Pricolo V E, Potenti F M, Luks F I
Department of Surgery, Rhode Island Hospital and Brown University, Providence, USA.
Dis Colon Rectum. 1996 Aug;39(8):871-7. doi: 10.1007/BF02053985.
A prospective trial was conducted to evaluate use of certain preoperative criteria in the choice of operative technique for ileal pouch-anal anastomosis (IPAA). Handsewn vs. stapled anastomotic techniques were compared as was preservation vs. excision of the anal transition zone (ATZ).
Over an 18-month period, 40 consecutive patients underwent restorative proctocolectomy with IPAA for ulcerative colitis (31 cases) or familial adenomatous polyposis (9 cases). In 28 patients, ATZ was completely excised, by either a transanal mucosectomy with handsewn anastomosis (Group I, 13 cases) or by double-stapled technique (Group II, 15 cases). The ATZ was preserved and the anastomosis was double-stapled in colitis patients with suboptimum sphincter function and/or greater than 50 years of age in the absence of dysplasia or severe distal proctitis (Group III, 12 cases).
Groups I and II patients were homogeneous in their preoperative variables and had equivalent functional outcome. Group III patients were older (P = 0.0001), with weaker preoperative anal sphincter resting tone (P = 0.024). Compared with Groups I and II, patients in Group III had significantly greater 24-hour stool frequency (P = 0.0056), daytime stool frequency (P = 0.0125), and incidence of daytime fecal seepage (P = 0.007). There was no significant difference in other outcome variables in Group III patients. There was no difference in morbidity in the three groups.
Transanal mucosectomy with handsewn anastomosis provided early functional results equivalent to low anal transection with double-stapled IPAA in younger patients with excellent preoperative sphincter function. A double-stapled technique with preservation of the ATZ may be reserved for older patients, with poorer anal sphincter function, at minimum dysplasia/cancer risk, to optimize continence figures.
进行一项前瞻性试验，以评估某些术前标准在回肠储袋肛管吻合术（IPAA）手术技术选择中的应用。比较了手工缝合与吻合器吻合技术，以及肛管移行区（ATZ）的保留与切除情况。
在18个月的时间里，40例连续性患者因溃疡性结肠炎（31例）或家族性腺瘤性息肉病（9例）接受了IPAA的直肠结肠切除重建术。28例患者中，ATZ被完全切除，其中13例采用经肛门黏膜切除术并手工缝合吻合（I组），15例采用双吻合器技术（II组）。对于括约肌功能欠佳和/或年龄大于50岁且无发育异常或严重直肠远端炎的结肠炎患者，保留ATZ并采用双吻合器吻合（III组，12例）。
I组和II组患者术前变量相似，功能结局相当。III组患者年龄较大（P = 0.0001），术前肛门括约肌静息张力较弱（P = 0.024）。与I组和II组相比，III组患者24小时排便次数显著更多（P = 0.0056）、白天排便次数更多（P = 0.0125）、白天粪便渗漏发生率更高（P = 0.007）。III组患者其他结局变量无显著差异。三组患者的发病率无差异。
对于术前括约肌功能良好的年轻患者，经肛门黏膜切除术并手工缝合吻合可提供与低位肛管横断术及双吻合器IPAA相当的早期功能结果。对于年龄较大、肛门括约肌功能较差、发育异常/癌症风险最低的患者，可保留ATZ采用双吻合器技术，以优化控便情况。
