外括约肌主动收缩放松训练改善肛门失禁患者的肛门节制

Voluntary contraction training of external anal sphincter for improvement of the anal control of patients with fecal incontinence

目的:观察肛门失禁患者进行外括约肌主动收缩和放松的生物反馈训练后肛门节制功能的变化,分析外括约肌主动收缩训练改善肛门节制的可能机制。方法:于1998-10/1999-05在解放军总医院小儿外科采用CTD-SYNECTICS公司生产的直肠测压仪对27例正常儿童和另12例失禁患儿进行括约肌主动收缩状态下压力的测定,得到外括约肌收缩压力增加值。2004-10/2006-05在解放军总医院小儿外科采用生物反馈训练仪(CTD-SYNECTICS公司生产,通过可视动画形式和可听的声音高低信号形式将直肠肛门动力情况反映出来,通过指导者的语言讲解,配合正确的动画曲线和声音信号的指导训练,纠正异常的直肠肛门动力。)对13例不同年龄段的失禁患者进行括约肌主动收缩和放松的生物反馈训练。其中儿童7例,成人6例。每次外括约肌持续收缩的时间根据患者的耐受程度一般为5～10s,放松10s,完成6～8次上述收缩和放松动作后休息10min。儿童每次持续1～1.5h,成人1.5～2h,平均训练6次。记录首末次训练外括约肌收缩电位平均值的变化;直肠测压获得的距离肛门缘3,2,1cm层面8个方向外括约肌收缩压力的增加值。结果:全部参与实验的正常儿童27例、肛门失禁患儿12例和接受生物反馈训练的失禁患者13例均进入结果分析。①接受生物反馈训练的肛门失禁患者中10例末次训练外括约肌收缩电位的平均值显著大于首次训练(P<0.05),治疗有效率为76.92%(10/13)。②肛门失禁患者生物反馈训练前肛门外观呈开口状态,黏膜轻度外翻;10例经生物反馈训练治疗有效者肛门外观呈关闭状态,黏膜外翻消失。③正常儿童肛门外括约肌收缩状态下,距离肛门缘3,2,1cm层面,各方向括约肌收缩压力增加值分别为,后(6.133±7.263),(9.358±6.652),(9.412±6.628)kPa;右后:(2.611±2.609),(7.131±5.583),(7.116±6.355)kPa;右:(4.000±5.430),(8.810±6.271),(9.343±6.267)kPa;右前:(3.111±7.812),(7.264±7.441),(10.860±7.575)kPa;前:(2.467±6.559),(5.674±7.080),(11.600±8.099)kPa;左前:(2.289±5.876),(5.837±6.865),(12.390±9.169)kPa;左:(3.422±6.710),(7.161±6.313),(11.906±7.782)kPa;左后:(4.678±7.482),(8.252±6.537),(10.227±6.836)kPa,失禁患儿既不存在这种收缩压力增加值的显著梯度变化,也不存在压力增加值的方向变化。结论:正常儿童由近端向远端存在外括约肌主动收缩时存在压力显著增大的梯度变化,且存在外括约肌后方高压向前方高压的转变,形成对直肠肛门的直接方向压迫作用;失禁患儿无上述变化,可能是形成肛门失禁的机制之一。外括约肌主动收缩放松的生物反馈训练能加强外括约肌的收缩电位,有助于形成外括约肌压力纵向梯度变化及对直肠肛门的直接反向压迫机制。

AIM ： To observe the changes in anal control in patients with fecal incontinence after biofeedback training of squeezing and relaxing external anal sphincter （EAS）, so as to explore the possible mechanism of the voluntary contraction training to improve the anal control. METHODS： From October 1998 to May 1999, the squeezing pressure increase of 27 normal children and 12 child patients with fecal incontinence from the Department of Podiatric Surgery, General Hospital of Chinese PLA were measured with the rectum manometer produced by CTD-SYNECTICS Company to obtain the contraction pressure increase of EAS. From October 2004 to May 2006, the biofeedback training of squeezing and relaxing EAS of 13 patients with fecal incontinence including 7 children and 6 adults was carded out by biofeedback trainer produced by CTD-SYNECTICS Company, which could reflect the power of anorectum by visible dynamic pictures and audible high and low signals of sound to correct the abnormal power of anorectum through the speech explanation of instructor and exact training of dynamic pictures and sound signals in the Department of Pediatric Surgery, General Hospital of Chinese PLA. The contraction time of EAS ranged from 5 to 10 seconds and relaxed 10 seconds according to the tolerance of patients, and rested for 10 minutes after finishing previous contraction and relaxation for six to eight times. The training for children lasted 1-1.5 hours, and adults 1.5-2 hours for 6 times. The squeezing voltage changes of EAS at first and last session were recorded; and the contraction pressure increase of EAS from 8 directions at the layer of 3, 2 and 1 cm distance from anal verge were determined. RESULTS： All 27 normal children, 12 child patients with fecal incontinence and 13 patients given biofeedback training were involved in the result analysis. （1）Among the patients given biofeedback training, EAS squeezing voltages of 10 cases were higher at the end of the training than the first training （P 〈 0.05） with the efficacy of 76.92% （10/13）. （2）The anus of patients before biofeedback training was open, and the membrane was light valgoid; the anus of 10 cases that were effectively treated with biofeedback training was closod and the membrane eversion disappeared. （3）For the normal children, during the circumference of 3, 2, 1 cm from the anal verge, the pressure increases to each direction： back： （6.133±7.263）, （9.358±6.652）, （9.412±6.628） kPa; right diagonal back： （2.611±2.609）, （7.131±5.583）, （7.116±6.355） kPa; right side： （4.000±5.430）, （8.810±6.271）, （9.343±6.267） kPa; right diagonal front： （3.111±7.812）, （7.264±7.441）, （10.860±7.575） kPa; front： （2.467±6.559）, （5.674±7.080）, （11.600±8.099） kPa; left diagonal front： （2.289±5.876）, （5.837±6.865）, （12.390±9.169） kPa; left side： （3.422±6.710）, （7.161±6.313）, （11.906±7.782） kPa; left diagonal back： （4.678±7.482）, （8.252±6.537）, （10.227±6.836） kPa; While for the children with fecal incontinence, there were no gradient changes in pressure increase or maximal pressure increasing. CONCLUSION： In normal children, there are gradient changes in increasing pressure from the proximal to distal end and the transform of high voltage from back to front, which form a direct opposite compression to the anal canal; but no previous changes are found in the child patients, it may be one of the causes of fecal incontinence. Biofeedback training of squeezing and relaxing the EAS voluntarily could enhance the voltage increase of squeezing, and is helpful to strengthen the pressure increasing gradiently and direct opposite compression to the anal canal.