Young C J, Mathur M N, Eyers A A, Solomon M J
University of Sydney and Central Sydney, Department of Colorectal Surgery, New South Wales, Australia.
Dis Colon Rectum. 1998 Mar;41(3):344-9. doi: 10.1007/BF02237489.
Fecal incontinence from single anal sphincter defects are surgically remedial and commonly the result of obstetric injuries. Overlapping anal sphincter repair has previously been associated in small series with good results in 69 to 97 percent of patients.
The aims of this study were to assess the results of overlapping anal sphincter repair in one institution and to assess the effects of age, presence of a neuropathy, and addition of a temporary colostomy on the success of surgery.
A study of 57 overlapping anal sphincter repairs in 56 (54 females) patients at the Royal Prince Alfred Hospital during a six-year period was performed. All patients were investigated preoperatively with endoanal ultrasound and concentric needle electromyography. Patients have been assessed prospectively since 1994 with a questionnaire, including a four-point Likert scale of continence level, the St. Mark's incontinence scoring system (range, 0-13), the Pescatori incontinence scoring system (range, 0-6), and patient assessment of success or failure of the overlapping anal sphincter repair. A colostomy was selectively formed in conjunction with an overlapping anal sphincter repair in 21 patients (8 preoperatively, 13 simultaneously), and 18 patients had a concomitant neuropathy (3 unilateral, 15 bilateral).
After a median follow-up of 18 months, median continence scores overall had improved from St. Mark's incontinence scoring 13 to 3 (P < 0.0001) and Pescatori incontinence scoring 6 to 2 (P < 0.0001). Forty-nine of 57 (86 percent) repairs have been successful, and 8 are considered to be failures. Twenty-one of 27 (78 percent) repairs in patients younger than 40 years of age were successful, as were 28 of 30 (93 percent) repairs in patients older than 40 years of age (P = 0.10). Four of 18 (22 percent) repairs associated with a neuropathy failed compared with 4 of 39 (10 percent) without a neuropathy (P = 0.21). Improved or normal continence was achieved in 17 of 21 (81 percent) patients with a stoma and overlapping anal sphincter repair and in 32 of 36 (89 percent) patients with an overlapping anal sphincter repair alone (P = 0.32). The presence of a stoma did not improve the rate of wound healing by primary intention (62 percent for stoma vs. 64 percent for overlapping anal sphincter repair alone; P = 0.55).
Single anal sphincter defects can be successfully treated with an overlapping anal sphincter repair. There is no improvement in primary healing with selective stoma formation. Age of the patient and presence of a neuropathy should not detract from proceeding with overlapping anal sphincter repair when singular anal sphincter defects are detected on endoanal ultrasound in muscle that is still active.
因单一肛门括约肌缺陷导致的大便失禁可通过手术治疗，其常见病因是产科损伤。此前小样本研究表明，重叠式肛门括约肌修复术对69%至97%的患者疗效良好。
本研究旨在评估某机构采用重叠式肛门括约肌修复术的效果，以及年龄、神经病变的存在情况和临时结肠造口术对手术成功率的影响。
对皇家阿尔弗雷德王子医院6年间56例（54例女性）患者进行的57例重叠式肛门括约肌修复术展开研究。所有患者术前均接受肛门内超声检查和同心针电极肌电图检查。自1994年起对患者进行前瞻性评估，采用问卷调查，包括四级大便失禁程度Likert量表、圣马克大便失禁评分系统（范围0 - 13）、佩斯卡特里大便失禁评分系统（范围0 - 6），以及患者对重叠式肛门括约肌修复术成败的评估。21例患者（8例术前、13例同时进行）在重叠式肛门括约肌修复术的同时选择性地进行了结肠造口术，18例患者伴有神经病变（3例单侧、15例双侧）。
中位随访18个月后，总体中位大便失禁评分从圣马克大便失禁评分13分改善至3分（P < 0.0001），佩斯卡特里大便失禁评分从6分改善至2分（P < 0.0001）。57例修复术中49例（86%）成功，8例被视为失败。40岁以下患者的27例修复术中21例（78%）成功，40岁以上患者的30例修复术中28例（93%）成功（P = 0.10）。伴有神经病变的18例修复术中4例（22%）失败，无神经病变的39例中4例（10%）失败（P = 0.21）。21例进行造口术并接受重叠式肛门括约肌修复术的患者中17例（81%）实现了大便失禁改善或恢复正常，单纯接受重叠式肛门括约肌修复术的36例患者中32例（89%）实现了同样效果（P = 0.32）。造口术的存在并未提高一期伤口愈合率（造口术患者为62%，单纯重叠式肛门括约肌修复术患者为64%；P = 0.55）。
单一肛门括约肌缺陷可通过重叠式肛门括约肌修复术成功治疗。选择性造口术并不能改善一期愈合情况。当通过肛门内超声在仍有活性的肌肉中检测到单一肛门括约肌缺陷时，患者年龄和神经病变的存在不应妨碍进行重叠式肛门括约肌修复术。
