Suffizienz der End-zu-Endanastomose bei primärer Versorgung eines geburtstraumatischen Analsphinkterrisses

Zusammenfassung

Fragestellung: Beurteilung der Qualität einer End-zu-Endanastomose bei der Primärversorgung geburtshilflich bedingter Analsphinkterrisse. Patientinnen und Methode: 49 Frauen mit Dammriss III. Grades (DR III) sowie eine Kontrollgruppe von 42 Frauen wurden im Verlauf von 3 Jahren postpartum (pp) nachuntersucht. Ergebnisse: Die Primärversorgung durch End-zu-Endanastomose war sonographisch bei 22 (52,4 %) der Frauen insuffizient. 31 (63,2 %) Frauen entwickelten eine Analinkontinenz. Schlussfolgerungen: Die sonomorphologischen Ergebnisse nach End-zu-Endanastomose in dieser Studie sind unbefriedigend. In Anbetracht der hohen Zahl analinkontinenter Frauen nach DR III sollte die Prävention in den Vordergrund gestellt werden, das Benefit eines Second repair zu späterem Zeitpunkt ist zu diskutieren.

Abstract

Purpose: To assess the quality of end-to-end anastomosis in the primary repair of anal sphincter laceration occurring during delivery. Methods: Forty-nine women with third degree perineal laceration (PL III) and 42 controls were included in a 3-year postpartal follow-up study. Results: Ultrasound showed end-to-end anastomosis to be inadequate in 22 (48.1 %) women. Thirty-one (63.2 %) women developed grade I-III anal incontinence. Discussion: There was no correlation between ultrasound findings and the presence of anal incontinence. The unsatisfactory sonomorphometric outcome after 6 weeks results from inadequate repair with retraction of the sphincter ends. Defects newly demonstrated after 36 months indicate dedifferentiating atrophy with damage to peripheral motor nerves.

Schlüsselwörter

Geburtshilfliche Sphinkterrisse - End-zu-End-Anastomose - Analinkontinenz - Endoanale Sonographie

Key words

Obstetric anal sphincter laceration - end-to-end anastomosis - anal incontinence - endoanal ultrasonography

Literatur

• 1 Smith A RB. Role of connective tissue and muscle in pelvic floor dysfunction.  Current Opinion in Obstetrics and Gynecology. 1994;  6 317-319
• 2 Norton P A. Pelvic Floor Disorders: The Role of Fascia and Ligaments.  Clinical Obstetrics and gynecology. 1993;  36 926-928
• 3 Sultan A H. Anal incontinence after childbirth.  Current opinion in obstetrics and gynecology. 1997;  9 320-324
• 4 Phillips R KS. Faecal incontinence-Treatment:anal sphincter repair. In: Henry MM, Swashi M (eds). Coloproctology and the Pelvic Floor. Bullerworth-Heinemann, Oxford 1992
• 5 Laycock J. Clinical evaluation of the Pelvic Floor. In: Schüssler B, Norton P, Stanton S (eds). Pelvic floor Re-education. Principle and Practice. Springer, London 1994; pp 43-48
• 6 Sultan A H, Kamm M A, Bartram C I, Hudson C N. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair.  BMJ. 1994;  308 887-891
• 7 Sorensen M, Tetzschner T, Rasmussen O O, Bjarnesen J, Christiansen J. Sphincter rupture in childbirth.  Br J Surg. 1993;  80 392-394
• 8 Sultan A H, Monga A K, Kumar D, Stanton S L. Primary repair of obstetric anal sphincter rupture using the overlap technique.  Br J Obstet Gynaecol. 1999;  106 318-323
• 9 Franz H BG, Hirsch H A. Beckenbodenrekonstruktion nach geburtstraumatischen Schäden.  Zentralblatt für Chirurgie. 1996;  121 688-691
• 10 Kammerer-Dorak D H, Wesol A B, Rogers R G, Dominguez C E, Dorin M H. A prospective cohort study of women after primary repair of obstetric anal sphincter laceration.  Am J Obstet Gynecol. 1999;  181 1317-1323
• 11 Kamm M A. Obstetric damage and faecal incontinence.  Lancet. 1994;  344 730-733
• 12 Shull B L. Clinical evaluation of women with pelvic support defects.  Clinical Obstetrics and Gynecology. 1993;  36 939-951
• 13 Zetterström J, Lopez A, Anzen B O, Norman M, Holmström B O, Mellgren A. Anal sphincter tears at vaginal delivery: risk factors and clinical outcome of primary repair.  Obstet Gynecol. 1999;  94 21-28
• 14 Wolley R J. Benefits and risks of episiotomy: a review of the English language literature since 1980. Part I and II.  Obstet Gynaecol Surv. 1995;  50 806-835
• 15 Sultan A H, Kamm M A, Hudson C N, Thomas J M, Bartam C I. Anal sphincter disruption during vaginal delivery.  N Engl J Med. 1993;  329 1905-1911
• 16 Tjandra J J, Han W R, Goh J, Carey M, Dwyer P. Direct repair vs. overlapping sphincter repair: a randomized controlled trial.  Dis Colon Rectum. 2003;  46 937-942
• 17 Engel A F, Sultan A H, Kamm M A, Bartram C I, Nicholls R J. Anterior sphincter repair for patients with obstetric trauma.  Br J Surg. 1994;  81 1231-1234
• 18 Fleshman J W, Dreznik Z, Fry R D, Kodner I J. Anal sphincter repair for obstetric injury: manometric evaluation of functional results.  Dis Col Rectum. 1991;  99 724-726