Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome

Functional Constipation and Obstructed Defecation

Constipation encompasses symptoms of decreased colonic motility or difficulty with the defecation process. As a broad definition, this can be inclusive of functional constipation (FC) or colonic inertia, obstructed defecation (OD), and irritable bowel syndrome-constipation type (IBS-CS). After excluding IBS-C, FC and OD diagnosis and management require a multidisciplinary approach often involving nutritionists, pelvic floor therapists, urogynecologists, and colon and rectal surgeons. Differentiating the presence or absence of each can direct therapy and prognosticate chances for improvement in this often complex combination of disorders.

Does Rectocele Repair Combined with Other Perineal Surgeries Affect Outcome Compared to Solo Rectocele Repair?

OBJECTIVES

Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to analyze perioperative morbidity and mortality as well as long-term outcome of rectocele repair in combination with other perineal surgeries (RR combination) and compare this with solo rectocele repair (solo RR).

DESIGN

The type of study was case-control. Data of patients who received solo rectocele repair or rectocele repair in combination with other perineal surgeries between January 2011 and December 2015 were identified and reviewed in a prospectively maintained and IRB-approved database. Ninety-eight patients were included, including 41 patients in the solo RR group and 57 patients in the RR combination group. The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were observed.

METHODS

The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were compared, respectively. Covariate adjustment was analyzed by multivariate logistic and Cox regression analysis.

RESULTS

Ninety-eight patients with a median age of 57 were included, involving 41 patients in the solo RR group and 57 patients in the RR combination group. Other than the operative approach (p < 0.01), demographics and preoperative characteristics of the 2 groups were comparable. All variables, including length of stay, estimated blood loss, self-limiting rectal bleeding, transfusion, urinary retention, rectal stricture, rectal and perineal infection, rectovaginal abscess, reoperation, effective resolution of obstructive defecation symptoms, residual symptoms rate, and recurrence rate, were comparable among the 2 groups except for operative time (p = 0.03).

LIMITATIONS

This study is a single-center study, which may cause bias. In addition, the sample size is limited. Staging of rectocele and routine imaging studies were not performed.

CONCLUSIONS

Rectocele repair in combination with other perineal surgeries is feasible, and outcomes are comparable with solo rectocele repair. Transanal versus transvaginal repairs appear to have no influence on outcomes.

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome: An alternative option for selected patients

BACKGROUND

Abdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique for ODS are very limited.

AIM

To evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS.

METHODS

Consecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department. Patient demographics, perioperative surgical results, and postoperative follow-up outcomes were collected and analyzed. Long-term follow-up was evaluated with standardized questionnaires. The severity of symptoms was assessed by the objective Wexner Constipation Score (WCS) and ODS Score. The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score. Functional outcome was compared pre- and post-operatively for each patient. The primary outcomes were determined by the improvement in symptoms and quality of life. Secondary outcome measures were operating time, postoperative length of stay, morbidity and mortality, improvement of pelvic floor structure, and patient satisfaction.

RESULTS

Four patients underwent robotic-assisted surgery, and two patients underwent a laparoscopic-assisted procedure. The mean operating time for the robotic approach was 243 min (range 160–300 min), and the mean operating time for the laparoscopic approach was 230 min (range 220-240 min). The mean postoperative length of stay was 8.2 d (range 6-12 d). There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection and anastomosis leakage occurred. Six patients were followed up for 36 mo. The WCS, ODS, and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively (P < 0.05). The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication.

CONCLUSION

Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS. However, comprehensive preoperative evaluation and careful patient selection are essential.

OUTLET OBSTRUCTED CONSTIPATION AND FECAL INCONTINENCE: IS REHABILITATION TREATMENT THE WAY? MYTH OR REALITY

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

Stapled transanal rectal resection for the treatment of rectocele associated with obstructed defecation syndrome: a large series of 262 consecutive patients

BACKGROUND

This study aims to investigate functional results and recurrence rate after stapled transanal rectal resection (STARR) for rectocele associated with obstructive defection syndrome (ODS).

METHODS

A study was conducted on patients with ODS symptoms associated with symptomatic rectocele ≥ 3 cm on dynamic defecography who had STARR at our institution between 01/2007 and 12/2015. Data were prospectively collected and analyzed. ODS was evaluated using the Wexner constipation score. Primary outcomes were functional results, determined by the improvement in 6-month postoperative Wexner constipation score, and 1-year recurrence. Secondary outcomes were operative time, time to return to work, pain intensity measured using the visual analogue scale (VAS), patient satisfaction, and overall postoperative morbidity and mortality at 30 days.

RESULTS

Two-hundred-sixty-two consecutive female patients [median age 54 years (range 20-78)] were enrolled in the study. The median duration of follow-up was 79 months (range 30-138). Sixty (23%) patients experienced postoperative complications, but only 9 patients required reinterventions for surgical hemostasis (n = 7), fecal diversion for anastomotic leakage (n = 1), and recto-vaginal fistula repair (n = 1). Only 1 intraoperative complication (stapler misfire) was reported, and there were no deaths. There was a statistically significant (p < 0.001) reduction in the median (range) Wexner constipation score from 19 (14-24) preoperatively to 9 (5-15) 6 months postoperatively. Only 10 (4%) patients experienced recurrence and only 3 of them required additional reintervention. Patient satisfaction at 1 year was excellent in 86%, good in 13%, and poor in 1% of patients.

CONCLUSIONS

STARR is a safe, effective, and minimally invasive technique for the treatment of rectocele associated with ODS.

Advances in imaging diagnosis of rectocele

Rectocele is one of the common manifestations of outlet obstructive constipation. There are several imaging methods for evaluating rectocele including conventional defecography, dynamic nuclear magnetic resonance imaging (MRI) defecography and pelvic floor ultrasonography. These diagnostic techniques can identify the degree of rectocele and provide evidence for treatment. Defecography is still considered the gold standard for evaluating rectocele and guiding the operation, but it exposes patients to radiation. MRI defecography has the advantages of multi-dimensional imaging, excellent soft-tissue contrast and no radiation, and has broad prospects in the future, but it is expensive nowadays and has an unphysiological defecation way. Pelvic floor ultrasonography, especially endoanal and transperineal techniques, is able to identify all dysfunctions of the posterior pelvic floor compartment without radiation, but needs further studies.

Rectocele repair with stapled transvaginal rectal resection

BACKGROUND

Constipation is a clinical symptom in patients suffering from slow transit and/or obstructed defecation. Proper treatment requires the identification of all associated disorders and the quantification of symptoms. Rectocele can cause the symptoms of obstructed defecation syndrome (ODS). The aim of this study was to evaluate the clinical and functional outcomes of a novel technique of transvaginal stapled rectal resection (TVSRR) using a straight staple line, to treat rectocele.

METHODS

The study included 84 females [median age 51 years (range 29-73 years)], with obstructed defecation, grades II-III rectocele, and multiple abnormalities on defecography. The magnitude and degree of ODS were quantified by the Altomare ODS scoring system. Continence status was evaluated using the Pescatori scoring system. The rectal and vaginal manometric study, the index of patient satisfaction using a visual analog score (VAS), and the validated Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire results were recorded. All patients underwent TVSRR.

RESULTS

There were no intraoperative complications. Early postoperative complications were defecatory urgency in seven patients (8.3 %), dyspareunia in two (2.4 %), and rectovaginal fistula in one (1.2 %). Five patients (6 %) had recurrence of ODS symptoms. There was no significant change in continence pre- and postoperatively. The ODS score and VAS revealed significant improvement within the first postoperative year in 94 % of patients. The PAC-QOL questionnaire mean total scores indicated an improvement in both the patient satisfaction and the QOL during the 12-month follow-up. The self-reported definitive outcome was excellent in 46 patients (54.7 %), good in 29 (34.5 %), fairly good in 20 (23.8 %), and poor in five (6.0 %).

CONCLUSIONS

Vaginal repair carries no risk of fecal incontinence. Large anterior rectocele is considered the main indication for this technique. Using the linear stapler is a cost-effective, simple, and easy technique.