Rofo 2016; 188(01): 38-44
DOI: 10.1055/s-0041-105406
Abdomen
© Georg Thieme Verlag KG Stuttgart · New York

Changes in Dynamic Pelvic Floor Magnet Resonance Imaging and Patient Satisfaction after Resection Rectopexy for Obstructed Defecation Syndrome

Auswirkungen der Resektionsrektopexie auf den Beckenboden und die Lebensqualität von Patienten mit ODS (obstructed defecation syndrome)
M. Reichert
1   Department of General and Thoracic Surgery, University Hospital of Giessen, Germany
,
A. Busse
1   Department of General and Thoracic Surgery, University Hospital of Giessen, Germany
,
A. Hecker
1   Department of General and Thoracic Surgery, University Hospital of Giessen, Germany
,
I. Askevold
1   Department of General and Thoracic Surgery, University Hospital of Giessen, Germany
,
M. Kampschulte
2   Department of Diagnostic and Interventional Radiology, University Hospital of Giessen, Germany
,
O. Wüsten
2   Department of Diagnostic and Interventional Radiology, University Hospital of Giessen, Germany
,
G. A. Krombach
2   Department of Diagnostic and Interventional Radiology, University Hospital of Giessen, Germany
,
T. Schwandner
1   Department of General and Thoracic Surgery, University Hospital of Giessen, Germany
,
W. Padberg
1   Department of General and Thoracic Surgery, University Hospital of Giessen, Germany
› Author Affiliations
Further Information

Publication History

02 June 2015

26 July 2015

Publication Date:
01 September 2015 (online)

Abstract

Purpose: Resection rectopexy (RR) provides good functional results and low recurrence rates for the treatment of obstructed defecation syndrome based on rectal prolapse and cul-de-sac syndrome, whereas little is known about changes in pelvic floor dynamics and patient satisfaction after surgery.

Materials and Methods: Within three years 26 consecutive female patients were prospectively included. Indications for RR (22 laparoscopic, 3 primary open and 1 converted-to-open) were rectal prolapse III° in 11 patients and cul-de-sac syndrome in 15 patients. Patients’ quality of life (QOL), fecal behavior and defecation-associated pain were investigated before and after surgical treatment using anamnesis and clinical examination, Rand 36-idem health survey (SF-36), Cleveland-Clinic Incontinence Score (CCIS) and the visual analog scale for defecation-associated pain (VAS). Dynamic pelvic floor magnet resonance imaging (dPF-MRI) was used for the investigation of changes in pelvic floor anatomy and function before and after surgery.

Results: RR improved the rate of fecal incontinence (p < 0.01) and CCIS (p = 0.01). The use of laxatives (p = 0.01), the need for self-digitation (p = 0.02) and VAS (p < 0.01) were decreased, leading to improvements in QOL (overall p < 0.01). RR led to shortening of the H-line but not of the M-line under rest (p < 0.01) and during defecation (p = 0.04). A rectocele was co-incident in all patients in dPF-MRI before surgery. RR led to a reduction (p < 0.01) and declined protrusion (p = 0.03) of the rectocele. This results in a decreased rate of cul-de-sac (p < 0.01) and increased rate of complete defecation (p < 0.01) after surgery. At the 36-month follow-up no recurrence was observed.

Conclusion: RR promises high rates of patient satisfaction and improvement in pelvic floor anatomy in select patients.

Key Points:

• RR improves the pelvic floor anatomy of patients suffering from ODS

• RR improves the QOL of patients suffering from ODS

• An improvement in pelvic floor anatomy led to an improved QOL

• RR is an adequate treatment for select patients suffering from ODS

Citation Format:

• Reichert M, Busse A, Hecker A et al. Changes in Dynamic Pelvic Floor Magnet Resonance Imaging and Patient Satisfaction after Resection Rectopexy for Obstructed Defecation Syndrome. Fortschr Röntgenstr 2016; 188: 38 – 44

Zusammenfassung

Ziel: Die Resektionsrektopexie (RR) kann mit guten funktionellen postoperativen Ergebnissen und niedrigen Rezidivraten bei Patienten mit ODS (obstructed defecation syndrome) durch einen Rektumprolaps oder Sigmoidozele eingesetzt werden. Dabei ist jedoch wenig über die postoperativen dynamischen Veränderungen des Beckenbodens bekannt.

Material und Methoden: Innerhalb von drei Jahren wurden 26 Patientinnen prospektiv in die Studie eingeschlossen. Indikationen zur RR (22 laparoskopisch, 3 primär offen und 1 konvertiert) waren der Rektumprolaps III° bei 11 und die Sigmoidozele bei 15 Patientinnen. Lebensqualität (QOL), Stuhlgewohnheiten und defäkations-assoziierte Schmerzen wurden vor und nach der chirurgischen Therapie erfasst durch Anamnese, klinische Untersuchung, Rand 36-idem health survey (SF-36), Cleveland-Clinic Incontinence Score (CCIS) und visuelle Analogskala für defäkations-assoziierte Schmerzen (VAS). Veränderungen in der Beckenbodenanatomie und -funktion wurden mittels dynamischen Beckenboden-MRT (dPF-MRI) vor und nach RR erfasst.

Ergebnisse: Die RR verbessert den Grad der Stuhlinkontinenz (p < 0,01) und den CCIS (p = 0,01). Der Laxanzienabusus (p = 0,01), die Notwendigkeit der manuellen Stuhlausräumung (p = 0,02) und die VAS (p < 0,01) waren postoperativ reduziert, was in einer Verbesserung der QOL (overall p < 0,01) resultierte. MRT-morphologisch zeigte sich postoperativ eine Verkürzung der H-, jedoch nicht der M-Linie in Ruheposition (p < 0,01) und während des Defäkationsprozesses (p = 0,04). Bei allen Patienten wurde im präoperativen dPF-MRI eine Rektozele diagnostiziert, die sich postoperativ signifikant kleiner darstellte (p < 0,01). Durch die Veränderungen kam es postoperativ zu einer Verbesserung der Rate an kompletter Stuhlentleerung im dPF-MRI (p < 0,01). Im Follow-up von 36 Monaten konnten keine Rezidive beobachtet werden.

Schlussfolgerung: Die RR führt zu Verbesserungen der QOL und Beckenbodenanatomie sowie -funktion in ausgewählten Patienten mit ODS.

Kernaussagen:

• Die RR verbessert die Beckenbodenanatomie von Patienten mit ODS

• Die RR verbessert die Lebensqualität von Patienten mit ODS

• Verbesserungen in der Beckenbodenanatomie führen zu einer höheren QOL

• Die RR ist eine geeignete Therapieoption für ausgewählte Patienten mit ODS

 
  • References

  • 1 Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 2011; 106: 1582-1591 ; quiz 1581, 1592
  • 2 D'Hoore A, Penninckx F. Obstructed defecation. Colorectal Dis 2003; 5: 280-287
  • 3 Laubert T, Bader FG, Kleemann M et al. Outcome analysis of elderly patients undergoing laparoscopic resection rectopexy for rectal prolapse. Int J Colorectal Dis 2012; 27: 789-795
  • 4 Kim M, Isbert C. Anorectal functional diagnostics. Therapy algorithm for obstruction and incontinence. Chirurg 2013; 84: 7-14
  • 5 Andromanakos N, Skandalakis P, Troupis T et al. Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management. J Gastroenterol Hepatol 2006; 21: 638-646
  • 6 Bruch HP, Herold A, Schiedeck T et al. Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 1999; 42: 1189-1194 ; discussion 1194–1185
  • 7 Laubert T, Kleemann M, Roblick UJ et al. Obstructive defecation syndrome: 19 years of experience with laparoscopic resection rectopexy. Tech Coloproctol 2013; 17: 307-314
  • 8 Keighley MR, Fielding JW, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 1983; 70: 229-232
  • 9 Luukkonen P, Mikkonen U, Jarvinen H. Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis 1992; 7: 219-222
  • 10 Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach. Dis Colon Rectum 1999; 42: 655-660
  • 11 McKee RF, Lauder JC, Poon FW et al. A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet 1992; 174: 145-148
  • 12 Madoff RD, Williams JG, Wong WD et al. Long-term functional results of colon resection and rectopexy for overt rectal prolapse. Am J Gastroenterol 1992; 87: 101-104
  • 13 Bolog N, Weishaupt D. Dynamic MR imaging of outlet obstruction. Rom J Gastroenterol 2005; 14: 293-302
  • 14 Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36: 77-97
  • 15 Comiter CV, Vasavada SP, Barbaric ZL et al. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology 1999; 54: 454-457
  • 16 Yang A, Mostwin JL, Rosenshein NB et al. Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display. Radiology 1991; 179: 25-33
  • 17 Schwandner T, Hecker A, Hirschburger M et al. Does the STARR procedure change the pelvic floor: a preoperative and postoperative study with dynamic pelvic floor MRI. Dis Colon Rectum 2011; 54: 412-417
  • 18 Lehur PA, Stuto A, Fantoli M et al. Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized, controlled trial. Dis Colon Rectum 2008; 51: 1611-1618
  • 19 Formijne Jonkers HA, Draaisma WA, Wexner SD et al. Evaluation and surgical treatment of rectal prolapse: an international survey. Colorectal Dis 2013; 15: 115-119
  • 20 Laubert T, Kleemann M, Schorcht A et al. Laparoscopic resection rectopexy for rectal prolapse: a single-center study during 16 years. Surg Endosc 2010; 24: 2401-2406
  • 21 Williams JG, Rothenberger DA, Madoff RD et al. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 1992; 35: 830-834
  • 22 Kimmins MH, Evetts BK, Isler J et al. The Altemeier repair: outpatient treatment of rectal prolapse. Dis Colon Rectum 2001; 44: 565-570
  • 23 Oliver GC, Vachon D, Eisenstat TE et al. Delorme's procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases. Dis Colon Rectum 1994; 37: 461-467
  • 24 Riansuwan W, Hull TL, Bast J et al. Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World J Surg 2010; 34: 1116-1122
  • 25 Agachan F, Reissman P, Pfeifer J et al. Comparison of three perineal procedures for the treatment of rectal prolapse. South Med J 1997; 90: 925-932
  • 26 Kim DS, Tsang CB, Wong WD et al. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42: 460-466 ; discussion 466–469
  • 27 Demirbas S, Akin ML, Kalemoglu M et al. Comparison of laparoscopic and open surgery for total rectal prolapse. Surg Today 2005; 35: 446-452
  • 28 Kariv Y, Delaney CP, Casillas S et al. Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc 2006; 20: 35-42
  • 29 Tsiaoussis J, Chrysos E, Athanasakis E et al. Rectoanal intussusception: presentation of the disorder and late results of resection rectopexy. Dis Colon Rectum 2005; 48: 838-844
  • 30 Benoist S, Taffinder N, Gould S et al. Functional results two years after laparoscopic rectopexy. Am J Surg 2001; 182: 168-173
  • 31 Stevenson AR, Stitz RW, Lumley JW. Laparoscopic-assisted resection-rectopexy for rectal prolapse: early and medium follow-up. Dis Colon Rectum 1998; 41: 46-54
  • 32 Ashari LH, Lumley JW, Stevenson AR et al. Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience. Dis Colon Rectum 2005; 48: 982-987
  • 33 Johnson E, Carlsen E, Mjaland O et al. Resection rectopexy for internal rectal intussusception reduces constipation and incomplete evacuation of stool. Eur J Surg Suppl 2003; 51-56
  • 34 Johnson E, Stangeland A, Johannessen HO et al. Resection rectopexy for external rectal prolapse reduces constipation and anal incontinence. Scand J Surg 2007; 96: 56-61
  • 35 Kneist W, Kauff DW, Naumann G et al. Resection rectopexy--laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results. Langenbecks Arch Surg 2013; 398: 565-570
  • 36 Zittel TT, Manncke K, Haug S et al. Functional results after laparoscopic rectopexy for rectal prolapse. J Gastrointest Surg 2000; 4: 632-641
  • 37 Sezai D, Demirbas S, Akin L et al. The impact of laparoscopic resection rectopexy in patients with total rectal prolapse. Mil Med 2005; 170: 743-747
  • 38 Paetzel C, Strotzer M, Furst A et al. Dynamic MR defecography for diagnosis of combined functional disorders of the pelvic floor in proctology. Rofo 2001; 173: 410-415
  • 39 Roos JE, Weishaupt D, Wildermuth S et al. Experience of 4 years with open MR defecography: pictorial review of anorectal anatomy and disease. Radiographics 2002; 22: 817-832
  • 40 Siproudhis L, Dautreme S, Ropert A et al. Dyschezia and rectocele--a marriage of convenience? Physiologic evaluation of the rectocele in a group of 52 women complaining of difficulty in evacuation. Dis Colon Rectum 1993; 36: 1030-1036
  • 41 Maglinte DD, Kelvin FM, Fitzgerald K et al. Association of compartment defects in pelvic floor dysfunction. Am J Roentgenol 1999; 172: 439-444