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Ogunleye O, Abdelhafez AH, Matta E, Kramer L. Retrorectal Hernia: A Rare Cause of Constipation Diagnosed on Magnetic Resonance (MR) Defecography. Cureus 2024; 16:e58848. [PMID: 38784319 PMCID: PMC11112525 DOI: 10.7759/cureus.58848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Retrorectal herniation of the sigmoid colon is a rare condition characterized by the protrusion of a segment of the colon into the pre-sacral space and posterior to the rectum. This herniation occurs through a defect in the peritoneum, which may have developed secondary to congenital mechanisms, surgery, trauma, or inflammatory processes. Here, a case of retrorectal herniation of the sigmoid colon in an elderly female patient presenting with constipation is reported, with a review of the literature.
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Affiliation(s)
- Olanrewaju Ogunleye
- Department of Radiology, University of Texas Health Science Center at Houston, Houston, USA
| | - Abeer H Abdelhafez
- Department of Radiology, University of Texas Health Science Center at Houston, Houston, USA
| | - Eduardo Matta
- Department of Radiology, University of Texas Health Science Center at Houston, Houston, USA
| | - Larry Kramer
- Department of Radiology, University of Texas Health Science Center at Houston, Houston, USA
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2
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Pescatori M. A modified myotomy of the puborectalis for anismus. Tech Coloproctol 2023; 27:507-512. [PMID: 36725753 DOI: 10.1007/s10151-022-02748-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/22/2022] [Indexed: 02/03/2023]
Abstract
Anismus or non-relaxing puborectalis muscle (PRM) on straining may affect over 40% of patients with obstructed defecation (OD). Management is usually with biofeedback, or botulin toxin injection or partial puborectalis muscle myotomy. Such a procedure can be difficult technically. Bleeding and rectal injury may occur when detaching the PRM from the rectum. A partial modification of surgical technique may avoid these complications. The diagnosis should be confirmed with exclusion of sphincter compromise. Through two cutaneous incisions, an Ellis forceps is advanced through the ischio-rectal space, whilst finger pressure per rectum allows the puborectalis to be visualized and grasped by the forceps. Removal of some ischiorectal fat may be necessary to allow division of half the PRM under direct view. From October 2020 to October 2021, 5 patients underwent the modified technique in our department (4 males, median age 43 years [range 34-58 years], median follow-up 6 months [range 2-12 months]). No patients suffered from injury of the rectum or bleeding during or after surgery. Operative time was 30 min less than conventional PRM division, as the time-consuming "blind dissection" of PRM was avoided. Four patients regained appropriate relaxation of the PRM on straining. One male patient had temporary minor anal incontinence for 2 weeks. One male patient with severe mental distress continued to have with anismus and OD after surgery and refused psychiatric support. This modified procedure is feasible and safe and quicker than our conventional technique. More cases with longer follow-up are needed to confirm its efficacy.
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Affiliation(s)
- M Pescatori
- Coloproctology Units of Parioli and Cobellis Clinics, Rome and Vallo della Lucania, Italy.
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BONDURRI A, CAVALLO D, MAFFIOLI A, GUERCI C, DANELLI P. STARR vs. internal Delorme procedure for obstructed defecation: functional and QoL long-term results. Chirurgia (Bucur) 2023. [DOI: 10.23736/s0394-9508.22.05394-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Pescatori M, Zbar AP, Ayabaca SM. Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results. Surgery 2022; 172:1636-1641. [PMID: 36208984 DOI: 10.1016/j.surg.2022.05.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results. METHODS Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated. RESULTS Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured. CONCLUSION The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.
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Affiliation(s)
- Mario Pescatori
- Coloproctology Units, Parioli Clinic, Rome and Cobellis Clinic, Vallo della Lucania, Italy.
| | - Andrew Paul Zbar
- Department of General Surgery and Transplantation, Chaim Sheba Medical Center, University of Tel Aviv, Tel Aviv, Israel
| | - Stella Maris Ayabaca
- Coloproctology Units, Parioli Clinic, Rome and Cobellis Clinic, Vallo della Lucania, Italy
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Ripamonti L, Guttadauro A, Lo Bianco G, Rennis M, Maternini M, Cioffi G, Chiarelli M, De Simone M, Cioffi U, Gabrielli F. Stapled Transanal Rectal Resection (Starr) in the Treatment of Obstructed Defecation: A Systematic Review. Front Surg 2022; 9:790287. [PMID: 35237648 PMCID: PMC8882820 DOI: 10.3389/fsurg.2022.790287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/20/2022] [Indexed: 11/29/2022] Open
Abstract
Obstructed defecation syndrome (ODS) is a form of constipation that influences the quality of life in most patients and is an important health care issue. In 2004 Longo introduced a minimal invasive trans-anal approach known as Stapled Trans-Anal Rectal Resection (STARR) in order to correct mechanical disorders such as rectocele or rectal intussusception, two conditions present in more than 90% of patients with ODS. Considering the lack of a common view around ODS and STARR procedure. the aim of our study is to review the literature about preoperative assessment, operative features and outcomes of the STARR technique for the treatment of ODS. We performed a systematic search of literature, between January 2008 and December 2020 and 24 studies were included in this review. The total number of patients treated with STARR procedure was 4,464. In conclusion STARR surgical procedure has been proven to be safe and effective in treating symptoms of ODS and improving patients Quality of Life (QoL) and should be taken in consideration in the context of a holistic and multi modal approach to this complex condition. International guidelines are needed in order to optimize the diagnostic and therapeutic process and to improve outcomes.
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Affiliation(s)
- Lorenzo Ripamonti
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Angelo Guttadauro
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- General Surgery Department, Istituti Clinici Zucchi Monza, Monza, Italy
| | - Giulia Lo Bianco
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Maria Rennis
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Matteo Maternini
- General Surgery Department, Istituti Clinici Zucchi Monza, Monza, Italy
| | - Gerardo Cioffi
- Department of Sciences and Technologies, University of Sannio RCOST, Benevento, Italy
| | - Marco Chiarelli
- Department of Surgery, Ospedale Alessandro Manzoni, ASST Lecco, Lecco, Italy
| | | | - Ugo Cioffi
- Department of Surgery, University of Milan, Milan, Italy
| | - Francesco Gabrielli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- General Surgery Department, Istituti Clinici Zucchi Monza, Monza, Italy
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van Gruting IM, Stankiewicz A, Thakar R, Santoro GA, IntHout J, Sultan AH. Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome. Cochrane Database Syst Rev 2021; 9:CD011482. [PMID: 34553773 PMCID: PMC8459393 DOI: 10.1002/14651858.cd011482.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. OBJECTIVES To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. SEARCH METHODS We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. SELECTION CRITERIA Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. MAIN RESULTS Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. AUTHORS' CONCLUSIONS In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
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Affiliation(s)
- Isabelle Ma van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, Netherlands
| | | | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
| | - Giulio A Santoro
- Section of Anal Physiology and Ultrasound, Department of Surgery, Regional Hospital, Treviso, Italy
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
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Aumann G, Longo A. Il pavimento pelvico non esiste – transanale Verfahren in der Behandlung des obstruktiven Defäkationssyndroms und Descensus perinei. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Liu W, Sturiale A, Fabiani B, Giani I, Menconi C, Naldini G. Internal Delorme's Procedure for Treating ODS Associated With Impaired Anal Continence. Surg Innov 2017; 24:566-573. [PMID: 28778136 DOI: 10.1177/1553350617723771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the medium-term outcomes of internal Delorme's procedure for treating obstructed defecation syndrome (ODS) patients with impaired anal continence. PATIENTS AND METHODS In a retrospective study, 41 ODS patients who underwent internal Delorme's procedure between 2011 and 2015 were divided into 3 subgroups according to their associated symptoms of impaired continence, as urgency, passive fecal incontinence and both, before study. Then the patients' preoperative statuses, perioperative complications, and postoperative outcomes were investigated and collected from standardized questionnaires, including Altomare ODS score, Fecal Incontinence Severity Index (FISI), Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QoL), and Fecal Incontinence Quality of Life Scale (FIQLS). All results with a 2-tailed P < .05 were considered statistically significant. RESULTS At an average 2.8 years of follow-up, there were significant improvements ( P < .01) in Altomare ODS score, FISI, PAC-QoL, and FIQLS in all patients when comparing scores from before the operation with those at the final follow-up. Similar results were also observed in both the urgency subgroup and passive fecal incontinence subgroup, but there were no statistically significant improvements ( P > .05) in Altomare ODS score, FISI, PAC-QoL, or FIQLS in the urgency and passive fecal incontinence subgroups. Anorectal manometry showed the mean value of anal resting pressure increased 20%. Additionally, no major complications occurred. CONCLUSION Internal Delorme's procedure is effective without major morbidity for treating ODS associated with urgency or passive fecal incontinence, but it may be less effective for treating ODS associated with both urgency and passive fecal incontinence.
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Affiliation(s)
- Weicheng Liu
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
| | | | | | - Iacopo Giani
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
| | - Claudia Menconi
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
| | - Gabriele Naldini
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
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Piloni V, Possanzini M, Bergamasco M, Santi G. Postoperative MR Defecography following Failed STARR Procedure for Obstructive Defecation Syndrome: A Three-Centre Experience. Gastroenterol Res Pract 2017; 2017:4392918. [PMID: 29158730 PMCID: PMC5660778 DOI: 10.1155/2017/4392918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/16/2017] [Accepted: 08/30/2017] [Indexed: 12/14/2022] Open
Abstract
AIM To describe the abnormalities at MR imaging and related complaints in patients with poor outcome after STARR procedure. MATERIALS AND METHODS The medical records of 21 symptomatic patients from centre 1, 31 patients from centre 2, and 63 patients from centre 3 were reviewed with regard to findings at MR defecography and related symptoms. RESULTS Regardless of the centre, most relevant imaging features and related complaints were (a) impaired emptying (82.11%), related complaint ODS; (b) persistent rectocele >2 cm and intussusception (39.3%), split evacuation and digitation; (c) pelvic organ descent on straining (39.8%), prolapse sensation; (d) small neorectum and loss of contrast (32.5%), urgency and incontinence; (e) anastomotic stricture and granuloma (28.4%), pain; and (f) nonrelaxing puborectalis muscle (19.5%), tenesmus. Less frequent findings included rectal pocket formation (5.6%) and rectovaginal sinus tract (1.6%). Patients were referred to MR imaging with an average time interval of 5 ± 2, 4 ± 1, and 2 ± 1 years in the three centres, respectively, and only rarely by the same surgeon who performed the operation: 1/21 (4.8%) in centre 1, 3/39 (7.7%) in centre 2, and 9/63 (14.3%) in centre 3. CONCLUSION Most surgeons involved in STARR operation with subsequent poor outcome do not rely on MR imaging.
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Affiliation(s)
- Vittorio Piloni
- Radiologist Diagnostic Imaging Centre, Iniziativa Medica, Monselice, Padua, Italy
| | - Marco Possanzini
- Technician Diagnostic Imaging Centre, Villa Igea Clinic, Ancona, Italy
| | - Mattia Bergamasco
- Technician Diagnostic Imaging Centre, Iniziativa Medica, Monselice, Padua, Italy
| | - Gianluca Santi
- Technician Diagnostic Imaging Centre, Studio Ronconi, Acilia, Rome, Italy
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Piloni V, Possanzini M, Bergamasco M, Santi G. Postoperative MR Defecography following Failed STARR Procedure for Obstructive Defecation Syndrome: A Three-Centre Experience. Gastroenterol Res Pract 2017; 2017:1-8. [DOI: vittorio piloni, marco possanzini, mattia bergamasco, and gianluca santi.gastroenterology research and practice 2017, article id 4392918, https:/doi.org/10.1155/2017/4392918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023] Open
Abstract
Aim. To describe the abnormalities at MR imaging and related complaints in patients with poor outcome after STARR procedure. Materials and Methods. The medical records of 21 symptomatic patients from centre 1, 31 patients from centre 2, and 63 patients from centre 3 were reviewed with regard to findings at MR defecography and related symptoms. Results. Regardless of the centre, most relevant imaging features and related complaints were (a) impaired emptying (82.11%), related complaint ODS; (b) persistent rectocele >2 cm and intussusception (39.3%), split evacuation and digitation; (c) pelvic organ descent on straining (39.8%), prolapse sensation; (d) small neorectum and loss of contrast (32.5%), urgency and incontinence; (e) anastomotic stricture and granuloma (28.4%), pain; and (f) nonrelaxing puborectalis muscle (19.5%), tenesmus. Less frequent findings included rectal pocket formation (5.6%) and rectovaginal sinus tract (1.6%). Patients were referred to MR imaging with an average time interval of 5 ± 2, 4 ± 1, and 2 ± 1 years in the three centres, respectively, and only rarely by the same surgeon who performed the operation: 1/21 (4.8%) in centre 1, 3/39 (7.7%) in centre 2, and 9/63 (14.3%) in centre 3. Conclusion. Most surgeons involved in STARR operation with subsequent poor outcome do not rely on MR imaging.
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Affiliation(s)
- Vittorio Piloni
- Radiologist Diagnostic Imaging Centre, Iniziativa Medica, Monselice, Padua, Italy
| | - Marco Possanzini
- Technician Diagnostic Imaging Centre, Villa Igea Clinic, Ancona, Italy
| | - Mattia Bergamasco
- Technician Diagnostic Imaging Centre, Iniziativa Medica, Monselice, Padua, Italy
| | - Gianluca Santi
- Technician Diagnostic Imaging Centre, Studio Ronconi, Acilia, Rome, Italy
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Liu WC, Wan SL, Yaseen SM, Ren XH, Tian CP, Ding Z, Zheng KY, Wu YH, Jiang CQ, Qian Q. Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience. World J Gastroenterol 2016; 22:7983-7998. [PMID: 27672293 PMCID: PMC5028812 DOI: 10.3748/wjg.v22.i35.7983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/23/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors' center is also presented.
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14
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Cour F, Le Normand L, Meurette G. Traitement par voie basse des colpocèles postérieures : recommandations pour la pratique clinique. Prog Urol 2016; 26 Suppl 1:S47-60. [DOI: 10.1016/s1166-7087(16)30428-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Shafik AA, El Sibai O, Shafik IA. Rectocele repair with stapled transvaginal rectal resection. Tech Coloproctol 2015; 20:207-14. [PMID: 26711102 DOI: 10.1007/s10151-015-1410-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/02/2015] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- A A Shafik
- Department of Surgery, Faculty of Medicine, Cairo University, 7, Gamal Salem St., Off Mossadak St., Dokki, Cairo, Egypt.
| | - O El Sibai
- Department of Surgery, Faculty of Medicine, Menoufia University, Al Minufiya, Egypt
| | - I A Shafik
- Department of Surgery, Faculty of Medicine, Cairo University, 7, Gamal Salem St., Off Mossadak St., Dokki, Cairo, Egypt
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Racaniello E, Terzoni S, Accardi R, Ricci C, Boccasanta P, Destrebecq A. Quality of life of patients undergoing surgery for obstructed defecation syndrome: A before-after study. Int J Surg 2015; 21:18-21. [DOI: 10.1016/j.ijsu.2015.06.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/14/2015] [Accepted: 06/12/2015] [Indexed: 12/28/2022]
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Pescatori M, Podzemny V, Pescatori LC, Dore MP, Bassotti G. The PNEI holistic approach in coloproctology. Tech Coloproctol 2015; 19:269-273. [PMID: 25820513 DOI: 10.1007/s10151-015-1277-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 01/27/2015] [Indexed: 12/17/2022]
Abstract
The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloproctological disorders, by providing clinical cases and discussing them in light of this approach.
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Affiliation(s)
- M Pescatori
- Coloproctology Unit, Parioli Clinic, Rome, Italy,
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Guerra F, Crocetti D, Giuliani G, La Torre F. Surgery for anorectal strictures following stapled procedures. Colorectal Dis 2015; 17:266-268. [PMID: 25603879 DOI: 10.1111/codi.12904] [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] [Received: 12/15/2014] [Accepted: 12/22/2014] [Indexed: 02/08/2023]
Affiliation(s)
- F Guerra
- Department of Surgery, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy.
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Podzemny V, Pescatori LC, Pescatori M. Management of obstructed defecation. World J Gastroenterol 2015; 21:1053-1060. [PMID: 25632177 PMCID: PMC4306148 DOI: 10.3748/wjg.v21.i4.1053] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/03/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.
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Panicucci S, Martellucci J, Menconi C, Toniolo G, Naldini G. Correlation between outcome and instrumental findings after stapled transanal rectal resection for obstructed defecation syndrome. Surg Innov 2014; 21:469-475. [PMID: 24132467 DOI: 10.1177/1553350613505718] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Several studies show that stapled transanal rectal resection (STARR) significantly improves constipation in most patients, while others remain symptomatic for obstructed defecation syndrome (ODS). The aim of the study was to analyze clinical, manometric, and endoanal ultrasonography results in order to find any possible correlation between clinical and instrumental data, particularly in dissatisfied patients, both for those who remain symptomatic for ODS and for patients with new-onset fecal disorders. PATIENTS AND METHODS All patients underwent a preoperative and postoperative assessment based on clinical evaluation, proctoscopy, defecography, anorectal manometry, and endoanal ultrasonography. Furthermore, we asked patients about a subjective satisfaction grading of outcome. RESULTS From January 2007 to December 2009, 103 patients were treated in our department with STARR for ODS. Postoperative endoanal ultrasound did not demonstrate any variations compared with the preoperative one. Postoperative scores showed statistically significant improvement, with respect to the preoperative value, with good and sufficient scores in 79.6% of patients, and an overall rate of satisfaction of 87.1%. Fecal disorders, including also the slightest alteration of continence, occurred in 24% of patients, in particular soiling 1.8%, urgency 7.4%, occasional gas leakage 5.5%, and liquid/solid leakage 9.3%. Anorectal manometry revealed a statistically significant reduction only in sensitivity threshold and maximum tolerated volume compared to patients with no disorders of continence. CONCLUSION Results indicate good satisfaction grading and a statistically significant improvement in scores of constipation. There is no close correlation between satisfaction grading and scores. Besides, the assessment of patient's satisfaction often does not match the objective functional outcome.
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Affiliation(s)
| | - Jacopo Martellucci
- University Hospital of Pisa, Pisa, Italy University of Siena, Siena, Italy
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Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness. Clin Res Hepatol Gastroenterol 2014; 38:528-34. [PMID: 24486180 DOI: 10.1016/j.clinre.2013.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 12/06/2013] [Accepted: 12/22/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients. METHOD From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction. RESULTS Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR. CONCLUSIONS The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR. BRIEF SUMMARY In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.
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Pata G, Pasini M, Roncali S, Tognali D, Ragni F. Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition. Int J Surg Case Rep 2014; 5:527-31. [PMID: 25016079 PMCID: PMC4147571 DOI: 10.1016/j.ijscr.2014.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/03/2014] [Accepted: 04/10/2014] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures. PRESENTATION OF CASE We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient's quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures. DISCUSSION This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum. CONCLUSION In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.
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Affiliation(s)
- Giacomo Pata
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy.
| | - Mario Pasini
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy
| | - Stefano Roncali
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy
| | - Daniela Tognali
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, University of Brescia School of Medicine, Brescia, Italy
| | - Fulvio Ragni
- Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy
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Altomare DF, Di Lena M, Giuratrabocchetta S, Giannini I, Falagario M, Zbar AP, Rockwood T. The Three Axial Perineal Evaluation (TAPE) score: a new scoring system for comprehensive evaluation of pelvic floor function. Colorectal Dis 2014; 16:459-68. [PMID: 24450861 DOI: 10.1111/codi.12567] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 11/27/2013] [Indexed: 12/14/2022]
Abstract
AIM Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. METHOD A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. RESULTS There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. CONCLUSION The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management.
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Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
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Ohazuruike NL, Martellucci J, Menconi C, Panicucci S, Toniolo G, Naldini G. Short-term results after STARR versus internal Delorme for obstructed defecation: a non-randomized prospective study. Updates Surg 2014; 66:151-156. [PMID: 24430441 DOI: 10.1007/s13304-014-0247-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/04/2014] [Indexed: 12/17/2022]
Abstract
Obstructed defecation syndrome due to internal intussusception and rectocele is a common disease, and various transanal surgical techniques have been proposed. Aim of the present study was to compare the internal Delorme (ID) and the stapled transanal rectal resection (STARR) results in the treatment of patients with obstructed defecation syndrome. From September 2011 to May 2012, 23 patients were operated with STARR procedure and 12 patients with Delorme's procedure for obstructed defecation syndrome. All patients underwent preoperative assessment: clinical evaluation (Altomare ODS score, Wexner constipation scoring system), proctoscopy, defecography, anorectal manometry and endoanal ultrasonography. Surgery was proposed with: failure of medical therapy, incomplete defecation, and unsuccessful attempts with long periods spent in bathroom, defecation with digital assistance, use of enemas and defecography findings of rectoanal intussusception and rectocele. The average operative time was 28 min (range 15-65) for the STARR group and 56 min (range 28-96) for the ID group with a mean hospital stay of 2 days for both the procedures. The Wexner score significantly fell postoperatively from 17 to 4, 7 in STARR group and from 15.3 to 3.3 in the ID group. The Altomare score postoperatively fell from 18.2 to 5.5 for STARR group and from 16.5 to 5.3 for ID group. No statistically significant differences were observed between the two procedures considering the outcomes parameters and the complications. Both ID and STARR procedure seem to be effective in the treatment of ODS.
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Affiliation(s)
- N L Ohazuruike
- Department Section of Colonproctology and Perineal Surgery, Cisanello Hospital of Pisa, Pisa, Italy
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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: 0.8] [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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Mari FS, Nigri G, Di Cesare T, Gasparrini M, Flora B, Sebastiani C, Pancaldi A, Brescia A. Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations? Dis Colon Rectum 2014; 57:658-662. [PMID: 24819108 DOI: 10.1097/dcr.0000000000000024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line. OBJECTIVE This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques. DESIGN This is a retrospective study. SETTINGS The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital. PATIENTS All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples. INTERVENTIONS If identified, the retained staples were removed endoscopically or transanally. MAIN OUTCOME MEASURES After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms. RESULTS From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms. LIMITATIONS The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement. CONCLUSIONS The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.
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Affiliation(s)
- Francesco Saverio Mari
- Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea Hospital, School of Medicine and Psychology, University Sapienza of Rome, Rome, Italy
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Abstract
Sphincteroplasty (SP) is the operation most frequently performed in patients suffering from moderate-to-severe anal incontinence (AI) who do not respond to conservative treatment. Other costly surgeries, such as artificial bowel sphincter (ABS) and electro-stimulated graciloplasty, have been more or less abandoned due to their high morbidity rate. Minimally invasive procedures are widely used, such as sacral neuromodulation and injection of bulking agents, but both are costly and the latter may cure only mild incontinence. The early outcome of SP is usually good if the sphincters are not markedly denervated, but its effect diminishes over time. SP is more often performed for post-traumatic than for idiopathic AI. It may also be associated to the Altemeier procedure, aimed at reducing the recurrence rate of rectal prolapse, and may be useful when AI is due either to injury to the sphincter, or to a narrowed rectum following the procedure for prolapse and haemorrhoids (PPH) and stapled transanal rectal resection (STARR). The outcome of SP is likely to be improved with biological meshes and post-operative pelvic floor rehabilitation. SP is more effective in males than in multiparous women, whose sphincters are often denervated, and its post-operative morbidity is low. In conclusion, SP, being both low-cost and safe, remains a good option in the treatment of selected patients with AI.
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Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery 2013; 155:659-67. [PMID: 24508117 DOI: 10.1016/j.surg.2013.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 11/26/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined. METHODS A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management. RESULTS Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15). CONCLUSION Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.
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Affiliation(s)
- Caitlin W Hicks
- Department of Surgery, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA; Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Milena Weinstein
- Department of Gynecology, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - May Wakamatsu
- Department of Gynecology, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - Lieba Savitt
- Department of Surgery, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - Samantha Pulliam
- Department of Gynecology, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA
| | - Liliana Bordeianou
- Department of Surgery, Pelvic Floor Disorders Service, Massachusetts General Hospital, Boston, MA.
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Zhang B, Ding JH, Zhao YJ, Zhang M, Yin SH, Feng YY, Zhao K. Midterm outcome of stapled transanal rectal resection for obstructed defecation syndrome: A single-institution experience in China. World J Gastroenterol 2013; 19:6472-6478. [PMID: 24151367 PMCID: PMC3801319 DOI: 10.3748/wjg.v19.i38.6472] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 08/13/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess midterm results of stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS) and predictive factors for outcome.
METHODS: From May 2007 to May 2009, 75 female patients underwent STARR and were included in the present study. Preoperative and postoperative workup consisted of standardized interview and physical examination including proctoscopy, colonoscopy, anorectal manometry, and defecography. Clinical and functional results were assessed by standardized questionnaires for the assessment of constipation constipation scoring system (CSS), Longo’s ODS score, and symptom severity score (SSS), incontinence Wexner incontinence score (WS), quality of life Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QOL), and patient satisfaction visual analog scale (VAS). Data were collected prospectively at baseline, 12 and 30 mo.
RESULTS: The median follow-up was 30 mo (range, 30-46 mo). Late postoperative complications occurred in 11 (14.7%) patients. Three of these patients required procedure-related reintervention (one diverticulectomy and two excision of staple granuloma). Although the recurrence rate was 10.7%, constipation scores (CSS, ODS score and SSS) significantly improved after STARR (P < 0.0001). Significant reduction in ODS symptoms was matched by an improvement in the PAC-QOL and VAS (P < 0.0001), and the satisfaction index was excellent in 25 (33.3%) patients, good in 23 (30.7%), fairly good in 14 (18.7%), and poor in 13 (17.3%). Nevertheless, the WS increased after STARR (P = 0.0169). Incontinence was present or deteriorated in 8 (10.7%) patients; 6 (8%) of whom were new onsets. Univariate analysis revealed that the occurrence of fecal incontinence (preoperative, postoperative or new-onset incontinence; P = 0.028, 0.000, and 0.007, respectively) was associated with the success of the operation.
CONCLUSION: STARR is an acceptable procedure for the surgical correction of ODS. However, its impact on symptomatic recurrence and postoperative incontinence may be problematic.
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Reginelli A, Di Grezia G, Gatta G, Iacobellis F, Rossi C, Giganti M, Coppolino F, Brunese L. Role of conventional radiology and MRi defecography of pelvic floor hernias. BMC Surg 2013; 13 Suppl 2:S53. [PMID: 24267789 PMCID: PMC3851064 DOI: 10.1186/1471-2482-13-s2-s53] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background Purpose of the study is to define the role of conventional radiology and MRI in the evaluation of pelvic floor hernias in female pelvic floor disorders. Methods A MEDLINE and PubMed search was performed for journals before March 2013 with MeSH major terms 'MR Defecography' and 'pelvic floor hernias'. Results The prevalence of pelvic floor hernias at conventional radiology was higher if compared with that at MRI. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on conventional radiology than on MRI, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at conventional radiology was significantly higher than that at MRI. Conclusions MRI shows lower sensitivity than conventional radiology in the detection of pelvic floor hernias development. The less-invasive MRI may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.
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Guraya SY, Khairy GA. Stapled hemorrhoidectomy; results of a prospective clinical trial in saudi arabia. J Clin Diagn Res 2013; 7:1949-52. [PMID: 24179906 DOI: 10.7860/jcdr/2013/6995.3367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 08/13/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study was designed to evaluate the effectiveness of stapled hemorrhoidectomy (SH) in terms of cure of the symptoms and post-operative pain control. MATERIAL AND METHODS In this prospective clinical study, SH (Ethicon Endo-surgery, Cincinnati, OH) was performed for all patients with grade III and grade IV hemorrhoids, presenting to the surgical clinics of Ohud and Meeqat Hospitals Almadinah Almunawwarah Saudi Arabia. The results of SH were evaluated by a questionnaire focusing on the relief of symptoms, severity of post operative pain, and complications of SH. RESULTS Thirty patients (21 males and 9 females); with a mean age of 39.6 years were recruited in this study. Twenty six (86%) patients had grade III and 4 (14%) presented with grade IV hemorrhoids. Perianal prolapse was the most frequent presentation reported in 23 (76%). Mean operating time was 21.7 minutes (range; 17-36 minutes) whereas mean hospital stay was 1.9 days. Post-operative pain was tolerable (non-persistent) in 28 (93%) cases whereas 2 (7%) experienced mild pain requiring additional analgesia. Urinary retention was the most common complication found in 5 (16%) patients. All patients were cured of the hemorrhoids Conclusion: SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoepative pain, and early discharge from the hospital.
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Affiliation(s)
- Salman Yousuf Guraya
- Professor, Department of Surgery, College of Medicine Taibah University , Almadinah Almunawwarah Saudi Arabia
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32
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Abstract
The transanal operative procedure for the treatment of obstructive defecation syndrome (ODS) can be secondarily applied in cases of failure or ineffectiveness of conservative treatment. Clinically established transanal procedures are rectocele resection (RR), mucosectomy for internal rectal prolapse according to the Rehn-Delorme procedure (MR) and stapled transanal rectal resection (STARR Contour Transtar). Only few studies have indicated the value of RR and MR in the treatment of obstructive diseases and in general study quality and evidence level are low. There might be an indication in rectocele-associated symptoms, such as incomplete evacuation, straining and digitation. In contrast the STARR procedure has been well characterized by a large number of high quality studies providing an elevated evidence level for the treatment of ODS. Functional results are available with a follow-up of 1 year up to 68 months postoperatively. Response rates of up to 90% were reported whereas recurrence rates were given as a maximum of 18% at 68 months follow-up. In summary the STARR procedure provides good functional results for conservative refractory outlet obstruction with minor morbidity and outcome seems to remain stable in the long-term follow-up.
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Affiliation(s)
- C Isbert
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Zentrum Operative Medizin, Würzburg.
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Hicks CW, Weinstein M, Wakamatsu M, Pulliam S, Savitt L, Bordeianou L. Are rectoceles the cause or the result of obstructed defaecation syndrome? A prospective anorectal physiology study. Colorectal Dis 2013; 15:993-9. [PMID: 23527537 DOI: 10.1111/codi.12213] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 11/11/2012] [Indexed: 12/12/2022]
Abstract
AIM To determine the relationship between obstructed defaecation syndrome (ODS) and rectoceles. METHOD From December 2007 to November 2011, all female patients with ODS were prospectively evaluated with full interview, clinical examination and anorectal physiology testing. The characteristics of patients with and without rectoceles were compared, and logistic regression was utilized to identify factors predictive of patients having a rectocele beyond the introitus. RESULTS Of 239 patients with ODS, 90 (mean age: 52.3 ± 1.7 years) had a rectocele. Patients with rectoceles (R+) had a similar prevalence of incomplete emptying compared with patients with no rectocele (R-) (P ≥ 0.21), but only R+ patients reported splinting with defaecation (36.7% vs 0%; P < 0.0001). Anorectal manometry measurements, including mean resting pressure, maximum resting pressure and maximum squeeze pressure, were similar between groups (P ≥ 0.12). There were also no significant differences in rectal compliance (maximum tolerated volume) or rectal sensitivity (volume of first sensation) (P ≥ 0.65). R+ patients had greater difficulty expelling a 60 cm(3) balloon (70.1% R+ patients vs 57.5% R- patients; P = 0.05), but the prevalence of pelvic floor dyssynergia, as quantified by nonrelaxation on electromyography (EMG) testing, was similar to that of R- patients (P = 0.49). Logistic regression suggested that only difficulty with balloon expulsion was associated with higher odds of having a rectocele (OR = 3.00; P = 0.002), whereas mean resting pressure, EMG nonrelaxation and symptoms of incomplete emptying were not (P ≥ 0.12). CONCLUSION Rectoceles are not associated with an increased severity of ODS-type symptoms, anorectal abnormalities or pelvic floor dyssynergia in patients with ODS. This suggests that rectoceles may be the result, rather than the cause, of ODS.
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Affiliation(s)
- C W Hicks
- Department of Surgery, Massachusetts General Hospital Pelvic Floor Disorders Service, Boston, MA, USA
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2013. [PMID: 23049207 DOI: 10.3748/wjg.v] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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Adams K, Papagrigoriadis S. Stapled transanal rectal resection (STARR) for obstructive defaecation syndrome: patients with previous pelvic floor surgery have poorer long-term outcome. Colorectal Dis 2013; 15:477-80. [PMID: 23057812 DOI: 10.1111/codi.12054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 05/01/2012] [Indexed: 12/24/2022]
Abstract
AIM Stapled transanal rectal resection (STARR) is used for patients with obstructive defaecation syndrome (ODS) not responding to conservative management. Reports indicate mixed results and there are no studies publishing the long-term outcome. METHOD Following full investigation, 37 patients with ODS underwent a STARR procedure by one of the authors (SP) between 2005 and 2010. RESULTS The median (range) patient age was 53.0 (28-79) years and all were female. Median (range) follow up was 13 (0-57) months, and nine (24.3%) patients were followed for longer than 24 months. Eighteen patients had undergone at least one (and often multiple) previous gynaecological procedures, including hysterectomy (n = 14), colposuspension (n = 3), vaginal rectocele repair (n = 4) and pelvic floor repair (n = 5). Four patients had had at least one previous rectal operation [stapled anopexy (n = 3) and Delorme's procedure (n = 2)]. One patient did not attend for postoperative follow up. Of the remaining 36 patients, 18 had resolution of obstructive symptoms. Of the 18 with residual symptoms, 17 eventually reported the same level of symptoms as before the STARR procedure. There was a significant correlation between the presence of residual symptoms and long-term ODS recurrence (P < 0.0005). For those with residual symptoms, the mean (95% CI) time to symptom recurrence was 3 (2.86-11.81) months. Twenty (56%) patients were satisfied with the outcome from the STARR procedure. CONCLUSION Residual symptoms are a strong indicator of long-term failure. STARR was effective for symptom resolution in 50% of patients. Those who had undergone pelvic floor or rectal prolapse surgery were significantly more likely to experience recurrent symptoms.
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Affiliation(s)
- K Adams
- Department of Colorectal Surgery, King's College Hospital, London, UK.
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Clinical outcome after stapled transanal rectal resection for obstructed defecation syndrome: the first Iranian experience. Eur Surg 2013. [DOI: 10.1007/s10353-013-0189-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Masoni L, Mari FS, Favi F, Gasparrini M, Cosenza UM, Pindozzi F, Pancaldi A, Brescia A. Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity. Dis Colon Rectum 2013; 56:113-119. [PMID: 23222288 DOI: 10.1097/dcr.0b013e31826bda94] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS The entire study was conducted at a university hospital. PATIENTS : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.
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Affiliation(s)
- Luigi Masoni
- Department of Medical-Surgical Sciences and Translational Medicine, St. Andrea Hospital, School of Medicine and Psychology, University Sapienza of Rome, Rome, Italy
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Pescatori M. Troubleshooting the Starr Procedure. RECONSTRUCTIVE SURGERY OF THE RECTUM, ANUS AND PERINEUM 2013:305-313. [DOI: 10.1007/978-1-84882-413-3_27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M. German S3-Guideline: rectovaginal fistula. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2012; 10:Doc15. [PMID: 23255878 PMCID: PMC3525883 DOI: 10.3205/000166] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Indexed: 12/12/2022]
Abstract
Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. Methods: A systematic review of the literature was undertaken. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment). World J Gastroenterol 2012; 18:4994-5013. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/17/2011] [Accepted: 08/15/2012] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2012. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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Boenicke L, Kim M, Reibetanz J, Germer CT, Isbert C. Stapled transanal rectal resection and sacral nerve stimulation - impact on faecal incontinence and quality of life. Colorectal Dis 2012; 14:480-9. [PMID: 21689328 DOI: 10.1111/j.1463-1318.2011.02648.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM The aim of the study was to assess the impact of stapled transanal rectal resection (STARR) on pre-existing faecal incontinence and quality of life in patients suffering from obstructive defaecation syndrome (ODS) and to evaluate the efficiency of sequential sacral nerve stimulation (SNS) for improvement of persistent incontinence after STARR. METHOD Thirty-one patients with ODS and major faecal incontinence prior to STARR were prospectively enrolled. The outcome was measured using the Cleveland Clinic Constipation and Incontinence score (CCS, CCIS), Faecal Incontinence Qualities-of-Life Index (FIQL), Patient Assessment of Constipation Quality-of-Life (PAC-QOL) and EuroQol visual analogue scale (EQ-VAS). RESULTS The overall levels of constipation (CCS from 13.1 ± 3.8 to 6.2 ± 5.4; P < 0.001) and incontinence (CCIS from 12.6 ± 3.2 to 9.4 ± 5.1; P = 0.005) were significantly improved after STARR; concordantly, the global and specific quality of life were significantly improved. Following postoperative constipation and incontinence, three different groups of patients were differentially referred to SNS. In group I (n = 16, 52%), both constipation (CCS from 12.6 ± 4.0 to 3.6 ± 1.9; P < 0.001) and incontinence (CCSI from 12.43 ± 3.2 to 5.1 ± 1.9; P < 0.001) were improved. In group II (n = 8, 25%), only constipation was improved (CCS from 12.3 ± 2.3 to 3.3 ± 2.2; P < 0.001), while incontinence persisted (CCIS from 12.8 ± 2.9 to 13.1 ± 3.1; P > 0.05). In group III (n = 7, 23%) there was no improvement at all. Sacral nerve stimulation was successfully carried out in six (85%) of seven patients in group II (post-SNS CCSI 6.1 ± 1.7; P = 0.01) but failed in five of five patients in group III. CONCLUSION Stapled transanal rectal resection improves quality of life in ODS patients with both severe constipation and faecal incontinence. Sacral nerve stimulation may efficiently improve persisting incontinence after STARR in selected patients.
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Affiliation(s)
- L Boenicke
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital Würzburg, Würzburg, Germany.
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Hasan HM, Hasan HM. Stapled transanal rectal resection for the surgical treatment of obstructed defecation syndrome associated with rectocele and rectal intussusception. ISRN SURGERY 2012; 2012:652345. [PMID: 22577584 PMCID: PMC3346690 DOI: 10.5402/2012/652345] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 01/19/2012] [Indexed: 12/22/2022]
Abstract
Obstructed defecation syndrome (ODS) is one of the most widespread clinical problems which frequently affects middle-aged females. There is a new surgical technique called stapled transanal rectal resection (STARR) that makes it possible to remove the anorectal mucosa circumferential and reinforce the anterior anorectal junction wall with the use of a circular stapler. This surgical technique developed by Antonio Longo was proposed as an effective alternative for the treatment of ODS. In this study we present our preliminary results with the STARR operation for the treatment of ODS. For this purpose, 40 consecutive female patients with ODS due to rectal intussusception (RI) and/or rectocele (RE) were recruited in this prospective clinical study, from May 2008 to October 2010. No major operative or postoperative complications were recorded, and after 12-month follow-up, significant improvement in the ODS score system was observed, and the symptoms of constipation improved in 90% of patients; 20% of patients judged their final clinical outcome as excellent, 55% as good, and 15% as moderate, with only 10% having poor results. After analyzing our results we can conclude that STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception and/or rectocele and can be performed safely without major morbidity.
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Affiliation(s)
- Hesham M Hasan
- Department of General Surgery, Ain Shams University, Cairo, Egypt
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45
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Zorcolo L, Giordano P, Zbar AP, Wexner SD, Seow-Choen F, Occelli GL, Casula G. The Italian Society of Colo-Rectal Surgery Annual Report 2010: an educational review. Tech Coloproctol 2012; 16:9-19. [PMID: 22278408 DOI: 10.1007/s10151-012-0804-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- L Zorcolo
- Department of Surgery, Colorectal Unit, University of Cagliari, Cagliari, Italy
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Boenicke L, Reibetanz J, Kim M, Schlegel N, Germer CT, Isbert C. Predictive factors for postoperative constipation and continence after stapled transanal rectal resection. Br J Surg 2012; 99:416-22. [PMID: 22237693 DOI: 10.1002/bjs.7837] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although stapled transanal rectal resection (STARR) has become an important surgical option in the treatment of obstructive defaecation syndrome, objective data about parameters that predict its success or failure are not yet available. METHODS Medical history, clinical and radiomorphological data were obtained prospectively from a multi-institutional STARR registry. Predictive factors for postoperative constipation (Cleveland Clinic Constipation Score, CCS) and incontinence (Cleveland Clinic Incontinence Score, CCIS) were identified using univariable and multivariable analysis. RESULTS Data were obtained for 181 of 201 patients in the STARR registry, with completed median follow-up of 19·4 (range 12-41) months. Although the CCS decreased significantly overall (from mean(s.d.) 16·3(4·9) to 6·7(4·1); P < 0·001), 31 patients (17·1 per cent) complained about persisting constipation. CCIS levels remained unchanged overall, but 16 patients (8·8 per cent) had new-onset faecal incontinence. Multivariable analysis revealed that rectocele (β = -0·302, P < 0·001) and intussusception (β = -0·392, P < 0·001) were independent predictors of low CCS levels, and intussusception (β = -0·216, P = 0·001) and enterocele (β = -0·171, P = 0·012) were independent predictors of low CCIS levels. In contrast, small rectal diameter (β = -0·293, P < 0·001), low squeeze pressure (β = -0·188, P = 0·005) and increased pelvic floor descent at rest (β = 0·264, P < 0·001) predicted high CCIS levels. CONCLUSION Factors for a favourable outcome after STARR included rectocele, intussusception and enterocele, whereas small rectal diameter, low sphincter pressure and increased pelvic floor descent were unfavourable. These findings should be integrated into the therapy algorithm for STARR.
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Affiliation(s)
- L Boenicke
- Department of General, Visceral, Vascular and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
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Schwandner O. Indikationen und chirurgische Therapieoptionen beim obstruktiven Defäkationssyndrom. VISZERALMEDIZIN 2012. [DOI: 10.1159/000341787] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Pescatori M. Obstructed Defecation (OD) and Related Diseases. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:135-163. [DOI: 10.1007/978-88-470-2077-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Jiang C, Ding Z, Wang M, Yang G, Situ G, Wu Y, Zheng K, Tang S, Liu Z, Qian Q. A transanal procedure using an endoscopic linear stapler for obstructed defecation syndrome: the first Chinese experience. Tech Coloproctol 2011; 16:21-7. [PMID: 22116398 DOI: 10.1007/s10151-011-0789-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 11/03/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Transanal surgery using an endoscopic linear stapler is a recognized, but not widely performed technique for the treatment of obstructed defecation syndrome (ODS). A study of consecutive patients was conducted to evaluate the safety and effectiveness of the technique for the treatment of ODS in Chinese patients. METHODS From November 2008 to December 2010, 43 female patients with ODS caused by rectocele and/or rectal intussusception underwent transanal surgery using an endoscopic linear stapler in three Chinese hospitals. Clinical and functional data including the Wexner constipation score and outcome classification were analyzed retrospectively. RESULTS The average duration of surgery was 23 ± 4 min (range 15-30 min). Blood loss was 10 ± 2 ml (range 5-15 ml). The average postoperative hospital stay was 5 days (range 4-6 days). The pathologic findings showed that the specimen contained rectal muscle in all patients. Postoperative complications included 4 patients with transient fecal urgency, 3 patients with anorectal pain, and one patient with mild bleeding from the stapled suture line. Three patients reported minor fecal incontinence (Wexner score less than 3). During a median follow-up of 12 months (range, 3-26 months), the mean constipation score improved from preoperative 13.56 to postoperative 5.07 at 1 year (P < 0.05). The outcome at 1 year was excellent in 18 of 43 patients, good in 13, fairly good in 7, and poor in 5. Postoperative defecography was performed in 28 patients. Rectocele disappeared in 15 patients. Rectocele depth was reduced from 34 ± 4 mm preoperatively to 17 ± 3 mm postoperatively (P < 0.05). CONCLUSION The transanal procedure using an endoscopic linear stapler is an easy, safe, and effective option for selected patients with ODS. Long-term prospective, randomized, controlled studies are needed to confirm the advantages of this procedure in comparison with the traditional transanal and stapled transanal rectal resection (STARR) techniques.
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Affiliation(s)
- C Jiang
- Department of Colorectal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
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Biviano I, Badiali D, Candeloro L, Habib FI, Mongardini M, Caviglia A, Anzini F, Corazziari ES. Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders. World J Gastroenterol 2011; 17:4199-205. [PMID: 22072851 PMCID: PMC3208364 DOI: 10.3748/wjg.v17.i37.4199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/04/2011] [Accepted: 03/11/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To prospectively assess the efficacy and safety of stapled trans-anal rectal resection (STARR) compared to standard conservative treatment, and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR.
METHODS: Thirty patients (Female, 28; age: 51 ± 9 years) with rectocele or rectal intussusception, a defecation disorder, and functional constipation were submitted for STARR. Thirty comparable patients (Female, 30; age 53 ± 13 years), who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol, were assessed. Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment. A responder was defined as an absence of the Rome III diagnostic criteria for functional constipation. Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients, respectively.
RESULTS: After STARR, 53% of patients were responders; during conservative treatment, 75% were responders. After STARR, 30% of the patients reported the use of laxatives, 17% had intermittent anal pain, 13% had anal leakage, 13% required digital facilitation, 6% experienced defecatory urgency, 6% experienced fecal incontinence, and 6% required re-intervention. During macrogol therapy, 23% of the patients complained of abdominal bloating and 13% of borborygmi, and 3% required digital facilitation.No preoperative symptom, defecographic, or manometric finding predicted the outcome of STARR. Post-operative defecography showed a statistically significant reduction (P < 0.05) of the rectal diameter and rectocele. The post-operative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified, and that rectal compliance was reduced (P = 0.01).
CONCLUSION: STARR is not better and is less safe than macrogol in the treatment of defecation disorders. It could be considered as an alternative therapy in patients unresponsive to macrogol.
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