大便失禁的外科治疗现状

肛门失禁患者或肛门括约肌成型术后患者应用生物反馈治疗有效已有报道。目前对大便失禁治疗的方法还有外科手术治疗，包括肌肉转移术、人工肛门括约肌置入、骶神经刺激等方法。但外科治疗大便失禁的疗效仍然难以判断。这是因为许多文献是回顾性报道，且研究的病例数小，随机实验更少，文献中收集的数据不标准。尽管最近大便失禁症状的生活质量评定是非常有效，且获得广泛的使用，但大量的文献报道缺乏生活质量评定数据。     

肛裂括约肌切断术应用进展

发生于肛管皮肤的全层纵形裂开并形成感染性溃疡称为肛裂,20 ～ 40岁高发,男女发病比例为1.0:2.5,一般位于前后正中位,后位多见[1-4].以肛门周期性疼痛、出血、便秘为特点[5-9].肛裂的治疗方法有很多种,一般分为手术治疗和非手术治疗.手术治疗包括肛裂切除术、括约肌切断术、纵切横缝术、皮瓣移动术等.括约肌切断术临床应用广泛,但迄今为止无统一标准,临床医生常根据经验、手术操作习惯及熟练程度来决定括约肌切断术术式,手术操作细节为关键.     

1例股薄肌移植肛门括约肌成形术的术前、术后护理

正大便失禁或肛门失禁,是指粪便及气体不能完全自主控制,在不合适的时间、不合适的地点不自主地排出,严重影响患者的人格发展以及社交生活质量。先天性肛门括约肌发育不良可引起肌源性大便失禁~([1])。本院近期成功地实施了1例股薄肌移植肛门括约肌成形术治疗先天性肛门闭锁术后的肛门失禁。术后新括约肌能否达到预期效果,术前、术后护理至关重要。通过精心的护理及术后指导患者正确地训练收缩肛门,术后18 d,患者     

番泻叶致低血容量性休克1例

番泻叶是临床上较为常用的导泻药物 ,其不良反应少见。1999年 11月我科为 1例大便失禁病人行股薄肌带血管蒂肛门外括约肌成形术后排便困难的患儿用番泻叶通便 ,出现了低血容量性休克 ,现报道如下。1　病例介绍　　患儿 ,女 ,11岁。因肛门闭锁术后大便失禁 ,于 1999年 11月 12日入院。查体 :体温 36 .5℃ ,脉搏 88/ｍｉｎ ,呼吸2 0 /ｍｉｎ ,血压 14 /8ｋＰａ。 11年前即生后 6ｈ因肛门闭锁行肛门成形术 ,术后大便失禁。本次住院的目的是想通过再次手术改善大便失禁情况。入院后第 7天在硬膜外麻醉下行股薄肌带血管蒂肛门外括约肌成形术 ,术…     

肌源性大便失禁患者的康复与护理

目的 探讨肌源性大便失禁患者的护理方法与要点.方法 65例患者均为肌源性大便失禁病例,全部患者实行肛门括约肌重建手术,术后进行整体护理配合生物反馈康复训练.结果 治疗护理前尿布疹32例,肛周溃疡12例,泌尿系感染7例,术后切口感染16例.经过治疗护理后全部病例尿布疹消失,泌尿系感染均得到控制,肛周溃疡愈合,切口感染15例治愈,1例行肠造瘘后痊愈.随访6个月～2年,治疗护理前后患者的肛门临床评分分别为(1.72±0.22),(4.01±0.36)分,治疗护理后临床评分明显高于治疗前.结论 针对性选择灌肠方法,实施整体护理配合系统康复训练对肌源性大便失禁康复具有重要意义.     

瘘道潜剥切除一期缝合术治疗肛瘘的临床疗效

目的：观察瘘道潜剥切除一期缝合术治疗肛瘘的疗效。方法：对58例肛瘘患者采用瘘道潜剥切除一期缝合术治疗治疗。结果：总治愈率为94.8％，治愈者未出现肛门括约肌功能不全、大便失禁及局部瘢痕形成和肛门狭窄等现象。结论：瘘道潜剥切除一期缝合术治疗肛瘘可取得满意疗效，并能有效减少手术后遗症。     

32例保留肛门外括约肌低位直肠癌保肛术的临床分析

目的：探讨保留肛门外括约肌低位直肠癌保肛手术的应用。方法：在全直肠系膜切除的基础上,应用国产一次性管状吻合器,对32例低位直肠癌行保留肛门外括约肌超低位结肛吻合,随访12-36个月。回顾性分析其根治性、术后排便功能、手术并发症、局部复发率。结果：全组病例术后病理检查无切端癌残留,无大便失禁,无吻合口漏;全组无手术死亡;肿瘤局部复发率9.4%（3/32）。结论：低位直肠癌保留肛门外括约肌保肛手术,遵循肿瘤根治的原则下,能保留患者正常的肛门排便功能,明显改善该类患者的生活质量。     

肛肠手术中括约肌的处理

在肛肠手术中，如果误伤肛门括约肌可引起大便失禁。因此，在具体手术中，基层外科医生常易出现两种偏向：该切开的未予切开，不该切开的却造成误伤。笔者就自己20a实施肛肠手术治疗中处理括约肌的体会，总结如下。     

腹腔镜TME联合经肛门内括约肌切除术治疗超低位直肠癌

32例超低位直肠癌患者随机分为腹腔镜组和开腹组,腹腔镜组采用腹腔镜TME联合经肛门内括约肌切除术进行治疗,开腹组选择开腹经肛门括约肌间切除术(ISR)进行治疗,比较两组患者的手术指标、术后并发症、术后肛门功能及预后。结果腔镜组术中出血量、肛门排气时间及住院天数均优于开腹组,手术时间长于开腹组,差异均有统计学意义(P<0.05);而两组术后并发症发生率、排便频率、排便紧迫感、排便困难、Wexner评分比较差异无统计学意义(P>0.05)。腹腔镜TME联合经肛门内括约肌切除术治疗超低位直肠癌术中出血少、术后恢复快,可取得与开腹手术相似的肿瘤治疗效果.且并不会增加术后并发症发生率。     

利用股薄肌行肛门括约肌重建术的护理

肛门括约肌重建术,目前仍不失为改善人工肛门功能的较好术式之一。常利用的有股薄肌、臀大肌、会阴深浅横肌等。从而使直肠癌根治术后先天性肛门括约肌发育不良,以及因创伤和手术等造成肛门括约肌损伤而大便失禁的患者,解除“肛门口”终日潮湿,粪便外溢等精神及生活上的痛苦。为此,我院近年来开展了利用股薄肌行肛门括约肌重建术,效果较为满意。现介绍如下。临床资料 1.男女各1例,均为低位直肠癌。两年前在我院已行miles氏手术会阴部造瘘(即原位人工肛     

Why the most potent toxin may heal anal fissure

An anal fissure is a painful linear ulcer in the lower part of the anal canal. It is very often referred to as an ischemic ulcer. Anodermal blood flow is negatively correlated with resting pressure of the anus. Increased activity of the internal anal sphincter may decrease the anodermal blood supply by compressing arterioles. Surgical procedures and botulinum treatment for patients with chronic anal fissure produce a temporary reduction in anal pressure, reverse sphincter spasm, and promote fissure healing. However, recent studies have shown that fissure healing does not appear to be dependent on reduction in mean resting anal pressure. On the basis of the published literature, this article attempts to explain this phenomenon in detail. The mechanism of action of botulinum toxin on the internal anal sphincter is not yet fully understood. This review focuses on problems associated with anal fissure treatment and presents them from the wider angle of science about botulinum toxin. In our opinion, anodermal blood flow depends not only on the “mechanical” force of sphincters but also on biochemical processes that occur in the fissure region.     

Endosonographic imaging of anorectal diseases.

OBJECTIVE: The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography compared with magnetic resonance imaging are reviewed. Methods. Endosonographic imaging was performed with a Siemens (Erlangen, Germany) FI 400 ultrasound scanner with an end-fire 7.5-MHz biplane endorectal probe and a B-K Medical (Sandhoften, Denmark) scanner with an 1850 axial-type side-fire 5.0- to 10.0-MHz rotating endoscopic probe. RESULTS: Rectal carcinoma appears on endorectal sonography as a low-echogenicity lesion that abruptly interrupts the normal sequence of layers. The internal anal sphincter is seen very clearly on endoanal sonography, and it is easy to appreciate atrophy and small tears of this sphincter. Endoanal sonography cannot accurately show thinning of the external anal sphincter. Peroxide-enhanced endoanal sonography is especially useful for patients with recurrent perianal fistulas in whom scarring should be distinguished from recurrent fistulas and detection of the internal opening. However, sonography does not provide an adequate deep and global display of all adjacent pelvic and perineal spaces. CONCLUSIONS: Endosonography can accurately stage primary rectal tumors and assess the internal anal sphincter. Peroxide-enhanced 3-dimensional imaging can increase the utility of endoanal sonography in detection and characterization of perianal fistulas and planning of optimal therapy. However, magnetic resonance imaging can be used a complementary modality to endosonography, especially for evaluation of external anal sphincter atrophy and deep pelvic inflammation.     

骶神经刺激治疗功能性大便失禁的短期疗效分析

目的:评价骶神经刺激术(sacral nerve stimulation,SNS)对无括肌缺陷大便失禁(fecal incontinence,FI)患者的治疗效果。方法:选择无括约肌功能缺陷的2例FI患者,进行为期2周的骶神经刺激测试治疗(peripheral nerve evaluation,PNE;SNS的体外体验治疗)。测试过程中记录排便情况,每周FI次数减少≥50%时为治疗有效;同时进行克利夫兰FI评分表(CCF-FIS)及FI生活质量(FIQL)评分。结果:2例FI患者在测试期结束时每周FI次数均减少≥50%;排便急迫时控便时间由<1 min延长为1~5 min。2例患者的CCF-FIS评分分别由治疗前的15、16分降至治疗后的3、3分。2例患者治疗后FIQL明显改善。2例患者均永久植入骶神经刺激器。结论:SNS在短期内能安全、有效地改善无括约肌缺陷FI患者的临床症状,提高其生活质量。     

Endoanal sonography in assessment of fecal incontinence following obstetric trauma.

OBJECTIVES: Fecal incontinence is a common, incapacitating and largely unrecognized medical problem and can be caused by various factors. Obstetric trauma is the most common cause of fecal incontinence secondary to trauma. We aimed to analyze the role of endoanal ultrasound in assessment of this type of fecal incontinence, and report the functional results of surgical treatment. METHODS: We reviewed the records of all 22 patients with fecal incontinence secondary to obstetric trauma who were evaluated by endoanal ultrasound and underwent surgical management in our department from April to 1997 to April 2002. Pre- and postoperative evaluation of the degree of incontinence was done using the incontinence score of Jorge and Wexner. RESULTS: The patients had a median age of 43 (range, 29-68) years. All had vaginal deliveries, five of which (22.7%) were instrumental. Most of the patients had total fecal incontinence (solids) with preoperative incontinence score values of 15-20 (median, 18). Endoanal ultrasound confirmed structural defects in the anterior external anal sphincter alone in 16 (72.7%) patients, and both anterior external and internal sphincter defects in six (27.3%) patients. A thinned perineal body was present in all patients. All patients received surgical treatment with overlapping sphincteroplasty and there was improvement of continence in 19 (86.4%) patients with postoperative incontinence score values between 4 and 0 (median, 2). CONCLUSIONS: Endoanal sonography is an accurate method for assessing sphincter anatomy, delineating both internal and external anal sphincters. Surgical treatment of sphincter defects is associated with good outcome.     

Video-assisted anal fistula treatment combined with anal fistula plug for treatment of horseshoe anal fistula

ObjectiveHorseshoe anal fistula is a common anorectal disease, and there is no standard procedure for its treatment. In this study, we performed a modified surgical procedure for the treatment of horseshoe anal fistula and investigated its efficacy and adverse effects.MethodsWe retrospectively analyzed the outcomes of video-assisted anal fistula treatment combined with an anal fistula plug (VAAFT-Plug) in 26 patients with a horseshoe anal fistula. The follow-up period ranged from 6 to 18 months. Preoperative and postoperative data were collected to analyze the cure rate, anal sphincter function, and incidence of complications.ResultsThe surgeries were successfully performed in all patients, 23 of whom were cured (effective cure rate of 88.46%). Three patients developed recurrence and were cured after traditional surgery. No patients developed severe complications or postoperative anal incontinence. The VAAFT-Plug protocol was performed with a small incision in the fistula that subsequently promoted fistula healing and preserved sphincter function.ConclusionAlthough randomized controlled trials will be needed to fully validate these findings, our results suggest that VAAFT-Plug represents a promising treatment strategy for horseshoe anal fistulas. This technique preserves normal anal function and achieves satisfactory outcomes in most patients.     

Diagnosis and conservative therapy of anal fecal incontinence

The main diagnostic tool for patients with anal incontinence is the anorectal physiology. The anorectal sphincter can be reliably tested. Due to the fact that an obstetric damage is the most common cause of anal incontinence, the transanal endosonography is the imaging method of choice for detecting a muscle defect. With high frequency ultrasound probes (preferable 10 Mhz) the pathomorphology of the sphincter can be studied in details. If conservative treatment is failing, the neurophysiology testing is helpful in deciding which surgical method (sphincter repair in case of an intact nervus pudendus, artificial sphincter or sacral stimulation in case of neuropathy). The conservative treatment includes increasing the internal sphincter muscle tonus by applying Phenylephrine locally or Loperamid per os. The biofeedback is basically a physical muscle training of the external sphincter with a visual or acoustic feedback of the muscle function to the patient. However, newer studies show that by this method the sensory function and the coordination of the anal sphincter are improving as well. With these conservative treatment options most of the patients suffering from anal incontinence can be treated satisfactorily.     

改良后切加扩肛法治疗慢性肛裂临床观察

目的 探讨改良后位内括约肌部分切断术加指法扩肛的优越性.方法 本院收治肛裂病例200例,随机分组,治疗组和对照组各100例.治疗组采用改良后切法:于肛裂后正中偏右15°切开部分内括约肌(上下纵高0.5~0.9cm,内外横厚约0.4cm),配以手法扩肛.对照组采用传统后切法:于肛裂后正中切开内括约肌(上至齿线上0.3cm)作整体切断,开放创口.结果 治疗组疼痛缓解时间为(1.2±0.4)d,而对照组为(2.4±0.6)d;治疗组复发为0例,而对照组为4例;治疗组溃疡愈合时间为(11.5±1.5)d,而对照组为(16.5±2.5)d;治疗组肛门控制功能障碍为0例,而对照组为6例;治疗组治愈率为100%,而对照组为86%.结论 改良后切加扩肛术明显优于传统后切术,具有术中出血少,术后肛门疼痛轻,感染机会少,疗程短,治愈率高,无肛门控制功能障碍,愈后复发率极低等优点.另外,此法操作简便,便于临床应用.     

Inhibition of the external urethral sphincter and sacral reflex by anal stretch in spinal cord injured patients

Relaxation of both detrusor and external sphincter muscles by mechanical stretch instead of cutaneous stimulation of the anal sphincter has been recognized and applied clinically for bladder emptying and for aiding catheterization in patients with spastic urethral sphincter. In a three-year study anal stretch was included as part of urodynamic examination in patients who could potentially use this method for bladder management. Anal stretch was found to inhibit the bulbocavernosus reflex and to be a useful alternative technique for bladder emptying in patients having complete paraplegia with normal hand function and with detrusor-sphincter dyssynergia. It is recommended that anal stretch combined with Credé or Valsalva maneuvers be a part of the urodynamic study of such patients to determine whether or not these techniques can be utilized for bladder management.     

虚实结合挂线疗法治疗肛门括约肌上瘘的临床研究

目的比较虚实结合挂线疗法与传统弹力线挂线疗法治疗肛门括约肌上瘘的临床疗效。方法选取2016年1月至2017年1月于中日友好医院肛肠科诊断并住院手术治疗的肛门括约肌上瘘患者40例,采用随机数字表法分为治疗组(虚实结合挂线法)和对照组(传统弹力线挂线法)各20例。治疗组术中予深部括约肌实挂线,结扎线松动时不紧线,采用丝线虚挂引流,待脓腔肉芽组织填充后再拆线;对照组术中内口上方括约肌予弹力线实挂线,挂线后每1周紧线1次,直至所挂的括约肌完全切断。术后观察两组疼痛、创面愈合、肛门症状及复发情况,并做定期随访。结果治疗组治愈18例,显效2例,治愈率90%;对照组治愈17例,显效2例,有效1例,治愈率85%;两组差异无显著性(χ^2=3.031,P=0.420);随访24个月,治疗组均无复发,对照组12、24个月各复发1例。两组患者术后肛门症状评分随时间推移总体呈现下降趋势,术后3个月,治疗组肛门坠胀、肛门疼痛、肛门不适感评分低于对照组,差异有显著性(P<0.05);术后6个月,治疗组肛门失禁、肛门瘙痒及肛门不适感评分低于对照组,差异有显著性(P<0.05);术后12个月,治疗组肛门失禁、肛门坠胀及便急感评分低于对照组,差异有显著性(P<0.05);术后24个月,治疗组肛门失禁、脱出、肛门坠胀、肛门疼痛评分低于对照组,差异有显著性(P<0.05)。治疗组未出现括约肌完全切断情况,对照组括约肌完全切断时间6~29d,平均(13.73±4.88)d,其中术后第1周完全离断4例,术后第2周9例,术后3周5例,术后第4周1例,术后第5周1例。两组患者术后疼痛评分总体呈现下降趋势,其中两组术后3d疼痛评分程度相当,差异无显著性(P>0.05);在术后7、14d,治疗组疼痛评分显著低于对照组,差异有显著性(P<0.05);术后28、56d,两组疼痛情况差异无显著性(P>0.05);两组术后愈合时间24~37d,平均(27.87±4.85)d;对照组23~49d,平均(33.21±5.34)d,治疗组平均愈合时间显著低于对照组,差异有显著性(P<0.05)。两组术后创面面积都趋于减小,在术后7、14、28d,治疗组创面面积显著小于对照组,差异有显著性(P<0.05),在术后56d,两组患者创面面积差异无显著性(P>0.05)。结论虚实结合挂线法治疗肛门括约肌上瘘较传统挂线法能更好地保护肛直环,保护肛门括约肌功能,减少了肛门不全失禁的发生,同时降低术后疼痛,缩短愈合时间。     

脊髓损伤后肛门外括约肌的相关研究进展

脊髓损伤残损分级以ASIA为标准,且以肛门外括约肌有无自主收缩作为评判损伤程度的一个重要标准。脊髓损伤后肛门外括约肌压力测定及肌电图已有多篇报道,但是,肛门外括约肌压力测定及肌电图与脊髓损伤ASIA分级之间的关系及对预后的评价有待研究。