Lee S. Dvorkin

Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception

Objective  The aim of this study was to determine whether open‐magnet magnetic resonance (MR) defaecography could provide more useful clinical information than evacuation proctography (EP) alone in the evaluation of a cohort of patients with full‐thickness rectal intussusception and could assist in decisions concerning management.

Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers

Rectal intussusception is a common finding at evacuation proctography in both symptomatic and asymptomatic individuals. Little information exists, however, as to whether intussusception morphology differs between patients with evacuatory dysfunction and healthy volunteers.

Rectal hyposensitivity: a disorder of the rectal wall or the afferent pathway? An assessment using the barostat.

OBJECTIVE:Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension. Diagnosis on the basis of abnormal threshold volumes on balloon distension alone may be inaccurate due to the influence of differing rectal wall properties. The aim of this study was to investigate whether RH was actually due to impaired afferent nerve function or whether it could be secondary to abnormalities of the rectal wall.METHODS:A total of 50 patients were referred consecutively to a tertiary referral unit for physiologic assessment of constipation (Rome II criteria), 25 of whom had associated fecal incontinence. Thirty patients had RH (elevated threshold volumes on latex balloon distension), and 20 patients had normal rectal sensation (NS). Results were compared with those obtained in 20 healthy volunteers (HV). All subjects underwent standard anorectal physiologic investigation, and assessment of rectal compliance, adaptive response to isobaric distension at urge threshold, and postprandial rectal response, using an electromechanical barostat.RESULTS:Mean rectal compliance was significantly elevated in patients with RH compared to NS and HV (p < 0.001). However, 16 patients with RH (53%) had normal compliance. Intensity of the urge to defecate during random phasic isobaric distensions was significantly reduced in patients with RH compared to NS and HV (p < 0.001). The adaptive response at urge threshold was reduced in patients with RH compared to NS and HV (p < 0.001), although spontaneous adaptation at operating pressure was similar in all three groups studied (p= 0.3). Postprandially, responses were similar between groups.CONCLUSION:In patients found to have RH on simple balloon distension, impaired perception of rectal distension may be partly explained in one subgroup by abnormal rectal compliance. However, a second subgroup exists with normal rectal wall properties, suggestive of a true impairment of the afferent pathway. The barostat has an important role in the identification of these subgroups of patients.

Rectal Intussusception: Characterization of Symptomatology

PURPOSERectal intussusception is a common finding at evacuation proctography; however, its significance has been debated. This study was designed to characterize clinically and physiologically a large group of patients with rectal intussusception and test the hypothesis that certain symptoms are predictive of this finding on evacuation proctography.METHODSA total of 896 patients underwent evacuation proctography from which three groups were identified: those with isolated rectal intussusception (n = 125), those with isolated rectocele (n = 100), and those with both abnormalities (n = 152). Multivariate analyses were used to identify symptoms predictive of findings by evacuation proctography.RESULTSThe symptoms of anorectal pain and prolapse were highly predictive of the finding of isolated intussusception over rectocele (odds ratio, 3.6, P = 0.006; odds ratio, 4.9, P < 0.001) or combined intussusception and rectocele (odds ratio, 2.9, P = 0.02; odds ratio, 2.4, P = 0.03). The symptom of “toilet revisiting” was associated with the finding of rectoanal intussusception (odds ratio, 3.55, P = 0.04). Although patients with mechanically obstructing intussuscepta evacuated slower and less completely (P < 0.001) than those with nonobstructing intussuscepta, no symptom was predictive of this finding on evacuation proctography.CONCLUSIONSAlthough certain symptoms are predictive of the finding of rectal intussusception, there is a wide overlap with symptoms of rectocele, another common cause of evacuatory dysfunction. Furthermore, the observation that “obstruction to evacuation” made on proctography had no impact on the incidence of evacuatory symptoms suggests that beyond simply demonstrating the presence of an intussusception, analysis of proctography and subclassifying intussusception morphology seems of little clinical significance, and selection for surgical intervention on the basis of proctographic findings may be illogical.

Anal sphincter morphology in patients with full-thickness rectal prolapse.

PURPOSE: The aim of this study was to assess the morphologic change of the anal canal in patients with rectal prolapse. METHODS: The endoanal ultrasound scans of 18 patients with rectal prolapse were compared with those of 23 asymptomatic controls. The thickness and area of the internal anal sphincter and submucosa were measured at three levels. RESULTS: Qualitatively, patients with rectal prolapse showed a characteristic elliptical morphology in the anal canal with anterior/posterior submucosal distortion accounting for most of the change. Quantitatively, internal anal sphincter (IAS) and submucosa (SM) thicknesses and area were greater in all quadrants of the anal canal (especially upper) in patients with rectal prolapse compared with controls. There was statistical evidence (in a regression model) of a relationship between increases in all measured variables and the finding of rectal prolapse. CONCLUSIONS: The cause of sphincter distortion in rectal prolapse is unknown but may be a response to increased mechanical stress placed on the sphincter from the prolapse or an abnormal response by the sphincter complex to the prolapse. Patients found to have this feature on endoanal ultrasound should undergo clinical examination and defecography to look for rectal wall abnormalities.

EXternal Pelvic REctal SuSpension (Express procedure) for rectal intussusception, with and without rectocele repair†‡

The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients.

External Pelvic Rectal Suspension (The Express Procedure) for Full-Thickness Rectal Prolapse: Evolution of a New Technique

OBJECTIVEThe Délorme’s operation for rectal prolapse is a safe procedure but has a high recurrence rate. We aimed to develop an operation akin to it, but designed to reduce this deficit.PATIENTS AND METHODSThirty-one consecutive patients with rectal prolapse were included in the study. Initially, a conventional Délorme’s procedure was performed and sutures or strips of Gore-Tex® were attached circumferentially to the apex of the prolapse, tunneled subcutaneously, and anchored to the external surface of the pelvis. Subsequently, the procedure was modified. Acellular porcine collagen strips were used and buried within the apex without plication of the denuded rectal musculature. Patients were formally assessed preoperatively and four months postoperatively by symptom and quality of life questionnaires and subsequently by regular clinical review.RESULTSIn the Gore-Tex® group (N = 11; males:females = 10:1; mean age, 61 years) three patients underwent suture repair and eight had strip fixation. All suture repairs developed sepsis and one patient had a recurrence. Seven of the strip fixations (88 percent) developed sepsis that resulted in implant extrusion. There was one full-thickness and one mucosal recurrence after a median follow-up of 25 months. In the collagen group (N = 20; males:females = 2:18; mean age, 63 years), sepsis occurred in four patients, requiring surgical intervention in one patient (5 percent) (cf Gore-Tex® group, P = 0.002). There was one mucosal and three full-thickness (15 percent) recurrences after a median follow-up of 14 months (cf Gore-Tex® group, P = not significant). Significant improvements in symptom and quality of life scores were recorded in both groups at four months.CONCLUSIONA new, minimally invasive perineal procedure for rectal prolapse has been developed and initial data testify to its relative safety provided collagen is used. It remains to be seen whether long-term recurrence rates will be lower than those of conventional perineal procedures.

Rectal intussusception: a study of rectal biomechanics and visceroperception.

OBJECTIVES:Rectal intussusception (RI) is a significant cause of morbidity amongst those with a rectal evacuatory disorder. The pathophysiology is unknown, but may involve abnormal biomechanics of the rectal wall similar to that previously demonstrated in patients with overt rectal prolapse (RP). Using an electromechanical barostat, this study aimed to investigate the biomechanics and visceroperception of the rectal wall in patients with RI.METHODS:Twenty consecutive patients (12 females, median age 46 yr (range 24–66)) with symptomatic, full-thickness RI were studied. Patients underwent assessment of rectal compliance, visceroperception, adaptive response to isobaric distension at urge threshold, and assessment of the postprandial response. Results were compared with those obtained in 28 asymptomatic volunteers, 10 with RI (6 females, median age 29 yr (range 21–36)) and 18 (9 females, median age 33 yr (range 21–62)) without.RESULTS:In the absence of the clinical finding of solitary rectal ulcer syndrome (SRUS), patients with symptomatic RI have normal rectal wall biomechanics, as do asymptomatic volunteers with RI (p < 0.05). Patients with the clinical finding of SRUS had reduced compliance and adaptation. In all three groups, there was a linear relationship between rectal pressure and visceroperception. The postprandial contractile response was similar between groups.CONCLUSIONS:Patients with RI have normal rectal wall biomechanics. This is in contrast to patients with RP, and suggests that while they may represent different stages of the same disease process, they are physiologically distinct. In patients with RI and SRUS, rectal wall inflammation and fibrosis, perhaps arising secondary to the intussusception, may explain the physiological changes observed.

external Pelvic Rectal Suspension (the Express Procedure) for Internal Rectal Prolapse, with or without Concomitant Rectocele Repair: A Video Demonstration

PurposeInternal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol™), designed to correct internal rectal prolapse, with or without rectocele.MethodsInclusion criteria: severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol™ T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol™ patch in the rectovaginal plane.ResultsShort-term results for the “Express” are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography.ConclusionsThis procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.