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PubMed2004

Electrodynamic smooth muscle sphincter: development and biomechanical evaluation of a novel porcine artificial smooth muscle sphincter in a new in vitro stoma simulator.

AIM: Many authors have suggested that the activity of the enteric inhibitory nerves is important in regulating normal gastrointestinal motility and inducing smooth muscle relaxation. Hitherto, no experimental or clinical models exist that transfer these physiological aspects to creating an autologous artificial sphincter for the treatment of major incontinence. Therefore, this study was performed to determine the contractile and relaxant capacity of gastrointestinal muscle types and to investigate the efficiency of a novel smooth muscle sphincter, based on the non-adrenergic, non-cholinergic (NANC) receptive relaxation under electrical field stimulation (EFS). METHODS: For the first step, the isometric tension from isolated circular porcine fundus and colon muscle strips was recorded during pharmacological stimulation (TTX, L-NNA and atropine) and EFS. As a result, a continent electrodynamic smooth muscle sphincter (ESMS) was created by wrapping a fundus muscle flap around an isolated segment of porcine distal colon. The EFS of the free nerve fibers of the flap was realized using a circular platinum wire electrode. Parameters such as threshold of continence, intra/preluminal pressure and fluid passage were analyzed in a newly designed in vitro stoma simulator. RESULTS: Electrical field stimulation produced a maximal and voltage-dependent fundus relaxation to --12.4 mN/mm(2) (frequency of 40 Hz, pulse duration, train duration and voltage of 5 ms, 1 s and 60 mA respectively), which were abolished by N-nitro-L -arginine (L-NNA; 10(-4) M) in a dose-dependent manner, confirming that relaxant responses were mediated by NANC nerves. The results of eight ESMS showed that circular electrical stimulation of the muscle flap caused muscle relaxation with a concomitant and effective reduction in the occlusion pressure. CONCLUSION: The NANC-induced relaxation mechanism of porcine fundus preparations could be transferred to an efficient smooth muscle sphincter with a high threshold of continence and electrically controlled defecation.

Anal Canal↗
PubMed2005

Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation.

BACKGROUND: Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty. PATIENTS AND METHODS: Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression. RESULTS: Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05). CONCLUSIONS: Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.

Adult↗
PubMed2007

Ultrasonographic patterns in patients with obstructed defaecation.

BACKGROUND: Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal-vaginal-dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls. MATERIALS AND METHODS: Ninety-two consecutive patients (77 women; mean age 51 years; range 21-71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated. RESULTS: The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values. CONCLUSION: Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.

Adult↗
PubMed1996

The impact of anismus on the clinical outcome of rectocele repair.

There are doubts as to whether rectocele repair (RR) is beneficial for patients with concomitant anismus. The aim of this prospective study was to evaluate the effect of anismus on the clinical outcome of RR. In 71 out of 75 patients who underwent RR evacuation proctography (EP) was performed. Electromyography (EMG) of the pelvic floor and balloon expulsion test (BET) were carried out in 61 and 35 patients respectively. On EP, measuring the central anorectal angle (CARA) and the posterior anorectal angle (PARA), signs of anismus were found in 34 and 28 percent of the patients respectively. EMG and BET revealed anismus in 39 and 71 percent of the patients respectively. These results showed poor agreement. RR was successful in 53 (71%) out of 75 patients (follow up 14-74 months). No differences were found in clinical outcome in patients with and without signs of anismus. In conclusion, RR is beneficial for patients with obstructed defecation, and signs of anismus do not appear to be a contraindication for RR.

Adult↗
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↗
PubMed1998

Pelvic floor dyssynergia and bimodal rehabilitation: results of combined pelviperineal kinesitherapy and biofeedback training.

Dyschezia may be caused by pelvic floor dyssynergia, which takes place when a paradoxical contraction or a failure to relax the pelvic floor muscles occurs during attempts to defecate. The aim of our study was to set up a new bimodal rehabilitation programme for pelvic floor dyssynergia, which combined pelviperineal kinesitherapy and biofeedback, and to evaluate the results of this treatment. Thirty-five patients (age range: 28-64 years; mean age: 42.5 years) from the outpatient unit of the Clinica Chirurgica of the University of Florence, Italy, and an age-matched group of 10 healthy control subjects (age range: 31-59 years; mean age 45.7 years) with normal bowel habits and without any defecatory disorders, were studied. The 35 patients were symptomatic for dyschezia without slow colonic transit and had been diagnosed as being affected by pelvic floor dyssynergia. No evidence of any organic aetiology was present but all demonstrated both manometric and radiological evidence of inappropriate function of the pelvic floor. All of the patients underwent bimodal rehabilitation, using the combined training programme Clinical evaluation, computerized anorectal manometry and defecography were carried out 1 week before and 1 week after a completed course in bimodal rehabilitation. The control group underwent manometric and defecographic examination. Their results were compared with those of the 35 patients before and after training. After the programme, all 35 patients had a very significant increase in stool frequency (P < 0.001), while laxative and enema-induced bowel movements had become significantly less frequent (P < 0.001). After bimodal rehabilitation, computerized anorectal manometry showed some peculiar results. Resting anal canal pressure had increased but not significantly. Pre-programme values that indicated a shorter duration ("exhaustio") of maximal voluntary contraction than found in the controls had returned to normal values. The rectoanal inhibitory reflex (RAIR), with incomplete relaxation, which had been shorter than that of controls, became normal by the end of the rehabilitation. All RAIR parameters were significantly different especially when pre- and post-treatment values were compared (P < 0.001). No differences were found as regards rectal sensation parameters and rectal compliance between those before or after bimodal rehabilitation. Defecographic pretreatment X-ray films showed indentation of the puborectalis and poor anorectal angle (ARA) opening, at evacuation, with trapping barium of at 50%. After pelviperineal kinesitherapy and biofeedback training, the indentation had disappeared and the ARA had become significantly larger (P < 0.001) during evacuation. No differences were found after rehabilitation, when both were compared with those of controls. The pelvic floor descent was also significantly deeper (P < 0.001) than before the start of the programme. The bimodal rehabilitation technique can be considered a useful therapeutic option for functional dyschezia as shown by our clinical evaluations, manometric data and defecographic reports.

Adult↗
PubMed2003

Gastrointestinal transit after laparoscopic versus open colonic resection.

BACKGROUND: Multimodal rehabilitation with epidural analgesia, early oral nutrition and mobilization, and laxative use has decreased the duration of ileus after colonic surgery to about 2 days, as compared with the usual 3 to 5 days of rehabilitation required after open surgery and the slightly shorter time required with laparoscopic surgery. Gastrointestinal transit after colonic resection with laparoscopy or laparotomy was assessed. METHODS: In this study, 32 patients randomized to laparoscopic or open colonic resection received 4 MBq of 111indium diethylenetriamine pentaacetic acid, a tracer, at the end of surgery. Images of the abdomen were obtained 24 and 48 h postoperatively. An opaque abdominal dressing blinded care personnel and patients to the procedure. RESULTS: Defecation occurred on median day 2 postoperatively in both groups. At 48 h postoperatively, 53% of the tracer was excreted by patients in the laparoscopic group, as compared with 26% in the open group ( p > 0.05). CONCLUSION: Postoperative ileus and gastrointestinal transit normalized within 48 h after colonic resection in the patients who received multimodal rehabilitation. No significant difference was observed between the patients who underwent the laparoscopic procedure and those who underwent the open procedure.

Aged↗
PubMed2000

Autologous blood donation with recombinant human erythropoietin for abdominal aortic aneurysm surgery.

We evaluated the efficacy of autologous blood donation using recombinant human erythropoietin for elective abdominal aortic aneurysm (AAA) surgery regarding postoperative recovery. Twenty-five AAA patients who completed surgery without receiving a homologous blood transfusion were divided into two groups, consisting of a control group (n = 12) who did not bank any autologous blood, and a donation group (n = 13) who did bank more than 800 ml of autologous blood with the use of erythropoietin. The hematocrit (Ht) level of the control group decreased from 41.1% +/- 1.2% before the operation to 36.2% +/- 0.9% just afterwards (P > 0.01). In the donation group, however, the Ht did not change significantly during either the donation period or the perioperative period. The postoperative period before oral food intake and natural defecation were both significantly shorter in the donation group than in the control group. The first day of mobilization was also earlier in the donation group. In conclusion, autologous blood donation using erythropoietin for AAA surgery is therefore considered to promote the early recovery of patients.

Aged↗
PubMed2004

Manometric and clinical evaluation of patients after low anterior resection for rectal cancer.

The aim of this study was to examine the anorectal physiological and clinical changes that occur after low anterior resection for rectal cancer. Since 1998, 30 patients underwent laboratory tests of anorectal function, preoperatively and 1 month and 6 months after low anterior resection. Postoperatively all patients presented with increased bowel frequency, 60% of the patients with mild soiling and 30% with urgency for defecation. Six months after surgery there was a significant improvement of these symptoms. The anal resting pressure was significantly decreased postoperatively, while maximum squeezing pressure remained unchanged. The rectoanal inhibitory reflex was absent in 80% of the patients and at 6 months after surgery it tended to recover. Rectal capacity and compliance were reduced in all patients. In the current study, the majority of patients demonstrated manometric anorectal changes and clinical anorectal function disorders during the first year after surgery. We observed that these disorders correlated with the low level of the anastomosis.

Adult↗
PubMed2001

Associations of defecography and physiologic findings in male patients with rectocele.

This study evaluated the incidence and physiological findings in male patients with rectoceles. All defecographic studies were evaluated by a single colorectal surgeon. After diagnosis of rectocele in male patients, the patient's history, symptoms, and physiologic tests (anal manometry, pudendal nerve terminal motor latency [PNTML], assessment and electromyography [EMG]) were studied. A prominent rectocele was defined as one that did not empty during defecography and was associated with outlet obstructive syndrome. Forty (17%) rectoceles were diagnosed in 234 male patients with evacuatory disorders who underwent defecography. Rectoceles were anterior in 19 (48%) and posterior in 21 (52%) patients. The main complaint was constipation with difficult defecation in 33 (83%), followed by rectal pain in 5 (13%), rectal prolapse in 1 (3%), and incontinence in 1 (3%). Previous prostatic surgery had been performed in 16 (40%) patients. The mean age and duration of symptoms were 72.4 years (range, 30-88) and 10.3 years (range, 0.5-70), respectively. Excessive straining during evacuation was noted in 73%, unilateral or bilateral pudendal neuropathy in 24.5%, paradoxical puborectalis contraction in 49% and abnormal EMG in 11% of patients. Higher resting pressures with a mean 3.9 cm high pressure zone were noted in 29% of patients. The accompanying findings in defecography were, non-relaxing or partially relaxing puborectalis muscle (66%), perineal descent (65%), intussusception (23%), and sigmoidocele (15%). None of the patients underwent surgery for rectocele alone. In conclusion, rectocele is uncommon in males; it rarely appears as an isolated dysfunction as it is often associated with functional disorders of the pelvic floor. There is a frequent association between rectocele and prostatectomy. Clinical significance and therapeutic strategy remain unknown.

Adult↗
PubMed2002

Anorectal function after modern conformal radiation therapy for prostate cancer: a pilot study.

We evaluated whether, and if so to what extent, radiotherapy applied on a series of patients with prostate cancer influenced the patient's bowel habits and anorectal function. Ten consecutive patients participated in the study. The median age of the patients was 74 years (range, 61-71) and the average follow-up period was 22 (range, 15-28) months. Four patients were irradiated using external beam radiotherapy (2 Gy/day for a total of 70 Gy); 6 patients were irradiated with a combination of external beam radiotherapy (50 Gy, 2 Gy/day) and high dose rate brachytherapy (two 10-Gy fractions). Upon interview, patients disclosed characteristic functional disturbances such as urgency with occasional accidents, faecal soiling and spotting of underwear. Involuntary release of gas was another embarrassing problem. One or more of these problems were present in half of the patients. Endoscopy disclosed signs of mild proctitis. Sphincter pressure, rectal capacity and the volume threshold for appreciation of defecation urge were all significantly lower in patients than in 10 age-matched controls. In conclusion, disturbances of anorectal function with imperfection of incontinence still occur so some extent despite improved precision, and reduced margins offered by the modern conformal radiation therapy of prostate cancer. Anal sphincter function, the reservoir capacity of the rectum and its sensory function are adversely affected and radiation proctitis with rectal fibrosis and damage of the extrinsic innervations of the anal sphincters appear to be the principal causative factors. Although conformal radiotherapy together with better positioning may be two substantial improvements of modern radiotherapy, further improvements are needed.

Aged↗
PubMed2004

Prospective, randomized trial comparing diathermy excision and diathermy coagulation for symptomatic, prolapsed hemorrhoids.

PURPOSE: This study was designed to compare diathermy excision and diathermy coagulation in the treatment of symptomatic prolapsed piles. METHODS: Forty-five consecutive patients were randomly assigned to diathermy excision hemorrhoidectomy (Group A, n = 25) and diathermy coagulation (Group B, n = 20) under general anesthesia. RESULTS: The median duration of surgery was ten minutes for both groups. There was no statistical difference in the severity of postoperative pain at rest between the two groups, but Group A patients felt less pain during defecation on the third postoperative day (median, 5 (interquartile range, 3-7) vs. 8 (4-9); P = 0.04) and on the sixth postoperative day (median, 5 (interquartile range, 2-6) vs. 9 (5-10); P = 0.02). There was, however, no statistical difference in postoperative oral analgesics use and patients' satisfaction scores between the two groups. Complication rates were similar except that diathermy coagulation tended to leave some residual skin components of external hemorrhoid especially in very large prolapsed piles. Group A patients resumed work earlier (mean, 12 (range, 4-20) vs. 17 (11-21) days); however, this was not statistically significant ( P = 0.1). CONCLUSIONS: Diathermy coagulation of hemorrhoids is a simple technique and may be considered in suitable cases.

Adult↗
PubMed2004

Transverse coloplasty pouch after total mesorectal excision: functional assessment of evacuation.

PURPOSE: Colon pouch reconstruction after total mesorectal excision is functionally superior to straight colorectal/ anal anastomosis. In the long-term, stool evacuation difficulties could jeopardize the functional benefit. The transverse coloplasty pouch presents an alternative to the standard J-pouch. This study was designed to analyze functional outcome and defecography findings after total mesorectal excision and transverse coloplasty pouch reconstruction. METHODS: Thirty consecutive patients with cancer of the middle and lower third of the rectum underwent a total mesorectal excision and were examined in a prospective study. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Patients were examined within eight months by means of defecography, manometry, pouch volumetry, and a standardized continence questionnaire. RESULTS: Total mesorectal excision with transverse coloplasty pouch anastomosis was performed successfully in all patients. Symptomatic anastomotic leakage was observed in 2 of 30 patients and the radiologic leak rate was 4 of 30. All patients evacuated the pouch completely; none needed enemas or suppositories to facilitate defecation. Twenty-five of 27 patients had a maximum of three bowel movements per day, and all patients were continent for solid stools. Patients with abnormal findings on defecography proved more likely to have anal dysfunction. CONCLUSIONS: Transverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems. Urgency and incontinence correlate rather with impaired pelvic floor movement than with pouch size or anal sphincter tonus.

Aged↗
PubMed2005

Open vs. closed hemorrhoidectomy.

PURPOSE: This prospective, randomized, clinical trial compared the outcome of surgical hemorrhoidectomy by open and closed techniques in terms of postoperative pain, wound healing, and morbidity. METHODS: All consecutive patients with Grade III internal hemorrhoids with prominent external components or Grade IV hemorrhoids were randomly allocated to one of two groups. The entire wound was left open in the open group and completely closed using 5-0 chromic sutures in the closed group. Postoperative pain was assessed by a linear analog scale. Additional consumption of oxycodone hydrochloride on the day of surgery and at defecation during the first week was recorded. Patients were followed up 1, 2, and 3 weeks after the procedure. RESULTS: There were 40 patients in each group. Pain score at recovery from the anesthesia was significantly lower in the closed group (P < 0.05). Altogether, 15 percent of patients in the closed group required additional oxycodone hydrochloride for pain compared to 45 percent in the open group (P < 0.01). The pain score at the first bowel movement was significantly lower in the closed group (P < 0.01). Wound healing was significantly faster in the closed group: 75 percent of patients in the closed group had healed at 3 weeks after the procedure compared to 18 percent in the open group (P < 0.001). CONCLUSIONS: The closed technique is more advantageous with respect to less pain during the early postoperative period and faster wound healing.

Adult↗
PubMed2005

Long-term outcomes of transanal rectocele repair.

PURPOSE: This study was designed to assess the risk of rectocele recurrence after transanal repair and identify its predictive factors. METHODS: A series of 71 females who had undergone transanal repair of low isolated rectocele was retrospectively reviewed. The functional outcome was assessed by a standard questionnaire. The follow-up varied from 30 to 128 (mean, 74 +/- 30) months. Recurrences were evaluated by survival-analysis methods, and Cox's proportional hazar model was used to determine the optimal predictive factor for recurrence. RESULTS: Twenty-nine of 71 patients had isolated low rectocele recurrence, and 6 had a rectocele recurrence associated to an enterocele occurrence. The optimal predictive factor for rectocele recurrence was the persistence of symptoms two months after surgery. Although correlated to recurrences, preoperative manual pressure during defecation was not an independent predictive factor for recurrences. Preoperative defecographic parameters do not seem to influence clinical outcome of surgery, and preoperative manometric values did not determine which females could develop anal incontinence several years after surgery. CONCLUSIONS: The results of the transanal rectocele repair might progressively be worse during the length of the follow-up with a high recurrence rate (50 percent). Preoperative clinic, defecographic, or manometric parameters are not useful to identify females at risk for recurrence.

Adult↗
PubMed2005

Magnetic resonance imaging of the rectum during distension.

PURPOSE: A knowledge of the relationships between the rectum and its surrounding structures during distention may improve our understanding of the results of studies assessing rectal sensory-motor responses to distention. This magnetic resonance imaging study was designed to assess the shape of the rectum and the degree of distention at which the surrounding structures are compressed. METHODS: Nine healthy patients underwent magnetic resonance imaging of the rectum under resting conditions and after the inflation of a plastic bag to volumes of 50, 100, 150, 200, and 250 ml. The thickness of the rectovesical space was assessed as a measure of the compression of the perirectal structures, and the perception of sensations were recorded. RESULTS: The shape of the rectum changed from being quasicylindrical at distention volumes of <100 ml to bean-shaped at larger volumes. The thickness of the rectovesical space at a distention volume of 50 ml was the same as when the bag was not inflated, but it progressively decreased until the difference became statistically significant at distention volumes of > or = 200 ml, corresponding to a mean +/- standard deviation rectal radius of 2.66 +/- 0.37 cm. Statistically significant compression of the rectovesical space was recorded when the sensations of gas, desire to defecate, and urgency were perceived. CONCLUSIONS: The shape of the rectum changes during distention; it significantly compresses the extrarectal structures in the tested range of distention that induces non-painful sensations. Magnetic resonance imaging is a useful means of assessing the morphologic changes in the rectum during distention.

Adult↗
PubMed2002

Anal continence after rectocele repair.

INTRODUCTION: Rectocele may be associated with both chronic constipation and anal incontinence. Several different surgical procedures have been advocated for rectocele repair. The aim of the present study was to evaluate anorectal function and clinical outcome in a consecutive series of patients who underwent selected endorectal or transperineal surgery for rectocele for whom operative treatment was determined by clinical and proctographic features. Attention was paid to the cohort of rectocele patients presenting with incontinence as a leading symptom. METHODS: Sixty consecutive patients with symptomatic rectocele underwent surgical treatment at our institution. Fifty-eight of the patients were female (mean age 56; range, 21-70 years). Incontinence was graded according to a previously reported scoring system that accounts for the type and frequency of incontinence episodes. Preoperative anorectal manometry was performed using an open perfused polyethylene probe. Rectal sensation was recorded by balloon distention. Endoanal ultrasonography was performed with a 7.5-MHz probe. Preoperative defecography was performed at rest and on maximal squeeze and straining. Patients with obstructed defecation as their principal symptom, with associated mucosal rectal prolapse, underwent an endorectal procedure. For patients with associated anal incontinence (Grade B2 or greater), and without a rectal mucosal prolapse, a transperineal approach was performed with either an anterior external overlapping sphincteroplasty or levatorplasty. The median follow-up was 48 (range, 9-122) months. RESULTS: There was no operative mortality. Postoperative complications occurred in 18 patients (30 percent). Of 43 patients with incontinence, 34 (79 percent) were available for postoperative evaluation. None were fully continent. However, in 25 patients (73.5 percent), continence improved after surgery; half had only mucus soiling or loss of gas. Incontinence scores decreased (i.e., improved) from 4.8 +/- 0.9 to 3.9 +/- 0.9 (P = 0.002). A significant improvement was found both after transanal and perineal procedures. Only ten initially continent patients were available for postoperative assessment. All patients stated that they had clinical improvement in constipation. Their preoperative mean anal resting pressure was 62.5 +/- 3.9 (standard error of the mean) mmHg, with a postoperative mean of 75.5 +/- 7 mmHg. The preoperative mean squeeze pressure was 83.1 +/- 8.5 mmHg, with a mean postoperative squeeze pressure of 88.5 +/- 7.9 mmHg (P = not significant). The maximal tolerable volumes were all within normal limits, confirming the proctographic evidence that there were no cases of megarectum in our patient series. The pudendal nerve terminal motor latency was abnormal in all but two patients with incontinence (mean pudendal nerve terminal motor latency = 3.1; range, 1.2-4 milliseconds). Rectoceles recurred in six patients (10 percent): five after a Block procedure and one after a Sarles-type operation. The postoperative endosonographic appearance varied according to the nature of the procedure performed. CONCLUSION: There are few data concerning patients with rectocele who have associated anal incontinence, however, surgical decision analysis resulted in improvement in both constipation and incontinence in the majority of our patients with rectocele. Nevertheless, because none of the patients gained full continence postoperatively, pelvic floor rehabilitation might be also needed to achieve better sphincter function in patients with incontinence.

Adult↗
PubMed2002

Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study.

PURPOSE: Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. METHODS: A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. RESULTS: Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. CONCLUSION: Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.

Adult↗