centre of academic surgery barts and the london queen mary’s school of medicine and dentistry...
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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
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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
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Commonly diagnosed at evacuation proctography
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Surgical treatment of Rectal Intussusception
• Abdominal approach
• Perineal approach
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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
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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
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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
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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
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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™)
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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
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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
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Transversus perineii retracted upwards
Anterior rectal wall
Puborectalis
Operative details
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Results of the ‘Express’ procedure
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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
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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 _______________________________________________________
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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
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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)
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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)
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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
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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
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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
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Defecation should be natural
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Centre of Academic SurgeryBarts and The LondonQueen Mary’s School of Medicine and Dentistry
Rectal intussusception and Rectocoele
Point of ‘take-off’
ARJ
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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
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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
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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
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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
___________________________________________________________________
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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
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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