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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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Bladder dyssynergia: lack of sphincter relaxation on bladder contraction retention, incomplete emptying, reflux.
GERD: autonomic dysfunction
colonic and gastric overdistention incompetence of gastroesophageal sphincter.
Evaluation
REQUIRED MINIMAL STANDARD
History: exact time and level of injury, residual sensory or motor function? Specific current complaints (abdominal,
anorectal)? Change in baseline bowel function and management?
Clinical examination:
Abdominal exam: distention, fecal impaction, mass?
Anorectal exam: perineal descent, prolapse, ulcerations, tone?
Anoscopy/rigid sigmoidoscopy: polyps, mass, hemorrhoids, proctitis?
Except in emergency: full/partial colonic evaluation as per general screening guidelines and prior to any planned intervention.
ADDITIONAL TESTS (OPTIONAL)
Depending on likely diagnoses.
Urinalysis: rule out urinary tract infection or hematuria.
Decubitus: imaging to rule out osteomyelitis.
Classification
Grading of spinal cord injury according American Spinal Injury Association (ASIA) scale:
A. Complete: no sensory or motor function in sacral segments S4–S5.
B. Incomplete: sensory, but not motor, function below the neurologic level and extends to sacral segments S4–S5.
C. Incomplete: preserved motor function below neurologic level, strength of most key muscles below the neurologic
level < grade 3.
D. Incomplete: preserved motor function below neurologic level, strength of most key muscles below the neurologic
level
grade 3.
E. Normal: normal sensory and motor functions.
Bowel function in relation to level of SCI:
Lower motor neuron (LMN) colon (SCI below T12).
Upper motor neuron (UMN) colon (SCI above conus medullaris).
Nonoperative Treatment
Bowel management:
Bowel emptying programs: evacuation of rectum on fixed schedule (eg, daily or every other day) to minimize fecal
impaction and avoid reflex relaxation of internal sphincter with incontinence. Triggering of defecation reflex: digital
stimulation, manual evacuation, rectal stimulant suppository, enemas.
Between scheduled emptyings: stool softeners (eg, docusate sodium), colonic stimulants (eg, bisacodyl),
supplemental dietary fiber to induce better defecatory response.
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Bladder management: intermittent catheterization, indwelling Foley catheter, external condom catheter for males.
Local problems
primary conservative approach:
Hemorrhoids: dietary changes, mild laxatives.
Decubitus: primarily conservative management with optimized wound care, sitting aids.
Operative Treatment
INDICATION
Specific local symptoms/problems:
Extensive external hemorrhoids (interfering with hygiene).
Treatment-refractory hemorrhoids with bleeding/prolapse.
Rectal prolapse.
Abscess/fistula.
Anorectal stricture.
Acute treatment-refractory, complicated, or recurrent diverticulitis.
Treatment-refractory functional outlet obstruction.
OPERATIVE APPROACH
Office interventions for internal/external hemorrhoids, abscess, superficial fistula (premedicate with topical lidocaine
gel).
Appropriate local procedures: excisional vs stapled hemorrhoidectomy, drainage of abscess, fistulotomy vs seton
placement, stricturoplasty (with/without flap), perineal prolapse repair.
Abdominal procedures: segmental colectomy, rectopexy, creation of diverting colostomy.
Outcome
Leading causes of death after SCI: renal failure in the past; nowadays pneumonia, pulmonary embolism, septicemia.
Colorectal issues: matter of quality of life.
Follow-Up
Dependent on primary presenting symptom.
Cross-Reference
Hemorrhoids (455.X) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
Trauma (863.X) (Ch. 4)
Functional disorders—chronic constipation (564.0X) (Ch. 4)
Hemorrhoid office procedures (banding, sclerosing, infrared coagulation) (Ch. 5)
PELVIC FLOOR DYSFUNCTION (618.X)
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Overview
Pelvic floor dysfunction is a complex combination of problems related to the relaxation of the pelvic floor and suspension
structures for the pelvic organs. Associated with parity, increasing age, and obesity, pelvic floor dysfunction causes
significant morbidity and has a negative impact on the quality of life in aging women: dysfunction of urinary and/or fecal
control or evacuation, pelvic pain syndromes, pelvic organ prolapse syndrome (cystocele, rectocele, enterocele, vaginal
prolapse).
Epidemiology
Among women > 55 years of age, 50% have some symptoms of pelvic relaxation; ~75% by age of 75. Bladder-related
complaints increase threefold between ages 45 and 75 years. Pelvic organ prolapse: > 10% of women seek operative repair
by age 80.
Symptoms
Various combinations of urinary and/or fecal incontinence, urinary obstruction, obstructed defecation, perineal descent, and
pelvic organ prolapse, which is either visible or sensed as pelvic/perineal pressure or vaginal bulging of cystocele, rectocele,
enterocele, or uterine/vaginal prolapse, rectal prolapse, solitary rectal ulcer syndrome, sexual dysfunction.
Differential Diagnosis
Other causes of urinary and anorectal dysfunction.
Other causes of pelvic pain.
Pathology
Absence of primary pathology. Secondary pathology from prolapse, eg, solitary rectal ulcer syndrome.
Evaluation
REQUIRED MINIMAL STANDARD
History: careful evaluation of symptoms, questionnaires on primary and secondary problems.
Clinical examination: general appearance, habitus/nutritional status; anorectal exam—perineal descent, flattening of anal
"verge," visible rectal or vaginal prolapse (at rest, upon straining); rigid sigmoidoscopy, colposcopy.
Colonic evaluation as per guidelines.
Anophysiology testing, including balloon expulsion test.
Imaging:
– Dynamic MRI (Figure 4–22).
– Defecating proctogram (see Figure 2–6).
Figure 4–22.
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Pelvic floor dysfunction on dynamic MRI.
Urodynamics and GYN evaluation.
ADDITIONAL TESTS (OPTIONAL)
Sitzmark study?
CT abdomen/pelvis?
Classification
Anterior pelvic compartment: bladder, urethra.
Middle pelvic compartment: vagina, uterus.
Posterior pelvic compartment: rectum, anus.
Nonoperative Treatment
Lifestyle alteration, dietary modification, supplemental fibers.
Behavioral therapy, physical therapy, biofeedback training.
Pessary placement.
Electrogalvanic stimulation.
Pharmacologic treatment: eg, detrusor or levator hyperactivity, muscle-relaxing drugs, hormone-replacement therapy?
Operative Treatment
INDICATIONS
Isolated or combined pelvic organ prolapse, not responding to conservative management.
OPERATIVE APPROACH
Pelvic organ resuspension: rectopexy, sacrocolpopexy, and cystopexy (multidisciplinary approach).
Resection: sigmoid resection with/without rectopexy, hysterectomy.
Transanal/-perineal/-vaginal rectocele repair.
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Sacral nerve stimulation.
Outcome
Persistent/recurrent symptoms (20–30%), discrepancy between imaging results and functional performance.
Follow-Up
Functional reevaluation at regular intervals. Even after surgical approach role for physical therapy and biofeedback training
to further strengthen and recoordinate muscle function.
Cross-Reference
Anophysiology studies (Ch. 2)
Defecating proctogram (defecography) (Ch. 2)
Magnetic resonance imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Functional disorders—chronic constipation (1564.0X) (Ch. 4)
Functional disorders—irritable bowel syndrome (IBS, 564.1) (Ch. 4)
Rectocele repair (Ch. 5)
Rectal prolapse—perineal Delorme repair (Ch. 5)
Physical therapy/biofeedback training (Ch. 6)
RECTAL PROLAPSE (569.1)
Overview
Protrusion of the rectum below the anal verge: full-thickness prolapse (Figure 4–23) or mucosal prolapse. Associated with a
primary or secondary lack of pelvic suspension structures. Characteristic low peritoneal reflection, underdeveloped
mesorectum, and lack of lateral attachments. May occur alone or in conjunction with pelvic floor dysfunction and prolapse of
other pelvic organs. Etiology essentially unclear, reports on role of parity are controversial. Predisposing factors: age, chronic
constipation, malnutrition, consuming diseases (eg, cancer, tuberculosis), neuroleptic medications, neurologic diseases
(spinal cord, multiple sclerosis); in children: malnutrition, cystic fibrosis, diarrhea. Rectal tumor may be a "lead point" and
needs to be ruled out (rigid sigmoidoscopy). Chronic/recurrent prolapse may result in secondary pathologies: sphincter
distention with reduced contractility and fecal incontinence (partially reversible); solitary rectal ulcer syndrome;
myoinflammatory polyps.
Figure 4–23.
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Rectal prolapse.
Epidemiology
Most common in elderly females (impact of nulliparity vs multiparity controversial) or males < 50 years of age.
Symptoms
Occult/internal prolapse (rectal intussusception): pelvic pressure, fullness, constipation, pencil-like stools, mucous discharge.
External prolapse: bleeding, moisture, discomfort/pain, itching, fecal incontinence.
Nonreducible prolapse: pain, spasm; fever = alarming late sign.
Differential Diagnosis
Hemorrhoidal prolapse: radial pattern.
Protrusion of polyp, mass, hypertrophic anal papillae, condylomata.
Urogynecologic prolapse, rectocele.
Pathology
Chronic/recurring prolapse: solitary rectal ulcer syndrome with myofibrosis of lamina propria.
Acute prolapse: elements of acute inflammation (neutrophils), ischemia.
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Evaluation
REQUIRED MINIMAL STANDARD
History: extent of prolapse (length)? Site of prolapse (rectum, vagina)? Constipation/diarrhea? Change in bowel habits?
Incontinence (fecal/urinary)? Previous surgeries (eg, prolapse, hysterectomy, etc)? Previous colonic evaluations (flex
sigmoidoscopy, colonoscopy, barium enema)? Comorbidities (coronary artery disease, COPD, diabetes, liver/kidney disease,
weight loss, etc).
Clinical examination:
Elective: best to let patient take sitting position on toilet and trigger the prolapse by Valsalva maneuver: concentric
pattern vs radial pattern?
Acute setting: viability of prolapsed tissue? Local tenderness? Rectal mass? Fever? Fluid status/dehydration?
Rigid sigmoidoscopy: lead point?
Colonic evaluation prior to elective surgery.
ADDITIONAL TESTS (OPTIONAL)
Defecating proctogram (if unable to provoke prolapse during clinical exam).
Dynamic MRI.
Urogynecologic evaluation.
Classification
Occult/internal prolapse (intussusception) vs external prolapse.
Full-thickness prolapse vs mucosal prolapse.
Circumferential vs asymmetric prolapse.
Reversible prolapse vs irreducible/incarcerated prolapse.
Nonoperative Treatment
Elective situation, minimal prolapse, or inoperable patient: banding, stool regulation, injection of sclerosing agent.
Reduction of incarcerated prolapse with circumferential and axial pressure: perianal/pudendal nerve block (local anesthesia)
for sphincter relaxation and/or application of granular table sugar to reduce edema may facilitate maneuver.
Operative Treatment
INDICATION
Any rectal prolapse if patient operable, potential need to combine with urogynecologic procedure.
OPERATIVE APPROACH
Numerous procedures for rectal prolapse, but two major categories: abdominal approach vs perineal approach. Choice of
specific procedure dependent on patient fitness, history and type of previous prolapse operation, risk of recurrent prolapse,
patient preference for large vs small operation and willingness to accept recurrence, underlying constipation/diarrhea and/or
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fecal incontinence.
Abdominal Approach
Laparoscopic vs open sigmoid resection with complete posterior rectal mobilization, with/without rectopexy: lowest
recurrence rate, preferred approach for operable patients with significant constipation and patients in whom lifting the
rectum out of the pelvis would result in significant redundancy.
Laparoscopic vs open rectopexy after complete posterior rectal mobilization: preferred approach for operable patients
with element of incontinence
preservation of colonic length or for patients with previous Altemeier operation
(vascular supply). Variations: suture rectopexy, posterior implant rectopexy (Wells rectopexy, using
mesh/collagen/Ivalon sponge), anterior implant rectopexy (Ripstein rectopexy, using mesh/collagen sling: risk of
constipation due to kinking and narrowed passage).
Perineal Approach
Delorme procedure: complete mucosal stripping of prolapsed segment with muscular plication: possible benefit for
incontinence?
Altemeier procedure: perineal proctectomy, with/without levatorplasty: primary approach for emergency, better
perineal approach for every prolapse (compared with Delorme procedure); contraindicated after previous sigmoid
resection (blood supply!).
Thiersch repair: insertion mesh/wire/collagen cerclage to narrow anal canal and prevent exteriorization of
hypermobile rectum.
Outcome
Recurrence of rectal prolapse: 5–30% (depending on type of surgery).
Fecal incontinence: 60–70% improvement within 6 months, possibility of worsening control.
Constipation: worsening in up to 50% of patients with nonresective procedures.
Implant complication: overall low risk of implant erosion or migration, but synthetic implants can potentially cause major
problems that might require ostomy and complete removal of material.
Follow-Up
Functional reassessment (constipation, incontinence) after 3 and 6 months.
Cross-Reference
Defecating proctogram (defecography) (Ch. 2)
Magnetic resonance imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
Solitary rectal ulcer syndrome (SRUS, 569.41) (Ch. 4)
Functional disorders—irritable bowel syndrome (IBS, 564.1) (Ch. 4)
Rectal prolapse—perineal Delorme repair (Ch. 5)
FUNCTIONAL DISORDERS—CHRONIC CONSTIPATION (564.0X)
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Overview
Constipation is one of the most frequent patient complaints, but there is wide variability in how different patients or
physicians define constipation. Acute episode of constipation most frequently is associated with poor habits and medication
side effects (Table 4–9) with/without an additional problem site (anastomosis, anorectal pain, etc). Chronic constipation
belongs to a category of functional disorders: defined as conditions comprising a variable combination of chronic and
recurrent GI symptoms that lack a structural or biochemical abnormality:
GI transit and waste evacuation are either too slow (constipation), too fast (diarrhea), or in wrong direction (GERD).
Additional symptoms: pain/discomfort, urgency, gas production, nausea and vomiting.
Frequently associated with personality disorders.
Table 4–9. Constipating Medications.
Class Examples
Opioid analgesics Morphine agonists, codeine
Antidepressants (tri-/tetracyclic, monoamine oxidase inhibitors) Sertraline, bupropion tranylcypromine
Neuroleptics/antipsychotics Paroxetine
Parkinson medications Dopaminergic, anticholinergic
Anticonvulsants Phenytoin, clonazepam
5-HT
3
antagonists
Alosetron
Antacids Aluminum, calcium compounds
Antihypertensives Calcium channel blockers, clonidine
Anticholinergics Diphenoxylate, atropine, loperamide
Metal supplements Iron, bismuth
Nonsteroidal anti-inflammatory drugs (NSAIDs) Ibuprofen, diclofenac
Bile-acid binding resin Cholestyramine
Chemotherapy Vinca alkaloids
Long-term (ab-)use of stimulant laxatives All laxatives
Important to distinguish between short episode of constipation and chronic constipation:
defining criteria for chronic
constipation: Table 4–10. Overlapping pathophysiologic entities: slow-transit constipation (45–50%), pelvic floor
dysfunction/dyssynergia (50–60%), constipation-predominant IBS (50–60%). Ogilvie syndrome is a separate and
independent entity.
Table 4–10. Chronic Constipation Defining Criteria (Rome III Criteria, 2006).
Mandatory Symptoms Supportive Symptoms
Time factor: 2 of the following symptoms:
> 3 days per month in past 3
months
< 3 unassisted bowel movements per week Absence of loose stools (when not
taking laxatives)
Symptom onset
6 months before
diagnosis (when not taking a
Straining 25% of the time Insufficient criteria for irritable
bowel syndrome (IBS)
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laxative)
Sensation of incomplete evacuation
25% of the
time
< 2 bowel movements per week in
> 6 months (when not taking a
laxative)
Lumpy/hard/pellet-like stools
25% of the time
Sensation of anorectal obstruction or
blockage/prolonged time needed for defecation
25% of the time
Manual maneuvers 25% of the time
Physician's task is to delineate the symptom "constipation" as:
Result of a poor habits?
Caused by local morphologic problem (obstruction, etc)?
Caused by a systemic problem?
True functional problem of the intestines?
High likelihood of increasing frustration for patients (lack of improvement), physicians (lack of "easy" treatment, unfavorable
time/effort ratio for reimbursement, etc), insurers/employers (cost, absenteeism from work, indirect cost).
Epidemiology
Estimated US prevalence (including telephone survey): 12–20% (range 2–28%) or 63 million people; 40–50% of individuals
with > 5-year history of constipation; 2% of respondents use laxative at least every other day. Gender: female/male ratio =
1.6 to 2.3:1.
Symptoms
Defecation:
Decreased frequency of bowel movements: < 1 every 3 days.
Increased consistency of stools: lumpy/hard stool or stool pellets.
Need for straining or even manual disimpaction.
Need for external/transvaginal digital support.
Sense of incomplete evacuation; multiple/repetitive small bowel movements.
Abdominal symptoms: fullness, LLQ pain.
Secondary symptoms: depression, anal fissure, hemorrhoids, diverticulitis, overflow incontinence.
Absence of alarming symptoms: bleeding, weight loss, fever, etc.
Differential Diagnosis
Morphologic obstruction: partial or complete LBO.
Slow-transit constipation: absence of morphologic problem, intrinsic neuromuscular dysfunction with colonic inertia.
Pelvic floor dysfunction: functional outlet obstruction (anismus), intussusceptions, prolapse, rectocele.
IBS: absence of morphologic problem, normal-transit constipation, relief with defecation, ROME III criteria.