Skip to main content
SpringerLink
Log in

Anatomische Physiologie des Sphinkterorgans — funktionelle Grundlage beim sphinktererhaltenden Therapiekonzept des Rektumkarzinoms

Anatomy and physiology of the anal sphincters — Functional basis for the concept of sphincter-preservation in rectal surgery

  • Themenschwerpunkt: „Rektumkarzinom — Sphinktererhaltung“
  • Published:
Acta chirurgica Austriaca Aims and scope Submit manuscript

Zusammenfassung

Grundlagen: Die normale Anatomie und Physiologie des anorektalen Kontinenzorgans sind die Voraussetzung für den ungestörten Mechanismus von Defäkation bzw. fäkaler Kontinenz.

Methodik: Anhand anatomischer und physiologischer Untersuchungen werden die Grundlagen der Phinktererhaltung dargestellt.

Ergebnisse: Operationen am Sphinkterapparat können Inkontinenzsymptome nach sich ziehen, ebenso wie die teilweise oder vollständige Resektion des rektalen Reservoirs, die zusätzlich zu beträchtlichen Änderungen der Stuhlgewohnheiten führen kann. Die vordere Resektion mit koloanaler Anastomose als Modell eines extremen sphinktererhaltenden Verfahrens resultiert in einer Funktionseinschränkung des M. sphincter ani internus und einer erhöhten Stuhlfrequenz aufgrund des Reservoirverlusts. Die initialen Probleme von Defäkation und Kontinenz gehen in den ersten 12 Monaten nach Kolostomieverschluß zurück.

Schlußfolgerungen: Aufgrund des Risikos der postoperativen Inkontinenz ist bei Patienten mit tiefsitzendem Rektumkarzinom die Indikation zur extremen sphinktererhaltenden Operation nur bei präoperativ normaler Sphinkterfunktion zu stellen. Wesentliche Parameter werden durch präzise Kontinenzanamnese und Sphinktermanometrie erbracht.

Summary

Background: The normal anatomy and physiology of the anorectal organ of continence is the prerequisite for an undisturbed mechanism of defecation and fecal continence respectively.

Methods: By using anatomical and physiological data the basis of sphincterpreservation is described.

Results: Operations involving the sphincter apparatus may be followed by symptoms of incontinence, just as partial or total resection of the rectal reservoir, that in addition may lead to substantial changes of the bowel habits. Anterior resection with coloanal anastomosis as a model of an extreme sphinctersaving procedure results in a reduced function of the internal anal sphincter and in an increased frequency of evacuations due to the loss of reservoir. The initial problems of defecation and continence tend to improve during the first 12 months after closure of colostomy.

Conclusions: In view of the risk of postoperative incontinence in patients with low rectal cancer the indication for extreme sphinctersaving surgery depends on normal preoperative sphincterfunction. Relevant parameters are assessed by a precise history of continence and sphinctermanometry.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Bates T: Rectal prolapse after anorectal dilatation in the elderly. Br med J 1972;2:505.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Batignani G, Monaci I, Ficari F, Tonelli F: What affects continence after anterior resection of the rectum? Dis Colon Rectum 1991;34:329–335.

    Article  CAS  PubMed  Google Scholar 

  3. Bennett RC: A review of the results of orthodox treatment for anal fistulae. Proc Roy Soc Med 1962;55:756.

    CAS  PubMed  Google Scholar 

  4. Bennett RC, Goligher JC: Results of internal sphincterotomy for anal fissure. Br med J 1962;2:1500–1503.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Bennett RC, Friedman MH, Goligher JC: Late results of haemorrhoidectomy by ligature and excision. Br Med J 1963;2:216–219.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Castrini G, Pappalardo G, Mobarhan S: A new technique for ileoanal and coloanal anastomosis. Surgery 1985;97:111–116.

    CAS  PubMed  Google Scholar 

  7. Catchpole BN: Motor pattern of the left colon before and after surgery of rectal cancer: possible implications in other disorders. Gut 1988;29:624–630.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Deleu HWO: Het villeus adenoom van het rectum. Een transsphincterische benadering. Proefschrift. Brakkenstein, Nijmegen, 1980.

    Google Scholar 

  9. Duthie HL, Bennett RC: The relation of sensation in the anal canal to the function of the anal sphincter: a possible factor in anal continence. Gut 1963;4:179–182.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Enker WE, Stearns MW Jr, Janor AJ: Peranal colonal anastomosis following low anterior resection for rectal carcinoma. Dis Colon Rectum 1985;28:576–581.

    Article  CAS  PubMed  Google Scholar 

  11. Feil W, Wunderlich M, Kovats E, Neuhold N, Schemper M, Schiessel R: Rektumkarzinom: Prognostisch relevante Faktoren für die Entstehung von Lokalrezidiven nach radikaler vorderer Resektion. Wien klin Wschr 1990;13:363–369.

    Google Scholar 

  12. Gaston EA: Fecal continence following resections of various portions of the rectum with preservation of the anal sphincters. Surg Gyn Obstet 1948;87:669–678.

    CAS  Google Scholar 

  13. Gaston EA: Physiological basis for preservation of fecal continence after resection of the rectum. JAMA 1951;146:1486–1489.

    Article  CAS  Google Scholar 

  14. Goligher JC, Graham NG, Clark CG, DeDombal FT, Giles G: The value of stretching the anal sphincters in the relief of post-haemorrhoidectomy pain. Br J Surg 1969;56:859–861.

    Article  CAS  PubMed  Google Scholar 

  15. Goligher JC: The functional results after sphincter-saving resections of the rectum. Ann Roy Coll Surg Engl 1951;8:421–439.

    CAS  Google Scholar 

  16. Goligher JC, Duthie HL, DeDombal FT, McK Watts J: Abdomino-anal pull-through excision for tumours of the mid-third of the rectum. Br J Surg 1965;52:323–335.

    Article  CAS  PubMed  Google Scholar 

  17. Goligher JC: Surgery of the anus, rectum and colon. 5th ed. London, Baillière Tindall, 1984.

    Google Scholar 

  18. Goligher JC, Hughes ESR: Sensibility of the rectum and colon. Its role in the mechanism of anal continence. Lancet 1951;1:543–547.

    Article  CAS  PubMed  Google Scholar 

  19. Gowers WR: The automatic action of the sphincter ani. Proc Roy Soc Lond 1877;26:77–89.

    Article  Google Scholar 

  20. Gross E, Beersiek F, Eigler FW: Sphincterfunktion nach peranalen Anastomosen. Langenbecks Arch Chir 1980;353:207–216.

    Article  CAS  PubMed  Google Scholar 

  21. Hardcastle JD, Parks AG: A study of anal incontinence and some principles of surgical treatment. Proc Roy Soc Med 1970;63 (Suppl): 116–118.

    PubMed  PubMed Central  Google Scholar 

  22. Hautefeuille P, Valleur P, Perniceni T, Martin P, Galian A, Cherqui D, Hoang C: Functional and oncologic results after coloanal anastomosis for low rectal carcinoma. Ann Surg 1988;207:61–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Henry MM, Swash M: Assessment of pelvic floor disorders and incontinence by electrophysiological recording of the anal reflex. Lancet 1978;1:1290–1291.

    Article  CAS  PubMed  Google Scholar 

  24. Hoffmann DC, Goligher JC: Lateral subcutaneous internal sphinceterotomy in treatment of anal fissure. Br Med J 1970;3:673.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Horgan PG, O’Connell PR, Shinkwin CA, Kirwan WO: Effect of anterior resection on anal sphincter function. Br J Surg 1989;76:783–786.

    Article  CAS  PubMed  Google Scholar 

  26. Huber A, Wunderlich M: Gibt es ein Standardverfahren für die Hämorrhoidektomie? Chirurgische Gastroenterologie mit interdisziplinären Gesprächen 1986;2:23–26.

    Google Scholar 

  27. Iwai N, Hashimoto K, Yamane T, Kojima O, Nishioka B, Fujita Y, Majima S: Physiologic status of the anorectum following sphincter-saving resection for carcinoma of the rectum. Dis Colon Rectum 1982;25:652–659.

    Article  CAS  PubMed  Google Scholar 

  28. Keighley MRB, Matheson D: Functional results of rectal excision and endo-anal anastomosis. Br J Surg 1980;67:757–761.

    Article  CAS  PubMed  Google Scholar 

  29. Khubchandani IT, Reed JF: Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 1989;76:431–434.

    Article  CAS  PubMed  Google Scholar 

  30. Kirwan WO, Turnbull RB Jr, Fazio VW, Weakly FL: Pullthrough operation with delayed anastomosis for rectal cancer. Br J Surg 1978;65:695–698.

    Article  CAS  PubMed  Google Scholar 

  31. Kirwan WO, Riordain MG, Waldron R: Declining indications for abdominoperineal resection. Br J Surg 1989;76:1061–1063.

    Article  CAS  PubMed  Google Scholar 

  32. Lane RHS, Parks AG: Function of the anal sphincters following colo-anal anastomosis. Br J Surg 1977;64:596–599.

    Article  CAS  PubMed  Google Scholar 

  33. Leijonmarck CE, Löfberg R, Öst A, Hellers G: Long-term results: of ileorectal anastomosis in ulcerative colitis in Stockholm County. Dis Colon Rectum 1990;33:195–200.

    Article  CAS  PubMed  Google Scholar 

  34. Localio SA, Eng K, Coppa GF: Abdominosacral resection for midrectal cancer. A fifteen-year experience. Ann Surg 1983;198:320–324.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Marks, Ritchie: Anal fistulas at St. Mark’s Hospital. Br J Surg 1977;64:84.

    Article  CAS  PubMed  Google Scholar 

  36. Mason AY: Transsphincteric approach to rectal lesions. Surg Ann 1977;9:171.

    CAS  Google Scholar 

  37. McAnena OJ, Heald RJ, Lockhart-Mummery HE: Operative and functional results of total mesorectal excision with ultra-low anterior resection in the management of carcinoma of the lower one-third of the rectum. Surg Gyn Obstet 1990;170:517–521.

    CAS  Google Scholar 

  38. McDonald PJ, Heald RJ: A survey of postoperative function after rectal anastomosis with circular stapling devices. Br J Surg 1983;70:722–729.

    Google Scholar 

  39. Nicholls RJ, Lubowski DZ, Donaldson DR: Comparison of colonic reservoir and straight colo-anal reconstruction after rectal excision. Br J Surg 1988;75:318–320.

    Article  CAS  PubMed  Google Scholar 

  40. Oakley JR, Jagelman DG, Fazio VW, Lavery IC, Weakley FL, Easley K, Farmer RG: Complications and quality of life after ileorectal anastomosis for ulcerative colitis. Am J Surg 1985;149:23–30.

    Article  CAS  PubMed  Google Scholar 

  41. Oh C, Kark AE: The transsphincteric approach to mid and low rectal villous adenoma: anatomic basis of surgical treatment. Ann Surg 1972;176:605–612.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Olsen J, Mortensen PE, Krogh Petersen I, Christiansen J: Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation. A randomized study. Int J Colorect Dis 1987;2:155–157.

    Article  CAS  Google Scholar 

  43. Pappalardo G, Toccaceli S, Dionisio P, Castrini G, Ravo B: Preoperative and postoperative evaluation by manometric study of the anal sphincter after coloanal anastomosis for carcinoma. Dis Colon Rectum 1988;31:119–122.

    Article  CAS  PubMed  Google Scholar 

  44. Parks AG, Percy JP: Resection with sutured colo-anal anastomosis for rectal carcinoma. Br J Surg 1982;69:301–304.

    Article  CAS  PubMed  Google Scholar 

  45. Parks AG: Endoanal technique of low colonic anastomosis. Surg Techn Ill 1977;2:63–70.

    Google Scholar 

  46. Parks AG; Stitz RW: The treatment of high fistula-in-ano. Dis Colon Rectum 1976;19:487–499.

    Article  CAS  PubMed  Google Scholar 

  47. Read MG, Read NW, Haynes WG, Donnelly TC, Johnson AG: A prospective study of the effect of haemorrhoidectomy on sphincter function and faecal continence. Br J Surg 1982;69:396–398.

    Article  CAS  PubMed  Google Scholar 

  48. Read M, Read NW, Barber DC, Duthie HL: Effects of loparamide on anal sphincter function in patients complaining of chronic diarrhea with fecal incontinence and urgency. Dig Dis Sci 1982;27:807–814.

    Article  CAS  PubMed  Google Scholar 

  49. Rudd WWH: The transanal anastomosis: a sphincter-saving operation with improved continence. Dis Colon Rectum 1979;72:102–105.

    Article  Google Scholar 

  50. Schärli AF, Kiesewetter WB: Defecation and continence: Some new concepts. Dis Colon Rectum 1970;13:81–107.

    Article  PubMed  Google Scholar 

  51. Schweiger M, Schellerer W, Kuypers G: Kontinenz nach tiefer Rectumresektion. Langenbecks Arch Chir 1977;343:281–292.

    Article  CAS  PubMed  Google Scholar 

  52. Suzuki H, Matsumoto K, Amano S, Fujioka M, Honzumi M: Anorectal pressure and rectal compliance after low anterior resection. Br J Surg 1980;67:655–657.

    Article  CAS  PubMed  Google Scholar 

  53. Swash M: The neuropathology of idiopathic faecal incontinence, in Cavanagh NB, Thomas Smith W (edsg): Recent advances in neuropathology. Vol 2. Edinburgh, Churchill Livingstone, 1982, pp 243–271.

    Google Scholar 

  54. Thiede A, Jostarndt L, Troidl H, Poser HL, Bertz U, Hamelmann H: Der Wert der zirkulären maschinellen Colon- und Rectumanastomose (EEA). Eine prospektive Studie an 91 Patienten. Chirurg 1981;52:20–35.

    Google Scholar 

  55. Vellacott KD, Hardcastle JD: Is continued and dilatation necessary after a Lord’s procedure for haemorrhoids? Br J Surg 1980;67:658–659.

    Article  CAS  PubMed  Google Scholar 

  56. Vernava AM III, Robbins PL, Brabbee GW: Restorative resection: coloanal anastomosis for benign and malignant disease. Dis Colon Rectum 1989;32:690–693.

    Article  PubMed  Google Scholar 

  57. Watts JM, Bennett RC, Goligher JC: Stretching of the anal sphincters in the treatment of fissure-in-ano. Br Med J 1964;2:342.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Williams NS, Price R, Johnston D: The long term effect of sphincter preserving operations for rectal carcinoma on function of the anal sphincter in man. Br J Surg 1980;67:203–208.

    Article  CAS  PubMed  Google Scholar 

  59. Wunderlich M, Parks AG: Physiology and pathophysiology of the anal sphincters. Int Surg 1982;67:291–298.

    CAS  PubMed  Google Scholar 

  60. Wunderlich M, Teleky B, Schiessel R: Sphincterfunktion nach coloanaler Anastomose. Langenbecks Arch Chir 1986;367:259–269.

    Article  CAS  PubMed  Google Scholar 

  61. Wunderlich M, Karner-Hanusch J, Schiessel R: Results of coloanal anastomosis. A prospective study. Int J Colorect Dis 1986;1:157–161.

    Article  CAS  Google Scholar 

  62. Wunsch D, Teleky B, Wunderlich M: Operationsindikation bei fäkaler Inkontinenz: Sphinktermanometrie als Entscheidungshilfe. Acta chir Austriaca 1988;20:275–276.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Chirurgische Abteilung, A.ö. Krankenhaus Hollabrunn, Winiwarterstraße 6, A-2020, Hollabrunn, Germany

    M. Wunderlich

Authors
  1. M. Wunderlich
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wunderlich, M. Anatomische Physiologie des Sphinkterorgans — funktionelle Grundlage beim sphinktererhaltenden Therapiekonzept des Rektumkarzinoms. Acta Chir Austriaca 26, 130–136 (1994). https://doi.org/10.1007/BF02620012

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02620012

Schlüsselwörter

Key-words

Search

Navigation