da Silva Giovanna M, Jorge J Marcio N, Belin Bruce, Nogueras Juan J, Weiss Eric G, Vernava Anthony M, Habr-Gama Angelita, Wexner Steven D
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA.
Dis Colon Rectum. 2004 Feb;47(2):204-9. doi: 10.1007/s10350-003-0039-0.
Anorectal malformations are among the various etiologic factors causing fecal incontinence. Patients with imperforate anus are difficult to treat, specifically those with high lesions. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence. The aim of this study was to evaluate the results of these technologies in the treatment of patients with chronic fecal incontinence due to imperforate anus.
All patients with imperforate anus who had fecal incontinence and underwent either the artificial bowel sphincter procedure or the gracilis neosphincter procedure between February 1995 and December 2000 were evaluated. Preoperative and postoperative incontinence score (Cleveland Clinic Florida Incontinence Score; 0 = perfect continence; 20 = complete incontinence), quality of life, (Fecal Incontinence Quality of Life Scale, 29 items forming 4 scales), and manometric sphincter pressure results were compared.
Eleven patients had artificial bowel sphincter and five had the gracilis neosphincter (one nonstimulated) procedure. There were 11 males and 5 females of a mean age of 25.3 (range, 15-45) years. The mean follow-up time was 1.7 years (5 months to 5.7 years). Eight (50 percent) complications occurred in six patients, including three with fecal impaction (all artificial bowel sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and two patients with concomitant wound infection (one gracilis neosphincter, one artificial bowel sphincter); no patients had the devices explanted. Fourteen patients had manometric data (10 artificial bowel sphincter and 4 gracilis neosphincter) available. The overall incontinence score decreased from a preoperative mean of 18.5 to a postoperative mean of 7.5 in the artificial bowel sphincter group (P < 0.01) and from 17.4 to 9.4 in the gracilis neosphincter group (P = 0.06). All four Fecal Incontinence Quality of Life scales increased in both the artificial bowel sphincter (lifestyle and depression/self-perception, P = 0.02; coping/behavior and embarrassment, P = 0.03) and the gracilis neosphincter (lifestyle and coping, P = 0.06; depression and embarrassment, P = 0.05) patients. As well, the mean resting and squeeze pressures increased with both techniques (artificial bowel sphincter: P = 0.008 and P = 0.02, respectively; gracilis neosphincter: P = 0.4 and P = 0.1, respectively). All results were statistically significant in the artificial bowel sphincter group.
Artificial bowel sphincter and gracilis neosphincter are efficient methods to treat patients with imperforate anus. These techniques should be considered for patients with imperforate anus and severe fecal incontinence.
肛门直肠畸形是导致大便失禁的多种病因之一。肛门闭锁患者治疗困难，尤其是高位病变患者。人工肠括约肌和电刺激股薄肌新括约肌是用于治疗严重难治性大便失禁患者的两种相对较新的技术。本研究的目的是评估这些技术在治疗因肛门闭锁导致的慢性大便失禁患者中的效果。
对1995年2月至2000年12月间所有因大便失禁而行人工肠括约肌手术或股薄肌新括约肌手术的肛门闭锁患者进行评估。比较术前和术后的失禁评分（佛罗里达克利夫兰诊所失禁评分；0 = 完全控便；20 = 完全失禁）、生活质量（大便失禁生活质量量表，29个项目构成4个量表）以及测压括约肌压力结果。
11例患者接受了人工肠括约肌手术，5例接受了股薄肌新括约肌手术（1例未刺激）。患者共11例男性和5例女性，平均年龄25.3岁（范围15 - 45岁）。平均随访时间为1.7年（5个月至5.7年）。6例患者出现8例（50%）并发症，包括3例粪便嵌塞（均为人工肠括约肌组）、3例装置移位（2例股薄肌新括约肌组，1例人工肠括约肌组）以及2例伴有伤口感染（1例股薄肌新括约肌组，1例人工肠括约肌组）；无患者取出装置。14例患者有测压数据（10例人工肠括约肌组和4例股薄肌新括约肌组）。人工肠括约肌组的总体失禁评分从术前平均18.5降至术后平均7.5（P < 0.01），股薄肌新括约肌组从17.4降至9.4（P = 0.06）。人工肠括约肌组和股薄肌新括约肌组患者的所有4个大便失禁生活质量量表均有所提高（人工肠括约肌组：生活方式和抑郁/自我认知，P = 0.02；应对/行为和尴尬，P = 0.03；股薄肌新括约肌组：生活方式和应对，P = 0.06；抑郁和尴尬，P = 0.05）。此外，两种技术均使平均静息压力和收缩压力升高（人工肠括约肌组：分别为P = 0.008和P = 0.02；股薄肌新括约肌组：分别为P = 0.4和P = 0.1）。人工肠括约肌组的所有结果均具有统计学意义。
人工肠括约肌和股薄肌新括约肌是治疗肛门闭锁患者的有效方法。对于肛门闭锁且严重大便失禁的患者应考虑采用这些技术。
