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Otto SD, Oesterheld A, Ritz JP, Gröne J, Wolf KJ, Buhr HJ, Kroesen A. Rectal Anatomy After Rectopexy: Cinedefecography Versus MR-Defecography. J Surg Res 2011; 165:52-8. [PMID: 20031153 DOI: 10.1016/j.jss.2009.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 06/26/2009] [Accepted: 08/10/2009] [Indexed: 01/17/2023]
Affiliation(s)
- Susanne Dorothea Otto
- Department of General, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany.
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52
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Myung SJ, Lee TH, Huh KC, Choi SC, Sohn CI. [Diagnosis of constipation: a systematic review]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:316-24. [PMID: 20697191 DOI: 10.4166/kjg.2010.55.5.316] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
To diagnose constipation accurately in self-reported constipated patients is very important not to miss organic disease and prevent therapeutic abuse. To investigate the etiology of functional constipation is also important to determine the therapeutic modality of constipation. In this systemic review, the clinical usefulness of symptom evaluation, diagnostic tests to rule out organic and systemic disease, and functional tests to discriminate underlying pathophysiology in the diagnosis of constipation were discussed. No specific symptoms or tests were available to predict organic versus functional constipation or differentiate slow transit constipation versus evacuation disorder. Therefore, collaborative studies are necessary to determine the pathophysiology of this disorder.
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Affiliation(s)
- Seung-Jae Myung
- Department of Medicine, Sungkyunkwan University, School of Medicine, Seoul, Korea
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53
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Steensma AB, Oom DMJ, Burger CW, Schouten WR. Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound. Colorectal Dis 2010; 12:533-9. [PMID: 19438878 DOI: 10.1111/j.1463-1318.2009.01936.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Evacuation proctography (EP) is considered to be the gold standard investigation for the diagnosis of posterior compartment prolapse. 3D transperineal ultrasound (3DTPUS) imaging of the pelvic floor is a noninvasive investigation for detection of pelvic floor abnormalities. This study compared EP with 3DTPUS in diagnosing posterior compartment prolapse. METHOD In a prospective observational study, patients with symptoms related to posterior compartment prolapse participated in a standardized interview, clinical examination, 3DTPUS and EP. Both examinations were analysed separately by two experienced investigators, blinded against the clinical data and against the results of the other imaging technique. After the examinations, all patients were asked to fill out a standardized questionnaire concerning their subjective experience. RESULTS Between 2005 and 2007, 75 patients were included with a median age of 59 years (range 22-83). The Cohen's Kappa Index for enterocole was 0.65 (good) and for rectocele it was 0.55 (moderate). The level of correlation for intussusception was fair (kappa = 0.21). CONCLUSION This study showed moderate to good agreement between 3DTPUS and EP for detecting enterocele and rectocele.
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Affiliation(s)
- A B Steensma
- Department of Obstetrics & Gynaecology, Erasmus Medical Center, Rotterdam, the Netherlands.
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54
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Rognlid M, Lindsetmo RO. Overaktiv bekkenbunn-syndrom. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:2016-20. [DOI: 10.4045/tidsskr.09.0124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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55
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Lapray JF, Costa P, Delmas V, Haab F. Rôle de l’imagerie dans l’exploration des troubles de la statique pelvienne. Prog Urol 2009; 19:953-69. [DOI: 10.1016/j.purol.2009.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
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Rectocele and intussusception: is there any coherence in symptoms or additional pelvic floor disorders? Tech Coloproctol 2009; 13:17-25; discussion 25-6. [PMID: 19288249 DOI: 10.1007/s10151-009-0454-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 12/04/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with a rectocele often suffer from such symptoms as obstructed defaecation, urine or stool incontinence and pain. The aim of this study was to assess other concomitant pelvic floor disorders and their influence on pelvic function. METHODS Included in the study were 37 female patients with a significant rectocele and defaecation disorder. Medical history and symptoms were analysed in terms of validated functional scores. All patients underwent open magnetic resonance defaecography (MRD) in a sitting position. Imaging was analysed for the presence and size of the rectocele, intussusception and other pelvic floor disorders. RESULTS Patients with a higher body mass index tended to have a larger rectocele, whereas age and vaginal birth did not correlate with the size of the rectocele. In 67.5% of the patients with a previously diagnosed rectocele, an intussusception was diagnosed on MRD. This group suffered from significantly worse urine incontinence (p=0.023) and from accessory enteroceles 64%, compared with 17% (p=0.013) for those with a simple rectocele. Patients with higher grade intussusception suffered more frequently from incontinence than from constipation. CONCLUSION Patients with a symptomatic rectocele frequently have other pelvic floor disorders that significantly influence the pattern of symptoms. Knowledge of all the afflictions is essential for determining the optimal treatment for each individual patient.
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Colaiacomo MC, Masselli G, Polettini E, Lanciotti S, Casciani E, Bertini L, Gualdi G. Dynamic MR imaging of the pelvic floor: a pictorial review. Radiographics 2009; 29:e35. [PMID: 19270071 DOI: 10.1148/rg.e35] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pelvic floor dysfunctions involving some or all pelvic viscera are complex conditions that occur frequently and primarily affect adult women. Because abnormalities of the three pelvic compartments are frequently associated, a complete survey of the entire pelvis is necessary for optimal patient management, especially before surgical correction is attempted. With the increasing use of magnetic resonance (MR) imaging in assessing functional disorders of the pelvic floor, familiarity with normal imaging findings and features of pathologic conditions are important for radiologists. Dynamic MR imaging of the pelvic floor is an excellent tool for assessing functional disorders of the pelvic floor such as pelvic organ prolapse, outlet obstruction, and incontinence. Findings reported at dynamic MR imaging of the pelvic floor are valuable for selecting patients who are candidates for surgical treatment and for choosing the appropriate surgical approach. This pictorial essay reviews MR imaging findings of pelvic organ prolapse, fecal incontinence, and obstructed defecation. Supplemental material available at http://radiographics.rsnajnls.org/cgi/content/full/e35v1/DC1.
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Affiliation(s)
- Maria Chiara Colaiacomo
- Department of Radiology DEA, Umberto I General Hospital, University of Rome La Sapienza, viale del Policlinico 155-00161, Rome, Italy.
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58
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Brennan D, Williams G, Kruskal J. Practical performance of defecography for the evaluation of constipation and incontinence. Semin Ultrasound CT MR 2009; 29:420-6. [PMID: 19166039 DOI: 10.1053/j.sult.2008.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
By opacifying the sigmoid, rectum, and vagina with different barium consistencies and using fluoroscopy to evaluate the mechanics of defecation in a physiologic setting, a wide range of pathologies associated with constipation and incontinence can be diagnosed. This review article discusses the primary indications for fluoroscopic defecography, techniques, common diagnoses, and challenges faced in clinical practice.
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Affiliation(s)
- Darren Brennan
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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59
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Dann EW. Magnetic Resonance Defecography: An Evaluation of Obstructed Defecation and Pelvic Floor Weakness. Semin Ultrasound CT MR 2008; 29:414-9. [DOI: 10.1053/j.sult.2008.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Broekhuis SR, Kluivers KB, Hendriks JCM, Vierhout ME, Barentsz JO, Fütterer JJ. Dynamic magnetic resonance imaging: reliability of anatomical landmarks and reference lines used to assess pelvic organ prolapse. Int Urogynecol J 2008; 20:141-8. [PMID: 19002366 DOI: 10.1007/s00192-008-0760-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 10/21/2008] [Indexed: 10/21/2022]
Abstract
The aim of this study was to determine the intra- and interobserver reliability of dynamic magnetic resonance (MR) staging in pelvic organ prolapse patients. In 30 patients with pelvic organ prolapse, dynamic MR images were assessed independently by two observers. Various anatomical landmarks to asses pelvic organ prolapse were used in relation to the pubococcygeal line, H-line, and mid-pubic line. Clinical measurement points were assessed in relation to the mid-pubic line. The intraclass correlation coefficients (ICC) were calculated to describe the intra- and interobserver reliability. Overall, the intra- and interobserver reliability of MR imaging measurements was excellent to good. The pubococcygeal line showed superior reliability (ICC range 0.70-0.99). The reliability of clinical measurement points, however, were only moderate (ICC range 0.20-0.96). The intra- and interobserver reliability of quantitative prolapse staging on dynamic MR imaging were good to excellent. The pubococcygeal line appears the most reliable to use.
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Affiliation(s)
- Suzan R Broekhuis
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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61
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Savoye-Collet C, Koning E, Dacher JN. Radiologic evaluation of pelvic floor disorders. Gastroenterol Clin North Am 2008; 37:553-67, viii. [PMID: 18793996 DOI: 10.1016/j.gtc.2008.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Several imaging modalities are available ranging from fluoroscopic techniques to ultrasonography and MRI for the evaluation of patients with pelvic floors disorders. High-resolution ultrasonography and MRI not only provide superior delineation of the pelvic floor anatomy but also reveal pathology and functional changes. This article focuses on standard imaging procedures including defecography, ultrasonography, and MRI and discusses its use in clinical practice by illustrating both normal and abnormal patterns.
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Affiliation(s)
- Celine Savoye-Collet
- Radiology Department, Rouen University Hospital Charles Nicolle, 1 Rue de Germont, F-76031 Rouen, France.
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62
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Bader FG, Bouchard R, Lubienski A, Keller R, Mirow L, Czymek R, Habermann JK, Bruch HP, Roblick UJ. [Progress in diagnostics of anorectal disorders. Part II: radiology]. Chirurg 2008; 79:410-7. [PMID: 18418564 DOI: 10.1007/s00104-008-1544-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.
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Affiliation(s)
- F G Bader
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburgerallee 160, 23538 Lübeck
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63
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MR Defecography: Prospective Comparison of Two Rectal Enema Compositions. AJR Am J Roentgenol 2008; 190:W118-24. [DOI: 10.2214/ajr.07.2906] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Ganeshan A, Anderson E, Upponi S, Planner A, Slater A, Moore N, D'Costa H, Bungay H. Imaging of obstructed defecation. Clin Radiol 2008; 63:18-26. [DOI: 10.1016/j.crad.2007.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Revised: 04/25/2007] [Accepted: 05/01/2007] [Indexed: 10/22/2022]
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Grasso RF, Piciucchi S, Quattrocchi CC, Sammarra M, Ripetti V, Zobel BB. Posterior pelvic floor disorders: a prospective comparison using introital ultrasound and colpocystodefecography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:86-94. [PMID: 17587218 DOI: 10.1002/uog.4047] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To compare introital ultrasound with colpocystodefecography (CCD) in quantifying the anorectal angle and in the diagnosis of posterior pelvic floor disorders. METHODS Forty-three consecutive women with functional impairment of the posterior pelvic floor were enrolled after a clinical evaluation. Using both CCD and introital ultrasound examination, the anorectal angle was measured during squeezing to evaluate the strength of voluntary muscle contraction and during straining to assess pelvic floor relaxation. Rectocele depth and the presence of intussusception were assessed. The performance of CCD and that of introital ultrasound were compared. RESULTS Good concordance was obtained between introital ultrasound and CCD. The intraclass correlation coefficient was 0.82 (95% CI, 0.69-0.89) for measurement of the anorectal angle during squeezing and 0.67 (95% CI, 0.47-0.81) during straining. Rectoceles > 4 cm on CCD were detected by introital ultrasound in 100% of cases, and there was 91% agreement for rectal intussusception. Cohen's kappa index was moderate for rectocele assessment (0.41, P < 0.01) and excellent for intussusception (0.91, P < 0.001). It was also noted that introital ultrasound could be used to detect pelvic floor dyssynergia. CONCLUSIONS Introital ultrasound is a simple, accurate, non-invasive method with which to assess anorectal dynamics.
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Affiliation(s)
- R F Grasso
- Interdisciplinary Center for Biomedical Research, Department of Radiology, University Campus Bio-Medico, Rome, Italy
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67
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68
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Murad-Regadas SM, Regadas FSP, Rodrigues LV, Souza MHLP, Lima DMR, Silva FRS, Filho FSPR. A novel procedure to assess anismus using three-dimensional dynamic anal ultrasonography. Colorectal Dis 2007; 9:159-65. [PMID: 17223941 DOI: 10.1111/j.1463-1318.2006.01157.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aimed to determine the value of three-dimensional (3D) dynamic endosonography in the assessment of anismus. METHOD Sixty-one women submitted to anorectal manometry were enrolled including 40 healthy women and 21 patients with anismus diagnosed by manometry. Patients were submitted to 3D endosonography. Images were acquired at rest and during straining and analysed in axial and midline longitudinal planes. Sphincter integrity was quantified. The angle between the internal edge of the puborectalis with a vertical line according to the anal canal axis was calculated at rest and during straining. RESULTS The angle increased in 39 of the 40 normal individuals and decreased in all patients with anismus during straining compared with the angle at rest (88.36 degrees ) and straining (98.65 degrees ) in normal individuals. In the anismus group, the angle decreased at rest (90.91 degrees ) and straining (84.89 degrees ). The difference between angle sizes in normal and anismus patients during straining was statistically significant (P < 0.5). CONCLUSION Three-dimensional endosonography is a useful method to assess patients with anismus confirming the anorectal manometric results.
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Affiliation(s)
- S M Murad-Regadas
- Anorectal Physiology Unit, Clinic Hospital, Federal University of Ceara, Fortaleza, Ceara, Brazil.
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69
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Abstract
During the past few years, significant developments have taken place in the understanding and diagnosis of defecation disorders. Several innovative manometric, neurophysiologic, and radiologic techniques have been discovered, which have improved the accuracy of identifying the neuromuscular and pathophysiologic mechanisms of chronic constipation. Such approaches have led to improved management of these patients. In this review, we summarize and highlight recent advances in the utility of diagnostic testing of chronic constipation.
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Affiliation(s)
- Jose M Remes-Troche
- 4612 JCP, The University of Iowa Hospital and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
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70
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Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: Indications, techniques and MRI features. Eur J Radiol 2006; 61:462-72. [PMID: 17145152 DOI: 10.1016/j.ejrad.2006.11.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Revised: 10/29/2006] [Accepted: 11/02/2006] [Indexed: 11/20/2022]
Abstract
Pelvic floor weakness is characterized by abnormal symptomatic displacement of pelvic organs. It represents a complex clinical problem most commonly seen in middle-aged and elderly parous women. Its diagnosis remains difficult in many cases, since these disorders typically present with nonspecific symptoms, such as pelvic pain, incontinence and constipation. Fluoroscopic colpocystodefecography has been proven to surpass physical examination in the detection and characterization of functional abnormalities of the anorectum and surrounding pelvic structures. Similarly, MR defecography, performed either with an open- or closed-configuration unit, appears to be an accurate imaging technique to assess clinically relevant pelvic floor abnormalities. Moreover, MR defecography negates the need to expose the patient to harmful ionizing radiation and allows excellent depiction of the surrounding soft tissues of the pelvis. In this manuscript, we review the techniques and indications of MR defecography, and illustrate the MRI features of a vast array of morphologic and functional pelvic floor disorders, with emphasis on the posterior pelvic compartment (anorectum).
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Affiliation(s)
- Koenraad J Mortele
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston MA 02115, USA.
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71
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ANDERSON EM, FERRETT CG, LINDSEY I. Imaging of the pelvic floor. IMAGING 2006. [DOI: 10.1259/imaging/58681082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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72
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Schwizer W, Steingoetter A, Fox M. Magnetic resonance imaging for the assessment of gastrointestinal function. Scand J Gastroenterol 2006; 41:1245-60. [PMID: 17060117 DOI: 10.1080/00365520600827188] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Werner Schwizer
- Clinic of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland.
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73
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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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74
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Hetzer FH, Andreisek G, Tsagari C, Sahrbacher U, Weishaupt D. MR Defecography in Patients with Fecal Incontinence: Imaging Findings and Their Effect on Surgical Management. Radiology 2006; 240:449-57. [PMID: 16801366 DOI: 10.1148/radiol.2401050648] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively evaluate magnetic resonance (MR) defecography findings in patients with fecal incontinence who were evaluated for surgical treatment and to assess the influence of MR defecography on surgical therapy. MATERIALS AND METHODS Institutional review board approval was obtained. Informed consent was waived; however, written informed consent for imaging was obtained. Fifty patients (44 women, six men; mean age, 61 years) with fecal incontinence were placed in a sitting position and underwent MR defecography performed with an open-configuration MR system. Midsagittal T1-weighted MR images were obtained at rest, at maximal contraction of the sphincter, and at defecation. Images were prospectively and retrospectively reviewed by two independent observers for a variety of findings. Interobserver agreement was analyzed by calculating kappa statistics. Prospective interpretation of MR defecography findings was used to influence surgical therapy, and retrospective interpretation was used for concomitant pelvic floor disorders. RESULTS MR defecography revealed rectal descent of more than 6 cm (relative to the pubococcygeal line) in 47 (94%) of 50 patients. A bladder descent of more than 3 cm was present in 20 (40%) of 50 patients, and a vaginal vault descent of more than 3 cm was present in 19 (43%) of 44 women. Moreover, 17 (34%) anterior proctoceles, 16 (32%) enteroceles, and 10 (20%) rectal prolapses were noted. Interobserver agreement was good to excellent (kappa = 0.6-0.91) for image analysis results. MR defecography findings led to changes in the surgical approach in 22 (67%) of 33 patients who underwent surgery. CONCLUSION MR defecography may demonstrate a variety of abnormal findings in patients who are considered candidates for surgical therapy for fecal incontinence, and the findings may influence the surgical treatment that is subsequently chosen. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/2402050648/DC1
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Affiliation(s)
- Franc H Hetzer
- Division of Visceral and Transplantation Surgery, University Hospital, Raemistrasse 100, 8091 Zurich, Switzerland
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75
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Abstract
Physiopathological and clinical interpretation of the descending perineum as described by A. Parks in 1970 remains difficult. This review is based on the literature between 1966 and 2004. The observed symptoms are more often due to associated lesions. The descending perineum on X-ray is not always symptomatic. Colpocystography shows the descent of the perineum and pelvic disorders from the anterior and middle parts of the perineum whereas defecography seems to provide a better diagnosis of dyschesia due to posterior damage (such as rectocele or endo-anal intussusception). The first step of treatment is reeducation and medical treatment because there is no consensus for surgical therapy. Soft sacrocolpopexy by the abdominal approach with three meshes, one under the bladder, one in front of and one behind the rectum can be proposed for complete descending perineum. Transanal rectal resection by staple could be useful when the descending perineum is only associated with a rectocele and/or an intra-anal intussusception.
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Affiliation(s)
- Richard Villet
- Service de Chirurgie Viscérale et Gynécologique, Groupe Hospitalier Diaconesses-Croix-Saint-Simon, Site Reuilly, Paris.
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76
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Terra MP, Stoker J. The current role of imaging techniques in faecal incontinence. Eur Radiol 2006; 16:1727-36. [PMID: 16688456 DOI: 10.1007/s00330-006-0225-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Revised: 02/12/2006] [Accepted: 02/28/2006] [Indexed: 01/12/2023]
Abstract
Faecal incontinence is a common multifactorial disorder. Major causes of faecal incontinence are related to vaginal delivery and prior anorectal surgery. In addition to medical history and physical examination, several anorectal functional tests and imaging techniques can be used to assess the underlying pathophysiology and to guide treatment planning in faecal incontinent patients. Anorectal functional tests provide functional information, but the potential strength comes from combining test results. Imaging techniques, including defecography, endoanal sonography, and magnetic resonance (MR) imaging, provide structural information about the anorectal region with a direct clinical impact. The major role of imaging techniques in faecal incontinence is visualising the structural and functional integrity of the anal sphincter complex. Both two-dimensional endoanal sonography and endoanal MR imaging are accurate tools to depict anal sphincter defects. The major advantage of endoanal MR imaging is the accurate demonstration of external anal sphincter atrophy. Recent studies have suggested that external phased array MR imaging and three-dimensional endoanal sonography are also valuable tools in the diagnostic work up of faecal incontinence. Decisions about the preferred technique will mainly be determined by availability and local expertise. This article demonstrates the current role of tests, predominantly imaging tests, in the diagnostic work up of faecal incontinence.
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Affiliation(s)
- M P Terra
- Department of Radiology, G1-229, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Dvorkin LS, Gladman MA, Epstein J, Scott SM, Williams NS, Lunniss PJ. Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers. Br J Surg 2005; 92:866-72. [PMID: 15898121 DOI: 10.1002/bjs.4912] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Abstract
Background
Rectal intussusception is a common finding at evacuation proctography in both symptomatic and asymptomatic individuals. Little information exists, however, as to whether intussusception morphology differs between patients with evacuatory dysfunction and healthy volunteers.
Methods
Thirty patients (19 women; median age 44 (range 21–76) years) with disordered rectal evacuation, in whom an isolated intussusception was seen on proctography, were studied. Various morphological parameters were measured, and compared with those from 11 asymptomatic controls (six women; median age 30 (range 24–38) years) found, from 31 volunteers, to have rectal intussusception. Intussusceptum thickness greater than 3 mm was designated as full thickness. Intussuscepta impeding evacuation were deemed to be occluding.
Results
Twenty-two patients had full-thickness intussusception, compared with two controls (P = 0·003). Intussusceptum thickness was significantly greater in the symptomatic group (anterior component: P = 0·004; posterior: P = 0·011). Twenty patients in the symptomatic group, but only three subjects in the control group, had a mechanically occluding intussusception (P = 0·043), although only three patients demonstrated evacuatory dynamics outside the normal range.
Conclusion
Rectal intussusception in patients with evacuatory dysfunction is more advanced morphologically than that seen in asymptomatic controls; it is predominantly full thickness in patients and mucosal in controls. However, caution is required when selecting patients for intervention based solely on radiological findings.
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Affiliation(s)
- L S Dvorkin
- Gastrointestinal Physiology Unit, Centre for Academic Surgery, Royal London Hospital, UK
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78
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Martin RCG. Intraoperative magnetic resonance imaging ablation of hepatic tumors. Am J Surg 2005; 189:388-94. [PMID: 15820448 DOI: 10.1016/j.amjsurg.2005.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Revised: 09/11/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND The use of hepatic ablation of tumors for both primary and secondary cancers has continued to increase at a significant rate. The most significant increase in the use of hepatic ablation has come from image-guided techniques with computed axial tomography and ultrasound. Limitations to targeting hepatic lesions by these techniques remain morbid obesity, abnormal hepatic parenchyma, and inability to visualize lesions without the use of intravenous contrast. In contrast, magnetic resonance imaging (MRI) has continued to provide a high contrast of soft tissue-to-lesion conspicuity without the need for intravenous dye. The recent development of open-configuration magnetic resonance scanners--which have allowed improved patient access, near real-time imaging, and more available MRI-compatible equipment--has opened up an entire new area of image-guided surgical and interventional procedures. METHODS The principles and indications for all types of image-guided hepatic ablations are described. RESULTS The success and limitations of image-guided ablation techniques. CONCLUSIONS Image-guided hepatic ablation represents a useful technique in managing hepatic tumors. Intraoperative MRI represents a new technique with initial success that has been limited to European centers. Further evaluation in United States centers has demonstrated intraoperative MRI to be useful for certain hepatic tumors that cannot be adequately visualized by ultrasound or computed axial tomography. A multidisciplinary approach involving a surgical oncologist and interventional radiologist remains integral to the short- and long-term success of image-guided ablation.
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Affiliation(s)
- Robert C G Martin
- Department of Surgery, Division of Surgical Oncology and Center for Advanced Surgical Technologies, Norton Healthcare, University of Louisville, 315 East Broadway, No. 313, Louisville, KY 40202, USA.
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79
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Affiliation(s)
- C I Bartram
- Radiology Service, St. Mark's Hospital, Northwick Park, Harrow, HA1 3UJ, United Kingdom.
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80
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Kelvin FM, Maglinte DDT. Dynamic evaluation of female pelvic organ prolapse by extended proctography. Radiol Clin North Am 2003; 41:395-407. [PMID: 12659345 DOI: 10.1016/s0033-8389(02)00118-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
More accurate preoperative assessment by DCP or MR imaging hopefully should reduce the incidence of operative failure. These techniques help the surgeon to plan the different components of pelvic reconstructive surgery and, importantly, whether a transvaginal or transabdominal approach will be required. The current trend is toward the transabdominal route. Available evidence suggests that the reoperative rate is halved when the abdominal approach is employed. Large enteroceles and marked vaginal vault prolapse, in particular, are much more amenable to correction by transabdominal surgery. It should be recognized that enteroceles and sigmoidoceles often escape preoperative detection unless radiologic evaluation is performed. Global assessment of pelvic organ prolapse is optimized by ensuring that competing organs are effectively emptied by virtue of a triphasic approach. As expressed succinctly by Halligan, "the global pelvic floor specialist has arrived, and his closest ally is the radiologist".
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Affiliation(s)
- Frederick M Kelvin
- Department of Radiology, Methodist Hospital of Indiana, 1701 North Senate Boulevard, Indianapolis, IN 46202, USA.
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