Anal Sphincter Repair zur Therapie der Stuhlinkontinenz – Wann und wie?

Zusammenfassung

Die anale Inkontinenz ist eine Erkrankung mit hoher Prävalenz in der Bevölkerung. Für einen Großteil der Patienten bedeutet die Erkrankung eine schwere Belastung und führt nicht selten zur sozialen Isolation. Ein palpatorisch und endosonografisch nachgewiesener Sphinkterdefekt kann durch Sphinkterrekonstruktion mit ähnlichen Ergebnissen als End-zu-End-Naht oder in überlappender Technik durchgeführt werden. Eine Verbesserung der Kontinenz kann dadurch bei mehr als 60 % der Patienten erreicht werden. Dieser Effekt lässt aber im Verlauf der Zeit nach, sodass nach 5 Jahren nur noch bei 40–50 % der Patienten die Kontinenzleistung erhalten ist. Die Prognose verschlechtert sich im höheren Lebensalter und bei gleichzeitiger Beckenbodensenkung. Bei der neurogenen Inkontinenz kommt das Prinzip des Anal Repairs zur Anwendung mit Raffung des inneren und äußeren Schließmuskels sowie der Beckenbodenmuskulatur. Dies kann als Posterior oder Anterior Repair bzw. in Kombination (Total Pelvic Floor Repair) durchgeführt werden. Die Erfolgsrate ist gering, sodass diese Verfahren heute nur noch selten zur Anwendung kommen, insbesondere da mit der Sakralnervenstimulation ein weniger invasives, aber auch viel teureres Verfahren zur Verfügung steht. Schwierig bleibt die Interpretation der publizierten Ergebnisse, da der Erfolg der OP sehr unterschiedlich gemessen wird: Subjektive Verbesserung, Zufriedenheit, Veränderung eines Inkontinenzscores oder Erlangung vollständiger Kontinenz. Als gesichert kann allerdings angesehen werden, dass bei einer traumatischen Sphinkterläsion die Ergebnisse nach sofortiger Sphinkterrekonstruktion besser sind als bei einem zweizeitigen Vorgehen mit primärer Stomaanlage.

Abstract

Anal incontinence is a disease of high prevalence. For many patients the disease causes severe stress and often results in social isolation. Whenever a sphincter lesion has been diagnosed by digital rectal examination and endosonographic access, anal sphincter reconstruction can be performed with the same results either in overlapping or in end-to-end suture technique. sing these procedures, in more than 60 % of patients the continence can be initially improved. However, benefit decreases after 5 years down to 40–50 %. The prognosis gets worse with increasing age and supplementary descending pelvic floor. Anal repair with reconstruction of internal and external sphincters is performed in neurogenic incontinence. This can be achieved by posterior or anterior anal repair (total pelvic floor repair). Nowadays these procedures are not common, due to unsuccessfulness. Instead, sacral nerve stimulation as a more expensive but less invasive method has displaced the anal repair on this indication. Interpretation of the published results remains delicate because of heterogenous evaluation criteria of postoperative outcome: subjective amelioration, postoperative satisfaction and quality of life, improvement of incontinence score or achievement of complete anal continence. However, it is proven that after immediate reconstruction of traumatic sphincter lesions the postoperative outcome is better than a two-step operation with primary ostomy.

Schlüsselwörter

Koloproktologie - Stuhlinkontinenz - Sphinkterdefekt - Anal Repair - Sphinkteroplastik

Key words

coloproctology - faecal incontinence - anal sphincter defect - anal repair - sphincteroplasty

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