Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1408_Библиотеки_им_академика_М_И_Перельмана
.pdf
FIG. 20.3 Key hole anal deformity after fistulotomy.
FIG. 20.4 Defecographic radiogram showing a full-thickness rectoanal intussusception with a sigmoidocele.
254 ANORECTAL DISORDERS
Several surgical options have been suggested to treat this syndrome with different
approaches (perineal, transanal, transvaginal, abdominal, etc.). Despite these operations’
aim to cure obstructed defecation, they might themselves become the cause of the onset
of other anorectal disturbances, including urge defecation, anal incontinence, and anorectal pain. In particular, the stapled transanal rectal resection (STARR), which consists of a
transanal resection of the rectum using two circular staplers or one of the new highvolume circular staplers, has determined a relevant number of patients with significant
and complex pelvic-floor functional disturbances including urge incontinence, pain,
and fragm ented defecation.
10
Some of these problems seem to be related to a decreased
rectal compliance caused by the partial resection of the rectal ampulla; damage to the anal
sphincter is also possible.
20.2.5 Surgery for External Rectal Prolapse
External rectal prolapse is often associated with patulous anus resulting in fecal incontinence, soiling, and hemorrhage (Fig. 20.5). Sometimes these patients can also complain of
obstructed defecation. Surgery for external rectal prolapse has long been and continues to
be debated, there is no full agreement between coloproctologists as to whether an abdominal approach (rectopexy) is better than a perineal approach.
11
The options for a perineal
approach include the Delorme operation
12
(rectal mucosectomy and muscle pli cation)
and the Altemeier operation (rectosigmoid resection and coloanal anastomosis plus levatorplasty).
13
In both operations persistence of fecal incontinence is a common complaint,
irrespectively of prolapse recurrence.
20.2.6 Surgery for Imperforate Anus
Most of the patients operated for imperforate anus at childbirth suffer from fecal incontinence and wet anus, sometimes with rectal prolapse. The absence of an adequate anal
sphincter and of the sensitive anoderm with mucosal ectropion (
Fig. 20.6) explains this
poor anal function.
FIG. 20.5 Full-thickness rectal prolapse during pushing.
Chapter 20 • Postsurgical Anorectal Disorders 255
20.2.7 Surgery for Rectal Cancer
Removal of the rectum followed by a colorectal or coloanal anastomosis implies several
important changes in the physiology of defecation, since these patients have lost their
physiologic reservoir, have low neorectal compliance, and simultaneous difficulty in defecation. It happens because of the different anatomy and physiology of the colon where
the muscle layers are arranged longitudinally and circularly to promote peristalsis, compared to the rectum where their contraction allows its emptying.
Furthermore, the anal sphincter function may be damaged by pelvic surgery and/or
neoadjuvant radiotherapy resulting in low anal pressures. These abnormalities can cause
low anterior resection syndrome (LARS),
14
which occurs in about 80% of these patients
and is characterized by fecal incontinence, fragmented defecation, and tenesmus. The
severity of this syndrome is usually scored by the LARS score
15
and the most important
etiologic factors are the low level of the anastomosis and the neoadjuvant radiotherapy.
20.3 Diagnosis of Anorectal Dysfunctions
20.3.1 Anorectal Manovolumetry
Anorectal manometry plays an important role in investigating anorectal coordination and
sensorimotor function. A recent review from the International Anorectal Physiology Working Group has also provided an appraisal of the current indi cations, clinical utility,
strengths, and limitations of the most widely available tests of anorectal function.
16
FIG. 20.6 Anal mucosal ectropion: note the absence of the transitional epithelium of the anal canal and the low
resting anal tone.
256 ANORECTAL DISORDERS
The exam is performed with the patient in the Sims position with an empty rectal ampulla.
The anal sphincter function should focus on the resting and squeezing pressure, ability to
relax, and endurance of the contraction. The rectoanal sensorimotor function is investigated by the rectoanal inhibitory reflex (absent in the Hirschsprung’s disease, but often
missing after low anterior resection of the rectum and occasionally after STARR operation), the rectal volume threshold, the volume to induce defecation, and the maximum
tolerable volume. The rat e between the volume required to induce defecation and the
pressure developed into the rectum defines the rectal compliance. In some operations
(STARR, stapled hemorrhoidopexy, low anterior resection of the rectum) these parameters
are significantly altered explaining the fecal urgency oft en complained of by these
patients. Low resting anal pressures are commonly registered in patients complaining
of fecal incontinence after fistulotomy, Milligan-Morgan operations, or lateral internal
sphincterotomy for fissure.
17
There is no international consensus on standard ranges
for all these parameters, since they depend on the age and gender of the patients and
the different equipment used (water perfused or microsensor probes). Therefore the
adoption of internal standards is recommended in each colorectal unit.
Anorectal manovolumetry has a potential role also in evaluating patients with
obstructed defecation resulting from other types of anorectal surgery. A high sphincter
tone and nonrelaxing puborectalis sphincter (pelvic floor dyssinergia) may be responsible
for cases of functional obstructed defecation.
18
An abnormally high rectal compliance,
often associated with an increased sensory threshold of the rectal distension could suggest
impaired parasympathetic innervation of the anorectum.
20.3.2 Transanal Ultrasound
Transanal ultrasound examination of the anal canal and low rectum, especially if performed with the 3D resolution devices, has gained wide acceptance among proctologists
thanks to its accuracy in evaluating anal fistulas, sphincter defects, and early cancer.
Its use in patients with fecal incontinence after anorectal surgery could reveal a discontinuity of internal or external (or both) anal sphincter and describe the extension of the
lesion. On the other hand, patients complaining of postoperative anal incontinence,
but with integrity of the sphincters, might have endured a nerve injury during the surgical
maneuvers.
Sometimes anal pain can also be explained by transana l ultrasound when infected foci
or internal abscesses are detected. In patients who underwent STARR or stapled hemorrhoidectomy, the retained staples can be easily detected by ultrasound (
Fig. 20.7).
20.3.3 Dynamic Defecography
X-ray and magnetic resonance (MR) colpodefecography represent the most accurate
radiological investigations for the identification of the morpho-functional rectum disorders responsible for obstructed defecation. They also can detect associated pelvic-floor
dysfunction involving other pelvic organs (cystocele, enterocele, genital prolapse
19
).
Chapter 20 • Postsurgical Anorectal Disorders 257
While MR colpodefecography has the clear advantage in being free of X-ray exposure and
giving an overall visualization of the pelvic organs, the traditional X-ray defecography has
been demonstrated to be more cost/effective and is therefore the most widely adopted
technique.
20
The most frequent findings in patients with obstructed defecation is rectal intussusception, often associated with nonemptying rectocele. Rectocele alone is another common cause of defecatory disturbances. Other common findings are perineal descend,
mucosal prolapse, and enterocele. All these findings should be checked postoperatively
to confirm the success of the surgical correction by a postoperative defecography, which
is mandatory in cases of operation failure. Another frequent condition in patients with
obstructed defecation syndrome (ODS) is the failure of rectal emptying due to nonrelaxing
puborectalis muscle during defecation. This is clearly demonstrated by the changes in the
anorectal angle, which remains acute or even more sharp during the attempts to defecate.
20.3.4 Electrophysiological Anal Tests
Electrophysiological anal tests include electromyography (EMG), pudendal nerve terminal motor latency (PNTML), and brain evoked potentials latency reflex. These tests provide a neurophysiological assessment of the anorectum and pelvic floor. In the early
1980s–1990s the great interest in these tests faded since they do not contribute to the
choice of a surgical treatment and have poor predictability on the response to surgery
for functional diseases.
21
However, they still deserve attention for clinical research
purposes.
22
FIG. 20.7 3D transanal ultrasound showing multiple hyperechoic spots due to retained staples after stapled
hemorrhoidopexy.
258 ANORECTAL DISORDERS
The electromyographic study of the sphincter allows the evaluation of the muscle’s
electrical activity, which can be impaired in patients with fecal inco ntinence in the case
of denervation. Electrical silence usually corresponds to scar tissue after muscle damage
during childbirth or after anal fistulas
23
surgery.
With the introduction of 3D ultrasound, which provides clear images of both sphincters, the interest in this test decreased in clinical practice.
Pudendal nerve motor latency and evoked potentials latency reflexes provide interesting
information about the integrity of the neural pathways involved in the pelvic floor of
patients affected by fecal incontinence, but their application is limited to the research field.
20.4 Treatments
20.4.1 Anal Incontinence and Soiling After Hemorrhoidectomy and After
Lateral Internal Sphincterotomy for Anal Fissure
These are usually less severe. The treatment of this passive form of anal incontinence
includes biofeedback training and physio kinesitherapy as the first approach. The modality of this rehabilitative therapy is poorly standardized and, despite several studies reporting excellent results, the scientific evidence of its efficacy is still modest.
24,25
In cases of
failure of conservative treatments, the injection of submucosal bulking agents
26–28
or (bet-
ter) of expandable prosthesis
29,30
(Gatekeeper/Sphinkeeper) is a rational approach since
this aims to restore the resting anal tone without influencing the squeezing pressure of the
external anal sphincter.
20.4.2 Anal Incontinence and Soiling After Fistulotomy or Cutting Seton
In most of these patients part of the external anal sphincter is damaged or interrupted but
the muscle innervation is preserved resulting mainly in an urge fecal incontin ence. Possible treatment options include overlapping sphincteroplasty
31
and/or sacral nerve stim-
ulation.
32
Sphincteroplasty is the most obvious choice despite its being blamed for having
poor long-term outcome. Although the rationale behind the use of SNS in the presence of
muscle defect seems to be poor and its long-term efficacy is uncertain, the usefulness of
this approach has recently been reported,
32
supporting the idea that the main effect of
SNS is centrally mediated.
33
Actually, long-term worsening of symptoms is a common
finding in all procedures concerning fecal incontinence, including sacral nerve stimulation.
34
The role of physiotherapy and biofeedback in supporting surgery in these cases
is also advocated by some authors.
35
20.4.3 Urge Incontinence After Stapled Hemorrhoidopexy or STARR
Operation
Fecal urgency associated with incontinence after stapled hemorrhoidopexy or STARR
operation is one of the most difficult types of functional disturbance to treat, since in these
Chapter 20 • Postsurgical Anorectal Disorders 259
patients the anal sphincters are working normally but the rectal compliance is often
strongly reduced. Prolonged biofe edback training combined with dietary suggestions
could help some of these patients. SNS also has been proposed for this type of incontinence with a positive response being reported in about one-third of the patients.
36
Recently other less invasive peripheral nerve stimulation, like posterior tibial nerve
electrostimulation (PTNS), has been tested with encouraging results.
37,38
20.4.4 Persistent Pain After Stapled Hemorrhoidopexy or STARR
Some patientsundergoing stapled hemorrhoidopexyor STARR operation complain of a persistent perineal/anal pain refractive to any pharmacological treatment. In some cases, the
wrong placement of the staplers (too close to the dentate line) can be blamed for this symptomatology and the consequent removal of the staplers can alleviate this symptom, in other
cases the reasonfor the pain is not detected by any instrumental investigation.In a few cases
an altered PNTML can be identified but its clinical significance is ignored. Some of these
patients have improved after SNS
39
while the role of biofeedback training is uncertain.
40
20.4.5 Obstructed Defecation for Anal Stricture After
Hemorrhoidectomy
The treatment of anal stricture may require the periodic use of Hegar anal dilators in order
to dilatate the scar allowing an easier passage of the stools. Whenever possible these
patients should be submitted to anoplasty ( V-Yor house advancement flap). Furthermore,
they should also be encouraged to have a high fiber diet and/or take osmotic laxatives in
order to have soft stools thus preventing the formation of fecalomas.
20.4.6 Obstructed Defecation After Stapled Hemorrhoidopexy or STARR
Operation for Rectocele/Intussusception
Persistence or the de novo occurrence of ODS symptoms is not rare after these operations,
particularly after STARR.
41,42
In cases of persistence morpho-functional abnormalities of
the defecation, alternative surgical approaches should be considered. Some patientsundergoingSTARRhave importantresidual rectocele or persistenceof rectorectal intussusception.
Inthe first case a perineal (transvaginal)approachto treat the rectocele is indicated,while the
persistence of rectorectal intussusception needs a rectopexy by abdominal approach.
20.4.7 Treatment of Low Anterior Resection Syndrome
This condition affects the quality of life of patients undergoing rectal resection for cancer
so severely that some of them prefer to return to a life with a stoma.
43,44
A recent review
on this topic
45
reports ei ght studies in which these patients were treated by sacral nerve
stimulation, six by pelvic floor rehabilitation, three by simple transanal irrigation, and two
by percutaneous tibial nerve stimulation. All these studies report modest and inconstant
symptom improvements, but no treatment seems to be really effective.
260 ANORECTAL DISORDERS
References
1. ETC M, Morgan CN, Jones LE, Officer R. Surgical anatomy of the anal canal and operative treatment of
Haemorrhoids. Lancet. 1937;11:1119–1124.
2. Ferguson JA, Heaton JR. Closed hemorrhoidectomy. Dis Colon Rectum. 1959;2(2):176–179.
3. Altomare DF, Rinaldi M, Chiumarulo C, Palasciano N. Treatment of external anorectal mucosal pro-
lapse with circular stapler: an easy and effective new surgical technique. Dis Colon Rectum. 1999;42
(8):1102–1105.
4. Altomare DF, Rinaldi M, Sallustio PL, Martino P, De Fazio M, Memeo V. Long-term effects of stapled
haemorrhoidectomy on internal anal function and sensitivity. Br J Surg. 2001;88(11):1487–1491.
5. Boccasanta P, Venturi M, Roviaro G. Stapled transanal rectal resection versus stapled anopexy in the
cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial. Int J Colorectal Dis.
2007;22(3):245–251.
6. Correa-Rovelo JM, Tellez O, Obrego´n L, et al. Prospective study of factors affecting postoperative pain
and symptom persistence after stapled rectal mucosectomy for hemorrhoids: a need for preservation
of squamous epithelium. Dis Colon Rectum. 2003;46(7):955–962.
7. Pescatori M, Spyrou M, Cobellis L, Bottini C, Tessera G. The rectal pocket syndrome after stapled
mucosectomy. Colorectal Dis. 2006;8:808–811.
8. Altomare DF, Binda GA, Canuti S, Landolfi V, Trompetto M, Villani RD. The management of patients
with primary chronic anal fissure: a position paper. Tech Coloproctol. 2011;15(2):135–141.
9. Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg.
1989;76(5):431–434.
10. Dodi G, Pietroletti R, Milito G, Binda G, Pescatori M. Bleeding, incontinence, pain and constipation
after STARR transanal double stapling rectotomy for obstructed defecation. Tech Coloproctol.
2003;7(3):148–153.
11. Senapati A, Gray RG, Middleton LJ, et al. PROSPER: a randomised comparison of surgical treatments
for rectal prolapse. Colorectal Dis. 2013;15(7):858–868.
12. Binda GA, Serventi A. Perineal approach to external rectal prolapse: the Delorme procedure. In: -
Altomare DF, Pucciani F, eds. Rectal Prolapse. Diagnosis and Clinical Management. Berlin: SpringerVerlag; 2008:89–95.
13. Altomare DF, Binda G, Ganio E, De Nardi P, Giamundo P, Pescatori M; Rectal Prolapse Study Group.
Long-term outcome of Altemeier’s procedure for rectal prolapse. Dis Colon Rectum 2009; 52(4):698–
703.
14.
Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL. Anterior resection syndrome. Lancet Oncol.
2012;13(9):e403–e408.
15. Emmertsen KJ,
Laurberg S. Low anterior resection syndrome score: development and validation of a
symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.
Ann Surg. 2012;255(5):922–928.
16. Carrington EV, Scott SM, Bharucha A, et al. Expert consensus document: advances in the evaluation of
anorectal function. Nat Rev Gastroenterol Hepatol. 2018;15(5):309–323.
https://doi.org/10.1038/
nrgastro.2018.27
Epub 2018 Apr 11. [Review].
17.
Cerdan FJ, Ruiz de Leon A, Azpiroz F, et al. Anal sphincter pressure in fissure-in-ano before and after
lateral internal sphincterotomy. Dis Colon Rectum. 1982;25:198–201.
18. Leroi AM, Berkelmans I, Denis P, et al. Anismus as a marker of sexual abuse. Consequences of abuse on
anorectal manometry motility. Dig Dis Sci. 1995;40:1411–1416.
19. Bove A, Pucciani F, Bellini M, et al. Consensus statement AIGO/SICCR: diagnosis and treatment of
chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 2012;18
(14):1555–1564.
Chapter 20 • Postsurgical Anorectal Disorders 261
20. Martı´n-Martı´n GP, Garcı´a-Armengol J, Roig-Vila JV, et al. Magnetic resonance defecography versus
videodefecography in the study of obstructed defecation syndrome: is videodefecography still the test
of choice after 50 years? Tech Coloproctol. 2017;21(10):795–802.
21. Gilliland R, Altomare DF, Moreira Jr H, Oliveira L, Gilliland JE, Wexner SD. Pudendal neuropathy is
predictive of failure following anterior overlapping sphincteroplasty. Dis Colon Rectum. 1998;41
(12):1516–1522.
22. Giani I, Novelli E, Martina S, et al. The effect of sacral nerve modulation on cerebral evoked potential
latency in fecal incontinence and constipation. Ann Surg. 2011;254(1):90–96.
23. M Z, Salcedo L, Hammel J, Hull T. Anal physiology testing in fecal incontinence: is it of any value? Int J
Colorectal Dis. 2010;25(2):277–282.
24. SS1 R, Benninga MA, Bharucha AE, Chiarioni G, Di Lorenzo C, Whitehead WE. ANMS-ESNM position
paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol
Motil. 2015;27(5):594–609.
25. JR1 G-M, Buenrostro-Acebes JM, Erciga-Vergara N, et al. Biofeedback effectiveness in patients with
fecal incontinence. Rev Med Inst Mex Seguro Soc. 2015;53(4):472–475.
26. Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence
in adults. Cochrane Database Syst Rev. 2013;2CD007959.
https://doi.org/10.10021/4651858.CD007959.
pub 3.
27.
Altomare DF, La Torre F, Rinaldi M, Binda GA, Pescatori M. Carbon-coated microbeads anal injection
in outpatient treatment of minor fecal incontinence. Dis Colon Rectum. 2008;51(4):432–435.
28. Dodi G, Jongen J, de la Portilla F, Raval M, Altomare DF, Lehur PA. An Open-Label, noncomparative,
Multicenter Study to evaluate efficacy and Safety of NASHA/Dx gel as a bulking agent for the treatment
of fecal incontinence. Gastroenterol Res Pract. 2010;2010467136.
29. Ratto C, Buntzen S, Aigner F, et al. Multicentre observational study of the Gatekeeper for faecal incon-
tinence. Br J Surg. 2016;103(3):290–299.
30. Ratto C, Donisi L, Litta F, Campennı`P, Parello A. Implantation of SphinKeeper(TM): a new artificial
anal sphincter. Tech Coloproctol. 2016;20(1):59–66.
31. Altomare DF, De Fazio M, Giuliani RT, Catalano G, Cuccia F. Sphincteroplasty for fecal incontinence in
the era of sacral nerve modulation. World J Gastroenterol. 2010;16(42):5267–5271.
32. Rodrigues FG, Chadi SA, Cracco AJ, et al. Faecal incontinence in patients with a sphincter defect: com-
parison of sphincteroplasty and sacral nerve stimulation. Colorectal Dis. 2017;19(5):456–461.
33. Altomare DF
, Giannini I, Giuratrabocchetta S, Digennaro R. The effects of sacral nerve stimulation on
continence are temporarily maintained after turning the stimulator off. Colorectal Dis. 2013;15(12):
e741–e748.
34. Altomare DF, Giuratrabocchetta S, Knowles CH, et al. Long-term outcomes of sacral nerve stimulation
for faecal incontinence. Br J Surg. 2015;102(4):407–415.
35. Ghahramani L, Mohammadipour M, Roshanravan R, et al. Efficacy of biofeedback therapy before and
after sphincteroplasty for fecal incontinence because of obstetric injury: a randomized controlled trial.
Iran J Med Sci. 2016;41(2):126–131.
36. Boenicke L, Kim M, Reibetanz J, Germer CT, Isbert C. Stapled transanal rectal resection and sacral
nerve stimulation—impact on faecal incontinence and quality of life. Colorectal Dis. 2012;14
(4):480–489.
37. van der Wilt AA, Giuliani G, Kubis C, et al. Randomized clinical trial of percutaneous tibial nerve stim-
ulation versus sham electrical stimulation in patients with faecal incontinence. Br J Surg. 2017;104
(9):1167–1176.
38. Altomare DF, Picciariello A, Ferrara C, Digennaro R, Ribas Y, De Fazio M. Short-term outcome of per-
cutaneous tibial nerve stimulation for low anterior resection syndrome: results of a pilot study. Colo-
rectal Dis. 2017;19(9):851–856.
262 ANORECTAL DISORDERS
39. Falletto E, Masin A, Lolli P, et al. Is sacral nerve stimulation an effective treatment for chronic idio-
pathic anal pain? Dis Colon Rectum. 2009;52(3):456–462.
40. Gilliland R, Heymen JS, Altomare DF, Vickers D, Wexner SD. Biofeedback for intractable rectal pain:
outcome and predictors of success. Dis Colon Rectum. 1997;40(2):190–196.
41. Piloni V, Possanzini M, Bergamasco M, Santi G. Postoperative MR defecography following failed
STARR procedure for obstructive defecation syndrome: a three-centre experience. Gastroenterol Res
Pract. 2017;20174392918.
42. Panicucci S, Martellucc J, Mencon C, Toniolo G, Naldini G. Correlation between outcome and instru-
mental findings after stapled transanal rectal resection for obstructed defecation syndrome. Surg
Innov. 2014;21(5):469–475.
43. Trenti L, Galvez A, Biondo S, et al. Quality of life and anterior resection syndrome after surgery for mid
to low rectal cancer: a cross-sectional study. Eur J Surg Oncol. 2018;44(7):1031–1039 pii: S0748-7983
(18)30994-6.
44. Digennaro R, Tondo M, Cuccia F, et al. Coloanal anastomosis or abdominoperineal resection for very
low rectal cancer: what will benefit, the surgeon’s pride or the patient’s quality of life? Int J Colorectal
Dis. 2013;28(7):949–957.
45. Dulskas A, Smolskas E, Kildusiene I, Samalavicius NE. Treatment possibilities for low anterior resec-
tion syndrome: a review of the literature. Int J Colorectal Dis. 2018;33(3):251–260.
Chapter 20 • Postsurgical Anorectal Disorders 263
Соседние файлы в папке Библиотека им академика М.И. Перельмана