centre of academic surgery barts and the london queen mary’s school of medicine and dentistry...

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


Rectal intussusception (RI)

Definition• full-thickness descent

of the rectal wallMellgren et al., 1994

Felt-Bersma & Cuesta, 2001

• Recto-rectal• Recto-anal


Commonly diagnosed at evacuation proctography


Surgical treatment of Rectal Intussusception

• Abdominal approach

• Perineal approach


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


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


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


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


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™)


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


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


Transversus perineii retracted upwards

Anterior rectal wall

Puborectalis

Operative details


Results of the ‘Express’ procedure


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


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 _______________________________________________________


Morbidity

• Vaginal perforation (n = 2)

• Anterior rectal wall perforation (n = 3) • 1 sepsis and subsequent stoma


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)


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)


Anatomical outcome: RI

_________________________________________________

Number of patients (n = 14)

_________________________________________________

Improved 10 (71)

Unchanged 3 (21)

Worsened 1 (7)

_________________________________________________

6 normal


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


Conclusion

• The “Express” procedure is a safe and effective surgical option for rectal intussusception and rectocoele in patients with evacuatory symptoms


Defecation should be natural


Rectal intussusception and Rectocoele

Point of ‘take-off’

ARJ


Aids to evacuation

PRE-OP POST-OP

Laxatives 6 3

Rectal Preparations

3 4

Rectal irrigation

2 1


SRUS

• 6 months after surgery, ulcers had healed in both patients


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


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

___________________________________________________________________


Functional outcome vs.

proctographic findings

• There were no significant differences in functional outcome scores between those with and those without postoperative intussuscepta


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

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