Anterior Rezeksiyonlarda Anastomoz için Kullanılan Staplerin Çeşitli Uygulama Şekillerinin Postoperatif Anal Fonksiyonlar Üzerine Olan Etkisi
Abstract
Introduction: Anterior resection (AR) and low anterior resection (LAR) are common surgical procedure for benign or malign
diseases. Some authors have reported following the anterior resection with stapled anastomosis, impairment of anorectal
function deals with insertion of transanal circular stapler which cause direct injury to anal sphincter muscles. We suggest that
anorectal function becomes better with usage dilator on stapler insertion.
Material and methods: A randomized, prospective clinical study was designed in which 40 patients undergoing anterior
resection with stapled anastomosis were undertaken in Ankara University of Medicine, Department of General Surgery
between January 2009 and September 2010. In the Group 1 (n=21); anastomoses were achieved by circular stapler which was
introduced transanally after manuel dilation of anal canal. In the other group (Group 2; n=19) after lubricating anal canal, anal
dilator was introduced to anal canal. Circular stapler was inserted through anal dilator and anastamoses were achieved. Preoperative
and postoperative evaluation was performed with Wexner Incontinence Score, Cleveland Clinic Quality of Life Scala,
anorectal manometry and endoanal ultrasound.
Results: In the Group 1; median age was 60 (range 31 – 70) years-old, and similar for the Group 2; 63 (range 36 – 70) years-old.
There was no statistical difference in age between the groups (p=0,239). There was no statistical difference also in ‘distance of
anastomosis from anal verge’ between the groups (p=0,667). Median measurement for ‘distance of anastomosis from anal
verge’ was 12 (range 8 – 20) cm, similar in the Group 1; 12 (range 8 – 16) cm. No patient had major incontinence in the postoperative
time, but 9 of 40 patients (%22,5) had minor incontinence in all groups. Median Wexner Incontinence Score was 0
(range 0-3) for all patients. There was no statitiscal difference in ‘soiling’, ‘ Wexner Incontinence Score’, ‘alteration of IAS and
EAS morphology’, defecation frequency’ and ‘pad usage’ between the groups (p>0,05; the order of group effect, time effect,
time*group interraction were irrelevant). Quality of life score was higher for all patients in the postoperative time. After the
operation all manometric pressures, functional anal canal length (FAKU) and RAIR (+) were lower in the groups. But mean
resting pressure (MDP) and FAKU measurements were also diminished in the groups, but were better in the Group 2 than
Group 1. There was statistical difference in MDP and FAKU value (p value, respectively; 0,044 and 0,013).
Conclusion: Anorectal manometric parameters were preserved better in the dilator group (Group 2). Better outcome in the
Group 2 was probably dealt with dilator which reflects to force equally, balanced and standardized on the anal canal. The
smaller size and appropriate dilator could be used for best clinical outcome in which wider patients were obtained as similarly
this randomized, prospective study.
Keywords
Anal Incontinence, Anorectal Function, Anterior Resection, Circular Stapler, Dilator
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