Der Wert der abdominalen Rektopexie bei obstruktiven Defäkationsstörungen

Zusammenfassung Diese prospektive klinische, manometrische, elektromyographische and radiologische Studie wurde durchgeführt, um den Erfolg der anteriorposterioren Rektopexie bei 18 weiblichen Patienten mit obstruktiven Defäkationsstörungen und unterschiedlichen Graden von Inkontinenz beurteilen zu können. Präoperativ wiesen 6 der Patientinnen eine rektale Intussuszeption, 4 einen inneren Prolaps der Rektumvorderwand und 5 eine Rektozele von mindestens 2 cm Größe auf. Alle hatten eine signifikante Beckenbodensenkung. Das Hauptziel dieser Studie war, durch Anwendung eines Defäkationsindexes die prä- und postoperative Darmentleerung besser beurteilen zu können. Diese Studie zeigt, daß die obstruktive Defäkation signifikant mit einem anhaltenden Stuhldranggefühl nach der Entleerung, einem Gefühl der unvollständigen Entleerung, perianalen Schmerzen und der manuellen Unterstützung bei der Entleerung verbunden ist. Alle Patienten, Durchschnittsalter 62 Jahre, unterzogen sich einer anterior-posterioren Rektopexie (Ivalon oder Vicryl) in Verbindung mit einem posterioren Pelvic-repair des M. puborectalis. Bei 2 Patienten wurde gleichzeitig eine Sigmoidektomie durchgeführt, in 11 Fällen wurde die Rektopexie mit einer Hemikolektomie links kombiniert und in 2 Fällen mit einer subtotalen Kolektomie. Die mittlere Follow-up-Zeit betrug 40,8 Monate (Spanne: 6–66 Monate). Postoperativ zeigte sich in der anorektalen Manometrie ein signifikanter Anstieg des Analdrucks in Ruhe and bei willkürli-cher Kontraktion. Die Kontinenz wurde bei 10 Patienten (55%) verbessert, 7 (39%) Patienten erlangten wieder die volle Kontinenz. Keine signifikanten Veränderungen zeigten der anorektale Winkel and der perineale Deszensus. Nur 8 Patienten berichteten postoperativ über eine vollständige Entleerung des Rektums bei der Defäkation.

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The value of abdominal rectopexy in obstructive defecation. A prospective study with a defecation index, manometry and radiology

A prospective clinical, manometric, electromyographic and radiological study was conducted to judge the degree of success achieved with anterior-posterior rectopexy in 18 female patients suffering from obstructed defecation and varying degrees of incontinence. Prior to being operated on, 6 of the patients showed symptoms of intussusception, 4 an internal prolapse of the anterior rectum wall, and 5 a rectocele at least 2 cm in size; all of them had significant perianal descent. The main aim of this study was more precise definition of the pre- and postoperative bowel evacuation using a defecation index. This study shows that obstructed defecation is significantly associated with a lasting feeling of needing to defecate after evacuation, a sensation of incomplete evacuation, perianal pain and necessity for manual support during defecation. The patients had a mean age of 62 (range, 38–78) years. All underwent anterior-posterior rectopexy (Ivalon or Vicryl) with posterior pelvic repair of the puborectalis muscle. In 2 patients rectopexy was combined with sigmoidectomy, in 11 cases, with left hemicolectomy, and in 2, with subtotal colectomy. The median follow-up was 40.8 months (range, 6–66 months). Postoperatively anorectal manometry showed a significant increase in the resting anal pressure and the maximum voluntary pressure (P = 0.05). Continence was improved in 10 patients (55%), 7 (39%) of whom regained normal continence. No significant change in pelvic descent or anorectal angle was observed. Only 8 patients reported a complete evacuation of the rectum postoperatively.

     

Recurrence and Quality of Life Following Perineal Proctectomy for Rectal Prolapse

Background  Surgical outcome and quality of life (QOL) following perineal proctectomy for rectal prolapse remain poorly documented. Methods  From 1994 to 2004, patients with full-thickness rectal prolapse were treated exclusively with perineal proctectomy independent of age or comorbidities. Subjective patient assessments and recurrences were determined retrospectively from hospital and clinic records. Consenting patients completed the gastrointestinal quality of life index (GIQLI). Results  Perineal proctectomy was performed in 103 consecutive patients with a median age of 75 years (range 30–94). Most patients underwent concurrent levatorplasty (anterior 85.8%, posterior 67.9%). Durable results were obtained in all patients; the recurrence rate was 8.5% over a mean follow-up of 36 months. Preoperatively, 75.5% of patients reported fecal incontinence, and 32.1% had obstructed defecation. Incontinence significantly improved post-proctectomy (41.5%, p < 0.001), as did constipation (10.4%, p < 0.001). GIQLI respondents reported satisfaction following proctectomy with 63% scoring within one standard deviation of healthy controls. Patients with recurrent prolapse reported a lower QOL. Risk factors for recurrence included duration of prolapse, need for posterior levatorplasty, and prior anorectal surgery. Conclusions  Perineal proctectomy provides significant relief from fecal incontinence and obstructive symptoms caused by rectal prolapse, with an acceptable recurrence rate and low morbidity. This study was supported exclusively using institutional funding.     

Anteriore und posteriore rektopexie mit levatorraffung bei patienten mit rektumprolaps und inkontinenz

Zusammenfassung Diese prospektive klinische, manometrische und radiologische Studie bei 18 weiblichen Patienten mit komplettem Rektumprolaps und einer Inkontinenz unterschiedlicher Ausprägung untersucht die Ergebnisse der dorsalen abdominellen Rektopexie (Ivalon oder Vicryl) in Verbindung mit einer hinteren pelvinen Raffung des M. puborectalis. Das Durchschnittsalter der Patientinnen lag bei 62 Jahren. Bei 13 der Prolapspatienten, die zusätzlich an einer Obstipation litten, wurde eine kombinierte Rektopexie mit Sigmoidektomie durchgeführt. Postoperativ kam es zu einer signifikanten Erhöhung des Ruhe- und Kontraktionsdrucks (p = 0,01). Bei 16 Patienten (89%) kam es zu einer Verbesserung der Kontinenzleistung, in 9 Fällen (56%) zu einer kompletten Wiederherstellung der Kontinenz. Es wurde postoperativ keine signifikante Veränderung in bezug auf die Beckenbodenebene und den anorektalen Winkel beobachtet. Die abdominelle Rektopexie mit Resektion konnte die Obstipation bei 9 von 13 Patienten (70%) beseitigen.

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Anterior and posterior rectopexy with pelvic repair in patients with rectal prolapse and incontinence

A prospective clinical, manometric and radiological study has been performed, before and after rectopexy, on 18 female patients with complete rectal prolapse, and varying degrees of incontinence. All patients, mean age 62 years, underwent anterior-posterior fixation (Ivalon or Vicryl) of the rectum with posterior pelvic repair of the puborectalis muscle. 13 patients with obstipation and rectal prolapse were treated by rectopexy combined with sigmoidectomy. Postoperatively there was a significant increase in the resting anal pressure and maximum voluntary contraction pressure (p = 0.01). Continence was improved in 16 patients (89 percent), 9 (56 percent) of whom regained normal continence. No significant change in pelvic descent or anorectal angle was seen postoperatively. Following abdominal rectopexy and resection obstipation was reduced in 9 of 13 patients (70 percent).

     

Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse. A prospective study

Background Laparoscopic rectopexy offers the advantages of the open transabdominal approach while decreasing the surgical comorbidity. The aim of this prospective study was to assess the clinical and functional outcome of laparoscopic Wells procedure for full-thickness rectal prolapse. Methods Between 1999 and 2005, 77 patients underwent laparoscopic modified Wells procedure for full-thickness rectal prolapse. The patients were evaluated postoperatively for resolution of their prolapse and functional outcome, as well as for their satisfaction level regarding the procedure. Results Laparoscopy was successful in all but one case. There were no major intra- or postoperative complications and the mean hospital stay was 4.9 days. Approximately half of the patients had some degree of fecal incontinence preoperatively. At long-term follow up, 89 percent experienced alleviation of symptoms. Constipation was improved in 36% of cases. Eighteen percent of the patients suffered a new onset of constipation. Recurrent prolapse was observed in one patient. Ninety percent of the patients were satisfied at long-term follow-up. Conclusion The laparoscopic Wells procedure for rectal prolapse had good functional results, a low recurrence rate and proved to be a feasible and safe procedure. Postoperative constipation remains a problem, which should be solved.     

Long-term outcome after laparoscopic and open surgery for rectal prolapse

Background Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited. Methods Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey. Results A total of 111 patients (age, 56.8 ± 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17). Conclusions The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.     

Klinische Anatomie und Biomechanik des Sprunggelenkes unter besonderer Berücksichtigung der Endoprothetik

Zusammenfassung Die Articulatio talocruralis (oberes Sprunggelenk) erlaubt dem Fuß die elementaren Bewegungen der plantaren Flexion und der dorsalen Extension. Die Morphologie des Gelenks ist diesen Hauptbewegungen angepasst. Es ist allerdings kein reines Scharniergelenk, sondern es treten zusätzliche Rotations- und Translationsbewegungen auf. Das distale Fibulaende zeigt individuell unterschiedliche Kompensationswegungen.Gelenkkräfte werden vornehmlich über die distale Tibiagelenkfläche und die Facies superior der Trochlea tali übertragen; allerdings sind die laterale fibulotalare und die mediale tibiotalare Artikulation mitbeteiligt. Über den Talus werden Kräfte in den Rückund in den Vorfuß geleitet, er dient als alleiniger Kraftverteiler.Die prothetische Versorgung des oberen Sprunggelenks muss den kinematischen und kinetischen Anforderungen Rechnung tragen, d. h. Drehen und Gleiten müssen möglich bleiben und zur Kraftübertragung sollten die Kontaktflächen zwischen den Prothesenkomponenten selbst und zwischen Prothesenelement und Knochenlager groß sein. Die Verankerung des talaren Prothesenteils sollte die arteriellen intraossären Gefäße des Sprungbeins nicht wesentlich beeinträchtigen, da ansonsten die Gefahr der Knochennekrose besteht.     

Die Begründung,die Technik und die Ergebnisse der knappen transanoabdominalen Kontinenzresektion

Zusammenfassung Für Rectumcarcinome in den letzten 8 cm wird eine kontinenzerhaltende Operation empfohlen; sie wird knappe Kontinenzresektion genannt. In ausgewählten Fällen garantiert die Entfernung der Hauptmetastasenstraße mit den Grenzlamellen eine gründliche Excision des Tumors. Klappen in den Lymphgefäßen erlauben nur einen Lymphstrom nach abdominal. Das Fehlen von Lymphknoten distal der hinteren Grenzlamelle und die Lokalisation des Tumorwachstums mit dem sichtbaren Tumorrand gestatten Radikalität auch mit einem 2 cm Abstand der distalen Resektionsgrenze von der Geschwulst. Die transabdominale Resektionstechnik wird empfohlen. Von 156 Nachuntersuchten betrug die 5-Jahresheilung bei der Rectumamputation 50%, bei der abdominalen Kontinenzresektion 62%, für die knappe Kontinenzresektion 69%.

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Anatomical basis, technique and results of transanoabdominal ultrashort resection of the rectum

Summary Ultrashort resections of the rectum have been recommended for rectal carcinomas extending below eight cm from the dentate line in order to preserve anal continence. Resection of the main lymphatic pathways together with the adjacent lamellae is important for radical removal of all tumor cells. Valves in the rectal lymph vessels allow lymph fluids to drain only in a cranial direction. There are no lymph nodes below the dorsal adjacent lamella. Thus, a distal margin of two cm from the tumor is sufficient to minimize the risk of recurrence. We recommend a transano-abdominal approach for very low rectal carcinomas. During the past years, we have operated on 156 patients with rectal carcinomas and found five-year-survival rates of 50 percent with rectum resections with colostomies, 62 percent with low anterior resections and 69% with ultra-short sphincter-preserving resections.

     

Ergebnisse der operativen Behandlung des idiopathischen Klumpfußes unter Verwendung eines dorsomedialen Zugangs mit Weichteilpräparation „à la carte“

ZusammenfassungEinleitung In unserer Klinik wird seit über 30 Jahren die operative Behandlung von Klumpfüßen über einen dorsomedialen Zugang durchgeführt. Postoperativ erfolgt zunächst eine Gipsbehandlung, dann eine konsequente Nachbehandlung mit Orthesen und Winkeleinlagen.Material und Methode Zwischen dem 1. 6. 1986 und dem 31. 12. 2000 wurden 130 primäre Klumpfußweichteiloperationen bei 86 Patienten durchgeführt. 119 (92%) Füße konnten nach durchschnittlich 4,5 Jahren klinisch-radiologisch nachuntersucht werden. Das durchschnittliche Alter bei der Operation betrug 7,6 Monate. Klassifikation nach Dimeglio und Score nach Laaveg und Ponseti dienten zur Beurteilung. Die gemessenen Winkel in den belasteten Röntgenbildern des Fußes a.p. und seitlich prä- und postoperativ wurden verglichen, Komplikationen und Rezidive dokumentiert.Ergebnisse 29 (22,3%) Füße wiesen einen Schweregrad IV nach Dimeglio, 58 (44,6%) Grad III und 43 (33,1%) Grad II auf. Ein Klumpfußrezidiv war bei 9 (7,6%) Fällen zu beobachten. Alle Winkel verbesserten sich signifikant. Bei der Nachuntersuchung wurden durchschnittlich 95,4±9,2 Punkte nach dem Score von Laaveg und Ponseti erzielt.Schlussfolgerung Der von uns verwendete dorsomediale Zugangsweg erlaubt eine ausgezeichnete Klumpfußkorrektur mit geringer Rezidiv- und Komplikationsrate.     

Laparoscopic rectopexy according to Wells

Background: The laparoscopic approach usually reduces the morbidity of procedures performed by laparotomy. The aim of this study was to demonstrate the usefulness of laparoscopic rectopexy. Methods: A total of 37 patients were included in this prospective study. The indication was true rectal prolapse in all patients. Incontinence was seen in 33% of the patients. A slightly modified Wells procedure was performed laparoscopically. Postoperatively, the patients were evaluated for resolution of the prolapse and incontinence. They were also questioned about their satisfaction with the procedure. Results: Laparoscopy was successful in all but one case. Follow-up is available in 32 of 37 patients. Prolapse was cured in all patients, and the incontinence resolved in 11 of 12. In addition, 38% of the patients experienced significant constipation preoperatively versus 5% postoperatively. Received: 22 January/Accepted: 7 May 1998     

Rectal prolapse: which surgical option is appropriate?

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme’s procedure and perineal rectosigmoidectomy (Altemeier’s procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection–rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection–rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy “which operation is appropriate?” cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.