Internal rectal intussusception--fact or fancy?

Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension)

AIM

To assess the outcomes of rectal suspension procedures (forms of rectopexy) 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

Eighteen articles were identified, providing data on outcomes in 1238 patients. All studies reported only on laparoscopic approaches. Length of procedures ranged between 1.5 to 3.5 h, and length of stay between 4 to 5 days. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 5-15%, with mesh complications accounting for 0.5% of patients overall. No mortality was reported after any procedures in a total of 1044 patients. Although inconsistently reported, good or satisfactory outcome occurred in 83% (74-91%) of patients; 86% (20-97%) of patients reported improvements in constipation after laparoscopic ventral mesh rectopexy (LVMR). About 2-7% of patients developed anatomical recurrence. Patient selection was inconsistently documented. As most common indication, high grade rectal intussusception was corrected in 80-100% of cases after robotic or LVMR. Healing of prolapse-associated solitary rectal ulcer syndrome occurred in around 80% of patients after LVMR.

CONCLUSION

Evidence supporting rectal suspension procedures is currently derived from poor quality studies. Methodologically robust trials are needed to inform future clinical decision making.

Abdominal rectopexy for the treatment of internal rectal prolapse: a systematic review and meta-analysis

AIM

Internal rectal prolapse (IRP) is a unique functional disorder that presents with a wide spectrum of clinical symptoms, including constipation and/or faecal incontinence (FI). The present review aims to analyse the results of trials evaluating the role of abdominal rectopexy in the treatment of IRP with regard to regarding functional and technical outcomes.

METHOD

A systematic review of the literature for the role of abdominal rectopexy in patients with IRP was conducted. PubMed/Medline, Embase and the Cochrane Central Register of Controlled Trials were searched for published and unpublished studies from January 2000 to December 2015.

RESULTS

We reviewed 14 studies including 1301 patients (1180 women) of a median age of 59 years. The weighted mean rates of improvement of obstructed defaecation (OD) and FI across the studies were 73.9% and 60.2%, respectively. Twelve studies reported clinical recurrence in 84 (6.9%) patients. The weighted mean recurrence rate of IRP among the studies was 5.8% (95% CI: 4.2-7.5). Two hundred and thirty complications were reported with a weighted mean complication rate of 15%. Resection rectopexy had lower recurrence rates than did ventral rectopexy, whereas ventral rectopexy achieved better symptomatic improvement, a shorter operative time and a lower complication rate.

CONCLUSION

Abdominal rectopexy for IRP attained satisfactory results with improvement of OD and, to a lesser extent, FI, a low incidence of recurrence and an acceptable morbidity rate. Although ventral rectopexy was associated with higher recurrence rates, lower complication rates and better improvement of bowel symptoms than resection rectopexy, these findings cannot be confirmed owing to the limitations of this review.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

[Transabdominal procedures for functional bowel diseases]

Incontinence and constipation can occur in cases of pelvic floor dysfunction. Purely morphological changes without severe clinical symptoms are not an indication for surgery. Abdominal operations can be classified into procedures with dorsal (with or without bowel resection and with or without mesh implantation) and procedures with ventral rectopexy (with mesh). With respect to constipation and incontinence suture rectopexy alone is inferior to all other procedures. Dorsal and ventral mesh rectopexy and resection rectopexy are all comparable with respect to improvement of incontinence. Ventral rectopexy without dorsal mobilization and resection rectopexy are superior to mesh rectopexy with respect to constipation. Due to poor evidential status treatment is carried out from a pragmatic viewpoint.

Treatment of obstructed defecation

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.

Constipation and obstructed defecation

Difficulties with bowel function are common and may be due to several causes including slow colonic transit and obstructed defecation. The anatomical and pathophysiological changes associated with these conditions are varying, often incompletely understood, and in many cases have limited treatment outcomes. Patients present with variable complaints and have previously tried a plethora of over-the-counter medications in an effort to relieve their symptoms. Physicians need an organized approach to manage these patients optimally. Improvements over the past few years in our understanding of the complex process of defecation, along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results.

Assessing the safety, effectiveness, and quality of life after the STARR procedure for obstructed defecation: results of the German STARR registry

BACKGROUND

Internal rectal prolapse and rectocele are frequent clinical findings in patients with obstructed defecation syndrome (ODS). However, there is still no evidence whether stapled transanal rectal resection (STARR) provides a safe and effective surgical option. Therefore, the German STARR registry was initiated to assess safety, effectiveness, and quality of life.

METHODS

The German STARR registry was designed as an interventional, prospective, multicenter audit. Primary outcomes include safety (morbidity and adverse events), effectiveness (ODS, symptom severity, and incontinence scores), and quality of life (PAC-QoL and EQ-5D) documented at baseline and at 6 and 12 months. Statistical evaluation was performed by an independent research organization of clinical epidemiology.

RESULTS

Complete data of 379 patients (78% females, mean age 57.8 years) were entered into the registry database. Mean operative time was 40 min, mean hospitalization was 5.5 days. A total of 103 complications and adverse events were reported in 80 patients (21.1%) including staple line complications (minor bleeding, infection, or partial dehiscence; 7.1%), major bleeding (2.9%), and postsurgical stenosis (2.1%). Comparisons of ODS and symptom severity scores (SSS) demonstrated a significant reduction in ODS score between baseline (mean 11.14) and 6 months (mean 6.43), which was maintained at 12 months (mean 6.45), and SSS at preoperative and at 6- and 12-month follow-up (13.02 vs. 7.34 vs. 6.59; paired t test, p < 0.001). Significant reduction in ODS symptoms was matched by an improvement in quality of life as judged by symptom-specific PAC-QoL and generic ED-5Q (utility and visual analog scale) scores and was not associated with an impairment of incontinence score following STARR (p > 0.05). However, 11 patients (2.9%) showed de novo incontinence, and new-onset symptoms of fecal urgency were observed in 25.3% of patients.

CONCLUSION

These data indicate that STARR is a safe and effective procedure. However, conclusions are limited due to the selection and reporting bias of a registry. The problem of fecal urgency needs cautious reassessment.

A modified Delorme's operation for the treatment of rectal mucosal prolapse

AIMS

Many procedures have been described for the treatment of rectal internal mucosal prolapse (RMP), but the therapeutic effect is questionable. This work is to evaluate clinical and functional outcome of a modified Delorme's operation-trans-anal purse-string sutures for rectal mucosa and submucosa (TAS) for the treatment of RMP.

METHODS

The clinical data of 58 patients with rectal mucosal prolapse treated with rectal mucosa and submucosal tissue (TAS) between June 2004 and June 2008 were analyzed retrospectively.

RESULTS

No patient died. Satisfaction with surgery was high in 48 cases (82.8%), moderate in seven (12.1%), and low in three (5.17%). Prolapse relapse rate was 5.17%. Anal tenesmus and urge to defecate resolved in 52 (89.7%) patients. Constipation improved in 25 of 28 (89.3%) previously constipated patients. No surgery-associated constipation occurred. The mean operative time was 31 (range 22-46) min. Mean hospital stay was 3 days (range 2-6). Mean patient follow-up was 32 months (range 12-60).

CONCLUSIONS

From our data, TAS for the treatment of RMP showed encouraging results with little complications and an acceptable relapse rate. This economical procedure induces only mild trauma and is easy to perform, making it worthy of further practice and investigation.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography

PURPOSE

This study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD).

MATERIALS AND METHODS

Three hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I-105 nulliparous, Group II-165 had at least one vaginal delivery, and Group III-comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions.

RESULTS

No statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively.

CONCLUSION

The distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

Complications and reinterventions after surgery for obstructed defecation

PURPOSE

Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation.

METHODS

We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed.

RESULTS

Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years.

CONCLUSIONS

Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.

Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is a rare disorder often misdiagnosed as a malignant ulcer. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless, the endoscopic and clinical presentations may be confusing. The aim of the present study was to assess the clinical findings, surgical treatment, and outcomes in patients who suffer from SRUS.

MATERIALS AND METHODS

A retrospective chart review was undertaken, from January 1989 to May 2005 for all patients who were diagnosed with SRUS. Data recorded included: patient's age, gender, clinical presentation, past surgical history, diagnostic and preoperative workup, operative procedure, complications, and outcomes.

RESULTS

During the study period, 23 patients were diagnosed with SRUS. Seven patients received only medical treatment, and in three patients, the ulcer healed after medical treatment. Sixteen patients underwent surgical treatment. In four patients, the symptoms persisted after surgery. Two patients presented with postoperative rectal bleeding requiring surgical intervention. Three patients developed late postoperative sexual dysfunction. One patient continued suffering from rectal pain after a colostomy was constructed. Median follow-up was 14 (range 2-84) months.

CONCLUSION

The results of this study show clearly that every patient with SRUS must be assessed individually. Initial treatment should include conservative measures. In patients with refractory symptoms, surgical treatment should be considered. Results of anterior resection and protocolectomy are satisfactory for solitary rectal ulcer.

Functional results of laparoscopic resection rectopexy for symptomatic rectal intussusception

PURPOSE

This study was designed to assess the role of laparoscopic resection rectopexy for symptomatic rectal intussusception in patients who failed medical treatment. The functional outcomes of laparoscopic resection rectopexy were evaluated.

METHODS

Patients who underwent laparoscopic resection rectopexy for rectal intussusception between July 1998 and November 2004 were identified. All patients with obstructed defecation failing medical treatment were included. Data were prospectively collected for the perioperative period. A follow-up questionnaire was used to assess functional outcome.

RESULTS

Between 1998 and 2004, a total of 56 patients (53 females (95 percent); age range, 23-83 years) underwent laparoscopic resection rectopexy for rectal intussusception. The median operative time was 123 minutes. Morbidity was 7 percent, and there was no mortality. Fifty-two patients were available for follow-up, and of these 33 (63 percent) reported an overall improvement in their function after surgery. Of 28 patients suffering constipation, 15 (53 percent) reported an improvement in bowel frequency. Sixty-seven percent of patients incontinent before surgery improved. Symptoms of incomplete evacuation resolved in 38 percent of affected patients. Thirty-six percent of patients needing to strain at stool did not have this problem after surgery. Median follow-up was 44 (range, 15-92) months.

CONCLUSIONS

The management of patients with rectal intussusception and obstructed defecation failing medical treatment is challenging. Laparoscopic resection rectopexy is an option that might offer symptomatic relief and improved function. Further studies are required to define the selection criteria to optimize the outcome in this patient group.

The corner of the coloproctologist: what to ask to radiologist

Defecation disorders, fecal incontinence, often associated to urinary and genital dysfunction, represent symptoms of a large number of functional and structural alterations of pelvic floor. They can be evaluated by functional and morphologic tests. A perfect anatomic and functional knowledge of the anorectum and pelvic floor is indispensable for a correct diagnostic and therapeutic path. Incontinence due to sphincter lesions can be diagnosed only by imaging techniques. In defecation disorders the issue is complex because functional and anatomic alterations can coexist. The radiological diagnosis of dyssynergic defecation is a diagnosis of confidence that enhances its value when manometric and electromyographic evidence of pelvic dyssynergia are detected. When anatomical alterations are detected the aim is to understand their physiopathology, to make a more precise diagnosis and treatment, and to minimize the errors of an inappropriate therapy. Our attention is focused on the information provided by imaging techniques about anorectum and pelvic floor abnormalities for optimal therapeutic planning.

Treatment of obstructed defecation

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.

Rectoanal intussusception: presentation of the disorder and late results of resection rectopexy

BACKGROUND

Rectoanal intussusception may cause symptoms of obstructed defecation, and functional results of prosthesis rectopexy are usually not satisfactory. The aim of this study was to assess several parameters of the disorder and to evaluate the outcome of resection rectopexy.

METHODS

During a 10-year period, 27 female patients with symptomatic large rectoanal intussusception had resection rectopexy (23 laparoscopy; 4 laparotomy). Conservative treatment, including biofeedback treatment in 22 patients, had failed in all cases. Preoperative and postoperative evaluation included clinical assessment, anorectal manometry, evacuation defecography, and colon transit studies. Follow-up ranged between one and five years.

RESULTS

Length of intussusception was 2 to 4.9 cm and was significantly related to pelvic floor descent (P = 0.003) and inversely related to resting anal pressures (P < 0.001). Eleven patients had undergone a previous hysterectomy, 9 had enterocele-sigmoidocele, 7 had incontinence of varying severity, and 8 had a solitary rectal ulcer. Colon transit was abnormal in all but five cases. Immediate functional results were bad in two-thirds of the cases; tenesmus, urge to defecate, and frequent stools were the main complaints. By the time these symptoms had subsided, and one year after surgery, all but two patients were satisfied with the outcome. Intussusception was reduced in all cases, anal sphincter tone recovered (P = 0.002), perineal descent decreased (P < 0.001), and colonic transit was accelerated (P < 0.001). Patients available at five-year follow-up had no or only minor defecatory problems.

CONCLUSION

Resection rectopexy improves symptoms of obstructed defecation attributed to large rectoanal intussusception.

Dynamic evaluation of the anorectum

The evaluation of EP is complicated by the lack of any gold standard and a shifting clinical emphasis as management regimens go in and out of favor. As with all functional bowel disease, there is a residue of patients who are difficult to manage, and in whom a clinician will want maximum information before deciding on treatment. The examination has been criticized as lacking clinical relevance, and of having poor interobserver reliability except for rectal emptying and rectocele formation. Others have found a higher (83.3%) observer accuracy and a high yield of positive diagnoses. A questionnaire showed that clinicians found EP of major benefit in 40%, altering management from surgical to medical in 14% and vice versa in 4%. Radiographic examinations only impact on clinical management when findings alter management. Management protocols are evolving in functional disorders, but important features that EP reveals are anismus, trapping in rectoceles, IAI, and rectal prolapse. EP is the only method to diagnose some of these conditions and within defined parameters is extremely valuable in clinical management.

Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction

OBJECTIVE

The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction.

STUDY DESIGN

Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis).

RESULTS

All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding.

CONCLUSION

The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence.

Predictive value of impaired evacuation at proctography in diagnosing anismus

OBJECTIVE

We aimed to determine the positive predictive value of impaired evacuation during evacuation proctography for the subsequent diagnosis of anismus.

SUBJECTS AND METHODS

Thirty-one adults with signs of impaired evacuation (defined as the inability to evacuate two thirds of a 120 mL contrast enema within 30 sec) during evacuation proctography underwent subsequent anorectal physiologic testing for anismus. A physiologic diagnosis of anismus was based on a typical clinical history of the condition combined with impaired rectal balloon expulsion or abnormal surface electromyogram.

RESULTS

Twenty-eight (90%) of the 31 patients with impaired proctographic evacuation were found to have anismus at subsequent physiologic testing. Among the 28 were all 10 patients who evacuated no contrast medium and all 11 patients with inadequate pelvic floor descent, giving evacuation proctography a positive predictive value of 90% for the diagnosis of anismus. A prominent puborectal impression was seen in only three subjects during proctography, one of whom subsequently showed no physiologic sign of anismus.

CONCLUSION

Impaired evacuation during evacuation proctography is highly predictive for diagnosis of anismus.

Outcome and management of patients with large rectoanal intussusception

OBJECTIVES

Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome.

METHODS

Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception > or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse.

RESULTS

Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12-118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37-91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0-5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group 1 (8.1+/-2.8 vs 0.8+/-0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7+/-4.2 to 1.1+/-5.4 vs 1.4+/-2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse.

CONCLUSIONS

This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.

Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects

OBJECTIVE

The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse.

MATERIALS AND METHODS

Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination.

RESULTS

Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding.

CONCLUSION

Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Long-term results and functional outcome after Ripstein rectopexy

PURPOSE

The aim of this study was to evaluate operative mortality, morbidity, and functional results after Ripstein rectopexy for rectal prolapse and internal rectal intussusception.

METHODS

Sixty-nine patients with rectal prolapse and 43 with internal rectal intussusception were included. All patient records were studied and complications registered. Long-term follow-up was possible in 105 patients and performed by clinical examination and standardized interview, telephone interview, or patient records. Seventy-six patients were prospectively evaluated, comparing bowel function before and after rectopexy.

RESULTS

There was no operative mortality. Operative morbidity was 33 percent, and most complications were minor. Severe early complications included one large-bowel obstruction and one transient ureteric stenosis. Median time of follow-up was seven years in patients with rectal prolapse and 5.4 years in patients with internal rectal intussusception. Late complications included two rectovaginal fistulas and one lethal sigmoid fecaloma. Five patients underwent subtotal colectomy for severe constipation. There was one recurrent prolapse (1.6 percent). Functional evaluation showed that incontinence improved (P = 0.049), whereas the number of bowel movements per week decreased (P < 0.001). Frequency of emptying difficulties did not change significantly in patients with rectal prolapse but increased in patients with internal rectal intussusception (P = 0.038).

CONCLUSION

Ripstein rectopexy can be performed with low mortality and recurrence rate, but with a high early complication rate. There were also some serious late complications. Continence was improved, although increased constipation was a problem in some patients, especially among those with internal rectal intussusception.

Internal rectal intussusception seldom develops into total rectal prolapse

PURPOSE

This study was designed to analyze how often internal rectal intussusception develops into total rectal prolapse.

METHODS

Repeated investigations with defecography were performed in 312 patients because of persisting symptoms. In 79 patients who had a rectal intussusception at the first defecography, results of the second defecography and the patients' records were studied.

RESULTS

A total of 38 patients had not undergone any surgical treatment of rectal intussusception or rectal prolapse between the first and second defecographies. One of these patients had a rectal prolapse at the second defecography, and another developed a clinical prolapse after the second defecography.

CONCLUSIONS

The present study demonstrates that the risk of developing a rectal prolapse in patients with rectal intussusception is small. This risk should, therefore, not be used as an indication for surgery.

A constipation scoring system to simplify evaluation and management of constipated patients

PURPOSE

Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients.

MATERIALS AND METHODS

All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele.

RESULTS

A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14-92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P < 0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9).

CONCLUSION

The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.