Results and FollowUp

Nature's Quick Constipation Cure

Constipation Help Relief In Minutes

Get Instant Access

Between 1985 and 2003, 69 cases of PH fulfilled the inclusion criteria outlined earlier in this chapter and subsequently underwent partial division of the puborectalis muscle. The day

Figure 26.5. Surgical procedure for PH: an incision is made while the patient is in the prone jackknife position (PH, puborectalis hypertrophy).

following the procedure, all patients reportedly had frequent discharge of gas, and within 7 days 90% of the patients were passing soft or formed stools at least once daily. Defecography performed 4 weeks after the procedure revealed a flatter anorectal angle during evacuation than that noted prior to surgery. The defecography of two typical patients are shown in Figures 26.9 and 26.10. At a median follow-up of 6 years (range 1-18), 42 (61%) of patients can freely defecate whereas 19 (28%) still experience some difficulty and require laxatives or have subsequent anal dilation. Six patients evacuate with significant difficultly and require the use of enemas for complete evacuation. The two patients who evacuate less than once weekly had endorectal ultrasonographic findings of perineal abscess. In these patients, a second division of the puborectalis was undertaken. Three patients reported slight incontinence to gas and liquid while all patients were fully continent.

Wasserman3 proposed spasmodic hypertrophy of the puborectalis muscle. He reported on four patients, three of whom underwent partial resection of the puborectalis muscle with excellent results. Partial resection of the puborec-talis muscles was advocated by Wallace and Madden,18 based on their series of 33 adults and 11 children. Kawano et al19 reported relief of symptoms in three of seven patients who under-

Figure 26.6. Surgical procedure for PH: dissection (PH, puborectalis hypertrophy).

Figure 26.6. Surgical procedure for PH: dissection (PH, puborectalis hypertrophy).

Figure 26.7. Surgical procedure for PH: clamping the puborectalis Figure 26.8. Surgical procedure for PH: resection (PH, puborectalis muscle (PH, puborectalis hypertrophy). hypertrophy).
Figure 26.9. Preoperative defeco-graphy (top) and postoperative defeco-graphy (bottom).

went partial resection of the puborectalis muscle. However, in the series of Barnes et al,20 only two of nine patients who received complete division of the puborectalis muscle obtained relief, while seven had symptomatic improvement. This report suggests that complete divi sion is not as effective as partial resection, and the rate of fecal incontinence is higher after complete puborectalis division. Liu et al21 studied 149 patients who underwent partial division of the puborectalis muscle and found complete resolution of symptoms and no incontinence in 134

Figure 26.10. Preoperative (top) defecography. Note the shelf sign at rest (left) and during attempted but unsuccessful evacuation (right). Postoperative defecography (bottom) shows normal anatomy at rest (left) and during successful evacuation (right).

Table 26.3. The results of division of the puborectalis muscle

Reference

Diagnosis

Procedure

n

Success rate

n

%

Wasserman (1964)3

Puborectalis syndrome

Posterior partial resection

4

B

75

Wallace (1969)18

Puborectalis syndrome

Posterior partial resection

44

BB

75

Keighley (1984)24

Outlet syndrome

Partial division

7

1

14

Barnes (1985)20

Chronic constipation

Partial division

9

2

22

Kamm (1988)22

Chronic constipation

Partial division

18

4

22

Kawano (1997)19

Puborectalis syndrome

Partial resection

7

B

43

Yu (1990)2B

Puborectalis syndrome

Partial resection

18

15

8B

Liu (2001)21

Puborectalis syndrome

Partial resection

149

134

90

Xu (2002)25

Puborectalis hypertrophy

Partial resection

29

28

97

(90%) patients. The results of division of the puborectalis muscle are summarized in Table 26.3.

Two factors may explain the significant variability of the operative results. One is the diversity in the operative indications among the various series. For instance, Kamm et al22 included megarectum as an indication for pub-orectalis division. Other series include patients who have had one or more concomitant causes of outlet obstruction constipation. Puborectalis division is only valuable in patients with PH without other concomitant causes of constipation. A second factor is the differing surgical techniques among the surgeons. There are three methods for this procedure: posterior partial resection; posterior division; and lateral, unilateral, or bilateral resection. Division of the pub-orectalis alone may not allow complete muscle end retraction, as adhesions may develop and can cause symptom recurrence. For this reason, the partial resection should extend from the posterior rectal wall to the puborectalis muscle, dissecting both cut ends as widely as possible. At least a 1.5-cm width of muscle should be resected.

Why does partial resection of the puborectalis muscle fail? The reasons for failure may include concomitant unrecognized anatomic outlet obstruction due to either intussusception or rectocele. The authors emphasize the importance of thorough preoperative physiologic evaluation and exclusion or successful treatment of all other causes of constipation. Incompletely resected adhesions or fibrous bands between the pub-orectalis muscles and rectal wall may result in a persistent stricture and continued symptoms. If an insufficient width of puborectalis muscle (less than 1.5 cm) is resected, the cut ends may re-adhese and cause stricture recurrence. Postoperative balloon dilation of the rectum may prevent adhesion recurrence. The authors treated two patients whose symptoms recurred owing to adhesions between the resected ends who subsequently underwent a second procedure.

Was this article helpful?

0 0
Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment