Outlet Obstruction: Diagnosis Outlet Obstruction: Diagnosis and treatment 2008and treatment 2008

FerencFerenc JakabJakabFalk Symposium

2008. Budapest, May 2-3Uzsoki Teaching Hospital, Surgery & Vascular Surgery

Budapest, Hungary

DEFINITON

The OUTLET OBSTRUCTION The OUTLET OBSTRUCTION SYNDROME encompasses all pelvic floor SYNDROME encompasses all pelvic floor abnormalities which are responsible for an abnormalities which are responsible for an incomplete evacuation of fecal contents incomplete evacuation of fecal contents from the rectum. from the rectum. OOSOOS is related to is related to anatomic alterationsanatomic alterations / / rectocelerectocele, , enteroceleenterocele/ which may be associated with / which may be associated with functional functional disordersdisorders, such as paradoxical pub, such as paradoxical puboorectalisrectaliscontractioncontraction

DEFINITONOUTLET OBSTRUCTION SYNDROME is associated with a FAILURE of RELAXATION or even with a paradoxicalcontraction of the puborectal muscle during straining accentuating the flap-valve reaction of the anorectal angle and resulting in an obstruction to the onward passage of stool. Ifinally resulting CONSTIPATION.

SIGNIFICANCE OF PUBORECTALIS MUSCLENormal defecation:Normal defecation:

puborectalpuborectal muscle relaxes muscle relaxes rectoanalrectoanal angle straightensangle straightenssolid faces is getting to anal canalsolid faces is getting to anal canal

The failure of The failure of puborectalispuborectalis muscle to muscle to relax alone leads to functional outlet relax alone leads to functional outlet obstructionobstruction

PREVALENCE I.

The prevalence of constipation in adults The prevalence of constipation in adults may be as high as 28% accounting for may be as high as 28% accounting for more than 2.5 million outpatient medical more than 2.5 million outpatient medical visits in the U.S. yearly.visits in the U.S. yearly.

Di Palma J.A. Ann J. Gastroenterol2001; 96 S140

Di Palma J.A. Ann J. Gastroenterol2001; 96 S140

PREVALENCE II.

The OUTLET The OUTLET OBSTRUCTION OBSTRUCTION SYNDROME SYNDROME may may be observed in half be observed in half of constipated of constipated patientspatients

D’Hoore A: Colorectal Dis: 2003; 5.280D’Hoore A: Colorectal Dis: 2003; 5.280

CAUSES OF CONSTIPATIONI. Extrainestinal

1. Endocrine: hypercalcemia, hypocalemia2. Metabolic: hypercalcemia, hypocalemia3. Neurologic: Parkinson’s disease, multiple sclerosis, spinal

cord lesions, musculardystrophies, autonomic neuropathy4. Rheumatologic: systemic sclerosis5. Psychological: depression, eating disorders6. Medications: narcotics, anticholinergics, antipsychotics,

calcium channel blockers, anti-Parkinson’s therapy, anticonvulsants, tricyclic anticdepressants, iron, calcium, aluminium antacids, sucralfate

Andromanakos N et al: J. Gastroenterol. Hepatol 2006; 21. 638Andromanakos N et al: J. Gastroenterol. Hepatol 2006; 21. 638

CAUSES OF CONSTIPATIONII. IntestinalA Colon 1. Functional: slow transit, irritable bowel syndrome2. Organic: neoplasms, polyps, diverticulum disease, strictures,

aganglionosisB Anorectum and pelvic floor1. Megarectum2. Neoplasms, polyps3. Anal stenosis (after surgery, radiation or Crohn’s disease))4. External compression5. Aganglionosis

Andromanakos N et al: J. Gastroenterol. Hepatol 2006; 21. 638Andromanakos N et al: J. Gastroenterol. Hepatol 2006; 21. 638

CAUSES OF CONSTIPATION6. Internal rectal prolapse7. Complete rectal prolapse8. Mucosal rectal prolapse9. Solitary rectal ulcer10. Congenital or acquired internal anal

sphincter myopathy11. Anismus12. Descending perineum syndrome13. Enterocele14. Rectocele

Andromanakos N et al: J. Gastroenterol. Hepatol 2006; 21. 638

Andromanakos N et al: J. Gastroenterol. Hepatol 2006; 21. 638

CAUSES OF OUTLET OBSTRUCTION

Functional causes Morphological causesAnismus RectoceleHirschprungs’disease EnteroceleChagas disease Rectal prolapseHereditary internal sphincter Descending perineummyopathy syndromeCentral nervous lesions Rectal tumors

Posttherapeutical stenosisof the anorectum

TYPES OF CONSTIPATION

1. 1. Slow transit colonic constipationSlow transit colonic constipation2. Outlet Obstruction2. Outlet Obstruction3. 3. 1 + 21 + 2

DIAGNOSIS OF OUTLET OBSTRUCTION

-- Physical examinationPhysical examination-- Barium X ray Barium X ray defecographydefecography-- Colonic transit time testColonic transit time test-- AnorectalAnorectal manometrymanometry-- Balloon expulsion testBalloon expulsion test-- Electromyography (EM)Electromyography (EM)-- Dynamic MR imagingDynamic MR imaging-- EndorectalEndorectal, , EndocanalEndocanal USUS

PHYSICAL EXAMINATION

EnteroceleRectocele

Perineal descentRectal prolapseSkin irritation

Anal sphincter toneScarsDisimpaction

StenosisProlapsinghemorrhoids

Digital maneuverNeoplasmsFissureStraining at stool

StoolPetulous anusAbnormal defecation

Digital examination (at rest, squeeze, straining)

Perineal inspectionHistoryPhysical examination

BARIUM X RAY DEFECOGRAPHY

For documenting the extent of For documenting the extent of rectoanalrectoanal intussusceptionintussusception::

WexnerWexner’’ss classificationclassificationMartiMarti’’s classifications classification

Andromanakos N et al: J. Gastroenterol. Hepatol2006; 21. 638

Andromanakos N et al: J. Gastroenterol. Hepatol2006; 21. 638

COLONIC TRANSIT STUDIESThis test estimates the colonic function by in taking 20 radiopaque markers, or isotopically labelled solid particles

Normal transit < 5 remaining markersObstructive > 5 markers in rectosigmoidSlow > 5 markers throughout the colon

Diagnosis of Chronic Constipation

ANORECTAL MANOMETRYManometry helps to detect motor and sensory abnormalities of the anorectum during attempted defecation.

Maximal Anal Resting Pressure (MARP)Maximal Anal Squeezing Pressure (MASP)Rectal Sensitivity Threshold Volume (RSTV)Objective Recto Anal Inhibitory Reflex (RAIR)Maximum Tolerable Volume (MTV)

BALLOON EXPULSION TEST

Balloon inflated with 50 Balloon inflated with 50 –– 100 cc of 100 cc of saline should be expel from the saline should be expel from the rectum.rectum.Patients with pelvic outlet obstruction Patients with pelvic outlet obstruction are unable to expel the balloon.are unable to expel the balloon.

BALLOON TOPOGRAPHY

The pressure of the cylindrical flexible balloon placed into the anal canal and rectum, filled with liquid radiopaque under low pressure is controlled, the shape of the balloon is visualized.

Failure of puborectalis muscle to relax and the maintenance of anorectal angle can be diagnosed.

ELECTROMYOGRAPHY (EM)

Tonic activity inhibition of the striated Tonic activity inhibition of the striated pelvic floor muscles (including the pelvic floor muscles (including the puborectalispuborectalis muscle) is considered to muscle) is considered to normally occur in straining and during normally occur in straining and during defecationdefecation

Rosato G. Complex AnorectalDisorders 2005; 153. 29.

Rosato G. Complex AnorectalDisorders 2005; 153. 29.

DYNAMIC MR IMAGING

N. Bolog J Gastroenterol 2005. 14.293-302

N. Bolog J Gastroenterol 2005. 14.293-302

ENDORECTAL US

P. Zabar: Complex AnorectalDisorders 2005; 263.3

P. Zabar: Complex AnorectalDisorders 2005; 263.3

DYNAMIC TRANSPERINEAL ULTRASOUND

Beer-Gabel M et al.: Dis Colon Rectum 2002. 45 239Beer-Gabel M et al.: Dis Colon Rectum 2002. 45 239

CONSTIPATION OF ANORECTAL OUTLET OBSTRUCTION

MEGARECTUM

Primary or secondary megarectum is a disorder of the rectal sensation and a high compliance.

CONSTIPATION OF ANORECTAL OUTLET OBSTRUCTION

Failure of relaxation or paradoxicalcontraction of puborectalis muscle

ANISMUS (Spastic pelvic floorsyndrome)

CONSTIPATION OF ANORECTAL OUTLET OBSTRUCTION

HIRSCHSPRUNG DISEASE

The abscence of the recto-anal inhibitory reflex leads to functional distal obstruction.

CONSTIPATION OF ANORECTAL OUTLET OBSTRUCTION

DESCENDING PERINEUM SYNDROME

The anterior rectal wall protrudes into the anal canal, and the protrusive mucosa may act as a plug of the anal canal.

CONSTIPATION OF ANORECTAL OUTLET OBSTRUCTION

RECTAL PROLAPSE: The anal canal is blocked from the protruding rectumENTEROCELE: anterior or posterior enteroceles head to mechanical obstruction of the rectumRECTOCELE: Influence of regional forces lead to stool into the rectocele rather than take outlet of anal canal

MANAGEMENT / TREATMENT OF OOSEducation Fiber diet (bulk, lubricating, stimulating, osmotic)LaxativesBiofeedback trainingColhicin, Misoprostil, Botulinum toxinSurgical options

SLOGAN OF SURGICAL TREATMENT FOR OOS 2008

„Surgery should be considered as a last resort for constipated patients.”

MANAGEMENT ALGORITHM FOR THE PATIENT WITH CONSTIPATION

PRINCIPLES OF SURGICAL INTERVENTIONS FOR OOS

proven the proven the abscenabscencce of primary colonic e of primary colonic constipationconstipation

patients with impaired sphincter formation patients with impaired sphincter formation should be excludedshould be excluded

surgery surgery mainlymainly for the repair or removal of for the repair or removal of the specific anatomic defectthe specific anatomic defect

MANAGEMENT OF OOS

Rectal neoplasm SurgeryMegarectum STC + IRA

Total proctocolectomy + ileal pouchDuhamel operation

Impaired rectal sensation Biofeedback training or Electrical stimulation SNS

Hirschsprung disease Pull – through procedure Rectal or anorectal myectomy

Anismus – or spastic pelvic Division of puborectalis musclefloor syndroma Botilinum toxin A

Biofeedback training

+ slow colonic transit Colectomy

CAUSE OF FECAL OPTIONIMPACTION

B. Holzer: ASCRS 2007. 170

V. Ripetti. Surg. 2006; 02.009B. Holzer: ASCRS 2007. 170

V. Ripetti. Surg. 2006; 02.009

MANAGEMENT OF OOS

Rectocele Simple repair+ slow colonic transit retropexy transabdominally

pelvic floor repairDescending perineum syndrome Biofeedback therapy+ denervation Dilation, sphincterotomy

Internal rectal prolapse ?Complete rectal prolapse Transabdominal repair

Resection, pexyLaparoscopic repairSutures, clips,Mesh

CAUSE OF FECAL OPTIONIMPACTION

SURGICAL OPTIONS

vaginal or perineal levator plastyopen rectopexieslaparoscopic rectopexieslaparoscopic resection, retropexytransrectalis excisionstapler- assisted trans – anal surgery (double –

stapled) antegrade colonic enema (Malone procedure)STC with IRA (laparoscopic, hand assisted)segmental resection Auguste T. Gastroenterol Clin.

Biol. 2006; 30.659Auguste T. Gastroenterol Clin. Biol. 2006; 30.659

93112n.a.1122003FitzHarris10040.742001Athanasakis83308.8302001Pikarsky87.5241.9242000Fan

Succes%

No megacolon

Follow up (years)

NYearAuthor

LONGTERM RESULTS OF STC with IRA

CONCLUSION

Conservative treatment options should Conservative treatment options should tried until they tried until they araree exhausted.exhausted.

SSegmentegmentaal resection may be a good l resection may be a good option for isolated option for isolated megasigmoidmegasigmoid, , sigmoidocelesigmoidocele, or , or recurecurrrent sigmoid rent sigmoid volvulusvolvulus..

CONCLUSION

In general patients with GID should not In general patients with GID should not be offered any be offered any sursurggicalical options because of options because of their anticipated poor result.their anticipated poor result.

MMoreoveroreover, patients with psychiatric , patients with psychiatric disorders should be actively discouraged disorders should be actively discouraged from resection, as they tend to have from resection, as they tend to have poorer prognosis.poorer prognosis.

CONCLUSION

Colectomy is not a treatment option for pain and / or abdominal bloating.

Surgical interventions are numerous, covering wide range of interventions from endorectalrepair of rectocele through stapler assisted transanal surgery to proctocolectomy with restorative ileo- anal reservoir.

CONCLUSION

The repair of specific anatomic defects are indicated if the absence of primarily colonic obstipation is proven.

Moreover, patients with impaired sphincter function should be exluded due to the high risk of inducing definitive postoperative incontinence.

CONCLUSION

The detailed surgical indications are hot spots in 2008.

The patholophysiology of outlet obstruction syndrome is still far to be clearly understood, for this reason surgery should be taken into consideration if the patients is unresponsive to conservative treatment.