Obstructed Defecation Research Articles

S122 Three-Dimensional Morphologic Analysis of Severe, Occult Ileoanal Pouch Pathology Using Manual Staple-Line Segmentation: A Proof-of-Concept Study

Background: Twisted pouch syndrome (TPS), in which ileoanal (IPAA) patients is constructed in a twisted manner, was described as the develop the triad of small bowel obstructive (SBO) symptoms inlcuding obstructive defecation, erratic bowel habits, and severe abdominopelvic pain due to torsion of the pouch. Despite an exhaustive work-up, TPS was often not diagnosed until the time of redo pouch surgery, which requires disconnecting and reconnecting the pouch in a non-twisted manner, or neo-IPAA construction. Preoperative 3-dimensional (3D) reconstruction of IPAA radiographic computed tomography (CT) imaging has not previously been described. We aimed to determine if manual segmentation of staple-lines is feasible to aid in the preoperative diagnosis of otherwise occult IPAA pathology. Methods: This study represents a proof-of-concept cases series of patients undergoing surgical management of severe pouch dysfunction to determine if 3D manual segmentation of the linear pouch staple-line morphology could be used to diagnose variations of TPS. Manual segmentation of preoperative CT images was performed using standard, commercially available software to construct preoperative 3D video clips. Results: Patient 1 was a 35-year-old female with recurrent midgut volvulus resulting in SBO’s despite multiple laparotomies. Standard preoperative imaging did not reveal an obvious cause. Preoperative endoscopy suggested a chronic pouch volvulus, and 3D reconstruction revealed a 360-degree spiraling of the upper half of her pouch, and this was confirmed to be the lead point at the time of pelvic adhesiolysis, secondary to a occult tip of the J leak which caused the tip of the J to volvulize behind the pouch. The volvulus was reduced, pouch pexied, and she was diverted with intentional tension. After this staged surgical correction, there was no recurrence of her volvulus or SBO at 14 months. Patient 2 was a 19-year-old female with recurrent SBOs every several weeks, presumed secondary to pelvic floor dysfunction. Preoperative imaging was unrevealing, and preoperative endoscopy revealed a tip of the J on the left. 3D reconstruction revealed straight staple-lines, but the tip of the J and afferent limb both to the left of midline. Intraoperatively she was found to have an unintentionally 180-degree twisting of her pouch with the mesentery anteriorly. After redo IPAA, she had no further SBOs at 2 months. Patient 3 was a 33-year-old female with severe pouch dysfunction. Preoperative imaging was unrevealing, and preoperative endoscopy showed spiraling of the lower half of her pouch. 3D reconstruction revealed a 360-degree spiraling of the lower half of her pouch. 3D reconstruction was consistent with TPS which was confirmed at time of redo IPAA. Conclusion(s): Three-dimensional segmentation of ileoanal pouch staple-line morphology is highly feasible using readily available technology. In our practice, this has proven to be an extremely useful, “go to” radiologic adjunct which may be used to successfully diagnose occult mechanical pouch complications requiring redo pouch surgery. Further study, to characterize and validate, with comparison to normal pouches, is ongoing of what we have observed to be a clinical breakthrough to aid in the diagnosis of twisted pouch syndrome.

An Unusual Presentation of Obstructive Defecation

An Unusual Presentation of Obstructive Defecation

Patientpathway in a tertiary referral pelvic floor unit: Telephone triage assessment clinic.

To meet the increasing demands for colorectal pelvic floor services, a dedicated telephone triage assessment clinic (TTAC) was set up to establish a more efficient pathway, and reduce waiting timesand patient's visits to the hospital. The primary aim of this study was to review TTAC in patients suffering from pelvic floor dysfunction and assess its feasibility. Secondary aims include measurement of waiting times for TTAC, main presenting complaints, and main treatment outcomes, including the need for review by a consultant surgeon. Review of data collected retrospectively in a single tertiary referral center collected from an institutional database. Between January 2016 and October 2017, 1192 patients referred to our pelvic floor unit were suitable for TTAC. Of these, 694 patients had complete records. There were 66 without follow-up after the initial TTAC, leaving 628 patients for analysis. In all, 86%were femalesand 14% were males, with a mean age of 52 years (range: 18-89). The median waiting time for TTAC was 31 days (range: 0-184). The main presenting complaint during the TTAC was obstructive defecation in 69.4%, fecal incontinence in 28.5%, and rectal prolapse in 2.1%. In our study, 611 patients had conservative management (97.3%), with a median of three sessions per patient (range: 1-16), while 82 patients (13.1%) needed a surgical intervention. Only 223 patients (35.5%) were reviewed by a consultant at some stage during the study period. To optimize resources, an adequate triage system allowed us to streamline the pathway for each individual patient with pelvic floor dysfunction according to their symptoms and/or testresults with the aim of reducing waiting times and expediting treatment.

Proctalgia and obstructive defecation syndrome secondary to internal anal sphincter idiopathic hypertrophy

Proctalgia and obstructive defecation syndrome secondary to internal anal sphincter idiopathic hypertrophy

Tailoring surgery for obstructed defecation syndrome to the ‘iceberg diagram’: Long-term results

BackgroundPatients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results. MethodsPatients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated. ResultsOf the 80 operated patients, 73 were females; median age was 47 (range 26–78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured. ConclusionThe use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent “submerged lesions’ that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

Predictive factors for functional failure of ventral mesh rectopexy in the treatment of rectal prolapse and obstructed defecation

BackgroundVentral mesh rectopexy (VMR) is widely accepted for the treatment of rectal prolapse or obstructed defecation. However, despite good anatomical results, the improvement of functional symptoms (constipation or incontinence) cannot always be obtained and in some cases these symptoms may even worsen. The aim of the present study was to identify possible predictors of functional failure after VMR.MethodsData of all consecutive patients who had VMR for the treatment of rectal prolapse and/or obstructed defecation between January 2017 and December 2020 in three different pelvic floor surgical centres in Italy were analysed to identify possible predictors of functional failure, intended as persistence, worsening or new onset of constipation or faecal incontinence. Symptom severity was assessed pre- and postoperatively with the Wexner Constipation score and Obstructed Defecation Syndrome score. Quality of life was assessed, also before and after treatment, with the Patients Assessment of Constipation Quality of Life questionnaire, the Pelvic Floor Disability Index and the Pelvic Floor Impact Questionnaire. Faecal incontinence was evaluated with the Cleveland Clinic Incontinence Score. The functional outcomes before and after surgery were compared.ResultsSixty-one patients were included (M:F ratio 3:60, median age 64 years [range 33–88 years]). Forty-two patients (68.9%) had obstructed defecation syndrome, 12(19.7%) had faecal incontinence and 7 patients (11.5%) had both. A statistically significant reduction between pre- and postoperative Obstructed Defecation Syndrome and Wexner scores was reported (p < 0.0001 in both cases). However, the postoperative presence of constipation occurred in 22 patients (36.1%) (this included 3 cases of new-onset constipation). The presence of redundant colon and the pre-existent constipation were associated with an increased risk of persistence of constipation postoperatively or new-onset constipation (p = 0.004 and p < 0.0001, respectively). The use of postoperative pelvic floor rehabilitation (p = 0.034) may reduce the risk of postoperative constipation.ConclusionsVMR is a safe and effective intervention for correcting the anatomical defect of rectal prolapse. The degree of prolapse, the presence of dolichocolon and pre-existing constipation are risk factors for the persistence or new onset of postoperative constipation. Postoperative rehabilitation treatment may reduce this risk.

S167 Comparison of High-Resolution Anorectal Manometry and Magnetic Resonance Defecography in Patients With Obstructive Defecation: Are Both Tests Necessary?

Introduction: Investigation of evacuation disorders is often pursued in patients with symptoms of obstructive defecation. High-resolution anorectal manometry (HR-ARM) is a simple, safe and widely available test to diagnose pelvic floor dysfunction. A more costly and less accessible test is magnetic resonance defecography (MRD). This study aims to qualify the added value of MRD in diagnosing pelvic floor disorders. Methods: HR-ARM and MRD performed in patients with a diagnosis of constipation between 1/1/2020 and 5/15/22 at Mayo Clinic were identified using Epic SlicerDicer. Univariate and multivariate analyses were used to compare findings on MRD in patients with and without abnormal HR-ARM. Results: Seventy-six consecutive patients (81.8% female, 94.8% white, age 19-82) who underwent both HR-ARM and MRD were included. The majority had evidence of dyssynergia on HR-ARM (n=49, 64.5%). Patients with dyssynergia on HR-ARM were significantly more likely to have prolonged balloon expulsion at both >60 and >30 seconds (p< 0.00001) and incomplete gel expulsion on MRD (p=0.00008) (Table). However, they were not more likely to have a clinically significant rectocele measuring >2cm (p=0.5093) or evidence of rectal prolapse (p=0.071). An increased number of vaginal deliveries was correlated with a higher likelihood of having a rectocele >2cm (r=0.24, p< 0.05). Conclusion: Anatomic findings on MRD were similar between patients with and without evidence of dyssynergia identified by HR-ARM. In this retrospective review, undergoing MRD in addition to HR-ARM does not appear to provide additional diagnostic information to guide therapeutic recommendations. Large prospective studies to evaluate the added value of MRD are needed. Table 1. - Findings on MRD and balloon expulsion test in patients with and without dyssynergia on HR-ARM Dyssynergia on HR-ARM No dyssynergia on HR-ARM P value n= 49 (64.5%) n = 27 (35.5%) Balloon Expulsion >60 sec 30 (61.2%) 0 (0.0%) p< 0.00001 Balloon Expulsion >30 sec 32 (65.3%) 2 (7.4%) p< 0.00001 < 50% gel expulsion on MR 26 (53.1%) 2 (7.4%) p=0.00008 Rectocele on MR 26 (53.1%) 22 (81.5%) p=0.0139 >2 cm Rectocele on MR 21 (42.9%) 16 (59.3%) p=0.5093 >3 cm Rectocele on MR 10 (20.4%) 9 (33.3%) p=0.2113 >4 cm Rectocele on MR 3 (6.1%) 3 (11.1%) p=0.4413 Rectal Prolapse 5 (10%) 7 (31.8%) p=0.071

Biofeedback pelvic floor muscle training versus posterior tibial nerve electrostimulation in treatment of functional obstructed defecation: a prospective randomized clinical trial

BackgroundFunctional obstructed defecation is a common anorectal problem among adult population. The objective was to compare the short-term efficacy of biofeedback pelvic floor muscle training versus transcutaneous posterior tibial nerve electrostimulation in treatment of patients with functional obstructed defecation.ResultsThere were 41 patients completed the study. There were no statistical significant differences between biofeedback pelvic floor muscle training group and transcutaneous posterior tibial nerve electrostimulation group regarding different clinical characteristics, as well as, electrophysiological findings. There was statistically significant reduction in all outcome measures after intervention in both groups. The primary outcome measure was Modified obstructed defecation score. Secondary outcome measures were Patient Assessment of Constipation-Quality of Life questionnaire, time of toileting, and maximum anal pressure during straining to evacuate. No significant differences were present between both groups regarding different outcome measures in the pretreatment and post-treatment assessments. Successful outcome was reported in 81% of patients in biofeedback pelvic floor muscle training group in comparison to 40% of patients in the posterior tibial nerve electrostimulation group according to the Modified obstructed defecation score which was the primary outcome measure.ConclusionsBoth biofeedback pelvic floor muscle training and posterior tibial nerve electrostimulation are considered effective methods in the treatment of functional obstructed defecation. However, biofeedback pelvic floor muscle training seems to be more effective and superior in comparison to posterior tibial nerve electrostimulation. Posterior tibial nerve electrostimulation could be combined with biofeedback pelvic floor muscle training or considered as a second line therapy after failure of biofeedback pelvic floor muscle training.Trial registrationPan African Clinical Trials Registry, PACTR202009762113535. Registered 2 September 2020—retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12321.

Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

BackgroundSurgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers.MethodsSurgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient’s anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario.ResultsTwenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10–20 (54%) to 21–50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function.ConclusionsThe complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.

Pelvic pain is a common prolapse symptom and improvement after ventral mesh rectopexy is more frequent than deterioration or de novo pain.

The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR). Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale. Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0-10.0 years). Symptoms of obstructed defaecation were significantly more common (p= 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common (p= 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger (p= 0.01) and more likely to have revisional surgery after VMR (p= 0.0003), but there was no relation to the indication for surgery (p= 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old (p= 0.001), when obstructed defaecation was the indication (p= 0.03), in mesh erosion (p= <0.05) and when associated with revisional surgery (p= 0.005). Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

Higher Symptom Score, Larger Residual Rectocele, and Lower Rectal Compliance Predict Failure of Improvement after Surgical Treatment of Rectocele

Abstract Background Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09–1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43–6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907–0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure.

ESCP President's report.

ESCP President's report.

Native Tissue Posterior Compartment Repair for Isolated Posterior Vaginal Prolapse: Anatomical and Functional Outcomes.

Background and Objectives: Posterior compartment prolapse is associated with constipation and obstructed defecation syndrome. However, there is still a lack of consensus on the optimal treatment for this condition. We aim to investigate functional, anatomical, and quality-of-life outcomes of native tissue transvaginal repair of isolated symptomatic rectocele. Materials and Methods: We retrospective analyzed patients who underwent transvaginal native tissue repair for stage ≥ II and symptomatic posterior vaginal wall prolapse between January 2018 and June 2021. Anatomical and functional outcomes were evaluated. Wexner constipation score was used to assess bowel symptoms, while the Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Results: Twenty-eight patients were included in the analysis. The median age was 64.5 years, and half of them underwent a previous hysterectomy for benign reasons. The median follow-up time was 33.5 months. A significant anatomical improvement in the posterior compartment was noticed compared with preoperative assessment (p < 0.001 for Ap and Bp), with only two (7.1%) anatomical recurrences. Additionally, obstructed defecation symptoms decreased significantly compared to baseline (p < 0.001), as well as vaginal bulging, with no new-onset cases of fecal incontinence or de novo dyspareunia. PGI-I resulted in 89.2% of patients being satisfied (PGI-I ≥ 2), with a median score of 1.5. Conclusions: Transvaginal native tissue repair for isolated posterior prolapse is safe and effective in managing bowel symptoms, with excellent anatomical and functional outcomes and satisfactory improvement in patients’ quality of life.

Assessment of results of suture rectopexy technique for obstructed defecation syndrome, analysis of recurrent factors

Abstract Introduction: Based on the obliterative suture technique or stapled transanal rectal resection procedure (STARR technique), Nguyen Trung Vinh introduced Suture Rectopexy Technique for Rectal Intussusception associated with Rectocele can not be treated by preservative management. This study aimed to to evaluate the recurrent factors after surgery. Patients and methods: 54 female patients with Obstructed Defecation Syndrome (ODS) underwent Suture Rectopexy for Rectal Intussusception associated with Rectocele from 2017 to 2020 at Trieu An Hospital. These patients were followed up and evaluated up to 18 months after surgery.The related factors evaluated were: Defecation Syndrome, ages, number of delivery, defecation duration, pre-operative ODS (Obstructive Defaecation Syndrome Score), size of rectocele on MRI, images of rectocele on MRI, post-operative urinary retention, anal stricture after surgery. Results: Suture Rectopexy Technique was performed on 54 patients, of them, there were 40 patients had fully follow up for18 months. The improvement of defecation syndrome according to ROME IV after 18 months was 87.5%. ODS (Obstrucive defaecation syndrome Score) post surgery 18 months was 8,13 ± 3,95, the improvement was statiscally significant compares to pre surgery which was 14,6 ± 1,78 (P &lt; 0,05). There were no severe complications recorded. The reccurent factor was found is the defecation duration before surgery. Conclusions: Suture Rectopexy Technique for Rectal Intussusception associated with Rectocele is highly efficient and safe. The reccurent factor was found is the defecation duration before surgery. Keywords: Suture Rectopexy Technique, Rectal intussusception, Rectocele, Constipation,Oobstructed Defecation Syndrome (ODS).

Transcutaneous Tibial Nerve Stimulation as Therapy for Functional Constipation.

Functional constipation is a common disorder that is difficult to treat on occasion. Symptoms of this condition can per- sist despite dietary modification, exercise, and medication. Results of neuromodulation with nerve stimulation have been promising in terms of efficiency for treatment-resistant patients. This study aimed to investigate the efficacy of bilateral transcutaneous tibial nerve stimulation as a noninvasive treatment method for functional constipation. We evaluated 105 patients with functional constipation diagnosed using the Rome IV criteria. Bilateral transcutaneous elec- trical nerve stimulation was utilized for transcutaneous tibial nerve stimulation for 6 weeks; 3 sessions were conducted every week, with each session lasting for at least 30 minutes. The Constipation Severity Instrument was used before treatment, at the end of 6 weeks, and at 12 weeks (6 weeks after the end of treatment). The effects of transcutaneous tibial nerve stimulation on the time spent in the toilet and the use of softeners were investigated. Of the 105 patients included in the study, 41 (39%) were male. The mean age was 43.1 (range, 19-64 years). Transcutaneous tibial nerve stimulation was found to reduce the time patients spent in the toilet. The use of softeners decreased from 76.2% to 20% (P < .001). Obstructive defecation (P < .001), colonic inertia (P < .001), pain (P < .001), and Constipation Severity Instrument total score (P < .001) improved after the 6-week treatment period. The treatment effect persisted until the 12th week. Bilateral transcutaneous tibial nerve stimulation is a noninvasive, easily applicable, and effective treatment for functional constipation, without major adverse effects. Large randomized controlled trials are required so that transcutaneous tibial nerve stimula- tion can be established as an alternative treatment for functional constipation that is resistant to standard care and laxative agents.

Laparoscopic ventral rectopexy plus sacral colpopexy: continuous locked suture for mesh fixation. A randomized clinical trial.

Laparoscopic ventral rectopexy (LVR) plus sacral colpopexy (LSC) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to rectal-mesh fixation during LVR with continuous locked suture. This is a prospective randomized double-blinded clinical trial enrolling 80 patients with severe POP and obstructed defecation syndrome (ODS) from November 2016 to January 2021. Patients underwent a "two-meshes" LSC plus LVR and were randomized, regarding rectal mesh fixation, in Group A (extracorporeal interrupted 0 delayed absorbable sutures) and Group B ("U-shaped" running locked 0 delayed absorbable suture). Our primary endpoints were the operative times (OT); the secondary endpoints were the incidence of anatomical failures, vaginal mesh erosions and surgical complications. A total of 75 patients completed the study. Baseline characteristics were similar between the groups. Overall OT (156 vs 138min; p < 0.05; treatment reduction of 11.5%) and LVR mesh fixation time (29 vs 16min; p < 0.05; treatment reduction of 44%), resulted in significantly lower in Group B. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. PGI-I, FSDS and Wexner questionnaires resulted significantly improved after surgery, without statistical differences between the studied surgical procedures. Laparoscopic continuous locked 0 absorbable suture for LVR mesh fixation guaranteed a faster and effective alternative to multiple interrupted sutures. The significant OT reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LVR. NCT05254860 (13/02/2017).

Reconstruction of the rectovaginal septum with a W-mesh for rectocele

Aim: to assess of late results of original method of rectocele repair with non-absorbable polypropylene W-form mesh. Patients and methods: the pilot study included 37 patients which underwent surgery for rectocele repair using original technique of W-mesh. The late results were assessed in 21 (56.6 %) of them ≥ 6 month after surgery. Before the surgery and 6 months after, patients underwent a clinical assessment of symptoms. Specialized questionnaires for assessment of constipation (Colonic evacuation disorder scale, PFDI-20, Cleveland Clinic Constipation Score) were used. Defecography and anorectal manometry were performed before and in 6-months after surgery for evaluation of pelvic floor disorders. Results: no obstructive defecation symptoms were revealed in 85.7% of patients 6 month after surgery.In ≥ 6 months after surgery all questionnaires showed decrease in scores by more than 2 times. Comparison of the results before and 6 months after the surgery showed significant differences for all questionnaires (p &lt; 0.0001). According to defecography performed before and after the surgery a significant reduction (p &lt; 0.05) of rectocele depth, time of rectal voiding (decreased by 1.5 times) and residual volume of contrast agent (decreased by 2.5 times) were revealed. There are no severe complications requiring re-operation were observed. Conclusion: transvaginal mesh repair of symptomatic rectocele demonstrated good clinical results 6 months after surgery. Good results were revealed in 85,7 % of patients confirmed by specialized questionnaires and defecography.

Efficiency and safety of laparoscopic ventral mesh rectopexy (a systematic review)

Aim: to assess the efficacy and safety of laparoscopic ventral mesh rectopexy in patients with rectocele and rectal prolapse. Materials and methods: a systematic review of the literature on the efficacy and safety of laparoscopic ventral mesh rectopexy in patients with rectocele and/or rectal prolapse. After compiling a search query, 2716 publications were found in the PubMed, MEDLINE, EMBASE, Scopus, Cochrane library, CENTRAL, ISI Web of Science and eLibrary databases. Twenty-four papers were selected according to the inclusion criteria for the review, with a total number of 2101 operated patients. Results: the follow up period after surgery ranged 30.1 (12-74) months. In 20 of 34 studies, the median age of patients was over 60 years, with a median of 62.1 years. The mean operative time was 122.3 minutes (85 to 200 minutes). Complications were revealed in 138 patients (6.5 % observations), recurrence — in 4.1 %. A significant improvement in the symptoms of obstructive defecation was noted in 79.6 %. Conclusion: laparoscopic ventral mesh rectopexy is an effective method for posterior pelvic floor compartment prolapse in terms of both anatomical and functional results. It is safe and has a low risk of complications. However, further research is required to develop indications for the use of this proctdure as a “gold standard”.

Correlation Between Poor Defecation Habits and Postoperative Hemorrhoid Recurrence.

BackgroundThe relationship between hemorrhoid recurrence and poor defecation habits is poorly understood. This study aimed to analyze the effects of poor defecation habits on postoperative hemorrhoid recurrence.Materials and MethodWe performed a retrospective study on 1,162 consecutive patients who underwent a surgical procedure for hemorrhoids at the Sixth Affiliated Hospital of Sun Yat-Sen University from December 2016 to May 2020. All patients were followed for 12 months post-operatively. Patients were monitored for disease recurrence. Patient defecation habits were assessed using an obstructive defecation syndrome (ODS) score.ResultsPatients with a score of 0–4 had a mild defecation disorder, 5–8 a moderate defecation disorder, and 9 or more ODS. Of the 1,162 patients, 1,144 (98.45%) had a mild defecation disorder, 13 (1.12%) had a moderate defecation disorder, and 9 (0.43%) had ODS. Older patients were significantly more likely to have worse defecation habits (P < 0.001). A higher ODS score correlated with a higher maximum anal squeeze pressure (P = 0.07) and a more severe inability for the anus to relax during simulated evacuation (P = 0.002). The maximum rectum threshold was also found to be the highest in ODS patients (P = 0.010). The proportion of Procedure for prolapsing hemorrhoids (PPH) was the highest in the moderate defecation disorder group (53.85), followed by the ODS group (40.00) and the mild defecation disorder group (P = 0.023). Recurrence occurred in 5.51% of patients in the mild defecation disorder group, 38.46% of the moderate defecation disorder group, and 60% of the ODS group (P < 0.001). Multivariate analysis confirmed a higher ODS score (P < 0.001) was an independent predictor of recurrence. Furthermore, patients who occasionally exercised (P = 0.01) and patients who exercised regularly (P = 0.021) were less likely to have a recurrence.ConclusionPatients with unresolved defecation disorders are more likely to have their hemorrhoids recur and are unlikely to be satisfied with surgical management.

Obstruktive Defäkationsstörungen

BackgroundObstructed defecation is a subcategory of chronic constipation, representing an outlet obstruction of the rectum that can be associated with severe functional impairment and decreased quality of life.ObjectivesThe aim is to present the diagnostic assessment, differential diagnoses, and treatment options for obstructed defecation and their evaluation against the background of current studies.Materials and methodsSelected studies are presented.ResultsDiagnosis of obstructed defecation syndrome requires a meticulous workup in order to rule out pelvic floor dyssynergia or slow transit constipation. After primary conservative treatment with medication, pelvic floor retraining and irrigation, surgical procedures can be considered in case of refractory course and evidence of morphological changes as rectocele or intussusception, with adequate functional results.ConclusionsPatient selection and an accurate diagnostic evaluation are decisive for successful treatment of obstructed defecation syndrome.