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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
EXternal Pelvic REctal SuSpension Using Permacol Implant
The ‘Express’ Procedure
P Giordano
ACOI 2005
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Rectal intussusception (RI)
Definition• full-thickness descent
of the rectal wallMellgren et al., 1994
Felt-Bersma & Cuesta, 2001
• Recto-rectal• Recto-anal
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Commonly diagnosed at evacuation proctography
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Surgical treatment of Rectal Intussusception
• Abdominal approach
• Perineal approach
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Abdominal procedures
• Abdominal rectopexy is the preferred technique
• full rectal mobilisation • potential morbidity• high rate of post-
operative constipation• variable results• anatomy vs. symptoms
Schultz et al., 1996Schultz et al., 2000Johansson et al., 1985
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Perineal procedures
• Intra-rectal Délorme’s • rectal mucosectomy / vertical plication of the rectal
wall
• technically demanding
• low morbidity
• functional results• 60 - 70% improved evacuatory symptoms
• faecal continence improved in minority
• recurrence unknown
Berman et al., 1985, 1990, Sielezneff et al., 1999, Liberman et al., 2000
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Intussusception and Rectocoele
• RI and rectocoele frequently co-exist
• Choi et al., 2001
• RI often seen to block rectocoele
• Rectopexy fails to deal with a co-existent rectocoele
Rectocoele
Recal Intussusception
Obstructed Rectocoele
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Treatment of Rectocoele
• Trans-anal / trans-vaginal / STARR
• Trans-perineal mesh repair procedures
• Functional outcome• 40% to 90% success rate
• Kenton et al., 1999
• Lopez et al., 2001
• Recurrence rate• up to 50%
• Tjandra et al., 2001
} The conventional approach is to consider rectocoele as merely a weakness in the rectovaginal septum
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
EXternal Pelvic REctal SuSpensionThe ‘Express’ procedure
NS Williams, LS Dvorkin, P Giordano et al. Br J Surg 2005;92:598-604
Aim
• To develop a minimally invasive perineal procedure to correct RI + rectocoele
• Using an acellular porcine collagen implant (Permacol™)
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Patient Selection
Inclusion Criteria:
• Circumferential / full-thickness RI
• Symptoms consistent with physiological findings
• Failed maximal conservative therapy
• Rectocoele > 2 cm and retains neo-stool
Exclusion Criteria:
• Organic disease
• Delayed colonic transit
• Rectal hyposensitivity
• Overt rectal prolapse
• <18 years old
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Clinical and physiological assessment
• Clinical symptom questionnaires• GIQOL Index• SF36-v2 • Intussusception symptom score
• Comprehensive anorectal physiological investigation • stationary pull-through manometry• rectal sensory thresholds• PNTML• EAUS• evacuation proctography
• Post-operative assessment at 6 months
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Transversus perineii retracted upwards
Anterior rectal wall
Puborectalis
Operative details
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Results of the ‘Express’ procedure
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Demographics
• N = 17 (13 F)
• Median age 47 years (20 – 67)
• Median follow-up 12 months (6 - 20)
• 13 (all F) had concomitant rectocoele repair
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Morbidity________________________________________________________
Rectal Intussusception (n = 17)
________________________________________________________
Wound pain / neuralgia 3 (18%) Sepsis requiring intervention 2 (12%) Minor wound erosion 1 (6%) Transient bladder dysfunction 1 (6%) Implant extrusion 0 Sexual dysfunction 0 _______________________________________________________
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Morbidity
• Vaginal perforation (n = 2)
• Anterior rectal wall perforation (n = 3) • 1 sepsis and subsequent stoma
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Functional outcome: clinical symptom score
PRE-OP
median (range)
POST-OP
median (range)
P value *
Prolapse 11 (0 - 17) 4 (0 - 11) 0.0004
Evacuation 11 (3 - 15) 6 (1 - 13) 0.002
Incontinence 6 (0 - 16) 5 (0 - 14) 0.3
* Wilcoxon signed rank test (n=15)
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Functional outcome: quality of life score
PRE-OP
median (range)
POST-OP
median (range)
P value *
Prolapse 7 (0 - 14) 2 (0 - 8) 0.001
Evacuation 10 (0 - 18) 5 (0 - 16) 0.009
Incontinence 5 (0 - 16) 3 (0 - 13) 0.147
* Wilcoxon signed rank test (n=15)
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Anatomical outcome: RI
_________________________________________________
Number of patients (n = 14)
_________________________________________________
Improved 10 (71)
Unchanged 3 (21)
Worsened 1 (7)
_________________________________________________
6 normal
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Anatomical outcome: rectocoele(n = 11)
0
1
2
3
4
5
6
7
8
9
PRE-OP POST-OP
Re
cto
ce
le s
ize
(c
m)
8 = normal
3 = persistent
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Conclusion
• The “Express” procedure is a safe and effective surgical option for rectal intussusception and rectocoele in patients with evacuatory symptoms
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Defecation should be natural
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Rectal intussusception and Rectocoele
Point of ‘take-off’
ARJ
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Aids to evacuation
PRE-OP POST-OP
Laxatives 6 3
Rectal Preparations
3 4
Rectal irrigation
2 1
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
SRUS
• 6 months after surgery, ulcers had healed in both patients
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Faecal incontinence
• Preoperatively• Faecal incontinence: 5 (29%)• Faecal urgency: 2• Passive leakage of mucus: 2
• Postoperatively• 1 became fully continent and 1 developed PFL• Faecal urgency unchanged• Passive leakage of mucus resolved in 1 patient
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Anorectal physiological investigation
____________________________________________________________________
Physiological Pre-operatively Post-operatively P value
parameter
____________________________________________________________________
Resting pressure (cmH2O) 70 (12-123) 76 (7-150) 0.791 Squeeze increment (cmH2O) 60 (16 - 103) 58 (13 - 130) 0.381
FCS 40 (10 - 90) 35 (10 - 120) 0.384
DDV 90 (50 - 140) 70 (30-150) 0.09
MTV 160 (60-220) 115 (60-220) 0.039
Pudendal neuropathy 2 4 0.652
Sphincter defects 6 6 1.0
___________________________________________________________________
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Functional outcome vs.
proctographic findings
• There were no significant differences in functional outcome scores between those with and those without postoperative intussuscepta
Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Evacuatory dynamics
___________________________________________________________________
Parameter Preoperatively Postoperatively P value _________________________________________________________________________ % neo-stool evacuated 80 (60 - 100) 80 (60 - 95) 0.81 (during initial effort) Time for evacuation * 60 (30 - 240) 60 (10 - 120) 0.06 (during initial effort) Total evacuatory time * 180 (40 - 240) 150 (40 - 240) 0.08 __________________________________________________________________ * Time is recorded in seconds