اندیکاسیون سزارین از دیدگاه پروکتولوژیست

1. اندیکاسیون سزارین از دیدگاه پروکتولوژیست دکتر رسول عزیزی جراح کولورکتال، دانشیار گروه جراحی دانشکده پزشکی دانشگاه علوم پزشکی ایران مجتمع رسول اکرم، بخش جراحی E-mail:razizimd@hotmail.com

2. Anatomy & physiology of continenceintroduction The ability to retain a bodily discharge voluntarily”. The word has its origins from the Latin continere or tenere, which means “to hold”. The anorectum is the caudal end of the gastrointestinal tract, and is responsible for fecal continence and defecation. In humans, defecation is a viscero somatic reflex that is often preceded by several attempts to preserve continence

4. Mechanisms of Continence and Defecation

5. Risk Factors in Fecal IncontinenceObstetric Events *Sphincteric Injury *Pudental Nerve Injury *Secondary Rectal Sensorimotor Dysfunction

6. There is now clear recognition, supported by a considerable body of evidence, that Obstetric trauma is, by far, the major risk factor for the development of acquired fecal incontinence in women Kamm MA (1994) Obstetric damage and fecal incontinence.Lancet 344:730Bharucha AE (2003) Fecal incontinence. Gastroenterology124:1672-1685

7. In a frequentlyreferenced study by Sultan and colleagues in 1993,ultasound at 6 weeks postpartum revealed sphincter injuries in 35% of primiparous women and 44% of multiparous women. Sultan AH, Kamm MA, Hudson CN et al (1993) Anal sphincter disruption during vaginal delivery. N Eng J Med 329:1905–1911

9. 1-Chaliha C, Kalia V, Stanton SL et al (1999) Antenata prediction of postpartum urinary and fecal incontinence ObstetGynecol 94:689-694 MacArthur C, Glazener CM, Wilson PD, et al(2001) Obstetric practice and faecal incontinence three months after delivery. BJOG 108:678-683 MacArthur C, Bick DE, Keighley MR (1997) Faecal incontinence after childbirth. Br J Obstet Gynaeco104:46-50– the prevalence ofsymptoms of fecal incontinence postpartum instudies involving >130 subjects and shows thatgreater than 10% of women will complain of bowelsymptoms in the first few months following childbirth

10. Oberwalder and colleagues performed a meta-analysis of 717 vaginal deliveries has threenotable results: First, the incidence of anal sphincterdefects in primiparous women was 26.9%. Second,multiparous women had an 8.5% incidence of newsphincter defects. Third, the calculated probabilitythat postpartum fecal incontinence was due to asphincter defect was 76.8–82.8%. Oberwalder M, Connor J, Wexner SD (2003) Metaanalysis to determine the incidence of obstetric anal sphincter damage. Br J Surg 90:1333–1337

11. Episiotomy was at one time believed to be protectiveto the perineum during childbirth and was usedto prevent the occurrence of third- and fourth-degreetears . There is now evidence that episiotomy notonly fails to protect the perineum but has beenassociated with increased tearing and anal sphincterinjury 1-Thacker SB, Banta HD (1983) Benefits and risks of episiotomy: an interpretive review of the English language literature. Obstet Gynecol Surv 38:322–338 2-Klein MC, Gauthier RJ, Robbins JM et al (1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 171:591–598

12. Many papers have been published regardingobstetric lesions as they relate to incontinence. However,it is difficult to accurately quantify the prevalenceof obstetric injury and its effect on the incidenceof incontinence.

13. In addition to direct trauma to the sphincter muscle,pudendal neuropathy is another consequence ofvaginal delivery, which contributes to fecal incontinence.The pudendal nerve is believed to be damagedby the fetal head, which compresses the nerve, causingischemia or stretching its branches repeated pregnancies and deliveries add to the damage, the neuropathy progresses as the woman ages, and the worsening over time causes significant fecal incontinence that presents between 50 and 60 years of age

14. Cesarean section has been advocated as an optionto protect the pelvic floor and reduce the incidence ofpostpartum fecal incontinence; however, this issue iscontroversial. Cesarean section performed aftercervical dilation, especially if performed late in thesecond stage of labor, is not entirely protectiveagainst direct sphincter trauma or pudendal neuropathy At this time, the best practice seems to be evaluation of a woman’s risk factors, informed consent regarding her risk of pelvic floor trauma from vaginal delivery, proper recognition of injury at the time of delivery , and effective postpartum evaluation

15. Nelson et al. covering 15 studies encompassing3,010 Caesarean section and 11,440 vaginal deliveries showed no difference between the rate of either fecal or flatus incontinence between the two different modes of delivery. The implication of both of these studies is that it is pregnancy itself, perhaps in relation to connective tissue properties or perhaps an inherited susceptibility, that can lead to pelvic floor disorders. Nelson RL, Westercamp M, Furner SE (2006)A systematic review of the efficacy of Cesarean section in the preservation of anal continence. Dis Colon Rectum49:1587-1595

16. Risk Factors • Anorectal Anomalies • Spina Bifida • Isolated Sacral Agenesis • Hirschprung’s Disease • Cerebrovascular Accidents • Parkinson's Disease • Multiple Sclerosis • Spinal Cord Injury • Diabetes Mellitus • Ageing • Inflammatory Bowel Disease • Irritable Bowel Syndrome • Anal Surgery • Rectal Resection • Rectal Evacuatory Disorder • Rectal prolapse