Boccasanta Paolo, Venturi Marco, Salamina Giovanni, Cesana Bruno Mario, Bernasconi Francesco, Roviaro Giancarlo
1st Department of General Surgery, Ospedale Maggiore di Milano, I.R.C.C.S. University of Milan, Milan, Italy.
Int J Colorectal Dis. 2004 Jul;19(4):359-69. doi: 10.1007/s00384-003-0572-2. Epub 2004 Mar 13.
A randomised trial was undertaken to compare the clinical and functional results of two novel transanal stapled techniques in patients with outlet obstruction syndrome.
Ninety-six females with outlet obstruction were treated with medical therapy and biofeedback for 2 months; 67 non-responders were evaluated by the Constipation Scoring and Continence Grading Systems, clinical examination, endoscopy, dynamic defecography, anorectal manometry, transanal ultrasound and anal EMG, and 50 of them, all affected with descending perineum, intussusception and rectocele, were randomly assigned to two groups and operated on: 25 patients (mean age 53.2+/-15.3 years) underwent a single Stapled Trans-Anal Prolapsectomy, associated with Perineal Levatorplasty (STAPL Group), and the other 25 (mean 54.6+/-14.2 years) underwent a double Stapled Trans-Anal Rectal Resection (STARR Group). Patients were followed-up for a mean period of 23.4+/-5.1 months in STAPL Group and 22.3+/-4.8 in STARR Group.
STARR Group showed a significantly (p<0.0001) lower pattern of postoperative pain and a greater decrease (P=0.0117) of the rectal sensitivity threshold volume; otherwise, no differences were found in operative time, hospital stay, or time of inability to work. Complications included delayed healing of the perineal wound (ten), dyspareunia (five), urinary retention (two) and stenosis (one) in STAPL Group, and urge to defecate (four), transitory incontinence to flatus (two), urinary retention (two), bleeding (one) and stenosis (one) in STARR Group. All constipation symptoms significantly improved without worsening of anal continence and with excellent/good outcome at 20 months in 76 and 88% of patients of STAPL Group and STARR Group, respectively. Seven patients of STAPL Group had a little residual rectocele, while both intussusception and rectocele were corrected in all patients of STARR Group. Neither operation modified anal pressures or caused lesions of anal sphincters.
Both techniques are safe and effective in the treatment of outlet obstruction; nevertheless, the double Stapled Trans-Anal Rectal Resection seems to be preferable due to less pain, absence of dyspareunia, reduced rectal sensitivity threshold volume and absence of residual rectocele at defecography.
开展一项随机试验，比较两种新型经肛门吻合技术治疗出口梗阻综合征患者的临床及功能结果。
96名出口梗阻女性患者接受了2个月的药物治疗及生物反馈治疗；67名无反应者通过便秘评分和控便分级系统、临床检查、内镜检查、动态排粪造影、肛肠测压、经肛门超声及肛门肌电图进行评估，其中50名均患有会阴下降、直肠套叠和直肠膨出，被随机分为两组并接受手术：25例患者（平均年龄53.2±15.3岁）接受了单次经肛门吻合器直肠脱垂切除术联合会阴提肌成形术（STAPL组），另外25例（平均54.6±14.2岁）接受了双次经肛门吻合器直肠切除术（STARR组）。STAPL组患者平均随访23.4±5.1个月，STARR组为22.3±4.8个月。
STARR组术后疼痛程度显著更低（p<0.0001），直肠感觉阈值容积下降幅度更大（P=0.0117）；此外，两组在手术时间、住院时间或无法工作时间方面未发现差异。并发症包括STAPL组会阴伤口延迟愈合（10例）、性交困难（5例）、尿潴留（2例）和狭窄（1例），以及STARR组便意（4例）、短暂性排气失禁（2例）、尿潴留（2例）、出血（1例）和狭窄（1例）。所有便秘症状均显著改善，肛门控便能力未恶化，STAPL组和STARR组分别有76%和88%的患者在20个月时预后良好/优秀。STAPL组7例患者有轻度残余直肠膨出，而STARR组所有患者的直肠套叠和直肠膨出均得到纠正。两种手术均未改变肛门压力或导致肛门括约肌损伤。
两种技术在治疗出口梗阻方面均安全有效；然而，双次经肛门吻合器直肠切除术似乎更可取，因为其疼痛较轻。无性交困难、直肠感觉阈值容积降低且排粪造影时无残余直肠膨出。
