摘要:
目的 探讨耻骨直肠肌(PRM)部分切除联合内括约肌(IAS)离断术治疗肛管高压性耻骨直肠肌综合征(PRS)临床疗效.方法 2013年1月至2015年5月期间,武汉大学中南医院对25例肛管高压性PRS患者施行PRM部分切除联合IAS离断术治疗,在缝扎器暴露下触摸确定PRM的位置,用电刀在其表面3~5点之间做一横形切口;在5点方向用血管钳挑起部分PRM,切除长约0.5 cm肌组织.在肛管8~10点方向,电刀切长约1 cm横形切口,用血管钳挑起部分IAS并切断.术前及术后3月常规进行肛管直肠测压和排粪造影,并分别于术前和术后3、6、12月进行Wexner便秘评分和Cleveland Clinic失禁评分.本研究在中国临床试验注册中心注册(注册号:ChiCTR-ORB-16007695).结果 25例患者中男性18例,女性7例,平均年龄55岁,平均病程9年.术后3月肛管静息压和肛管最大收缩压较术前均显著降低[分别为(53.56±9.05)mmHg比(92.44±7.06)mmHg和(142.80±20.35)mmHg比(210.88±20.56)mmHg,均P=0.000],静息相和力排相肛直角均显著升高[分别为(102.32±4.96)°比(95.88±4.01)°和(117.88±5.95)°比(89.52±3.25)°,P=0.000].术后3、6、12月Wexner便秘评分分别为(8.28±3.91)、(7.40±3.64)和(8.04±4.74),均较术前(16.00±3.69)显著下降(均P0.05);Cleveland Clinic失禁评分显示,术后6、12月评分均为0.25例手术患者中,有效者20例(80%).结论 PRM部分切除联合IAS离断术能有效降低术后肛管压力,改善出口梗阻症状,是治疗肛管高压性PRS的有效术式.%mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o' clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number:ChiCTR-ORB-16007695). Results Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [(53.56 ± 9.05) mmHg vs. (92.44 ± 7.06) mmHg, (142.80 ± 20.35) mmHg vs. (210.88 ± 20.56) mmHg, respectively, both P = 0.000]; anorectal angulation at resting state and forced defecation state increased significantly [(102.32 ± 4.96)° vs. (95.88 ± 4.01)°, (117.88 ± 5.95)° vs. (89.52 ± 3.25)°, respectively, both P=0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28 ± 3.91, 7.40 ± 3.64 and 8.04 ± 4.74) was significantly lower than the preoperative score (16.00 ± 3.69, all P 0.05). Cleveland Clinic incontinence score was 0 at postoperative 6 and 12 months, and revealed 20 cases were effective among all the surgical patients (80%). Comclusiom Partial resection of puborectalis combined with mutilation of internal anal sphincter can effectively reduce anal pressure and improve symptoms of outlet obstruction, which is an effective method in the treatment of puborectalis syndrome with high anal pressure.