회장낭-항문문합술 환자의 항문직장 내압검사 소견
Manometric Assessment after Ileal Pouch- Anal Anastomosis
유창식, 김희철, 박상규, 조영규, 김숙영, 홍현기, 김진천,
소속 상세정보
유창식 ( Yu Chang-Sik )
울산대학교 의과대학 외과학교실
김희철 ( Kim Hee-Cheol )
울산대학교 의과대학 외과학교실
박상규 ( Park Sang-Kyu )
울산대학교 의과대학 외과학교실
조영규 ( Cho Young-Kyu )
울산대학교 의과대학 외과학교실
김숙영 ( Kim Suk-Young )
울산대학교 의과대학 외과학교실
홍현기 ( Hong Hyun-Ki )
울산대학교 의과대학 외과학교실
김진천 ( Kim Jin-Cheon )
울산대학교 의과대학 외과학교실
KMID : 0356720010170040187
Abstract
Purpose: Functional derangement in bowel movement after ileal pouch-anal anastomosis (IPAA) is not infrequent. It results from several mechanisms mainly decreased rectal reservoir capacity and rectal sensation. Anal sphincter or pelvic nerve damage during surgery contributes physiological changes, also. This study was performed to evaluate manometric changes after IPAA and compare them with functional outcomes regarding anastomotic technique.
Methods: Forty seven (M：F=23：24) patients who underwent IPAA and manometric assessment were enrolled. Pathological diagnoses of them were 32 ulcerative colitis, 12 familial adenomatous polyposis, and 3 hereditary non-polyposis colorectal cancer. Every pouch was constructed in J shape, 15cm length. Pouch-anal anastomosis was performed by 27 hand-sewn and 20 double stapling technique. Diverting ileostomy was performed in 30 cases (64%) and closed 2∼3 months after IPAA. Manometry was performed preoperatively and 3 to 6 months interval, postoperatively. Twenty two patients underwent full manometic assessment pre- and post-operatively. The others did it either pre or postsoperatively. Functional outcome was investigated at the median follow-up period 25 (2∼54) months. Statistical analysis was performed by using Chi- square and Fisher’s exact test. Significance was assigned to a P value of ＜0.05.
Results: Maximum resting pressure (MRP) was significantly decreased postoperatively (85.2 vs. 60.6 mmHg; P=0.002). This phenomenon could be observed throughout the follow-up period. However, the difference was getting smaller as times went by. Rectoanal inhibitory reflex (RAIR) was identified 96% preoperatively, and only 22% postoperatively (P=0.000). Rectal compliance was decreased at the time of ileostomy closure, and improved remarkably since 6 months after closure. In comparison of manometric findings according to anastomotic technique, MRP in hand- sewn group was significantly decreased (52.3 vs. 77.0 mmHg; P=0.003). RAIR could be identified more frequently in double stapled group (31.6 vs. 15.4%; P＞0.05). Postoperative stood frequency and incontinence rate were not different between two groups. Thirty one percent of patients revealed night time seepage. MRP of this seepage group was significantly lower than the other group (67.9 vs. 48.4 mmHg; P=0.038).
Conclusion: Characteristic changes of manometric findings after IPAA were summarized as decrease of MRP and disappearance of RAIR. Rectal compliance was significantly improved since 6 months after IPAA or ileostomy closure. Decrease of MRP was more remarkable in hand-sewn group. However, we could not find any difference in functional outcomes between two anastomotic techniques. MRP was a crutial factor for postoperative seepage.
키워드
회장낭-항문문합술;항문직장 내압검사;문합방법;배변 기능
Ileal pouch-anal anastomosis;Manometry;Anastomosis technique;Functional outcome
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