Anterior Rezeksiyonlarda Anastomoz için Kullanılan Staplerin Çeşitli Uygulama Şekillerinin Postoperatif Anal Fonksiyonlar Üzerine Olan Etkisi

Year 2016, Volume: 69 Issue: 1, 53 - 59, 03.06.2016

Mustafa Berkeşoğlu , Ayhan Bülent Erkek Mehmet Ayhan Kuzu , Erkinbek Orazokunov Gökçe Aylaz Sedef Kuran , Can Ateş , Semih Başkan , Atilla Törüner

https://izlik.org/JA25RU32YL

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

Project Number

-

Anterior Rezeksiyonlarda Anastomoz için Kullanılan Staplerin Çeşitli Uygulama Sekillerinin Postoperatif Anal Fonksiyonlar Üzerine Olan Etkisi

https://izlik.org/JA25RU32YL

Abstract

Giri􀄹: Anterior (AR) ya da a􀄹a􀃾 anterior rezeksiyonlar (LAR); benign ya da malign nedenlerle sklkla ba􀄹vurulan cerrahi yöntemlerdir.
Anastomoz için stapler kullanlan anterior rezeksiyonlardan sonra anorektal fonksiyonlarda saptanan bozulmann
nedeni olarak ‘stapler uygulanrken anal sfinkterlerin travmatize edilmesinin’ üzerinde durulmu􀄹tur. ‘Dilatör’ kullanmyla
anterior rezeksiyon ameliyatlarnda postoperatif dönemde anorektal fonksiyonlarn korunmas hedeflenmi􀄹tir.

Materyal ve Metod: Çal􀄹ma randomize, prospektif klinik çal􀄹ma olarak düzenlenmi􀄹tir. Ankara Üniversitesi Tp Fakültesi
Genel Cerrahi Klini􀃾i’nde Ocak 2009 - Eylül 2010 tarihleri arasnda ‘dairesel stapler kullanlmas planlanan’a AR yaplacak olan
hastalar çal􀄹maya alnm􀄹tr. Anastomoz a􀄹amasnda bir grupta (n=21) ‘parmak dilatasyonu sonras direkt olarak’ dairesel
stapler uygulanm􀄹tr (Grup 1). Di􀃾er grupta (n=19) ise stapler yerle􀄹tirilirken ‘anal dilatör’ içerisinden ilerletilmi􀄹tir (Grup 2).
Hastalarn de􀃾erlendirilmesinde preoperatif ve postoperatif dönemlerde; ‘Wexner 􀄝nkontinans skorlama sistemi’, ‘Cleveland
Clinic ya􀄹am kalitesi anketi’, anorektal manometri, endoanal USG kullanlm􀄹tr.

Bulgular: Ya􀄹 bakmndan gruplar arasnda istatistiksel olarak anlaml fark saptanmam􀄹tr (p=0,239). Grup 1’de ya􀄹 için ortanca
de􀃾er; 60 (31 – 70), Grup 2’de ise; 63 (36 – 70)’dir. Anastomozun ‘anal verge’den uzakl􀃾 bakmndan gruplar arasnda
istatistiksel olarak anlaml fark saptanmam􀄹tr (p=0,667). Grup 1’de anastomoz hattnn ‘anal verge’den uzakl􀃾 12 (8 – 20)
cm’dir, Grup 2’de ise 12 (8 – 16) cm’dir. Hiçbir grupta major inkontinansa rastlanmam􀄹tr, toplam 9/40 hastada (%22,5) minör
inkontinans saptanm􀄹tr. Tüm hastalar için hesaplanan Wexner inkontinans skoru; 0 (0-3)’dr. Analiz sonuçlarna göre gruplar
arasnda inkontinans varl􀃾, ‘soiling’ varl􀃾, ped kullanm, Wexner inkontinans skoru􀀃internal anal sfinkterde ve eksternal anal
sfinkterde de􀃾i􀄹iklik, günlük defekasyon says gibi de􀃾i􀄹kenler için grup etkisi, zaman etkisi ve grup*zaman etkile􀄹imi açsndan
istatistiksel olarak anlaml fark saptanmam􀄹tr (p>0,05). Cleveland Clinic Ya􀄹am Kalitesi Skorunun her iki grupta da postoperatif
dönemde daha yüksek oldu􀃾u saptanm􀄹tr. Postoperatif dönemde manometrik basnç de􀃾erleri, RA􀄝R pozitifli􀃾i ve
FAKU her iki grupta da azalm􀄹tr. ODPB de􀃾eri ve FAKU’da saptanan azalma; Grup 1’de daha belirgindir. Fark istatistiksel
olarak anlamldr (ODPB ve FAKU için srasyla p=0,044 ve p=0,013).

Sonuç: Dilatör kullanlan grupta (Grup 2) anorektal parametrelerin nispeten daha iyi korunmu􀄹 olmasnn muhtemel nedeni
sabit bir dilatörün anal kanala yerle􀄹tirilmesi ile tüm anal kanala e􀄹it oranda kuvvetin, daha standart bir yöntemle uygulanm􀄹
olmas olarak dü􀄹ünülmü􀄹tür. Dairesel stapler çapna uygun ve daha küçük çaptaki dilatörler kullanlarak geni􀄹 hasta serileriyle
olu􀄹turulan, benzer 􀄹ekilde düzenlenmi􀄹 randomize, prospektif, klinik çal􀄹malarla daha iyi sonuçlar elde edilebilece􀃾i dü􀄹ünülmü
􀄹tür.

Keywords

Anal Inkontinans , Anorektal Fonksiyonlar , Anterior Rezeksiyon , Dairesel Stapler , Dilator

Ethical Statement

-

Supporting Institution

-

Project Number

-

Thanks

-

References

• 1.􀀃 Bhangu A, Kiran RP, Slesser A, et al. Survival after resection of colorectal cancer based on anatomical segment of involvement. Ann Surg Oncol. 2013;20:4161-4168.
• 2.􀀃 Ho Y-H, Low D, Goh H-S. Bowel function survey after segmental colorectal resections. Dis Colon Rectum 1996;39:307-310.
• 3.􀀃 Heald RJ, Moran BJ, Ryall RDH, et al. The Basingstoke Experience of Total Mesorectal Excision, 1978-1997. Arch Surg. 1998;133:894-898.
• 4.􀀃 Shrikhande SV, Saoji RR, Barreto SG, et al. Outcomes of resection for rectal cancer India: The impact of the double stapling technique. World J of Surg Oncology 2007,5:35.
• 5.􀀃 Luke M, Kirkegaard P, Lendorf A, et al. Pelvic Recurrence Rate After Abdominoperineal Resection and Low Anterior Resection for Rectal Cancer Before and After Introduction of the Stapling Technique. World J. Surg. 1983;7:616-619.
• 6.􀀃 Winter DC, Murphy A, Kell MR, et al. Perioperative Topical Nitrate and Sphincter Function in Patients Undergoing Transanal Stapled Anastomosis: A Randomized, Placebo-Controlled, Double- Blinded Trial. Dis Colon Rectum 2004;47:697–703.
• 7.􀀃 Ho YH, Tan M, Leong A, et al. Anal pressures impaired by stapler insertion during colorectal anastomosis: a randomized controlled trial. Dis Colon Rectum 1999;42:89-95.
• 8.􀀃 Nakahara S, Itoh H, Mibu R, et al. Clinical and Manometric Evaluation of Anorectal Function Following Low Anterior Resection with Low Anastornotic Line Using an EEA Stapler for Rectal Cancer. Dis Colon Rectum 1988;31:762-766.
• 9.􀀃 Jiang JK, Lin JK. Anorectal dysfunction following low anterior resection for rectal carcinoma: A comparison between handsewn and stapled anastomosis. Colorectal Disease 1999;1:73–79.
• 10.􀀃 Farouk R, Duthie GS, Lee PWR, et al. Endosonographic evidence of injury to the internal anal sphincter after low anterior resection: long-term follow-up. Dis Colon Rectum 1998;41:888-891.
• 11.􀀃 Fantina AC, Hetzerb FH, Christa AD, et al. Influence of stapler haemorrhoidectomy on anorectal function and on patients’ acceptance. Swiss Med Weekly 2002;132:38–42.
• 12.􀀃 Ho YH, Seow-Choen F, Tsang C, et al. Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Br J of Surg 2001;88:1449-1455.
• 13.􀀃 Altomare DF, Rinaldi M, Sallustio PL, et al. Long-term effects of stapled haemorrhoidectomyon internal anal function andsensitivity. Br J Surg 2001;88:1487–1491.
• 14.􀀃 Mlakar B, Košorok P. Complications andresults after stapled haemorrhoidopexy as a day surgical procedure. Tech Coloproctol2003;7:164–168.
• 15.􀀃Williamson MER, Lewis WG Holdsworth PJ, et al. Decrease in the anorectal pressure gradient after low anterior resection of the rectum A study using continuous ambulatory manometry. Dis Colon Rectum 1994;37:1228-1231.
• 16.􀀃 Di Matteo G, Mascagni D, Zeri KP, et al. Evaluation of anal function after surgeryfor rectal cancer. Journal of Surgical Oncology 2000, Vol:74, Issue:1, 11–14.
• 17.􀀃 Rasmussen OO, Petersen IK, Christiansen J. Anorectal function following low anterior resection. Colorectal Disease 2003;5:258–261.
• 18.􀀃 Molloy RG, Moran KT, Coulter J, et al. Mechanism of sphincter impairment following low anterior resection. Dis Colo Rectum 1992;35;462-464.
• 19.􀀃 Nakada I, Kawasaki S, Sonoda Y, et al. Abdominal stapled side-to-end anastomosis( Baker type) in low and high anterior resection: experiences and results in 69 consecutive patients at a regional general hospital in Japan. Colorectal Disease 2004;6:165-170.
• 20.􀀃 Khoury DA, Opelka FG. Anoscopicassisted insertion of end-to-end anastomosing staplers. Dis Colon Rectum; 1995;38:553-554.
• 21.􀀃Guweidhi A, Steffen R, Metzger A, et al. Circular Stapler Introducer: A Novel Device to Facilitate Stapled Colorectal Anastomosis. Dis Colon Rectum 2009;52:746- 748.
• 22.􀀃 Limbert M, De Almeida JM. Colorectal Anastomosis After Laparoscopic Low Anterior Resection with Total Mesorectal Excision: A Difficult Problem Made Simple. Dis Colon Rectum 2009;52:2048– 2050.
• 23.􀀃 Pietsch AP, Fietkau R, Klautke G, et al. Effect of neoadjuvant chemoradiation on postoperative fecal continence and anal sphincter function in rectal cancer patients. Int J Colorectal Dis 2007;22:1311– 1317.
• 24.􀀃 Welsh FKS, McFall M, Mitchell G, et al. Pre-operative short-course radiotherapy is associated with faecal incontinence after anterior resection. Colorectal Disease 2003; Vol 5, Issue 6: 563–568.