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Habeeb TAAM, Podda M, Chiaretti M, Kechagias A, Lledó JB, Kalmoush AE, Mustafa FM, Nassar MS, Labib MF, Teama SRA, Elshafey MH, Elbelkasi H, Alsaad MIA, Sallam AM, Ashour H, Mansour MI, Mostafa A, Elshahidy TM, Yehia AM, Rushdy T, Ramadan A, Hamed AEM, Yassin MA, Metwalli AEM. Comparative study of laparoscopic ventral mesh rectopexy versus perineal stapler resection for external full-thickness rectal prolapse in elderly patients: enhanced outcomes and reduced recurrence rates-a retrospective cohort study. Tech Coloproctol 2024; 28:48. [PMID: 38619626 PMCID: PMC11018677 DOI: 10.1007/s10151-024-02919-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/16/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND In elderly patients with external full-thickness rectal prolapse (EFTRP), the exact differences in postoperative recurrence and functional outcomes between laparoscopic ventral mesh rectopexy (LVMR) and perineal stapler resection (PSR) have not yet been investigated. METHODS We conducted a retrospective multicenter study on 330 elderly patients divided into LVMR group (n = 250) and PSR (n = 80) from April 2012 to April 2019. Patients were evaluated before and after surgery by Wexner incontinence scale, Altomare constipation scale, and patient satisfaction questionnaire. The primary outcomes were incidence and risk factors for EFTRP recurrence. Secondary outcomes were postoperative incontinence, constipation, and patient satisfaction. RESULTS LVMR was associated with fewer postoperative complications (p < 0.001), lower prolapse recurrence (p < 0.001), lower Wexner incontinence score (p = 0.03), and lower Altomare's score (p = 0.047). Furthermore, LVMR demonstrated a significantly higher surgery-recurrence interval (p < 0.001), incontinence improvement (p = 0.019), and patient satisfaction (p < 0.001) than PSR. Three and 13 patients developed new symptoms in LVMR and PSR, respectively. The predictors for prolapse recurrence were LVMR (associated with 93% risk reduction of recurrence, OR 0.067, 95% CI 0.03-0.347, p = 0.001), symptom duration (prolonged duration was associated with an increased risk of recurrence, OR 1.131, 95% CI 1.036-1.236, p = 0.006), and length of prolapse (increased length was associated with a high recurrence risk (OR = 1.407, 95% CI = 1.197-1.655, p < 0.001). CONCLUSIONS LVMR is safe for EFTRP treatment in elderly patients with low recurrence, and improved postoperative functional outcomes. TRIAL REGISTRATION Clinical Trial.gov (NCT05915936), retrospectively registered on June 14, 2023.
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Affiliation(s)
- T A A M Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt.
| | - M Podda
- Department of Surgical Science, Cagliari University Hospital, Monserrato, 09042, Cagliari, Italy
| | - M Chiaretti
- Paride Stefanini General and Specialist Surgery Department, Sapienza University of Rome IT, Rome, Italy
| | - A Kechagias
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland
| | - J B Lledó
- Department of Surgery, La Fe University Hospital, Valencia, Spain
| | | | - Fawzy M Mustafa
- General Surgery Department, Faculty of Medicine, Al-Azher University, Cairo, Egypt
| | | | - Mohamed Fathy Labib
- General Surgery Department, Faculty of Medicine, Al-Azher University, Cairo, Egypt
| | | | | | - Hamdi Elbelkasi
- General Surgery Department, Mataryia Teaching Hospital (GOTHI), Cairo, Egypt
| | | | - Ahmed M Sallam
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Hassan Ashour
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Mohamed Ibrahim Mansour
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Abdelshafy Mostafa
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Tamer Mohamed Elshahidy
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Ahmed M Yehia
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Tamer Rushdy
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Alaaedin Ramadan
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Abd Elwahab M Hamed
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Mahmoud Abdou Yassin
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
| | - Abd-Elrahman M Metwalli
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Sharqia, Egypt
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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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Miyano G, Yamada S, Murakami H, Lane GJ, Yamataka A. Case report: Gross persistent rectal prolapse. A case treated without mesh using deep retrorectal dissection/suturing. Front Pediatr 2022; 10:900081. [PMID: 36061389 PMCID: PMC9433537 DOI: 10.3389/fped.2022.900081] [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: 03/19/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
A previously well 15-year-old male presented with a history of gross rectal prolapse (GRP) involving full-thickness rectal prolapse of increasing severity and incidence over 6 months that occurred with every bowel motion, varying from 10 to 40 cm. He denied constipation and passed a soft motion once daily, adeptly reducing his prolapsed rectum after each motion. This case illustrates technical challenges and planning for surgical intervention for optimal treatment in keeping with an FDA alert issued April, 2019 banning surgical mesh for pelvic organ prolapse. Preoperative fluoroscopic defecography confirmed rectal prolapse beginning with eversion of the anal verge identified on inspection. For surgery, general anesthesia was induced, he was placed in a Trendelenburg position, and four ports were inserted. The peritoneum was incised and blunt dissection used to expose the levator ani complex (LAC) taking care to prevent lateral nerve injury and preserve regional vascularity. Seven polypropylene sutures were used to fix the seromuscular posterior wall of the rectum to the median raphe of the LAC, the presacral fascia, and the periosteum of the sacral promontory. Operative time was 170 min. Postoperative recovery and progress were unremarkable. Currently, 5 years postoperatively, defecation is regular without recurrence of prolapse. For prolapse involving protrusion of the upper rectum without eversion of the anal verge, rectal fixation to the sacral promontory without further dissection beyond the peritoneal reflection is adequate, but when extensive prolapse is associated with eversion of the anal verge, more extensive blunt dissection from the peritoneal reflection to the LAC with multiple rectopexy sutures is valid for reducing risks for recurrence and eliminating mesh-related complications.
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Affiliation(s)
- Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shunsuke Yamada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Murakami
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Yao YB, Yin HQ, Wang HJ, Liang HT, Wang B, Wang C. Is the transperineal ultrasonography approach effective for the diagnosis of rectocele? Gastroenterol Rep (Oxf) 2021; 9:461-469. [PMID: 34733532 PMCID: PMC8560031 DOI: 10.1093/gastro/goab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background Transperineal ultrasonography has been used as a diagnostic imaging modality for rectocele for many years. However, the consistency of ultrasonography and defecography in evaluating the severity of rectocele was not satisfactory. This study aimed to evaluate the agreement in the measurement of rectocele parameters between the two methods in different positions and provide clinical implications for the diagnosis of rectocele. Methods In this pilot study, participants were recruited in an outpatient clinic of a tertiary hospital between December 2017 and December 2019. All participants separately underwent defecation proctography at sitting and squatting positions, and undertook transperineal ultrasonography at left lateral, sitting, and squatting positions. The consistency of ultrasonography and defecography was evaluated. Results Thirty female volunteers with rectocele were included in this study. The degree of anorectal angle was significantly larger at rest and during contraction, maximal Valsalva, and evacuation; the depth of the rectocele was significantly deeper during maximal Valsalva and evacuation; and the length of the perineum descending was significantly longer during contraction and maximal Valsalva in using squatting position compared to the sitting position when performing the defecation proctography. The degree of anorectal angle, the depth of rectocele, the area of levator hiatus, and the volume of the rectocele were significantly different in using squatting, sitting, and left lateral positions when performing the transperineal ultrasonography. Bland-Altman semi-quantitative plots showed good consistency in the measurement of the anorectal angle and the depth of the rectocele between proctography and ultrasonography in both sitting and squatting positions. Conclusions The findings of our study may be considered as the preliminary evidence to support the use of transperineal ultrasonography with sitting and squatting positions as the imaging test of choice for evaluating patients with rectocele.
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Affiliation(s)
- Yi-Bo Yao
- Department of Proctology, Longhua Hospital affiliated to Shanghai University of TCM, Shanghai, P. R. China
| | - Hao-Qiang Yin
- Department of Ultrasonic, Longhua Hospital affiliated to Shanghai University of TCM, Shanghai, P. R. China
| | - Hai-Jun Wang
- Department of Proctology, Longhua Hospital affiliated to Shanghai University of TCM, Shanghai, P. R. China
| | - Hong-Tao Liang
- Department of Proctology, Longhua Hospital affiliated to Shanghai University of TCM, Shanghai, P. R. China
| | - Bo Wang
- Shanghai Hao Zhuo Data Service Co. Ltd, Shanghai, P. R. China
| | - Chen Wang
- Department of Proctology, Longhua Hospital affiliated to Shanghai University of TCM, Shanghai, P. R. China
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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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Asfour V, Gibbs K, Wertheim D, Digesu GA, Fernando R, Khullar V. Anal canal to pubis angle: a novel clinical ultrasound technique for the assessment of the anorectal region. Int Urogynecol J 2021; 32:2421-2427. [PMID: 34236466 PMCID: PMC8418589 DOI: 10.1007/s00192-021-04855-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/09/2021] [Indexed: 11/24/2022]
Abstract
Introduction and hypothesis Posterior compartment prolapse is associated with severe morbidity including faecal incontinence and defaecation dysfunction. The aim of this study was to develop and validate a novel ultrasound marker (anal canal to pubis angle) for the assessment of the anal axis in the context of posterior compartment prolapse in women and in controls (healthy, nulliparous, non-pregnant volunteers). Methods Anal canal to pubis (AC/Pubis) angle is measured with 2D transperineal ultrasound in precisely the midsagittal plane. The image was inverted and zoomed out and the angle opened to 107° (maximum). The image includes the pubis, urethra and anal canal. The angle measurement starts from the anal canal, pivots on the anorectal junction and ends at the shadow of the pubis. Inter- and intra-observer agreement in AC/Pubis angle measurement was assessed and the angles measured in the two groups compared. Results Forty women with posterior prolapse and 17 controls were included. Close agreement was observed in inter- and intra-observer AC/Pubis angle measurements assessed with Bland-Altman analysis. AC/Pubis angle is significantly wider in prolapse patients compared to controls (t-test, p < 0.001), with mean AC/Pubis angle in prolapse patients 122.9° (SD 15.6°) and controls 98.2° (SD 15.9°). Conclusion The AC/Pubis angle is a novel validated 2D ultrasound technique for the assessment of the anorectal axis that potentially can be performed using equipment that is widely available in routine clinical practice. The AC/Pubis angle is significantly wider in prolapse patients compared to controls.
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Affiliation(s)
- Victoria Asfour
- St Mary's hospital, Imperial College Healthcare NHS Trust, Paddington, W2 1NY, UK. .,London North West University Healthcare NHS Trust, London, UK.
| | - Kayleigh Gibbs
- St Mary's hospital, Imperial College Healthcare NHS Trust, Paddington, W2 1NY, UK
| | - David Wertheim
- School of Computer Science and Mathematics, Kingston University, Surrey, UK
| | | | - Ruwan Fernando
- St Mary's hospital, Imperial College Healthcare NHS Trust, Paddington, W2 1NY, UK
| | - Vik Khullar
- St Mary's hospital, Imperial College Healthcare NHS Trust, Paddington, W2 1NY, UK
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Magnetic imaging defecography results are comparable to high-resolution manometry and conventional X-ray defecography in the assessment of functional pelvic floor disorders. Tech Coloproctol 2020; 24:1155-1161. [DOI: 10.1007/s10151-020-02292-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/02/2020] [Indexed: 12/17/2022]
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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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11
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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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12
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Videodefecography is still superior to magnetic resonance defecography in the study of obstructed defecation syndrome. Tech Coloproctol 2018; 22:321-322. [DOI: 10.1007/s10151-018-1748-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022]
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