Staffan Bremmer

Results of rectocele repair. A prospective study.

PURPOSE: This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation. METHODS: Twentyfive patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology. RESULTS: Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction. CONCLUSIONS: Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.

Defecography : results of investigations in 2,816 patients

PURPOSE: This study was designed to analyze the frequency of different findings at defecography in patients with defecation disorders and see in what way the evaluation could be improved. METHODS: The reports of investigations in 2,816 patients were analyzed. RESULTS: Twenty‐three percent of the investigations were considered normal. Thirty‐one percent of the patients had rectal intussusception, 13 percent had rectal prolapse, 27 percent had rectocele, and 19 percent had enterocele. Twenty‐one percent of the patients had a combination of two or three of these diagnoses. The combination of rectocele and enterocele was rare. The majority of patients with enterocele had other concomitant findings. Patients with or without abnormal perineal descent had similar frequencies of rectal prolapse, rectal intussusception, and enterocele. Rectocele was more common in patients with abnormal perineal descent. CONCLUSIONS: Defecography is valuable when investigating patients with defecation disorders. Pathologic findings were found in 77 percent of the patients. A standardized protocol should ensure a complete evaluation of defecography.

Simultaneous defecography and peritoneography in defecation disorders

A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel. PURPOSE: This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders. METHODS: Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed. RESULTS: All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas—a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele. CONCLUSIONS: Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.

Defaeco-Peritoneography in the Diagnosis of Rectal Intussusception and Rectal Prolapse

Purpose: The aim of the present study was to evaluate the use of defaeco-peritone-ography in diagnosing rectal intussusception as distinct from mucosal folds in the rectum, and rectal prolapse as distinct from mucosal prolapse. Material and Methods: Fifty-seven patients with defaecation disorders were examined by means of defaeco-peritoneography. Results: Twenty-three patients had rectal intussusception and 7 patients had rectal prolapse at defaeco-peritoneography. All these patients had a rectal peritoneocele in the serosal ring-pocket of the rectal intussusception or in the rectal prolapse. Twenty-seven patients had neither rectal intussusception nor rectal prolapse and none of these patients had a rectal peritoneocele. Conclusion: The present study demonstrated that only patients with a rectal intussusception or rectal prolapse have a rectal peritoneocele. Defaeco-peritoneography therefore offers correct diagnosis of rectal intussusception as distinct from mucosal folds in the rectum, and of rectal prolapse as distinct from mucosal prolapse.

Peritoneocele and enterocele. Formation and transformation during rectal evacuation as studied by means of defaeco-peritoneography.

Purpose: to study, by means of defaeco-peritoneography, the formation and transformation of the peritoneocele, with and without an enterocele, during rectal evacuation Material and Methods: Forty-six patients with a peritoneocele at defaeco-peritoneography were selected for the study, and examined at three different stages: 1) at the start with a contrast-filled rectum; 2) at maximum straining; and 3) at rest after rectal evacuation Results: Fourteen patients had a peritoneocele at the start. These peritoneoceles were largest at maximum straining and were all still present at rest after rectal evacuation. in 32 patients defaeco-peritoneography was regarded as normal at the start. at maximum straining these patients developed a peritoneocele and 20 of these were still present after rectal evacuation. No enterocele was seen at the start. at maximum straining 21 patients developed an enterocele and 15 of these were still present after rectal evacuation. Liquid in varying amounts was found in the peritoneoceles Conclusion: the present study demonstrated that peritoneoceles were present at different stages of the defaeco-peritoneographic investigations. Peritoneoceles were most frequent and largest at maximum straining. an enterocele was present in half of the peritoneoceles at maximum straining, but never at the start. Liquid was often present in the peritoneoceles

Pelvic anatomy and pathology is influenced by distention of the rectum

PURPOSE: The aim of the present study was to evaluate how distention of the rectum with contrast medium at defecoperitoneography affected pelvic anatomy,i.e.,position, form, and size, of organs and pouch of Douglas. PATIENTS AND METHODS: Twenty-six female patients with a peritoneocele at defecoperitoneography were selected for the present study. Radiographs taken at the start, before, and after filling the rectum with contrast medium were compared. RESULTS: There was an obvious change in the position of the organs in the pelvis when the rectum was distended with contrast medium. The peritoneocele disappeared completely in 19 of the patients and was reduced in size in the remaining 7 patients, and the enterocele disappeared completely in 13 patients. The small bowel and vaginal portion of the uterus moved cranially. CONCLUSIONS: A distended rectum may conceal existing pathology, such as peritoneocele and enterocele, at defecoperitoneography. Defecoperitoneography should, therefore, include a radiograph before the rectum is filled. This radiograph shows the habitual anatomy of the patient in the sitting position and may demonstrate pathologic findings.