Zusammenfassung
Seit 25 Jahren werden geklammerte transanale Resektionsverfahren angewandt. Um die Jahrtausendwende haben sich transanale Operationen bei obstruktiven Stuhlentleerungsstörungen etabliert. Ausgehend von der Mukosaresektion in Staplertechnik, entwickelte sich zunächst ein Doppelstaplerverfahren, und schließlich wurden mannigfaltige transanale Resektionsverfahren vorgestellt und etabliert. Anfänglich wurden sehr gute Ergebnisse mit deutlichen Verbesserungen der Stuhlentleerungsstörungen beschrieben. Schon bald aber häuften sich die Publikationen über Komplikationen und den mangelnden Benefit der Operation. Das nur schwer eindeutig kategorisierbare obstruktive Defäkationssyndrom als solches wurde in der Folge für die mangelnden operativen Verbesserungen ausgemacht. Es war vom Eisbergsyndrom die Rede, bei dem es neben objektivierbaren auch eine Menge an verborgenen Ätiologien für das Krankheitsbild gibt. Erfolgreich therapierbar mit alleiniger transanaler Rektumresektion erscheinen aber allenfalls ganz isolierte Rektozelen und Intussuszeptionen bei sonst erhaltener Beckenbodenstabilität. Ist aber die Rektozele mit einem Genitalprolaps vergesellschaftet, was überwiegend der Fall ist, kann die obstruktive Entleerungsstörung nicht allein mit transanaler Resektion therapiert werden. Vielmehr stehen reponierende, suspendierende Verfahren im Vordergrund. Antonio Longo hat 2012 eine laparoskopische Operation etabliert, bei der die Ligamenta cadinalia des Uterus seitlich netzverstärkt werden, die sog. „pelvic organ prolapse suspension“. Die Zusammenarbeit mit den behandelnden Gynäkologen ist für eine erfolgreiche Behandlung essenziell, außerdem eine gute Patientenbegleitung, der rechtzeitige Beginn mit konservativen und operativen Maßnahmen und eine sorgfältige und eher zurückhaltende Indikationsstellung.
Abstract
Stapled transanal resection methods have been used for 25 years. Transanal operations for obstructed stool emptying disorders were established at the turn of the millennium. Starting from the mucosal resection using the stapling technique, a double stapling procedure was initially developed and finally a multitude of transanal resection procedures were presented and established. Initially, very good results with significant improvement of the stool emptying disorders were described. Soon, however, publications abounded about complications and the lack of benefits of the operation. The obstructed defecation syndrome as such, which is difficult to clearly categorize, was subsequently identified as the reason for the lack of surgical improvements. There was talk of the iceberg syndrome, in which there are not only objectifiable etiologies but also a large number of hidden etiologies for the disease picture. Successfully treatable with transanal rectal resection alone, however, appear to be at best completely isolated rectoceles and intussusceptions in otherwise preserved pelvic floor stability; however, if the rectocele is associated with a genital prolapse, and this is predominantly the case, the obstructed emptying disorder cannot be treated with transanal resection alone. The focus is more on repositioning and suspending procedures. Antonio Longo established a laparoscopic operation in 2012, in which the cardinal ligaments of the uterus are laterally strengthened with meshes, so-called pelvic organ prolapse suspension. The cooperation with the treating gynecologists is essential for a successful treatment as well as a good patient accompaniment, the timely initiation of conservative and operative measures and an extremely careful and relatively cautious assessment of the indications.
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Aumann, G., Longo, A. Il pavimento pelvico non esiste – transanale Verfahren in der Behandlung des obstruktiven Defäkationssyndroms und Descensus perinei. coloproctology 43, 338–344 (2021). https://doi.org/10.1007/s00053-021-00557-x
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DOI: https://doi.org/10.1007/s00053-021-00557-x
Schlüsselwörter
- Beckenbodeninsuffizienz
- Funktionelle Entleerungsstörung
- Transanale Rektumresektion
- Laparoskopische transabdominelle Suspensionsverfahren
- STARR-Operation