Magnetic Resonance Imaging Defecography Research Articles

To explore the pathogenesis of anterior resection syndrome by magnetic resonance imaging rectal defecography.

Over 90% of rectal cancer patients develop low anterior resection syndrome (LARS) after sphincter-preserving resection. The current globally recognized evaluation method has many drawbacks and its subjectivity is too strong, which hinders the research and treatment of LARS. To evaluate the anorectal function after colorectal cancer surgery by quantifying the index of magnetic resonance imaging (MRI) defecography, and pathogenesis of LARS. We evaluated 34 patients using the standard LARS score, and a new LARS evaluation index was established using the dynamic images of MRI defecography to verify the LARS score. In the LARS score model, there were 10 (29.41%) mild and 24 (70.58%) severe cases of LARS. The comparison of defecation rate between the two groups was 29.36 ± 14.17% versus 46.83 ± 18.62% (P = 0.004); and MRI-rectal compliance (MRI-RC) score was 3.63 ± 1.96 versus 7.0 ± 3.21 (P = 0.001). Severe and mild LARS had significant differences using the two evaluation methods. There was a significant negative correlation between LARS and MRI-RC score (P < 0.001), and they had a negative correlation with defecation rate (P = 0.028). MRI defecography and standard LARS score can both be used as an evaluation index to study the pathogenesis of LARS.

Mesorectal reconstruction with pedicled greater omental transplantation to relieve low anterior resection syndrome following total intersphincteric resection in patients with ultra-low rectal cancer

BackgroundTotal intersphincteric resection (ISR) is the ultimate anus-preserving surgery for patients with ultra-low rectal cancer (ULRC), which can result in various degrees of anorectal dysfunction. Known as low anterior resection syndrome (LARS), it seriously affects the postoperative quality of life of patients. The aim of this study was to discuss the value of mesorectal reconstruction with pedicled greater omental transplantation (PGOT) to relieve LARS following total ISR in patients with ULRC, hoping to provide new ideas and strategies for the prevention and improvement of LARS.MethodsWe retrospectively analyzed hospitalization data and postoperative anorectal function of 26 ULRC patients, who were met inclusion and exclusion criteria in our center from January 2015 to February 2022. And combined with the results of anorectal manometry and rectal magnetic resonance imaging (MRI) defecography of some patients, we assessed comprehensively anorectal physiological and morphological changes of the patients after surgery, and their correlation with LARS.ResultsIn this study, 26 patients with ULRC were enrolled and divided into observation group (n = 15) and control group (n = 11) according to whether PGOT was performed. There were no significant differences in surgical results such as operative time, intraoperative blood loss and postoperative complications between the two groups (P > 0.05). Postoperative follow-up showed that patients in both groups showed severe LARS within 3 months after surgery, but from the 3rd month after surgery, LARS in both groups gradually began to decrease, especially in the observation group, which showed faster recovery and better recovery, with statistically significant difference (P < 0.001). Through anorectal manometry, the mean rectal resting pressure in the observation group was significantly lower than that in the control group (P = 0.010). In addition, the postoperative thickness of the posterior rectal mesenterium in the observation group was significantly higher than that in the control group (P = 0.001), and also higher than the preoperative level (P = 0.018). Moreover, rectal MRI defecography showed that the neo-rectum had good compliance under the matting of greater omentum, and its intestinal peristalsis was coordinated.ConclusionsULRC patients, with the help of greater omentum, coordinated their neo-rectum peristalsis after total ISR and recovery of LARS was faster and better. PGOT is expected to be an effective strategy for LARS prevention and treatment of ULRC patients after surgery and is worthy of clinical promotion.

The Role of Magnetic Resonance Imaging Defecography in the Evaluation of Patients With Chronic Constipation

IntroductionPelvic floor dysfunction is one of the major causes of primary chronic constipation. Our study aims to assess utility of defecography using magnetic resonance imaging (MRI) in assessing pelvic floor dysfunction in these patients. MethodsMR defecography studies of 50 patients with chronic constipation done on 1.5 T/3 T MRI machines were analyzed retrospectively. Midline sagittal images were evaluated during rest, strain, and defecation phases. ResultsOf 50 patients, 62% had only compartment III involved, 8% had compartments II and III involved, 8% had compartments I and III involved, and 16% had all 3 compartments involved, the remaining 6% had no compartment involvement. Of the 21 patients with rectocele, anterior rectocele was more common than posterior. Anorectal angles were compared with the three grades of anorectal descent. Both moderate and severe grades of anorectal descent had an abnormal angle. ConclusionDynamic MR defecography helps identify pelvic floor dysfunction in patients with chronic constipation and helps design surgical repair to avoid recurrence.

Advantages of total proctocolectomy with straight ileoanal anastomosis plus pedicled omental transposition for familial adenomatous polyposis: a preliminary study

PurposeTo achieve excellent postoperative bowel function in familial adenomatous polyposis (FAP) patients, it is important to reconstruct the digestive tract. The aim of this study is to preliminarily discuss the advantages of total proctocolectomy with straight ileoanal anastomosis (TPC-SIAA) plus pedicled omental transposition for FAP.MethodsA retrospective study was carried out in two hospitals analysing data for FAP patients who underwent surgical treatments between 2015 and 2021. Perioperative outcomes and early and mid-term anal functions were analysed.ResultsAfter excluding 4 patients who underwent total proctocolectomy with permanent ileostomy, 10 patients were enrolled in the study. Among the 10 patients, 3 received TPC-SIAA plus pedicled omental transposition, 3 received total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA), and 4 received total colectomy with ileal pouch-rectal anastomosis (TC-IPRA). Except for one case conversion to laparotomy, laparoscopic surgery was performed for the other cases. The incidence of early postoperative complications was apparently higher with pouch anastomosis (57.1%) than straight anastomosis (0%). Frequencies of bowel movement and low anterior resection syndrome (LARS) score were higher for TPC-SIAA than the other two surgical procedures in the early term; over time, however, the frequencies of bowel movement and LARS score both showed a decreasing trend. In addition, combined with anorectal pressure detection and magnetic resonance imaging defecography at the 3rd month after TPC-SIAA plus pedicled omental transposition, defecation coordination was good. The dynamics and receptivity of the new rectum tended to be as expected.ConclusionAlthough the three surgical procedures are safe and feasible surgical options for FAP, TPC-SIAA plus pedicled omental transposition is more consistent with intestinal physiology, with good intestinal compliance, and anal function tended to be as expected over time. Nevertheless, more extensive studies are needed to confirm these benefits.

The Effect of Biofeedback Therapy Combined with Comprehensive Nursing Intervention on the Quality of Life of Patients with Functional Constipation Based on Dynamic Magnetic Resonance Defecation.

In order to study the quality of life of patients with functional constipation based on dynamic magnetic resonance defecation, the biofeedback therapy combined with comprehensive nursing intervention was used to diagnose and treat the patients, so as to explore its clinical efficacy and its impact on patients' quality of life. The obstructed defecation surgical treatment carries frequent recurrences, and dynamic magnetic resonance imaging defecography evaluated and elucidated the underlying anatomic features. This research selected 80 patients who came to our hospital for treatment of functional constipation and evaluated and recorded various clinical indicators before and after treatment in the form of questionnaire survey. The results showed that the clinical symptom scores of patients with functional constipation before and after treatment were greatly different (P < 0.05). Thus, the biofeedback therapy combined with comprehensive nursing intervention showed a good clinical effect in the treatment of patients with functional constipation and significantly improved the quality of life of patients, showing high clinical application and promotion value. A convenient diagnostic procedure is represented by the dynamic magnetic resonance imaging in females, especially pelvic floor organs dynamic imaging during defecation.

Comparison of magnetic resonance defecography with pelvic floor ultrasound and vaginal inspection in the urogynecological diagnosis of pelvic floor dysfunction.

Introduction:The aim of the study is to evaluate the use of pelvic floor (PF) ultrasound and vaginal inspection in the quantification of prolapse and to compare findings with magnetic resonance (MR) defecography in a blind study.Materials and Methods:Data from the dynamic MR imaging (MRI) defecography were compared and evaluated with PF ultrasound and vaginal examinations (VEs) in 45 female patients aged from 52 to 94, between the years 2016 and 2018. With regard to the pelvic organ prolapse (POP), MRI defecography revealed changes in the mid-pubic line. According to Bump et al., the bladder neck descent, degree of the retrovesical angle, and urethral rotation were measured to identify anterior vaginal wall descent extent. POP quantification (POP-Q) was determined by VE.Results:With regard to the presence of a Grade II prolapse in the anterior and posterior vaginal walls, the intraclass correlation coefficient (ICC) showed a significant correspondence (ICC = 0.85, 95% confidence interval [CI] 0.67–0.92), (ICC = 0.77, 95% CI 0.63–0.88). With regard to the accordance in the ICC between the VE results (POP-Q) and the dynamic MRI defecography, there was an excellent match in high Grade III and IV in all compartments. In addition to bladder neck funneling, hypermobility of the urethra was identified by ultrasound in seven women (n 7/45, 15.5%).Conclusion:Despite different reference systems in the quantification of results, both the methods allow for a similarly successful separate assessment of all three compartments. The agreement between methods and interobserver agreement for the clinical diagnosis is good. Based on the results, we would recommend the supplemental dynamic PF ultrasound for part of the noninvasive examination for the diagnosis of POP.

Systematic review with meta‐analysis: defecography should be a first‐line diagnostic modality in patients with refractory constipation

Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined. To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers. Electronic searches of major databases were performed without date restrictions. From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P=0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study). Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.

Functional Disorders: Rectoanal Intussusception.

Rectoanal intussusception is an invagination of the rectal wall into the lumen of the rectum. Patients may present with constipation, incomplete evacuation, incontinence, or may be asymptomatic. Defecography has been the gold standard for detection. Magnetic resonance imaging defecography and dynamic anal endosonography are alternatives to conventional defecography. However, both methods are not as sensitive as conventional defecography. Treatment options range from conservative/medical treatment such as biofeedback to surgical procedures such as Delorme, rectopexy, and stapled transanal rectal resection. Recent studies conducted after a trial of failed nonoperative management show adequate results with operations performed for rectal intussusception with or without rectocele if other causes of constipation are not present.

Midpubic Line to Stage Pelvic Organ Prolapse by MRI Defecography As Compared to POP-Q

Objective: To compare the degree of pelvic organ prolapse (POP) as measured by the pelvic organ prolapse quantification (POP-Q) system to the degree of prolapse as measured by magnetic resonance imaging (MRI) defecography and to merge clinical and radiologic terminology in reference to POP. Methods: A retrospective analysis of 29 patients who presented with POP and defecatory complaints and underwent MRI defecography (2008-2011). POP-Q scores were recorded by two attending urogynecologists. A radiologist, blinded to the clinical POP-Q scores, measured the maximum prolapse of the anterior vagina, posterior vagina, and vaginal apex/cervix on each subject’s MRI. Results: Prolapse as measured by MRI defecography was significantly more advanced as compared to the clinical POP-Q measurements in all three compartments studied. The differences were both statistically significant and potentially, clinically relevant. A mean difference of 2.0 centimeters ± 1.5 SD, 2.3 centimeters ± 2.7 SD, and 5.0 centimeters ± 2.0 SD was observed in the anterior, apical, and posterior vaginal compartments, respectively.

Effects of dynamic transperineal ultrasound and dynamic magnetic resonance imaging defecography in the diagnosis of rectocele

Objective To evaluate the agreement between dynamic transperineal ultrasound (DTP-US)and dynamic magnetic resonance imaging defecography (DMRD) in the diagnosis of rectocele,and to compare the correlation and difference between the depth of rectocele measured by DTP-US and DMRD.Methods The clinical data of 18 female patients with rectocele who were admitted to the Third Affiliated Hospital of Nanjing University of Chinese Medicine from September 2011 to May 2012 were retrospectively analyzed.All patients received examination via DTP-US and DMRD,and the agreement of the 2 diagnosing methods was analysed.The accurate rates of the detection of other pelvic floor abnormalities by the 2 methods were calculated.The agreement of DTP-US and DMRD in diagnosing rectocele was analysed by Cohen's kappa test.The difference of the depth of rectocele measured by DTP-US and DMRD was compared by paired samplet test,and the correlation of the depth of rectocele measured by DTP-US and DMRD was analyzed by using the Pearson correlation coefficient.Results Of the 14 patients diagnosed by DTP-US,there were 7 patients with bladder prolapse,5 with unrelaxed pelvic floor,2 with uterine prolapse,2 with rectal internal mucous intussusception and 1 with enterocele; of the 18 patients diagnosed by DMRD,there were 12 patients with bladder prolapse,8 with unrelaxed pelvic floor,8 with uterine prolapse,6 with rectal internal mucous intussusception and 1 with enterocele.The agreement coefficient between DTP-US and DMRD in diagnosing rectocele was obvious (κ =0.737,P ＜ 0.05).The depth of the rectocele detected by DTP-US and DMRD were (15 ±6)mm (range,7-24 mm) and (27 ±7)mm (range,20-41 mm),with significant difference between the 2 groups (t =-16.124,P ＜0.05).There was a high coefficient between DTP-US and DMRD in detecting the depth of rectocele (| r | =0.874,P ＜ 0.05).The depth of rectocele detected by DMRD increased as the increase of depth of rectocele detected by DTP-US (| r | =1.000,P ＜ 0.05).Conclusions The agreement between DTP-US and DMRD in diagnosing rectocele is high.The depth of rectocele measured by the 2 methods not only has statistically significance,but also exists a high degree of correlation.While DTP-US is superior to DMRD in terms of quick diagnosis and better telerance of patients. Key words: Rectocele; Dynamic transperineal ultrasound; Dynamic magnetic resonance imaging defecography ; Constipation ; Outlet obstruction constipation

Descending Perineum Syndrome: A Fresh Look at an Interesting and Complex Pelvic Floor Disorder

Descending Perineum Syndrome (DPS) is a rare but complex clinical entity of pelvic floor dysfunction presenting mostly with defecatory dysfunction and to lesser extent can cause voiding dysfunctions. Despite early interest and well characterization of DPS in the literature, to date, there is no consensus on the best approach for treatment. Biofeedback and physical therapy can in mild cases. In this study, we constructed the cohort of patients who have been diagnosed with DPS and underwent surgical treatment at Mayo Clinic, Rochester, from January 1, 2002, through September 1, 2013. This is a historical cohort study. The Mayo Clinic Electronic Medical Record Linkage System was utilized to identify participants. The Mayo Clinic surgical index was searched using the corresponding ICD-9 codes related to sacrocolpopexy along with Halban and Moschowitz culdoplasty. This was further word searched for phrases related to DPS including “perineal descent,” “hernia of Douglas pouch,” and “peritoneocele.” Medical records were reviewed to verify the selection and document diagnosis of DPS based on criteria from magnetic resonance imaging (MRI) defecography or clinical examination of perineal ballooning. Statistical analysis was performed using JMP 9.0 software (SAS Inc., Carey, NC). Of 93 patients who were identified, only 61 had confirmed diagnosis of DPS. The median age of diagnosis was 56 years (range, 19-84 years), median parity of 2 (range, 0-9) with 9 (15%) that were nulliparas. The median BMI was 24.6 kg/m2 with 10 (16.4%) with BMI >30. Presenting symptoms included defecatory dysfunction with infrequent bowel movement in all patients, with incomplete emptying in 87%, deep perineal pain in 70%, rectal prolapse in 65%, and fecal incontinence in 36%. On MRI, evidence of anatomic abnormality in the anal internal and external anal sphincter along with puborectalis in 30% of cases while functional (Figure). All patients had surgical treatment that included a modified sacrocolpopexy with extension of the mesh the pelvic side wall in 27 patients (44.3%) while 29 patients (47.4%) had some sort of uterosacral plication with culdoplasty, and 4 patients had a combined procedure. Improvement of defecatory dysfunction was noted in 49 patients (80.3%) at their postoperative visit. DPS is a complex pelvic floor disorder. Diagnosis can be done by physical examination and confirmed by MRI defecography. Surgical treatment can help to improve defecatory dysfunction in selected patients.

Symptomatic rectocele: what are the indications for repair?

BackgroundThe surgical indications for symptomatic rectocele are undefined, and surgery has high recurrence rates. We implemented magnetic resonance imaging defecography (MRID) to determine if utilizing strict inclusion criteria for rectocele repair improves outcomes. MethodsPatients with obstructive defecation syndrome (ODS) who underwent dynamic MRID were evaluated. Indications for surgical repair were defecation requiring manual assistance and the following MRID results: anterior defect >2 cm, incomplete evacuation, and the absence of perineal descent. Primary outcomes were the change in quality of life (QOL) scores and recurrence. ResultsFrom 2006 to 2013, 143 patients who presented with ODS underwent MRID. Seventeen patients met the criteria for repair. Recurrence was low (5.8%) with a median follow-up of 23 months, QOL scores improved from 57.3 to 76.5 (P = .041). ConclusionsA minority of patients (12%) with ODS met the above criteria for rectocele repair. Patients who underwent repair had a significant improvement in QOL and low recurrence rate.

Evaluation of Constipation

The evaluation of the chronically constipated patient is multifaceted and challenging. Many clinicians define constipation according to the latest Rome III diagnostic criteria for functional gastrointestinal disorders. Female sex, older age, low fiber diet, a sedentary life style, malnutrition, polypharmacy, and a lower socioeconomic status have all been identified as risk factors for functional constipation. In elderly patients, it is important to rule out a colonic malignancy as the cause of constipation. The initial evaluation of the constipated patient includes a detailed history to elicit symptoms distinguishing slow transit constipation from obstructive defecation. Slow transit and obstructive defecation are the two major subtypes of functional constipation. In addition, the clinician should identify any secondary causes of constipation. The office examination of the constipated patient includes an abdominal, perineal, and a rectal exam. Many patients improve with lifestyle modification. When dietary interventions and lifestyle modifications fail, many diagnostic studies are available to further evaluate the constipated patient. Sitzmark transit study, nuclear scintigraphic defecography, electromyography, anorectal manometry, balloon expulsion test, paradoxical puborectalis contraction, cinedefecography, and dynamic magnetic resonance imaging defecography have all been used to diagnose the underlying causes of functional constipation.

Role of dynamic magnetic resonance imaging in management of obstructed defecation case series

Aims Surgical treatment of obstructed defecation (OD) carries frequent recurrences. The aim of the study was to evaluate the role dynamic magnetic resonance imaging defecography, and to elucidate the underlying anatomic and pathophysiologic background of pelvic floor disorders in these patients in order to minimize failures. Patients and methods Forty consecutive constipated patients with OD symptoms (31 females) with mean age 48.15 ± 14.29 years. They underwent perineal examination, proctoscopy, anorectal manometry and Dynamic MRI defecography. The different pelvic floor morphology was recorded. The type and outcome of treatment whether conservative or surgical were also recorded. Results The dynamic MRI of the pelvic floor showed 23 patients with descending perineum, 32 rectoceles (28 females), 12 cystoceles (10 females), 6 enteroceles (4 females), 18 intussusceptions (14 females), and 7 dyskinetic puborectalis muscle (3 females). The diagnosis of combined pelvic floor disorders with dynamic MRI defecography was consistent with clinical results in 70% and there were additional diagnostic parameters in 30% of patients. Dynamic MRI findings changed treatment decision in 8 patients 20% with surgical treatment performed in 25 patients (8 stappled trans-anal rectal resection, 11 trans-anal Delorme's, 6 trans-abdominal combined repair), and conservative treatment in 15 patients. Conclusions Dynamic magnetic resonance imaging represents a convenient diagnostic procedure in females and to a lesser extent in males, especially in terms of dynamic imaging of pelvic floor organs during defecation. In addition to the clinical assessment, dynamic magnetic resonance imaging had clinical impact in OD and interdisciplinary treatment.

Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations

Background Magnetic resonance imaging (MRI) of the pelvic floor allows better assessment of pelvic pathology and has a potential as an adjunct for therapy planning. In complex congenital malformations of the pelvic floor and continence organs, it plays a major role in assessing urinary and fecal incontinence or constipation, especially when performed as a dynamic investigation such as MRI defecography. Patients and Methods Twenty-three patients (3-21 years old) with urinary and/or fecal incontinence or constipation attributable to congenital malformations of the pelvic region presented at our institution. The diagnoses were anorectal malformations (18), bladder exstrophy (2), and cloacal exstrophy (3). All patients underwent static and dynamic MRI of the pelvic floor with rest, squeeze, and evacuation in supine position. Results Morphology and function of the pelvic floor and pelvic organs could be demonstrated in each case. The reason for urinary incontinence, fecal incontinence, or constipation could be defined, and an individual therapeutic management concept was made based upon the data obtained by the investigation. Conclusions The advantages of this method, in comparison to others, are direct visualization of the pelvic floor muscles and continence organs and their anatomical relationship during different functional actions. Pelvic floor dysfunction is often the reason for fecal and urinary incontinence and can be detected by MRI. Especially in children, minimizing radiation exposure is of major concern. Disadvantages are the costs and long investigation time.

Stapled Transanal Rectal Resection Under Laparoscopic Surveillance for Rectocele and Concomitant Enterocele

Stapled transanal rectal resection recently became a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential threat to structures located in front of the anterior rectal wall. We decided to perform a combined procedure of transanal rectal resection with a simultaneous laparoscopy for patients with obstructed defecation syndrome and an enterocele. Between November 2002 and May 2005 a total of 41 patients were treated surgically for obstructed defecation syndrome. Four patients with concomitant enterocele underwent stapled transanal rectal resection under laparoscopic surveillance. Before surgery all patients underwent preoperative assessment, including clinical examination, colonoscopy, conventional video defecography, dynamic magnetic resonance imaging defecography, gynecology examinations, and psychologic evaluation. The mean operative time was 50 (+/-16.5) minutes for the conventional stapled transanal rectal resection and 67 (+/-14.1) minutes for combined laparoscopy and stapled transanal rectal resection (P < 0.01). Three major complications were observed: two had bleeding in the staple line (one from each group) and one had a late abscess in the staple line. The combination of the stapled transanal rectal resection procedure and laparoscopy provides the opportunity to perform transanal rectal resection without the threat of intra-abdominal lesions caused by enterocele.