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Li W, Wu Z, Ozuner G. Does Rectocele Repair Combined with Other Perineal Surgeries Affect Outcome Compared to Solo Rectocele Repair? Gynecol Obstet Invest 2021; 86:454-459. [PMID: 34689138 DOI: 10.1159/000519516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 08/29/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to analyze perioperative morbidity and mortality as well as long-term outcome of rectocele repair in combination with other perineal surgeries (RR combination) and compare this with solo rectocele repair (solo RR). DESIGN The type of study was case-control. Data of patients who received solo rectocele repair or rectocele repair in combination with other perineal surgeries between January 2011 and December 2015 were identified and reviewed in a prospectively maintained and IRB-approved database. Ninety-eight patients were included, including 41 patients in the solo RR group and 57 patients in the RR combination group. The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were observed. METHODS The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were compared, respectively. Covariate adjustment was analyzed by multivariate logistic and Cox regression analysis. RESULTS Ninety-eight patients with a median age of 57 were included, involving 41 patients in the solo RR group and 57 patients in the RR combination group. Other than the operative approach (p < 0.01), demographics and preoperative characteristics of the 2 groups were comparable. All variables, including length of stay, estimated blood loss, self-limiting rectal bleeding, transfusion, urinary retention, rectal stricture, rectal and perineal infection, rectovaginal abscess, reoperation, effective resolution of obstructive defecation symptoms, residual symptoms rate, and recurrence rate, were comparable among the 2 groups except for operative time (p = 0.03). LIMITATIONS This study is a single-center study, which may cause bias. In addition, the sample size is limited. Staging of rectocele and routine imaging studies were not performed. CONCLUSIONS Rectocele repair in combination with other perineal surgeries is feasible, and outcomes are comparable with solo rectocele repair. Transanal versus transvaginal repairs appear to have no influence on outcomes.
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Affiliation(s)
- Wanglin Li
- Department of Colorectal & Anal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Zixin Wu
- Department of Colorectal & Anal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Gokhan Ozuner
- Department of Colon and Rectal Surgery, Weill Cornell Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York, New York, USA
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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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Lin HC, Chen HX, Huang L, Zhu YX, Zhou Q, Li J, Xu YJ, Ren DL, Wang JP. Prognostic and predictive value of interstitial cells of Cajal populations following stapled transanal rectal resection (STARR) in patients with obstructed defecation syndrome. Gastroenterol Rep (Oxf) 2018; 6:270-276. [PMID: 30430015 PMCID: PMC6225818 DOI: 10.1093/gastro/goy034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/11/2018] [Accepted: 09/10/2018] [Indexed: 12/30/2022] Open
Abstract
Objective The present study was designed to evaluate the functional outcome of stapled transanal rectal resection (STARR) and to examine the relationship between the population density of the interstitial cells of Cajal (ICC) and the efficacy of the STARR operation in the management of obstructed defecation syndrome (ODS) patients. Methods Full-thickness rectal samples were obtained from 50 ODS patients who underwent STARR. Samples were analysed using ICC immunohistochemistry. Clinical and functional parameters obtained with defecography and anorectal manometry were compared with 20 controls. Results ICCs were significantly decreased in patients in the submucosal (SM), intramuscular (IM) and myenteric (MY) regions when compared with the control group (P < 0.05). The mean pre-operative Cleveland Constipation Score (CCS) was 24.2 ± 4.1, whilst the CCS at 1, 2, 3, 4 and 5 years post-operatively decreased significantly (P < 0.05). At 3 post-operative years, 58.3% (28/48) of the patients reported a favorable outcome (CCS ≤ 10). On univariate analysis, the functional results were worse in those with pre-operative digitation (P = 0.017), a decreased ICC-MY cell population (P = 0.067), a higher resting anal canal pressure (P = 0.039) and a higher rectal sensory threshold (P = 0.073). Multivariate analysis showed the decreased ICC-MY cell population was an independent predictor for low unfavorable functional outcome (odds ratio = 0.097, 95% confidence interval: 0.012–0.766). Conclusions STARR achieved acceptable results at the cost of a slight deterioration over a more prolonged follow-up. Patients with a decreased ICC number in the rectal specimen showed an unfavorable functional outcome where pre-operative histological assessment of a full-thickness rectal sample might predict for the functional outcome following STARR.
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Affiliation(s)
- Hong-Cheng Lin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Hua-Xian Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Liang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Ya-Xi Zhu
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qian Zhou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Juan Li
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Yu-Jie Xu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Dong-Lin Ren
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian-Ping Wang
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
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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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Liu WC, Wan SL, Yaseen SM, Ren XH, Tian CP, Ding Z, Zheng KY, Wu YH, Jiang CQ, Qian Q. Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience. World J Gastroenterol 2016; 22:7983-7998. [PMID: 27672293 PMCID: PMC5028812 DOI: 10.3748/wjg.v22.i35.7983] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/23/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors’ center is also presented.
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Murad-Regadas SM, Regadas FSP, Rodrigues LV, Fernandes GODS, Buchen G, Kenmoti VT. Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome. ARQUIVOS DE GASTROENTEROLOGIA 2012; 49:135-42. [PMID: 22767001 DOI: 10.1590/s0004-28032012000200008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/18/2011] [Indexed: 12/17/2022]
Abstract
CONTEXT Management of patients with obstructed defecation syndrome is still controversial. OBJECTIVE To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. METHODS The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. RESULTS Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. CONCLUSIONS Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts.
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Song KH, Lee DS, Shin JK, Lee SJ, Lee JB, Yook EG, Lee DH, Kim DS. Clinical outcomes of stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS): a single institution experience in South Korea. Int J Colorectal Dis 2011; 26:693-8. [PMID: 21311891 DOI: 10.1007/s00384-011-1147-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to assess both the short- and long-term functional outcomes of stapled transanal rectal resection (STARR) in ODS patients. PATIENTS AND METHODS We performed a retrospective review of data that were collected from January 2005 to October 2008. Between January 2005 to June 2006, 58 patients who underwent STARR were enrolled in this study. Follow-up was scheduled for 3 months and 1 year after surgery with the Cleveland Clinic Florida (CCF) constipation score and satisfaction grade. To evaluate the long-term functional outcome, we interviewed the patients by telephone using questionnaires for the CCF score and satisfaction grade on October 2008. RESULTS The median follow-up period was 34 months (range, 27-46 months). The mean age and sex ratio were 54 years (range, 19-85 years) and 8:50 (M/F). The mean CCF constipation scores were 17.6 before the surgery, 9.5 at 3 months, 9.6 at 12 months, and 10.3 at the time of the latest interview. The satisfaction grade, which was rated as excellent and good by 63.4% of the patients at the time of the latest interview, was worse than that at 3 months (37.8%). Among the cases of the excellent group (19 cases) at postoperative 3 months, 13 cases (68.4%) were classified as excellent or good at the time of the latest interview. CONCLUSION The STARR is a safe and effective surgical procedure for restoring the anatomy and function in ODS patients. Strict selection of patients is needed in enhancing and maintaining the patients' satisfaction after the procedure.
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Affiliation(s)
- Kee Ho Song
- Department of Surgery, Daehang Hospital, 481-10, Bangbae3-dong, Seocho-gu, Seoul 137-820, South Korea
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Arroyo A, González-Argenté FX, García-Domingo M, Espin-Basany E, De-la-Portilla F, Pérez-Vicente F, Calpena R. Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome. Br J Surg 2008; 95:1521-7. [PMID: 18942056 DOI: 10.1002/bjs.6328] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND This prospective multicentre study assessed the safety and effectiveness of stapled transanal rectal resection (STARR) for treatment of obstructive defaecation syndrome (ODS). METHODS Between February 2001 and June 2006, 104 patients diagnosed with ODS were treated with STARR. Follow-up was scheduled for 1, 3 and 6 months after surgery, and annually thereafter. Variables related to the patient, surgical technique and outcome were analysed. RESULTS Mean operating time was 46.7 min. Haemorrhage at the staple line occurred in 55 patients (52.9 per cent). Three patients required surgical revision in the first 48 h owing to persistent bleeding. The median postoperative pain score was 2.4 on a scale from 1 to 10. Mean hospital stay was 2.2 days. The mean constipation score improved from 13.5 before surgery to 5.1 at 1-year follow-up (P = 0.006). Twenty-three patients reported faecal incontinence at 4 weeks after surgery, but only nine still had minor residual incontinence by 1 year. At a median follow-up of 26 (range 12-72) months, ODS had recurred or persisted radiologically and/or clinically in 11 patients. CONCLUSION STARR is associated with low morbidity and a short hospital stay, and is an effective alternative treatment for ODS.
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Affiliation(s)
- A Arroyo
- Coloproctology Unit, Hospital General Universitario Elche, Elche, Spain.
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Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am 2008; 37:645-68, ix. [PMID: 18794001 DOI: 10.1016/j.gtc.2008.06.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.
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Gagliardi G, Pescatori M, Altomare DF, Binda GA, Bottini C, Dodi G, Filingeri V, Milito G, Rinaldi M, Romano G, Spazzafumo L, Trompetto M. Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum 2008; 51:186-95; discussion 195. [PMID: 18157718 DOI: 10.1007/s10350-007-9096-0] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 02/13/2007] [Accepted: 04/10/2007] [Indexed: 02/07/2023]
Abstract
PURPOSE Obstructed defecation may be treated by stapled transanal rectal resection, but different complications and recurrence rates have been reported. The present study was designed to evaluate stapled transanal rectal resection results, outcome predictive factors, and nature of complications. METHODS Clinical and functional data of 123 patients were retrospectively analyzed. All patients had symptoms of obstructed defecation before surgery and had rectocele and/or intussusception. Of them, 85 were operated on by the authors and 38 were referred after stapled transanal rectal resection had been performed elsewhere. RESULTS At a median follow-up of 17 (range, 3-44) months, 65 percent of the patients operated on by the authors had subjective improvement. Recurrent rectocele was present in 29 percent and recurrent intussusception was present in 28 percent of patients. At univariate analysis, results were worse in those with preoperative digitation (P<0.01), puborectalis dyssynergia (P<0.05), enterocele (P<0.05), larger size rectocele (P<0.05), lower bowel frequency (P<0.05), and sense of incomplete evacuation (P<0.05). Bleeding was the most common perioperative complication occurring in 12 percent of cases. Reoperations were needed in 16 patients (19 percent): 9 for recurrent disease. In the 38 patients referred after stapled transanal rectal resection, the most common problems were perineal pain (53 percent), constipation with recurrent rectocele and/or intussusception (50 percent), and incontinence (28 percent). Of these patients, 14 (37 percent) underwent reoperations: 7 for recurrence. Three patients presented with a rectovaginal fistula. One other patient died for necrotizing pelvic fasciitis. CONCLUSIONS Stapled transanal rectal resection achieved acceptable results at the cost of a high reoperation rate. Patients with puborectalis dyssynergia and lower bowel frequency may do worse because surgery does not address the causes of their constipation. Patients with large rectoceles, enteroceles, digitation, and a sense of incomplete evacuation may have more advanced pelvic floor disease for which stapled transanal rectal resection, which simply removes redundant tissue, may not be adequate. This, together with the complications observed in patients referred after stapled transanal rectal resection, suggests that this procedure should be performed by colorectal surgeons and in carefully selected patients.
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Affiliation(s)
- Giuseppe Gagliardi
- General Surgery, Clinica Pineta Grande, Via Domiziana Km. 30, Castel Volturno (Caserta) 81030, Italy.
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Statique pelvipérinéale postérieure de la femme et ses troubles : données anatomiques et cliniques. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s0246-1064(08)45460-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Leventoğlu S, Menteş BB, Akin M, Karen M, Karamercan A, Oğuz M. Transperineal rectocele repair with polyglycolic acid mesh: a case series. Dis Colon Rectum 2007; 50:2085-92; discussion 2092-5. [PMID: 18049839 DOI: 10.1007/s10350-007-9067-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 04/02/2007] [Accepted: 04/06/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the outcome of transperineal rectocele repair using polyglycolic acid mesh. METHODS Eighty-three consecutive females with predominant, symptomatic Stage II or Stage III rectocele underwent transperineal rectocele repair using polyglycolic acid (Soft PGA Felt(R)) mesh and finished their six-month follow-up. No additional interventions, including levatoroplasty or perineorraphy, were performed. The preoperative and postoperative symptom scores and stages of the posterior vaginal wall prolapse were recorded. The end points were reassessed at six months, postoperatively. RESULTS Preoperatively, 39 patients had Stage II and 44 patients had Stage III rectocele. The mean total symptom score was 9.87 +/- 1.93, which was reduced to 1.62 +/- 0.59 postoperatively (P < 0.0001). Objective evaluation of anatomic repair revealed that 74 patients (89.2 percent) had anatomic cure. Surgical complications were seen in a total of seven patients (8.4 percent), including hemorrhage (3.6 percent) and wound infection (4.8 percent). Mesh erosion, mesh infection, or worsening of sexual function was not noted. CONCLUSIONS Transperineal repair of rectocele with the polyglycolic acid mesh is an efficient therapy for patients with rectocele. It is highly successful in eliminating symptoms of obstructed defecation, and it is free of significant complications.
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Affiliation(s)
- Sezai Leventoğlu
- Gazi University Medical School, Department of Surgery, Colorectal Surgery Unit, Ankara, 06500, Turkey
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Touchais JY, Koning E, Savoye-Collet C, Leroi AM, Denis P. [Role of defecography in female posterior pelvic floor abnormalities]. ACTA ACUST UNITED AC 2007; 35:1257-63. [PMID: 18035577 DOI: 10.1016/j.gyobfe.2007.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 09/28/2007] [Indexed: 12/18/2022]
Abstract
Pelvic floor abnormalities often impact significantly the quality of life and result in a variety of symptoms, including chronic pelvic pain, fecal incontinence, and obstructed constipation. Fluoroscopic defecography and MR defecography enable identification of rectocele, rectal prolapse, enterocele, sigmoidocele with high prevalence in female patients with obstructed constipation, fecal incontinence, and chronic pelvic pain. In this manuscript, we describe the techniques and indications of the two techniques of defecography. We discuss the abnormalities of the posterior pelvic floor compartment at the origin of constipation, incontinence, chronic pelvic pain. Finally we compare the data obtained by clinical examination and defecography, remembering that 50% of enterocele and 100% of sigmoidocele are missed at clinical examination.
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Affiliation(s)
- J-Y Touchais
- Service de physiologie digestive, urinaire, respiratoire et sportive, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
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Arroyo A, Pérez-Vicente F, Serrano P, Sánchez A, Miranda E, Navarro JM, Candela F, Calpena R. Evaluation of the stapled transanal rectal resection technique with two staplers in the treatment of obstructive defecation syndrome. J Am Coll Surg 2006; 204:56-63. [PMID: 17189113 DOI: 10.1016/j.jamcollsurg.2006.09.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Revised: 09/18/2006] [Accepted: 09/19/2006] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study was designed to assess the safety and effectiveness of stapled transanal rectal resection (STARR) and to compare the results of two staplers. STUDY DESIGN From February 2001 to June 2005, 37 patients diagnosed with obstructive defecation syndrome were treated with the STARR technique. We analyzed variables related to the patient, diagnosis based on anorectal exploration, surgical technique used, and clinical and radiologic results. We compared these results in patients with procedure prolapsed hemorrhoids (PPH)33-01 (group 1, n = 17) or PPH33-03 (group 2, n = 20). The patients were followed postoperatively at 1, 3, and 6 months, and annually. RESULTS Intraoperative hemorrhage at the stapled suture occurred in 13 patients from group 1 and in 6 patients from group 2 (p = 0.03). The degree of postoperative pain was not different between the two groups. During the followup period, radiologic and clinical correction of the rectocele and intussusception was found in 94.6% of the patients, with a recurrence in 1 patient from each group. One patient from group 1 developed stenosis of the anastomosis, which improved with digital dilatations. Six patients from group 1 and none from group 2 (p < 0.05) had granulomas on the staple line at the sites of the reabsorbable reinforcing stitches, which were related to postoperative bleeding and anal discomfort. CONCLUSIONS STARR is an effective alternative for treatment of obstructive defecation syndrome, with a low morbidity and a shorter hospital stay. The use of PPH33-03 instead of PPH33-01 decreases the risk of hemorrhagic complications and enables more secure implantation as an outpatient procedure.
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Affiliation(s)
- Antonio Arroyo
- Coloproctology Unit, Department of Surgery, University Hospital of Elche, Alicante, Spain
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15
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Staumont G. [Diagnosis and treatment of dyschezia]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:427-38. [PMID: 16633309 DOI: 10.1016/s0399-8320(06)73198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Escribano-Guijarro J, Jáñez-Furió M, Sánchez-Colodrón E, Angulo-Cuesta J, González-García FJ, Cárdenas-Olivas JL. La perineoplastia protésica del tabique rectovaginal, vía transvaginal, en el tratamiento del rectocele y enterocele. Resultados de 77 casos. Cir Esp 2006; 79:108-13. [PMID: 16539949 DOI: 10.1016/s0009-739x(06)70829-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Anatomical and functional outcomes after transvaginal perineoplasty of the vaginal septum using polypropylene mesh in 77 patients with rectocele, enterocele, or both were studied. The frequency of other associated pelvic floor defects was also analyzed. PATIENTS AND METHOD Between 1997 and May 2005, 77 patients underwent surgery (30 for enterocele, 33 for rectocele and 14 for both defects). In all patients, complete dissection of the rectovaginal space, resection of the redundant vaginal wall tissue, suturing of the polypropylene mesh to the lateral bundles of the puborectal muscle, and posterior colporrhaphy were performed. In enteroceles, Douglas' pouch was resected before the mesh was placed. RESULTS During follow-up, there were 3 minimal vaginal dehiscences requiring partial extirpation of the mesh in 2 (12.1%), and 1 (1.2%) rectocele recurrence. No subsequent mesh extrusions or recurrences were detected during follow-up. The frequency of associated pelvic floor disorders was 92%. CONCLUSIONS In our experience, placement of polypropylene mesh in the rectovaginal septum with lateral suturing to puborectal muscle bundles provides excellent results compared with other approaches and meshes that are not sutured and fixed in the rectovaginal space, leading to mesh infection, extrusion or complete removal.
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17
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Thornton MJ, Lam A, King DW. Laparoscopic or transanal repair of rectocele? A retrospective matched cohort study. Dis Colon Rectum 2005; 48:792-8. [PMID: 15785902 DOI: 10.1007/s10350-004-0843-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of the study was to analyze the functional and physiologic outcome of patients undergoing laparoscopic rectocele repair compared to a matched cohort undergoing transanal repair. METHODS Forty patients with a rectocele who had undergone laparoscopic pelvic floor repair by a laparoscopic gynecologist were matched for age and rectocele size with 40 patients who had undergone a transanal repair by a colorectal surgeon. All patients had clinical evidence of a symptomatic rectocele. All patients were assessed postoperatively with a quality of life (SF-36) score, a modified St. Mark's continence score, a urinary dysfunction score, a Watt's sexual dysfunction score, and a linear analog patient satisfaction score. Fifteen patients in each group had also undergone preoperative and postoperative anal manometry. RESULTS At 44 months median follow-up, the transanal approach resulted in significantly more patients reporting bowel symptom alleviation (P < 0.002) and higher patient satisfaction (P < 0.003). The bowel symptom improvement was also sustained over a significantly longer period (P < 0.03). Only 11 patients (28 percent) in the laparoscopic group reported more than 50 percent improvement in their bowel symptoms compared to 25 patients (63 percent) in the transanal group. On univariate analysis of 50 percent bowel symptom improvement, a larger rectocele (P < 0.009), transanal repair (P < 0.02), and presenting with obstructive defecation rather than fecal incontinence (P < 0.03) were statistically significant. Rectocele size (P < 0.012) and treatment cohort (P < 0.006) remained significant on multivariate analysis. Postoperatively, bowel symptom alleviation correlated with patient satisfaction in both groups (P < 0.015). Although not statistically significant, five patients (13 percent) in the transanal group developed postoperative fecal incontinence, which was associated with a low maximum anal resting pressure preoperatively that was further diminished postoperatively (P > 0.06). Only one patient (3 percent) in the laparoscopic group reported a decline in fecal continence, but four patients (10 percent) reported worsening of their symptoms of obstructed defecation. Postoperative dyspareunia was reported by 24 patients in total (30 percent), with significantly more in the transanal group (P > 0.05). CONCLUSIONS The transanal repair results in a statistically greater alleviation of bowel symptoms and greater patient satisfaction scores. However, this approach may have a greater degree of functional co-morbidity than the laparoscopic rectocele repair.
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Affiliation(s)
- M J Thornton
- Department of Colorectal Surgery, St. George Hospital, Sydney, Australia
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Lechaux JP, Lechaux D, Bataille P, Bars I. Traitement de la rectocèle par voie périnéale avec prothèse. Une étude prospective. ACTA ACUST UNITED AC 2004; 129:211-7. [PMID: 15191847 DOI: 10.1016/j.anchir.2004.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2003] [Accepted: 03/23/2004] [Indexed: 11/22/2022]
Abstract
PURPOSE To assess the long term results of a transperineal repair of rectocele with a prosthetic mesh and the criteria for selecting the patients. METHODS Twenty-five consecutive patients (median age: 60 years) with a symptom-giving rectocele have been operated upon. Indication for surgery was: an obstructed defecation (N = 22); a fecal incontinence (N = 1); a pelvic heaviness with dyspareunia (N = 1) or a severe rectal syndrome (N = 1). Patients were evaluated by physical examination and, preoperatively, by defecography and anorectal manometry. The rectovaginal septum was repaired, through a perineal approach, with an absorbable (N = 5) or non absorbable (N = 20) prosthetic mesh. Long term results were assessed after a median follow-up of 45 (range 12-120) months by physical examination and a standardized questionnaire. The presence of the following three symptoms was evaluated: feeling of incomplete emptying, prolonged and unsuccessful straining at stool, digital assistance. Outcome was considered as successful when none of these symptoms were present, as good when minor emptying difficulties persisted, as moderate when emptying difficulties were associated with straining, as a failure when the symptomatic triad was unchanged. A general satisfaction score was established. RESULTS All the patients had the defect of the rectovaginal septum corrected. Four patients had a low residual rectocele associated, in two cases, with a rectal prolapse subsequently treated by a Delorme's operation. Outcome in patients complaining of obstructed defecation was considered excellent or good in 80% of patients, moderate in 9% and poor in 9%. Subjective scoring showed a significantly better result in cases of success. Among 11 incontinent patients, seven (63.5%) improved or regained full continence. Dyspareunia in three cases was corrected. Age, parity, digital assistance, previous gynecologic surgery, use of laxatives, size of rectocele, type of mesh, anatomical result of repair had no significant prognostic value. On the other hand, in patients with obstructed defecation, clinical and manometric signs of anal hyperactivity of the pelvic floor or anismus (N = 4) were significantly related to a poor result (P < 0.001). CONCLUSION Surgical repair with a prosthetic mesh is an efficient therapy in patients with obstructed defecation and/or incontinence caused by a rectocele. Clinical and defecographic parameters have no influence on outcome. Preoperative manometric data may help in selecting patients. In case of anal hyperactivity or anismus, given the risk of functional failure, behavioral retraining must be considered as first-line treatment.
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Affiliation(s)
- J P Lechaux
- Clinique Geoffroy-Saint-Hilaire, 59, rue Geoffroy-Saint-Hilaire, 75005 Paris, France.
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Shafik A, El-Sibai O, Shafik AA, Ahmed I. On the pathogenesis of rectocele: the concept of the rectovaginal pressure gradient. Int Urogynecol J 2003; 14:310-5; discussion 315. [PMID: 14618306 DOI: 10.1007/s00192-003-1087-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2002] [Accepted: 04/24/2003] [Indexed: 12/24/2022]
Abstract
Coughing or straining evokes reflex bulbocavernosus (BCM) and puborectalis (PRM) muscle contraction, which apparently transforms the vagina into a closed high-pressure cavity. This elevated vaginal pressure counteracts the increased intra-abdominal pressure and the tendency of the uterus to prolapse, and also supports the rectovaginal septum against the high straining-induced intrarectal pressure and possible consequent rectocele (posterior vaginal prolapse) formation. We investigated the hypothesis that a weak BCM and PRM share in the genesis of rectocele by changing the rectovaginal pressure gradient. Twenty-three women with rectocele (mean age 43.2+/-6.6 years) and 12 healthy women volunteers (mean age 41.6+/-6.2 years) were studied. The response of the intrarectal (intra-abdominal) and intravaginal pressure, as well as the EMG activity of the BCM and PRM to straining or coughing, was recorded. In the healthy volunteers the rectal and vaginal pressures showed a significant increase on coughing or straining, with no significant difference between the rectal or vaginal pressures. Also, the BCM and PRM EMG activity exhibited a significant increase. Rectocele patients showed a significantly low resting vaginal pressure. The increase in rectal and vaginal pressure, as well as of the EMG activity of the BCM and PRM on straining or coughing, was significantly lower and the latency of the EMG response was significantly longer than those of the healthy volunteers. A difference in the rectovaginal pressure gradient showing a significant increase in the rectal against the vaginal pressure, particularly on coughing or straining, is suggested to be the basic factor in the genesis of rectocele. This pressure difference appears to be caused by diminished BCM and PRM contractile activity. A disrupted rectovaginal septum is not a prerequisite for rectocele formation, as the septum appears normal in obstructed defecation despite the common occurrence of rectocele. A histopathologic study of the septum in rectocele seems necessary.
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Affiliation(s)
- Ahmed Shafik
- Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, 2 Talaat Harb Street, 11121 Cairo, Egypt.
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21
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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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Sloots CEJ, Meulen AJ, Felt-Bersma RJF. Rectocele repair improves evacuation and prolapse complaints independent of anorectal function and colonic transit time. Int J Colorectal Dis 2003; 18:342-8. [PMID: 12774250 DOI: 10.1007/s00384-002-0469-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2002] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Evacuation disorders associated with a rectocele can be improved by rectocele repair. This study investigated whether anorectal function tests results change after rectocele repair. PATIENTS AND METHODS Fourteen patients with 2nd or 3rd degree rectocele and evacuation disorder were treated by posterior colporrhaphy and evaluated pre- and postoperatively (after 8 months, range 3-14) using questionnaires, anal manometry and endosonography, rectal barostat testing, and colonic transit time measurement with radio-opaque markers. Results from female controls were used for comparison. RESULTS Preoperatively, rectocele patients had high maximal basal sphincter pressures, large sphincter lengths, and low maximal squeeze pressures, with an anal sphincter defect in seven and lower visceral sensitivity scores than in controls. Postprandial rectal responses (more than 10% decrease in postprandial volume after 1 h) were found in 3 of 14 patients compared to 2 of 11 parous and 9 of 11 nulliparous controls. After repair, a rectocele of 2nd degree was found in four patients. Questionnaire scores were significantly decreased for straining, evacuation disorder, manual support, and protrusion. Overall patient satisfaction with the operation scored 8.25 (range 3-10). Defecation frequencies and stool consistencies were unaltered. Anal pressures, rectal compliance-curves, visceral sensitivity, and colonic transit times were unaltered after the rectocele repair. CONCLUSION Rectocele repair improved complaints of evacuation disorder and protrusion, but defecation frequency and stool consistency were not affected. Anorectal function was unaltered after rectocele repair. Selection of patients for rectocele repair should be performed based on evacuation and protrusion complaints, anorectal function, or colonic transit time measurements have a limited role.
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Affiliation(s)
- C E J Sloots
- Department of Gastroenterology, Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
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Abstract
The evaluation of EP is complicated by the lack of any gold standard and a shifting clinical emphasis as management regimens go in and out of favor. As with all functional bowel disease, there is a residue of patients who are difficult to manage, and in whom a clinician will want maximum information before deciding on treatment. The examination has been criticized as lacking clinical relevance, and of having poor interobserver reliability except for rectal emptying and rectocele formation. Others have found a higher (83.3%) observer accuracy and a high yield of positive diagnoses. A questionnaire showed that clinicians found EP of major benefit in 40%, altering management from surgical to medical in 14% and vice versa in 4%. Radiographic examinations only impact on clinical management when findings alter management. Management protocols are evolving in functional disorders, but important features that EP reveals are anismus, trapping in rectoceles, IAI, and rectal prolapse. EP is the only method to diagnose some of these conditions and within defined parameters is extremely valuable in clinical management.
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Affiliation(s)
- Clive Bartram
- Imperial College Faculty of Medicine and Department of Intestinal Imaging, St. Mark's Hospital, Northwick Park Harrow HA1 3UJ, United Kingdom.
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Abstract
A posterior vaginal wall prolapse, also known as a rectocele, is a common condition and is an outpouching of the posterior vaginal wall and anterior rectal wall into the lumen of the vagina.1-5 Although more common in parous women, rectoceles of over 1 cm in size have been demonstrated in over 40% of nulliparous women. As rectoceles may be asymptomatic, their true prevalence is not clear. Many women with rectoceles present to their gynaecologist who may not ascertain any anorectal symptoms or perform a rectal examination. Conversely, colorectal surgeons often disregard a vaginal examination.6 Conventionally, gynaecologists have managed rectoceles, but increasingly colorectal surgeons are involved because of the prevalence of anorectal symptoms. There are many surgical techniques for the management of a symptomatic rectocele. There is, however, little data to suggest which is the most effective technique, or whether specific techniques are more appropriate in certain circumstances.7
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Affiliation(s)
- Judith T W Goh
- Department of Urogynaecology, Royal Women's Hospital and Department of Surgery, Colorectal Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Abstract
BACKGROUND We have recently demonstrated that rectal distension effected left colonic contraction, which probably acts to feed the rectum with fecal matter each time the rectum distends and evacuates its contents. This effect was postulated to occur through the recto-colic reflex. As the colonic status in rectal inertia constipation was scarcely addressed in the literature, we investigated this point. METHODS The response of the colonic pressure to rectal balloon distension in increments of 10 mL of water was studied in 38 patients with rectal inertia constipation (IC) (age 42.6 +/- 14.3 years, 29 women) and 12 healthy volunteers (40.9 +/- 12.2 years, nine women). The rectal and colonic pressures were measured by saline-perfused tubes connected to a pneumohydraulic infusion system. The rectum was distended by a condom applied to the end of a 10-F catheter. RESULTS The rectal and left colonic resting pressures were significantly lower in the patients than in the controls (P < 0.5, P < 0.05, respectively). In the healthy volunteers, rectal distension up to first rectal sensation produced no significant rectal or colonic pressure changes (P > 0.05, P > 0.05). At urge, rectal and left colonic pressures increased significantly (P < 0.001, P < 0.001, respectively), but there were no changes in the right colonic pressure (P > 0.05). The colonic response lasted as long as the rectum was distended. In IC, patients did not perceive the first rectal or urge sensation up to a rectal balloon filling of 300 mL; there was no rectal or colonic pressure response (P > 0.05, P > 0.05). CONCLUSION In normal subjects, left colonic contraction on rectal distension probably acts to feed the rectum with fecal material. In IC, the low left colonic resting pressure assumedly points to left colonic hypotonia which appears to aggravate the constipation produced by the inertic rectum. Furthermore, non-response of the left colon to rectal distension probably impedes rectal feeding with fecal matter and enhances constipation.
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Affiliation(s)
- Ahmed Shafik
- Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Maria G, Brisinda G, Bentivoglio AR, Albanese A, Sganga G, Castagneto M. Anterior rectocele due to obstructed defecation relieved by botulinum toxin. Surgery 2001; 129:524-9. [PMID: 11331443 DOI: 10.1067/msy.2001.112737] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background. Surgical repair of rectocele does not always alleviate symptoms related to difficulty in defecation, and some patients have impaired fecal continence after surgical treatment. To avoid complications of surgical repair, we investigated the efficacy of botulinum toxin in treating patients with symptomatic rectocele. Methods. Fourteen female patients with anterior rectocele were included in the study. The patients were studied by using anorectal manometry and defecography, and then treated with a total of 30 units of type A botulinum toxin, injected into 3 sites, 2 on either side of the puborectalis muscle and the third anteriorly in the external anal sphincter, under ultrasonographic guidance. Results. After 2 months, symptomatic improvement was noted in 9 patients (P =.0003). At the same time, rectocele depth (mean +/- SD) was reduced from 4.3 +/- 0.6 cm to 1.8 +/- 0.5 cm (P =.0000001) and rectocele area from 9.2 +/- 1.3 cm(2) to 2.8 +/- 1.6 cm(2) (P =.0000001). Anorectal manometry demonstrated decreased tone during straining from 70 +/- 28 mm Hg at baseline to 41 +/- 19 mm Hg at 1 month (P =.003) and to 41 +/- 22 mm Hg at 2 months (P =.005). No permanent complications were observed in any patient for a mean follow-up period of 18 +/- 4 months. At 1 year evaluation, incomplete or digitally assisted rectal voiding was not reported by any patient, and a rectocele was not found at physical examination. Four recurrent, asymptomatic rectoceles were noted at defecography. Conclusions. Botulinum toxin injections should be considered as a simple therapeutic approach in patients with anterior rectocele. The treatment is safe and less expensive than surgical repair. A more precise method of toxin injections under transrectal ultrasonography accounts for the high success rate. Repeated injections may be necessary to maintain the clinical improvement.
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Affiliation(s)
- G Maria
- Department of Surgery and the Department of Neurology, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, Italy
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Felt-Bersma RJ, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome. Gastroenterol Clin North Am 2001; 30:199-222. [PMID: 11394031 DOI: 10.1016/s0889-8553(05)70174-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.
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Affiliation(s)
- R J Felt-Bersma
- Department of Gastroenterology, University Hospital Rotterdam Dijkzigt, The Netherlands
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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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Lau CW, Heymen S, Alabaz O, Iroatulam AJ, Wexner SD. Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction. Dis Colon Rectum 2000; 43:478-82. [PMID: 10789742 DOI: 10.1007/bf02237190] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent). RESULTS Whereas 65 patients failed to complete the course of biofeedback therapy, 108 (62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5 (8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P = not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.
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Affiliation(s)
- C W Lau
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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Cundiff GW, Nygaard I, Bland DR, Versi E. Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders. Am J Obstet Gynecol 2000; 182:S1-S10. [PMID: 10649148 DOI: 10.1016/s0002-9378(00)70522-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Multidisciplinary Symposium on Defecatory Disorders was created to delineate the breadth of defecatory disorders and propose investigations to address identified knowledge deficits. Seven experts in defecatory disorders and 24 members of the American Urogynecologic Society were invited. The experts provided brief summaries of the scope of defecatory disorders from the perspectives of their specialties. The group then divided into 3 subgroups that focused on pathophysiology, imaging, and evaluation and treatment. Defecatory disorders, including anal incontinence and constipation, are common among women of all ages. Determination of their prevalence is complicated by a lack of standardized definitions. Defecatory disorders carry lengthy differential diagnoses. Imaging studies and anorectal testing, although not standardized, can aid in distinguishing different causes of dysfunction. The lack of uniformity in diagnosis and evaluation compromises comparisons of different treatments. Standardization of diagnoses and diagnostic modalities is essential to the design of meaningful evaluations of treatments for defecatory disorders.
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Affiliation(s)
- G W Cundiff
- Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD 212287, USA
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Tjandra JJ, Ooi BS, Tang CL, Dwyer P, Carey M. Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus. Dis Colon Rectum 1999; 42:1544-50. [PMID: 10613472 DOI: 10.1007/bf02236204] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Rectocele is often associated with anorectal symptoms. Various surgical techniques have been described to repair the rectocele. The surgical results are variable. This study evaluated the results of transanal repair of rectocele, with particular emphasis on the impact of concomitant anismus on postoperative functional outcome. METHODS Fifty-nine consecutive females who underwent transanal repair of rectocele for obstructed defecation were prospectively reviewed. All 59 patients were parous with a median parity of 2 (range, 1-6) and a median age of 58 (range, 46-68) years. The median length of follow-up was 19 (range, 6-40) months. Anismus was detected by anorectal physiology and defecography. The functional outcome was assessed by a standard questionnaire, physical examination, anorectal manometry, neurophysiology, and defecography. The quality-of-life index was obtained using a visual analog scale (from 1-10, with 10 being the best). RESULTS The functional outcome of transanal repair of rectocele was superior in patients without anismus. Forty (93 percent) of the 43 patients without anismus showed improved evacuation after repair compared with 6 (38 percent) of the 16 patients with anismus (P<0.05). The quality-of-life index improved (9 vs. 4) if anismus was not present (P<0.05). There were minimal complications. Hemorrhage requiring blood transfusion (2 units) occurred in one patient and urinary retention in another. CONCLUSION Transanal repair of rectocele is safe and, in the absence of anismus, effectively corrects obstructed defecation.
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Affiliation(s)
- J J Tjandra
- Department of Surgery, University of Melbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Affiliation(s)
- Keighley
- University Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
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Schouten WR, Gosselink MJ, Boerma MO, Ginai AZ. Rectal wall contractility in response to an evoked urge to defecate in patients with obstructed defecation. Dis Colon Rectum 1998; 41:473-9. [PMID: 9559633 DOI: 10.1007/bf02235762] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to examine rectal sensory perception and rectal wall contractility in response to an evoked urge to defecate and to identify differences between control subjects and patients with obstructed defecation. METHODS Twenty control patients (10 men; median age, 47 (range, 17-78) years) and 29 female patients with disabling obstructed defecation (median age, 48 (range, 18-70) years) entered the study. Under radiologic control, an infinitely compliant barostat balloon was inserted over a guide wire into the proximal part of the rectum. Additionally, a latex balloon was introduced into the distal part of the rectum. This latex balloon was inflated until an urge to defecate was experienced. Simultaneously, rectal wall contractility was assessed by measuring the variations in barostat balloon volume. These variations were expressed as percentage changes from baseline volume. RESULTS By comparing controls and patients with obstructed defecation, a significant difference was found regarding mean distending volume required to elicit an urge to defecate (135 +/- 38 vs. 214 +/- 87 ml of air; P < 0.001, Mann-Whitney U-test). In all controls, the evocation of an urge to defecate induced a pronounced increase in rectal tone, proximal to the distal stimulating balloon. By comparing controls and patients, the increase in rectal tone was found to be significantly higher in control subjects (35 +/- 10 vs. 9 +/- 10 percent; P < 0.001). Twenty-five patients (86 percent) showed no or only minimum (<20 percent) increase in rectal tone during the perception of an urge to defecate. In 14 of these patients, the threshold for this perception was increased. Only four patients (14 percent) showed a relatively normal increase (>20 percent) in rectal tone. However, their threshold for perception was greatly increased. CONCLUSION The assembly used in this study provides a useful tool for investigation of rectal evacuation. In all of our patients, obstructed defecation was associated with abnormal rectal sensory perception and/or altered rectal wall contractility.
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Affiliation(s)
- W R Schouten
- Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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