EXternal Pelvic REctal SuSpension
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EXternal Pelvic REctal SuSpension Using Permacol Implant The ‘Express’ Procedure. P Giordano ACOI 2005. Rectal intussusception (RI). Definition full-thickness descent of the rectal wall Mellgren et al ., 1994 Felt-Bersma & Cuesta, 2001 Recto-rectal Recto-anal.

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EXternal Pelvic REctal SuSpension Using Permacol Implant The ‘Express’ Procedure

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External pelvic rectal suspension using permacol implant the express procedure

EXternal Pelvic REctal SuSpension Using Permacol Implant

The ‘Express’ Procedure

P Giordano

ACOI 2005


External pelvic rectal suspension using permacol implant the express procedure

Rectal intussusception (RI)

  • Definition

  • full-thickness descent of the rectal wall

    • Mellgren et al., 1994

    • Felt-Bersma & Cuesta, 2001

    • Recto-rectal

    • Recto-anal


External pelvic rectal suspension using permacol implant the express procedure

Commonly diagnosed at evacuation proctography


Surgical treatment of rectal intussusception

Surgical treatment of Rectal Intussusception

  • Abdominal approach

  • Perineal approach


External pelvic rectal suspension using permacol implant the express procedure

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., 1996

Schultz et al., 2000

Johansson et al., 1985


Perineal procedures

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


External pelvic rectal suspension using permacol implant the express procedure

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

    Obstructed Rectocoele

    Recal Intussusception


    Treatment of rectocoele

    Treatment of Rectocoele

    }

    The conventional approach is to consider rectocoele as merely a weakness in the rectovaginal septum

    • 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


  • External pelvic rectal suspension using permacol implant the express procedure

    EXternal Pelvic REctal SuSpensionThe ‘Express’ procedureNSWilliams, LS Dvorkin, P Giordano et al. Br J Surg 2005;92:598-604Aim

    • 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

    Patient Selection


    Clinical and physiological assessment

    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


  • Operative details

    Operative details

    Transversus perineii retracted upwards

    Anterior rectal wall

    Puborectalis


    Results of the express procedure

    Results of the ‘Express’ procedure


    Demographics

    Demographics

    • N = 17 (13 F)

    • Median age 47 years (20 – 67)

    • Median follow-up 12months (6 - 20)

    • 13 (all F) had concomitant rectocoele repair


    Morbidity

    Morbidity


    Morbidity1

    Morbidity

    • Vaginal perforation (n = 2)

    • Anterior rectal wall perforation (n = 3)

      • 1 sepsis and subsequent stoma


    Functional outcome clinical symptom score

    Functional outcome: clinical symptom score

    * Wilcoxon signed rank test (n=15)


    Functional outcome quality of life score

    Functional outcome: quality of life score

    * Wilcoxon signed rank test (n=15)


    Anatomical outcome ri

    Anatomical outcome: RI

    6 normal


    Anatomical outcome rectocoele n 11

    Anatomical outcome: rectocoele(n = 11)

    8 = normal

    3 = persistent


    Conclusion

    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

    Defecation should be natural


    Rectal intussusception and rectocoele

    Rectal intussusception and Rectocoele

    Point of ‘take-off’

    ARJ


    Aids to evacuation

    Aids to evacuation


    External pelvic rectal suspension using permacol implant the express procedure

    SRUS

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


    Faecal incontinence

    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

    Anorectal physiological investigation


    Functional outcome vs proctographic findings

    Functional outcome vs. proctographic findings

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


    Evacuatory dynamics

    Evacuatory dynamics


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