Boccasanta Paolo, Venturi Marco, Roviaro Giancarlo
Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS Foundation, Milan, 1st Department of General Surgery, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.
Int J Colorectal Dis. 2007 Mar;22(3):245-51. doi: 10.1007/s00384-006-0196-4. Epub 2006 Oct 5.
A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse.
Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography.
At a mean follow-up of 8.1+/-2.0 and 7.9+/-1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p=0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p=0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p=0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p=0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse.
STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.
近期多篇论文报道了痔吻合器固定术（SA）后失败率显著，可能原因是吻合器套管容积有限导致脱垂组织切除不完全。经肛门吻合器直肠切除术（STARR）已被证明可通过使用两个吻合器成功治愈直肠脱垂和直肠膨出。本随机研究的目的是评估SA和STARR术后脱垂痔合并直肠脱垂患者残留疾病的发生率。
根据有效的便秘和控便评分、临床检查、结肠镜检查、肛肠测压和排粪造影选择68例患者并随机分组：34例行SA手术，34例行STARR手术。对手术患者进行临床检查、术后疼痛视觉模拟评分、满意度指数和排粪造影随访。
SA组和STARR组的平均随访时间分别为8.1±2.0个月和7.9±1.8个月，第一组残留疾病的发生率显著更高（SA组为29.4%，STARR组为5.9%，p = 0.007），而STARR术后残留皮赘的发生率显著更低（23.5%对比SA术后的58.8%，p = 0.03）。所有残留疾病患者在手术时均显示脱垂组织超过肛门扩张器长度的一半。STARR组的手术时间和短暂性便急发生率显著更高（分别为p = 0.001和0.08），而SA术后总体患者满意度指数的不良结果发生率显著更高（p = 0.04）。住院时间、手术并发症、术后疼痛、恢复正常活动时间、控便和便秘评分方面未发现显著差异。STARR术后所有排粪造影参数均显著改善，而SA术后仅直肠脱垂有减轻趋势。
对于脱垂痔合并直肠脱垂患者，STARR比SA能更完整地切除脱垂组织，发病率相同，残留疾病和皮赘的发生率显著更低。肛门扩张器可用于选择手术技术。
