Choi J S, Hwang Y H, Salum M R, Weiss E G, Pikarsky A J, Nogueras J J, Wexner S D
Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA.
Am J Gastroenterol. 2001 Mar;96(3):740-4. doi: 10.1111/j.1572-0241.2001.03615.x.
Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome.
Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception > or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse.
Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12-118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37-91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0-5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group 1 (8.1+/-2.8 vs 0.8+/-0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7+/-4.2 to 1.1+/-5.4 vs 1.4+/-2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse.
This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.
直肠套叠是指直肠呈漏斗状内折，发生于排便时。本研究旨在评估巨大直肠套叠患者随访期间发生直肠全层脱垂的风险，以及治疗是否能改善功能结局。
回顾性评估1988年9月至1997年7月间经排粪造影诊断为巨大直肠套叠（套叠≥10mm，延伸至肛管）的患者。体格检查或排粪造影发现直肠全层脱垂的患者、结肠无力患者或有直肠脱垂手术史的患者被排除。根据接受的治疗将患者分为三组：第一组，保守饮食治疗；第二组，生物反馈治疗；第三组，手术治疗。通过邮寄问卷或电话访谈获取结局。参数包括年龄、性别、既往病史和手术史、排便习惯改变、大便失禁评分以及直肠全层脱垂的发生情况。
63例患者中，18例被排除（7例确诊为直肠全层脱垂，4例曾接受直肠脱垂手术，3例有结肠无力，4例死亡）。其余45例患者中的36例（80%）获得了随访数据。该组患者的平均随访时间为45个月（范围12 - 118个月）。有34名女性和2名男性，平均年龄72.4岁（范围37 - 91岁）。套叠的平均大小为2.2cm（范围1.0 - 5.0cm）。患者分类如下：第一组，13例患者（36.1%）；第二组，13例患者（36.1%）；第三组，10例患者（27.8%）。主观上，三组中分别有5例（38.5%）、4例（30.8%）和6例（60.0%）患者症状改善（p>0.05）。在便秘患者中，与第一组相比，第二组每周辅助排便次数（从诊断到目前）的减少更为显著（分别为8.1±2.8次和0.8±0.5次，p = 0.004）。在大便失禁患者中，与第一组或第三组相比，第二组的失禁评分改善更明显（从诊断到目前，分别从3.7±4.2降至1.1±5.4和1.4±2.2，p>0.05）。6例患者（第一组中的2例、第二组中的3例和第三组中的1例）在排便时有直肠脱垂感；然而，第一组中只有1例患者发生了直肠全层脱垂。
本研究表明，接受内科治疗的巨大直肠套叠患者发生直肠全层脱垂的风险非常小（1/26，3.8%）。此外，生物反馈有助于改善这些患者的便秘和失禁症状。因此，生物反馈应被视为巨大直肠套叠的首选初始治疗方法。
