significantly higher voluntary contraction pressure and less external sphincter abnormalities than patients with urge faecal incontinence or both passive and urge faecal incontinence. The structural abnormalities of the internal and external anal sphincters identified on anal ultrasonography were significantly associated with a low maximum resting pressure and with a low voluntary contraction pressure, respectively. The causes identified for this faecal incontinence were: in 90 patients idiopathic, in 76 obstetric injury, in 36 internal anal sphincter degeneration, in 20 anal surgical injury, in 6 rectal prolapse, and in 9 patients miscellaneous. CONCLUSIONS: The anal sphincter structure as demonstrated by ultrasonography was closely related to the anorectal function, as determined by anorectal physiological tests, and the observations from these were reflected in the range of patient-reported symptoms. Anal ultrasonography and anorectal physiological tests are useful tools, enabling us to identify the mechanisms and causes of faecal incontinence in at least 60% of the patients.     

Evaluation and surgical treatment of severe chronic constipation.

Patients with chronic constipation may have one of several physiologic disorders, not all of which are amenable to operative therapy. The aim of this study was to test colonic and pelvic floor function preoperatively, to identify patients suitable for surgery based on these studies, and to determine operative outcome over time. Between 1987 and January 1991, 277 patients referred for severe symptoms of chronic intractable constipation underwent colon transit studies, measurement of anal canal pressures and reflexes, and measurements of anorectal angle movements and efficiency of evacuation. Balloon expulsion studies, electromyography of the pelvic floor, and defecating proctograms also were done. Based on these studies, patients were categorized as having: slow transit constipation (STC), 29 patients; pelvic floor dysfunction (PFD), 37 patients; STC + PFD, combined slow transit and pelvic floor dysfunction, 14 patients; and irritable bowel syndrome (IBS), 197 patients. Slow transit constipation patients underwent abdominal colectomy and reanastomosis. Pelvic floor dysfunction patients underwent pelvic floor retraining only. Patients with STC + PFD underwent pelvic floor retraining followed by abdominal colectomy. Irritable bowel syndrome patients were treated symptomatically. Among the 38 patients operated on (STC and STC + PFD), there was no operative mortality. Prolonged ileus developed in 13%, and small bowel obstruction occurred in 11% of patients. On follow-up, a mean of 20 months after ileorectostomy, no patient was constipated, none required a laxative, and none was incontinent. The mean number of stools per day was four. The authors concluded that a prospective evaluation of colonic and pelvic floor function reliably delineated constipated patients with slow transit, suitable for operative management, from those with pure pelvic floor dysfunction or irritable bowel syndrome, who were not. Abdominal colectomy and ileorectostomy in the slow transit patients was safe and effective, resulting in prompt and prolonged relief of constipation.     

Role of the atrial natriuretic factor in obstetric spinal hypotension

BACKGROUND: In recent years, the concept of prophylactic volume expansion to prevent hypotension caused by spinal anesthesia has been challenged. Investigators have reevaluated the concept of prehydration in the obstetric patient and the physiologic mechanisms involved. This article addresses whether the hypotensive effects attributed to the atrial natriuretic factor are the reason for the apparent failure of prehydration. METHODS: Atrial natriuretic factor was measured before (baseline) and 10 min after spinal anesthetic drug injection (control) in 48 healthy pregnant patients scheduled for elective cesarean section. Sixteen patients received hydration with 15 ml/kg crystalloid immediately before spinal anesthesia, 16 patients received the same volume starting with the spinal anesthetic injection, and the remaining 16 patients received no prehydration (control). Blood pressure, heart rate, ephedrine requirements, infused fluids, and urine output were measured. RESULTS: Atrial natriuretic factor concentrations increased significantly in prehydrated patients but not in the control group. There was a significant correlation in the change in atrial natriuretic factor concentrations and urine output but no correlation in the control atrial natriuretic factor concentrations and blood pressure or ephedrine requirements. Ephedrine requirements and blood pressure did not differ significantly among study groups. CONCLUSIONS: Atrial natriuretic factor is a potent endogenous diuretic in the pregnant patient but does not appear to be involved in short-term cardiovascular homeostasis after spinal anesthesia. Prehydration appears to be an ineffective measure to prevent post spinal hypotension in the obstetric patient [corrected].     

Experience with uterine artery embolization in the treatment of massive postpartum hemorrhage

OBJECTIVE: To analyze our experience with uterine artery embolization in the management of massive hemorrhage in obstetric patients. PATIENTS AND METHODS: This observational, retrospective study analyzed all deliveries requiring a blood transfusion that were performed in the maternity unit of Hospital Universitario La Paz between January 1, 2000 and December 31, 2005. RESULTS: A total of 57,835 deliveries were performed with an incidence of postpartum hemorrhage of 0.7% (406 episodes). Uterine artery embolization was performed on 51 patients and 45 patients underwent obstetric hysterectomy. Both procedures were performed on 11 patients. Ten of the patients who underwent obstetric hysterectomy subsequently required uterine artery embolization, whereas only 1 patient required an obstetric hysterectomy following embolization because the hemorrhage was not resolved. The mean consumption of blood products for patients who underwent obstetric hysterectomy was twice that for patients who underwent uterine artery embolization. There were no complications secondary to embolization. CONCLUSIONS: Uterine artery embolization is a safe and effective procedure for managing massive postpartum hemorrhage.     

Role of the martius procedure in the management of urinary-vaginal fistulas

BACKGROUND: Urinary-vaginal fistula is one of the most common and dreaded complications of obstetric trauma in developing countries. Management of these fistulas is complicated by the presence of substantial urethral loss and the tendency of the repair to break down. STUDY DESIGN: We retrospectively studied 46 patients with urinary-vaginal fistulas operated on in our institution over 5 years. Most of the patients had obstetric trauma as the causative factor. Twelve patients had urethrovaginal and 34 had vesicovaginal fistulas. Of the 12 patients with urethrovaginal fistulas, 8 underwent a Martius procedure and 4 were treated with simple anatomic repair. Of the 34 patients with vesicovaginal fistulas, 13 underwent a Martius procedure and 21 were treated with anatomic repair. Nineteen patients had recurrent fistulas and 17 had multiple fistulas. RESULTS: Only one patient with a urethrovaginal fistula treated with a Martius procedure had recurrence, compared with three of four of the patients having anatomic repair. None of the patients with vesicovaginal fistulas treated with a Martius flap had recurrence, compared with 4 of 21 in the anatomic-repair group (19.05%). Thirteen patients with single fistulas (7 urethrovaginal and 6 vesicovaginal) treated with a Martius procedure healed well without failure, compared with 1 failure among 16 fistulas (1 urethrovaginal and 15 vesicovaginal) in the anatomic-repair group. In the group of patients with multiple fistulas, the Martius flap also showed a definite advantage. Eight patients with multiple fistulas were offered the Martius flap. The procedures were successful in all but one, compared with six failures out of nine treated with anatomic repair. None of the patients having primary treatment with the Martius flap had postoperative recurrence, compared with 3 of 18 having anatomic repair (16.67%). Only 1 of 12 patients with recurrent fistulas undergoing Martius flap repair had failure (8.33%), compared with 4 of 7 undergoing anatomic repair (57.14%). None of the patients treated with the Martius procedure experienced dyspareunia postoperatively, compared with 33.33% of the patients treated with anatomic repair. CONCLUSIONS: The overall success rate was far better and the complication rate (especially incontinence and dyspareunia) was considerably less with the Martius procedure. We recommend the Martius procedure for urethrovaginal and vesicovaginal fistulas, especially those that are recurrent or multiple.