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PubMed2006

Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial.

PURPOSE: A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse. METHODS: Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography. RESULTS: At a mean follow-up of 8.1+/-2.0 and 7.9+/-1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p=0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p=0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p=0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p=0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse. CONCLUSIONS: STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.

Anal Canal↗
PubMed1996

Vaginal repair of rectocele after dynamic graciloplasty for fecal incontinence due to imperforate anus.

A 35-years-old woman developed obstructed defecation due to a large (6 cm) non-emptying rectocele one year after successful electrostimulated gracilis neosphincter operation for correction of fecal incontinence after surgery for imperforate anus. Surgical correction of the rectocele was performed by a trans-vaginal approach due to the poor elasticity of the neoanus and avoidance of possible damage to the neosphincter. After physiological investigations, including defecography, the patient had a resection of the posterior vaginal mucosal wall, a double layer plication of the muscular wall with non-absorbable suture and a longitudinal mucosal suture. The postoperative course was uneventful. Defecography, performed 3 and 6 months later, showed a marked reduction of the rectocele (2 cm) which corresponded to clinical improvement. Occurrence of disabling rectocele can be considered a possible long term complication after successful electrostimulated neosphincter procedure in patients at risk for developing a rectocele; a successful repair can be obtained using trans-vaginal approach without the risk of neosphincter damage. Transvaginal repair of rectocele in similar clinical situations may be recommended.

Adult↗
PubMed1999

A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment.

The management of rectal internal mucosal prolapse (RIMP) is not based on an accepted classification of the lesion which helps to choose the appropriate treatment. The aim of this prospective study was to report a new endoscopic grading of RIMP and to evaluate its clinical value. Thirty-two patients (7 men, 25 women; mean age 56 years, range 28-72) affected by symptomatic RIMP were prospectively classified as follows: RIMP was defined as first degree when detectable below the anorectal ring on straining, as second degree when it reached the dentate line, and as third degree when it reached the anal verge. Anal manometry was carried out in 26 patients, and anal ultrasound and defecography in 6 prior to surgery. A correlation was found between the occurrence and severity of symptoms and the degree of the prolapse as obstructed defecation, bleeding and fecal soiling affected mainly patients with third-degree RIMP. At manometry the maximal resting tone was 60+/-23 mm Hg and voluntary contraction 96+/-41 mm Hg (mean+/-SEM). At anal ultrasound the mean internal sphincter thickness was 2.1+/-0.2 mm, and external sphincter thickness was 7.0+/-0.8 mm. A significant rectocele and rectal intussusception (n = 2) and a nonrelaxing puborectalis muscle on straining (n = 2) were observed at defecography in cases with third-degree RIMP. The anorectal angle was 100+/-75 degrees at rest, 63+/-20 degrees on squeezing, and 115+/-9 degrees on straining. A conservative treatment with high-fiber diet and/or rubber band ligation was carried out in all cases of first and in most patients with second-degree RIMP (n = 26). Those who required surgery, i.e., stapled transanal excision of the prolapse (n = 6), had either severely symptomatic third-degree RIMP with solitary ulcer syndrome (n = 4) or second-degree RIMP (n = 2). A positive outcome was achieved in 71% of cases. The proposed classification evaluated by the present study may be of clinical value in managing rectal internal mucosal prolapse.

Adult↗
PubMed2004

One-year follow-up study on the effects of electrogalvanic stimulation in chronic idiopathic constipation with pelvic floor dyssynergia.

BACKGROUND: Constipation is a commonly reported symptom, and pelvic floor dyssynergia is frequently documented in constipated patients. The standard therapeutic approach for pelvic floor dyssynergia is biofeedback training, but long-term studies show that a significant percentage of patients remain symptomatic. Alternative or adjunctive therapeutic options are needed. AIMS: The purpose of this study was to evaluate the long-term effects of electrogalvanic stimulation in patients with pelvic floor dyssynergia and severe constipation, to see whether this treatment may be of some benefit. PATIENTS AND METHODS: Thirty consecutive constipated patients with clinical and instrumental evidence of pelvic floor dyssynergia entered the study and were treated with a standard high-frequency galvanic electrostimulation protocol. Clinical and instrumental (colon transit time, anorectal manometry, defecography, rectal balloon expulsion) assessment evaluations were performed basally and one year after the treatment. RESULTS: Overall, approximately 50 percent of patients showed significant improvement after electrogalvanic treatment, from both a clinical and an instrumental point of view, as shown by the objective measurements obtained through manometry, defecography, and the balloon expulsion test. The benefit was limited to normal transit constipation patients. CONCLUSIONS: Because of the relatively simple, painless and effective nature of electrogalvanic stimulation, we concluded that it may represent a useful adjunct to the therapeutic armamentarium for pelvic floor dyssynergia in normal transit constipation.

Adult↗
PubMed2004

Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial.

PURPOSE: This prospective, multicenter trial was designed to assess the safety and effectiveness of a novel technique in the treatment of outlet obstruction caused by the combination of intussusception and rectocele by using a double-transanal, 33-mm circular stapler. METHODS: From January to October 2001, 90 patients with outlet obstruction were operated on and followed (mean, 16.3 +/- 2.9 months) by the validated Constipation Scoring and Continence Grading Systems, clinical examination, defecography, and anorectal manometry. Anal ultrasound also was performed in 58 multiparous patients. RESULTS: Operative time and hospital stay were short (mean, 43.3 +/- 8.7 minutes and 2.1 +/- 0.8 days, respectively), and postoperative pain was minimal. The mean time to resume normal activity was 10.2 +/- 4.5 days. Complications were 17.8 percent fecal urgency, 8.9 percent incontinence to flatus, 5.5 percent urinary retention, 4.4 percent bleeding, 3.3 percent anastomotic stenosis, and 1.1 percent pneumonia. All constipation symptoms significantly improved (P < 0.001) without worsening of anal continence. No patient complained of dyspareunia. At postoperative defecography, all patients had a double incisure of the lower rectal outline in the site of anastomosis, with the disappearance of both intussusception and rectocele. Anal pressure was not significantly modified, whereas rectal compliance was restored (P < 0.05). No lesions of anal sphincters caused by the operation were found in multiparous patients. The outcome at one year was excellent in 48 of 90 patients, good in 33, fairly good in 5, and poor in 4. CONCLUSIONS: This novel technique seems to be safe and effective in the treatment of outlet obstruction caused by the combination of intussusception and rectocele. Randomized trials are required to confirm these findings.

Adult↗
PubMed2004

Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study.

PURPOSE: This study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair. METHODS: Thirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded. RESULTS: The study groups were comparable in terms of demographic factors and rectocelerelated symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 +/- 1.6 cm vs. 5.6 +/- 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement. CONCLUSION: Patients' symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.

Adult↗
PubMed2006

Stapled transanal rectal resection under laparoscopic surveillance for rectocele and concomitant enterocele.

PURPOSE: Stapled transanal rectal resection recently became a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential threat to structures located in front of the anterior rectal wall. We decided to perform a combined procedure of transanal rectal resection with a simultaneous laparoscopy for patients with obstructed defecation syndrome and an enterocele. METHODS: Between November 2002 and May 2005 a total of 41 patients were treated surgically for obstructed defecation syndrome. Four patients with concomitant enterocele underwent stapled transanal rectal resection under laparoscopic surveillance. Before surgery all patients underwent preoperative assessment, including clinical examination, colonoscopy, conventional video defecography, dynamic magnetic resonance imaging defecography, gynecology examinations, and psychologic evaluation. RESULTS: The mean operative time was 50 (+/-16.5) minutes for the conventional stapled transanal rectal resection and 67 (+/-14.1) minutes for combined laparoscopy and stapled transanal rectal resection (P < 0.01). Three major complications were observed: two had bleeding in the staple line (one from each group) and one had a late abscess in the staple line. CONCLUSIONS: The combination of the stapled transanal rectal resection procedure and laparoscopy provides the opportunity to perform transanal rectal resection without the threat of intra-abdominal lesions caused by enterocele.

Digestive System Surgical Procedures↗
PubMed2001

Outlet Dysfunction Constipation.

The diagnosis of outlet dysfunction constipation in patients with idiopathic constipation that responds poorly or not at all to conservative measures, such as fiber supplements, fluids, and stimulant laxatives, is based upon diagnostic testing. These tests include colonic transit of radio-opaque markers, anorectal manometry or electromyography, barium defecography, and expulsion of a water-filled balloon. The literature suggests that conditions such as pelvic floor dyssynergia exist but may be over-diagnosed as a laboratory artifact. In our laboratory, we screen patients with balloon expulsion studies, and then test for dyssynergia only if the result of the balloon expulsion test is abnormal. In my opinion, anal sphincter electromyogram and manometry are equivalent in establishing the diagnosis. Barium defecography is helpful in making a diagnosis of a rectocele, but I prefer to document that vaginal pressure on the rectocele significantly improves rectal evacuation. Manometry also helps to establish the presence of megarectum, hypotonia, and weak expulsion efforts. Conceptually, biofeedback training, which incorporates simulated defecation, is the most logical approach to pelvic floor dyssynergia. It incurs no risk and benefits 60% to 80% of patients. The drawbacks are the time-intensive nature of the therapy and the short-term costs, which are offset if there is sustained benefit. There is no evidence that biofeedback is helpful in children with constipation. Habit training has established benefits, but recurrences are frequent and long-term reinforcement is helpful to maintain success. Laxatives and enemas are adjunctive therapies in both habit training and biofeedback. Surgery is effective in those uncommon patients with physiologically significant rectoceles, but surgical division of the puborectalis muscle is risky and unproven. Likewise, botulinum toxin injection into the puborectalis is unproven, but the effects are rarely permanent should incontinence occur. Diagnostic measures and therapeutic success are enhanced when patients are seen in centers experienced with the evaluation of these disorders.

Journal Article↗
PubMed2005

Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children.

BACKGROUND: The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children. METHODS: Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children. RESULTS: The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders (P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3 degrees +/- 15.1 degrees vs 84.7 degrees +/- 8.3 degrees vs 79.0 degrees +/- 11.6 degrees, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6 degrees +/- 15.9 degrees vs 111.0 degrees +/- 14.3 degrees, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 +/- 8.2 vs >188 hours, P < .01; 6.3 +/- 4.1 vs >60 hours, P < .01; 11.8 +/- 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 +/- 5.6 vs 28.1 +/- 10.1 hours, P < .05; 12.2 +/- 6.7 vs 9.8 +/- 4.0 hours, P < .05). CONCLUSIONS: The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the "neorectosigmoid", an open and fixed anorectal angle, and ischemia of the pull-through segment.

Adolescent↗
PubMed2003

[Which functional diagnostic tools do German coloproctologists favour?].

AIM: We tried to evaluate the role of anorectal functional diagnostic tools according to the judgement of German coloproctologists. METHOD: Questionnaires concerning accuracy of different diagnostic tests were sent to 585 physicians specialized in coloproctology. RESULTS: 261 (44.6 %) completed forms were returned. An analysis of the answers revealed that endorectal sonography is widely (73 %) regarded as useful and reliable diagnostic tool. Though manometry is still frequently used, only 50.5 % of the coloproctologists made their decision concerning the further treatment depending on the results of this method. Other radiologic methods as defecography and colon transit time are still regularly performed, though video-defecography is not accepted by most coloproctologists. Neurological investigations as pudendal nerve terminal latency, surface-EMG and needle-EMG are exclusively applied in specialized departments. DISCUSSION: Regarding the variety of diagnostic tools and its different appraisal a consensus should be defined. The usefulness of neurological examination techniques needs to be clarified before their performance can be recommended for a wide-spread routine work up.

Colonic Diseases↗
PubMed2004

Diagnostic features and treatment modalities in solitary rectal ulcer syndrome.

Solitary rectal ulcer syndrome (SRUS) is a traumatic lesion of the anterior or circular rectal wall caused by straining due to functional disorders of defecation. Defecography, transrectal ultrasonography or anorectal manometry are suitable procedures that may be used to detect the causative disorder and should, therefore, be performed in patients with solitary rectal ulcer syndrome. Histopathological features of SRUS are characteristic and pathognomonic, nevertheless the endoscopic and clinical presentations may be confusing. The lesions may mimic other rectal pathologies and lead to wrong diagnosis. We retrospectively evaluated 34 patients with SRUS who had various treatments. Rectosigmoidoscopy, defecography, transrectal ultrasonography and anorectal manometry were performed for evaluation of cases. The operative management was rectopexy in 26 patients, rectal mucosectomy in 4 patients, segmental colonic resection in 2 patients, local excision in 1 patient and colostomy in 1 patient. Total regression and healing of the ulcer occurred in 32 of 34 patients. Partial regression of symptoms in 2 patients, who underwent rectopexy and rectal mucosectomy, occurred, but we could not get complete healing.

Adult↗
PubMed2006

Update of tests of colon and rectal structure and function.

This review deals with the indications, methods, strengths, and limitations of anorectal testing in clinical practice. In chronic constipation, anal manometry and a rectal balloon expulsion test, occasionally supplemented by defecography, are useful to identify a functional defecatory disorder, because symptoms may respond to pelvic floor retraining. In patients with fecal incontinence, diagnostic testing complements the clinical assessment for evaluating the pathophysiology and guiding management. Manometry measures anal resting and squeeze pressures, which predominantly reflect internal and external anal sphincter function, respectively. Defecation may be indirectly assessed by measuring the recto-anal pressure gradient during straining and by the rectal balloon expulsion test. Endoanal ultrasound and magnetic resonance imaging (MRI) can identify anal sphincter structural pathology, which may be clinically occult, and/or amenable to surgical repair. Only MRI can identify external sphincter atrophy, whereas ultrasound is more sensitive for internal sphincter imaging. By characterizing rectal evacuation and puborectalis contraction, barium defecography may demonstrate an evacuation disorder, excessive perineal descent or a rectocele. Dynamic MRI can provide similar information and also image the bladder and genital organs without radiation exposure. Because the measurement of pudendal nerve latencies suffers from several limitations, anal sphincter electromyography is recommended when neurogenic sphincter weakness is suspected.

Anal Canal↗
PubMed1998

Transsacral rectopexy for complete rectal prolapse.

A prospective study was carried out to analyze the clinical and functional results of transsacral rectopexy with a DEXON mesh in the elderly or poor risk patients with complete rectal prolapse. Six patients with complete rectal prolapse were operated from 1994 to 1996. All patients could be traced for examination with anorectal manometry and defecography. None of the patients had recurrence for the longest three years. In postoperative clinical symptoms, fecal incontinence score recovered from the preoperative mean score of 3.8 to the postoperative 1.2 and constipation was improved in 4 out of 5 cases (80.0%). Straining anorectal angle (S-ARA) by defecography improved from the preoperative value of 120.6 +/- 6.9 degrees to the postoperative value of 98.5 +/- 3.5 degrees (p < 0.05) and the perineal descent (PD) improved from the preoperative value of 16.2 +/- 2.5 cm to the postoperative value 8.1 +/- 1.3 cm (p < 0.05). Maximal resting pressure (MRP) increased from the preoperative value of 20.5 +/- 3.7 cmH2O to the postoperative value of 40.5 +/- 4.8 cmH2O (p < 0.05). Transsacral rectopexy with DEXON mesh for complete rectal prolapse is useful as this technique is simple to conduct, can be applied to the elderly or poor risk patients, replaces rectal prolapse, improves defecation troubles and recovers fecal incontinence.

Aged↗
PubMed1990

Clinical indications for anorectal function investigations.

Interest in anorectal function investigation tests has increased, and new investigation techniques have been introduced, gaining new insight in the pathogenesis of fecal incontinence and constipation. Normal values in anorectal function tests have shown a large overlap between controls and patients with fecal incontinence or constipation. Therefore, the pure clinical indications for the individual anorectal function tests are small, and the strength comes from combining these test results. When the patient is not eligible for surgery or biofeedback, there is no indication to perform anorectal function tests. Guidelines for selective use of anorectal function tests are given. In patients with fecal incontinence, the clinical consequence of demonstrating severe pudendal neuropathy is not yet clear. Defecography is important to demonstrate an intussusception as a treatable cause of incontinence. In patients with constipation an anal EMG (of defecography) can diagnose the spastic pelvic floor syndrome, which should be treated with relaxation exercises or biofeedback. Patients with other anorectal diseases, patients receiving a stoma, and patients considered for reanastomosis operation after (partial) colectomy may benefit from anorectal function tests.

Anal Canal↗
PubMed1995

Treatment of internal rectal intussusception in patients with chronic constipation.

BACKGROUND: The significance of internal rectal intussusception (rectal invagination) in chronic constipation dominated by symptoms of obstructed defecation is not fully clarified. METHODS: Seventeen consecutive patients with chronic constipation and a history of obstructed defecation with internal rectal intussusception demonstrated by defecography were treated by perineal rectopexy. RESULTS: Of 15 patients followed up for more than 2 years defecography showed total disappearance of the intussusception in 12. Five of these claimed substantial improvement (42%; 17-72%). Three of four patients with concomitant anal incontinence became fully or partly continent after the rectopexy. CONCLUSION: In some patients with chronic constipation, dominated by symptoms of obstructed defecation, rectal invagination may be an aggravating factor. The study indicates that rectal invagination does not seem to be the cause but rather a consequence of the obstructed defecation. In selected patients, including those with concomitant faecal incontinence, surgical treatment of the intussusception by a minor procedure may be indicated.

Constipation↗
PubMed2005

[Comparative study between dynamic MRI and pelvic organography in diagnosis of pelvic floor disorders].

OBJECTIVE: To evaluate the clinical value of simultaneously combined pelvic floor dynamic MRI and pelvic organography in diagnosing female pelvic floor disorders and search for the best imaging model for diagnosing pelvic floor disorders. METHODS: Thirty women with pelvic floor disorders received pelvic floor dynamic MRI and simultaneously combined pelvic organography including cystourethrography, peritoneography, vaginography and defecography. Clinical diagnostic value was compared between this two methods. RESULTS: The diagnostic accuracy of pelvic floor dynamic MRI and simultaneously combined pelvic organograph for cystocele,anorectal junction abnormal descent, pelvic floor hernia,uterocervical prolapse was 100%, 95.2 %, 86.7%, 85.7% respectively. Rectocele and prolapse of rectal were diagnosed by pelvic organograph in 12 and 28 cases respectively, while only 6 and 0 cases were diagnosed by pelvic floor dynamic MRI respectively. The mean examining time of pelvic floor dynamic MRI and simultaneously combined pelvic organography was (16 +/- 3)min, (34 +/- 9)min respectively (P< 0.01). CONCLUSION: Pelvic floor dynamic MRI combined with defecography is the best imaging model for diagnosing pelvic floor disorders.

Adult↗
PubMed1989

[Anteroposterior rectopexy for disorders of rectal stasis: clinical and radiologic results. Value of digital subtraction rectography. Apropos of 30 cases].

We report the results of 30 antero-posterior rectopexies (APR) for rectal kinetic disorders with descending perineum syndrome. All patients were investigated by digital subtraction defecography and ano-rectal manometry. The associated surgical procedures were: sphincterotomy (n = 13) for outlet obstruction demonstrated by anal manometry or balloon expulsion test: hypertonic sphincter (n = 7), narrow fibrous sphincter (n = 6); 10 cases of prolapsectomy with extended anterior mucosectomy to reduce anterior rectal prolapse; 2 sigmoidectomy for dolichosigmoid. Best results (mean follow-up: 12 months, 3-26) were observed for ano-rectal or pelvic pain and rectal bleeding, which were cured in more than 80% of cases. Faecal incontinence (n = 5) was cured in all cases. Although normalisation of bowel movements and easier defecation were observed in 78% of cases, improvement in the dyschezic syndrome was differently perceived by the patients. Postoperative investigation demonstrated the probable cause of surgical failures (23%): impairment of rectal sensitivity (n = 2), anismus (n = 3), motor constipation (n = 4), with dolichosigmoid (n = 3). Severe perineal deficiency was also noted in 4 cases. Solitary ulcer (n = 6), anterior proctitis (n = 8), were cured within 2 months. Postoperative defecography showed correction of rectal intussusception without impairment of anterior rectal motility during defecation. These results confirm the efficacy of ARP for treatment of rectal intussusception or anterior rectocele. This functional rectopexy avoids the rectal "sling effect" of standard rectopexy which usually increases rectal dysfunction. Nevertheless, ARP alone seems to be insufficient when the associated functional or organic disorders implicated in rectal dysfunction are not also corrected, essentially outlet obstruction and dolichosigmoid.

Adult↗
PubMed1989

Internal intussusception of the rectum: a changing perspective.

Internal intussusception of the rectum is the funnel-shaped infolding of the rectum during straining to defecate. Patients present with multiple symptoms; most commonly rectal pressure and pain in association with constipation and straining. Defecography (videofluoroscopy during defecation) is the method of choice for diagnosing this problem. Rectal mobility from the sacrum, infolding of the rectum and sphincter relaxation can be used to grade the findings on defecography (Grade I-IV). The optimal therapy for internal intussusception of the rectum is unknown because the cause of the problem is unknown. Conservative management is recommended in all but the most severely symptomatic patients.

Defecation↗