Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation

PURPOSE: The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation. METHODS: All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5–54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair. RESULTS: Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19vs. 10, preoperativevs. postoperative;P=0.02) and the need to use digital assistance vaginally (13vs. 6;P=0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22vs. 18 percent;P=0.95), the percentage reduction in rectocele area (65vs. 62 percent;P=0.95), or a rectocele width of more than 2 cm (44vs. 50 percent;P=0.80), didvs. did not feel improved, respectively. CONCLUSION: Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.     

Results, Outcome Predictors, and Complications after Stapled Transanal Rectal Resection for Obstructed Defecation

Purpose Obstructed defecation may be treated by stapled transanal rectal resection, but different complications and recurrence rates have been reported. The present study was designed to evaluate stapled transanal rectal resection results, outcome predictive factors, and nature of complications. Methods Clinical and functional data of 123 patients were retrospectively analyzed. All patients had symptoms of obstructed defecation before surgery and had rectocele and/or intussusception. Of them, 85 were operated on by the authors and 38 were referred after stapled transanal rectal resection had been performed elsewhere. Results At a median follow-up of 17 (range, 3–44) months, 65 percent of the patients operated on by the authors had subjective improvement. Recurrent rectocele was present in 29 percent and recurrent intussusception was present in 28 percent of patients. At univariate analysis, results were worse in those with preoperative digitation (P < 0.01), puborectalis dyssynergia (P < 0.05), enterocele (P < 0.05), larger size rectocele (P < 0.05), lower bowel frequency (P < 0.05), and sense of incomplete evacuation (P < 0.05). Bleeding was the most common perioperative complication occurring in 12 percent of cases. Reoperations were needed in 16 patients (19 percent): 9 for recurrent disease. In the 38 patients referred after stapled transanal rectal resection, the most common problems were perineal pain (53 percent), constipation with recurrent rectocele and/or intussusception (50 percent), and incontinence (28 percent). Of these patients, 14 (37 percent) underwent reoperations: 7 for recurrence. Three patients presented with a rectovaginal fistula. One other patient died for necrotizing pelvic fasciitis. Conclusions Stapled transanal rectal resection achieved acceptable results at the cost of a high reoperation rate. Patients with puborectalis dyssynergia and lower bowel frequency may do worse because surgery does not address the causes of their constipation. Patients with large rectoceles, enteroceles, digitation, and a sense of incomplete evacuation may have more advanced pelvic floor disease for which stapled transanal rectal resection, which simply removes redundant tissue, may not be adequate. This, together with the complications observed in patients referred after stapled transanal rectal resection, suggests that this procedure should be performed by colorectal surgeons and in carefully selected patients. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7 2006. Reprints are not available.     

实时三维超声鉴别诊断阴道后壁膨出病变

目的 探讨经会阴实时三维超声鉴别诊断阴道后壁膨出病变的价值。方法 对91例临床确诊为阴道后壁膨出的患者应用经会阴实时三维超声进行检查,评价图像质量,并分析其声像图特点。结果 91例患者均能配合并完成检查。图像质量评分均为3分。超声诊断直肠膨出38例,会阴体过度运动48例,肠疝5例。直肠膨出及会阴体过度运动均表现为直肠壶腹部不同程度下移至参考线以下,但只有前者膨出物突向阴道内;肠疝表现为疝出物位于直肠壶腹部与阴道间。结论 经会阴实时三维超声可用于阴道后壁膨出病变的鉴别诊断,可为临床治疗提供更多有价值的信息。     

动态经会阴超声与动态MRI排粪造影检查对直肠前突诊断的差异

目的 探讨动态经会阴超声（DTP-US）与动态MRI排粪造影（DMRD）检查诊断直肠前突的一致性,比较这两种诊断方法测量直肠前突深度之间的差异性和相关性.方法 回顾性分析2011年9月至2012年5月南京中医药大学第三附属医院收治的18名女性直肠前突患者的临床资料.对所有患者进行DTP-US与DMRD检查,比较两种诊断方法的一致性,并观察两种方法对盆底其他异常情况的检出率.DTP-US与DMRD检查诊断直肠前突的一致性采用Cohen＇s κ系数检验,DTP-US与DMRD检查测量的直肠前突深度的比较采用配对样本t检验,两者所测量的直肠前突深度的相关性采用Pearson等级相关检验.结果 DTP-US检查诊断的14例直肠前突的患者中,合并膀胱脱垂7例、盆底失弛缓5例、子宫脱垂2例、直肠黏膜内套叠2例、肠疝1例;DMRD检查诊断的18例直肠前突的患者中,合并膀胱脱垂12例、盆底失弛缓8例、子宫脱垂8例、直肠黏膜内套叠6例、肠疝1例.DTP-US与DMRD检查诊断直肠前突具有充分的一致性（κ =0.737,P＜O.05）.DTP-US与DMRD检查测量直肠前突的深度分别为（15±6） mm（7～24 mm）和（27 ±7）mm（20～41 mm）,两者比较,差异有统计学意义（t=-16.124,P＜0.05）.DTP-US与DMRD检查测量直肠前突深度高度相关（｜r｜ =0.874,P＜0.05）.随着DTP-US检查所测量的直肠前突深度的增大,DMRD检查所测量的直肠前突深度亦随之相应增大（｜r｜=1.000,P＜0.05）.结论 DTP-US与DMRD检查诊断直肠前突的一致性高,两者所测量的直肠前突深度之间存在差异和高度相关性.DTP-US因诊断迅速,患者耐受性好而优于DMRD检查.     

经会阴横切口横缝肛提肌治疗直肠前突性功能性便秘

目的 探讨经会阴横切横缝法治疗直肠前突性功能性便秘的疗效。方法 2011年9月～2013年3月,选取菏泽家政职业学院附属医院直肠前突性功能性便秘38例,采用会阴部横行切口,钝性分离直肠阴道隔,7号线横行缝合两侧肛提肌。结果 手术时间23～40min,平均28min;术中出血8～35ml,平均15ml;术后疼痛I度35例,Ⅱ度3例;肛门坠胀感36例;住院时间6～10d,平均8d。术后随访时间7～12个月,便秘治愈36例,好转2例。结论 经会阴入路横行缝合法治疗直肠前突性功能性便秘疗效肯定,手术安全。     

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive ‘revolution’ of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.     

PPH术加经会阴补片修补术治疗中重度直肠前突临床观察(附15例报告)

目的:探讨治疗中重度直肠前突方法的手术方式。方法:回顾性分析2004年10月至2006年2月PPH术 经会阴置入补片修补的方法治疗中重度直肠前突15例临床资料。结果:15例全部治愈。术前症状消失,排便通畅,平均手术时间42min,术后住院时间平均4·8d,无1例出现严重并发症。结论:使用PPH 经会阴置入补片修补的方法治疗中重度直肠前突疗效好,并发症少。     

Transvaginal excision of a retrorectal tumor presenting as rectocele

Tumors occupying the retrorectal (presacral) space are uncommon and heterogeneous. It is estimated that an average of two patients with retrorectal tumors will be diagnosed per year in a standard metropolitan area. They are usually asymptomatic and diagnosed during routine physical examination incidentally. Our case was admitted with complaints of a swelling in her vagina, constipation, and difficulty in emptying her bowels. The diagnosis and treatment utilizing transvaginal approach in this case is discussed in comparison with the literature. Up to our knowledge, this is the first case presenting as rectocele and second case of retrorectal tumor surgically treated using transvaginal approach.     

硬化注射加柱状缝合治疗直肠前突的临床研究

目的:探讨硬化注射加柱状缝合法治疗直肠前突的有效性.方法:将180例中度及中度以上的直肠前突患者随机分成两组,各90例.试验组行硬化注射加柱状缝合法治疗,对照组行经阴道切开修补术,并观察两组的治疗效果及并发症.结果:治疗后两组患者症状评分较治疗前降低,两组治疗效果相比无统计学差异,但试验组在术中出血、术后疼痛等并发症方面则优于对照组.结论:硬化注射加柱状缝合法是一种简便有效的治疗直肠前突的方法.     

Patient characteristics and management of dermal allograft extrusions

The objective of this study was to describe our rate of extrusion of dermal allograft material when used in anterior or posterior colporrhaphy and to review our success in treating extrusions with conservative management. A retrospective review of all subjects who underwent vaginal reconstruction using dermal allograft material from 1 January 2000 to 31 August 2003 was performed. Demographics, medical history, and follow-up were evaluated. For subjects who developed an extrusion, treatment details were recorded. Sixty-nine subjects underwent colporrhaphy using dermal allograft material during the defined time period: 21 anterior, 45 posterior, and 3 both. Five subjects did not appear for follow-up. Seven subjects (10.9%) developed an extrusion: three subjects anteriorly and four subjects posteriorly. There were no differences between subjects with and without extrusions based on recorded risk factors. Median time to the discovery of extrusion was 4 weeks (range: 1–6 weeks). All patients were managed with estrogen vaginal cream. Median documented healing time was 13 weeks (range: 5–40 weeks), and no serious morbidity was encountered. Graft extrusion is an uncommon complication when reinforcing vaginal tissue with dermal allograft material and can be safely and effectively managed with vaginal estrogen and expectant management.