Abstract
Anal sphincter function after restorative proctocolectomy has mainly been investigated by anal manometry. A significant decrease of basal pressure up to 45%, has been recorded postoperatively, possibly due to sphincter stretch during endoanal mucosectomy. Both abdominal mucosectomy and anastomosis at the level of the anorectal ring have been reported to prevent anal sphincter damage and lead to better continence. The striated sphincter is not significantly affected by the surgical procedure. Pouchanal inhibitory reflex is partly maintained in the presence of a rectal cuff which leaves the ganglionic plexus unaltered; a satisfactory continence is also retained in the absence of the reflex when the rectum is totally excised.
Pouch capacity, compliance and motility have been investigated by endoluminal balloon and probes. Pouch emptying has been studied by a “porridge” test, by a semi-solid medium labelled with technetium-99, and by other methods. A more effective storage function is achieved by large capacity reservoirs which lower the bowel frequency. The motor response to pouch distension, to a meal, and to pharmacological stimuli is usually counteracted by sphincter contraction. Ileal hypermotility may lead to fecal leakage mainly in the presence of weak sphincters. Poor pouch emptying may be related to an anal stricture.
Résumé
On a évalué par manométrie anale la fonction sphinctérienne après coloprotectomie avec rétablissement de continuité. En post-opératoire, on enregistre une baisse de la pression de base de 45%, probablement due à l'etirement du sphincter pendant la mucosectomie endoanale. La mucosectomie par voie abdominale et l'anastomose au niveau de la ligne pectinée sont deux gestes reputés pour éviter le thaumatisme du sphincter et pour améliorer la continence post-opératoire. Le sphincter strié, par contre, n'est normalement pas beaucoup touché par cette opération. Le réflexe inhibitoire réservoir-anus est maintenu car le plexus ganglionnaire du manchon rectal reste intact. La continence est bonne malgré l'absence du circuit réflexe due à l'exérèse rectale. La capacité du réservoir, la compliance et la mobilité rectales ont été étudiées par ballonnets et sondes endocavitaires. La vidange du réservoir a été étudiée notamment par le test au “porridge” et par l'évacuation aux radionucléides semi-solides au Technetium 99. On améliore la fonction de réservoir en augmentant le volume du réservoir, ce qui diminue la fréquence des selles. La réponse motrice à la distension due réservoir, aux repas et aux stimulations pharmacologiques va souvent de pair avec une contraction sphinctérienne. L'hypercinétique iléale peut être responsable d'une incontinence, surtout lorsque le muscle sphinctérien est faible. La mauvaise vidange est parfois en rapport avec une sténose au niveau de l'anastomose anale.
Resumen
La función del esfínter anal luego de proctocolectomía restaurativa ha sido investigada mediante manometría anal principalmente. Una disminución significativa de la presión basal, hasta de 45%, ha sido registrado entel postoperatorio, posiblemente debido al estiramiento del estínter durante la mucosectomía endoanal. Tanto la mucosectomía abdominal como la anastomosis al nivel del anillo ano-rectal han sido acreditados en la prevención del daño del esfíner, lo cual significa mejor continencia. El efínter “hiperstirado” no resulta afectado en forma significativa por el procedimiento quirúrgico. El reflejo inhibitorio bolsa-anal se mantiene parcialmente en presencia de un mango rectal que no altera el plejo ganglionar; también se retiene un grado satisfactorio de continencia en ausencia del reflejo cuando se reseca totalmente el recto.
La capacidad de la bolsa, su compliancia y su motilidad han sido estudiados mediante balones y sondas endoluminales. El vaciamiento de la bolsa ha sido investigado por diversos métodos. Es eviednte que se logra una mejor función de almacenamiento con reservorios de gran capacidad, con los cuales se observa una disminución de la frecuencia de las evacuaciones. La respuesta motora a la distensión de la bolsa, a una comida o a estímulos farmacológicos es usualmente contrapuesta por la contracción del esfínter. La hipermotilidad ileal puede llevar a escape fecal en presencia de esfínteres débiles. El vaciamiento pobre de la bolsa puede estar relacionado con estrechez anal.
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Pescatori, M. The results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease: The manometric assessment of pouch continence and its reservoir function. World J. Surg. 16, 872–879 (1992). https://doi.org/10.1007/BF02066984
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DOI: https://doi.org/10.1007/BF02066984