直肠前突致便秘8例诊治体会

便秘是肛肠疾病中较常见的症状,病因繁多,直肠前突(RC)作为便秘的一个重要原因,近年来已引起临床医生重视。笔者对200例排粪障碍病人进行纤维结肠镜检查以排除占位性、机械性梗阻及结肠性便秘(肠易激惹综合征、乙状结肠冗长、横结肠冗长),并经肛直肠指诊触及肛管上端直肠前壁有一圆形或卵圆形深浅不一的囊状凹陷突向阴道,共查出直肠前突8例,现浅析如下。     

老年女性直肠前突合并直肠内脱垂118例的治疗体会

1996年2月～2006年10月我们对118例直肠前突合并直肠内脱垂的老年女性患者，采用经直肠行直肠前突修补术、直肠内脱垂注射术治疗，取得了满意的效果。     

直肠黏膜环切术治疗直肠前突30例疗效观察

目的观察直肠黏膜环切术(PPH)治疗直肠前突的临床疗效。方法将60例直肠前突患者随机分为治疗组30例,采用PPH术;对照组30例,采用经直肠切开修补术(Sehapayah法)。观察两组患者治愈率及术后并发症。结果治疗组与对照组治愈率分别为70.0%和43.3%,差异有统计学意义(P0.05)。术后排空困难、会阴膨出感的发生率治疗组低于对照组(P0.05或0.01)。结论治疗直肠前突PPH术与传统经直肠切开前突修补术相比,具有手术操作简单、术后并发症少、恢复时间短、安全性高等优点。     

老年女性便秘的常见原因—直肠前突

本文对69例老年便秘患者进行排粪造影检查,发现33例有不同程度直肠前突,占48.67％,其中女性30例(90.91％),特别是经产妇,在各种造成便秘的原因中居首位。排粪造影简单易行,而且准确可靠,是一种诊断直肠前突的理想方法。     

PPH治疗老年女性直肠前突伴直肠黏膜内脱垂

直肠前突伴直肠黏膜内脱垂在临床上十分常见。我院自2006年1月起,应用吻合器痔上黏膜环切术（PPH）加直肠前壁柱状缝合治疗直肠前突伴直肠黏膜内脱垂,疗效显著,并发症少。现将治疗方法及体会报告如下。     

湿秘的辨证及直肠前突的治疗经验

湿秘是便秘的一种类型,目前尚未被广大医务工作者认识,然而,在古代宋朝时期已有记载.所谓湿秘,是指大肠传导功能失常,导致大便秘结,排便周期延长;或周期不长,但粪质干结,排便艰难;或粪质不硬,虽有便意,但便出不畅的病证.     

直肠前壁修补加行肛管侧切术治疗直肠前突

目的结直肠前壁修补加行肛管侧切术治疗直肠前突方法129例女性直肠前突中有86例伴有肛管狭窄,通过经阴道行直肠前壁修补术及对伴有肛管狭窄者加行肛管侧切术治疗.手术步骤.①经横切除阴道的带状后壁,显露直肠的疝袋前壁;②用2-0肠线将肌层组织连同显露的前直肠壁(疝袋),重叠连续缝合.③显露会阴部已被伸展的肛门括约肌变薄的前部分,将其缝合,缩短并增强;④用3-0肠线垂直缝合阴道粘膜,会阴皮肤用丝线间断缝合2～3针,7d拆线;⑤肛管狭窄者则在肛左侧或右侧行内括约肌切断术.结果术后随访80例,3mo内全部有效,18mo内62例治愈,16例有效,2例无效,治疗效果良好.结论由于肛管的狭窄,当排粪时受阻,造成压力方向的改变,久而久之,相对地增大会阴体,阴道也增宽,会阴体下移,直肠前壁粘膜前突脱垂,粪块易嵌入此部,并积存,引起排粪障碍.通过经阴道直肠前壁修补加行肛管例切术,修补了直肠前壁,并扩大了肛管,减少了出口的阻力,以达到治疗直肠前突的目的.     

经直肠修补联合PPH治疗直肠前突及黏膜脱垂32例疗效分析

2006年12月-2008年4月,我们对32例直肠前突〉3．5cm、直肠黏膜脱垂的患者,实施直肠前突修补联合直肠黏膜环切（PPH）治疗,术后效果良好。现报告如下。     

经直肠补片修补并行为调整治疗直肠前突型便秘效果观察

目的探讨医用聚丙烯补片经直肠修补并行为调整治疗直肠前突型便秘的临床疗效。方法将90例经排粪造影证实为中、重度直肠前突型便秘患者随机分为观察组60例和对照组30例,观察组行经直肠补片修补并行为调整治疗,对照组采用shepayak手术,比较两组疗效。结果观察组及对照组总有效率分别为98.3%、73.3%,P〈0.01。结论医用聚丙烯补片经直肠修补并行为调整治疗直肠前突型便秘效果确切。     

四联疗法治疗中重度直肠前突合并直肠黏膜内套叠的疗效观察

目的探讨治疗中、重度直肠前突伴直肠黏膜内套叠引起的直肠排空障碍型便秘的手术方法和治疗效果。方法对32例中、重度直肠前突伴直肠黏膜内套叠采用吻合器直肠黏膜环形切除吻合、直肠前壁闭式缝合、消痔灵注射和肛门内括约肌部分切断术治疗。结果 28例治愈,4例明显好转,有效率为100%。结论吻合器直肠黏膜环形切除吻合、直肠前壁闭式缝合、消痔灵注射和肛门内括约肌部分切断术治疗中、重度直肠前突伴直肠黏膜内套叠引起的直肠排空障碍型便秘创伤小、操作简单、疗效显著、并发症少、患者痛苦小、愈合快。     

Endo-rectal repair of rectocele

Rectocele may cause colorectal symptoms particularly difficulty in evacuation. It is readily identified on clinical examination of the perineum but the pathophysiological abnormality can easily be defined by defaecography. Between 1984 and 1988 we have operated on 16 patients who presented with difficulty in evacuation associated with rectocele. We have used a simple endo-anal repair aimed to restore a firm recto-vaginal septum. Excellent functional results were obtained in 11 patients, 4 were considerably improved and one patient had a poor result.     

Results of rectocele repair

PURPOSE: This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation. METHODS: Twentyfive patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology. RESULTS: Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction. CONCLUSIONS: Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.Poster presentation at the XVth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Singapore, July 2 to 6, 1994.     

Endorectal repair of rectocele

A modification of Sullivan's procedure for endorectal repair of “low” rectocele was completed in 59 patients with local anesthesia. Associated anorectal pathology was corrected in all patients. The technique is described. At follow-up, the results were as follows: 37 excellent (62.7 per cent), 10 good (16.9 per cent), eight fair (13.6 per cent), and four poor (6.7 per cent). Read at the meeting of the American Society of Colon and Rectal Surgeons, San Francisco, California, May 2 to 6 1982.     

Treatment of impaired defecation associated with rectocele by behavioral retraining (biofeedback)

PURPOSE: Large rectoceles have been associated with symptoms of impaired rectal evacuation, often leading to rectocele repair. However, these symptoms, or the anatomic abnormality, may be caused, at least in part, by a primary disturbance of rectoanal coordination. This study aimed to determine the efficacy of biofeedback therapy in such patients. METHODS: Thirty-two female patients (median age, 52 years) complaining of impaired rectal evacuation and with a rectocele greater than 2 cm at proctography were evaluated by structured questionnaire before, immediately after treatment, and at follow-up. Physiologic and proctographic findings were related to outcome. RESULTS: Immediate results were available in 32 patients and medium-term follow-up (median, 10; range, 2–30 months) in 25 patients. At follow-up 14 (56 percent) patients felt a little and 4 (16 percent) patients felt major improvement in symptoms, including 3 (12 percent) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (from 72 to 50 percent), feeling of incomplete evacuation (from 78 to 59 percent), need to assist defecation digitally (from 84 to 63 percent), and need to use an evacuant (from 47 to 28 percent), and this was maintained at follow-up. Bowel frequency was significantly normalized at follow-up (P=0.02). Pretreatment presence of symptoms of digitally assisting defecation, pelvic floor incoordination, and proctographic rectocele size and contrast trapping, did not predict outcome. CONCLUSIONS: Behavioral therapy, including biofeedback, leads to major symptom relief in a minority, and partial symptom relief in a majority, of patients with a feeling of impaired defecation and the presence of a large rectocele. Residual symptoms are common. Biofeedback may be a reasonable first-line treatment for such patients.     

Anterior rectocele and anorectal dysfunction

The two types of anterior rectocele, distension or Type 1 rectocele (T1R) and displacement or Type 2 rectocele (T2R), have different anatomical, clinical and therapeutic profiles. The aim of this study was to assess anorectal function in patients with distension or displacement rectocele. Three groups of female patients and one group of healthy female subjects were studied. Both the 10 Group 1 subjects, who had been diagnosed as having T1R, and the 10 Group 2 women who had been diagnosed as having T2R, were symptomatic for digital evacuation of the rectum. The 10 Group 3 females had complained of severe idiopathic constipation but had no defecatory disorders. The control group was made up of 10 healthy volunteers. All patients and controls underwent clinical evaluation, colonic transit time (CTT), computerized anorectal manometry (CAM), and defecography. Bowel movements and clinical evaluation were similar for both rectocele groups. In Group 1, CAM detected significantly higher anal pressure (P<0.05) and more impaired rectoanal inhibitory reflex (RAIR) (P<0.01) in comparison to the other patients and controls. In Group 2, the lowest anal pressure (P<0.001) was noted but RAIR was normal. Defecographic results, at rest and during evacuation, showed a significantly (P<0.001) higher anorectal angle and a more abnormal pelvic floor descent in Group 2 than in the other study groups and controls. Therefore, peculiar anorectal function was present in patients with anterior rectocele. A pelvic floor dyssynergia was noted in the distension rectocele group, while a fall of the pelvic floor was noted in the displacement rectocele group.

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Résumé Les deux types de rectocèle antérieure, rectocèle par distension ou de type 1 (T1R) et rectocèle par déplacement ou type 2 (T2R) ont des profils anatomiques cliniques et thérapeutiques différents. Le but de cette étude était d'étudier la fonction anorectale chez des patientes avec des rectocèles par distension ou déplacement. Trois groupes de patientes de sexe féminin et un groupe de sujets témoins de sexe féminin ont été étudiés. Les 10 sujets du groupe 1 chez lesquels un diagnostic de rectocèle de type 1 avait été posé et les 10 patientes du groupe 2 porteuses d'une rectocèle de type T2R étaient symptomatiques et nécessitainet des manuvres digitales pour évacuer le rectum. Les 10 patientes du groupe 3 se plaignaient d'une constipation idiopathique sévère mais n'avaient pas de troubles de la défécation. Le groupe contrôle était constitué de 10 femmes volontaires en bonne santé. L'ensemble des patients et des sujets contrôles ont été soumis à une évaluation clinique, à une détermination du temps de transit colique (CTT), une manométrie anorectale digitalisée (CAM) et une défécographic. Les exonérations et l'évaluation clinique étaient similaires dans les deux groupes de patientes porteuses de rectocèle. Dans le groupe 1, la manométrie a mis en évidence une pression anale significativement plus élevée (P<0.05) et une altération du réflexe rectoanal inhibiteur (RAIR) (P<0.01) en comparaison avec les autres patients et le groupe contrôle. Dans le groupe 2, la pression anale est nettement abaissée (P<0.001) mais le réflexe recto-anal inhibiteur était normal. La défécographie au repos et durant l'évacuation a montré un angle ano-rectal plus élevé (P<0.001) et une descente du plancher périnéal plus marquée dans le groupe 2 que dans les autres groupes étudiés et le groupe de contrôle. En conséquence, les patientes porteuses d'une rectocèle antérieure présentent une fonction ano-rectale particulière. Une dyssynergie du plancher pelvien est notée dans le groupe de rectocèle avec distension alors qu'une chute du plancher périnéal est mise en évidence dans le groupe de rectocèle avec déplacement.

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Supported in part by a grant from Ministero dell'Università e della Ricerca Scientifica e Tecnologica     

胸腰椎骨折的治疗进展

随着工业现代化和交通事业的快速发展,各种高能量损伤导致胸腰椎骨折的病例逐渐增多,给人们的健康带来很大的危害,如何规范治疗胸腰椎骨折成为骨科医师面临的挑战。经过几十年研究,对胸腰椎骨折的分型评分方法、手术入路的选择、手术方式的选择等形成了一定的共识,但仍存在一些争议。该文就胸腰椎骨折的分型、治疗原则、手术入路、手术方式进行综述,以期为骨科医师诊治胸腰椎骨折提供参考。