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Surgery Dec 2022Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has...
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.
Topics: Female; Humans; Adult; Middle Aged; Aged; Male; Rectocele; Defecography; Defecation; Syndrome; Postoperative Complications; Constipation; Treatment Outcome
PubMed: 36208984
DOI: 10.1016/j.surg.2022.05.030 -
Medicina (Kaunas, Lithuania) Aug 2022Background and Objectives: Posterior compartment prolapse is associated with constipation and obstructed defecation syndrome. However, there is still a lack of consensus...
Background and Objectives: Posterior compartment prolapse is associated with constipation and obstructed defecation syndrome. However, there is still a lack of consensus on the optimal treatment for this condition. We aim to investigate functional, anatomical, and quality-of-life outcomes of native tissue transvaginal repair of isolated symptomatic rectocele. Materials and Methods: We retrospective analyzed patients who underwent transvaginal native tissue repair for stage ≥ II and symptomatic posterior vaginal wall prolapse between January 2018 and June 2021. Anatomical and functional outcomes were evaluated. Wexner constipation score was used to assess bowel symptoms, while the Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Results: Twenty-eight patients were included in the analysis. The median age was 64.5 years, and half of them underwent a previous hysterectomy for benign reasons. The median follow-up time was 33.5 months. A significant anatomical improvement in the posterior compartment was noticed compared with preoperative assessment (p < 0.001 for Ap and Bp), with only two (7.1%) anatomical recurrences. Additionally, obstructed defecation symptoms decreased significantly compared to baseline (p < 0.001), as well as vaginal bulging, with no new-onset cases of fecal incontinence or de novo dyspareunia. PGI-I resulted in 89.2% of patients being satisfied (PGI-I ≥ 2), with a median score of 1.5. Conclusions: Transvaginal native tissue repair for isolated posterior prolapse is safe and effective in managing bowel symptoms, with excellent anatomical and functional outcomes and satisfactory improvement in patients’ quality of life.
Topics: Constipation; Female; Gynecologic Surgical Procedures; Humans; Middle Aged; Pelvic Organ Prolapse; Quality of Life; Retrospective Studies; Treatment Outcome; Uterine Prolapse
PubMed: 36143829
DOI: 10.3390/medicina58091152 -
Techniques in Coloproctology Dec 2022Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of...
BACKGROUND
Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers.
METHODS
Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient's anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario.
RESULTS
Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10-20 (54%) to 21-50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function.
CONCLUSIONS
The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.
Topics: Female; Humans; Rectocele; Defecation; Intussusception; Constipation; Colorectal Surgery; Surgical Stapling; Treatment Outcome; Syndrome; Rectum
PubMed: 36104607
DOI: 10.1007/s10151-022-02705-x -
Neurogastroenterology and Motility Nov 2022More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation.... (Review)
Review
BACKGROUND
More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful.
PURPOSE
We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.
Topics: Aged; Colorectal Neoplasms; Constipation; Defecography; Female; Humans; Prospective Studies; Rectocele; Retrospective Studies
PubMed: 36102693
DOI: 10.1111/nmo.14453 -
Revista Espanola de Medicina Nuclear E... 2022Chronic constipation is a common pathology in clinical practice. In the absence of response to treatment, assessment of gastrointestinal function is recommended. This...
AIM
Chronic constipation is a common pathology in clinical practice. In the absence of response to treatment, assessment of gastrointestinal function is recommended. This can be performed by scintigraphy, although its use is not widespread. The aim of this paper was to assess the utility of gastrointestinal transits scintigraphy in patients with chronic constipation.
MATERIAL AND METHODS
Twenty patients (13 children) sent for scintigraphy for chronic constipation refractory to treatment, syringomyelia, rectocele or abdominal migraine were evaluated. All underwent clinical assessment, analytical determination, radiological imaging and/or rectal biopsy. A complete study protocol was performed, including gastric emptying, small bowel and colonic transits scintigraphy. For this, a dose of [In]In-DTPA diluted in water (37MBq) was administered together with standardized food. Following international guidelines, regions of interest were defined in the stomach, terminal ileum and different regions of the large intestine to calculate the geometric center as a measure of progression.
RESULTS
Of the 13 pediatric patients, 10 had abnormal gammagraphic patterns, with treatment being modified in 8 of them. Most of the children showed no alterations on radiological explorations. In adult patients, the results of the test changed the therapeutic management in all of them.
CONCLUSIONS
Scintigraphic study provided useful information in the study of chronic constipation, influencing the diagnosis and therapeutic management of the patient. The physiological and quantitative information it provides allows both global and regional of gastrointestinal transit time determination.
Topics: Adult; Child; Colon; Constipation; Gastric Emptying; Gastrointestinal Transit; Humans; Radionuclide Imaging
PubMed: 35963760
DOI: 10.1016/j.remnie.2022.07.009 -
Annals of Medicine and Surgery (2012) Jul 2022Anorectal functional disorder encompasses arrays of conditions including Obstructive Defecation Syndrome (ODS) and Fecal Incontinence (FI). Biofeedback Therapy (BFT)...
BACKGROUND
Anorectal functional disorder encompasses arrays of conditions including Obstructive Defecation Syndrome (ODS) and Fecal Incontinence (FI). Biofeedback Therapy (BFT) serves as first line therapy to re-train pelvic floor coordination, rectal sensation and strengthening pelvic floor muscle. The aim of this study is determining the efficacy of BFT in our centre.
METHODS
This is a retrospective observational cohort study of patients attended biofeedback therapy session from January 2013 to December 2018. Descriptive statistic was used to analyse the data.
RESULT
Total 99 patients with mean age of 44.6 ± 18.1 with female 56% (n = 55) and male 44% (n = 44) attended BFT session. Overall, 77 had CC (77%) and 23 (23%) had FI. Mean number of sessions was 11.8. Overall improvement rate 42 (42%), no improvement 32 (32%) and defaulted 26 (26%). In patients with CC, 32 (41.6%) had improvement in symptoms, 23 (29.9%) had no improvements, 22 (28.6%) defaulted BFT.Patients with FI, 7 (30.4%) had Obstetric Sphincter Injury, 7 (30.4%) had traumatic anal injury, 3 (13.0%) has Low Anterior Resection Syndrome, 2 (8.7%) had sphincter injury following anal sepsis, 2 (13.0%) had rectocele repair and 1 (4.3%) were idiopathic. 9 patients (39.1%) had stoma created. Overall response rate was: 10 patients (43.5%) had improvement in symptoms, 9 patients (39.1%) had no improvement, 4 patients (17.4%) defaulted therapy.
CONCLUSION
Our outcome rate is lower compared to published due the limited access and logistic restrictions. This issue should be given great consideration such as broadening the service and training.
PubMed: 35860081
DOI: 10.1016/j.amsu.2022.103848 -
Neurourology and Urodynamics Aug 2022The mid-vagina (MV) represents Level II of the vagina. The surgical anatomy of the MV has not been recently subject to a comprehensive examination and description. MV... (Review)
Review
AIM
The mid-vagina (MV) represents Level II of the vagina. The surgical anatomy of the MV has not been recently subject to a comprehensive examination and description. MV surgery involving anterior and posterior colporrhaphy represents a key part of surgery for a majority of pelvic organ prolapse (POP).
METHODS
Literature review and surgical observations of many aspects of the MV were performed including MV length and width; MV shape; immediate relationships; histological analysis; anterior and posterior MV prolapse assessment and anterior MV surgical aspects. Unpublished pre- and postoperative quantitative data on 300 women undergoing posterior vaginal compartment repairs are presented.
RESULTS
The MV runs from the lower limit of the vaginal vault (VV) to the hymen. Its length is a mean of 5 cm. Its shape in section overall is a compressed rectangle. Its longitudinal shape is created by its anterior and posterior walls being inverse trapezoid in shape. Histology comprises three layers: (i) mucosa; (ii) muscularis; (iii) adventitia. MV prolapse staging uses pelvic organ prolapse quantification (POP-Q). Anterior MV prolapse can be quantitatively assessed using POP-Q while posterior MV prolapse can be assessed with POP-Q or PR-Q. Around 50% of both cystocele and rectocele are due to VV defects. POP will increase anterior MV width and length. Native tissue anterior colporrhaphy is the current conventional repair with mesh disadvantages outweighing advantages. Posteriorly, Level II (MV) defects are far smaller (mean 1.3 cm) than Level I (mean 6.0 cm) and Level III (mean 2.9 cm).
CONCLUSION
An understanding of the surgical anatomy of the MV can assist anterior and posterior colporrhaphy. In particular, if VV support is employed, the Level II component of a posterior repair should be relatively small.
Topics: Cystocele; Female; Humans; Pelvic Organ Prolapse; Postoperative Period; Surgical Mesh; Treatment Outcome; Vagina
PubMed: 35731184
DOI: 10.1002/nau.24994 -
Sao Paulo Medical Journal = Revista... 2022Apical prolapsus refers to downward displacement of the vaginal apex, uterus or cervix. Pelvic organ prolapse (POP) can significantly affect women's daily activities and...
BACKGROUND
Apical prolapsus refers to downward displacement of the vaginal apex, uterus or cervix. Pelvic organ prolapse (POP) can significantly affect women's daily activities and sexuality.
OBJECTIVE
To investigate, at the mid-term follow-up after laparoscopic pectopexy surgery, whether this procedure improved the patients' quality of life and sexual function.
DESIGN AND SETTING
In this cross-sectional study, data on patients who underwent laparoscopic pectopexy in the Gazi Yasargil Education and Research Hospital were evaluated.
METHODS
Thirty-five patients with symptomatic apical prolapse and POP quantification stage II and higher were included in this study. We used the Turkish version of the female sexual function index (FSFI) questionnaire to assess preoperative and postoperative sexual dysfunction, and the Turkish version of the Prolapse Quality of Life Questionnaire (P-QOL) to evaluate the severity of POP and its impact on quality of life.
RESULTS
The mean age, parity and length of follow-up of the patients were 36.08 ± 9.04 years, 4.00 ± 1.86 and 28.88 ± 5.88 months, respectively. The most common complications were de novo rectocele in three patients (8.6%) and de novo cystocele in two patients (5.7%). All the FSFI and P-QOL scores were statistically significantly improved in the postoperative period (P < 0.001 for all scores of both FSFI and P-QOL).
CONCLUSION
The quality of life and sexual function of the patients who underwent laparoscopic pectopexy were found to have become statistically improved at the midterm follow-up. Laparoscopic pectopexy was found to be a viable, effective and safe procedure.
Topics: Adult; Cross-Sectional Studies; Female; Follow-Up Studies; Humans; Laparoscopy; Middle Aged; Pregnancy; Prolapse; Quality of Life
PubMed: 35674612
DOI: 10.1590/1516-3180.2021.0488.R1.171121 -
Nigerian Journal of Clinical Practice May 2022Treatment of total genital prolapse in elderly patients is still controversial in terms of postoperative objective and subjective results.
Comparison of long-term results of obliterative colpocleisis and reconstructive vaginal surgery including sacrospinous ligament fixation in patients with total genital prolapse.
BACKGROUND
Treatment of total genital prolapse in elderly patients is still controversial in terms of postoperative objective and subjective results.
AIM
The present study aimed to compare the long-term objective and subjective cure rates of sacrospinous ligament fixation and Le Fort operation for treatment of total genital prolapse.
PATIENTS AND METHODS
Patients over the age of 60 with stage 3 or 4 pelvic organ prolapse that presented to the Obstetrics and Gynaecology Clinic of the Faculty of Medicine of *** University. The study sample consisted of 17 patients that underwent Le Fort operation and 29 patients that underwent sacrospinous ligament fixation. Data on duration of operation, intraoperative complications, duration of hospital stay, and differences between preoperative and postoperative estimated blood loss, postoperative complications, and relapse in the long term were obtained. Questionnaires exploring quality of life, incontinence, and pelvic floor disorders were applied to the patients.
RESULTS
As subjective cure rates, postoperative patient satisfaction (P = 0.001), regret rate (P = 0.038) and recommendation rate (P = 0.044), as well as postoperative questionnaire results, Pelvic Floor Impact Questionnaire and SF36 were found to be significantly better in the Le Fort group (respectively P = 0.039 and 0.042). As objective cure rates, there was no difference between the two groups in terms of postoperative cystocele, rectocele, and cystorectocele (P = 0.955) and postoperative recurrence of prolapse beyond the hymen (P: 0.893). Duration of operation and duration of hospital stay were found to be significantly shorter in the Le Fort group (respectively P = 0.032 and 0.012).
CONCLUSION
Le Fort operation could be the intervention of choice in sexually inactive elderly patients with stage 3 or 4 pelvic organ prolapse.
Topics: Aged; Female; Genital Diseases, Female; Gynecologic Surgical Procedures; Humans; Ligaments; Pelvic Organ Prolapse; Pregnancy; Quality of Life; Retrospective Studies; Treatment Outcome; Vagina
PubMed: 35593601
DOI: 10.4103/njcp.njcp_1449_21