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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 67 | Prospective, Randomized, Controlled Trial of Proximally Based vs. Distally Based Gluteus Maximus Flap for Anal Incontinence in Cadavers [2002년 8월 DCR] | 2011-11-17 | 4013 |
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Rattaplee Pak-art, M.D., Pumin Silapunt, M.D., Tanom Bunaprasert, M.D.,Tanvaa Tansatit, M.D., Tanit Vajrabukka, M.B., Ch.B., F.R.C.S.(Edinb.)
From the Departments of Surgery and Anatomy, Faculty of Medicine, King Chulalongkorn Memorial
Hospital, Bangkok, Thailand PURPOSE: The aim of this study was to compare the lengths of proximally based and distally based gluteus maximus flaps created as for anal sphincter reconstruction in soft human cadavers.
METHODS: Twelve soft cadavers were used in this prospective, randomized, controlled study. In
each cadaver, a proximally based flap of the gluteus maximus muscle was performed on one side and a distally based flap on the other. All flaps were carefully dissected with neurovascular preservation by one surgeon. After the dissected flap was placed across the anus, the length of the flap that projected beyond the anus was measured. The differences between such lengths of both types of flaps were assessed by paired t-test. RESULTS: The average lengths of the parts that projected beyond the anus for proximally based and distally based flaps were 8.08 and 4.50 (standard deviation, 0.51 and 0.79) cm, respectively. The average difference was 3.58 (standard deviation, 0.51) cm, which was statistically significant (P < 0.001). CONCLUSION: Results showed that proximally based flaps were significantly longer than distally based flaps and that transposition and wrapping around the anus with proximally based flaps were always easily performed without tension. These findings support the use of unilateral proximally
based gluteus maximus flaps instead of unilateral or bilateral distally based flaps in patients with anal incontinence. The location of the neurovascular pedicle of the gluteus maximus was consistent at 1 cm superior and lateral to ischial tuberosity. Knowledge of this landmark allows quick and safe dissection of the gluteus maximus flap. Major incontinence has considerable social consequences and demands an effort at some form of definitive therapy. Overlapping sphincteroplasty, simple apposition of external sphincter muscle, and Parks’ postanal repair provide excellent results in most patients who have adequate residual sphincter
muscle mass. Muscle transposition is reserved for situations in which massive trauma or infection in the perineum has destroyed the bulk of the patient’s sphincter mechanism. The gluteus maximus muscle is ideally suited for transposition to the perianal region. It is a well-vascularized muscle supplied by the inferior gluteal artery and innervated by the inferior gluteal nerve. It is a natural synergist of the external sphincter. Compared with the gracilis muscle, the gluteus maximus
muscle is larger and stronger. It provides adequate muscle bulk around the anal canal. The gluteus muscle is activated during walking, which helps to maintain its trophic status and keeps continuous contraction even without electric stimulators. The inferior half of the muscle can be readily harvested without detriment to gait or pelvic stability. In the majority of reports, distally based gluteus maximus flaps were created bilaterally because of the
inadequacy of length obtained from a one-sided flap. Some authors recommended a proximally based flap. However, there is no consensus regarding which flap is longer and thus more suitable for transposition. The purpose of the present study was to evaluate the length of proximally based and distally based gluteus maximus flaps in soft cadavers after full mobilization as for transposition in anal sphincter reconstruction. |
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