肛门括约肌损伤的手术选择

<正>无论是传统的括约肌学说,还是括约肌肌鞘学说及近年的三肌袢学说,括约肌对肛门的自制都极为关键~([-3])。不同程度、类型的损伤都会导致不同程度的肛门功能丧失即肛门失禁。一、肛门括约肌损伤的原因及分度导致肛门括约肌损伤的原因有产伤、肛门局部外伤、骨盆外伤、腹盆腔复合伤及不恰当的肛门手术。其中产伤导致的肛门括约肌损伤最为常见,包括会阴撕     

肛门内括约肌解剖生理学研究进展

肛管被肛门括约肌复合体（anal sphincter complex）围绕，肛门括约肌复合体由互相重叠的两层肌肉构成。其外层为肛门外括约肌（external anal sphincter，EAS），它是骨骼肌，为随意肌。肛门括约肌复合体的内层为肛门内括约肌（internal anal sphincter，IAS），它是肛门括约肌复合体的不随意的平滑肌部分。     

产科肛门括约肌损伤的危险因素分析及护理措施探讨

为探究产科肛门括约肌损伤的危险因素及护理措施,选取2019年4月至2020年3月于我院经阴道分娩的312例产妇为研究对象,通过查阅产妇病历资料统计基线资料,将产妇分为肛门括约肌损伤组和未损伤组,采用Logistic回归分析影响产妇肛门括约肌损伤的危险因素并探讨相关护理措施.结果显示,肛门括约肌损伤组产妇年龄31～40岁...     

产科肛门括约肌损伤风险预测模型研究进展

对分娩所致的肛门括约肌损伤风险预测模型进行综述,包括研究人群、研究方法、相关风险因素及模型性能等,为临床构建产科肛门括约肌损伤风险预测模型及应用提供借鉴,实现产科肛门括约肌损伤的早期筛查、早期预防.     

张力—应力定律对肛门外括约肌损伤和生长发育的影响

作者对３７只豚鼠进行了肛门外托约肌急性和慢性扩张实验。作者认为肛门外括约肌牵拉长度、肛管压力、肌肉损伤及生长之间存在着一种依从关系。此关系对指导和改进先天性肛门直肠畸形的治疗有重要意义。     

肛门括约肌的生理功能与神经分布

肛门括约肌位于直肠下段,环绕肛管,其分为肛门内括约肌和肛门外括约肌。肛门内括约肌、肛门外括约肌、耻骨直肠肌及联合纵肌共同组成肛管直肠环的主要部分,在肛门节制功能中起重要作用。     

皮瓣移植肛门成形加内括约肌切断术治疗肛门狭窄

目的：总结皮瓣移植肛门成形加内括约肌切断术治疗肛门狭窄的临床疗效。方法：32例肛门狭窄患者中18例采用屋形皮瓣移植加肛门内括约肌切断术治疗,14例采用菱形皮瓣移植加肛门内括约肌切断术治疗。结果：29例症状缓解,3例自觉排便困难。结论：皮瓣移植肛门成形加内括约肌切断术治疗肛门狭窄,保证了手术成功率和治疗的彻底性。     

分娩时肛门括约肌损伤产妇真实体验的Meta整合

目的 系统评价分娩时肛门括约肌损伤产妇的真实体验,为制订针对性护理措施提供参考。方法计算机检索PubMed、Embase、Web of Science、Medline、中国知网、万方、维普等中英文数据库,检索关于分娩时肛门括约肌损伤产妇真实体验和心理感受的质性研究,检索时限为建库至2022年1月。依据2016版澳大利亚JBI循证卫生保健中心质性研究质量评价标准评价文献质量,利用汇集性整合法进行结果整合。结果共纳入10篇研究,提炼出91研究结果,将相似结果归纳形成8个新类别,最终得出4个整合结果：对日常生活的影响,对身心方面的影响,产妇缺乏医疗支持与互动,积极恢复、继续生活。结论护理人员应关注和了解分娩时肛门括约肌损伤产妇的真实体验,识别肛门括约肌损伤高危因素,给予针对性干预措施,同时建立多学科产后随访团队,协助产妇更好地重返社会,提高生活质量。     

开放性肛门直肠损伤15例诊治体会

肛门直肠有坚实骨盆保护，部位隐秘．损伤通常南高速机动车事故，高处坠落，牛角顶伤引起。多伴有合并伤。局部污染严重，感染易扩散到肛门直肠间隙。如诊治不当，可发生严重的并发症。回顾本院1995年至2007年收治15例开放性肛门直肠损伤病例的诊治，报告如下。     

小儿直肠肛门损伤的诊治分析

目的：探讨小儿直肠肛门损伤的早期诊断及治疗方法。方法：21例患儿,单纯性直肠损伤12例,复杂性直肠损伤9例,受伤原因车祸最多,共12例。结果：15例行单纯修补,5例行结肠造瘘,1例仅行异物取出术。术后治愈20例,治愈率95.2％。结论：小儿直肠肛门损伤多为外伤所致。对医源性损伤提出预防方法,可减少发病,主张早期诊断,及时治疗。     

Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function

Objective The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity. Method Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano‐rectal pathology were prospectively assessed by manometry and anal endosonography. Results Anterior anal fissures were identified in a younger age group [33 years (IQR 26–37) vs 41 years (IQR 36–52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4–35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH₂O (IQR 126–196) vs 205 cmH₂O (IQR 174–262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4–55.7)]. Conclusions Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.     

The treatment of postoperative anal sphincter insufficiency

Postoperative anal sphincter insufficiency was revealed in 94 patients, ageing 14-64 yrs. Surgical treatment was conducted in 80 of them: sphincteroplasty--in 29, sphincterolevatoroplasty--in 37, sphincterogluteoplasty--in 8, plasty, using the m. gluteus maximus flap--in 6. Results of the patients treatment, followed up 1-4 yrs, were: good--in 54 (76.1%), fair--in 11 (15.5%) and poor--in 6 (8.4%) of them.     

The prevalence of anal incontinence in post-partum women following obstetrical anal sphincter injury

Introduction and hypothesis  

The primary objective of this study was to determine the prevalence of anal incontinence (AI) in post-partum women following obstetrical anal sphincter injury (OASI). We also assessed quality of life and prevalence of other pelvic floor symptoms.     

Long‐term anal continence and quality of life following postpartum anal sphincter injury

Objective Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long‐term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3). Method In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound. Results Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3. Conclusion Our study indicates that long‐term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).     

A prior cesarean section and incidence of obstetric anal sphincter injury

Introduction and hypothesis

Obstetric anal sphincter injury (OASIS) following birth may have serious, long-term effects on affected women, including fecal incontinence, despite primary repair.

Methods

This was a retrospective population-based register study. Women with OASIS grouped by order of vaginal delivery and prior cesarean section (CS) were compared separately with women without OASIS using logistic regression analysis. The aim was to assess an association between prior CS and incidence of OASIS across groups of women categorized according to singleton first, second, and third vaginal deliveries between 1997 and 2007 in Finland.

Results

The incidence of OASIS was 1.8 % at a first vaginal delivery after a prior CS compared with 1.0 % at a first vaginal delivery without prior CS. After adjustment prior CS was associated with a 1.42-fold risk of OASIS only at the first vaginal delivery, with no further significant risk after one or two previous vaginal deliveries. One centimeter increase in maternal height was associated with a 2 % decrease in OASIS incidence at the first vaginal delivery.

Conclusions

Prior CS is a significant risk factor for OASIS at the first vaginal delivery. This suggests that relative fetopelvic disproportion leading to CS for a first delivery also predisposes to OASIS at a first vaginal delivery since 40 % of the increased incidence of OASIS risk was explained by birthweight and 4 % by maternal height.     

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

Objective  Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.
Method  Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n  = 103; delayed, n  = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes – probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.
Results  Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated £2750, giving an ICER of £487 per QALY. DS produced a gain of 3.73 QALYs for a cost of £2667, giving an ICER of £719 per QALY. Both procedures fell below the £10 000 per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.
Conclusion  If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.     

Surgical treatment of postnatal insufficiency of the anal sphincter

From the analysis of 91 cases of postnatal insufficiency of the anal constrictor some causes of occurrence of various types of this condition were revealed. Depending on the type of insufficiency indications to different operation methods were elaborated. The selection of operation methods is grounded on immediate and late results of the treatment.