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이상전 충북대학교 의학연구소 2001 忠北醫大學術誌 Vol.11 No.2
자궁탈에 동반된 직장질루는 매우 드문 질환이다. 본 증례는 자궁탈이 있던 노파로서 항문직장륜 직상방에 직장질루가 발생하여 이를 통해 직장 전벽이 탈출된 경우이다. 자궁탈이 질후벽의 약화와 긴 종주형 열개를 초래하고 직장 질루도 발생하여 누공을 통해 직장 전벽이 외번되어 탈출되어 나온 것으로 추정된다. 경복강으로 자궁전적출술 및 양측 부속기 절제술을 시행하고 직장을 직장질루 수준 하방까지 박리한 후 절제한 다음 경회음 접근으로 결장항문 문함을 시행하였다. 그리고 질후벽 열개를 누공을 포함하여 복구한 후 망막을 질 후벽과 결장항문 문합부 사이에 끼워 넣어 고정시켰다. 수술후 재발의 징후나 변실금 증상이 없이 양호한 결과를 얻었기에 보고하는 바이다. Rectovaginal fistula associated with uterine prolapse is a very rare entity. The case presented here is that of an elderly woman with uterine prolapse, associated with the anterior rectal wall herniation through rectovaginal fistula just above the anorectal ring. It is thought that uterine prolapse had caused weakness and a long diastasis of the posterior vaginal wall, and also rectovaginal fistula, then the anterior rectal wall herniated with eversion through rectovaginal fistula. Total abdominal hysterectomy with bilateral salpingooophorectomy was performed. The rectum was mobilized down to just beyond the level of the rectovaginal fistula and rejected at that point. Then, from a perineal approach, coloanal anastomosis was performed according to Parks' sleeve anastomosis technique. After repair of the long diastasis of the posterior vaginal wall with inclusion of the fistula opening, a portion of the omentum was interposed between the posterior vaginal wall and the coloanal anastomosis site.
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이상전 대한대장항문학회 2008 Annals of Coloproctolgy Vol.24 No.1
Many patients have functional disturbances after a traditional restorative rectal resection, complaining of urgency, frequent bowel movements, and occasional fecal incontinence. The rectal reservoir function is disturbed, and this is related to the size of the rectal remnant and the elastic properties of the neorectal wall. A straight anastomosis is recommended when the reservoir capacity of the rectal remnant is sufficient. A side-to-end anastomosis is probably preferable to an end-to-end anastomosis. If a straight anastomosis is considered, the descending colon is much better than the sigmoid colon. If optimal functional results are to be obtained soon after surgery, construction of a pouch is recommended when the rectal remnant is very short. There seems to be a balance between continence without urgency and evacuation ability. For patients with weak sphincter muscles and habitually loose feces, the surgeon should tailor the length of the pouch to be longer whereas it should be made smaller for patients with a pre-operative tendency toward constipation. In the long-term, bowel adaptation may also enable the function after a straight anastomosis to approximate that of a colonic J-pouch anal anastomosis. Where the pelvis is too narrow for a bulky colonic J-pouch anal anastomosis, a coloplasty-anal- anastomosis is an option. The latter results in postoperative bowel function comparable with that of the colonic J-pouch. Traditionally, poor bowel function has been managed expectantly. The colonic adaptation may take one or two years to occur after a low anterior resection. The patient is advised to take adequate soluble fiber in the diet and to avoid foods which aggravate the bowel dysfunction. Those with increased stool frequency are prescribed constipating agents to help control the symptoms. Patients with rectal evacuation problems are prescribed regular laxatives and enemas.
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이상전 충북대학교 의과대학 충북대학교 의학연구소 1999 忠北醫大學術誌 Vol.9 No.1
연구목적 : 직장류로 경질적 교정술을 시행한 환자들을 대상으로 임상적 고찰을 하여 이 질환의 임상적 양상과 이 술식의 술후 성적을 분석하여 이 술식의 유용성을 알아보고자 하였다. 대상 및 방법 : 충북대학교병원 외과에서 직장류로 진단 받고 보존적 요법을 시행하여도 증상의 현저한 호전이 없어 경질적 교정술을 시행 받은 환자 중 6개월 이상 추적이 가능했던 22명(33세-72세, 평균 43.6세)을 대상으로 임상적 고찰을 하였다. 술 전 임상증상에 관한 문진, 회음부 진찰을 통해 직장류를 진단하였으며 확진과 동반된 질환의 유무를 확인하기 위해 배변조영술을 시행하였다. 수술 대상은 보존적 요법을 시행하여도 증상의 현저한 호전이 없으며 변을 배출시키기 위해 질 속에 손가락을 집어넣어 직장을 향해 질후벽을 누르거나 직접 손가락으로 변을 파내는 경우, 배변조영술에서 직장류에 모조변이 고이는 경우, 크기가 아주 크며 직장 전방벽 탈출이 동반된 경우로 제한하였다. 결 과 : 대상 환자는 모두 여자였으며 나이는 33세에서 72세로 평균 43.6세였으며 30대와 40대가 가장 많았다. 임상 증상으로는 만성적으로 배변시 항상 힘을 주는 것 21예, 배변을 하여도 변이 남아 있는 느낌 20예, 변을 배출시키기 위해 손을 사용하는 것 15예, 직장충만감 14예 등이었다. 증상 발생 시부터 교정술을 시행하기까지의 경과 기간은 4개월에서 25년으로 평균 3.4년이었다. 이학적 진찰상 동반된 질환으로는 치액 7예, 직장점막탈출 5명, 치골직장근이완부전 2예, 방광류 1예, 소장류 1예 있었다. 배변조영술상 직장류만 관찰된 경우가 14예이었고 그 외 동반 병변으로는 직장내부중첩 10예, 치골직장근이완부전 3예, 소장류 1예 있었다. 동반 질환에 대한 수술로 치핵절제술 6예, 탄성고무결찰 술 1예, 직장내부중첩에 대한 Gant-Miwa 수술 6예, 소장류 교정술 1예 시행하였다. 술후 증상의 현저한 호전을 보인 경우가 19예로 86.4%를 차지하였으나, 별 변화가 없었던 경우도 2예 있었으며 일시적인 증상 호전을 보였으나 직장류가 다시 발생한 경우도 1예 있었다. 그리고 창상 감염은 단 한 예도 볼 수 없었다. 결론 : 직장류 환자에서 수술 적응증을 신중히 선택하여 경질적 교정술을 시행하면 우수한 성적을 기대할 수 있다고 생각한다. Purpose : The aim of this study was to review our experience with patients with rectoceles using selective criterior for operative repair and to critically review our surgical results. Materials and Method : Clinical review about twenty-two women who underwent transvaginal repair of rectocele was performed. Preoperatively clinical interview, physical examination on the perineum, and defecography was done. Indications for the repair were 1) Sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation 2) Retention of artifical stool in the rectocele on defecography 3) Very large rectocele with internal anterior rectal wall prolapse. At sixth month postoperatively clinical interview and physical examination for any evidence of rectocele were performed. Result : Symptoms for rectocele consisted of excessive straining, sensation of incomplete evacuation, manual assistance, sense of fullness in 21, 20, 15, 14 cases respectively. Associated diseases on the physical examination were hemorrhoid, rectal mucosal prolapse, nonrelaxing puborectalis, cystocele, enterocele in 7, 5, 2, 1, 1 cases respectively. Findings on the defecography were rectocele only, intussusception, nonrelaxing puborectalis, enterocele, in 14, 7, 3, 1 cases respectively. Operation for associated diseases were hemorrhoidectomy, elastic band ligation, Gant-Miwa operation, repair of enterocele in 6, 1, 6, 1 cases respectively. Postoperatively the symptoms remarkably improved in 19 patients, whereas they did not in 2 patients. In one patient the symptom improved immediately after the operation but it recurred 5 months thereafter. We could not find any sexual or wound complications after the operation. Conclusion : Our data suggest that careful selection of patients using specific criteria may result in very good clinical results.
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이상전 대한대장항문학회 2005 Annals of Coloproctolgy Vol.21 No.5
Human colonic motor activity is quite a complex issue and is a relatively difficult topic to investigate, still only partly understood and investigated, due to anatomic and physiological difficulties. Colonic motility measurement are hampered by the relative inaccessibility of the colon, especially in the unprepared state. Major motor events are infrequent, necessitating long observation periods. Moreover, correlating intraluminal pressure changes with stool transport is difficult. Disturbances of normal colonic motor activity may interfere with healthy colonic physiologic function. The pathophysiological mechanisms responsible for colonic motility disorders are still less understood. In recent years, however, some more data have been obtained, even in proximal segments. These data have helped in elucidating, although only in part, some pathophysiological mechanisms of colonic motility disorders. In this review article, after a brief of relevant normal aspects of colorectal motility in man, we limit our discussion to more common motility disorders involving the colon and rectum. In particular, what is known or hypothesized regarding the underlying pathophysiology of slow-transit constipation, diverticular diseases, irritable bowel syndrome, and intestinal pseudo-obstruction is reviewed.
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