Clinical efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter in the treatment of puborectalis syndrome with high anal pressure

Objective To explore the efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter (IAS) in the treatment of puborectalis syndrome with high anal pressure. Methods Twenty-five cases of puborectalis syndrome with high anal resting pressure in the preoperative examination received the operation of partial resection of puborectalis combined with mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o'clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ORB-16007695) . Results Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [ (53.56 ± 9.05) mmHg vs. (92.44 ± 7.06) mmHg, (142.80 ± 20.35) mmHg vs. (210.88 ± 20.56) mmHg, respectively, both P= 0.000]; anorectal angulation at resting state and forced defecation state increased significantly [ (102.32 ± 4.96) ° vs. (95.88 ± 4.01) °, (117.88 ± 5.95) ° vs. (89.52 ± 3.25) °, respectively, both P= 0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28 ± 3.91, 7.40 ± 3.64 and 8.04 ± 4.74) was significantly lower than the preoperative score (16.00 ± 3.69, all P 0.05) . Cleveland Clinic incontinence score was 0 at postoperative 6 and 12 months, and revealed 20 cases were effective among all the surgical patients (80%) . Conclusion Partial resection of puborectalis combined with mutilation of internal anal sphincter can effectively reduce anal pressure and improve symptoms of outlet obstruction, which is an effective method in the treatment of puborectalis syndrome with high anal pressure. Key words: Puborectalis syndrome; Anal resting pressure; Anal maximal squeeze pressure; Internal anal sphincter; Anorectal angulation; Constiption