Transcript THE ‘EXPRESS’ PROCEDURE FOR RECTAL INTUSSUSCEPTION

EXternal Pelvic REctal SuSpension
Using Permacol Implant
The ‘Express’ Procedure
P Giordano
ACOI 2005
Barts and The London
Queen Mary’s School of Medicine and Dentistry
Centre of Academic Surgery
Rectal intussusception (RI)
Definition
• full-thickness descent
of the rectal wall
Mellgren et al., 1994
Felt-Bersma & Cuesta, 2001
• Recto-rectal
• Recto-anal
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Commonly diagnosed at
evacuation proctography
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Surgical treatment of Rectal
Intussusception
• Abdominal approach
• Perineal approach
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Abdominal procedures
• Abdominal rectopexy is
the preferred technique
• full rectal mobilisation
• potential morbidity
• high rate of postoperative constipation
• variable results
• anatomy vs. symptoms
Schultz et al., 1996
Schultz et al., 2000
Johansson et al., 1985
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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
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Intussusception and Rectocoele
• RI and rectocoele
frequently co-exist
Rectocoele
• Choi et al., 2001
• RI often seen to block
rectocoele
Obstructed
Rectocoele
• Rectopexy fails to deal
with a co-existent
rectocoele
Recal Intussusception
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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
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The conventional approach is
to consider rectocoele as
merely a weakness in the
rectovaginal septum
EXternal Pelvic REctal SuSpension
The ‘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™)
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Patient Selection
Inclusion Criteria:
•
•
•
•
Circumferential / fullthickness RI
Symptoms consistent
with physiological
findings
Failed maximal
conservative therapy
Rectocoele > 2 cm and
retains neo-stool
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Exclusion Criteria:
• Organic disease
• Delayed colonic transit
• Rectal hyposensitivity
• Overt rectal prolapse
• <18 years old
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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
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Operative details
Transversus
perineii
retracted
upwards
Anterior
rectal wall
Puborectalis
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Centre of Academic Surgery
Barts and The London
Queen Mary’s School of Medicine and Dentistry
Centre of Academic Surgery
Barts and The London
Queen Mary’s School of Medicine and Dentistry
Centre of Academic Surgery
Barts and The London
Queen Mary’s School of Medicine and Dentistry
Centre of Academic Surgery
Results of the ‘Express’ procedure
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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
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Morbidity
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Rectal Intussusception (n = 17)
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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
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Morbidity
• Vaginal perforation (n = 2)
• Anterior rectal wall perforation (n = 3)
• 1 sepsis and subsequent stoma
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Functional outcome: clinical symptom
score
POST-OP
median
(range)
4 (0 - 11)
P value *
Prolapse
PRE-OP
median
(range)
11 (0 - 17)
Evacuation
11 (3 - 15)
6 (1 - 13)
0.002
Incontinence
6 (0 - 16)
5 (0 - 14)
0.3
* Wilcoxon signed rank test (n=15)
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0.0004
Functional outcome: quality of life score
POST-OP
median
(range)
2 (0 - 8)
P value *
Prolapse
PRE-OP
median
(range)
7 (0 - 14)
Evacuation
10 (0 - 18)
5 (0 - 16)
0.009
Incontinence
5 (0 - 16)
3 (0 - 13)
0.147
* Wilcoxon signed rank test (n=15)
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0.001
Anatomical outcome: RI
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Number of patients (n = 14)
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Improved
10 (71)
Unchanged
3 (21)
Worsened
1 (7)
6 normal
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Anatomical outcome: rectocoele
(n = 11)
9
Rectocele size (cm)
8
7
8 = normal
6
3 = persistent
5
4
3
2
1
0
PRE-OP
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POST-OP
Conclusion
• The “Express” procedure is a safe and
effective surgical option for rectal
intussusception and rectocoele in patients
with evacuatory symptoms
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Defecation should be natural
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Rectal intussusception and Rectocoele
Point of ‘take-off’
ARJ
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Aids to evacuation
PRE-OP
POST-OP
Laxatives
6
3
Rectal
Preparations
3
4
Rectal
irrigation
2
1
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SRUS
• 6 months after surgery, ulcers had
healed in both patients
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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
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Anorectal physiological investigation
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Physiological
Pre-operatively
Post-operatively
P value
parameter
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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
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Functional outcome
vs.
proctographic findings
• There were no significant differences in
functional outcome scores between those
with and those without postoperative
intussuscepta
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Evacuatory dynamics
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Parameter
Preoperatively
Postoperatively
P value
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% neo-stool evacuated
(during initial effort)
80 (60 - 100)
80 (60 - 95)
0.81
Time for evacuation *
(during initial effort)
60 (30 - 240)
60 (10 - 120)
0.06
Total evacuatory time *
180 (40 - 240)
150 (40 - 240)
0.08
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* Time is recorded in seconds
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