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Lukies M, Harisis G, Jarema A, Scicchitano M, MacLaurin W. Defecating proctography: A pictorial essay. Radiography (Lond) 2022; 28:628-633. [PMID: 35569315 DOI: 10.1016/j.radi.2022.04.012] [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: 02/26/2022] [Revised: 04/11/2022] [Accepted: 04/23/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To provide an illustrative description of the technique and spectrum of findings in defecating proctography. KEY FINDINGS Important findings on defecating proctography include rectocoele, enterocoele, sigmoidocoele, cystocoele, intussusception, rectal prolapse, descending perineum, incomplete emptying, anismus, and faecal incontinence. This review article illustrates these key findings with examples. CONCLUSION Defecating proctography is a well-established and cost-effective method of assessing disordered defecation. In conjunction with clinical information and other diagnostic tests, findings on defecating proctography can guide appropriate multidisciplinary management and may lead to improvement in embarrassing and debilitating symptoms in many patients. IMPLICATIONS FOR PRACTICE This review article provides a suggested technique and covers the spectrum of findings on defecating proctography.
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Affiliation(s)
- M Lukies
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia.
| | - G Harisis
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - A Jarema
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - M Scicchitano
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - W MacLaurin
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
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Tsunoda A, Takahashi T, Kusanagi H. Reappraising the Role of Enterocele in the Obstructed Defecation Syndrome: Is Radiological Impaired Rectal Emptying Significant in Enterocele? J Anus Rectum Colon 2022; 6:113-120. [PMID: 35572488 PMCID: PMC9045857 DOI: 10.23922/jarc.2021-064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/10/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives: The role of enterocele in the obstructed defecation syndrome (ODS) has remained to be controversial, as patients with enterocele frequently exhibit multiple risk factors, including aging, parity, concomitant different abnormalities, previous histories of pelvic surgery, and incomplete emptying of the rectum. Thus, in this study, we aimed to investigate the association between enterocele and ODS using multivariate analysis. Methods: Between June 2013 and June 2021, 336 women underwent defecography as they had symptoms of ODS. Of those, 293 women (87%) who had anatomical abnormalities were included in this study. Results: Enterocele was detected in 104 (36%) patients. More women with enterocele had histories of hysterectomy compared to those without enterocele (29% vs. 10%, P < 0.0001). The frequency of radiological incomplete emptying was found to be significantly lower in women with enterocele (36%) than in those without enterocele (50%), whereas the mean (95% confidence interval) ODS scores in women with enterocele were significantly higher than those without enterocele [12.1 (11.0-13.3) versus 10.8 (10.5-11.5), P = 0.023]. As per the results of our multivariate analysis, it was determined that the presence of enterocele was associated with higher ODS scores (P = 0.028). However, the small differences in the mean score (1.3) would be clinically negligible. The specific radiological type of enterocele which compressed the rectal ampulla at the beginning of defecation was not associated with the increased ODS scores. Conclusions: The presence of enterocele may not be a primary cause of ODS. Other anatomical abnormalities combined with enterocele, or the hernia itself, may have a role in causing ODS.
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Affiliation(s)
- Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center
| | - Tomoko Takahashi
- Department of Gastroenterological Surgery, Kameda Medical Center
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center
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3
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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Maeda K, Koide Y, Katsuno H, Hanai T, Masumori K, Matsuoka H, Endo TS, Cheong YC. Transvaginal peritoneocele repair with anterior levatorplasty for patients with a rectocele and an enterocele. Surg Today 2020; 51:844-847. [PMID: 33030652 DOI: 10.1007/s00595-020-02161-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022]
Abstract
Enteroceles and rectoceles are often identified as the cause of a vaginal mass and pelvic discomfort. The combination of a rectocele and an enterocele as pelvic organ prolapses is not infrequent; however, there are few reports on possible simultaneous treatments of these two conditions. We report a new and simple procedure for repairing an enterocele during a transvaginal anterior levatorplasty with posterior colporrhaphy for a rectocele repair. This technique involves making an excision in the peritoneal sac, with high ligation, and attaching the uterine cervix and/or cardinal ligament to the upper most part of the approximation of the levator muscles, to reinforce and lift the deep peritoneal sac. This procedure allows for transvaginal repair of both an enterocele and a rectocele. The enterocele is visualized by applying barium to the posterior vaginal wall during defecography.
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Affiliation(s)
- Kotaro Maeda
- International Medical Center, Fujita Health University Hospital, 1-98, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yoshikazu Koide
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Tsunekazu Hanai
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Koji Masumori
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomoyo Shi Endo
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Yeong Cheol Cheong
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
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Brochard C, Ropert A, Chambaz M, Gouriou C, Cardaillac C, Grainville T, Bouguen G, Siproudhis L. Chronic pelvic pain and rectal prolapse invite consideration of enterocele. Colorectal Dis 2020; 22:325-330. [PMID: 31622543 DOI: 10.1111/codi.14877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/30/2019] [Indexed: 02/04/2023]
Abstract
AIM Data on the pathogenesis and symptoms of enterocele are limited. The objectives of this study were to determine the clinical phenotype of patients with enterocele, to highlight the main functional and/or anatomical associations and to improve the accuracy of the preoperative assessment of pelvic floor disorders. METHOD A total of 588 patients who were referred to a tertiary unit for an anorectal complaint completed a self-administered questionnaire and underwent physical examination, anorectal manometry and defaecography. Using defaecography, enterocele was defined as a radiological hernia of the small bowel into an enlarged rectovaginal space. One hundred and thirty-five patients with enterocele were age- and gender-matched with 270 patients without enterocele. Factors associated with enterocele were assessed using univariate and multivariate analysis models. RESULTS Patients with enterocele were less frequently obese than patients without enterocele (8/135 vs 36/270; P = 0.02) and more frequently had a past history of pelvic surgery (51/135 vs 75/270; P = 0.04). They complained more frequently of pelvic pain on bearing down (29/135 vs 24/270; P = 0.003), anal procidentia (37/135 vs 46/270; P = 0.01) and more frequently had irritable bowel syndrome (83/135 vs 131/270; P = 0.01) and severe constipation according to the Kess score (104/135 vs 182/270; P = 0.04). Anorectal function was comparable between the two groups. Patients with enterocele had more frequent rectoceles and overt rectal prolapses than patients without enterocele. CONCLUSIONS Enterocele should be investigated in patients with chronic pelvic pain, overt rectal prolapse and/or a past history of pelvic surgery.
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Affiliation(s)
- C Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennesss 1, Rennes, France.,Services d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,INSERM U1241, Equipe EXPRES, Université de Rennes 1, Rennes, France.,INPHY, Université de Rennes 1, Rennes, France
| | - A Ropert
- Services d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,INPHY, Université de Rennes 1, Rennes, France
| | - M Chambaz
- Services d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - C Gouriou
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennesss 1, Rennes, France
| | - C Cardaillac
- Service de Gynécologie-obstétrique et Médecine de la Reproduction, Hôpital Mère-Enfant, CHU de Nantes, Nantes, France
| | - T Grainville
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennesss 1, Rennes, France
| | - G Bouguen
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennesss 1, Rennes, France.,INSERM U1241, Equipe EXPRES, Université de Rennes 1, Rennes, France.,INPHY, Université de Rennes 1, Rennes, France
| | - L Siproudhis
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennesss 1, Rennes, France.,INSERM U1241, Equipe EXPRES, Université de Rennes 1, Rennes, France.,INPHY, Université de Rennes 1, Rennes, France
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Gültekin FA. Short term outcome of laparoscopic ventral mesh rectopexy for rectal and complex pelvic organ prolapse: case series. Turk J Surg 2019; 35:91-97. [PMID: 32550312 DOI: 10.5578/turkjsurg.4157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022]
Abstract
Objectives Laparoscopic ventral mesh rectopexy (LVMR) is a technique gaining more recognition for the management of pelvic floor disorders, such as external rectal prolapse (ERP), high grade internal rectal prolapse (IRP) and rectocele. LVMR also allows correction of coexisted pelvic organ prolapse. This study aimed to evaluate the safety, efficacy and functional outcome of LVMR for rectal and complex pelvic organ prolapse. Material and Methods All patients who underwent LVMR from February 2014 to October 2017 were included into the study. The patients were evaluated preoperatively and three months postoperatively. Surgical complications and functional results in terms of fecal incontinence (measured with the Wexner Incontinence Score= WIS) and constipation (measured with the Wexner Constipation Score= WCS) were analyzed. Results Thirty (4 males) patients underwent LVMR. Seventeen (56.6%) patients had complex pelvic organ prolapse according to MRI findings. Median operative time and postoperative stay were 110 minutes and 4 days, respectively. No mesh-related complication and recurrence were observed. Before surgery, 21 (70%) patients had complained about symptoms of obstructed defecation. WCS decreased significantly from median 19 to 6 (p <0.001). Preoperative median WIS of 9 patients was 14 and went down to 6 postoperatively (p= 0.008). WCS significantly improved after LVMR in patients with symptomatic rectocele combined with enterocele or sigmoidocele (p= 0.005), and significant improvement was also observed in patients with symptomatic rectocele combined with gynecologic organ prolapse, preoperative median WCS was 18 and the postoperative value fell to 8 (p= 0.005). Conclusion LVMR is an effective surgical option for rectal and complex pelvic organ prolapse with short-term follow-up.
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Affiliation(s)
- Fatma Ayça Gültekin
- Zonguldak Bülent Ecevit Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Zonguldak, Türkiye
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7
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Kim NY, Kim DH, Pickhardt PJ, Carchman EH, Wald A, Robbins JB. Defecography: An Overview of Technique, Interpretation, and Impact on Patient Care. Gastroenterol Clin North Am 2018; 47:553-568. [PMID: 30115437 DOI: 10.1016/j.gtc.2018.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pelvic floor and defecatory dysfunction are common in the female patient population. When combined with physical examination, barium defecography allows for accurate and expanded assessment of the underlying pathology and helps to guide future intervention. Understanding the imaging findings of barium defecography in the spectrum of pathology of the anorectum and pelvic floor allows one to appropriately triage and treat patients presenting with defecatory dysfunction.
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Affiliation(s)
- Nathan Y Kim
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - David H Kim
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Evie H Carchman
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Arnold Wald
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
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8
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Mege D, Sans A, Maignan A, Duclos J, Frasconi C, Le Huu Nho R, Pirro N, Sielezneff I. Temporary successful results of ventral rectopexy for enterocele surgical correction, about 138 patients. Int J Colorectal Dis 2017; 32:1569-1575. [PMID: 28803377 DOI: 10.1007/s00384-017-2887-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE This work aimed to analyse short- and long-term results of enterocele surgical treatment by ventral rectopexy. METHODS All females who underwent ventral rectopexy for enterocele in our department were included. All patients underwent standardized preoperative evaluation. Data was retrospectively collected, after examination of patients or by telephone survey. Postoperative evaluation was performed by an independent observer. RESULTS One hundred thirty-eight females (median age = 63 years [21-86 years]) were included. They were postmenopausal and multiparous in 94 and 70% of cases, respectively. Pelvic pressure, vaginal prolapse, or the both were observed in 28, 16 or 56% of the patients, respectively. The most frequent associated symptoms were dyschezia (63%) and faecal incontinence (30%). On preoperative workup, enterocele was isolated in two cases. Rectocele, internal rectal prolapse and cervicocystoptosis were the most frequently associated pelvic floor disorders. Ventral rectopexy was performed through laparoscopy in 128 patients (93%). In the short term, all pelvic symptoms were significantly improved, except urinary incontinence. At the end of follow-up (56 months [7-125]), specific symptoms and dyschezia were still significantly improved. Secondary failure was reported in 31% of patients. By multivariate analysis, two predictive factors for long-term failure were found: diagnosis of rectocele on preoperative MRI (odd ratio = 15; 95% CI 1.4-163; p = 0.03) and conversion into open surgery (odd ratio = 8; 95% CI 1.4-43; p = 0.02). CONCLUSION This study suggests that ventral rectopexy is an effective treatment of enterocele, but secondary failure can be observed. Patients should be informed of the potential risk of long-term degradation.
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Affiliation(s)
- Diane Mege
- Aix-Marseille Université, 13284, Marseille, France.
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France.
| | - Arnaud Sans
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
| | - Aurélie Maignan
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
| | - Julie Duclos
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
| | - Cécilia Frasconi
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
| | - Remy Le Huu Nho
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
| | - Nicolas Pirro
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
| | - Igor Sielezneff
- Aix-Marseille Université, 13284, Marseille, France
- APHM, Hôpital Timone, Service de chirurgie digestive et oncologique, pôle ACCORD, 13385, Marseille, France
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Dimitriou N, Shah V, Stark D, Mathew R, Miller AS, Yeung JMC. Defecating Disorders: A Common Cause of Constipation in Women. WOMENS HEALTH 2015; 11:485-500. [DOI: 10.2217/whe.15.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.
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Affiliation(s)
- Nikoletta Dimitriou
- 1st Department of Surgery, University of Athens, Medical School, Laiko Hospital, Athens, Greece
| | - Vikas Shah
- Department of Radiology, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Diane Stark
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Ronnie Mathew
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Andrew S Miller
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Justin MC Yeung
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
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10
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Bogaerts-Samama MJW, Driessen SRC, Jenninga E, Delemarre JBVM, Trimbos JB, Westerweel ME. Outcome and medium-term functional results of anterior rectopexy for rectocele repair. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s10397-014-0862-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Lone F, Sultan AH, Stankiewicz A, Thakar R. The value of pre-operative multicompartment pelvic floor ultrasonography: a 1-year prospective study. Br J Radiol 2014; 87:20140145. [PMID: 24959953 DOI: 10.1259/bjr.20140145] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Comprehensive assessment of the pelvic floor (PF) provides information and diagnoses of coexisting abnormalities that may affect operative decisions. Our aim was to establish if pre-operative PF ultrasonography (PFUS) in patients complaining of PF dysfunction can complement clinical findings and contribute to additional management strategies. METHODS Females were recruited from the urogynaecology/gynaecology clinics between July and October 2009 and underwent pelvic organ prolapse quantification (POPQ) by an independent examiner. PFUS was performed using two-dimensional (2D) transperineal ultrasound (TPUS), high-frequency 2D/three-dimensional (3D) endovaginal ultrasound (EVUS) using a biplane probe with linear and transverse arrays and a 360° rotational 3D-EVUS. The clinician performing PFUS was blinded to POPQ results. POPQ and PFUS were repeated at 1 year. Two clinicians analysed the scans independently. RESULTS 158 of 160 females had a POPQ and PFUS. 105 females had pelvic organ prolapse and/or incontinence and 53 asymptomatic females were controls. 26 additional ultrasound diagnoses were noted at baseline and 46 at 1 year using 2D-TPUS and EVUS. Only one female with additional diagnoses on PFUS needed surgical intervention for this condition. CONCLUSION Multicompartment PFUS identifies additional conditions to that diagnosed on clinical assessment. However, it neither changes the initial surgical management nor the management at 1-year follow-up and therefore clinical assessment should not be substituted by PFUS. ADVANCES IN KNOWLEDGE PFUS can be helpful in providing additional information; however, it does not change the initial management of the patient and therefore should not replace clinical assessment.
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Affiliation(s)
- F Lone
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London, UK
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12
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Zbar AP. Posterior pelvic floor disorders and obstructed defecation syndrome: clinical and therapeutic approach. ACTA ACUST UNITED AC 2014; 38:894-902. [PMID: 22415627 DOI: 10.1007/s00261-012-9878-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There are no clear recommended imaging guidelines for the assessment of patients presenting primarily with obstructed defecation syndrome and defecation difficulty. The gold standard has always been the defecating proctogram which may require a rather poorly tolerated extended technique involving high-radiation exposure in young women which includes cystography, vaginography, small bowel opacification, and occasional peritoneography. The development of dynamic magnetic resonance imaging has obviated many of these extended techniques and may be supplemented by novel ultrasonographic methods including dynamic transperineal sonography, real-time 3D translabial ultrasound and 3D dynamic echodefecography. Patients potentially suitable for surgical treatment display a multiplicity of pelvic floor and perineal soft-tissue anomalies where one pathology (such as rectocele or enterocele) are considered dominant. Despite the introduction of recent stapled and robotic technologies, there is a dual dialog concerning the functional outcome of these procedures. Imaging and surgical algorithms for these patients are provided.
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Affiliation(s)
- Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel Aviv Israel Affiliated with Sackler Medical School and Tel Aviv University, Tel Aviv, Israel,
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13
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Abstract
Incontinence and constipation can occur in cases of pelvic floor dysfunction. Purely morphological changes without severe clinical symptoms are not an indication for surgery. Abdominal operations can be classified into procedures with dorsal (with or without bowel resection and with or without mesh implantation) and procedures with ventral rectopexy (with mesh). With respect to constipation and incontinence suture rectopexy alone is inferior to all other procedures. Dorsal and ventral mesh rectopexy and resection rectopexy are all comparable with respect to improvement of incontinence. Ventral rectopexy without dorsal mobilization and resection rectopexy are superior to mesh rectopexy with respect to constipation. Due to poor evidential status treatment is carried out from a pragmatic viewpoint.
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Affiliation(s)
- P Kienle
- Chirurgische Klinik, Universitätsklinikum Mannheim.
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14
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Xu CY, Ding SQ, Xue YH, Ding YJ. Diagnostic value of pelvic floor ultrasound in constipation due to female pelvic floor dysfunction. Shijie Huaren Xiaohua Zazhi 2012; 20:2931-2936. [DOI: 10.11569/wcjd.v20.i30.2931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Constipation caused by female pelvic floor dysfunction (FPFD) is closely related to pathological changes in the front, middle and back basins. Constipation caused by pathological changes in the back basin manifests itself as rectocele, internal rectal intussusception, enterocele, descending perineum, and pelvic floor dyssynergia. Constipation due to the pathological changes in the front and middle basins not only manifests the above symptoms but also exhibits the symptoms of uterine and bladder prolapse. Pelvic floor ultrasound allows observing pathological changes in the front, middle and back basins in patients with constipation caused by FPFD, analyzing the changes in structure and function of static and dynamic pelvic floors, and making a more systematic assessment of female pelvic floor lesions, which is conducive to guiding constipation treatment. Therefore, pelvic floor ultrasound has great value in constipation caused by FPFD. In this paper, we review the diagnostic value of pelvic floor ultrasound in constipation due to female pelvic floor dysfunction.
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15
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Pironi D, Pontone S, Podzemny V, Panarese A, Vendettuoli M, Mascagni D, Filippini A. Combined Burch urethropexy and anterior rectopexy in pelvic organ prolapse: skip the mesh. Langenbecks Arch Surg 2012; 397:1157-65. [PMID: 22895847 DOI: 10.1007/s00423-012-0985-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 07/18/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE Pelvic organ prolapse (POP) is a common accompaniment of advancing age. Current repair techniques incorporate transvaginal and transabdominal approaches with or without prosthetic mesh insertion. In this paper, we present the short- and medium-term results of a unit policy directed at patients with POP of combined abdominal rectopexy and Burch retropubic urethropexy without the use of prosthetic mesh assessing its safety profile in selected cases. METHODS Between January 2009 and January 2011, 16 women with tri-compartmental prolapse who had all undergone prior hysterectomy underwent combined surgical pelvic floor repair. Preoperative symptom assessment by validated questionnaires and clinical examination were pre- and postoperatively recorded. Cures were defined as either optimal or satisfactory outcomes based on combined clinical, radiological examinations and reported patient satisfaction. RESULTS The mean age of the 16 patients was 57.2 years, and their mean BMI was 28.6 (±5 SD). Pelvic examination revealed a POP-Q stage III prolapse in 12 patients and stage IV in 4 patients. The mean operating time was 57.5 min (range 40-85), with a mean length of hospital stay of 4.5 days. Cystocele and enterocele resolution was noted in every case on dynamic magnetic resonance imaging (MRI). CONCLUSIONS Our results in a small patient cohort employing a simple 'all-in-one' repair approach combining a retropubic colposuspension with an anterior rectopexy appear to be satisfactory. Further larger randomized studies are required, incorporating a laparoscopic arm in order to determine the longer-term effectiveness of this approach.
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Affiliation(s)
- Daniele Pironi
- Department of Surgical Sciences, "Sapienza" University of Rome, V.le Regina Elena n° 324, 00161 Rome, Italy
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Steensma AB, Oom DMJ, Burger CW, Schouten WR. Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound. Colorectal Dis 2010; 12:533-9. [PMID: 19438878 DOI: 10.1111/j.1463-1318.2009.01936.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Evacuation proctography (EP) is considered to be the gold standard investigation for the diagnosis of posterior compartment prolapse. 3D transperineal ultrasound (3DTPUS) imaging of the pelvic floor is a noninvasive investigation for detection of pelvic floor abnormalities. This study compared EP with 3DTPUS in diagnosing posterior compartment prolapse. METHOD In a prospective observational study, patients with symptoms related to posterior compartment prolapse participated in a standardized interview, clinical examination, 3DTPUS and EP. Both examinations were analysed separately by two experienced investigators, blinded against the clinical data and against the results of the other imaging technique. After the examinations, all patients were asked to fill out a standardized questionnaire concerning their subjective experience. RESULTS Between 2005 and 2007, 75 patients were included with a median age of 59 years (range 22-83). The Cohen's Kappa Index for enterocole was 0.65 (good) and for rectocele it was 0.55 (moderate). The level of correlation for intussusception was fair (kappa = 0.21). CONCLUSION This study showed moderate to good agreement between 3DTPUS and EP for detecting enterocele and rectocele.
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Affiliation(s)
- A B Steensma
- Department of Obstetrics & Gynaecology, Erasmus Medical Center, Rotterdam, the Netherlands.
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Zbar A. Dynamic magnetic resonance imaging and transperineal sonography in the assessment of patients presenting primarily with evacuatory difficulty: a short position paper. ACTA CHIRURGICA IUGOSLAVICA 2010; 57:97-104. [PMID: 21066992 DOI: 10.2298/aci1003097z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Patients presenting with primary evacuatory difficulty have a multiplicity of pelvic floor and perineal soft tissue anomalies. The radiological assessment of these patients requires modalities which monitor the dynamic interaction of pelvic organs during provocative manoeuvres such as straining and simulated defaecation. The advantages and disadvantages of these complementary modalities, (dynamic magnetic resonance imaging, dynamic transperineal sonography and dynamic 2- and 3-dimensional endoanal sonography) are provided in this position paper.
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Affiliation(s)
- A Zbar
- University of New England, New South Wales, Australia
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Knowles CH, Dinning PG, Pescatori M, Rintala R, Rosen H. Surgical management of constipation. Neurogastroenterol Motil 2009; 21 Suppl 2:62-71. [PMID: 19824939 DOI: 10.1111/j.1365-2982.2009.01405.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review addresses the range of operations suggested to be of contemporary value in the treatment of constipation with critical evaluation of efficacy data, complications, patient selection, controversies and areas for future research.
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Affiliation(s)
- C H Knowles
- Queen Mary University London, Barts and the London School of Medicine & Dentistry, London, UK.
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19
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Abstract
Pelvic floor disorders that affect defecation consist of structural disorders (eg, rectocele) and functional disorders (eg, dyssynergic defecation). Evaluation includes a thorough history and physical examination, a careful digital rectal examination, and physiologic tests such as anorectal manometry, colonic transit study, and balloon expulsion test. Defecography and dynamic MRI may facilitate detection of structural defects. Management consists of education and counseling regarding bowel function, diet, laxatives, and behavioral therapies. Recently, several randomized, clinical trials have shown that biofeedback therapy is effective in dyssynergic defecation. Dyssynergia may also coexist in structural disorders such as solitary rectal ulcer syndrome or rectocele. Hence, before proceeding with surgery, neuromuscular training or biofeedback should be considered. Several surgical approaches, including stapled transanal rectal resection, have been advocated, but well-controlled randomized studies are lacking and their efficacy is unproven.
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Affiliation(s)
- Satish S C Rao
- The University of Iowa Hospitals and Clinics, Internal Medicine, GI Division, 200 Hawkins Drive, 4612 JCP, Iowa City, IA 52242, USA.
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Pescatori M, Zbar AP. Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*. Colorectal Dis 2009; 11:410-9. [PMID: 18637923 DOI: 10.1111/j.1463-1318.2008.01626.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period. METHOD Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months). RESULTS Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05). CONCLUSION Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.
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Affiliation(s)
- M Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospital, Rome, Italy.
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Oom DMJ, Gosselink MP, Schouten WR. Enterocele--diagnosis and treatment. ACTA ACUST UNITED AC 2009; 33:135-7. [PMID: 19200673 DOI: 10.1016/j.gcb.2009.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- D M J Oom
- Colorectal Research Group, Erasmus Medical Center, Room Ba. 181's, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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Pescatori M. Long-term follow-up of simultaneous abdominoperineal repair of enterorectocele and internal mucosal prolapse. Dis Colon Rectum 2009; 52:327-35. [PMID: 19279431 DOI: 10.1007/dcr.0b013e31819a21d8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enterorectocele with recto-rectal intussusception and internal mucosal prolapse (ER-RI-MP) may require surgery for obstructed defecation, but symptoms tend to recur if only one lesion is corrected. This prospective study was designed to investigate the results of an abdominoperineal procedure aimed at treating all these lesions in one stage. METHODS Thirteen women with constipation (median age, 58 years) and ER-RI-MP underwent Douglas pouch suture, mesh obliteration of the pelvic inlet with or without rectopexy, and omentoplasty plus rectocele and prolapse obliteration. Constipation was scored on a scale from 0 to 20. Proctoscopy, enterocolpodefecography, manometry, anal-vaginal-perineal ultrasound, and psychological evaluation were performed before and after surgery. RESULTS Bleeding requiring transfusion, pelvic hygroma, and ureteric stricture requiring adhesiolysis occurred in three patients. Constipation score significantly decreased from a mean (+/- standard error of the mean) of 16 +/- 0.6 before to 7 +/- 0.9 after surgery (P < 0.0001). Seven patients were considered cured, five improved, and one remained unchanged at a median follow-up of 42 months. Anorectal physiology and imaging returned to normal in seven patients. Four patients had successful rehabilitation and psychotherapy for anismus, rectal hyposensation, and depression. CONCLUSIONS Simultaneous abdominoperineal ER-RI-MP repair integrated with conservative treatment of associated dysfunctions achieved a satisfactory long-term outcome. The results need to be confirmed in larger series.
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Affiliation(s)
- Mario Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospitals, Rome, Italy.
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Abstract
BACKGROUND/AIMS The stapled transanal rectal resection (STARR) procedure has been suggested as a simple surgical option for patients presenting with evacuatory difficulty in the clinical presence of a rectocele. Most of these patients have a multiplicity of pelvic floor pathology unaddressed by the performance of one procedure. The aim of the study was to assess an unselected group of patients referred to a tertiary coloproctological unit following performance of the STARR procedure for obstructed defecation (OD) where the procedure was complicated or had failed. MATERIALS AND METHODS Anorectal, urogynecological, and psychological examination with objective constipation/incontinence scoring, anal-vaginal-perineal ultrasound, manometry, and defecography were selectively performed utilizing the Iceberg Diagram to detect occult pelvic floor pathology. RESULTS Twenty patients were referred with 13 cases (female, 10; median age, 65 years; range, 40-72) operated upon. Post-STARR surgery was performed for three complications and ten failures including recurrent OD, severe proctalgia, and fecal incontinence. Overall, 11 patients underwent biofeedback therapy and psychotherapy. Of the operated group, 11 patients had a median of four associated disorders. Seven patients had a significant psychological overlay with severe depression or anxiety and four heterogeneous anal sphincter defects. Operative procedures were tailored to the clinical findings using enterocele repair, staple removal, fistulectomy, rectosigmoid resection, and levatorplasty where appropriate. Twelve patients were evaluated after a median follow-up of 18 months. Of these, six (all with psychoneurosis) remained unchanged. Three patients with no psychological overlay were asymptomatic with a further two improved. CONCLUSION The STARR procedure, when complicated or failed, has a poor outcome following surgical reintervention. It requires careful patient selection to determine the associated pelvic floor pathology and pre-existent psychopathology.
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Boffi F. Retained staples causing rectal bleeding and severe proctalgia after the STARR procedure. Tech Coloproctol 2008; 12:135-6. [PMID: 18545877 DOI: 10.1007/s10151-008-0412-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Wijffels N, Cunningham C, Lindsey I. Reply to: Rectocele repair by anterolateral rectopexy; long-term functional outcome (Oom et al.). Colorectal Dis 2008; 10:849; author reply 849-50. [PMID: 18843792 DOI: 10.1111/j.1463-1318.2008.01687.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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