Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation
Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation
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DOI：
10.1007/s10350-007-9096-0
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发表时间：
2008-02-01
影响因子：
3.9
通讯作者：
Trompetto, Mario
中科院分区：
文献类型：
--
作者：
Gagliardi, Giuseppe;Pescatori, Mario;Trompetto, Mario
目的：经肛门吻合器直肠切除术可以治疗梗阻性排便障碍，但有不同的并发症和复发率的报道。本研究旨在评估经肛门吻合器直肠切除术的结果、结果预测因素和并发症的性质。方法：回顾分析123例患者的临床和功能资料。所有患者术前均有排便障碍症状，并有直肠前突和/或肠套叠。结果：中位随访17(3~44)个月，65%的患者主观感觉改善。29%的患者出现复发性直肠前突，28%的患者出现复发性肠套叠。在单因素分析中，术前有食指(P<；0.01)、耻骨直肠肌协同障碍(P<；0.05)、肠膨出(P<；0.05)、直肠前突较大(P<；0.05)、排便频率较低(P<；0.05)和排空不全(P<；0.05)的患者的结果更差。出血是最常见的围手术期并发症，占12%。16名患者(19%)需要再次手术：9名患者因复发而需要再次手术。在经肛门吻合器直肠切除术后转诊的38例患者中，最常见的问题是会阴疼痛(53%)、便秘并反复发生直肠前突和/或肠套叠(50%)，以及大小便失禁(28%)。在这些患者中，14人(37%)接受了再次手术：7人因复发。3例患者出现直肠阴道瘘。另1例死于坏死性盆腔筋膜炎。结论：经肛门吻合器直肠切除术以较高的再手术率为代价，取得了可接受的效果。耻骨直肠肌协同障碍和排便频率较低的患者可能情况更糟，因为手术没有解决他们便秘的原因。有巨大的直肠前突、肠膨出、指状物和排空不全的患者可能有更晚期的盆底疾病，而单纯去除多余组织的经肛门吻合器直肠切除术可能不足以治疗这种疾病。这一点，加上在经肛门吻合器直肠切除术后转诊的患者中观察到的并发症，表明这种手术应该由结直肠外科医生和仔细挑选的患者进行。
PURPOSE: Obstructed defecation may be treated by stapled transanal rectal resection, but different complications and recurrence rates have been reported. The present study was designed to evaluate stapled transanal rectal resection results, outcome predictive factors, and nature of complications.METHODS: Clinical and functional data of 123 patients were retrospectively analyzed. All patients had symptoms of obstructed defecation before surgery and had rectocele and/or intussusception. Of them, 85 were operated on by the authors and 38 were referred after stapled transanal rectal resection had been performed elsewhere.RESULTS: At a median follow-up of 17 (range, 3-44) months, 65 percent of the patients operated on by the authors had subjective improvement. Recurrent rectocele was present in 29 percent and recurrent intussusception was present in 28 percent of patients. At univariate analysis, results were worse in those with preoperative digitation (P < 0.01), puborectalis dyssynergia (P < 0.05), enterocele (P < 0.05), larger size rectocele (P < 0.05), lower bowel frequency (P < 0.05), and sense of incomplete evacuation (P < 0.05). Bleeding was the most common perioperative complication occurring in 12 percent of cases. Reoperations were needed in 16 patients (19 percent): 9 for recurrent disease. In the 38 patients referred after stapled transanal rectal resection, the most common problems were perineal pain (53 percent), constipation with recurrent rectocele and/or intussusception (50 percent), and incontinence (28 percent). Of these patients, 14 (37 percent) underwent reoperations: 7 for recurrence. Three patients presented with a rectovaginal fistula. One other patient died for necrotizing pelvic fasciitis.CONCLUSIONS: Stapled transanal rectal resection achieved acceptable results at the cost of a high reoperation rate. Patients with puborectalis dyssynergia and lower bowel frequency may do worse because surgery does not address the causes of their constipation. Patients with large rectoceles, enteroceles, digitation, and a sense of incomplete evacuation may have more advanced pelvic floor disease for which stapled transanal rectal resection, which simply removes redundant tissue, may not be adequate. This, together with the complications observed in patients referred after stapled transanal rectal resection, suggests that this procedure should be performed by colorectal surgeons and in carefully selected patients.