直肠下端黏膜环切术联合直肠前壁黏膜柱状缝合术治疗女性直肠前突所致出口梗阻型便秘的研究

Clinical evaluation of combined treatment of rectal wall repair with procedure for prolapse and haemorrhoids for outlet obstruction defecation syndrome induced by rectocele in women

目的 探讨直肠前突所致出口梗阻型便秘（ODS）患者经直肠下端黏膜环切术（PPH）和直肠黏膜柱状缝合术治疗后直肠前突的形态学及排便功能改善程度.方法 按照罗马Ⅲ标准选择伴有直肠前突的口梗阻型便秘患者145例,随机分为PPH联合直肠前壁黏膜柱状缝合修补组（A组,68例）和单纯直肠前壁修补组（B组,77例）.分别于术前和术后3、6、12、24个月行排粪造影检查,采用Longo＇s便秘严重程度评分标准评估便秘症状.比较两组患者术后直肠前突的程度、便秘改善率和复发率.结果 A组病例术后3、6、12个月患者的直肠前突值较术前明显下降（P＜0.05）;从术前的4.9cm分别下降为2.4、2.7、3.1、3.6cm.B组病例从4.4cm分别下降为2.1、2.4、2.8、3.1cm.便秘严重程度A组Longo＇s评分由术前的（18.1±4.3）分下降至术后的（8.3±2.1）分（P＜0.05）;B组由术前的（16.9±3.5）分下降至术后的（8.6±2.4）分（P＜0.05）.A组改善率由术后3个月的85.3％下降至术后24个月的49.2％,复发率由2.0％上升至16.3％ （P ＜0.05）;B组改善率由术后3个月的84.1％下降至术后24个月的52.1％,复发率由1.5％上升至16.9％（P＜0.05）.结论 PPH联合直肠前壁黏膜柱状缝合术能纠正出口梗阻型便秘患者的直肠前突形态学及排便功能紊乱,短期疗效好,长期疗效有待进一步观察.直肠前突并不一定是便秘的手术指征.

Objective To evaluate the clinical value of combined use of procedure for prolapse and haemorrhoids （PPH） with rectal wall repair for obstructive defecation syndrome （ODS） induced by rectocele in women.Methods From March 2011 to March 2013, one hundred and forty-five female patients with obstructive defecation due to anterior rectocele were randomly divided into group A （n =68） and group B （n =77）.The patients in group A receipted combined treatment of procedure for PPH with rectal wall repair, and those in group B underwent monotreatment of rectal wall repair.The preoperative and postoperative defecography at 3rd, 6th, 12th and 24th month was examined.Data were collected prospectively from standardized questionnaires for the assessment of constipation （constipation scoring system, Longo＇ s ODS score system, symptom severity score）, patient＇s satisfaction （visual analogue scale）, and quality of life （Patient Assessment of Constipation-Quality of Life questionnaire）.Results Follow-up defecographic findings showed that rectocele size was significantly decreased from 4.9 cm to 2.4, 2.7, 3.1, 3.6 cm respectively （P 〈0.05） in group A at 3rd, 6th, 12th, 24th month after operation.Also, the size of rectocle was significant decreased from 4.4 cm to 2.1, 2.4, 2.8, 3.1 cm respectively （P 〈 0.05） at 3rd, 6th, 12th, and 24th month in group B.The Longo＇ s ODS score in group A was decreased from preoperative 18.1 to postoperative 8.3 （P 〈 0.05）, and that in group B from 16.9 to 8.6 （P 〈 0.05）.The total efficiency in group A was significantly decreased from 85.3% at 3rd month after surgery to 49.2% at 24th month, and symptomatic recurrence index was increased from 2.0% to 16.3% （P 〈0.05）.In group B, the total efficiency was decreased from 84.1% to 52.1%, and recurrence index increased from 1.5% to 16.9% （P 〈 0.05）, respectively.Conclusion Combined treatment of PPH with transanal repair of rectocele is an effective technique in improving anatomical defect and symptom of patients with ODS due to rectocele in short time, however clinical outcomes might become progressively worse as the length of the follow-up is increased.Rectocele may be not an indication for surgical repair.