THE ‘EXPRESS’ PROCEDURE FOR RECTAL INTUSSUSCEPTION

1
EXternal Pelvic REctal SuSpension Using Permacol
Implant The Express Procedure
P Giordano ACOI 2005
2
Rectal intussusception (RI)

• Definition
• full-thickness descent of the rectal wall
• Mellgren et al., 1994
• Felt-Bersma Cuesta, 2001
• Recto-rectal
• Recto-anal

3
 
Commonly diagnosed at evacuation proctography
4
Surgical treatment of Rectal Intussusception

• Abdominal approach
• Perineal approach

5
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
6
Perineal procedures

• Intra-rectal Délormes
• 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
7
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
8
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

9
EXternal Pelvic REctal SuSpensionThe Express
procedure NS Williams, LS Dvorkin, P Giordano et
al. Br J Surg 200592598-604 Aim

• To develop a minimally invasive perineal
  procedure to correct RI rectocoele
• Using an acellular porcine collagen implant
  (Permacol)

10
Patient Selection

• Inclusion Criteria
• Circumferential / full-thickness RI
• Symptoms consistent with physiological findings
• Failed maximal conservative therapy
• Rectocoele gt 2 cm and retains neo-stool

• Exclusion Criteria
• Organic disease
• Delayed colonic transit
• Rectal hyposensitivity
• Overt rectal prolapse
• lt18 years old

11
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

12
Operative details
Transversus perineii retracted upwards
Anterior rectal wall
Puborectalis
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
Results of the Express procedure
17
Demographics

• N 17 (13 F)
• Median age 47 years (20 67)
• Median follow-up 12 months (6 - 20)
• 13 (all F) had concomitant rectocoele repair

18
Morbidity
19
Morbidity

• Vaginal perforation (n 2)
• Anterior rectal wall perforation (n 3)
• 1 sepsis and subsequent stoma

20
Functional outcome clinical symptom score
Wilcoxon signed rank test (n15)
21
Functional outcome quality of life score
Wilcoxon signed rank test (n15)
22
Anatomical outcome RI
6 normal
23
Anatomical outcome rectocoele(n 11)
8 normal 3 persistent
24
Conclusion

• The Express procedure is a safe and effective
  surgical option for rectal intussusception and
  rectocoele in patients with evacuatory symptoms

25
Defecation should be natural
26
Rectal intussusception and Rectocoele
Point of take-off
ARJ
27
Aids to evacuation
28
SRUS

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

29
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

30
Anorectal physiological investigation
31
Functional outcome vs. proctographic findings

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

32
Evacuatory dynamics