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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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Albayati S, Bhai D, Descallar J, Turner CE, Berney C, Morgan MJ. Pelvic floor training improves faecal incontinence and obstructed defaecation despite the presence of rectal intussusception. ANZ J Surg 2023; 93:1253-1256. [PMID: 36484354 DOI: 10.1111/ans.18200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/06/2022] [Accepted: 11/29/2022] [Indexed: 11/30/2023]
Abstract
BACKGROUND Rectal intussusception is often observed in patients with faecal incontinence and obstructed defaecation. The aim of this study is to assess if pelvic floor training improves faecal incontinence and obstructed defaecation in patients with rectal intussusception. METHODS Case notes of all patients referred to Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018 for the management of faecal incontinence and obstructed defaecation and rectal intussusception were retrospectively reviewed using a prospectively maintained database. St Mark's faecal incontinence and Cleveland clinic constipation scores were obtained from patients before and after they underwent pelvic floor training. RESULTS One hundred and thirty-one patients underwent pelvic floor training at Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018. Sixty-one patients had rectal intussusception (22 low-grade and 39 high-grade). Median St Marks score improved following pelvic floor training from 8 to 1 (P < 0.001). Median Cleveland Clinic constipation score improved from 8 to 5 (P < 0.001). In patients with low grade rectal intussusception, pelvic floor training improved median St Mark's score from 3 to 0 (P = 0.003), whereas Cleveland Clinic constipation score improved from 9 to 7 (P < 0.001). In patients with high-grade rectal intussusception, pelvic floor training improved median St Mark's score from 9 to 2 (P < 0.001), whereas median Cleveland Clinic constipation score improved from 8 to 4 (P < 0.001). CONCLUSION Pelvic floor training without biofeedback therapy improves faecal incontinence and obstructed defaecation. Improvement in symptoms is unrelated to rectal intussusception observed on proctography or at examination under anaesthesia in these patients.
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Affiliation(s)
- Sinan Albayati
- Department of Surgery, Nepean Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Doleen Bhai
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Joseph Descallar
- South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Catherine E Turner
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Christophe Berney
- South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Matthew J Morgan
- South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
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3
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Rectal Intussusception: Medical management and timing of the decision to operate. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Tsunoda A, Takahashi T, Osawa I. Effect of posture on anorectal manometric measurements in female patients with fecal incontinence and rectoanal intussusception. BMC Gastroenterol 2022; 22:479. [PMID: 36418959 PMCID: PMC9682782 DOI: 10.1186/s12876-022-02581-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE This study aimed to investigate the influence of erect position on anorectal manometry in patients with rectoanal intussusception (RAI). METHODS This was a single center prospective observational study. Eighty female patients with fecal incontinence (FI) who underwent defecography between 1st January 2016 and 30th April 2022 were included. The effect of posture on commonly measured parameters during manometry was assessed in the left-lateral and erect positions. The severity of FI was assessed using FI Severity Index (FISI). RESULTS Defecography showed that 30 patients had circumferential RAI (CRAI), and 50 had non-CRAI. There were no significant differences in age, parity, FI type, and FISI scores between the groups. However, FISI scores were significantly lower in 51 patients with passive FI than 12 patients with mixed FI type [21 (8-38) vs. 32 (8-43), P = 0.007]. Endo-anal ultrasound showed no significant difference in the incidence of sphincter defects between the groups. Maximum squeeze pressure was significantly lower in the erect position than in the left-lateral position in the CRAI patients [119 cm H2O (59‒454 cm H2O) vs. 145 cm H2O (65‒604 cm H2O), P = 0.006] however, this finding was not observed in the non-CRAI group and the subgroup of anterior RAI patients. In either group, maximum resting pressure, defecation desire volume, and maximum tolerated volume were significantly higher, while anal canal length was significantly shorter in the erect position than in the left-lateral position, respectively. CONCLUSION Voluntary contraction in female FI patients with CRAI was suppressed in the erect position.
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Affiliation(s)
- Akira Tsunoda
- grid.414927.d0000 0004 0378 2140Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-Cho, Kamogawa City, Chiba 296-8602 Japan
| | - Tomoko Takahashi
- grid.414927.d0000 0004 0378 2140Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-Cho, Kamogawa City, Chiba 296-8602 Japan
| | - Ikuko Osawa
- grid.414927.d0000 0004 0378 2140Department of Clinical Laboratory, Kameda Medical Center, 929 Higashi-Cho, Kamogawa City, Chiba 296-8602 Japan
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Shin JW, Hong KD, Lee DH, Kim DS, Lee DS. Laparoscopic Ventral Mesh Rectopexy (LVMR) for Internal and External Rectal Prolapse: An Analysis of 122 Consecutive Patients. Surg Laparosc Endosc Percutan Tech 2021; 31:479-484. [PMID: 34398130 DOI: 10.1097/sle.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Even though several reports have been published on the results of laparoscopic ventral mesh rectopexy (LVMR) in Asia, there are few mid-term or long-term results of LVMR. The authors aimed to evaluate the results of LVMR in patients with internal rectal prolapse (IRP) external rectal prolapse (ERP). MATERIALS AND METHODS From September 2013 to January 2019, 122 patients with IRP (n=48) or ERP (n=74) underwent LVMR. Constipation and fecal incontinence (FI) scores were evaluated using the Cleveland Clinic Florida score preoperatively and postoperatively. The questionnaire for the change of obstructed defecation or FI symptoms after surgery was also administered to grade the results as cured, improved, unchanged, or worsened for each survey. RESULTS The mean age of the patients was 61.9 years. The mean operation time was 116.5 minutes, and the mean hospital stay was 5.1 days. The mean follow-up was 42.1 months. There were no mesh-related complications. Eight patients (10.7%) among the ERP group required additional surgery for recurrent full-thickness prolapse. Eleven patients (14.7%) who had mucosal prolapse within 2 cm underwent stapled hemorrhoidopexy after LVMR. In the postoperative 6-month period, the overall constipation score (7.12) significantly improved compared with the preoperative score (13.03) (P<0.001), whereas the FI score significantly improved after surgery (12.16 to 8.92; P<0.001). CONCLUSION LVMR is a feasible and safe technique and favorable recurrence for ERP. Functional outcomes of obstructed defecation and FI were improved and the satisfaction of LVMR was high after the surgery. LVMR can be considered a recommended surgical option to treat ERP and IRP.
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Affiliation(s)
- Jae-Won Shin
- Department of Surgery, Colorectal Division, Daehang Hospital, Seoul
| | - Kwang-Dae Hong
- Department of Surgery, Colorectal Division, Korea University Ansan Hospital, Ansan, Korea
| | - Doo-Han Lee
- Department of Surgery, Colorectal Division, Daehang Hospital, Seoul
| | - Do-Sun Kim
- Department of Surgery, Colorectal Division, Daehang Hospital, Seoul
| | - Doo-Seok Lee
- Department of Surgery, Colorectal Division, Daehang Hospital, Seoul
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Emile S, Shalaby M, Elshobaky A, Khafagy W, Farid M. Utility of the Mansoura Numeroalphabetic Constipation Score in detection of obstructed defaecation syndrome and prediction of the outcome of treatment. Colorectal Dis 2020; 22:1348-1358. [PMID: 32333504 DOI: 10.1111/codi.15082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/01/2020] [Indexed: 02/08/2023]
Abstract
AIM Thorough assessment of obstructed defaecation syndrome (ODS) is imperative for the selection of treatment options. The present study aimed to examine the utility of the Mansoura Numeroalphabetic Constipation Score (MNCS) in distinguishing patients with ODS from healthy control subjects and in predicting the outcome of treatment of ODS. METHODS Patients with ODS associated with anterior rectocele and/or rectoanal intussusception were assessed with the MNCS at the first visit to the clinic. All patients were offered conservative treatment for 3 months and patients who improved were continued on conservative treatment for six more months while patients who failed were treated surgically. The MNCS was reassessed at the end of follow-up in both groups. A cohort of healthy controls was compared to ODS patients with regard to age, sex and baseline MNCS. RESULTS In all, 124 ODS patients and 53 healthy controls were included. The ODS patients had a significantly higher baseline MNCS than controls (9.5 ± 1.5 vs 0.76 ± 0.71, P < 0.0001). Forty of 124 patients improved after conservative management and showed a significant decrease in MNCS (6.9 ± 1.08 to 3.1 ± 1.2, P < 0.0001). Eighty-four (67.8%) patients failed to respond to conservative measures and were surgically treated, 77 (91.6%) of whom showed significant improvement in symptoms postoperatively while seven (8.4%) failed to improve; the difference in postoperative MNCS between the two groups was significant. CONCLUSION The MNCS successfully distinguished ODS patients from controls and was able to predict the outcome of ODS treatment.
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Affiliation(s)
- S Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - M Shalaby
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - A Elshobaky
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - W Khafagy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - M Farid
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
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Yagi Y, Tsunoda A, Takahashi T, Kusanagi H. Rectoanal intussusception is very common in patients with fecal incontinence. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 2:162-167. [PMID: 31559359 PMCID: PMC6752137 DOI: 10.23922/jarc.2017-048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/18/2018] [Indexed: 12/31/2022]
Abstract
Objectives: Fecal incontinence (FI) is a multifactorial disorder, the etiology of which is not fully understood. Recent data have shown the significance of rectoanal intussusception (RAI) in the evaluation of FI. The present study aimed to determine the incidence of RAI in patients with FI. Methods: Between June 2010 and February 2016, 74 patients, who were evaluated using evacuation proctography, anorectal manometry, ultrasound, and incontinence scores, were included in this study. RAI was diagnosed when the apex of the rectal intussusception (RI) impinged on the internal anal orifice or was intra-anal, based on the images taken during maximal straining defecation at evacuation proctography. The characteristics of RAI patients were further analyzed. Results: There were 59 women (80%) and 15 men, with a median age of 74 (52-93) years. Sixty patients (81%) had RI, and 56 (76%) showed RAI. The incidence of RAI among the 32 patients with FI alone and the 42 patients with FI and symptoms of obstructed defecation (OD) was 72% (23/32) and 79% (33/42), respectively. The incidence of RAI was not significantly different between the patients with normal manometry (maximum resting pressure [MRP] ≥55 cmH2O and maximum squeeze pressure [MSP] ≥150 cmH2O, n=26) and those with subnormal manometry (MRP <55 cmH2O and/or MSP <150 cmH2O, n=48). Conclusion: RAI is common in patients with FI. Evacuation proctography should be taken into account as a part of the regular study of FI patients.
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Affiliation(s)
- Yuma Yagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
| | - Tomoko Takahashi
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Chiba, Japan
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8
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Management of patients with rectal prolapse: the 2017 Dutch guidelines. Tech Coloproctol 2018; 22:589-596. [DOI: 10.1007/s10151-018-1830-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023]
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Benezech A, Cappiello M, Baumstarck K, Grimaud JC, Bouvier M, Vitton V. Rectal intussusception: can high resolution three-dimensional ano-rectal manometry compete with conventional defecography? Neurogastroenterol Motil 2017; 29. [PMID: 27891706 DOI: 10.1111/nmo.12978] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/21/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Three-dimensional high-resolution anorectal manometry (3DHRAM), used for exploring anorectal disorders, was recently developed, providing interesting topographic data for the diagnosis of pelvic floor disorders such as excessive perineal descent. The aim of our study was to define a diagnostic strategy based on selected 3DHRAM parameters to identify rectal intussusceptions (RI), considering conventional defecography (CD) as the gold standard. METHODS All patients referred to our center in the previous 6 months for 3DHRAM to explore fecal incontinence or constipation, and who previously achieved CD, were eligible. 3DHRAM results were obtained for all classical parameters and the presence of a narrow band of high pressure in the anal canal during attempted defecation, which was recently found to be associated with RI in some studies. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criterion in order to propose a diagnostic strategy for RI. KEY RESULTS Twenty-six patients (66%) presented with RI on CD. On 3DHRAM, according to our diagnostic strategy, the most relevant manometric criterion for the diagnosis of RI was the association of an anterior additional high-pressure area and an excessive perineal descent, with a positive predictive value of 100% [81.5-100], a specificity of 100% [75.3-100] and a sensibility of 69.2% [48.2-85.7]. CONCLUSIONS & INFERENCES In this study, 3DHRAM was used to diagnose RI, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.
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Affiliation(s)
- A Benezech
- Service de Gastroentérologie, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France.,Plateforme d'interface clinique, CRN2M CNRS UMR 7286, Aix-Marseille Université, Marseille, France
| | - M Cappiello
- Service de Gastroentérologie, Centre Hospitalier Général de Martigues, Martigues, France
| | - K Baumstarck
- Unité d'Aide Méthodologique à la Recherche Clinique, EA 3279, Laboratoire de Santé Publique, Aix-Marseille Université, Marseille, France
| | - J-C Grimaud
- Service de Gastroentérologie, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France.,Plateforme d'interface clinique, CRN2M CNRS UMR 7286, Aix-Marseille Université, Marseille, France
| | - M Bouvier
- Service de Gastroentérologie, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France.,Plateforme d'interface clinique, CRN2M CNRS UMR 7286, Aix-Marseille Université, Marseille, France
| | - V Vitton
- Service de Gastroentérologie, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France.,Plateforme d'interface clinique, CRN2M CNRS UMR 7286, Aix-Marseille Université, Marseille, France
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Emile SH, Elfeki HA, Youssef M, Farid M, Wexner SD. Abdominal rectopexy for the treatment of internal rectal prolapse: a systematic review and meta-analysis. Colorectal Dis 2017; 19:O13-O24. [PMID: 27943547 DOI: 10.1111/codi.13574] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/09/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- S H Emile
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Egypt
| | - H A Elfeki
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Egypt
| | - M Youssef
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Egypt
| | - M Farid
- General Surgery Department, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Egypt
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Abstract
Rectoanal intussusception is an invagination of the rectal wall into the lumen of the rectum. Patients may present with constipation, incomplete evacuation, incontinence, or may be asymptomatic. Defecography has been the gold standard for detection. Magnetic resonance imaging defecography and dynamic anal endosonography are alternatives to conventional defecography. However, both methods are not as sensitive as conventional defecography. Treatment options range from conservative/medical treatment such as biofeedback to surgical procedures such as Delorme, rectopexy, and stapled transanal rectal resection. Recent studies conducted after a trial of failed nonoperative management show adequate results with operations performed for rectal intussusception with or without rectocele if other causes of constipation are not present.
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Affiliation(s)
- Kristen Blaker
- Department of Surgery, Division of General Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joselin L Anandam
- Department of Surgery, Division of General Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Giannakaki V, Bordeianou L. Surgical management of severe constipation due to slow transit and obstructed defecation syndrome. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2015.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dimitriou N, Shah V, Stark D, Mathew R, Miller AS, Yeung JMC. Defecating Disorders: A Common Cause of Constipation in Women. WOMENS HEALTH 2015; 11:485-500. [DOI: 10.2217/whe.15.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Nikoletta Dimitriou
- 1st Department of Surgery, University of Athens, Medical School, Laiko Hospital, Athens, Greece
| | - Vikas Shah
- Department of Radiology, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Diane Stark
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Ronnie Mathew
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Andrew S Miller
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Justin MC Yeung
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
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Podzemny V, Pescatori LC, Pescatori M. Management of obstructed defecation. World J Gastroenterol 2015; 21:1053-1060. [PMID: 25632177 PMCID: PMC4306148 DOI: 10.3748/wjg.v21.i4.1053] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/03/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.
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Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery 2013; 155:659-67. [PMID: 24508117 DOI: 10.1016/j.surg.2013.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 11/26/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined. METHODS A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management. RESULTS Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15). CONCLUSION Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.
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Affiliation(s)
- Caitlin W Hicks
- Department of Surgery, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA; Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Milena Weinstein
- Department of Gynecology, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - May Wakamatsu
- Department of Gynecology, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - Lieba Savitt
- Department of Surgery, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - Samantha Pulliam
- Department of Gynecology, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - Liliana Bordeianou
- Department of Surgery, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA.
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Abstract
Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.
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Formijne Jonkers HA, Draaisma WA, Wexner SD, Broeders IAMJ, Bemelman WA, Lindsey I, Consten ECJ. Evaluation and surgical treatment of rectal prolapse: an international survey. Colorectal Dis 2013; 15:115-9. [PMID: 22726304 DOI: 10.1111/j.1463-1318.2012.03135.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AIM Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP. METHOD A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail. RESULTS In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients. CONCLUSION The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.
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Abstract
Rectoanal intussusception (RI) is a telescoping of the rectal wall during defecation. RI is an easily recognizable physiologic phenomenon on defecography. The management, however, is much more controversial. Two predominant hypotheses exist regarding the etiology of RI: RI as a primary disorder, and RI as a secondary phenomenon. The diagnosis may be suspected based on clinical symptoms of obstructive defecation. Diagnostic modalities include defecography as the gold standard. Dynamic pelvic magnetic resonance imaging (DPMRI) and transperineal ultrasound are attractive alternatives to defecography; however, their sensitivity is poor in comparison to the gold standard at this time. Management strategies including conservative measures such as biofeedback and surgical procedures including mucosal proctectomy (Delorme), rectopexy, and stapled transanal rectal resection (STARR) procedures have varied degrees of efficacy.
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Affiliation(s)
- Eric G Weiss
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA.
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Abstract
Difficulties with bowel function are common and may be due to several causes including slow colonic transit and obstructed defecation. The anatomical and pathophysiological changes associated with these conditions are varying, often incompletely understood, and in many cases have limited treatment outcomes. Patients present with variable complaints and have previously tried a plethora of over-the-counter medications in an effort to relieve their symptoms. Physicians need an organized approach to manage these patients optimally. Improvements over the past few years in our understanding of the complex process of defecation, along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results.
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Affiliation(s)
- Scott R Steele
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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Farouk R, Bhardwaj R, Phillips RKS. Stapled transanal resection of the rectum (STARR) for the obstructed defaecation syndrome. Ann R Coll Surg Engl 2009; 91:287-91. [PMID: 19416586 DOI: 10.1308/003588409x428315] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ridzuan Farouk
- Department of Surgery, Royal Berkshire Hospital, Reading, UK.
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Pescatori M, Milito G, Fiorino M, Cadeddu F. Complications and reinterventions after surgery for obstructed defecation. Int J Colorectal Dis 2009; 24:951-9. [PMID: 19165491 DOI: 10.1007/s00384-009-0639-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation. METHODS We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed. RESULTS Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years. CONCLUSIONS Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.
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Affiliation(s)
- Mario Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospitals, Rome, Italy
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Pescatori M. Long-term follow-up of simultaneous abdominoperineal repair of enterorectocele and internal mucosal prolapse. Dis Colon Rectum 2009; 52:327-35. [PMID: 19279431 DOI: 10.1007/dcr.0b013e31819a21d8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enterorectocele with recto-rectal intussusception and internal mucosal prolapse (ER-RI-MP) may require surgery for obstructed defecation, but symptoms tend to recur if only one lesion is corrected. This prospective study was designed to investigate the results of an abdominoperineal procedure aimed at treating all these lesions in one stage. METHODS Thirteen women with constipation (median age, 58 years) and ER-RI-MP underwent Douglas pouch suture, mesh obliteration of the pelvic inlet with or without rectopexy, and omentoplasty plus rectocele and prolapse obliteration. Constipation was scored on a scale from 0 to 20. Proctoscopy, enterocolpodefecography, manometry, anal-vaginal-perineal ultrasound, and psychological evaluation were performed before and after surgery. RESULTS Bleeding requiring transfusion, pelvic hygroma, and ureteric stricture requiring adhesiolysis occurred in three patients. Constipation score significantly decreased from a mean (+/- standard error of the mean) of 16 +/- 0.6 before to 7 +/- 0.9 after surgery (P < 0.0001). Seven patients were considered cured, five improved, and one remained unchanged at a median follow-up of 42 months. Anorectal physiology and imaging returned to normal in seven patients. Four patients had successful rehabilitation and psychotherapy for anismus, rectal hyposensation, and depression. CONCLUSIONS Simultaneous abdominoperineal ER-RI-MP repair integrated with conservative treatment of associated dysfunctions achieved a satisfactory long-term outcome. The results need to be confirmed in larger series.
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Affiliation(s)
- Mario Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospitals, Rome, 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: 1.6] [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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Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am 2008; 37:645-68, ix. [PMID: 18794001 DOI: 10.1016/j.gtc.2008.06.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.
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Gagliardi G, Pescatori M, Altomare DF, Binda GA, Bottini C, Dodi G, Filingeri V, Milito G, Rinaldi M, Romano G, Spazzafumo L, Trompetto M. Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum 2008; 51:186-95; discussion 195. [PMID: 18157718 DOI: 10.1007/s10350-007-9096-0] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 02/13/2007] [Accepted: 04/10/2007] [Indexed: 02/07/2023]
Abstract
PURPOSE Obstructed defecation may be treated by stapled transanal rectal resection, but different complications and recurrence rates have been reported. The present study was designed to evaluate stapled transanal rectal resection results, outcome predictive factors, and nature of complications. METHODS Clinical and functional data of 123 patients were retrospectively analyzed. All patients had symptoms of obstructed defecation before surgery and had rectocele and/or intussusception. Of them, 85 were operated on by the authors and 38 were referred after stapled transanal rectal resection had been performed elsewhere. RESULTS At a median follow-up of 17 (range, 3-44) months, 65 percent of the patients operated on by the authors had subjective improvement. Recurrent rectocele was present in 29 percent and recurrent intussusception was present in 28 percent of patients. At univariate analysis, results were worse in those with preoperative digitation (P<0.01), puborectalis dyssynergia (P<0.05), enterocele (P<0.05), larger size rectocele (P<0.05), lower bowel frequency (P<0.05), and sense of incomplete evacuation (P<0.05). Bleeding was the most common perioperative complication occurring in 12 percent of cases. Reoperations were needed in 16 patients (19 percent): 9 for recurrent disease. In the 38 patients referred after stapled transanal rectal resection, the most common problems were perineal pain (53 percent), constipation with recurrent rectocele and/or intussusception (50 percent), and incontinence (28 percent). Of these patients, 14 (37 percent) underwent reoperations: 7 for recurrence. Three patients presented with a rectovaginal fistula. One other patient died for necrotizing pelvic fasciitis. CONCLUSIONS Stapled transanal rectal resection achieved acceptable results at the cost of a high reoperation rate. Patients with puborectalis dyssynergia and lower bowel frequency may do worse because surgery does not address the causes of their constipation. Patients with large rectoceles, enteroceles, digitation, and a sense of incomplete evacuation may have more advanced pelvic floor disease for which stapled transanal rectal resection, which simply removes redundant tissue, may not be adequate. This, together with the complications observed in patients referred after stapled transanal rectal resection, suggests that this procedure should be performed by colorectal surgeons and in carefully selected patients.
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Affiliation(s)
- Giuseppe Gagliardi
- General Surgery, Clinica Pineta Grande, Via Domiziana Km. 30, Castel Volturno (Caserta) 81030, Italy.
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Szojda MM, Tanis E, Mulder CJJ, Felt-Bersma RJF. Referral for anorectal function evaluation is indicated in 65% and beneficial in 92% of patients. World J Gastroenterol 2008; 14:272-7. [PMID: 18186567 PMCID: PMC2675126 DOI: 10.3748/wjg.14.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the indicated referrals to a tertiary centre for patients with anorectal symptoms, the effect of the advised treatment and the discomfort of the tests.
METHODS: In a retrospective study, patients referred for anorectal function evaluation (AFE) between May 2004 and October 2006 were sent a questionnaire, as were the doctors who referred them. AFE consisted of anal manometry, rectal compliance measurement and anal endosonography. An indicated referral was defined as needing AFE to establish a diagnosis with clinical consequence (fecal incontinence without diarrhea, 3rd degree anal sphincter rupture, congenital anorectal disorder, inflammatory bowel disease with anorectal complaints and preoperative in patients for re-anastomosis or enterostoma, anal fissure, fistula or constipation). Anal ultrasound is always indicated in patients with fistula, anal manometry and rectal compliance when impaired continence reserve is suspected. The therapeutic effect was noted as improvement, no improvement but reassurance, and deterioration.
RESULTS: From the 216 patients referred, 167 (78%) returned the questionnaire. The referrals were indicated in 65%. Of these, 80% followed the proposed advice. Improvement was achieved in 35% and a reassurance in 57% of the patients, no difference existed between patient groups. On a VAS scale (1 to 10) symptoms improved from 4.0 to 7.2. Most patients reported no or little discomfort with AFE.
CONCLUSION: Referral for AFE was indicated in 65%. Beneficial effect was seen in 92%: 35% improved and 57% was reassured. Advice was followed in 80%. Better instruction about indication for AFE referral is warranted.
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