Rasmussen Ole Ø
Department of Surgery D, Glostrup Hospital.
Dan Med Bull. 2003 Aug;50(3):262-82.
The thesis consists of ten previously published studies and a review. The physiological and pathophysiological mechanisms in fecal incontinence has been studied by anal manometry, both by standard static anal manometry and by a new method, dynamic anal manometry, where anal sphincter pressure can be measured during simultaneous opening and closing of the anal canal. Patients with fecal incontinence showed abnormal sphincter pressures more frequently when dynamic anal manometry was used compared to standard anal manometry. The physiology and pathophysiology of the rectum was studied using rectal compliance measurements. Patients with normal anorectal function had a large variation in rectal compliance. Patients with fecal incontinence had as a group, lower rectal compliance than continent patients. This may lead to increased frequency of incontinence episodes in patients with fecal incontinence. The relationship between idiopathic fecal incontinence and pudendal nerve terminal latency was studied in 178 patients. The far majority of patients had normal latencies, and there was no correlation between latency and anal manometry. In contrast to previous suggestions, idiopathic fecal incontinence does not seem to be caused by pudendal nerve damage. Reconstruction of the external anal sphincter in patients with fecal incontinence due to obstetric sphincter lesion showed a poorer functional result among patients older than forty years compared to younger. This indicates that the general muscular weakening with age contribute to the incontinence in these patients. The treatment of more complicated forms of fecal incontinence consists of, apart from conservative treatment or colostomi, mainly in muscle transpositions or artificial anal sphincter. Transposition of the distal part of the gluteus maximus muscle to encircle the anal canal, did not lead to acceptable continence in any of the patients studied. Transposition of the gracilis muscle lead to acceptable continence in half the patients. Patients where the transposed muscle were stimulated by a neurostimulator had satisfactory continence in most cases. However, with this method several re-operations were necessary in some patients. In addition, some patients developed severe evacuation difficulties. Implantation of an artificial sphincter resulted in long-term improvement of continence in that half of patients in whom the artificial sphincter remained implanted. The other half of the patients had the artificial sphincter explanted due to various reasons, most frequently due to infection around the device. In selected patients with more complicated fecal incontinence, stimulated gracilis transposition or implantation of an artificial anal sphincter may be offered as an alternative to colostomy. Sacral nerve stimulation is a new method which seems to provide the best results among the more advanced procedures. Its minimally invasive character also contribute to the increasing use of this method in the last few years. Evaluation and treatment of fecal incontinence is presently in a state of rapid change with focus on more elaborate investigative methods and more diversified treatment.
本论文由十项先前发表的研究及一篇综述组成。通过肛门测压法对大便失禁的生理和病理生理机制进行了研究，包括标准静态肛门测压法以及一种新方法——动态肛门测压法，后者可在肛管同时开合过程中测量肛门括约肌压力。与标准肛门测压法相比，使用动态肛门测压法时，大便失禁患者出现异常括约肌压力的情况更为频繁。通过直肠顺应性测量研究了直肠的生理和病理生理。肛门直肠功能正常的患者直肠顺应性差异较大。大便失禁患者总体的直肠顺应性低于大便能自控的患者。这可能导致大便失禁患者失禁发作频率增加。对178例患者研究了特发性大便失禁与阴部神经末梢潜伏期之间的关系。绝大多数患者潜伏期正常，潜伏期与肛门测压之间无相关性。与先前的观点相反，特发性大便失禁似乎并非由阴部神经损伤所致。因产科括约肌损伤导致大便失禁的患者，行肛门外括约肌重建术时，40岁以上患者的功能恢复结果比年轻患者差。这表明随着年龄增长出现的全身肌肉衰弱导致了这些患者的失禁。除保守治疗或结肠造口术外，更复杂形式的大便失禁治疗主要包括肌肉移位术或人工肛门括约肌植入术。将臀大肌远端部分移位以环绕肛管，在所研究的任何患者中均未实现可接受的控便效果。股薄肌移位术使半数患者实现了可接受的控便。在多数情况下，经神经刺激器刺激移位肌肉的患者控便效果良好。然而，采用这种方法，部分患者需要多次再次手术。此外，部分患者出现了严重的排便困难。植入人工括约肌使半数植入人工括约肌的患者实现了控便的长期改善。另一半患者因各种原因取出了人工括约肌，最常见的原因是装置周围感染。对于部分选择的更复杂大便失禁患者，可提供刺激股薄肌移位术或植入人工肛门括约肌作为结肠造口术的替代方案。骶神经刺激是一种新方法，在更先进的治疗方法中似乎效果最佳。其微创特性也促使该方法在过去几年中使用日益增多。目前，大便失禁的评估和治疗正处于快速变化阶段，重点在于更精细的检查方法和更多样化的治疗。
