Carditello Antonio, Milone Antonino, Stilo Francesco, Mollo Francesco, Basile Maurizio
Ia Clinica Chirurgica, Dipartimento di Discipline Chirurgiche Generali e Speciali Policlinico Universitario di Messina.
Chir Ital. 2003 Sep-Oct;55(5):687-92.
In recent years the number of patients with partial or total rectal prolapse has increased. Numerous techniques and surgical approaches have been described for its treatment. In this study we examine the main ones and stress the advantages of the transanal-perineal resection technique according to Altemeier and modified by Prasad, which we have used to treat the condition in the last 15 years. From 1988 to 2002, 269 patients with "haemorrhoidal prolapse" were referred to our department; 146 were females (54%), and the mean age was 58 years. Clinical examination and proctosigmoidoscopy revealed the presence of total rectal prolapse in 41 patients (15%, 32 F, 9 M), complicated in 4 cases by moderate incontinence and associated in 3 cases with post-haemorrhoidectomy stenosis. These 41 patients underwent transanal resection according to Altemeier. Thirty-four of them (83%) were operated on under local anaesthesia with sedation, 5 patients (12%) under peridural anaesthesia and 2 patients (5%) under narcosis. The mean hospital stay was 5 days and depended on the time of the first spontaneous evacuation. Check-ups were performed after 7 days, 1 months and every 3 months for 1 year. There was no postoperative mortality, and only 1 case of postoperative haemorrhage, which did not require reoperation, in a patient with a previous myocardial infarct who spontaneously continued to take salicylates up to 24 h before surgery. Thirty-three patients (80%) had their first postoperative evacuation within 48 h of surgery after taking sorbitol orally in the evening, 6 patients (15%) within 72 h, and 2 patients (5%) on postoperative day 4. No evacuative enemas were performed. We observed clinical healing in all patients 1 month after the operation, and regular, spontaneous evacuations without the use of oral laxatives. Stool or gas incontinence were never observed or reported. During the follow-up, only in 2% of cases did we observe partial recurrence of the prolapse. The choice between the numerous surgical techniques for correcting rectal prolapse, depends on the state of the disease, on the patient's general condition and on the surgeon's experience with the various techniques. The perineal approach proposed by Altemeier and modified by Prasad presents a low risk of mortality and immediate complications, as confirmed by our experience, even in high risk patients, and relatively easy execution. It would appear, moreover, to be the only technique capable of correcting the preoperative incontinence sometimes present.
近年来，部分或完全直肠脱垂患者的数量有所增加。针对其治疗，已有众多技术和手术方法被描述。在本研究中，我们审视了主要的技术和方法，并着重强调了根据阿尔特迈尔（Altemeier）术式并经普拉萨德（Prasad）改良的经肛门 - 会阴切除术的优点，在过去15年里我们一直使用该方法治疗这种病症。1988年至2002年期间，269例“痔脱垂”患者被转诊至我科；其中146例为女性（54%），平均年龄为58岁。临床检查和直肠乙状结肠镜检查发现41例患者（15%，32例女性，9例男性）存在完全直肠脱垂，4例合并中度大便失禁，3例伴有痔切除术后狭窄。这41例患者接受了根据阿尔特迈尔术式的经肛门切除术。其中34例（83%）在局部麻醉加镇静下手术；5例（12%）在硬膜外麻醉下手术；2例（5%）在全身麻醉下手术。平均住院时间为5天，这取决于首次自主排便的时间。术后7天、1个月以及之后1年每3个月进行复查。无术后死亡病例，仅1例术后出血，该患者既往有心肌梗死病史，术前一直自行服用水杨酸盐直至手术前24小时，此例术后出血未行再次手术。33例患者（80%）在术后当晚口服山梨醇后48小时内首次自主排便；6例患者（15%）在72小时内排便；2例患者（5%）在术后第4天排便。未进行排便灌肠。术后1个月时我们观察到所有患者临床治愈，且无需口服泻药即可规律、自主排便。从未观察到或接到大便或气体失禁的报告。在随访期间，仅2%的病例出现脱垂部分复发。在众多用于矫正直肠脱垂的手术技术中进行选择，取决于疾病状态、患者的一般状况以及外科医生对各种技术的经验。如我们的经验所证实，阿尔特迈尔提出并经普拉萨德改良的会阴入路手术死亡率和近期并发症风险低，即使对高危患者也是如此，而且实施相对容易。此外，它似乎是唯一能够矫正有时存在的术前大便失禁的技术。
