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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. 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

slide2
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
slide5
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

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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

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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
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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)

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

slide28
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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