Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:
Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_953_Библиотеки_им_академика_М_И_Перельмана.pdf
Скачиваний:
0
Добавлен:
31.08.2026
Размер:
29 Мб
Скачать
☆
►Содержание►
suchasretentionandhydronephrosishavebeenreportedwith uninterruptedstimulation.
Patientscanincreaseordecreasetheintensityofstimulationinapreset range.Thisvariationisusuallydonetoensurethatthedeviceisworking
(asanadaptationtotheperceptionofstimulationcanbeobserved),and toadaptstimulationtovariationsinbodypositioning,suchasdecreased intensityduringnighttimeinasleepingposition,andtoadjustto insufficientclinicaleffectiveness.
SNStherapyrequiresmaintenance.Arelevantportionofpatientswill requirereadjustmentofthestimulationparameterstoensureconstant
optimaltherapeuticeffectivenessduringfollow-up.
FIGURE17-10Systemcomponents
(CourtesyofMedtronic,Inc.)

COMPLICATIONS

BatterylifeoftheINSislimited;batterysize,currentamplitude,and stimulationusagemainlydeterminelifespan,rangingfrom4to7years.
Acycledprogram(alternatingonandoffforasetduration)orswitching offthegeneratoratregularintervals(suchasduringsleep)helpsprolong it.AsthecurrentversionsoftheINSdonotincluderechargeable batteries,theINSneedstobeexchangedinaminorsurgicalintervention oncethebatteryisdrained.
TheINSandtheelectrodesaresensitivetomagneticfieldsandthe manufacturerrecommendsitsremovalifanMRIisneeded.Thecurrent
generationofstimulationsystemsisonlyclassifiedasconditionallysafe for1.5TheadcoilMRI.
Thedeviceisalsosensitivetounipolarcautery,andhencebipolar cauteryisadvisedforsurgicalinterventions.
ThemostfrequentcomplicationsassociatedwithchronicSNSareloss (orlack:inabilitytoreproducethetherapeuticeffectachievedduring
PNE)ofefficacyinanestimated12%,painin13%,infectionin4%,and adversestimulationeffects.
Ingeneral,onemustestablishwhetherthecomplicationisaresultofthe treatment—eithermechanicalorfunctional.Thelatterproblemcanoften
becorrectedbyreprogramming.Evenifaslightdislodgementofthe electrodeisinvolved,thearrangementofthecontactsatthetipofthe electrodesallowsstimulationfieldsofvarioussizesandshapesthatmay compensateforaminordislodgement.Thereprogrammingshould alwaysbedoneinastructuredmanner.Thealgorithmofreprogramming isthesameifadverseoruncomfortablestimulationeffectsoccur.
Ifelectrodemigrationhasoccurredandreprogrammingisineffective, revisionalsurgerywithrepositioningisunavoidable.Ifpotentiallossof
efficacyduetoother(notmechanical)causesissuspected, reimplantationofanewelectrodetoastimulation-naivesacralspinal nerveisadvised.
Painduringtherapycanalsoresultsimplyfromthepresenceofthe deviceorfromstimulation.Toexcludepainsecondarytostimulation,
theINSshouldbeswitchedoffforaperiodoftimetoclarifywhetherthe painiscausedbythecurrent.
Lateinfectionsarefortunatelyrareandareusuallyapparentfrom clinicalsignssuchasredness,warmth,anddischarge.Ifnotresolved
withadequateantibiotictherapy(coveringStaphylococcusaureus), removalofthedevice—mostcommonlythecompletedevice—is unavoidable.Oncetheinfectionhasbeenovercome,reimplantationofa newsystemcanbeconsidered.
Ingeneral,seriouscomplicationsrequiringdeviceremovalarerare (<5%),mostlypromptedbyinfectionordevicemalfunction.

RESULTS

Sinceitsfirstuseintreatingfecalincontinence,theclinicalefficacyof SNShasbeenconfirmedwithreproducibleresultsinmultiplestudies. Thesestudiesvaryregardingoutcomecriteria,buttypicallyeitherthe frequencyofinvoluntarylossofbowelcontentortheCCF-FISisused. Themajorityofstudiesreportasignificantimprovementinsymptoms, short-andmid-term,regardlessoftheoutcomemeasure(Table17-1). Withsymptomimprovement,qualityoflifealsoimproves.Thereis increasingevidencethattheeffectofSNSremainsstable:asustained clinicalbenefithasbeendemonstratedforupto20years.
TABLE17-1
Mid-andLong-termResultsofSNSforFecalIncontinence(PerProtocolAnalysis)
Incontinenceepisodes/ weekmedian(range)
Author Year
Patients(n)
(follow-up)
Median
follow-up Baseline
Last
follow-up
Medianscore
baseline(range)
FOLLOW-UP12–36MO
Uludag 2004 50 24
*
8(n.a.) 1(n.a.)
Melenhorst 2007 100 36
*
10(n.c.) 2(n.c.)
Dudding 2008 51 24 6(0–81) 1(0–59)
Brouwer 2010 55 36
*
n.a. n.a. 15(13–18)
Michelsen 2010 126 24 n.a. n.a. 16(6–20)
Gallas 2011 200 24
*
n.a. n.a. 14(2–20)
Hollingshead 2011 86 33 9(7)
†
1(2)
†
Mellgren 2011 120 36
*
9(n.a.)
†
2(n.a.)
†
Wong 2011 61 31 n.a. n.a. 14(n.a.)
FOLLOW-UP>36MO
Melenhorst 2007 100 48
*
60
*
10(n.a.)
†
10(n.a.)
†
2(n.c.)
†
2(n.c.)
†
Altomare 2009 60 74
†
4(n.a.)
†
1(n.c.)
†
Brouwer 2010 55 48
*
n.a. n.a. 15(13–18)
Faucheron 2010 87 45 n.a. n.a. 13(6–19)
Michelsen 2010 126 72
*
n.a. n.a. 20(12–20)
Uludag 2011 50 60 8(n.a.) n.a.
Lim 2011 53 51
†
n.a. n.a. 12(9–15)
Duelund-Jakobsen 2012 147 46 6(n.c.) 1(n.c.)
Faucheron 2012 57 63 n.a. n.a. 14(4–19)
Damon 2013 119 48
†
n.a. n.a.
Mellgren 2013 120 >60 9(n.a.) 2(n.a.)
Maeda 2014 108 60
*
n.a. n.a. 16(6–20)
Altomare 2015 272 84 7(4–11) 0.3(0–3) 16(13–18)
Mellgren 2011 120 36 9.4 1.7
*
FISI39.9
Hull 2013 76 60 9.1 1.7 FISI37.95
*
Valuesatspecifictime.
†
Meanvalue,standarddeviation. FISI,fecalincontinenceseverityindex;n.a.,datanotavailable;n.c.,notcalculable. ModifiedfromO’ConnellandKnowles,2017.
Patientselectionforpermanentstimulationisuniform,directedbythe
outcomeofthetemporaryteststimulation,whichishighlypredictive.
TherangeofindicationsforSNSinfecalincontinencehassteadily evolved.Earlyapplicationwasconfinedtoadistinctgroupofpatients presentingwithweak,butmorphologicallyintact,analsphincteric,and pelvicfloormusculature.Basedonthehighlypredictivevalueofa positiveresulttotrialstimulation,whichcarriesminimalrisk,andthe increasingknowledgethattheeffectofSNSisnotlimitedtothemuscle, butinvolvesavarietyofphysiologicalfunctionscontributingto continence,theuseofPNEwasexpanded.Thisexpansionresultedina broaderapplicationofpermanentSNS,evenforpatientswithstructural defectsoftheinternalandexternalanalsphincters.Today,SNS representsanessentialpartofthesurgicalarmamentariumtotreatfecal incontinence.Italsocarriespotentialforpatientswithconcurrentfecal andurinaryincontinence.
p.134
p.135
Asystematiccomparisonwithothersurgicaltechniques—basedonthe existinglevelofevidence—hasledtothecurrentguidelinesofthe InternationalConsultationofIncontinence.Surgicaltreatmentoffecal incontinenceisadvisedifconservativemeansdonotresultinadequate symptomrelief.Iffecalincontinencesecondarytootherunderlying conditionsisexcluded(suchashigh-gradeinternalrectalprolapse),the choiceoftreatmentisdirectedbythefindingsofendoanalultrasound.In thetreatmentalgorithm,SNSiscentral:itisrecommendedinpatients presentingwithoutasphinctericlesionandasatherapeuticalternativeto surgicalrepairinthosewithasphinctericgapofupto180degrees. Althoughtheresultsofthelatterindicationaremorerecent,therecent findingsareconsistent.

CONCLUSIONS

SNShasevolvedtobecomeanestablishedtreatmentforfecal incontinence.
Thetherapyisminimallyinvasiveandrelativelylowrisk. Patientselectionisbasedonatherapeutictrialphase,which—ifclinically
efficient—ishighlypredictiveoftheoutcomeofapermanentstimulation. TheresultsofSNSarereproducible,andanincreasingbodyofevidence
indicatessustainability. Thetherapyisreversible.
Thetherapyrequiresmaintenance.
RECOMMENDEDREFERENCESAND READINGS
AltomareDF,GiuratrabocchettaS,KnowlesCH,MuñozDuyosA,Robert-YapJ,MatzelKE;
EuropeanSNSOutcomeStudyGroup.Long-termoutcomesofsacralnervestimulationfor
faecalincontinence.BrJSurg2015;102:407–15. HullT,GieseC,WexnerSD,etal;SNSStudyGroup.Long-termdurabilityofsacralnerve
stimulationtherapyforchronicfecalincontinence.DisColonRectum2013;56(2):234–45. JorgeJM,WexnerSD.Etiologyandmanagementoffecalincontinence.DisColonRectum
1993;36(1):77–97. MaedaY,LundbyL,BuntzenS,LaurbergS.Suboptimaloutcomefollowingsacralnerve
stimulationforfaecalincontinence.BrJSurg2011;98:140–7. MaedaY,MatzelK,LundbyL,BuntzenS,LaurbergS.Postoperativeissuesofsacralnerve
stimulationforfaecalincontinenceandconstipation:asystematicliteraturereviewand
treatmentguideline.DisColonRectum2011;54:1443–60. MatzelKE,KammMA,StösserM,etal.Sacralnervestimulationforfaecalincontinence:a
multicenterstudy.Lancet2004;363:1270–6. MatzelKE,StadelmaierU,HohenfellnerM,GallFP.Electricalstimulationofsacralspinalnerves
fortreatmentoffaecalincontinence.Lancet1995;346:1124–7. MelenhorstJ,KochSM,UludagO,vanGemertWG,BaetenCG.Sacralneuromodulationin
patientswithfaecalincontinence:resultsofthefirst100permanentimplantations.Colorectal
Dis2007;9:725–30. MellgrenA,WexnerSD,CollerJA,etal;SNSStudyGroup.Long-termefficacyandsafetyofsacral
nervestimulationforfecalincontinence.DisColonRectum2011;54(9):1065–75. O’ConnellR,KnowlesC.Surgeryforfecalincontinence.In:AbramsP,CardozoL,WaggA,Wein
A,eds.Incontinence.6thed.Bristol,UK:InternationalContinenceSociety,2017:2087–142. TanJJ,ChanM,TjandraJJ.Evolvingtherapyforfaecalincontinence.DisColonRectum
2007;50:1950–6. WexnerSD,CollerJA,DevroedeG,etal.Sacralnervestimulationforfaecalincontinence:results
ofa120-patientprospectivemulticenterstudy.AnnSurg2010;251:441–9.
PARTV
PERINEALPROLAPSEREPAIR
Chapter18
DelormeProcedure
DeborahS.Keller,HemanM.Joshi,andC.
RichardCohen

INTRODUCTION

Rectalprolapseisadebilitatingconditionthataffectsthepatient’spelvic flooranatomy,function,andqualityoflife.Rectalprolapseisfrequently associatedwithprogressivefecalincontinence,constipation,andother pelvicfloordisorders,suchasmulticompartmentprolapseandurinary incontinence.Symptomsofrectalprolapseincludethephysicalfeelingof abulge,mucusdrainage,tenesmus,rectalpainandpressure,andrectal bleeding.Surgeryistheonlycurativetreatmentforrectalprolapse,anda varietyofproceduresareavailable.
TheDelormeprocedureisamucosalsleeveresectionperformedviaa perinealapproachforfull-thicknessexternalrectalprolapse.After reproducingtheprolapse,themucosaisstrippedfromtheprolapsed segmentandresected,themusclelayersareplicated,theprolapse inverted,andthemucosaisreapproximated.
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности