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Pääkkö E, Mäkelä‐Kaikkonen J, Laukkanen H, Ohtonen P, Laitakari K, Rautio T, Oikarinen H. X-ray video defaecography is superior to magnetic resonance defaecography in the imaging of defaecation disorders. Colorectal Dis 2022; 24:747-753. [PMID: 35119795 PMCID: PMC9307008 DOI: 10.1111/codi.16081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/30/2021] [Accepted: 01/12/2022] [Indexed: 02/08/2023]
Abstract
AIM The aim of this work was to study the technical success and diagnostic capability of magnetic resonance defaecography (MRD) compared with video defaecography (VD). METHOD Sixty four women with defaecation disorders underwent both MRD and x-ray VD over 1 year. The assessment by two radiologists in consensus was retrospective and blinded. The technical success of straining and evacuation was evaluated subjectively. The presence of enterocele, intussusception, rectocele and dyssynergic defaecation was analysed according to established criteria, with VD as the standard of reference. RESULTS It was found that 62/64 (96.9%) VD studies were technically fully diagnostic compared with 29/64 (45.3%) for MRD. The number of partially diagnostic studies was 1/64 (1.6%) for VD versus 21/64 (32.8%) for MRD, with 1/64 (1.6%) (VD) and 14/64 (21.9%) (MRD) being nondiagnostic. Thirty enteroceles were observed by VD compared with seven in MRD with moderate agreement (κ = 0.41). Altogether 53 intussusceptions were observed by VD compared with 27 by MRD with poor agreement (κ = -0.10 and κ = 0.02 in recto-rectal and recto-anal intussusception, respectively). Moderate agreement (κ = 0.47) was observed in diagnosing rectocele, with 47 cases by VD and 29 by MRD. Dyssynergic defaecation was observed in three patients by VD and in 11 patients by MRD, with slight agreement (κ = 0.14). CONCLUSION The technical success and diagnostic capabilities of VD are better than those of MRD. VD remains the method of choice in the imaging of defaecation disorders.
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Affiliation(s)
- Eija Pääkkö
- Department of Diagnostic RadiologyOulu University HospitalOuluFinland
| | - Johanna Mäkelä‐Kaikkonen
- Division of GastroenterologyDepartment of SurgeryOulu University HospitalOuluFinland,Medical Research Center OuluCenter of Surgical ResearchUniversity of OuluOuluFinland
| | - Hannele Laukkanen
- Department of Diagnostic RadiologyOulu University HospitalOuluFinland
| | - Pasi Ohtonen
- Division of Operative CareOulu University HospitalOuluFinland,The Research Unit of Surgery, Anesthesia and Intensive CareUniversity of OuluOuluFinland
| | - Kirsi Laitakari
- Division of GastroenterologyDepartment of SurgeryOulu University HospitalOuluFinland,Medical Research Center OuluCenter of Surgical ResearchUniversity of OuluOuluFinland
| | - Tero Rautio
- Division of GastroenterologyDepartment of SurgeryOulu University HospitalOuluFinland,Medical Research Center OuluCenter of Surgical ResearchUniversity of OuluOuluFinland
| | - Heljä Oikarinen
- Department of Diagnostic RadiologyOulu University HospitalOuluFinland
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Sharma A, Herekar A, Yan Y, Karunaratne T, Rao SSC. Dyssynergic Defecation and Other Evacuation Disorders. Gastroenterol Clin North Am 2022; 51:55-69. [PMID: 35135665 DOI: 10.1016/j.gtc.2021.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.
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Affiliation(s)
- Amol Sharma
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA.
| | - Anam Herekar
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tennekoon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Ventral Prosthesis Rectopexy for obstructed defaecation syndrome: a systematic review and meta-analysis. Updates Surg 2021; 74:11-21. [PMID: 34665411 DOI: 10.1007/s13304-021-01177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
Obstructed Defecation Syndrome (ODS) is a rather complex entity concerning mainly females and causing primarily constipation. Surgical treatment in the form of Ventral Prosthesis Rectopexy (VPR) has been proposed and seems to have the best outcomes. However, the selection criteria of patients to undergo this kind of operation are not clear and the reported outcomes are mainly short-term and data on long-term outcomes is scarce. This study assesses new evidence on the efficacy of VPR for the treatment of ODS, specifically focusing on inclusion criteria for surgery and the long-term outcomes. A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VPR for ODS from 2000 to March 2020. No language restrictions were made. All studies on VPR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers. Fourteen studies including 963 patients were eligible for analysis. The immediate postoperative morbidity rate was 8.9%. A significant improvement in constipation symptoms was observed in the 12-month postoperative period for ODS (p < 0.0001). Current evidence shows that VPR offers symptomatic relief to the majority of patients with ODS, improving both constipation-like symptoms and faecal incontinence for at least 1-2 years postoperatively. Some studies report on functional results after longer follow-up, showing sustainable improvement, although in a lesser extent.
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van Gruting IM, Stankiewicz A, Thakar R, Santoro GA, IntHout J, Sultan AH. Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome. Cochrane Database Syst Rev 2021; 9:CD011482. [PMID: 34553773 PMCID: PMC8459393 DOI: 10.1002/14651858.cd011482.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. OBJECTIVES To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. SEARCH METHODS We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. SELECTION CRITERIA Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. MAIN RESULTS Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. AUTHORS' CONCLUSIONS In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
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Affiliation(s)
- Isabelle Ma van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, Netherlands
| | | | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
| | - Giulio A Santoro
- Section of Anal Physiology and Ultrasound, Department of Surgery, Regional Hospital, Treviso, Italy
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
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Serra J, Pohl D, Azpiroz F, Chiarioni G, Ducrotté P, Gourcerol G, Hungin APS, Layer P, Mendive JM, Pfeifer J, Rogler G, Scott SM, Simrén M, Whorwell P. European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterol Motil 2020; 32:e13762. [PMID: 31756783 DOI: 10.1111/nmo.13762] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.
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Affiliation(s)
- Jordi Serra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - Daniel Pohl
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy.,UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Philippe Ducrotté
- Department of Gastroenterology, UMR INSERM 1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - A Pali S Hungin
- General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
| | - Juan-Manuel Mendive
- Sant Adrià de Besòs (Barcelona) Catalan Institut of Health (ICS), La Mina Primary Health Care Centre, Badalona, Spain
| | - Johann Pfeifer
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Rogler
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - S Mark Scott
- Neurogastroenterology Group, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts, UK.,The London School of Medicine & Dentistry, Queen Mary University London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Whorwell
- Division of Diabetes, Endocrinology & Gastroenterology, Neurogastroenterology Unit, Wythenshawe Hospital, University of Manchester, Manchester, UK
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Putz C, Alt CD, Wagner B, Gantz S, Gerner HJ, Weidner N, Grenacher L, Hensel C. MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury. Spinal Cord 2019; 58:203-210. [PMID: 31506586 DOI: 10.1038/s41393-019-0351-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A prospective single arm study. OBJECTIVES Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI. SETTING A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center. METHODS Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated. RESULTS The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score. CONCLUSIONS MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.
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Affiliation(s)
- Cornelia Putz
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Celine D Alt
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,University Duesseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, 40225, Duesseldorf, Germany
| | - Bjoern Wagner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Simone Gantz
- Department of Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Hans J Gerner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Lars Grenacher
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Diagnostic Clinic Munich, Department of Radiology and Nuclear Medicine, Augustenstraße 115, 80798, Muenchen, Germany
| | - Cornelia Hensel
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
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Rostaminia G, Abramowitch S, Chang C, Goldberg RP. Descent and hypermobility of the rectum in women with obstructed defecation symptoms. Int Urogynecol J 2019; 31:337-349. [DOI: 10.1007/s00192-019-03934-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 03/14/2019] [Indexed: 12/15/2022]
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Grossi U, Di Tanna GL, Heinrich H, Taylor SA, Knowles CH, Scott SM. Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation. Aliment Pharmacol Ther 2018; 48:1186-1201. [PMID: 30417419 DOI: 10.1111/apt.15039] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/16/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined. AIM To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers. METHODS Electronic searches of major databases were performed without date restrictions. RESULTS From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4 cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P = 0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study). CONCLUSIONS Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.
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Affiliation(s)
- Ugo Grossi
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Luca Di Tanna
- Department of Econometrics, Statistics and Applied Economics, Riskcenter - IREA, Universitat de Barcelona, Barcelona, Spain
| | - Henriette Heinrich
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Charles H Knowles
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Mark Scott
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Schawkat K, Pfister B, Parker H, Heinrich H, Barth BK, Weishaupt D, Fox M, Reiner CS. Dynamic MRI of the pelvic floor: comparison of performance in supine vs left lateral body position. Br J Radiol 2018; 91:20180393. [PMID: 30160176 DOI: 10.1259/bjr.20180393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE: To investigate the performance of MR-defecography (MRD) in lateral body position as an alternative to supine position. METHODS: 22 consecutive patients (16 females; mean age 51 ± 19.4) with obstructed defecation and 20 healthy volunteers (11 females; mean age 33.4 ± 11.5) underwent MRD in a closed-configuration 3T-MRI in supine and lateral position. MRD included T2 weighted images at rest and during defecation after filling the rectum with 250 ml water-based gel. Measurements were performed in reference to the pubococcygeal line and grade of evacuation was assessed. Image quality (IQ) was rated on a 5-point-scale (5 = excellent). RESULTS: In patients grades of middle and posterior compartment descent were similar in both body positions (p > 0.05). Grades of anterior compartment descent were significantly higher in lateral position (21/22 vs 17/22 patients with normal or small descent, p < 0.034). In volunteers grades of descent were similar for all compartments in supine and lateral position (p > 0.05). When attempting to defecate in supine position 6/22 (27%) patients showed no evacuation, while in lateral position only 3/22 (14%) were not able to evacuate. IQ in patients was equal at rest (4.4 ± 0.5 and 4.7 ± 0.6, p > 0.05) and slightly better in supine compared to the lateral position during defecation (4.5 ± 0.4 vs 3.9 ± 0.9, p < 0.017). IQ in volunteers was equal in supine and lateral position (p > 0.05). CONCLUSION: In lateral position, more patients were able to evacuate with similar grades of pelvic floor descent compared to supine position. MRD in lateral position may be a valuable alternative for patients unable to defecate in supine position. ADVANCES IN KNOWLEDGE: In lateral position, more patients were able to evacuate during MRD. MRD in lateral position may be an alternative for patients unable to defecate in supine position.
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Affiliation(s)
- Khoschy Schawkat
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Bettina Pfister
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Helen Parker
- 2 University Zurich , Zurich , Switzerland.,3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,4 Institute of Health and Society, Newcastle University , Newcastle upon Tyne , UK
| | - Henriette Heinrich
- 3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,5 Gastroenterology, Abdominal Center, St. Claraspital , Basel , Switzerland
| | - Borna K Barth
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Dominik Weishaupt
- 6 Department of Radiology, Stadtspital Triemli , Zurich , Switzerland
| | - Mark Fox
- 3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,5 Gastroenterology, Abdominal Center, St. Claraspital , Basel , Switzerland
| | - Caecilia S Reiner
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
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Mari FS, Pezzatini M, Gasparrini M, Antonio B. STARR with Contour Transtar for Obstructed Defecation Syndrome: Long-Term Results. World J Surg 2018; 41:2906-2911. [PMID: 28600694 DOI: 10.1007/s00268-017-4084-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Obstructed defecation syndrome (ODS) is a widespread and disabling syndrome. With this study, we want to evaluate the long-term results of stapled transanal rectal resection (STARR) performed with Contour Transtar device in the treatment for ODS. A re-evaluation of 113 patients subjected to STARR from June 2007 to January 2010 was conducted. METHODS All the patients treated for symptomatic ODS with STARR with Contour Transtar were included in the study. We re-evaluate all patients treated in the study period with clinical examination and specific questionnaire to verify the stability of the functional results and the satisfaction at 5 years from surgery. Constipation was graded using the Agachan-Wexner constipation score; eventual use of aids to defecate and patient satisfaction were assessed preoperatively, 6 months and 5 years after surgery. Long-term complications were also investigated. RESULTS Constipation intensity decreased from the preoperative value of 15.8 (±4.9) to 5.2 (±3.9) (p < 0.0001) at 6 months and remained stable after 5 years (7.4 ± 4.1; p < 0.01). Patients who use laxatives and enema decrease from 74 (77%) and 27 (28%) to only 16 (17%; p < 0.001) and 5 (5%; p < 0.001), respectively, at 5-year follow-up. None continue to help themselves with digitations after surgery. Also the satisfaction rate remained stable (3.64 vs 3.81) during the 5 years of the study. CONCLUSION The long-term results have demonstrated the efficacy of the STARR with Contour Transtar in treating ODS and the stability over time of the defecatory improvements. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT02971332.
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Affiliation(s)
- Francesco Saverio Mari
- UO Week Day Surgery, St. Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy.
- Department of Medical and Surgical Sciences and Translational Medicine, University Sapienza of Rome, Rome, Italy.
| | - Massimo Pezzatini
- UO Week Day Surgery, St. Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy
- Department of Medical and Surgical Sciences and Translational Medicine, University Sapienza of Rome, Rome, Italy
| | - Marcello Gasparrini
- UO Week Day Surgery, St. Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy
- Department of Medical and Surgical Sciences and Translational Medicine, University Sapienza of Rome, Rome, Italy
| | - Brescia Antonio
- UO Week Day Surgery, St. Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy
- Department of Medical and Surgical Sciences and Translational Medicine, University Sapienza of Rome, Rome, Italy
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Carrington EV, Scott SM, Bharucha A, Mion F, Remes-Troche JM, Malcolm A, Heinrich H, Fox M, Rao SS. Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 2018; 15:309-323. [PMID: 29636555 PMCID: PMC6028941 DOI: 10.1038/nrgastro.2018.27] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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Affiliation(s)
- Emma V. Carrington
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - S. Mark Scott
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Adil Bharucha
- Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, MN, USA
| | - François Mion
- Exploration Fonctionnelle Digestive, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon I University and Inserm 1032 LabTAU, Lyon, France
| | - Jose M. Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México
| | - Allison Malcolm
- Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia
| | - Henriette Heinrich
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
- Clinic for Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Satish S. Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia
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Piloni V, Bergamasco M, Melara G, Garavello P. The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome. Tech Coloproctol 2018; 22:179-190. [PMID: 29512048 DOI: 10.1007/s10151-018-1759-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 09/09/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND The aim of the present study was to assess the relationship between symptoms of obstructed defecation and findings on magnetic resonance (MR) defecography in males with obstructed defecation syndrome (ODS). METHODS Thirty-six males with ODS who underwent MR defecography at our institution between March 2013 and February 2016 were asked in a telephone interview about their symptoms and subsequent treatment, either medical or surgical. Patients were divided into 2 groups, one with anismus (Group 1) and one with prolapse without anismus (Group 2). The interaction between ODS type and symptoms with MR findings was assessed by multivariate analysis for categorical data using a hierarchical log-linear model. MR imaging findings included lateral and/or posterior rectocele, rectal prolapse, intussusception, ballooning of levator hiatus with impingement of pelvic organs and dyskinetic puborectalis muscle. RESULTS There were 21 males with ODS due to anismus (Group 1) and 15 with ODS due to rectal prolapse/intussusception (Group 2). Mean age of the entire group was 53.6 ± 4.1 years (range 18-77 years). Patients in Group 1 were slightly older than those in Group 2 (age peak, sixth decade in 47.6 vs 20.0%, p < 0.05). Symptoms most frequently associated with Group 1 patients included small volume and hard feces (85.0%, p < 0.01), excessive strain at stool (81.0%, p < 0.05), tenesmus and fecaloma formation (57.1 and 42.9%, p < 0.05); symptoms most frequently associated with Group 2 patients included mucous discharge, rectal bleeding and pain (86.7%, p < 0.05), prolonged toilet time (73.3%, p < 0.05), fragmented evacuation with or without digitation (66.7%, p < 0.005). Voiding outflow obstruction was more frequent in Group 1 (19.0 vs 13.3%; p < 0.05), while non-bacterial prostatitis and sexual dysfunction prevailed in Group 2 (26.7 and 46.7%, p < 0.05). At MR defecography, two major categories of findings were detected: a dyskinetic pattern (Type 1), seen in all Group 1 patients, which was characterized by non-relaxing puborectalis muscle, sand-glass configuration of the anorectum, poor emptying rate, limited pelvic floor descent and final residue ≥ 2/3; and a prolapsing pattern (Type 2), seen in all Group 2 patients, which was characterized by rectal prolapse/intussusception, ballooning of the levator hiatus with impingement of the rectal floor and prostatic base, excessive pelvic floor descent and residue ≤ 1/2. Posterolateral outpouching defined as perineal hernia was present in 28.6% of patients in Group 1 and were absent in Group 2. The average levator plate angle on straining differed significantly in the two patterns (21.3° ± 4.1 in Group 1 vs 65.6° ± 8.1 in Group 2; p < 0.05). Responses to the phone interview were obtained from 31 patients (18 of Group 1 and 13 of Group 2, response rate, 86.1%). Patients of Group 1 were always treated without surgery (i.e., biofeedback, dietary regimen, laxatives and/or enemas) which resulted in symptomatic improvement in 12/18 cases (66.6%). Of the patients in Group 2, 2/13 (15.3) underwent surgical repair, consisting of stapled transanal rectal resection (STARR) which resulted in symptom recurrence after 6 months and laparoscopic ventral rectopexy which resulted in symptom improvement. The other 11 patients of Group 2 were treated without surgery with symptoms improvement in 3 (27.3%). CONCLUSIONS The appearance of various abnormalities at MR defecography in men with ODS shows 2 distinct patterns which may have potential relevance for treatment planning, whether conservative or surgical.
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Affiliation(s)
- V Piloni
- Affidea - Diagnostic Imaging Centre, Monselice, Padova, Italy.
- , Ancona, Italy.
| | - M Bergamasco
- Affidea - Diagnostic Imaging Centre, Monselice, Padova, Italy
| | - G Melara
- Affidea - Diagnostic Imaging Centre, Monselice, Padova, Italy
| | - P Garavello
- Affidea - Diagnostic Imaging Centre, Monselice, Padova, Italy
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Piloni V, Bergamasco M, Melara G, Garavello P. The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome. Tech Coloproctol 2018; 22:179-190. [DOI: 7) the clinical value of magnetic resonance defecography in males with obstructed defecation syndrome.v piloni, m.bergamasco, g.melara, p.garavello.techniques in coloproctology https:/doi.org/10.1007/s10151-018-1759-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 09/09/2017] [Indexed: 09/10/2023]
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Ramage L, Georgiou P, Qiu S, McLean P, Khan N, Kontnvounisios C, Tekkis P, Tan E. Can we correlate pelvic floor dysfunction severity on MR defecography with patient-reported symptom severity? Updates Surg 2017; 70:467-476. [PMID: 29255962 PMCID: PMC6244712 DOI: 10.1007/s13304-017-0506-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/02/2017] [Indexed: 12/15/2022]
Abstract
MR defecography (MRD) is an alternative to conventional defecography (CD) which allows for dynamic visualisation of the pelvic floor. The aim of this study was to assess whether MRI features indicative of pelvic floor dysfunction correlated with patient-reported symptom severity. MR proctograms were matched to a prospectively-maintained functional database. Univariate and multivariate analyses were performed using pre-treatment questionnaire responses to the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score (WIS), and modified Obstructed Defecation Symptom (ODS) Score. 302 MRI proctograms were performed between January 2012 and April 2015. 170 patients were included. Patients with a rectocele > 2 cm (p = 0.003; OR 5.756) or MRD features suggestive of puborectalis syndrome (p = 0.025; OR 8.602) were more likely to report a higher ODS score on multivariate analysis. Lack of rectal evacuation was negatively associated with an abnormal WIS (p = 0.007; OR 0.228). Age > 50 (p = 0.027, OR 2.204) and a history of pelvic floor surgery (p = 0.042, OR 0.359) were correlated with an abnormal BBUSQ incontinence score. Lack of rectal evacuation (p = 0.027, OR 3.602) was associated with an abnormal BBUSQ constipation score. Age > 50 (p = 0.07, OR 0.156) and the presence of rectoanal intussusception (p = 0.010, OR 0.138) were associated with an abnormal BBUSQ evacuation score. Whilst MRD is a useful tool in aiding multidisciplinary decision making, overall, it is poorly correlated with patient-reported symptom severity, and treatment decisions should not rest solely on results.
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Affiliation(s)
- Lisa Ramage
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Panagiotis Georgiou
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Shengyang Qiu
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Paul McLean
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Nasir Khan
- Department of Radiology, Chelsea Westminster Hospital, London, UK.,Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Christos Kontnvounisios
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK. .,Department of Colorectal Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
| | - Paris Tekkis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK.,Department of Colorectal Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Emile Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Republic of Singapore
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Postoperative MR Defecography following Failed STARR Procedure for Obstructive Defecation Syndrome: A Three-Centre Experience. Gastroenterol Res Pract 2017; 2017:4392918. [PMID: 29158730 PMCID: PMC5660778 DOI: 10.1155/2017/4392918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/16/2017] [Accepted: 08/30/2017] [Indexed: 12/14/2022] Open
Abstract
Aim To describe the abnormalities at MR imaging and related complaints in patients with poor outcome after STARR procedure. Materials and Methods The medical records of 21 symptomatic patients from centre 1, 31 patients from centre 2, and 63 patients from centre 3 were reviewed with regard to findings at MR defecography and related symptoms. Results Regardless of the centre, most relevant imaging features and related complaints were (a) impaired emptying (82.11%), related complaint ODS; (b) persistent rectocele >2 cm and intussusception (39.3%), split evacuation and digitation; (c) pelvic organ descent on straining (39.8%), prolapse sensation; (d) small neorectum and loss of contrast (32.5%), urgency and incontinence; (e) anastomotic stricture and granuloma (28.4%), pain; and (f) nonrelaxing puborectalis muscle (19.5%), tenesmus. Less frequent findings included rectal pocket formation (5.6%) and rectovaginal sinus tract (1.6%). Patients were referred to MR imaging with an average time interval of 5 ± 2, 4 ± 1, and 2 ± 1 years in the three centres, respectively, and only rarely by the same surgeon who performed the operation: 1/21 (4.8%) in centre 1, 3/39 (7.7%) in centre 2, and 9/63 (14.3%) in centre 3. Conclusion Most surgeons involved in STARR operation with subsequent poor outcome do not rely on MR imaging.
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16
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Martín-Martín GP, García-Armengol J, Roig-Vila JV, Espí-Macías A, Martínez-Sanjuán V, Mínguez-Pérez M, Lorenzo-Liñán MÁ, Mulas-Fernández C, González-Argenté FX. Magnetic resonance defecography versus videodefecography in the study of obstructed defecation syndrome: Is videodefecography still the test of choice after 50 years? Tech Coloproctol 2017; 21:795-802. [DOI: 10.1007/s10151-017-1666-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 07/19/2017] [Indexed: 01/12/2023]
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17
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Liu G, Cui Z, Dai Y, Yao Q, Xu J, Wu G. Paradoxical puborectalis syndrome on diffusion-weighted imaging: a retrospective study of 72 cases. Sci Rep 2017; 7:2925. [PMID: 28592800 PMCID: PMC5462772 DOI: 10.1038/s41598-017-03127-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 04/25/2017] [Indexed: 11/30/2022] Open
Abstract
This study aimed to evaluate the application value of diffusion-weighted imaging (DWI) for assessing paradoxical puborectalis syndrome (PPS) in patients with obstructive defecation syndrome (ODS). The medical records of 72 ODS patients who underwent magnetic resonance (MR)-DWI and MR-defecography were retrospectively reviewed. The differences in the apparent diffusion coefficients (ADCs) and the thickness of the right and left branches of the puborectalis muscles between the PPS(+) and PPS(−) groups were compared. In addition, the absolute within-patient differences between the right and left branches (ADC, thickness) were compared between the two groups. The absolute difference in ADCs (right branch - left branch) was significantly different between the two groups. Regardless of whether the ADC was acquired through single-ROI (0.10 ± 0.08 vs 0.23 ± 0.18, P = 0.000) or multi-ROI (0.16 ± 0.14 vs 0.27 ± 0.17, P = 0.009) analysis, the PPS(+) patients displayed a lower absolute ADC difference than did the PPS(−) patients. However, there was no statistically significant difference in the ADC value, thickness or the absolute difference in thickness between the two groups. These findings suggest that DWI may have value in quantitatively assessing the puborectalis muscle in ODS patients, whereas the value of puborectalis thickness in such aspect needs further study.
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Affiliation(s)
- Guiqin Liu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhe Cui
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yongming Dai
- Magnetic Resonance Imaging Institute for Biomedical Research, Wayne State University, Detroit, MI, USA
| | - Qiuying Yao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianrong Xu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Guangyu Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Piloni V, Possanzini M, Bergamasco M, Santi G. Postoperative MR Defecography following Failed STARR Procedure for Obstructive Defecation Syndrome: A Three-Centre Experience. Gastroenterol Res Pract 2017; 2017:1-8. [DOI: vittorio piloni, marco possanzini, mattia bergamasco, and gianluca santi.gastroenterology research and practice 2017, article id 4392918, https:/doi.org/10.1155/2017/4392918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023] Open
Abstract
Aim. To describe the abnormalities at MR imaging and related complaints in patients with poor outcome after STARR procedure. Materials and Methods. The medical records of 21 symptomatic patients from centre 1, 31 patients from centre 2, and 63 patients from centre 3 were reviewed with regard to findings at MR defecography and related symptoms. Results. Regardless of the centre, most relevant imaging features and related complaints were (a) impaired emptying (82.11%), related complaint ODS; (b) persistent rectocele >2 cm and intussusception (39.3%), split evacuation and digitation; (c) pelvic organ descent on straining (39.8%), prolapse sensation; (d) small neorectum and loss of contrast (32.5%), urgency and incontinence; (e) anastomotic stricture and granuloma (28.4%), pain; and (f) nonrelaxing puborectalis muscle (19.5%), tenesmus. Less frequent findings included rectal pocket formation (5.6%) and rectovaginal sinus tract (1.6%). Patients were referred to MR imaging with an average time interval of 5 ± 2, 4 ± 1, and 2 ± 1 years in the three centres, respectively, and only rarely by the same surgeon who performed the operation: 1/21 (4.8%) in centre 1, 3/39 (7.7%) in centre 2, and 9/63 (14.3%) in centre 3. Conclusion. Most surgeons involved in STARR operation with subsequent poor outcome do not rely on MR imaging.
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Affiliation(s)
- Vittorio Piloni
- Radiologist Diagnostic Imaging Centre, Iniziativa Medica, Monselice, Padua, Italy
| | - Marco Possanzini
- Technician Diagnostic Imaging Centre, Villa Igea Clinic, Ancona, Italy
| | - Mattia Bergamasco
- Technician Diagnostic Imaging Centre, Iniziativa Medica, Monselice, Padua, Italy
| | - Gianluca Santi
- Technician Diagnostic Imaging Centre, Studio Ronconi, Acilia, Rome, Italy
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Payne I, Grimm LM. Functional Disorders of Constipation: Paradoxical Puborectalis Contraction and Increased Perineal Descent. Clin Colon Rectal Surg 2016; 30:22-29. [PMID: 28144209 DOI: 10.1055/s-0036-1593430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Paradoxical puborectalis contraction (PPC) and increased perineal descent (IPD) are subclasses of obstructive defecation. Often these conditions coexist, which can make the evaluation, workup, and treatment difficult. After a thorough history and examination, workup begins with utilization of proven diagnostic modalities such as cinedefecography and anal manometry. Advancements in technology have increased the surgeon's diagnostic armamentarium. Biofeedback and pelvic floor therapy have proven efficacy for both conditions as first-line treatment. In circumstances where PPC is refractory to biofeedback therapy, botulinum toxin injection is recommended. Historically, pelvic floor repair has been met with suboptimal results. In IPD, surgical therapy now is directed toward the potentially attendant abnormalities such as rectoanal intussusception and rectal prolapse. When these associated abnormalities are not present, an ostomy should be considered in patients with IPD as well as medically refractory PPC.
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Affiliation(s)
- Isaac Payne
- Department of Surgery, University of South Alabama Medical Center, Mobile, Alabama
| | - Leander M Grimm
- Division of Colon & Rectal Surgery, Department of Surgery, University of South Alabama, Mobile, Alabama
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Parsy C, Cosson M, Quinton JF, Laurent N, Lucot JP, Tempremant F, Poncelet E. Mise au point sur l’hédrocèle, un trouble de la statique pelvienne méconnu. ACTA ACUST UNITED AC 2015; 43:459-64. [DOI: 10.1016/j.gyobfe.2015.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/23/2015] [Indexed: 11/25/2022]
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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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van Gruting IMA, Stankiewicz A, Thakar R, IntHout J, Santoro GA, Sultan AH. Imaging modalities for the detection of posterior compartment disorders in women with obstructed defaecation syndrome. Hippokratia 2015. [DOI: 10.1002/14651858.cd011482] [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]
Affiliation(s)
- Isabelle MA van Gruting
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
| | - Aleksandra Stankiewicz
- Croydon University Hospital; Department of Radiology; 530 London Road Croydon UK CR7 7YE
| | - Ranee Thakar
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
| | - Joanna IntHout
- Radboud university medical center; Radboud Institute for Health Sciences; Geert Grooteplein noord 21; route 133 Nijmegen Netherlands 6500 HB
| | - Giulio A Santoro
- Regional Hospital; Section of Anal Physiology and Ultrasound, Department of Surgery; Piazzale Ospedale 1 Treviso Italy 31100
| | - Abdul H Sultan
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
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Sonographic predictors of obstructive defecatory dysfunction. Int Urogynecol J 2014; 26:415-20. [DOI: 10.1007/s00192-014-2515-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/13/2014] [Indexed: 12/14/2022]
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Smith TK, Park KJ, Hennig GW. Colonic migrating motor complexes, high amplitude propagating contractions, neural reflexes and the importance of neuronal and mucosal serotonin. J Neurogastroenterol Motil 2014; 20:423-46. [PMID: 25273115 PMCID: PMC4204412 DOI: 10.5056/jnm14092] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/05/2014] [Accepted: 09/08/2014] [Indexed: 12/15/2022] Open
Abstract
The colonic migrating motor complex (CMMC) is a critical neurally mediated rhythmic propulsive contraction observed in the large intestine of many mammals. It seems to be equivalent to the high amplitude propagating contractions (HAPCs) in humans. This review focuses on the probable neural mechanisms involved in producing the CMMC or HAPC, their likely dependence on mucosal and neuronal serotonin and pacemaker insterstitial cells of Cajal networks and how intrinsic neural reflexes affect them. Discussed is the possibility that myenteric 5-hydroxytryptamine (5-HT) neurons are not only involved in tonic inhibition of the colon, but are also involved in generating the CMMC and modulation of the entire enteric nervous system, including coupling motility to secretion and blood flow. Mucosal 5-HT appears to be important for the initiation and effective propagation of CMMCs, although this mechanism is a longstanding controversy since the 1950s, which we will address. We argue that the slow apparent propagation of the CMMC/HAPC down the colon is unlikely to result from a slowly conducting wave front of neural activity, but more likely because of an interaction between ascending excitatory and descending (serotonergic) inhibitory neural pathways interacting both within the myenteric plexus and at the level of the muscle. That is, CMMC/HAPC propagation appears to be similar to esophageal peristalsis. The suppression of inhibitory (neuronal nitric oxide synthase) motor neurons and mucosal 5-HT release by an upregulation of prostaglandins has important implications in a number of gastrointestinal disorders, especially slow transit constipation.
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Affiliation(s)
- Terence K Smith
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, Nevada, USA
| | - Kyu Joo Park
- Department of Surgery, School of Medicine, Seoul National University, Seoul Korea
| | - Grant W Hennig
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, Nevada, USA
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Symptomatic rectocele: what are the indications for repair? Am J Surg 2013; 207:375-9; discussion 378-9. [PMID: 24444857 DOI: 10.1016/j.amjsurg.2013.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 12/26/2013] [Accepted: 12/26/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND The surgical indications for symptomatic rectocele are undefined, and surgery has high recurrence rates. We implemented magnetic resonance imaging defecography (MRID) to determine if utilizing strict inclusion criteria for rectocele repair improves outcomes. METHODS Patients with obstructive defecation syndrome (ODS) who underwent dynamic MRID were evaluated. Indications for surgical repair were defecation requiring manual assistance and the following MRID results: anterior defect >2 cm, incomplete evacuation, and the absence of perineal descent. Primary outcomes were the change in quality of life (QOL) scores and recurrence. RESULTS From 2006 to 2013, 143 patients who presented with ODS underwent MRID. Seventeen patients met the criteria for repair. Recurrence was low (5.8%) with a median follow-up of 23 months, QOL scores improved from 57.3 to 76.5 (P = .041). CONCLUSIONS A minority of patients (12%) with ODS met the above criteria for rectocele repair. Patients who underwent repair had a significant improvement in QOL and low recurrence rate.
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