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Tsunoda A, Takahashi T, Matsuda S, Kusanagi H. Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size. Int J Colorectal Dis 2023; 38:85. [PMID: 36977940 DOI: 10.1007/s00384-023-04373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). METHODS Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. RESULTS Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047). CONCLUSION The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.
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Affiliation(s)
- Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan.
| | - Tomoko Takahashi
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan
| | - Satoshi Matsuda
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan
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Emile SH, Elfallal AH, Abdelnaby M, Balata M. Higher Symptom Score, Larger Residual Rectocele, and Lower Rectal Compliance Predict Failure of Improvement after Surgical Treatment of Rectocele. JOURNAL OF COLOPROCTOLOGY 2022; 42:245-250. [DOI: 10.1055/s-0042-1756146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2025]
Abstract
Abstract
Background Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair.
Methods The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography.
Results A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09–1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43–6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907–0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15.
Conclusions Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure.
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Affiliation(s)
- Sameh Hany Emile
- Division of Colorectal Surgery, Department of General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Ahmed Hossam Elfallal
- Division of Colorectal Surgery, Department of General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Mahmoud Abdelnaby
- Division of Colorectal Surgery, Department of General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Mohamed Balata
- Division of Colorectal Surgery, Department of General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
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3
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Fathy M, Elfallal AH, Emile SH. Literature review of the outcome of and methods used to improve transperineal repair of rectocele. World J Gastrointest Surg 2021; 13:1063-1078. [PMID: 34621481 PMCID: PMC8462077 DOI: 10.4240/wjgs.v13.i9.1063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/18/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).
AIM To assess the current literature in regard to the outcome of the classical transperineal repair (TPR) of rectocele and its technical modifications.
METHODS An organized literature search for studies that assessed the outcome of TPR of rectocele was performed. PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020. The main outcome measures were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and quality of life.
RESULTS After screening of 306 studies, 24 articles were found eligible for inclusion to the review. Nine studies (301 patients) assessed the classical TPR of rectocele. The median rate of postoperative improvement in ODS symptoms was 72.7% (range, 45.8%-83.3%) and reduction in rectocele size ranged from 41.4%-95.0%. Modifications of the classical repair entailed omission of levatorplasty, addition of implant, concomitant lateral internal sphincterotomy, changing the direction of plication of rectovaginal septum, and site-specific repair.
CONCLUSION The transperineal repair of rectocele is associated with satisfactory, yet variable, improvement in ODS symptoms with parallel increase in quality-of-life score. Several modifications of the classical TPR were described. These modifications include omission of levatorplasty, insertion of implants, performing lateral sphincterotomy, changing the direction of classical plication, and site-specific repair. The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.
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Affiliation(s)
- Mohammad Fathy
- General Surgery, Mansoura University Faculty of Medicine, Mansoura 35516, Egypt
| | | | - Sameh Hany Emile
- General Surgery, Mansoura University Faculty of Medicine, Mansoura 35516, Egypt
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4
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Maeda Y, Espin-Basany E, Gorissen K, Kim M, Lehur PA, Lundby L, Negoi I, Norcic G, O'Connell PR, Rautio T, van Geluwe B, van Ramshorst GH, Warwick A, Vaizey CJ. European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery. Colorectal Dis 2021; 23:2228-2285. [PMID: 34060715 DOI: 10.1111/codi.15718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/31/2022]
Abstract
This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.
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Affiliation(s)
- Yasuko Maeda
- Cumberland Infirmary and University of Edinburgh, Carlisle, UK
| | | | | | - Mia Kim
- Department of General, Gastrointestinal, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Lilli Lundby
- Department of Surgery Pelvic Floor Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ionut Negoi
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregor Norcic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - P Ronan O'Connell
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Tero Rautio
- Medical Research Center, University of Oulu, Oulu, Finland
| | | | | | - Andrea Warwick
- QEII Jubilee Hospital, Acacia Ridge, Queensland, Australia
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Maeda K, Honda K, Koide Y, Katsuno H, Hanai T, Masumori K, Matsuoka H, Endo T, Cheong YC. Outcomes of Transvaginal Anterior Levatorplasty with Posterior Colporrhaphy for Symptomatic Rectocele. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:137-143. [PMID: 33937553 PMCID: PMC8084542 DOI: 10.23922/jarc.2020-062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/30/2020] [Indexed: 11/30/2022]
Abstract
Objectives: To clarify the long-term outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele with defecographic changes. Methods: Consecutive patients undergoing transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele were prospectively registered and retrospectively reviewed using medical records. Symptoms, fecal incontinence, and defecographic findings were evaluated before and after surgery. Results: Fifty-seven women (mean age, 68 years) were identified, and the median disease duration was 24 months. Symptoms of vaginal mass (n = 32) and difficult defecation (n = 21) disappeared (90.6% and 71.4%, respectively) or improved (6.3% and 28.6%, respectively) after surgery. However, the feeling of residual stool was unchanged in two of eight patients. Seventeen patients who performed digitation on defecation before surgery discontinued digitation after surgery. The proportion of patients who had fecal incontinence preoperatively (40.4%) decreased significantly after surgery (17.5%) during a median follow-up period of 47 months. Defecography revealed a disappearance or improvement of rectocele in all 18 patients examined. The average rectocele size decreased significantly in six improved patients (p = 0.0006, paired t-test). Conclusions: Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele was a useful option to improve symptoms and anatomical disorders in the long term, but it had limitations in improving defecatory symptoms.
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Affiliation(s)
- Kotaro Maeda
- International Medical Center Fujita Health University Hospital, Toyoake, Japan
| | | | - Yoshikazu Koide
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Tsunekazu Hanai
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Koji Masumori
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomoyoshi Endo
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Yeong Cheol Cheong
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
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Mandovra P, Kalikar V, Patankar RV. Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: Follow-up in the Indian population. J Minim Access Surg 2021; 17:305-310. [PMID: 32964866 PMCID: PMC8270038 DOI: 10.4103/jmas.jmas_292_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Context: Obstructive defecation syndrome (ODS) is a poorly understood cause of constipation. In selected patients not responding to conservative management, surgical options may be offered. Laparoscopic ventral mesh rectopexy (LVMR) is another surgical option which gained popularity in the past decade. Aim: This study aims to identify the efficacy of LVMR in the Indian population. Setting and Design: It is a retrospective analysis of prospectively collected data of patients who underwent LVMR from January 2015 to January 2017 at a tertiary centre in India. Subjects and Methods: Thirty patients fulfilled the inclusion criteria. Patients were periodically followed for 2 years. Pre- and post-operative modified Longo's ODS scores were recorded and compared. Furthermore, other complications were noted and evaluated. Statistical Analysis Used: Relevant statistical tests were used to analyse the collected data. Results: Thirty patients (28 females, 2 males, mean age: 52.4 years) underwent LVMR for ODS due to anatomical abnormality like rectorectal intussusceptions (RRIs) (36.7%), rectocele (13.3%), or combined RRI with rectocele (50%). The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% at 12-month follow-up and 93.2% fall on 2-year follow-up. The mean operative time was 115 min and the average hospital stay of patients who underwent LVMR was 3.26 days. Conclusion: LVMR is a safe surgical procedure with minimal complications and good functional results for ODS patients due to rectal anatomical abnormality. Further larger studies are required to decide the best treatment modality for ODS.
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Affiliation(s)
- Pranav Mandovra
- Digestive Disease Centre, Zen Hospital, Mumbai, Maharashtra, India
| | - Vishakha Kalikar
- Digestive Disease Centre, Zen Hospital, Mumbai, Maharashtra, India
| | - Roy V Patankar
- Digestive Disease Centre, Zen Hospital, Mumbai, Maharashtra, India
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Emile SH, Balata M, Omar W, Khafagy W, Elgendy H. Specific Changes in Manometric Parameters are Associated with Non-improvement in Symptoms after Rectocele Repair. Int Urogynecol J 2020; 31:2019-2025. [PMID: 32691118 DOI: 10.1007/s00192-020-04444-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The present study aimed to assess the changes in manometric parameters after transperineal repair (TPR) of rectocele and interpret failure of symptom improvement in light of these changes. METHODS This was an observational cohort study on patients with anterior rectocele who underwent TPR in the period of February 2016 to February 2019. Data collected included patients' demographics, rectocele size, Wexner constipation and incontinence scores, anal pressures, and rectal sensation before and 12 months after TPR. Analysis of data was done by paired t-test and chi-square test. RESULTS Forty-six female patients with a mean age of 43.2 ± 10.7 years were included. After a mean follow-up of 13.9 ± 2.7 months, 30 (65.2%) patients reported clinical improvement and 16 (34.8%) had no significant improvement. At 12 months after rectocele repair, the entire cohort studied showed an insignificant increase in the mean anal pressures and a significant decrease in the thresholds of first rectal sensation, first urge, intense urge, and maximum tolerable volume (MTV). Patients who clinically improved showed similar physiologic changes to the entire cohort examined, whereas patients who had no clinical improvement showed significant increases in the mean anal pressures and insignificant decreases in rectal sensation and MTV. CONCLUSION Patients who showed clinical improvement showed insignificant increases in anal pressures and significant decreases in thresholds of first rectal sensation, first urge, intense urge, and MTV. Contrarily, patients who did not show clinical improvement showed significant increases in anal pressures and insignificant reduction in sensory thresholds.
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Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt. .,General Surgery Department, Faculty of Medicine, Mansoura University Hospitals, Elgomhuoria Street, Mansoura city, Egypt.
| | - Mohammed Balata
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
| | - Waleed Omar
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
| | - Wael Khafagy
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
| | - Hesham Elgendy
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
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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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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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Sabooni K, Shahverdi E, Azizi R, Rashidian N, Keramati MR, Pirmohammad H, Konjedi MA, Shahverdi A, Kordehdeh NS. Stapled Trans Anal Rectal Resection and Its Complications in Treatment of Constipation Induced by Rectocele and Rectal Mucosal Prolapse. Indian J Surg 2018. [DOI: 10.1007/s12262-018-1761-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Patcharatrakul T, Rao SS. Update on the Pathophysiology and Management of Anorectal Disorders. Gut Liver 2018; 12:375-384. [PMID: 29050194 PMCID: PMC6027829 DOI: 10.5009/gnl17172] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/05/2017] [Accepted: 06/10/2017] [Indexed: 12/11/2022] Open
Abstract
Anorectal disorders are common and present with overlapping symptoms. They include several disorders with both structural and functional dysfunction(s). Because symptoms alone are poor predictors of the underlying pathophysiology, a diagnosis should only be made after evaluating symptoms and physiologic and structural abnormalities. A detailed history, a thorough physical and digital rectal examination and a systematic evaluation with high resolution and/or high definition three-dimensional (3D) anorectal manometry, 3D anal ultrasonography, magnetic resonance defecography and neurophysiology tests are essential to correctly identify these conditions. These physiological and imaging tests play a key role in facilitating a precise diagnosis and in providing a better understanding of the pathophysiology and functional anatomy. In turn, this leads to better and more comprehensive management using medical, behavioral and surgical approaches. For example, patients presenting with difficult defecation may demonstrate dyssynergic defecation and will benefit from biofeedback therapy before considering surgical treatment of coexisting anomalies such as rectoceles or intussusception. Similarly, patients with significant rectal prolapse and pelvic floor dysfunction or patients with complex enteroceles and pelvic organ prolapse may benefit from combined behavioral and surgical approaches, including an open, laparoscopic, transabdominal or transanal, and/or robotic-assisted surgery. Here, we provide an update on the pathophysiology, diagnosis, and management of selected common anorectal disorders.
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Affiliation(s)
- Tanisa Patcharatrakul
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA,
USA
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok,
Thailand
| | - Satish S.C. Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA,
USA
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12
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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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13
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Zimmermann EF, Hayes RS, Daniels IR, Smart NJ, Warwick AM. Transperineal rectocele repair: a systematic review. ANZ J Surg 2017; 87:773-779. [PMID: 28871666 DOI: 10.1111/ans.14068] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/08/2017] [Accepted: 04/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transperineal rectocele repairs, either as isolated fascial repair or in combination with mesh augmentation, are hypothesized to reduce the risk of complications compared with alternative techniques. AIM The aim of this study was to ascertain long-term success and complication rates following transperineal rectocele repairs. METHOD A literature search of PubMed and Embase was performed using the terms 'transperineal rectocele', 'rectocele', 'transperineal' and 'repair'. Prospective studies, case series and retrospective case note analyses from 1 January 1994 to 1 December 2016 were included. Those that detailed outcomes of the transperineal approach or compared it to transanal/transvaginal approaches were included. The main outcome measures were reported complications and functional outcome scores. RESULTS A total of 14 studies were included. Of 566 patients, 333 (58.8%) underwent a transperineal rectocele repair and 220 (41.2%) a transanal repair. Complications were identified in 27 (12.3%) of the 220 transanal repairs and in 41 (12.3%) of the 333 transperineal repairs. A significant complication following transperineal repair was noted in eight studies. There are not enough data to make a reliable comparison between mesh and non-mesh transperineal repairs or to compare biological and synthetic mesh use. LIMITATIONS Outcome reporting differed between studies, precluding a full meta-analysis. CONCLUSION Transperineal rectocele repair offers an effective method of symptom improvement and appears to have a similar complication rate as transanal rectocele repair. Concomitant use of synthetic and biological mesh augmentation is becoming more common; however, high-quality comparative data are lacking, so a direct comparison between surgical approaches is not yet possible.
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Affiliation(s)
- Eleanor F Zimmermann
- Urology, Alexandra Hospital, Redditch, Worcestershire Acute Hospitals NHS Trust, UK
| | - Richard S Hayes
- Colorectal Surgery, Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - Ian R Daniels
- Colorectal Surgery, Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - Neil J Smart
- Colorectal Surgery, Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - Andrea M Warwick
- Colorectal Surgery, Redcliffe Hospital, Redcliffe, Queensland, Australia
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14
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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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15
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Baffy N, Foxx-Orenstein AE, Harris LA, Sterler S. Intractable Constipation in the Elderly. ACTA ACUST UNITED AC 2017; 15:363-381. [PMID: 28801825 DOI: 10.1007/s11938-017-0142-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.
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Affiliation(s)
- Noemi Baffy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
| | - Amy E Foxx-Orenstein
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA.
| | - Lucinda A Harris
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
| | - Susan Sterler
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
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16
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Youssef M, Emile SH, Thabet W, Elfeki HA, Magdy A, Omar W, Khafagy W, Farid M. Comparative Study Between Trans-perineal Repair With or Without Limited Internal Sphincterotomy in the Treatment of Type I Anterior Rectocele: a Randomized Controlled Trial. J Gastrointest Surg 2017; 21:380-388. [PMID: 27778256 DOI: 10.1007/s11605-016-3299-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/04/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Two types of rectocele exist; type I is characterized by relatively high resting anal pressures, whereas type II has lower resting anal pressures with associated pelvic organ prolapse. We compared trans-perineal repair (TPR) of rectocele with or without limited internal sphincterotomy (LIS) in the treatment of type I anterior rectocele. PATIENTS AND INTERVENTIONS Consecutive patients with anterior rectocele were evaluated for inclusion. Sixty-two female patients with type I anterior rectocele were randomized and equally allocated to receive TPR alone (group I) or TPR with LIS (group II). The primary outcome was the clinical improvement of constipation. Secondary outcomes were recurrence of rectocele, operative time, and postoperative complications including fecal incontinence (FI). RESULTS Clinical improvement of constipation and patients' satisfaction were significantly higher in group II at 1 year of follow-up (93.3 versus 70 %). Constipation scores significantly decreased in both groups postoperatively with more reduction being observed in group II (11.1 ± 2.1 in group I versus 8 ± 1.97 in group II). Significant reduction in the resting anal pressure was noticed in group II. Recurrence was recorded in three (10 %) patients of group I and one patient of group II. No significant differences between the two groups regarding the operative time and hospital stay were noted. CONCLUSION Adding LIS to TPR of type I rectocele achieved better clinical improvement than TPR alone. The only drawback of LIS was the development of a minor degree of FI, which was temporary in duration.
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Affiliation(s)
- Mohamed Youssef
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
| | - Sameh Hany Emile
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt.
| | - Waleed Thabet
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
| | - Hossam Ayman Elfeki
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
| | - Alaa Magdy
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
| | - Waleed Omar
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
| | - Wael Khafagy
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
| | - Mohamed Farid
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University Hospitals, El Gomhuoria Street, Mansoura City, Dakahlia Providence, Egypt
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17
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Abstract
Rectoceles are a very common finding in patients, and symptoms most commonly include pelvic pain, pressure, or difficulty with passing stool. However, there are often other associated pelvic floor disorders that accompany rectoceles, making the clinical significance of it in an individual patient often hard to determine. When evaluating a patient with a rectocele, a thorough history and physical exam must be conducted to help delineate other causes of these symptoms. Treatment consists of addressing other defecatory disorders through various methods, with surgery reserved for select cases in which obstructed defecation is well documented.
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Affiliation(s)
- W Conan Mustain
- Division of Colon and Rectal Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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18
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Ren XH, Yaseen SM, Cao YL, Liu WC, Shrestha S, Ding Z, Wu YH, Zheng KY, Qian Q, Jiang CQ. A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'. Int J Surg 2016; 32:58-64. [PMID: 27345262 DOI: 10.1016/j.ijsu.2016.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/16/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up. METHODS From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded. RESULTS The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up. CONCLUSIONS The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.
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Affiliation(s)
- X H Ren
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - S M Yaseen
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - Y L Cao
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - W C Liu
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - S Shrestha
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - Z Ding
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - Y H Wu
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - K Y Zheng
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - Q Qian
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China
| | - C Q Jiang
- Department of Colorectal and Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China.
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19
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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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20
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Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness. Clin Res Hepatol Gastroenterol 2014; 38:528-34. [PMID: 24486180 DOI: 10.1016/j.clinre.2013.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 12/06/2013] [Accepted: 12/22/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients. METHOD From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction. RESULTS Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR. CONCLUSIONS The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR. BRIEF SUMMARY In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.
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21
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Brusciano L, Limongelli P, del Genio G, Di Stazio C, Rossetti G, Sansone S, Tolone S, Lucido F, D'Alessandro A, Docimo G, Docimo L. Short-term outcomes after rehabilitation treatment in patients selected by a novel rehabilitation score system (Brusciano score) with or without previous stapled transanal rectal resection (STARR) for rectal outlet obstruction. Int J Colorectal Dis 2013; 28:783-93. [PMID: 22983757 DOI: 10.1007/s00384-012-1565-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to examine short-term outcomes of rehabilitation treatment in patients with or without previous stapled transanal resection (STARR) for rectal outlet obstruction by using a novel rehabilitation score system (Brusciano score). METHODS This is a retrospective cohort study conducted at a single tertiary referral institution including all patients with chronic functional constipation admitted to the outpatient unit from 2004 to 2009. RESULTS Among 330 consecutive patients, 247 (74.8 %) (204 females and 43 males) showing a significantly higher rehabilitation score (mean of 15.7 ± 1.8; range, 7-25) than healthy controls (mean, 3.2 ± 1.2; range 2-6) (p < .0001) were selected for rehabilitation. Of the 247 patients evaluated, group A (no previous surgery) consisted of 170 patients (53 males; mean age, 44.8 ± 12.9 years; range, 19-80) of which 38 presented mixed constipation, whereas group B (previous surgery) consisted of 77 patients (18 males; mean age, 47.0 ± 11.2 years; range, 22-81). The Brusciano score, Agachan-Wexner score and quality of life improved in both groups of patients after treatment. Better improvements of Brusciano and Agachan-Wexner scores were observed in patients with previous STARR (group B). CONCLUSIONS The rehabilitation score system employed in this study seems to be a useful tool in selecting and assessing the outcome of patients who might benefit from rehabilitation treatment. Constipation and quality of life were significantly improved by the rehabilitation treatment. Further studies are needed to clarify either the impact of rehabilitation treatment on long-term outcome of patients treated for rectal outlet obstruction or its role in those who develop problems over time.
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Affiliation(s)
- L Brusciano
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy.
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22
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2013. [PMID: 23049207 DOI: 10.3748/wjg.v] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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23
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment). World J Gastroenterol 2012; 18:4994-5013. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/17/2011] [Accepted: 08/15/2012] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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24
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2012. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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Gomelsky A, Dmochowski RR. Posterior-compartment repair: a urology perspective. Urol Clin North Am 2012; 39:371-6. [PMID: 22877720 DOI: 10.1016/j.ucl.2012.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The prevalence of posterior-compartment prolapse (rectocele) is not known. The authors have found that operative repair symptomatically improved a majority of patients with impaired defecation associated with a large rectocele, but this improvement was likely related at least in part to factors other than the size of the rectocele. Multiple surgical techniques are available for rectocele repair, and the literature is not clear regarding indications for each type of surgical intervention. This article reviews the literature regarding various types of posterior-compartment repair, and draws conclusions regarding their absolute efficacy and relative efficacy in comparison with one another.
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Affiliation(s)
- Alex Gomelsky
- Department of Urology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA.
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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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Mahmoud SA, Omar W, Farid M. Transanal repair for treatment of rectocele in obstructed defaecation: manual or stapled. Colorectal Dis 2012; 14:104-10. [PMID: 21070566 DOI: 10.1111/j.1463-1318.2010.02502.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM Our aim is to evaluate the results of transanal repair of rectocele, either manual or stapled, considering the anatomic, manometric and symptomatic improvement. METHODS Forty-five female patients with obstructed defaecation due to anterior rectocele were operated on in the Colorectal Surgery Unit, Mansoura University Hospital, after history taking, detailed questionnaire analysis, barium enema, anorectal manometric studies, EMG studies, anal endosonography, balloon expulsion test, colonic transit time and defaecographic studies. Transanal manual repair was performed for 23 patients (group 1), and transanal stapled repair (group 2) was performed for 22 patients. Postoperative complications were recorded, and the patients were followed up for 1 year. Functional results were evaluated at 3, 6 and 12 months after surgery by questionnaire, anorectal manometry and evacuation proctography. RESULTS Time of operation and hospital stay were significantly shorter in group 2. Postoperatively, there was no mortality or major morbidity. Two patients in group 1 experienced temporary anal incontinence (A3 and B1 stages). There were no reported adverse effects on sexual life, but significant clinical improvement was observed in both groups after surgery. Manometrically, there was a significant improvement in MARP, FLAC, RS, UTDV and MTV in both groups (significantly better in the early postoperative period in the stapled group). Also, follow-up defaecographic findings showed a significant decrease in the rectocele size in all the patients. CONCLUSION Transanal repair of rectocele is a safe and effective technique in improving symptomatic rectocele. Stapled repair offers the advantage of short operative time, no comorbidity, and shorter hospital stay.
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Affiliation(s)
- S A Mahmoud
- Colorectal Surgery Unit, General Surgery Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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Biviano I, Badiali D, Candeloro L, Habib FI, Mongardini M, Caviglia A, Anzini F, Corazziari ES. Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders. World J Gastroenterol 2011; 17:4199-205. [PMID: 22072851 PMCID: PMC3208364 DOI: 10.3748/wjg.v17.i37.4199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/04/2011] [Accepted: 03/11/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To prospectively assess the efficacy and safety of stapled trans-anal rectal resection (STARR) compared to standard conservative treatment, and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR.
METHODS: Thirty patients (Female, 28; age: 51 ± 9 years) with rectocele or rectal intussusception, a defecation disorder, and functional constipation were submitted for STARR. Thirty comparable patients (Female, 30; age 53 ± 13 years), who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol, were assessed. Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment. A responder was defined as an absence of the Rome III diagnostic criteria for functional constipation. Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients, respectively.
RESULTS: After STARR, 53% of patients were responders; during conservative treatment, 75% were responders. After STARR, 30% of the patients reported the use of laxatives, 17% had intermittent anal pain, 13% had anal leakage, 13% required digital facilitation, 6% experienced defecatory urgency, 6% experienced fecal incontinence, and 6% required re-intervention. During macrogol therapy, 23% of the patients complained of abdominal bloating and 13% of borborygmi, and 3% required digital facilitation.No preoperative symptom, defecographic, or manometric finding predicted the outcome of STARR. Post-operative defecography showed a statistically significant reduction (P < 0.05) of the rectal diameter and rectocele. The post-operative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified, and that rectal compliance was reduced (P = 0.01).
CONCLUSION: STARR is not better and is less safe than macrogol in the treatment of defecation disorders. It could be considered as an alternative therapy in patients unresponsive to macrogol.
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Wong M, Meurette G, Abet E, Podevin J, Lehur PA. Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele. Colorectal Dis 2011; 13:1019-23. [PMID: 20553314 DOI: 10.1111/j.1463-1318.2010.02349.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Laparoscopic ventral mesh rectopexy, previously described for external rectal prolapse, was evaluated for symptomatic complex rectocoele. METHOD From January 2004 to December 2008, 84 (50.9%) patients (mean age 64 ± 5 years) underwent laparoscopic ventral mesh rectopexy for symptomatic complex rectocoele, confirmed preoperatively on dynamic defaecography, with 26 (31%) patients having a concurrent cystocoele. The operative technique was standardized, and those with cystocoele underwent bladder mesh suspension during the same procedure. Prospectively collected data were analysed for preoperative symptoms, operative and functional results [constipation, faecal incontinence (FI), dyspareunia and satisfaction score]. RESULTS The conversion rate was 3.6% and perioperative morbidity 4.8% with no mortality. At a median follow up of 29 (4-59) months, there was a significant decrease in vaginal discomfort (86-20%) and obstructed defaecation symptoms (83-46%), P < 0.001. There was no significant change in FI (20-16%), no worsening of preoperative symptoms or new complaints of constipation, dyspareunia or FI. Overall, 88% of patients reported an improvement in overall well-being. CONCLUSION Laparoscopic ventral mesh rectopexy is a safe and effective method for treating symptomatic complex rectocoele.
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Affiliation(s)
- M Wong
- Clinique de Chirurgie Digestive et Endocrinienne (CCDE), Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes Hotel Dieu, Nantes, France
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Maglinte DDT, Bartram CI, Hale DA, Park J, Kohli MD, Robb BW, Romano S, Lappas JC. Functional imaging of the pelvic floor. Radiology 2011; 258:23-39. [PMID: 21183491 DOI: 10.1148/radiol.10092367] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The clinical treatment of patients with anorectal and pelvic floor dysfunction is often difficult. Dynamic cystocolpoproctography (DCP) has evolved from a method of evaluating the anorectum for functional disorders to its current status as a functional method of evaluating the global pelvic floor for defecatory disorders and pelvic organ prolapse. It has both high observer accuracy and a high yield of positive diagnoses. Clinicians find it a useful diagnostic tool that can alter management decisions from surgical to medical and vice versa in many cases. Functional radiography provides the maximum stress to the pelvic floor, resulting in levator ani relaxation accompanied by rectal emptying-which is needed to diagnose defecatory disorders. It also provides organ-specific quantificative information about female pelvic organ prolapse-information that usually can only be inferred by means of physical examination. The application of functional radiography to the assessment of defecatory disorders and pelvic organ prolapse has highlighted the limitations of physical examination. It has become clear that pelvic floor disorders rarely occur in isolation and that global pelvic floor assessment is necessary. Despite the advances in other imaging methods, DCP has remained a practical, cost-effective procedure for the evaluation of anorectal and pelvic floor dysfunction. In this article, the authors describe the technique they use when performing DCP, define the radiographic criteria used for diagnosis, and discuss the limitations and clinical utility of DCP.
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Affiliation(s)
- Dean D T Maglinte
- Department of Radiology, Indiana University School of Medicine, Indiana University Hospital, 550 N University Blvd, UH0279, Indianapolis, IN 46202-5253, USA.
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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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Ellis CN. Outcomes after the repair of rectoceles with transperineal insertion of a bioprosthetic graft. Dis Colon Rectum 2010; 53:213-8. [PMID: 20087097 DOI: 10.1007/dcr.0b013e3181c8e549] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was performed to determine the early outcomes with the use of bioprosthetic grafts for the management of rectoceles and to compare them to those achieved with transanal techniques. METHODS A retrospective analysis of prospectively collected data was performed for patients treated for a rectocele. Data collected included age, technique of repair, complications, and functional outcomes. Defecatory function was determined using the Birmingham Bowel and Urinary Symptoms Questionnaire, a validated instrument for the measurement of bowel symptoms. The questionnaire was administered preoperatively and at 12 weeks and 12 months postoperatively. RESULTS In this series, 88 women underwent a transanal repair, compared to 32 women who had their rectocele managed with a bioprosthetic graft. After 1 year of follow-up, patients whose rectocele was repaired using a bioprosthetic had significantly fewer complications with comparable functional results between the 2 techniques. CONCLUSIONS These data suggest that transperineal, bioprosthetic repair of rectoceles is associated with similar functional results but fewer complications when compared to transanal techniques during the early postoperative period. Randomized studies with longer-term follow-up will be required before the role of bioprosthetic repair of rectoceles can be determined.
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Affiliation(s)
- C Neal Ellis
- Department of Surgery, University of South Alabama, Mobile, Alabama 36617, USA.
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Abstract
PURPOSE To determine the outcomes of patients after transanal rectocele repair. METHODS The Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ-22), a validated instrument to evaluate bowel and urinary symptoms, was completed preoperatively by all patients undergoing transanal rectocele repair and postoperatively at a median interval of 8 months. The BBUSQ-22 was also administered to a control group of 50 asymptomatic female patients. The preoperative and postoperative BBUSQ-22 results for the 9 items pertaining to bowel function were compared to each other and to the responses from the control group. RESULTS Between April 1, 2001 and December 31, 2003, 88 women underwent transanal rectocele repair. Compared to the control group, patients with rectocele were significantly more symptomatic on all of the questions except the ability to hold bowel movements longer than 5 minutes. A significant improvement was reported postoperatively in all areas except pain with bowel movement and ability to hold bowel movements longer than 5 minutes. When the postoperative responses were compared to the control group, there were no significant differences except for a more frequent need for digital assistance and painful defecation in the surgical group. CONCLUSION Transanal rectocele repair results in significant improvement in defecation and continence, with postoperative bowel function comparable to control patients in 7 of the 9 areas evaluated.
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Affiliation(s)
- Kerry L Hammond
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Karling P, Abrahamsson H, Dolk A, Hallböök O, Hellström PM, Knowles CH, Kjellström L, Lindberg G, Lindfors PJ, Nyhlin H, Ohlsson B, Schmidt PT, Sjölund K, Sjövall H, Walter S. Function and dysfunction of the colon and anorectum in adults: working team report of the Swedish Motility Group (SMoG). Scand J Gastroenterol 2009; 44:646-60. [PMID: 19191186 DOI: 10.1080/00365520902718713] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Symptoms of fecal incontinence and constipation are common in the general population. These can, however, be unreliably reported and are poorly discriminatory for underlying pathophysiology. Furthermore, both symptoms may coexist. In the elderly, fecal impaction always must be excluded. For patients with constipation, colon transit studies, anorectal manometry and defecography may help to identify patients with slow-transit constipation and/or pelvic floor dysfunction. The best documented medical treatments for constipation are the macrogols, lactulose and isphagula. Evolving drugs include lubiprostone, which enhances colonic secretion by activating chloride channels. Surgery is restricted for a highly selected group of patients with severe slow-transit constipation and for those with large rectoceles that demonstrably cause rectal evacuatory impairment. For patients with fecal incontinence that does not resolve on antidiarrheal treatment, functional and structural evaluation with anorectal manometry and endoanal ultrasound or magnetic resonance (MR) of the anal canal may help to guide management. Sacral nerve stimulation is a rapidly evolving alternative when other treatments such as biofeedback and direct sphincter repair have failed. Advances in understanding the pathophysiology as a guide to treatment of patients with constipation and fecal incontinence is a continuing important goal for translational research. The content of this article is a summary of presentations given by the authors at the Fourth Meeting of the Swedish Motility Group, held in Gothenburg in April 2007.
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Affiliation(s)
- Pontus Karling
- Department of Internal Medicine, Umeå University Hospital, Sweden.
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Reboa G, Gipponi M, Ligorio M, Marino P, Lantieri F, Lantieri F. The impact of stapled transanal rectal resection on anorectal function in patients with obstructed defecation syndrome. Dis Colon Rectum 2009; 52:1598-604. [PMID: 19690488 DOI: 10.1007/dcr.0b013e3181a74111] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE A careful preoperative selection of patients was performed in order to identify those eligible for stapled transanal rectal resection to correct obstructed defecation syndrome. The aim was to assess the consequences of surgery on anorectal function and patient outcomes. METHODS From January 2004 to June 2007, 33 female patients (median age, 56.3 years; range, 27-77 years) eligible for stapled transanal rectal resection completed standardized questionnaires for the assessment of constipation (constipation scoring system), quality of life (Patient Assessment of Constipation-Quality of Life Questionnaire), and patient satisfaction (visual analogue scale). A complete clinical reassessment including anorectal manometry and defecography was performed after one year. RESULTS At a median follow-up of 18 months, significant improvement in constipation scoring system, quality of life, and visual analog scale (P < 0.0001) was observed. Postoperative defecography confirmed the correction of internal rectal prolapse (P < 0.01) and rectocele (P < 0.0001) with an increase in rectal sensitivity (P < 0.0001). Significant correlations were observed between rectocele correction and rectal sensitivity, as evidenced by a decrease in rectal sensory threshold volumes (P = 0.017; Phi = 0.7), increased rectal sensitivity, and patient's satisfaction index (P = 0.011; Phi = 0.64). CONCLUSIONS Stapled transanal rectal resection allowed for the correction of rectocele and intussusceptions. These corrections increased rectal sensitivity, diminished symptoms of obstructed defecation syndrome, and improved the quality of life of patients.
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Affiliation(s)
- Giuliano Reboa
- U.O. General Surgery, Colo-Rectal Unit, A.O.U. San Martino, Genoa, Italy
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Brusciano L, Limongelli P, del Genio G, Rossetti G, Sansone S, Healey A, Maffettone V, Napolitano V, Pizza F, Tolone S, del Genio A. Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders. Int J Colorectal Dis 2009; 24:961-7. [PMID: 19271224 DOI: 10.1007/s00384-009-0678-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE The aims of this study were to evaluate several clinical and instrumental parameters in a large number of patients with constipation and incontinence as well as in healthy controls and discuss their potential implications in the functional aspects of these disorders. METHODS Eighty-four constipated and 38 incontinent patients and 45 healthy controls were submitted to a protocol based on proctologic examination, clinico-physiatric assessment, and instrumental evaluation. RESULTS Constipated and incontinent patients had significantly worse lumbar lordosis as well as lower rate in the presence of perineal defense reflex than controls. Constipated but not incontinent patients had a lower rate of puborectalis relaxation than controls. Furthermore, worse pubococcygeal tests and a higher rate of muscle synergies presence, either agonist or antagonist, were observed in both constipated and incontinent patients compared to controls. CONCLUSIONS This study has demonstrated strong correlations between physiatric disorders and the symptoms of constipation and incontinence. Further studies designed to demonstrate a causal relationship between these parameters and the success of a specific treatment of the physiatric disorders on the proctology symptoms are warranted.
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Affiliation(s)
- L Brusciano
- First Division of General and Gastrointestinal Surgery, Second University of Naples, Naples, Italy.
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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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Augmented repairs and use of interposition grafts in pelvic reconstructive surgery: Part II. CURRENT BLADDER DYSFUNCTION REPORTS 2008. [DOI: 10.1007/s11884-007-0013-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sajid MS, Baig MK. Persistent symptoms of functional outlet obstruction after rectocele repair. Colorectal Dis 2007; 9:573-4; author reply 574-5. [PMID: 17573757 DOI: 10.1111/j.1463-1318.2007.01289.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Nano M, Ferronato M, Solej M, D'Amico S. A novel technique for rectocele repair in elderly women. Tech Coloproctol 2007; 11:149-51. [PMID: 17510739 DOI: 10.1007/s10151-007-0346-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 12/09/2006] [Indexed: 12/15/2022]
Abstract
We have developed a transvaginal technique for rectocele repair which we believe to be particularly suitable for older woman. A transverse incision was made in the mucocutaneous border of the vaginal introitus. The rectal wall was separated from the rectovaginal septum. The vaginal wall was divided in the middle. The first flap was sewn to the second and this onto the first. This intervention permits the contemporary correction of other pathologies frequently found in older women, such as cystocele and prolapse of the uterus. Twenty-two elderly women underwent operations using this technique; the mean follow-up period was 48 months (range, 24-84 months). The need to assist evacuation digitally disappeared in all patients.
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Affiliation(s)
- M Nano
- Third Section of General Surgery, Department of Clinical Pathophysiology, University of Turin, Via Genova 3, I-10126 Turin, Italy.
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Chartier-Kastler E, Ayoub N, Mozer P, Richard F, Ruffion A. Chapitre H - Les conséquences neuro-urologiques de la chirurgie de l’incontinence urinaire d’effort et de la statique pelvienne. Prog Urol 2007; 17:385-92. [PMID: 17622064 DOI: 10.1016/s1166-7087(07)92335-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is difficult to prove the neurourological origin of a voiding disorder, pain or postoperative functional disorders after stress urinary incontinence and pelvic repair surgery and their incidence is difficult to evaluate. The purpose of this chapter is to review the data of the literature concerning complications of this type of surgery, possibly related to a neurological injury, regardless of the site. The most frequently encountered postoperative problem is acute urinary retention. Prevention of acute urinary retention must be based on preoperative assessment looking for risk factors and the quality of postoperative resumption of voiding after removal of the bladder catheter Medium-term and long-term de novo dysuria and/or urgency must be analysed according to a neurourological approach, looking for obstruction (that must be removed) and complications related to the implanted prosthetic material or to the operative technique. The most difficult symptom to assess is postoperative pelvic pain "induced" by surgery. It can be accentuated by a previously undiagnosed concomitant spinal or regional lesion (hip) and the diagnostic assessment must be based on a multidisciplinary approach. This review emphasizes the low level of proof of data of the literature in this field and supports the impression that prospective data from homogeneous cohorts must be recorded in registries, for example, despite the difficulty of long-term evaluation (> 5 years). In the future, patients in whom prosthetic material is implanted should probably be encouraged to more readily cooperate in this field to ensure continuing improvement of the quality of surgical care.
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Puigdollers A, Fernández-Fraga X, Azpiroz F. Persistent symptoms of functional outlet obstruction after rectocele repair. Colorectal Dis 2007; 9:262-5. [PMID: 17298626 DOI: 10.1111/j.1463-1318.2006.01155.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Rectocele is frequently associated with constipation, but it is not known whether a causal relationship exists. OBJECTIVE To determine the effect of rectocele repair on symptoms of constipation. METHOD Thirty-five women (28-79 years) consecutively operated for rectocele repair (11 transanal approach and 24 transperineal) were included in the prospective study. Using a structured questionnaire, the following criteria for constipation were evaluated: (a) straining, (b) sensation of anal blockage, (c) sensation of incomplete evacuation, (d) manual manoeuvres to facilitate defecation, (e) stool consistency and (f) stool frequency. The evaluation was performed before and 1 year after rectocele repair. RESULTS Before the operation all patients had two or more constipation criteria, including sensation of anal blockage. One year after the operation, the incidence of all symptoms significantly improved (from 3.9 +/- 0.2 to 1.9 +/- 0.3; P < 0.01). However, in 18 patients two or more criteria of constipation persisted, two patients presented one criterion, and only 15 patients became asymptomatic. Neither parity nor the type of surgical approach (endorectal vs transperineal) was related to the response to treatment. In eight patients who had a previous hysterectomy the result was significantly worse. CONCLUSION In a considerable proportion of patients, constipation persists after rectocele repair, suggesting that these symptoms are related to an underlying dysfunction.
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Affiliation(s)
- A Puigdollers
- Proctology Unit, Hospital of Mollet, Barcelona, Spain
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Maglinte DDT, Bartram C. Dynamic imaging of posterior compartment pelvic floor dysfunction by evacuation proctography: techniques, indications, results and limitations. Eur J Radiol 2006; 61:454-61. [PMID: 17161573 DOI: 10.1016/j.ejrad.2006.07.031] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Accepted: 07/26/2006] [Indexed: 11/24/2022]
Abstract
The clinical management of patients with anorectal and pelvic floor dysfunction is often difficult. Evacuation proctography has evolved from a method to evaluate the anorectum for functional disorders to its current status as a practical method for evaluating anorectal dysfunction and pelvic floor prolapse. It has a high observer accuracy and yield of positive diagnosis. Clinicians find it of major benefit and has altered management from surgical to medical and vice versa in a significant number of cases.
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Affiliation(s)
- Dean D T Maglinte
- Department of Radiology, Indiana University Medical Center, University Hospital and Outpatient Center, 550 N. University Blvd. UH 0279, Indianapolis, IN 46202, USA.
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Hübner M, Hetzer F, Weishaupt D, Hahnloser D, Clavien PA, Demartines N. A prospective comparison between clinical outcome and open-configuration magnetic resonance defecography findings before and after surgery for symptomatic rectocele. Colorectal Dis 2006; 8:605-11. [PMID: 16919115 DOI: 10.1111/j.1463-1318.2006.01026.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The correlation between clinical symptoms and anatomical findings by conventional imaging is poor in patients with rectoceles. The aim of this prospective study was to assess and to correlate symptomatic changes after anterior levatorplasty with morphologic changes visualized by magnetic resonance defecography (MRD). METHOD Fourteen women with a median age of 57 (range 37-83) accepted to participate. Seven of 14 had previous hysterectomy. Patients underwent MRD before surgery and again 6 months postsurgery. Pre- and postoperative symptoms and quality of life (QoL) (Eypasch) were assessed. Faecal and urinary incontinence were graded (Wexner- / Hanley-score). RESULTS The median Eypasch-score improved from 90 (range 38-106) to 106 (range 29-133) after surgery (P = 0.016). Similarly, the Wexner-score ameliorated from 8 (range 0-20) to 4.5 (range 0-18; P = 0.02). Seven patients described new dyspareunia postoperatively. The median follow up was 16.5 months (range 9-45). The median rectocele size decreased from 37 mm (range 30-48) preoperatively to 12 mm (range 0-42) postoperatively (P = 0.004). Furthermore, enteroceles were corrected and pelvic floor descent was significantly reduced after surgery. Only the clinical symptom of incomplete evacuation strongly correlated with the respective radiological finding of contrast dye trapping (Rho = 0.822; P = 0.001). CONCLUSION Anterior levatorplasty improved QoL in patients with symptomatic rectocele. Postsurgical correction of rectocele is accurately documented by MRD. Only moderate correlation between morphologic and clinical improvements was observed.
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Affiliation(s)
- M Hübner
- Department of Visceral Surgery and Transplantation, University Hospital, Zurich, Switzerland
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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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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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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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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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Abstract
PURPOSE This study was designed to assess the risk of rectocele recurrence after transanal repair and identify its predictive factors. METHODS A series of 71 females who had undergone transanal repair of low isolated rectocele was retrospectively reviewed. The functional outcome was assessed by a standard questionnaire. The follow-up varied from 30 to 128 (mean, 74 +/- 30) months. Recurrences were evaluated by survival-analysis methods, and Cox's proportional hazar model was used to determine the optimal predictive factor for recurrence. RESULTS Twenty-nine of 71 patients had isolated low rectocele recurrence, and 6 had a rectocele recurrence associated to an enterocele occurrence. The optimal predictive factor for rectocele recurrence was the persistence of symptoms two months after surgery. Although correlated to recurrences, preoperative manual pressure during defecation was not an independent predictive factor for recurrences. Preoperative defecographic parameters do not seem to influence clinical outcome of surgery, and preoperative manometric values did not determine which females could develop anal incontinence several years after surgery. CONCLUSIONS The results of the transanal rectocele repair might progressively be worse during the length of the follow-up with a high recurrence rate (50 percent). Preoperative clinic, defecographic, or manometric parameters are not useful to identify females at risk for recurrence.
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Affiliation(s)
- Horace Roman
- Department of Digestive Surgery, Rouen University Hospital-Charles Nicolle, Rouen, France
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