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Grossi U, Vollebregt PF, Knowles CH, Scott SM. Revisiting the accuracy of anorectal manometry for dyssynergic defaecation. Eur J Gastroenterol Hepatol 2024; 36:1149. [PMID: 39101443 DOI: 10.1097/meg.0000000000002803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Affiliation(s)
- Ugo Grossi
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Department of Trauma and Orthopaedic Surgery, Blizard Institute, Queen Mary University of London, London, UK
- Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padova, Padova, Italy
| | - Paul F Vollebregt
- Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padova, Padova, Italy
| | - Charles H Knowles
- Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padova, Padova, Italy
| | - S Mark Scott
- Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padova, Padova, Italy
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Mundet L, Raventós A, Carrión S, Bascompte C, Clavé P. Characterization of obstructive defecation from a structural and a functional perspective. GASTROENTEROLOGIA Y HEPATOLOGIA 2024:502219. [PMID: 38857752 DOI: 10.1016/j.gastrohep.2024.502219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/06/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND/AIMS Defecation disorders can occur as a consequence of functional or structural anorectal dysfunctions during voiding. The aims of this study is to assess the prevalence of structural (SDD) vs functional (FDD) defecation disorders among patients with clinical complaints of obstructive defecation (OD) and their relationship with patients' expulsive capacity. PATIENTS AND METHODS Retrospective study of 588 patients with OD studied between 2012 and 2020 with evacuation defecography (ED), and anorectal manometry (ARM) in a subgroup of 294. RESULTS 90.3% patients were women, age was 58.5±12.4 years. Most (83.7%) had SDD (43.7% rectocele, 45.3% prolapse, 19.3% enterocele, and 8.5% megarectum), all SDD being more prevalent in women except for megarectum. Functional assessments showed: (a) absence of rectification of anorectal angle in 51% of patients and poor pelvic descent in 31.6% at ED and (b) dyssynergic defecation in 89.9%, hypertonic IAS in 44%, and 33.3% rectal hyposensitivity, at ARM. Overall, 46.4% of patients were categorized as pure SDD, 37.3% a combination of SDD+FDD, and 16.3% as having pure FDD. Rectal emptying was impaired in 66.2% of SDD, 71.3% of FDD and in 78% of patients with both (p=0.017). CONCLUSIONS There was a high prevalence of SDD in middle-aged women with complaints of OD. Incomplete rectal emptying was more prevalent in FDD than in SDD although FDD and SDD frequently coexist. We recommend a stepwise therapeutic approach always starting with therapy directed to improve FDD and relaxation of striated pelvic floor muscles.
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Affiliation(s)
- Lluís Mundet
- Gastrointestinal Motility Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Spain.
| | - Alba Raventós
- Gastrointestinal Motility Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Sílvia Carrión
- Gastrointestinal Motility Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Cristina Bascompte
- Gastrointestinal Motility Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Pere Clavé
- Gastrointestinal Motility Unit, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
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Wattchow DA, Brookes SJ, Spencer NJ, Heitmann PT, De Giorgio R, Costa M, Dinning PG. From the organ bath to the whole person: a review of human colonic motility. ANZ J Surg 2024; 94:320-326. [PMID: 37974532 DOI: 10.1111/ans.18779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
Motor function of the colon is essential for health. Our current understanding of the mechanisms that underlie colonic motility are based upon a range of experimental techniques, including molecular biology, single cell studies, recordings from muscle strips, analysis of part or whole organ ex vivo through to in vivo human recordings. For the surgeon involved in the clinical management of colonic conditions this amounts to a formidable volume of material. Here, we synthesize the key findings from these various experimental approaches so that surgeons can be better armed to deal with the complexities of the colon.
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Affiliation(s)
- David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Simon J Brookes
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Nick J Spencer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Marcello Costa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
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Dexter E, Walshaw J, Wynn H, Dimashki S, Leo A, Lindsey I, Yiasemidou M. Faecal incontinence-a comprehensive review. Front Surg 2024; 11:1340720. [PMID: 38362459 PMCID: PMC10867159 DOI: 10.3389/fsurg.2024.1340720] [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: 11/18/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date. Methods A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities. Result and discussion This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).
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Affiliation(s)
- Eloise Dexter
- Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Josephine Walshaw
- Leeds Institute of Medical Research, St James’ University Hospital, University of Leeds, Leeds, United Kingdom
- Department of Health Research, University of York, York, United Kingdom
| | - Hannah Wynn
- Upper Gastrointestinal Surgery, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Safaa Dimashki
- Plastic Surgery, Mid Yorkshire Teaching NHS Trust, Wakefield, United Kingdom
| | - Alex Leo
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ian Lindsey
- Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Marina Yiasemidou
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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Norton C, Bannister S, Booth L, Brown SR, Cross S, Eldridge S, Emmett C, Grossi U, Jordan M, Lacy-Colson J, Mason J, McLaughlin J, Moss-Morris R, Scott SM, Stevens N, Taheri S, Taylor SA, Yiannakou Y, Knowles CH. Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: A randomized controlled trial. Colorectal Dis 2023; 25:2243-2256. [PMID: 37684725 DOI: 10.1111/codi.16738] [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: 02/21/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 09/10/2023]
Abstract
AIM The aim was to determine whether specialist-led habit training using Habit Training with Biofeedback (HTBF) is more effective than specialist-led habit training alone (HT) for chronic constipation and whether outcomes of interventions are improved by stratification to HTBF or HT based on diagnosis (functional defaecation disorder vs. no functional defaecation disorder) by radio-physiological investigations (INVEST). METHOD This was a parallel three-arm randomized single-blinded controlled trial, permitting two randomized comparisons: HTBF versus HT alone; INVEST- versus no-INVEST-guided intervention. The inclusion criteria were age 18-70 years; attending specialist hospitals in England; self-reported constipation for >6 months; refractory to basic treatment. The main exclusions were secondary constipation and previous experience of the trial interventions. The primary outcome was the mean change in Patient Assessment of Constipation Quality of Life score at 6 months on intention to treat. The secondary outcomes were validated disease-specific and psychological questionnaires and cost-effectiveness (based on EQ-5D-5L). RESULTS In all, 182 patients were randomized 3:3:2 (target 384): HT n = 68; HTBF n = 68; INVEST-guided treatment n = 46. All interventions had similar reductions (improvement) in the primary outcome at 6 months (approximately -0.8 points of a 4-point scale) with no statistically significant difference between HT and HTBF (-0.03 points; 95% CI -0.33 to 0.27; P = 0.85) or INVEST versus no-INVEST (0.22; -0.11 to 0.55; P = 0.19). Secondary outcomes showed a benefit for all interventions with no evidence of greater cost-effectiveness of HTBF or INVEST compared with HT. CONCLUSION The results of the study at 6 months were inconclusive. However, with the caveat of under-recruitment and further attrition at 6 months, a simple, cheaper approach to intervention may be as clinically effective and more cost-effective than more complex and invasive approaches.
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Affiliation(s)
- Christine Norton
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sybil Bannister
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lesley Booth
- Bowel Research UK, Registered Charity, London, UK
| | - Steve R Brown
- Sheffield Teaching Hospitals NHS Trust & University of Sheffield, Sheffield, UK
| | - Samantha Cross
- Department Biostatistics and Health Informatics, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and dentistry, Queen Mary University of London, London, UK
| | | | - Ugo Grossi
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mary Jordan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, UK
| | - Jon Lacy-Colson
- Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, UK
| | - Rona Moss-Morris
- Department of Psychology, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
| | - S Mark Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shiva Taheri
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Yan Yiannakou
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Charles H Knowles
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Brillantino A, Iacobellis F, Maglio M, Grillo M, Vicenzo L, Monaco L, Romano L, Renzi A. The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients. Dis Colon Rectum 2023; 66:1508-1515. [PMID: 36952567 DOI: 10.1097/dcr.0000000000002526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear. OBJECTIVE This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity. DESIGN This was a prospective multicenter uncontrolled study. SETTINGS The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022. PATIENTS The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry. MAIN OUTCOME MEASURES Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score. RESULTS One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001). LIMITATIONS The study was limited by the small sample size and by the strong selection of the study population. CONCLUSIONS Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 . LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Antonio Brillantino
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Francesca Iacobellis
- Radiology Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Mauro Maglio
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Maurizio Grillo
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Luciano Vicenzo
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Luigi Monaco
- Surgery Department, "Villa Esther" Hospital, Via Due Principati, Avellino, Italy
| | - Luigia Romano
- Radiology Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Adolfo Renzi
- Surgery Department, Ospedale Buonconsiglio Fatebenefratelli, Naples, Italy
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Ahmad F, Tanguy S, Dubreuil A, Magnin A, Faucheron JL, de Loubens C. Flow simulations of rectal evacuation: towards a quantitative evaluation from video defaecography. Interface Focus 2022; 12:20220033. [PMID: 36330321 PMCID: PMC9560784 DOI: 10.1098/rsfs.2022.0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/24/2022] [Indexed: 10/16/2023] Open
Abstract
Mechanistic understanding of anorectal (patho)physiology is missing to improve the medical care of patients suffering from defaecation disorders. Our objective is to show that complex fluid dynamics modelling of video defaecography may open new perspectives in the diagnosis of defaecation disorders. Based on standard X-ray video defaecographies, we developed a bi-dimensional patient-specific simulation of the expulsion of soft materials, the faeces, by the rectum. The model quantified velocity, pressure and stress fields during the defaecation of a neostool with soft stool-like rheology for patients showing normal and pathological defaecatory function. In normal defaecation, the proximal-distal pressure gradient resulted from both the anorectal junction which formed a converging channel and the anal canal. The flow of the neostool through these anatomical parts was dominated by its shear-thinning viscous properties, rather than its yield stress. Consequently, the evacuation flow rate was significantly affected by variations in pressure applied by the rectum, and much less by the geometry of the anorectal junction. Lastly, we simulated impaired defaecations in the absence of obvious obstructive phenomena. Comparison with normal defaecation allowed us to discuss critical elements which should lead to effective medical management.
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Affiliation(s)
- Faisal Ahmad
- University Grenoble Alpes, CNRS, Grenoble INP, LRP, 38000 Grenoble, France
| | - Stéphane Tanguy
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC, Grenoble, France
| | | | - Albert Magnin
- University Grenoble Alpes, CNRS, Grenoble INP, LRP, 38000 Grenoble, France
| | - Jean-Luc Faucheron
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC, Grenoble, France
- Department of Surgery, Colorectal Unit, CHU Grenoble Alpes, University Grenoble Alpes, Grenoble, France
| | - Clément de Loubens
- University Grenoble Alpes, CNRS, Grenoble INP, LRP, 38000 Grenoble, France
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Bharucha AE, Knowles CH. Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era. Neurogastroenterol Motil 2022; 34:e14453. [PMID: 36102693 PMCID: PMC9887546 DOI: 10.1111/nmo.14453] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/06/2022] [Accepted: 08/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. PURPOSE We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles H Knowles
- Blizard Institute (Knowles), Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
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9
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Picciariello A, Rinaldi M, Grossi U, Trompetto M, Graziano G, Altomare DF, Gallo G. Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2022; 26:963-971. [PMID: 36104607 DOI: 10.1007/s10151-022-02705-x] [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] [Received: 03/27/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022]
Abstract
Abstract
Background
Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers.
Methods
Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient’s anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario.
Results
Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10–20 (54%) to 21–50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function.
Conclusions
The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.
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Grossi U, Lacy-Colson J, Brown SR, Cross S, Eldridge S, Jordan M, Mason J, Norton C, Scott SM, Stevens N, Taheri S, Knowles CH. Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation. Tech Coloproctol 2022; 26:941-952. [PMID: 35588336 PMCID: PMC9117980 DOI: 10.1007/s10151-022-02633-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/01/2022] [Indexed: 12/13/2022]
Abstract
Background The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up. Methods The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ). Results Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively). Conclusions With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse. Trial registration ISRCTN Registry (ISRCTN11747152). Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02633-w.
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Affiliation(s)
- U Grossi
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
- Department of Surgery, Oncology and Gastroenterology, DISCOG, University of Padua, Padua, Italy.
| | - J Lacy-Colson
- Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - S R Brown
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - S Cross
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Eldridge
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - M Jordan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - J Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - C Norton
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - S M Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Stevens
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Taheri
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - C H Knowles
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Platz Batista da Silva N, Schreyer AG. Funktionell-radiologische Diagnostik in der Koloproktologie. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00598-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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