نتايج جراحي رزكسيون ركتوم از طريق كانال آنال به روش STARR در درمان سندرم انسدادي دفع

Results of Stapled Transanal Rectal Resection in the Patients with Obstructed Deification Syndrome

زﻣﯿﻨﻪ و ﻫﺪف: ﺳﻨﺪرم اﻧﺴﺪادي دﻓﻊ ])Obstructed Deification Syndrome (ODS[ ﺑﻪ ﻣﺠﻤﻮﻋﻪ ﻋﻼﺋﻢ ﺑﺎﻟﯿﻨﯽ ﮔﻔﺘﻪ ﻣﯽﺷﻮد ﮐﻪ ﺑﻪ دﻟﯿﻞ اﯾﺠﺎد اﺧﺘﻼﻻت آﻧﺎﺗﻮﻣﯿﮏ و ﻋﻤﻠﮑﺮدي ﻋﻨﺎﺻﺮ ﻟﮕﻨﯽ ﻣﻨﺠﺮ ﺑﻪ ﻋﺪم ﺗﻮاﻧﺎﺋﯽ در دﻓﻊ ﻣﺪﻓﻮع از رﮐﺘﻮم ﻣﯽﺷﻮد. رﮐﺘﻮﺳﻞ و اﻧﻮاژﯾﻨﺎﺳﯿﻮن داﺧﻠﯽ ﺷﺎﯾﻌﺘـﺮﯾﻦ ﻋﻼﺋﻢ اﯾﻦ ﺳﻨﺪرم اﺳﺖ. اﯾﻦ ﺑﯿﻤﺎران اﻏﻠﺐ ﻧﯿﺎز ﺑﻪ اﺳﺘﻔﺎده ﻣﺪاوم از ﻣﻠﯿﻦﻫﺎ و ﻣﺴﻬﻞﻫﺎ داﺷﺘﻪ و ﺣﺘﯽ ﺑﻪ ﻣﻨﻈﻮر ﮐﻤﮏ ﺑﻪ ﺗﺨـﻠﯿﻪ ﻣـﺪﻓﻮع از ﺗﻨﻘﯿﻪ و ﯾﺎ ﻓﺸـﺎر ﺧﺎرﺟﯽ اﻧﮕﺸﺘﺎن ﺑﻪ ﭘﺮﯾﻨﻪ و ﯾﺎ واژن اﺳﺘﻔﺎده ﻣﯽﮐﻨﻨﺪ. ﻫـﺪف از اﻧﺠﺎم اﯾﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺮرﺳﯽ ﻧﺘﺎﯾﺞ درﻣﺎﻧﯽ اﯾﻦ ﺑﯿﻤﺎري ﺑﻪ روش ﺟـﺮاﺣﯽ ﺟﺪﯾﺪ ﺑﻮد ﮐﻪ ﺑﻪ وﺳﯿﻠﻪ دو اﺳﺘﺎﭘﻠﺮ ﺣﻠﻘﻮي ﺑﻨﺎم Stapled Trans Anal Rectal Resection) STARR( اﻧﺠﺎم ﻣﯽﺷﻮد. ﻣﻮاد و روش ﻫﺎ: اﯾﻦ ﻣﻄﺎﻟﻌﻪ در ﺳﺎلﻫﺎي 1390-1389 در ﺑﯿﻤﺎرﺳﺘﺎن ﺑﻘﯿﻪ اﷲ اﻻﻋﻈﻢ)ﻋﺞ( ﺗﻬﺮان اﻧﺠﺎم ﺷﺪه و از ﻧﻮع ﮐﺎرآزﻣﺎﯾﯽ ﻓﺎﻗﺪ ﮔﺮوه ﺷﺎﻫﺪ ﻣﯽﺑﺎﺷﺪ. در ﻣﻄﺎﻟﻌﻪ ﮐﻠﯿﻪ ﺑﯿﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم اﻧﺴﺪادي ﻣﺪﻓﻮع ﮐﻪ ﮐﺎﻧﺪﯾﺪ ﻋﻤﻞ ﺟﺮاﺣﯽ ﺑﺮوش STARR ﺑﻮدﻧﺪ، وارد ﻣﻄﺎﻟﻌﻪ ﺷﺪﻧﺪ. ﻣﺘﻐﯿﺮﻫﺎي ﻣﻮرد ﺑﺮرﺳﯽ ﻋﺒﺎرت ﺑﻮدﻧﺪ از: اﺣﺴﺎس ﺗﺨﻠﯿﻪ ﻧﺎﮐﺎﻣﻞ ﻣﺪﻓﻮع، زور زدن زﯾﺎد، دﺳﺘﮑﺎري ﺣﯿﻦ دﻓﻊ، ﻣﺼﺮف ﻣﻠﯿﻦ، اﺳﺘﻔﺎده از ﺗﻨﻘﯿﻪ، درد ﺣﯿﻦ اﺟﺎﺑﺖ ﻣﺰاج، ﺧﻮﻧﺮﯾﺰي ﻫﻤﺮاه دﻓﻊ، زﻣﺎن دﻓﻊ، ﺗﻌﺪاد دﻓﻌﺎت دﻓﻊ در ﻫﻔﺘﻪ. ﺑﺮاي ﺗﻌﯿﯿﻦ ﺷﺪت ﺑﯿﻤﺎري در دوران ﻗﺒﻞ و ﺑﻌﺪ از ﻋﻤﻞ از ﭘﺮﺳﺸﻨﺎﻣﻪ 40 اﻣﺘﯿﺎزي Longo اﺳﺘﻔﺎده ﺷﺪ. ﻋﻤﻞ ﺟﺮاﺣﯽ در وﺿﻌﯿﺖ ﻟﯿﺘﻮﺗﻮﻣﯽ و ﺑﺎ اﺳﺘﻔﺎده از دو اﺳﺘﺎﭘﻠﺮ PPH اﻧﺠﺎم ﺷﺪ و ﺑﯿﻤﺎران ﺑﻪ ﻣﺪت ﯾﮑﺴﺎل ﭘﺲ از ﺟﺮاﺣﯽ ﭘﯿﮕﯿﺮي ﺷﺪﻧﺪ. در اﺑﺘﺪا دادهﻫﺎ ﺑﺎ ﻣﯿﺎﻧﮕﯿﻦ، اﻧﺤﺮاف ﻣﻌﯿﺎر، ﻓﺮاواﻧﯽ و درﺻﺪ و ﺟﺪاول ﺗﻮﺻﯿﻒ ﺷﺪﻧﺪ. ﺑﺮاي ﻣﻘﺎﯾﺴﻪ ﻣﺘﻐﯿﺮﻫﺎ در ﻗﺒﻞ و ﺑﻌﺪ از ﻋﻤﻞ از آزﻣﻮن ﺗﯽ ﻣﺰدوج و در ﺻﻮرت ﻧﺒﻮدن ﺷﺮاﯾﻂ اﺳﺘﻔﺎده از ﻣﻌﺎدل ﻧﺎﭘﺎراﻣﺘﺮي آن وﯾﻠﮑﺎﮐﺴﻮن اﺳﺘﻔﺎده ﺷﺪ. ﺑﺮاي ﺑﺮرﺳﯽ ﻧﺮﻣﺎل ﺑﻮدن دادهﻫﺎ از آزﻣﻮن ﮐﻠﻤﻮﮔـﺮوف اﺳﻤﯿﺮﻧﻮف اﺳﺘﻔﺎده ﺷﺪ. ﺗﺤﻠﯿﻞﻫﺎ ﺑﺎ اﺳﺘﻔﺎده از ﻧﺮماﻓﺰار SPSS, Chicago IL, USA) SPSS 20( اﻧﺠﺎم ﺷﺪ. ﺳﻄﺢ ﻣﻌﻨﯽداري ﺗﻤﺎم آزﻣﻮنﻫﺎ 0/05 در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ. ﯾﺎﻓﺘﻪ ﻫﺎ: در اﯾﻦ ﻣﻄﺎﻟﻌﻪ 33 ﺑﯿﻤﺎر )30 زن و 3 ﻣـﺮد( ﺑﺎ ﻣﯿﺎﻧﮕﯿﻦ ﺳﻨﯽ 54 ﺳﺎل وارد ﺷﺪهاﻧﺪ. ﻣﯿﺎﻧﮕﯿﻦ ﻧﻤـﺮه ODS در ﺑﯿﻤﺎران ﻗﺒﻞ از ﻋﻤﻞ از 14/54±2/67 ﺑﻪ 4/24±2/10 ﺑﻌﺪ از ﻋﻤﻞ ﮐﺎﻫـﺶ ﯾﺎﻓﺖ. در دوران ﻗﺒﻞ و ﺑﻌﺪ از ﻋﻤﻞ در ﻣﯿﺎﻧﮕﯿـﻦ ﻧﻤـﺮه ODS ﺗﻔﺎوت ﻣﻌﻨﯽداري ﻣﺸﺎﻫﺪه ﺷﺪ )0.001

Introduction & Objective: Obstructed Deification Syndrome (ODS) is a condition that affects pelvic floor muscle and causes some structural and functional problems in defecation. Rectocele and intussusceptions are known as the two most important causes of this condition. In this prospective study we assessed the outcome of Stapled Transanal Rectal Resection (STARR) in the patients with ODS, and we tried to compare this results with similar studies. Materials & Methods: This prospective study was performed from April 2010 to March 2012 in the Baqiyatallah hospital in Tehran. All patient underwent STARR for the treatment of ODS enrolled in this study. Preoperative factors like incomplete defecation, straining, using of enema, laxatives, digitations… were assessed. We used Longo’s ODS score for assessment of the severity of pelvic floor’s malfunctions and also, visual analog scale (VAS) for assessing the patient satisfaction. Trans Anal Rectal Resection (STARR) procedure was performed using two circular staplers. All patients had at least one year follow- up after discharge. Results: 33 patients (30 females and 3 male) with an average age of 54, underwent STARR for the treatment of ODS. They had enrolled in this prospective study, and their ODS score was 15.3±3.1 before surgery and 4.9±2.3 after surgery (P<0.0001). Patient had best outcome in their daily defecation and quality of life in our study. After one year at least 27 patients (82%) were symptom free. Conclusions: According this study, we recommend that STARR procedure can be easily used as a treatment of choice for the treatment of rectocele, intussusception and rectal mucosal prolapse, because of its good results and low complications.