Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception

AIM:To evaluate the safety and efficacy of stapled transanal rectal resection(STARR),and to analyze the outcome of the patients 12-mo after the operation.METHODS:From May 2007 to October 2008,50 female patients with rectocele and/or rectal intussusception underwent STARR.The preoperative status,perioperative and postoperative complications at baseline,3,6 and 12-mo were assessed.Data were collected prospectively from standardized questionnaires for the assessment of constipation[constipation scoring system,Longo’s obstructed defecation syndrome(ODS)score system,symptom severity score],patient satisfaction (visual analogue scale),and quality of life(Patient Assessment of Constipation-Quality of Life Questionnaire).RESULTS:At a 12-mo follow-up,significant improvement in the constipation scoring system,ODS score system,symptom severity score,visual analog scale and quality of life(P<0.0001)was observed.The symptoms of constipation improved in 90%of patients at 12 mo after surgery.The self-reported definitive outcome was excellent in 15(30%)patients,fairly good in 8(16%),good in 22(44%),and poor in 5(10%).CONCLUSION:STARR can be performed safely without major morbidity.Moreover,the procedure seems to be effective for patients with obstructed defecation associated with symptomatic rectocele and rectal intussusception.

Khubchandani's procedure combined with stapled posterior rectal wall resection for rectocele

BACKGROUND Obstructed defecation syndrome(ODS) is a widespread disease in the world.Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection(STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.AIM To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani's procedure with stapled posterior rectal wall resection.METHODS A cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients(group A) underwent Khubchandani's procedure with stapled posterior rectal wall resection and 51 patients(group B) underwent the STARR procedure.Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.RESULTS In group A, 42 patients underwent Khubchandani's procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min(group A) vs39.24 ± 6.53 min(group B). Mean hospital stay was 3.15 ± 0.70 d(group A) vs 3.14± 0.54 d(group B). Mean blood loss was 10.91 ± 2.52 mL(group A) vs 10.14 ± 1.86 m L(group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm(group A) vs 4.18 ± 0.95 cm(group B) preoperatively to 1.19 ± 0.43 cm(group A) vs 1.54 ± 0.82 cm(group B)one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients'(30/34, 88.2%) final outcomes were judged as effective and 4(4/34,11.8%) as moderate in group A, whereas in group B, 30(30/37, 81.1%) patients' outcomes were judged as effective, 5(5/37, 13.5%) as moderate, and 2(2/37,5.4%) as poor.CONCLUSION Khubchandani's procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Measuring the space between vagina and rectum as it relates to rectocele

AIM:To measure the normal space between the posterior wall of the vagina and the anterior wall of the respectively rectum using computed tomography(CT) and reveal its were relationship to rectocele. METHODS:A total of twenty female volunteers without rectocele were examined by CT scan.We performed a middle level continuous horizontal pelvic scan from the upper part to the lower part and collected the measurement data to analyze the results using t-test. RESULTS:Twenty volunteers were enrolled in the study. The space between the posterior wall of the vagina and the anterior wall of the rectum was measured at three levels(upper 1/3,middle,lower 1/3 level of vagina). The results showed that the space from the posterior wall of the vagina to the anterior wall of the rectum at the upper 1/3 level and the middle level was 3.896 ±0.3617 mm and 4.6575±0.3052 mm,respectively. When the two groups of data were compared,we found the space at the upper 1/3 level was shorter than at the middle level(P<0.01).Moreover,at the lower 1/3 level the space measured was 10.058±0.4534 mm.The results revealed that the space at the lower 1/3 level was longer than that at the middle level(P<0.01). CONCLUSION:These measurement data may be helpful in assessing rectocele clinical diagnosis and functional outcomes of rectocele repair.

Therapeutic effects of the TST36 stapler on rectocele combined with internal rectal prolapse

BACKGROUND The most common causes of outlet obstructive constipation(OOC)are rectocele and internal rectal prolapse.The surgical methods for OOC are diverse and difficult,and the postoperative complications and recurrence rate are high,which results in both physical and mental pain in patients.With the continuous deepening of the surgeon’s concept of minimally invasive surgery and continuous in-depth research on the mechanism of OOC,the treatment concepts and surgical methods are continuously improved.AIM To determine the efficacy of the TST36 stapler in the treatment of rectocele combined with internal rectal prolapse.METHODS From January 2017 to July 2019,49 female patients with rectocele and internal rectal prolapse who met the inclusion criteria were selected for treatment using the TST36 stapler.RESULTS Forty-five patients were cured,4 patients improved,and the cure rate was 92%.The postoperative obstructed defecation syndrome score,the defecation frequency score,time/straining intensity,and sensation of incomplete evacuation were significantly decreased compared with these parameters before treatment,and the differences were statistically significant(P<0.05).The postoperative anal canal resting pressure and maximum squeeze pressure in patients decreased compared with before treatment,and the differences were statistically significant(P<0.05).The initial and maximum defecation thresholds after surgery were significantly lower than those before treatment,and the differences were statistically significant(P<0.05).The postoperative ratings of rectocele,resting phase,and defecation phase in these patients were significantly decreased compared with those before treatment,and the differences were statistically significant(P<0.05).CONCLUSION The TST36 stapler is safe and effective in treating rectocele combined with internal rectal prolapse and is worth promoting in clinical work.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele

BACKGROUND Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome(ODS).AIM To assess the current literature in regard to the outcome of the classical transperineal repair(TPR)of rectocele and its technical modifications.METHODS An organized literature search for studies that assessed the outcome of TPR of rectocele was performed.PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020.The main outcome measures were improvement in ODS symptoms,improvement in sexual functions and continence,changes in manometric parameters,and quality of life.RESULTS After screening of 306 studies,24 articles were found eligible for inclusion to the review.Nine studies(301 patients)assessed the classical TPR of rectocele.The median rate of postoperative improvement in ODS symptoms was 72.7%(range,45.8%-83.3%)and reduction in rectocele size ranged from 41.4%-95.0%.Modifications of the classical repair entailed omission of levatorplasty,addition of implant,concomitant lateral internal sphincterotomy,changing the direction of plication of rectovaginal septum,and site-specific repair.CONCLUSION The transperineal repair of rectocele is associated with satisfactory,yet variable,improvement in ODS symptoms with parallel increase in quality-of-life score.Several modifications of the classical TPR were described.These modifications include omission of levatorplasty,insertion of implants,performing lateral sphincterotomy,changing the direction of classical plication,and site-specific repair.The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.

Significance of defecography and the role of rectocele in constipated patients

Backround: Chronic constipation is a common, chronic and frequent problem of the general population. The aim of this study is to assess the efficacy of defecography in diagnosing the etiology of constipation and the relation between constipation and rectocele. Material-method: We have investigated 250 patients who have been admitted to our general surgery out-patient clinic with complaint of constipation using Rome III criteria and diagnostic defecography. Results: Out of 250 patients who were evaluated with defecography only 24 had normal findings. 136 patients were found to have rectocele. Conclusion: We propose that rectocele is an important etiology of constipation, and defecography should be considered early in the diagnosis of rectocele.

Bloodless Outpatient Surgical Treatment of Rectocele and Cystocele under Local Anesthesia

Background: Surgical treatment of rectocele and cystocele is usually performed in a hospital setting under regional (spinal or epidural) or general anesthesia, and patients commonly have to stay in the hospital for at least one or two days. The possibility of performing the surgery under local anesthesia, as an outpatient procedure with minimal bleeding and pain, no surgical assistants, with immediate discharge and, most importantly, without compromising postoperative results, is appealing. To our knowledge, no studies have evaluated whether performing rectocele and/or cystocele rectocele repair under local infiltration anesthesia and without separation of the vaginal mucosa from the underlying fascia achieves these goals. Objective: The aim of this study is to describe a new surgical technique for outpatient treatment of cystocele and rectocele under local anesthesia, and our initial results. Materials and Methods: Forty women underwent outpatient surgical repair of rectocele and/or cystocele between April and September 2020 at the ambulatory procedure room of the authors’ clinics. The technique consists of a triangular-shaped CO2 laser vaporization or electrocauterization of the posterior and/or anterior vaginal epithelium, followed by plication of the edges of the triangle with 0 polygalactin suture. A perineorrhaphy was always performed concomitantly with rectocele repair, and a transobturator sling was performed in women presenting with concomitant stress urinary incontinence. Postoperative evaluation included POP-Q measurement for each patient six months after the procedure, and resolution of prolapse was considered when anterior and/or posterior vaginal wall presented as stage 0 or 1. Pre and postoperative POP-Q measurements were analyzed using Wilcoxon signed-rank test. Results: The mean operating time was 21 minutes (range: 14 - 38 minutes). All patients tolerated the procedure well and were discharged immediately afterwards. There were no intraoperative or postoperative complications, and all patients had satisfactory healing of the vaginal mucosa. Bleeding from the rectocele and/or cystocele repair was minimal, and nobody required extra-anesthesia or transfer to a hospital surgical theater. At six month follow-up, pre and postoperative POP-Q measurements of points Ap, Bp, Aa and Ba were all statistically significant (Ap 1.6 ± 1.2 × -2.4 ± 0.9, Bp 2.6 ± 1.6 × -2.7 ± 1.4, Aa 1.4 ± 1.1 × -2.3 ± 0.8, and Ba 2.4 ± 1.5 × -2.5 ± 1.2) respectively, revealing satisfactory resolution of both rectocele and cystocele. Conclusion: Our initial results suggest that rectocele and cystocele may be safely and effectively treated under local anesthesia in an outpatient setting using this new technique.

Is the transperineal ultrasonography approach effective for the diagnosis of rectocele?

Background Transperineal ultrasonography has been used as a diagnostic imaging modality for rectocele for many years.However,the consistency of ultrasonography and defecography in evaluating the severity of rectocele was not satisfactory.This study aimed to evaluate the agreement in the measurement of rectocele parameters between the two methods in different positions and provide clinical implications for the diagnosis of rectocele.Methods In this pilot study,participants were recruited in an outpatient clinic of a tertiary hospital between December 2017 and December 2019.All participants separately underwent defecation proctography at sitting and squatting positions,and undertook transperineal ultrasonography at left lateral,sitting,and squatting positions.The consistency of ultrasonography and defecography was evaluated.Results Thirty female volunteers with rectocele were included in this study.The degree of anorectal angle was significantly larger at rest and during contraction,maximal Valsalva,and evacuation;the depth of the rectocele was significantly deeper during maximal Valsalva and evacuation;and the length of the perineumdescending was significantly longer during contraction and maximal Valsalva in using squatting position compared to the sitting position when performing the defecation proctography.The degree of anorectal angle,the depth of rectocele,the area of levator hiatus,and the volume of the rectocele were significantly different in using squatting,sitting,and left lateral positions when performing the transperineal ultrasonography.Bland-Altman semi-quantitative plots showed good consistency in the measurement of the anorectal angle and the depth of the rectocele between proctography and ultrasonography in both sitting and squatting positions.Conclusions The findings of our study may be considered as the preliminary evidence to support the use of transperineal ultrasonography with sitting and squatting positions as the imaging test of choice for evaluating patients with rectocele.

Outcomes of a modified Bresler procedure for the treatment of rectocele with rectal intussusception

Background:Obstructed defecation syndrome(ODS)is a condition that is frequently caused by rectocele and rectal intussusception.This study aimed to evaluate the effectiveness of a modified Bresler procedure for the treatment of ODS.The outcomes of this modified procedure were compared with the stapled transanal rectal resection(STARR)procedure.Methods:We performed a retrospective analysis of the clinical data from 76 female patients who presented with ODS between June 2014 and June 2016.The patients were divided into two treatment groups,namely Modified and STARR.Patients in the Modified group(n=36)underwent the modified Bresler procedure,which involved posterior rectal-wall resection using a circular tubular stapler with multilevel purse-string sutures.Patients in the STARR group(n=40)underwent the standard STARR procedure.We analysed post-operative complications,Wexner constipation scores(WCS),rectocele depths,and four-point post-operative satisfaction scales.Results:Patients in the Modified group exhibited shorter operative times and fewer post-operative complications(both P<0.05).At 12 months post-operatively,both the Modified and STARR groups displayed a significant improvement in the Wexner constipation score and the depth of rectocele.The post-operative WCS for the Modified group were significantly improved compared to those for the STARR group(P<0.05),while there was no significant difference in the rectocele depth between the two groups(P>0.05).Post-operative interviews at post-operative 12 months showed that patients in the Modified group had a better satisfaction(P=0.05).Conclusions:Our modified procedure may be an effective treatment strategy for patients experiencing ODS caused by rectocele and rectal intussusception,with fewer complications and effective relief of symptoms.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse

External and internal rectal prolapse with their affiliated rectocele and enterocele, are associated with debilitating symptoms such as obstructed defecation, pelvic pain and faecal incontinence. Since perineal procedures are associated with a higher recurrence rate, an abdominal approach is commonly preferred. Despite the description of greater than three hundred different procedures, thus far no clear superiority of one surgical technique has been demonstrated. Ventral mesh rectopexy(VMR) is a relatively new and promising technique to correct rectal prolapse. In contrast to the abdominal procedures of past decades, VMR avoids posterolateral rectal mobilisation and thereby minimizes the risk of postoperative constipation. Because of a perceived acceptable recurrence rate, good functional results and low mesh-related morbidity in the short to medium term, VMR has been popularized in the past decade. Laparoscopic or robotic-assisted VMR is now being progressively performed internationally and several articles and guidelines propose the procedure as the treatment of choice for rectal prolapse. In this article, an outline of the current status of laparoscopic and robotic ventral mesh rectopexy for the treatment of internal and external rectal prolapse is presented.

Gender influence on defecographic abnormalities in patients with posterior pelvic floor disorders

AIM:To compare defecographic abnormalities in symptomatic men and women and to analyze differences between men and age-and symptom-matched women.METHODS:Sixty-six men(mean age:55.4 years,range:20-81 years) who complained of constipation and/or fecal incontinence and/or pelvic pain underwent defecography after intake of a barium meal.Radiographs were analyzed for the diagnosis of rectocele,enterocele,intussusception and perineal descent.They were compared with age-and symptom-matched women(n = 198) who underwent defecography during the same period.RESULTS:Normal defecography was observed in 22.7% of men vs 5.5% of women(P < 0.001).Defecography in men compared with women showed 4.5%vs 44.4%(P < 0.001) rectocele,and 10.6% vs 29.8%(P < 0.001) enterocele,respectively.No difference was observed for the diagnosis of intussusception(57.6% vs 44.9%).Perineal descent at rest was more frequent in women(P < 0.005).CONCLUSION:For the same complaint,diagnosis of defecographic abnormalities was different in men than in women:rectocele,enterocele and perineal descent at rest were observed less frequently in men than in women.

Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders

AIM:To prospectively assess the eff icacy and safety of stapled trans-anal rectal resection(STARR) compared to standard conservative treatment,and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR.METHODS:Thirty patients(Female,28;age:51 ± 9 years) with rectocele or rectal intussusception,a defecation disorder,and functional constipation were submitted for STARR.Thirty comparable patients(Female,30;age 53 ± 13 years),who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol,were assessed.Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment.A responder was def ined as an absence of the Rome Ⅲ diagnostic criteria for functional constipation.Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients,respectively.RESULTS:After STARR,53% of patients were responders;during conservative treatment,75% were responders.After STARR,30% of the patients reported the use of laxatives,17% had intermittent anal pain,13% had anal leakage,13% required digital facilitation,6% experienced defecatory urgency,6% experienced fecal incontinence,and 6% required re-intervention.During macrogol therapy,23% of the patients complained of abdominal bloating and 13% of borborygmi,and 3% required digital facilitation.No preoperative symptom,defecographic,or manometric finding predicted the outcome of STARR.Post-operative defecography showed a statistically significant reduction(P < 0.05) of the rectal diameter and rectocele.The postoperative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified,and that rectal compliance was reduced(P = 0.01).CONCLUSION:STARR is not better and is less safe than macrogol in the treatment of defecation disorders.It could be considered as an alternative therapy in patients unresponsive to macrogol.

STARR手术治疗直肠前突20例疗效分析

STARR（stapled Tran sanal rectal Resection）手术是近年来意大利学者A·longo提出的用于治疗直肠前突的新术式。2009年6月～2010年6月收治行STARR手术患者20例,报告如下。资料与方法本组患者20例,均为女性;年龄23～80岁,平均51.5岁。临床表现：本组病例均有排便困难,便条细、便量少、肛门堵塞感、下坠感、排便不尽感、排便费时、费力。