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

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



Surgical treatment of rectal intussusception
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., 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


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 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



    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



    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 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



    Rectal intussusception and rectocoele
    Rectal intussusception and Rectocoele

    Point of ‘take-off’

    ARJ



    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



    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



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