Prohm P, Bönner C
Institute for Proctology, University of Witten/Herdecke, Wuppertal, Germany.
Dis Colon Rectum. 1995 Jul;38(7):735-8. doi: 10.1007/BF02048032.
Although many studies reported the association between high anal sphincter pressures and anal fissures, one question is open to date: is manometry really necessary for surgical management/does manometry influence the outcome?
Between October 1, 1990 and December 31, 1991, lateral sphincterotomy was performed in 177 patients with chronic anal fissure. In all patients the operation was performed as an outpatient procedure under local anesthetic. Electromanometry of the anal canal was carried out preoperatively to demonstrate the raised resting pressure profile within the anal canal. At the same time the maximum squeezing pressure was determined by electromanometry, and electromyography was performed to detect dysfunction of the external sphincter or the levators. The control group consisted of 14 proctologically healthy patients with a resting pressure of 74.4 +/- 8.9 and a maximum squeezing pressure of 130.2 +/- 15 (cm H2O). On the basis of resting pressures determined in healthy patients, an upper limit of 90 was defined as normal, taking into account the standard deviation and standard error rate. For statistical comparison patients were divided into two groups, retrospectively. All patients in Group A had a resting pressure of < or = 90, and all patients in Group B had a resting pressure of > 90. Six weeks after operation electromanometry was again performed to determine the resting pressure profile and maximum squeezing pressure of the sphincter system, and patients were examined to determine whether the fissure had healed.
As a result of the lateral sphincterotomy, the resting pressure was lowered in all patients from 106.6 +/- 21.5 to 80.9 +/- 10.4 and maximum squeezing pressure from 149.3 +/- 27.6 to 135.3 +/- 27.2. Both results were highly significant (P < 0.001, chi-squared). Regarding either reduction in postoperative resting pressure or continence, Groups A and B did not differ statistically. In Group A soiling occurred in 3.2 percent and Grade 1 incontinence in 3.2 percent (1 patient each), and in Group B only one patient (0.7 percent) complained of soiling. Recurrences occurred in 9.7 percent of patients in Group A and in 2.1 percent of patients in Group B (3 patients in each case).
Electromanometric examinations showed that internal sphincterotomy significantly reduces pressure within the anal canal, thus permitting the anal fissure to heal. No significant continence problems were observed. Although manometric selection of patients leads to different results regarding both postoperative continence and recurrence, these differences are not statistically significant. Therefore, it follows that, in experienced hands and using a standardized technique, manometry before surgical management of anal fissure by lateral sphincterotomy is probably superfluous.
尽管许多研究报道了高肛管括约肌压力与肛裂之间的关联，但至今仍有一个问题未解决：测压对于手术治疗是否真的必要/测压是否会影响治疗结果？
1990年10月1日至1991年12月31日期间，对177例慢性肛裂患者实施了侧方括约肌切开术。所有患者均在局部麻醉下作为门诊手术进行。术前进行肛管的电测压以显示肛管内静息压力升高的情况。同时通过电测压确定最大收缩压力，并进行肌电图检查以检测外括约肌或提肌的功能障碍。对照组由14例直肠检查正常的患者组成，其静息压力为74.4±8.9，最大收缩压力为130.2±15（cm H₂O）。根据健康患者测定的静息压力，考虑到标准差和标准误差率，将90定义为正常上限。为进行统计学比较，将患者回顾性地分为两组。A组所有患者的静息压力≤90，B组所有患者的静息压力＞90。术后六周再次进行电测压以确定括约肌系统的静息压力情况和最大收缩压力，并对患者进行检查以确定肛裂是否愈合。
侧方括约肌切开术后，所有患者的静息压力从106.6±21.5降至80.9±10.4，最大收缩压力从149.3±27.6降至135.3±27.2。这两个结果均具有高度统计学意义（P＜0.001，卡方检验）。在术后静息压力降低或控便能力方面，A组和B组在统计学上无差异。A组中3.2%的患者出现粪便污染，3.2%（各1例患者）出现1级失禁，B组只有1例患者（0.7%）主诉有粪便污染。A组9.7%的患者出现复发，B组2.1%的患者出现复发（每组各3例患者）。
电测压检查表明，内括约肌切开术可显著降低肛管内压力，从而使肛裂愈合。未观察到明显的控便问题。尽管对患者进行测压选择在术后控便能力和复发方面会导致不同结果，但这些差异无统计学意义。因此，由此可见，在经验丰富的医生手中并采用标准化技术时，在通过侧方括约肌切开术对肛裂进行手术治疗前进行测压可能是多余的。
