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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 59 | Previous Sphincter Repair Does Not Affect the Outcome of Repeat Repair [2002년 5월 DCR] | 2011-11-17 | 3689 |
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Pasquale Giordano, M.D., Adolfo Renzi, M.D., Jonathan Efron, M.D., Pascal Gervaz, M.D., Eric G. Weiss, M.D., Juan J. Nogueras, M.D., Steven D. Wexner, M.D.
From the Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
PURPOSE: As many as 60 percent of patients present with recurrent symptoms of fecal incontinence after anterior overlapping anal sphincter repair. The aim of this study was to assess the outcome of repeat overlapping anal sphincter repair.
METHODS: All female patients with obstetric sphincter damage who underwent anterior overlapping sphincter repair between November 1988 and June 2000 were reviewed. All patients were preoperatively assessed by anorectal manometry, electromyography, and pudendal nerve terminal motor latency; manometry was repeated during follow-up. Preoperative endoanal ultrasonography was available only after 1990. Clinical outcome was assessed according to the Cleveland Clinic Florida Incontinence
Score. RESULTS: One hundred fifty-one patients were available for analysis, 115 without previous surgery and 36 after at least one previous sphincter repair. The median follow-up was 13 (range, 1–64) months and 20 (range, 2–96) months, respectively. The median incontinence score improved from 18 to 5 (P< 0.0001) in patients without previous repair and from 17.5 to 7 (P< 0.0001) in patients after previous repair. In the former group, the outcome was good in 67 (58 percent) patients, adequate in 19 (16.5 percent), and poor in 29 (25.5 percent). In the group with previous sphincter repair, the outcome was good in 18 patients (50 percent), adequate in 4 (11 percent), and poor in 14 (39 percent; P = 0.2646). The mean resting pressure
increased from 20 (range, 3–43) mmHg to 24 (range, 10–44) mmHg and from 27 (range, 4–56) mmHg to 32 (range, 16–45) mmHg, respectively. The mean squeeze pressure increased from 60 (range, 23–63) mmHg to 67 (range, 33–114) mmHg and from 54 (range, 25–90) mmHg to 70 (range, 34–95) mmHg, respectively. CONCLUSION: Previous sphincter repair does not affect clinical outcome. Repeat anterior overlapping sphincter repair yields a significant improvement in the continence score and should be considered as the treatment of choice in patients with fecal incontinence who have had previous sphincter repair and
residual anterior sphincter damage. One of the most common causes of fecal incontinence is anterior disruption of the external anal sphincter caused by obstetric trauma. The standard treatment for this condition is anterior overlapping
anal sphincter repair. Although the early outcome of this procedure seems to be successful in 50 to 86 percent of patients, the long-term results have been less satisfactory. Many patients who present with symptoms of persistent fecal incontinence after overlapping sphincter repair have a residual anterior defect in the anal sphincter. The treatment options for these patients include repeat overlapping sphincter repair, dynamic graciloplasty, artificial bowel sphincter, and colostomy. The ultimate decision will be dependent on the patient and, to some extent, the surgeon. Repeat sphincter repair represents the easiest and most cost-effective option, with fewer complications and better patient compliance. However, it has not yet been determined whether the outcome of this procedure is affected by previous surgery and whether repeat sphincter repair is indeed an advisable option. The aim of this study was to assess the outcome of repeat overlapping sphincter repair in patients who had one or more previous failed repairs and presented with residual anterior anal sphincter damage. Their outcome was compared with the outcome of a similar group of patients who had not undergone previous sphincter repair. DISCUSSION
In this study, at a median follow-up of 20 months, repeat sphincteroplasty was successful in 62 percent
of patients with a residual anterior defect. There was overall marked clinical improvement, with a change in median IS from 17.5 preoperatively to 7 postoperatively, achieving results similar to those attained in patients without previous repair. Even more interestingly, patients with only one or two previous repairs had the same median postoperative IS as did patients with no previous surgery. However, the group who had undergone more than two previous repairs had poorer clinical results. Although the latter group included only five patients and the disparity in follow-up length between the two groups may explain the difference in outcome, this feature may still have important clinical implications. In another study that reviewed the clinical outcome of overlapping sphincteroplasty in patients with previous sphincter repair at a median follow-up of 20 months, Pinedo et al. showed that 15 of 23 patients reported a 50 percent or more clinical improvement with a median IS improvement from 19 preoperatively to 12 postoperatively (P < 0.001). However, all the patients in that study had only one or two previous sphincter repairs. A more recent study from Buie et al. included 24 patients with one previous repair and four patients with two previous repairs. At a mean follow-up of 43 months, the outcome in the group with only one previous repair was good in 58 percent of patients. These results were similar to those achieved in patients with previous repair (62 percent good outcome). However, in this study only one of the four patients with two previous repairs had a good outcome.
Although the reasons for failure of the repair are still not clearly understood, several studies have demonstrated that integrity of the repair is fundamental for a successful outcome. In this study, all the patients with a successful outcome had a good sphincter overlap on EAUS, whereas five of the eight patients with poor outcome had a residual sphincter defect. Therefore, a good overlap is of paramount importance for a satisfactory outcome also in patients with previous repairs. However, it is likely that other factors may contribute to the outcome of a repeat sphincter repair. Surgical dissection itself may cause some degree of devascularization and ischemia to the sphincter and jeopardize its innervation. Both phenomena may deteriorate the muscle function and lead to atrophy. Furthermore, surgical dissection causes further scarring of the sphincter and of the surrounding tissues. This dissection may not just directly affect the muscle function, but also make further surgical dissection difficult with increased risk of damage to the sphincter muscle. This damage may account for poorer outcome in patients with more than two previous repairs.
At present other treatment options for patients with failed sphincter repair include repeat sphincteroplasty,
postanal repair, graciloplasty, and artificial bowel sphincter. Postanal repair is normally reserved for patients with neurogenic fecal incontinence but has shown acceptable results in only 30 percent of patients and is rarely used. Nonstimulated graciloplasty is unable to provide the sustained contraction necessary to provide sphincteric function and has led to poor long-term results in clinical practice. Electrically stimulated graciloplasty provides a slow twitch muscle that is better suited to sphincteric function, with acceptable functional results of 56 to 80 percent. However, this procedure is expensive, complex, and associated with a high morbidity rate and requires good patient compliance to achieve optimal results. The newest option, the artificial bowel sphincter, is a less demanding procedure with results that seem to be encouraging, although infection and cuff erosion have been the main reasons of concern. |
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