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1
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Liu J, Shi X, Niu Z, Qian C. Comparative efficacy of intraoperative radiotherapy and external boost irradiation in early-stage breast cancer: a systematic review and meta-analysis. PeerJ 2023; 11:e15949. [PMID: 37744215 PMCID: PMC10512934 DOI: 10.7717/peerj.15949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023] Open
Abstract
External boost radiotherapy (EBRT) and intraoperative radiotherapy (IORT) are shown to be effective in patients with early-stage breast cancer. However, the difference between IORT and EBRT for patients' prognosis remains to be elucidated. The purpose of this meta-analysis is to investigate differences in local recurrence (LR), distant metastases, disease free survival (DFS), and overall survival (OS) between these two therapies. We searched the Cochrane Library, PubMed, Web of Science and Embase, from inception to Jan 10th, 2022. We used The Cochrane risk-of-bias assessment tool to assess the risk of bias of the included studies, and the STATA15.0 tool was used for the meta-analyses. Eight studies were ultimately included. Meta-analysis demonstrated that there was an inconsistent finding in the long-term risk of LR between the two radiotherapies, and there was no significant difference in short-term risk of LR, the metastasis rate, DFS, and OS IORT would be more convenient, less time-consuming, less costly, and more effective at reducing side effects and toxicity. However, these benefits must be balanced against the potential for increased risk of LR in the long term.
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Affiliation(s)
- Jiaxin Liu
- Xiamen Hospital, Fudan University Shanghai Cancer Center, Xiamen, China
| | - Xiaowei Shi
- Xiamen Hospital, Fudan University Shanghai Cancer Center, Xiamen, China
| | - Zhenbo Niu
- Affiliated Cancer Hospital of Harbin Medical University, Harbin, China
| | - Cheng Qian
- Affiliated Cancer Hospital of Harbin Medical University, Harbin, China
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2
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Bharucha AE, Knowles CH. Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era. Neurogastroenterol Motil 2022; 34:e14453. [PMID: 36102693 PMCID: PMC9887546 DOI: 10.1111/nmo.14453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/06/2022] [Accepted: 08/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. PURPOSE We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles H Knowles
- Blizard Institute (Knowles), Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
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3
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Omar W, Elfallal AH, Emile SH, Elshobaky A, Fouda E, Fathy M, Youssef M, El-Said M. Horizontal versus vertical plication of the rectovaginal septum in transperineal repair of anterior rectocele: a pilot randomized clinical trial. Colorectal Dis 2021; 23:923-931. [PMID: 33314521 DOI: 10.1111/codi.15483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/09/2020] [Accepted: 12/05/2020] [Indexed: 12/19/2022]
Abstract
AIM Anterior rectocele is usually an asymptomatic condition in many women, yet it can be associated with obstructed defaecation syndrome (ODS). Transperineal repair of rectocele (TPR) has been followed by variable rates of improvement in ODS. The present pilot randomized clinical trial aimed to evaluate the outcome of TPR with vertical plication (VP) of the rectovaginal septum compared to horizontal plication (HP). METHODS Adult women with anterior rectocele were recruited to the study and were randomly allocated to one of two equal groups. The first group underwent TPR with VP of the rectovaginal septum and the second group underwent TPR with HP. The main outcome measures were improvement in ODS, recurrence of rectocele, complications and dyspareunia. RESULTS The trial included 40 female patients with anterior rectocele. There was no significant difference between the two groups regarding the postoperative Wexner score. Complete cure and significant improvement in ODS symptoms were comparable after the two techniques. The reduction in rectocele size after HP was significantly greater than after VP (1.7 vs. 2.6, P < 0.0001). Significant improvement in dyspareunia was recorded after HP (P = 0.001) but not after VP (P = 0.1). There was no significant difference between the two groups with regard to operating time, complications and recurrence. CONCLUSION VP and HP of the rectovaginal septum in TPR were associated with a comparable improvement in ODS symptoms and similar complication rates. HP was followed by a greater reduction in the rectocele size and greater improvement in dyspareunia than VP.
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Affiliation(s)
- Waleed Omar
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Ahmed Hossam Elfallal
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Ayman Elshobaky
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Elyamani Fouda
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Mohammad Fathy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Mohamed Youssef
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Mohamed El-Said
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
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4
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Aubert M, Mege D, Le Huu Nho R, Meurette G, Sielezneff I. Surgical management of the rectocele - An update. J Visc Surg 2021; 158:145-157. [PMID: 33495108 DOI: 10.1016/j.jviscsurg.2020.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.
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Affiliation(s)
- M Aubert
- Department of digestive and general surgery, Aix Marseille university, Timone hospital, Assistance publique-Hopitaux de Marseille (AP-HM), 13354 Marseille, France
| | - D Mege
- Department of digestive and general surgery, Aix Marseille university, Timone hospital, Assistance publique-Hopitaux de Marseille (AP-HM), 13354 Marseille, France.
| | - R Le Huu Nho
- Department of digestive and general surgery, Aix Marseille university, Timone hospital, Assistance publique-Hopitaux de Marseille (AP-HM), 13354 Marseille, France
| | - G Meurette
- Department of cancer, digestive and endocrine surgery, Nantes university hospital, 44093 Nantes, France
| | - I Sielezneff
- Department of digestive and general surgery, Aix Marseille university, Timone hospital, Assistance publique-Hopitaux de Marseille (AP-HM), 13354 Marseille, France
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5
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Pagano C, Venturi M, Benegiamo G, Melada E, Vergani C. Mucopexy-Recto Anal Lifting (MuRAL) in managing obstructed defecation syndrome associated with prolapsed hemorrhoids and rectocele: preliminary results. Ann Surg Treat Res 2020; 98:277-282. [PMID: 32411633 PMCID: PMC7200604 DOI: 10.4174/astr.2020.98.5.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Treatment of rectocele associated with prolapsed hemorrhoids is a debated topic. Transanal stapling achieved good midterm results in patients with symptoms of obstructed defecation, nevertheless a number of severe complications have been reported. The aim of this study was to evaluate the safety and efficacy of a new endorectal manual technique in patients with obstructed defecation due to the combination of muco-hemorrhoidal prolapse and rectocele. Methods Patients enrolled after preoperative obstructed defecation syndrome (ODS) score, defecography and anoscopy were submitted to the novel Mucopexy-Recto Anal Lifting (MuRAL) combined with a modified Block procedure, and followed up by independent observers with digital exploration 3 weeks postoperatively, and digital exploration plus anoscopy at 3, 6, and 12 months. Operative time, hospital stay, numerating rating scale (NRS), ODS, satisfaction scores, and recurrence rate were recorded. Results Mean operative time was 35.7 minutes. Fifty-six patients completed 1-year follow-up: 7.1% had acute urinary retention, NRS score was < 3 from the third postoperative day, mean time of daily activity resumption was 12 days, none had persistent fecal urgency, 82% declared excellent/good satisfaction score, significant improvement of 6- and 12-month ODS score, no recurrence of rectocele, and 7.1% recurrence of prolapsed hemorrhoids were observed. Conclusion MuRAL associated with modified Block technique gave no severe complications and resulted in a safe and effective approach to symptomatic rectocele associated with muco-rectal prolapse. Further randomized studies, larger series, and longer follow-up are needed.
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Affiliation(s)
- Claudio Pagano
- General Surgery Unit, Vizzolo Predabissi Hospital, ASST Milano-Martesana, Vizzolo Predabissi (MI), Italy
| | - Marco Venturi
- Day/Week Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Guido Benegiamo
- General Surgery Unit, Vizzolo Predabissi Hospital, ASST Milano-Martesana, Vizzolo Predabissi (MI), Italy
| | - Ernesto Melada
- Day/Week Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Contardo Vergani
- Day/Week Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
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6
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Büyükaşık S, Bozkurt MA, Kapan S, Alis H. Analyzing the Role of Anal Sphincter Pressure in Rectocele Formation. Ann Coloproctol 2020; 36:330-334. [PMID: 32178503 PMCID: PMC7714383 DOI: 10.3393/ac.2019.09.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 09/15/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose Constipation is a common entity in society with various factors in the etiology. In this study, we evaluated the role of anal sphincter pressure of patients who refer to surgery clinic with complaint of constipation. Methods Sixty patients who refer to surgery clinic with complaint of constipation and were diagnosed with constipation due to Rome III criteria between July 2010 and September 2014. These patients were evaluated with defecography and were divided into 2 groups based on presence of rectocele. Both groups’ anal sphincter pressures were evaluated using anal manometry and findings were compared. Results The patients with rectocele and without rectocele using defecography were inspected with anal manometry regarding resting tone pressure, squeeze pressure, maximum squeeze pressure and simulated defecation response pressure, first sensation volume, urge sensation volume, and maximum tolerable volume. Results were compared and no significant difference was found regarding groups with rectocele and without rectocele (P > 0.05). Conclusion We have proved the hypothesis arguing that increased sphincter pressures do not play a role in the formation of rectocele by inducing an obstruction and the formation of dilation in proximal bowel, and demonstrated that the presence of rectocele is not dependent on an increase in sphincter pressures.
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Affiliation(s)
| | - Mehmet Abdussamet Bozkurt
- General Surgery Department, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Selin Kapan
- General Surgery Department, Istanbul Aydın Univercity, Istanbul, Turkey
| | - Halil Alis
- General Surgery Department, Istanbul Aydın Univercity, Istanbul, Turkey
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7
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Regadas FSP, Murad-Regadas SM, Rodrigues LV, Regadas Filho FSP, Vilarinho AS, Morano DP. Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes. Tech Coloproctol 2019; 24:65-73. [PMID: 31828573 DOI: 10.1007/s10151-019-02131-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 11/25/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results. METHODS Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6 months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis. RESULTS A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications. CONCLUSIONS The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.
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Affiliation(s)
- F S P Regadas
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil.
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil.
| | - S M Murad-Regadas
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Unit of Pelvic Floor and Anorectal Physiology, Clinical Hospital, Federal University of Ceará, Fortaleza, CE, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - L V Rodrigues
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - F S P Regadas Filho
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - A S Vilarinho
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - D P Morano
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
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8
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Kim JH, Kim DH, Lee YP. Long-term comparison of physiologic anorectal changes and recurrence between transanal repair and transanal repair with posterior colporrhaphy in rectocele. Asian J Surg 2019; 43:265-271. [PMID: 31036477 DOI: 10.1016/j.asjsur.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Rectocele is often associated with chronic constipation. Various surgical techniques have been described to repair rectoceles, but the results vary. The aim of this study was to compare the outcomes of transanal repair (TAR) and transanal repair with posterior colporrhaphy (TAR + PC). METHODS While 44 patients underwent TAR, 49 patients underwent TAR + PC for surgical repair of rectocele. Patients were followed up 3 months post-surgery for anorectal physiological changes. From the entire cohort of patients who underwent the surgical repair, 22 patients who underwent TAR and 25 patients who underwent TAR + PC agreed to participate in the 3-year post-treatment check-up. RESULTS Out of the 22 patients who underwent TAR, 3 patients (13.6%) scored more than 15 on the constipation scoring system (CSS), while 1 out of 25 patients who underwent TAR + PC scored more than 15 on the CSS 3 months post-treatment, which is considered as recurrence (p = 0.237). With 7 patients from the TAR group (31.8%) and 2 patients from the TAR + PC group (8.0%) showing recurrence of rectocele at 3-year post-treatment follow-up, this study found that TAR + PC had a much lower rate of recurrence than TAR. Furthermore, TAR + PC was found to be more effective than TAR in terms of rectal sensation, sensory threshold (p = 0.001), and early defecation urge (p = 0.003). CONCLUSIONS TAR + PC can help alleviate some symptoms by restoring the rectal sensation and improving the rectovaginal septum. It can be inferred that the addition of a simple treatment method can lead to a lower rate of recurrence.
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Affiliation(s)
- Joo Hyung Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea.
| | - Dae Hyun Kim
- Department of Health Services Administration, University of Alabama at Birmingham, AL, USA
| | - Yong Pyo Lee
- Department of Surgery, Hanvit Hospital, Suwon, Republic of Korea
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9
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Transperineal rectocele repair with biomesh: updating of a tertiary refer center prospective study. Int J Colorectal Dis 2018; 33:1583-1588. [PMID: 29675591 DOI: 10.1007/s00384-018-3054-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief. A variety of surgical procedures have been used in the rectocele repair to enhance anatomical and functional results and to improve long-term outcomes. METHODS In this prospective study, we treated 25 selected women suffering from simple symptomatic rectocele with transperineal repair using porcine dermal acellular collagen matrix Biomesh (Permacol®). Watson score and SF-36 questionnaire were used to evaluate postoperative outcomes and quality of life. RESULTS Follow-up ranged from 12 to 24 months, the mean total Watson score was significantly lower than the preoperative score (P < 0.001), and every patient has improved functional outcomes. There were no major intraoperative or postoperative complications. Two cases of urinary infection and 4 patients delayed wound healing were reported. Those patients who were sexually active prior to surgery have not experienced problems with sexual function or dyspareunia. CONCLUSIONS Despite lack of comparative study in literature, rectocele repair with Permacol® by the transperineal approach seems an effective and safe procedure that avoids some of the complications associated with synthetic mesh use.
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10
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Kim JH, Lee YP, Suh KW. Changes in anorectal physiology following injection sclerotherapy using aluminum potassium sulfate and tannic acid versus transanal repair in patients with symptomatic rectocele; a retrospective cohort study. BMC Surg 2018; 18:34. [PMID: 29855291 PMCID: PMC5984378 DOI: 10.1186/s12893-018-0363-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/22/2018] [Indexed: 01/27/2023] Open
Abstract
Background Following injection sclerotherapy using ALTA (aluminum potassium sulfate and tannic acid) (ALTAS) and transanal rectocele repair (TAR), changes in anorectal physiology were analyzed to compare the significance of the two treatments. Methods ALTAS was administered to 23 patients and 18 patients were treated using TAR. Efficacy measures included changes in defecography, anorectal manometry and constipation scoring system value. Results This was a retrospective cohort analysis conducted on prospectively collected data. Comparing anorectal physiology pre- and post- ALTAS, a statistically significant difference in push was observed with pre-ALTAS treatment (pre-A) at 104.33 ± 4.91° compared with post-ALTAS treatment (post-A) at 113.95 ± 4.74° (p < 0.001). With a pre-A value of 1.55 ± 0.18 cm and a post-A value of 2.46 ± 0.34 cm, perineal descent also showed an increase as well (p < 0.001). The rectocele size decreased post-A from a pre-A value of 7.74 ± 0.86 cm compared with a post-A value of 2.91 ± 0.52 cm (p < 0.001). The rectal sensation improved post-A compared with pre-A. Comparing anorectal physiology results of ALTAS and TAR treatments, no differences in defecography and rectal sensation were detected pre- and post-treatment. However, in terms of anorectal manometry, the mean resting pressure and maximal squeezing pressure showed statistical difference with two treatments. Conclusions ALTAS treatment is a feasible option resulting in rapid and effortless long-term outcome, with low rates of complications. Therefore, this treatment may be an effective alternative for patients with symptomatic rectocele.
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Affiliation(s)
- Joo Hyung Kim
- Department of Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
| | - Yong Pyo Lee
- Department of Surgery, Hanvit Hospital, 1017 Gyeongsu-daero, Jangan-gu, Suwon, Gyeonggi-do, 16300, Republic of Korea
| | - Kwang Wook Suh
- Department of Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
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11
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Grossi U, Horrocks EJ, Mason J, Knowles CH, Williams AB. Surgery for constipation: systematic review and practice recommendations: Results IV: Recto-vaginal reinforcement procedures. Colorectal Dis 2017; 19 Suppl 3:73-91. [PMID: 28960924 DOI: 10.1111/codi.13781] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To assess the outcomes of recto-vaginal reinforcement procedures in adults with chronic constipation. METHOD Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level. RESULTS Forty-three articles were identified, providing data on outcomes in 3346 patients. Average length of procedures ranged between 20 and 169 min, and length of stay between 1 and 15 days. Complications typically occurred after 7-17% of procedures (range 0-61%). Post-operative bleeding was uncommon (0-4%) as well as haematoma or sepsis (0-2%). Fistulation did not occur in most studies. Two procedure-related deaths were observed for 3209 patients. Although inconsistent, 78% of patients reported a satisfactory or good outcome, with 30-50% experiencing reduced symptoms of straining, incomplete emptying or reduced vaginal digitation. About 17% of patients developed anatomical recurrence. Considering measures of harm and global satisfaction rating scales, there was insufficient evidence to prefer one type of procedure over another. There was no evidence to support better outcomes based on selection of patients with a particular size or grade of rectocoele. CONCLUSION Evidence supporting recto-vaginal reinforcement procedures is currently derived from observational studies and comparisons, with only one high quality study. Large trials are needed to inform future clinical decision making.
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Affiliation(s)
- U Grossi
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - E J Horrocks
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - J Mason
- Health Economics, University of Warwick, Coventry, UK
| | - C H Knowles
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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- National Institute for Health Research: Chronic Constipation Treatment Pathway, London, UK
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- Affiliate section of the Association of Coloproctology of Great Britain and Ireland, London, UK
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12
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Abstract
The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.
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Bozkurt MA, Kocataş A, Karabulut M, Yırgın H, Kalaycı MU, Alış H. Two Etiological Reasons of Constipation: Anterior Rectocele and Internal Mucosal Intussusception. Indian J Surg 2015; 77:868-71. [PMID: 27011472 PMCID: PMC4775698 DOI: 10.1007/s12262-014-1042-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/27/2014] [Indexed: 02/07/2023] Open
Abstract
Chronic constipation is a common problem in the general population. Rome III criteria can be used for the diagnosis of chronic constipation. The aim of this study is to emphasize the importance of anterior rectocele and mucosal intussusception as two etiological factors for chronic constipation. One hundred patients were included in this study after excluding other causes of the constipation by medical history, physical examination, and laboratory and radiological studies in 108 total patients who were admitted consecutively to the outpatient clinic of the general surgery department of Dr. Sadi Konuk Bakirkoy Education and Research Hospital with the complaint of constipation between June 2009 and January 2010. It was found that 75 % of these patients had anterior rectocele and 66 % of them had internal intussusception which cause chronic constsipation. Anterior rectocele and internal rectal mucosal intussusception must be kept in mind as two significant reasons for chronic functional constipation.
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Affiliation(s)
| | - Ali Kocataş
- Dr. Sadi Konuk Education and Research Hospital, Tevfik Saglam Cad. No: 11, 34147 Istanbul, Turkey
| | - Mehmet Karabulut
- Dr. Sadi Konuk Education and Research Hospital, Tevfik Saglam Cad. No: 11, 34147 Istanbul, Turkey
| | - Hakan Yırgın
- Dr. Sadi Konuk Education and Research Hospital, Tevfik Saglam Cad. No: 11, 34147 Istanbul, Turkey
| | - Mustafa Uygar Kalaycı
- Dr. Sadi Konuk Education and Research Hospital, Tevfik Saglam Cad. No: 11, 34147 Istanbul, Turkey
| | - Halil Alış
- Dr. Sadi Konuk Education and Research Hospital, Tevfik Saglam Cad. No: 11, 34147 Istanbul, Turkey
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14
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Guzmán Rojas R, Kamisan Atan I, Shek KL, Dietz HP. Defect-specific rectocele repair: medium-term anatomical, functional and subjective outcomes. Aust N Z J Obstet Gynaecol 2015; 55:487-92. [DOI: 10.1111/ajo.12347] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/10/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Rodrigo Guzmán Rojas
- Departamento de Ginecología y Obstetricia; Facultad de Medicina; Clínica Alemana - Universidad del Desarrollo; Santiago Chile
- Departamento de Ginecología y Obstetricia; Hospital Clínico de la Universidad de Chile; Santiago Chile
| | - Ixora Kamisan Atan
- Department of Obstetrics and Gynaecology; Sydney Medical School Nepean; University of Sydney; Penrith NSW Australia
- Universiti Kebangsaan Malaysia Medical Centre; Kuala Lumpur Malaysia
| | - Ka Lai Shek
- Department of Obstetrics and Gynaecology; Sydney Medical School Nepean; University of Sydney; Penrith NSW Australia
- Department of Obstetrics and Gynaecology; Liverpool Hospital; University of Western Sydney; Sydney NSW Australia
| | - Hans Peter Dietz
- Department of Obstetrics and Gynaecology; Sydney Medical School Nepean; University of Sydney; Penrith NSW Australia
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15
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Abbott R, Ayres I, Hui E, Hui KK. Effect of perineal self-acupressure on constipation: a randomized controlled trial. J Gen Intern Med 2015; 30:434-9. [PMID: 25403522 PMCID: PMC4371012 DOI: 10.1007/s11606-014-3084-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/10/2014] [Accepted: 10/14/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND The efficacy of perineal self-acupressure in treating constipation is uncertain. OBJECTIVE We aimed to evaluate whether perineal self-acupressure would improve patient reports of quality of life and bowel function at 4 weeks after training. DESIGN A randomized, parallel group trial was conducted. SETTING The study took place at the UCLA Department of Medicine. PATIENTS One hundred adult patients who met Rome III criteria for functional constipation participated. INTERVENTION The control group received information about standard constipation treatment options, while the treatment group received training in perineal self-acupressure plus standard treatment options. MEASUREMENTS Primary outcome was the Patient Assessment of Constipation Quality of Life (PAC-QOL). Secondary outcomes included patient assessments of bowel function (as measured by a modified Bowel Function Index (BFI)), and health and well-being (as measured by the SF-12v2). RESULTS The mean PAC-QOL was improved by 0.76 in the treatment group and by 0.17 in the control group (treatment-effect difference, 0.59 [95 % CI, 0.37 to 0.81]; p < 0.01). The mean modified BFI was improved by 18.1 in the treatment group and by 4.2 in the control group (treatment-effect difference, 13.8 [95 % CI, 5.1 to 22.5]; p < 0.01). The mean SF-12v2 Physical Component Score was improved by 2.69 in the treatment group and reduced by 0.36 in the control group (treatment-effect difference, 3.05, [95 % CI, 0.85 to 5.25]; p < 0.01); and the mean SF-12v2 Mental Component Score was improved by 3.12 in the treatment group and improved by 0.30 in the control group (treatment-effect difference, 2.82, [95 % CI, -0.10 to 5.74]; p < 0.07). LIMITATION The trial was not blinded. CONCLUSION Among patients with constipation, perineal self-acupressure improves self-reported assessments of quality of life, bowel function, and health and well-being relative to providing standard constipation treatment options alone.
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Affiliation(s)
- Ryan Abbott
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, USA,
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Podzemny V, Pescatori LC, Pescatori M. Management of obstructed defecation. World J Gastroenterol 2015; 21:1053-1060. [PMID: 25632177 PMCID: PMC4306148 DOI: 10.3748/wjg.v21.i4.1053] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/03/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.
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17
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Zbar AP. Posterior pelvic floor disorders and obstructed defecation syndrome: clinical and therapeutic approach. ACTA ACUST UNITED AC 2014; 38:894-902. [PMID: 22415627 DOI: 10.1007/s00261-012-9878-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There are no clear recommended imaging guidelines for the assessment of patients presenting primarily with obstructed defecation syndrome and defecation difficulty. The gold standard has always been the defecating proctogram which may require a rather poorly tolerated extended technique involving high-radiation exposure in young women which includes cystography, vaginography, small bowel opacification, and occasional peritoneography. The development of dynamic magnetic resonance imaging has obviated many of these extended techniques and may be supplemented by novel ultrasonographic methods including dynamic transperineal sonography, real-time 3D translabial ultrasound and 3D dynamic echodefecography. Patients potentially suitable for surgical treatment display a multiplicity of pelvic floor and perineal soft-tissue anomalies where one pathology (such as rectocele or enterocele) are considered dominant. Despite the introduction of recent stapled and robotic technologies, there is a dual dialog concerning the functional outcome of these procedures. Imaging and surgical algorithms for these patients are provided.
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Affiliation(s)
- Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel Aviv Israel Affiliated with Sackler Medical School and Tel Aviv University, Tel Aviv, Israel,
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18
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Abstract
Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.
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Affiliation(s)
- C. Neal Ellis
- Division of Colorectal Surgery, West Penn Allegheny Health System, Pittsburgh, Pennsylvania.
| | - Rahila Essani
- Division of Colorectal Surgery, West Penn Allegheny Health System, Pittsburgh, Pennsylvania.
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Cruz JV, Regadas FSP, Murad-Regadas SM, Rodrigues LV, Benicio F, Leal R, Carvalho CG, Fernandes M, Roche LMC, Miranda AC, Câmara L, Pereira JC, Parra AM, Leal VM. TRREMS procedure (transanal repair of rectocele and rectal mucosectomy with one circular stapler): a prospective multicenter trial. ARQUIVOS DE GASTROENTEROLOGIA 2011; 48:3-7. [PMID: 21537534 DOI: 10.1590/s0004-28032011000100002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 05/11/2010] [Indexed: 12/26/2022]
Abstract
CONTEXT Since anorectocele is usually associated with mucosa prolapse and/or rectal intussusceptions, it was developed a stapled surgical technique using one circular stapler. OBJECTIVE To report the results of Transanal Repair of Rectocele and Rectal Mucosectomy with one Circular Stapler (TRREMS procedure) in the treatment of anorectocele with mucosa prolapse in a prospective multicenter trial. METHODS It was conducted by 14 surgeons and included 75 female patients, mean aged 49.6 years, with symptoms of obstructed defecation due to grade 2 (26.7%) and grade 3 (73.3%) anorectocele associated with mucosa prolapse and/or rectal intussusception (52.0%) and an average validated Wexner constipation score of 16. All patients were evaluated by a proctological examination, cinedefecography, anal manometry and colonic transit time. The TRREMS procedure consists of the manual removal of the rectocele wall with circumferential rectal mucosectomy performed with a circular stapler. The mean follow-up time was 21 months. RESULTS All patients presented obstructed defecation and they persisted with symptoms despite conservative treatment. The mean operative time was 42 minutes. In 13 (17.3%) patients, bleeding from the stapled line required hemostatic suture. Stapling was incomplete in 2 (2.6%). Forty-nine patients (65.3%) required 1 hospitalization day, the remainder (34.7%) 2 days. Postoperatively, 3 (4.0%) patients complained of persistent rectal pain and 7 (9.3%) developed stricture on the stapled suture subsequently treated by stricturectomy under anesthesia (n = 1), endoscopic stricturectomy with hot biopsy forceps (n = 3) and digital dilatation (n = 3). Postoperative cinedefecography showed residual grade I anorectoceles in 8 (10.6%). The mean Wexner constipation score decreased significantly from 16 to 4 (0-4: n = 68) (6: n = 6) (7: n = 1) (P<0.0001). CONCLUSION Current trial results suggest that TRREMS procedure is a safe and effective technique for the treatment of anorectocele associated with mucosa prolapse. The stapling technique is low-cost as requires the use of a single circular stapler.
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20
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Ding JH, Zhang B, Bi LX, Yin SH, Zhao K. Functional and morphologic outcome after stapled transanal rectal resection for obstructed defecation syndrome. Dis Colon Rectum 2011; 54:418-24. [PMID: 21383561 DOI: 10.1007/dcr.0b013e3182061c81] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Stapled transanal rectal resection is a novel surgery for obstructed defecation syndrome. Few data on the functional and morphologic outcome after the surgery have been reported. OBJECTIVE This study aimed to evaluate the functional and morphologic outcome after stapled transanal rectal resection. DESIGN This is a prospective study of consecutive patients undergoing transanal rectal resection. SETTING The study was conducted at a tertiary referral hospital, Beijing, China, from May 2007 to May 2009. PARTICIPANTS Eighty-six consecutive female patients with obstructed defecation syndrome were carefully selected. INTERVENTIONS All patients underwent stapled transanal rectal resection. MAIN OUTCOME MEASURES The main outcome measures were patients' symptoms, obstructed defecation syndrome score, Wexner incontinence score, anorectal manometry and defecography before and 1 year after surgery. RESULTS The occurrence of all symptoms were significantly reduced after the procedure (P < .0001). Obstructed defecation syndrome score was decreased from 18.17 ± 4.68 preoperatively to 7.36 ± 3.52 postoperatively (P < .0001) with the Wexner incontinence score unchanged. Maximum tolerable rectal volume was significantly decreased (236.08 ± 50.00 vs 205.25 ± 29.60, P < .0001) after surgery with anal sphincter pressures unchanged. Postoperative defecography was performed in 64 patients. Rectocele disappeared in 40 of 62 patients. The depth of rectocele was reduced from 35.40 ± 4.58 mm preoperatively to 19.77 ± 9.19 mm postoperatively (P < .0001). Incomplete evacuation disappeared in 41 of 51 patients. Intussusception was completely corrected in 39 of 56 patients. The reduction of obstructed defection syndrome score was greater in patients with both rectocele and intussusception corrected than others (12.75 ± 2.24 vs 9.17 ± 3.47; P < .0001). LIMITATIONS This study was limited owing to the lack of a control group and the medium-term results. CONCLUSIONS Stapled transanal rectal resection is an effective procedure for obstructed defecation syndrome. The functional outcome is good with the preservation of sphincter function and continence postoperatively. The morphologic outcome confirmed its efficacy in correcting rectocele and intussusception, and correlated well with clinical improvement.
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Affiliation(s)
- Jian-Hua Ding
- Department of Colorectal Surgery, Colorectal Disease Center of PLA, The Second Artillary General Hospital, Beijing, People's Republic of China.
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22
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Abstract
Difficulties with bowel function are common and may be due to several causes including slow colonic transit and obstructed defecation. The anatomical and pathophysiological changes associated with these conditions are varying, often incompletely understood, and in many cases have limited treatment outcomes. Patients present with variable complaints and have previously tried a plethora of over-the-counter medications in an effort to relieve their symptoms. Physicians need an organized approach to manage these patients optimally. Improvements over the past few years in our understanding of the complex process of defecation, along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results.
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Affiliation(s)
- Scott R Steele
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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23
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Farid M, Madbouly KM, Hussein A, Mahdy T, Moneim HA, Omar W. Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation. World J Surg 2010; 34:822-9. [PMID: 20091310 DOI: 10.1007/s00268-010-0390-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The present study was designed to evaluate functional outcome of perineal repair with and without levatorplasty versus transanal repair of rectocele in obstructed defecation. METHODS AND PATIENTS A total of 48 multiparous women with obstructed defecation caused by a rectocele were randomly allocated to three groups: transperineal repair with levatorplasty (TPR-LP; n = 16); transperineal repair without levatorplasty (TPR; n = 16); and transanal repair (TAR; n = 16). The study included defecographic assessment, anal manometry, symptom improvement, sexual function, and score on a function questionnaire. Assessments were done preoperatively and 6 months postoperatively. RESULTS Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in both groups with transperineal repair but not in the group with transanal repair. Significant reductions in mean anal resting pressure, maximum reflex volume, and urge-to-defecate volume were observed only with the transperineal approach (with and without levatorplasty). Functional score improved significantly in the transperineal groups (with levatorplasty, P < 0.001; without levatorplasty, P < 0.01), but not in the transanal group (P = 0.142). Levatorplasty added to transperineal repair significantly improved the overall functional score compared with transperineal repair alone (P < 0.01) and transanal repair TAR (P < 0.001). CONCLUSIONS Rectocele repair appears to improve anorectal function by improving rectal urge sensitivity. Transperineal repair of rectocele is superior to transanal repair in both structural and functional outcome. Levatorplasty improves functional outcome, but potential effects on dyspareunia should be discussed with the patient.
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Affiliation(s)
- Mohamed Farid
- Department of Surgery, University of Mansoura, Mansoura, Egypt
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24
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Toglia MR. Pathophysiology of anal incontinence, constipation, and defecatory dysfunction. Obstet Gynecol Clin North Am 2010; 36:659-71. [PMID: 19932420 DOI: 10.1016/j.ogc.2009.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Anorectal disorders cause significant discomfort and embarrassment in women. The onset typically follows childbirth and symptoms increase with age. This article discusses anal incontinence, defecatory dysfunction, rectal prolapse, and constipation.
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Affiliation(s)
- Marc R Toglia
- Department of Obstetrics and Gynecology, Thomas Jefferson University School of Medicine, Philadelphia, PA 19063, USA.
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25
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Elshazly WG, El Nekady AEA, Hassan H. Role of dynamic magnetic resonance imaging in management of obstructed defecation case series. Int J Surg 2010; 8:274-82. [PMID: 20219700 DOI: 10.1016/j.ijsu.2010.02.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 01/15/2010] [Accepted: 02/06/2010] [Indexed: 10/19/2022]
Abstract
AIMS Surgical treatment of obstructed defecation (OD) carries frequent recurrences. The aim of the study was to evaluate the role dynamic magnetic resonance imaging defecography, and to elucidate the underlying anatomic and pathophysiologic background of pelvic floor disorders in these patients in order to minimize failures. PATIENTS AND METHODS Forty consecutive constipated patients with OD symptoms (31 females) with mean age 48.15+/-14.29 years. They underwent perineal examination, proctoscopy, anorectal manometry and Dynamic MRI defecography. The different pelvic floor morphology was recorded. The type and outcome of treatment whether conservative or surgical were also recorded. RESULTS The dynamic MRI of the pelvic floor showed 23 patients with descending perineum, 32 rectoceles (28 females), 12 cystoceles (10 females), 6 enteroceles (4 females), 18 intussusceptions (14 females), and 7 dyskinetic puborectalis muscle (3 females). The diagnosis of combined pelvic floor disorders with dynamic MRI defecography was consistent with clinical results in 70% and there were additional diagnostic parameters in 30% of patients. Dynamic MRI findings changed treatment decision in 8 patients 20% with surgical treatment performed in 25 patients (8 stappled trans-anal rectal resection, 11 trans-anal Delorme's, 6 trans-abdominal combined repair), and conservative treatment in 15 patients. CONCLUSIONS Dynamic magnetic resonance imaging represents a convenient diagnostic procedure in females and to a lesser extent in males, especially in terms of dynamic imaging of pelvic floor organs during defecation. In addition to the clinical assessment, dynamic magnetic resonance imaging had clinical impact in OD and interdisciplinary treatment.
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Affiliation(s)
- Walid Galal Elshazly
- Colorectal Surgery, Surgical Department, Faculty of Medicine, University of Alexandria, Egypt.
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Schwandner T, Roblick MH, Hecker A, Brom A, Kierer W, Padberg W, Hirschburger M. Transvaginal rectal repair: a new treatment option for symptomatic rectocele? Int J Colorectal Dis 2009; 24:1429-34. [PMID: 19669767 DOI: 10.1007/s00384-009-0790-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Widely differing surgical methods have been propagated to correct symptomatic rectocele. With transvaginal rectal repair (TVRR), we evaluate a method to reestablish the continuity of the rectal muscle wall, strengthen the weakened tunica muscularis, and restore normal rectal capacity and function. METHODS Between 1997 and 2003, 102 female patients were treated by TVRR in cases of symptomatic rectocele. Patients without improvement following a stringent conservative treatment for a minimum of 3-6 months were selected for TVRR procedure. Patients with intussusception and slow-transit constipation were excluded from the study. To achieve optimal stabilization of the rectal wall, a transverse gathering of the rectocele was performed by a transvaginal access. RESULTS Average patient age was 60.9 years (47-76 years), operation time was 36.5 minutes (29-67 min.), in-hospital treatment lasted 4.1 days (2-7 days), and follow-up was 18.1 months (3-48 months). We observed complications in 11% of cases. Three months after the operation, 81% of the patients were symptom-free or improved. Following an average observation time of 18.1 months (3-48 months), 70% were still symptom-free or improved. CONCLUSIONS TVRR allows easy access for rectocele repair with a low rate of complications.
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Affiliation(s)
- Thilo Schwandner
- Department of General and Thoracic Surgery, Justus-Liebig-University Giessen, Giessen, Germany.
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Pescatori M, Milito G, Fiorino M, Cadeddu F. Complications and reinterventions after surgery for obstructed defecation. Int J Colorectal Dis 2009; 24:951-9. [PMID: 19165491 DOI: 10.1007/s00384-009-0639-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation. METHODS We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed. RESULTS Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years. CONCLUSIONS Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.
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Affiliation(s)
- Mario Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospitals, Rome, Italy
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28
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Pescatori M, Zbar AP. Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*. Colorectal Dis 2009; 11:410-9. [PMID: 18637923 DOI: 10.1111/j.1463-1318.2008.01626.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period. METHOD Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months). RESULTS Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05). CONCLUSION Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.
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Affiliation(s)
- M Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospital, Rome, Italy.
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Pinto RA, Sands DR. Surgery and sacral nerve stimulation for constipation and fecal incontinence. Gastrointest Endosc Clin N Am 2009; 19:83-116, vi-vii. [PMID: 19232283 DOI: 10.1016/j.giec.2008.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.
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Affiliation(s)
- Rodrigo A Pinto
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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Dindo D, Weishaupt D, Lehmann K, Hetzer FH, Clavien PA, Hahnloser D. Clinical and morphologic correlation after stapled transanal rectal resection for obstructed defecation syndrome. Dis Colon Rectum 2008; 51:1768-74. [PMID: 18581173 DOI: 10.1007/s10350-008-9412-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 04/25/2008] [Accepted: 05/03/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE The clinical and morphologic outcome of patients with obstructed defecation syndrome after stapled transanal rectal resection was prospectively evaluated. METHODS Twenty-four consecutive patients (22 women; median age, 61 (range, 36-74) years) who suffered from obstructed defecation syndrome and with rectal redundancy on magnetic resonance defecography were enrolled in the study. Constipation was assessed by using the Cleveland Constipation Score. Morphologic changes were determined by using closed-configuration magnetic resonance defecography before and after stapled transanal rectal resection. RESULTS After a median follow-up of 18 (range, 6-36) months, Cleveland Constipation Score significantly decreased from 11 (range, 1-23) preoperatively to 5 (range, 1-15) postoperatively (P = 0.02). In 15 of 20 patients, preexisting intussusception was no longer visible in the magnetic resonance defecography. Anterior rectoceles were significantly reduced in depth, from 30 mm to 23 mm (P = 0.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of the 24 patients; however, only two were severe (1 bleeding and 1 persisting pain requiring reintervention). CONCLUSIONS Clinical improvement of obstructed defecation syndrome after stapled transanal rectal resection correlates well with morphologic correction of the rectal redundancy, whereas correction of intussusception seems to be of particular importance in patients with obstructed defecation syndrome.
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Affiliation(s)
- Daniel Dindo
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital, Zurich, Switzerland
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Finco C, Savastano S, Luongo B, Sarzo G, Vecchiato M, Gasparini G, Merigliano S. Colpocystodefecography in obstructed defecation: is it really useful to the surgeon? Correlating clinical and radiological findings in surgery for obstructed defecation. Colorectal Dis 2008; 10:446-52. [PMID: 17868407 DOI: 10.1111/j.1463-1318.2007.01379.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Colpocystodefecography images the pelvic floor with the dynamics of defecation, but various authors claim that it overestimates clinical findings. The aim of this study was to evaluate the pre- and postoperative consistency between clinical and colpocystodefecographic findings in patients undergoing surgery for obstructed defecation. METHOD Between June 2001 and September 2003, 20 patients underwent transvaginal posterior colpoperineorrhaphy and rectal mucosal prolapsectomy with one circular stapler for symptomatic rectocele and concomitant anorectal prolapse. They were prospectively evaluated both before surgery by designed questionnaire on constipation and incontinence, proctological, gynaecological and urological examinations, colpocystodefecography and anorectal manometry, and after operation at 6 months by questionnaire and a proctological check-up. The mean follow-up was 30 months (24-48 months). RESULTS At 6 months the questionnaire revealed a major response in terms of symptoms. The proctological visit confirmed the absence of rectocele in 19 (95%) patients, while the anorectal prolapse had completely disappeared in 17 (85%) patients. Postoperative colpocystodefecography demonstrated a general reduction in the dimensions of the rectocele, which had completely disappeared in five (25%) patients; 40% of the patients had a persistent anorectal prolapse. CONCLUSION Preoperative data analysis showed a statistically significant correlation between clinical and radiological findings. Postoperatively the global clinical assessment correlated well with patient satisfaction, while there was evidence of a statistically significant difference between the radiological and clinical findings. Routine postoperative use of colpocystodefecography is unjustified unless there is clinical evidence of surgical failure.
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Affiliation(s)
- C Finco
- Department of Medical and Surgical Sciences, University of Padova, 3rd General Surgery Clinic, Coloproctological Unit, 'S. Antonio' Hospital, Padova, Italy.
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Ternent CA, Bastawrous AL, Morin NA, Ellis CN, Hyman NH, Buie WD. Practice parameters for the evaluation and management of constipation. Dis Colon Rectum 2007; 50:2013-22. [PMID: 17665250 DOI: 10.1007/s10350-007-9000-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Charles A Ternent
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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Joos AK, Palma P, Post S. Defäkationsstörungen - wann sind transperineale, transanale oder transvaginale Operationen indiziert? Visc Med 2007. [DOI: 10.1159/000106757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Abstract
PURPOSE This study was designed to evaluate the clinical and physiologic outcomes after transvaginal rectocele repair. METHODS Between June 2000 and January 2003, 30 females (mean age, 62 (range, 45-78) years) with a symptomatic large rectocele (>3 cm) underwent transvaginal rectocele repair (anterior levatorplasty). Six months after surgery, a physiologic evaluation was performed by using defecography (depth of rectocele) and anorectal manometry (maximum resting pressure, maximum squeeze pressure, rectal threshold, and maximum tolerable volume). Using a questionnaire, a clinical evaluation was performed one year after surgery to analyze symptoms, including difficult evacuation, digital support, sexual discomfort, as well as patient satisfaction. Follow-up of all patients was conducted during a median duration of 38 (range, 23-54) months. RESULTS There were no operative complications, such as hematoma, wound infection, or rectovaginal fistula. Difficult evacuation improved in 27 of 30 patients (90 percent) and completely disappeared in 9 patients. Postoperatively, digital support was no longer necessary during evacuation in 15 of 21 patients (71 percent). Overall patient satisfaction reached 25 of 30 (83 percent). Although mild sexual discomfort was observed in nine patients, it disappeared gradually and only one patient complained of persistent symptoms. No patient reported symptomatic recurrences at the end of the follow-up. The radiologic mean depth of the rectocele was significantly reduced: preoperative, 3.9 cm; postoperative, 0.5 cm. None of the physiologic parameters significantly changed after surgery. CONCLUSIONS Transvaginal rectocele repair can provide excellent long-term symptomatic relief and a high rate of patient satisfaction without any alteration in anorectal physiologic function.
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Affiliation(s)
- Tetsuo Yamana
- Department of Proctology, Social Health Insurance Hospital, 3-22-1 Hyakunincho Shinjuku-ku, Tokyo 169-0073, Japan.
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Chaliha C, Khullar V. Management of vaginal prolapse. WOMEN'S HEALTH (LONDON, ENGLAND) 2006; 2:279-287. [PMID: 19803899 DOI: 10.2217/17455057.2.2.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Vaginal prolapse is a common health problem, and although severe morbidity is rare, it can have marked effects on quality of life. The treatment of vaginal vault prolapse can be a difficult and challenging problem. A detailed history and clinical evaluation is required in order to plan the appropriate choice of procedure. There are numerous surgical procedures that have been described using either abdominal or vaginal approaches. The choice of procedure is often dependent on the individual surgeon's choice and experience, and should be tailored to the individual patient. The ideal procedure should have a low risk of morbidity and mortality, but should also have long-term durability. There is a need for large, randomized trials to evaluate surgical techniques to correct vaginal prolapse and related urinary, bowel and sexual dysfunction.
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Pescatori M, Boffi F, Russo A, Zbar AP. Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation. Int J Colorectal Dis 2006; 21:160-5. [PMID: 15947935 DOI: 10.1007/s00384-005-0758-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty. PATIENTS AND METHODS Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression. RESULTS Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05). CONCLUSIONS Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.
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Affiliation(s)
- M Pescatori
- Coloproctology Unit, Villa Flaminia Hospital, Rome, Italy.
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Birnbaum EH. What's new in colon and rectal surgery. J Am Coll Surg 2006; 202:485-94. [PMID: 16500254 DOI: 10.1016/j.jamcollsurg.2005.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Revised: 10/11/2005] [Accepted: 10/11/2005] [Indexed: 11/15/2022]
Affiliation(s)
- Elisa H Birnbaum
- Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
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Chaliha C, Khullar V. Surgical repair of vaginal prolapse: A gynaecological hernia. Int J Surg 2006; 4:242-50. [PMID: 17462358 DOI: 10.1016/j.ijsu.2005.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2005] [Indexed: 11/29/2022]
Abstract
Female pelvic organ prolapse refers to the descent of the pelvic organs towards or through the vagina. The similarities between vaginal prolapse and herniae in their aetiology and treatment make this an interesting area for all those operating in the pelvis. It is a common condition with prevalence estimates varying from 2% for symptomatic prolapse to 50% for asymptomatic prolapse [Samuelsson EC, Arne Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180:299-305]. Approximately 50% of parous women will have some degree and only 10-20% of these seek medical help [Beck RP. Pelvic relaxation prolapse. In: Kase NG, Weingold AB, editors. Principles and practice of clinical gynecology. New York: John Wiley; 1983. p. 677-85]. The lifetime risk for surgery for prolapse has been estimated to be around 11.1%, and 30% will undergo re-operation for recurrent prolapse [Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapsed and urinary incontinence. Obstet Gynecol 1997;89:501-6]. The aetiology of prolapse is multifactorial. Advancing age, parity and collagen weakness are all quoted as significant predisposing factors [Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapsed and urinary incontinence. Obstet Gynecol 1997;89:501-6; Maclennan AH, Taylor AW, Wilson, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynaecol 2000;107:1460-70]. Pathophysiological mechanisms that have been proposed include pelvic floor denervation, direct trauma to the pelvic floor musculature, abnormal synthesis and degradation of collagen and defects in endopelvic fascia [Al-Rawi ZS, Al-Rawi ZT. Joint hypermobility in women with genital prolapse. Lancet 1982;I:439-41; Gilpin SA, Gosling JA. Smith ARB, Warrell DW. The pathogenesis of genitourinary prolapse and stress incontinence in women. A histological and histochemical study. Br J Obstet Gynaecol 1989;96:15-23; Smith ARB, Hosker GL, Warrell DW. The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolapse and stress incontinence of urine. A neurophysiological study. Br J Obstet Gynaecol 1989;96:24-8; Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990;97:770-9]. The procedure of choice for reconstructive surgery to the vagina should be tailored to the individual patient and be of low morbidity and mortality, but at the same time with long-term durability.
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Abstract
Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve optimal outcomes. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. It must be remembered that the pelvis contains many structures and that defects of pelvic support or function frequently affect other pelvic organs. Optimal outcomes can be achieved only by selecting appropriate treatment modalities that address all of the components of an individual patient's problem.
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Affiliation(s)
- C Neal Ellis
- Department of Surgery, University of South Alabama, Mobile, AL 36617, USA.
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40
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Abbas SM, Bissett IP, Neill ME, Macmillan AK, Milne D, Parry BR. Long-term results of the anterior Délorme's operation in the management of symptomatic rectocele. Dis Colon Rectum 2005; 48:317-22. [PMID: 15812584 DOI: 10.1007/s10350-004-0819-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Although the results of surgery for symptomatic rectocele seem satisfactory initially, there is a trend toward deterioration with time. This study was designed to assess the long-term outcome of Anterior Délorme's operation for rectocele. METHODS Questionnaires were sent to all females who had Anterior Délorme's operation performed in Auckland between 1990 and 2000. The questionnaires included obstructed defecation symptoms and a validated fecal incontinence severity index questionnaire and fecal incontinence quality of life questionnaire. Preoperative and postoperative obstructed defecation symptoms and incontinence score were compared. RESULTS A total of 150 females (mean age, 56 (range, 30-83) years) who had an Anterior Délorme's operation for a rectocele were identified. One hundred seven patients (71.5 percent; mean age, 56 years) completed the questionnaire. Median follow-up was four (range, 2-11) years. The number of patients with obstructed defecation reduced from 87 preoperatively to 23 postoperatively using Rome II criteria (P < 0.0001). Postoperatively there was a reduction in the number of patients with each of the symptoms of obstructed defecation from 83 to 27 for straining, 87 to 33 for incomplete emptying, 64 to 14 for feeling of blockage, 41 to 10 for digitation (P < 0.0001 for all). The median incontinence score reduced from 20 of 61 preoperatively to 12 of 61 postoperatively (P = 0.0001). CONCLUSIONS In patients with symptomatic rectocele, Anterior Délorme's operation provides long-term benefit for patients with obstructed defecation and leads to a significant improvement of incontinence scores.
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Affiliation(s)
- S M Abbas
- Colorectal Unit, Department of Surgery, University of Auckland, 1001 Grafton, Auckland, New Zealand.
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41
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Affiliation(s)
- Ash Monga
- Princess Anne Hospital, Southampton University Hospitals Trust, UK
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42
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Heriot AG, Skull A, Kumar D. Functional and physiological outcome following transanal repair of rectocele. Br J Surg 2004; 91:1340-4. [PMID: 15376184 DOI: 10.1002/bjs.4543] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rectoceles are traditionally repaired transvaginally and sexual dysfunction can be a significant complication. The aim of this study was to evaluate the functional and physiological outcome following transanal repair of rectoceles. METHODS Forty-five patients of mean age 57.1 (range 34-78) years with a symptomatic anterior rectocele, selected by contrast retention greater than 15 per cent on isotope defaecography, underwent transanal repair of rectocele. Preoperative and postoperative symptoms were assessed by means of a questionnaire. A proportion of patients underwent anorectal physiology and isotope defaecography before and after surgery. RESULTS Median(range) follow-up was 24 (2-50) months. One patient developed a wound infection after surgery. Thirty-five patients reported an excellent, good or fair result, with seven reporting a moderate and three a poor result. There was a reduction in incomplete evacuation (P < 0.001) confirmed by isotope defaecography (mean(s.d.) rectal emptying before surgery 57(14) per cent versus 76(9) per cent after surgery; P = 0.020), and a reduction in vaginal (P < 0.001) and perineal (P = 0.004) digitation. Symptomatic feeling of prolapse (vaginal bulging) was significantly improved (P < 0.001). There was no increase in incontinence (P = 0.688). Resting and squeeze anal canal pressures were unchanged after operation. Surgery did not result in sexual dysfunction. CONCLUSION Transanal repair of rectocele is a safe alternative to posterior colporrhaphy. It provides improvement in symptoms, reflected by anatomical improvement with minimal complications and no increase in dyspareunia.
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Affiliation(s)
- A G Heriot
- Department of Colorectal Surgery, St George's Hospital, London, UK
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Nieminen K, Hiltunen KM, Laitinen J, Oksala J, Heinonen PK. Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study. Dis Colon Rectum 2004; 47:1636-42. [PMID: 15540292 DOI: 10.1007/s10350-004-0656-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair. METHODS Thirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded. RESULTS The study groups were comparable in terms of demographic factors and rectocelerelated symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 +/- 1.6 cm vs. 5.6 +/- 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement. CONCLUSION Patients' symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.
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Affiliation(s)
- Kari Nieminen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.
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Affiliation(s)
- Anthony Lembo
- Gastroenterology Division, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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45
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Zbar AP, Lienemann A, Fritsch H, Beer-Gabel M, Pescatori M. Rectocele: pathogenesis and surgical management. Int J Colorectal Dis 2003; 18:369-84. [PMID: 12665990 DOI: 10.1007/s00384-003-0478-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2003] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty. DISCUSSION The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation. CONCLUSION The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.
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Affiliation(s)
- A P Zbar
- Department of Medicine and Clinical Research, Queen Elizabeth Hospital, University of the West Indies, Martindales Road, St. Michael, Barbados.
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46
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Abstract
PURPOSE OF REVIEW There are very many types of operation for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task when selecting the most appropriate procedure(s) for an individual patient. Currently, the lifetime risk of undergoing prolapse or continence surgery in France is one in 11; up to 30% of patients will require repeat prolapse surgery, and 10% will require repeat continence surgery. Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for a definitive surgical cure. This review looks at the etiology, presentation and current surgical management of genital prolapse in females. RECENT FINDINGS There are three primary routes of access in reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) for the repair of anterior, superior and posterior defects; the choice often depends on the surgeon's experience. Of the abdominal repairs, abdominal sacrocolpopexy with mesh remains the 'gold standard'; the retropubic paravaginal repair and laparoscopic techniques have not gained widespread acceptance. The laparoscopic approach appears to be the least utilized, because of the great degree of technical difficulty associated with laparoscopic suturing. Of the vaginal restorative procedures, uterosacral ligament vault suspension and iliococcygeous and sacrospinous fixation have their proponents. However, there is increasing interest in the use of biological prostheses (allografts/xenografts) and synthetic absorbable meshes. SUMMARY Randomized controlled trials are required to evaluate the role of surgical procedures in reconstructive surgery, to determine which type of prosthesis is most suitable.
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Affiliation(s)
- Bruno Deval
- Department of Gynecology Hospital Beaujon, Clichy, France
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47
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Altomare DF, Rinaldi M, Veglia A, Petrolino M, De Fazio M, Sallustio P. Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique. Dis Colon Rectum 2002; 45:1549-52. [PMID: 12432306 DOI: 10.1007/s10350-004-6465-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to present a new technique for treatment of disabling rectocele when associated with internal mucosal prolapse or hemorrhoids using a 33-mm circular stapler. METHODS Eight female patients complaining of obstructed defecation because of distention rectocele associated with internal mucosal prolapse or hemorrhoids and perineal descent entered the study. The rectovaginal septum was opened by diathermy up to the end of the rectal wall weakness. The perineal wound and the anus were held open by a self-retractor. Using a transparent anoscope (PPH 01 system), 2 mucosal pursestrings were prepared 5 and 8 to 9 cm distant from the dentate line. Posteriorly, only the submucosa was included in the pursestring; anteriorly, it included the rectal wall, which was kept separate from the vaginal wall. A transanal 33-mm circular stapler was then used to close the rectocele and treat the mucosal prolapse. Before closing the perineum a levatorplasty was fashioned. RESULTS One patient had a vaginal tear during dissection of the septum, which healed spontaneously in one month. No other complications were recorded. Postoperative defecography showed correction of the rectocele and the posterior rectal prolapse in all patients. In two of them, a small lateral diverticulum could be seen, although this was asymptomatic. After a median follow-up of 12 months, all had significantly improved defecation (chronic constipation score dropped from 14.3 to 5, P < 0.04). CONCLUSION Combined perineal and endorectal stapler repair of rectocele may be a useful new surgical tool for correcting distention rectocele associated with mucosal prolapse or hemorrhoids and perineal descent in selected patients. A longer follow-up on a larger number of patients is needed to confirm these preliminary results.
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Affiliation(s)
- Donato F Altomare
- Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Units, University of Bari, Policlinico, piazza G. Cesare 11, 70124 Bari, Italy
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Deval B, Rafii A, Poilpot S, Wicart F, Aflak N, Levardon M. [New physiological, diagnostic and therapeutic concepts in the management of rectoceles in women]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2002; 30:180-94. [PMID: 11998206 DOI: 10.1016/s1297-9589(02)00294-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anterior rectocele is not only a herniation of the anterior rectal wall into the vagina, but rather a complex anatomical and functional abnormality which may be isolated or associated with other pelvic floor disorders. It could result in rectal obstruction with dyschezia, manual extraction of feces, and fecal or gas incontinence. The purpose of this review is to describe and to assess the most useful methods for the diagnosis and for the treatment of the rectocele. Data from physical examination may be improved by defecography. Surgery remains the main treatment: several surgical ways (perineal, anal, abdominal, laparoscopic) are described. Analysis of the anatomical and functional results allows to assess these techniques and to determine the best therapeutic option.
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Affiliation(s)
- B Deval
- Service de gynécologie-obstétrique, université Bichat-Beaujon, hôpital Beaujon, 100 Boulevard du Général-Leclerc, 92110 Clichy, France.
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Abstract
Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.
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Affiliation(s)
- N A Rotholtz
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida, USA
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Abstract
PURPOSE The aim of the present study was to analyze the prognostic value of clinical data and physiologic tests in patients undergoing rectocele repair for obstructed defecation. METHODS Between 1988 and 1996, 89 consecutive female patients with obstructed defecation caused by a rectocele were enrolled in the study. Median age at time of presentation was 55 (range, 35-81) years. All patients underwent a combined transvaginal and transanal rectocele repair. End evaluation to assess long-term results was performed by an independent observer after a median duration of follow up of 52 (range, 12-92) months. The presence of the following five symptoms was evaluated: prolonged and unsuccessful straining at stool, feelings of incomplete evacuation, manual assistance during defecation, false urge to defecate, and a stool frequency of less than three times per week. When none or just one of these symptoms was present, outcome of rectocele repair was considered successful. The outcome was considered as a failure when two or more of these symptoms were recorded. Furthermore, all patients were asked to score the outcome of their operations as excellent, good, moderate, or poor. Clinical data and the results of physiologic tests obtained in patients with a poor outcome of surgery were compared with those obtained in patients with a successful outcome. RESULTS Objective outcome of rectocele repair, based on the presence of symptoms, was found to be successful in 63 (71 percent) patients. Sixty-one patients considered outcome of surgery excellent or good (69 percent). Graded subjective outcomes between the two groups showed significantly better grades in cases of success. Duration of symptoms, number of symptoms, age, parity, and previous hysterectomy had no influence on the final outcome of surgery. Defecographic parameters, such as size of the rectocele, barium trapping in the rectocele, poor rectal evacuation, or intussusception, had no prognostic value. Signs of anismus based on defecography, electromyography, and balloon-expulsion studies did not influence outcome of surgery. The presence of symptoms such as defecation frequency, manual assistance, severe straining, false urge to defecate, or feelings of incomplete evacuation had no impact on the outcome. However, in patients without a daily urge to defecate or with a stool frequency of less than once per week, results of rectocele repair were significantly worse than in patients with a daily urge to defecate or a defecation frequency of more than once per week or both. In 14 of 26 patients with a poor outcome, colonic transit studies were performed. A delayed passage was observed throughout the entire colon in seven patients, in the left part of the colon and the rectosigmoid colon in four patients, and in the rectosigmoid colon in one patient. In two patients colonic transit was normal. CONCLUSIONS Combined transvaginal and transanal rectocele repair is beneficial for the majority of patients with obstructed defecation. In patients without a daily urge to defecate or a stool frequency of less than once per week, indicating colonic malfunctioning, the outcome of rectocele repair seems to be poor.
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Affiliation(s)
- J H van Dam
- Department of General Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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