Resección rectal por vía perineal mediante engrapadora lineal: experiencia inicial de una nueva técnica para el tratamiento del rectocele anterior / Rectal resection perineally via a linear stapler: initial experience of a new technique for the treatment of the anterior rectocele

Introducción: Analizar los resultados a corto y mediano plazo del tratamiento del rectocele anterior mediante la resección rectal transperineal con engrapadora lineal y refuerzo del tabique rectovaginal con malla. Prospectivo de casos consecutivos. Pacientes y método: Entre 01 de abril de 2008 y 31 de Marzo de 2010, 12 pacientes fueron tratados en nuestra institución por presentar diagnóstico de Rectocele Anterior. Los pacientes fueron evaluados por cirujanos entrenados; sometidos a manometría anorrectal y estudios imagenológicos dinámicos. Se realizó una técnica de Resección Rectal por vía perineal con engrapadora lineal y la aplicación de malla. Se aplicaron distintos scores para evaluar los resultados. Resultados: El 100% fueron sexo femenino, edad promedio 44,6 años. El tiempo promedio de cirugía fue 164 minutos (r: 135-180). No hubo complicaciones intraoperatorias. La estadía media hospitalaria fue 2,6 días. La morbilidad fue del 16,6% (2) y no hubo mortalidad relacionada al procedimiento. La evaluación basal del score ODS mostró un promedio de 19.16, mientras el promedio determinado al 7 y 21 día postoperatorio fue 0,5 y 0,16 respectivamente (P = 0,001). La evaluación del estreñimiento usando el score PAC-SYM mostró un resultado basal promedio de 17,08, mientras que al 7 y 21 día postoperatorio fue 3,25 y 1,32 respectivamente (P = 0,002). El cuestionario de Satisfacción a los 6 meses mostró mejoría significativa respecto al valor basal (p = 0,001). Conclusión: Esta nueva técnica permite restaurar el tabique rectovaginal resecando el defecto rectal. Los resultados funcionales obtenidos son favorables, con baja morbilidad y pocas complicaciones relacionadas al uso de mallas. (AU)

Objective: To analyze short and mid-term results of anterior rectocele treatment by trans perineal rectal resection with linear stapler and rectovaginal septum reinforcement with mesh. Patients and methods: Between 01April 2008 and 31 March 2010, 12 patients were treated at our institution with diagnosis of Anterior Rectocele. Patients were evaluated by trained surgeons, underwent anorectal manometry and dynamic images studies. We performed a novel technique called "Stapled Perineal Rectocele resection". Different scores were applied to evaluate the results. Results: 100% were female, average age 44.6 years. The mean surgical time was 164 minutes (r: 135-180). There were no intraoperative complications. The average hospital stay was 2.6 days. The morbidity was 16.6% (2) and there was no procedure-related mortality. Baseline of ODS showed an average score of 19.16, while the average determined at 7 and 21 days postoperatively was 0.5 and 0.16 respectively (P = 0.001). The assessment of constipation using the PAC-SYM score showed a mean baseline of 17.08 results, while at 7 and 21 days after surgery was 3.25 and 1.32 respectively (P = 0.002). The patient satisfaction score after six months showed significant improvement from baseline (p = 0.001). Conclusion: The novel technique restores rectovaginal septum and extirpates the rectal defect. The functional results are favorable, with low morbidity and few complications related to the use of mesh. (AU)

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions / Influência da idade, tipo de parto e paridade na prevalência das disfunções do assoalho pélvico no compartimento posterior

CONTEXT: The correlation between vaginal delivery, age and pelvic floor dysfunctions involving obstructed defecation is still a matter of controversy. OBJECTIVES: To determine the influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions in women with obstructed defecation syndrome. METHODS: Four hundred sixty-nine females with obstructed defecation syndrome were retrospectively evaluated using dynamic 3D ultrasonography to quantify posterior pelvic floor dysfunctions (rectocele grade II or III, rectal intussusception, paradoxical contraction/non-relaxation of the puborectalis and entero/ sigmoidocele grade III). In addition, sphincter damage was evaluated. Patients were grouped according to age (<50y x >50y) and stratified by mode of delivery and parity: group I (<50y): 218 patients, 75 nulliparous, 64 vaginal delivery and 79 only cesarean section and group II (>50y): 251 patients, 60 nulliparous, 148 vaginal delivery and 43 only caesarean section. Additionally, patients were stratified by number of vaginal deliveries: 0 - nulliparous (n = 135), 1 - vaginal (n = 46), >1 - vaginal (n = 166). RESULTS: Rectocele grade II or III, intussusception, rectocele + intussusception and sphincter damage were more prevalent in Group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001). The stratified groups (nulliparous, vaginal delivery and cesarean) did not differ significantly with regard to rectocele, intussusception or anismus in each age group. Entero/sigmoidocele was more prevalent in the vaginal group <50y and in the nulliparous and vaginal groups >50y. No correlation was found between rectocele and the number of vaginal deliveries. CONCLUSION: Higher age (>50 years) was shown to influence the prevalence of significant rectocele, intussusception and sphincter damage in women. However, delivery mode and parity were not correlated with the prevalence of rectocele, intussusception and anismus in women with obstructed defecation.

CONTEXTO: A correlação entre parto vaginal, idade e disfunções do assoalho pélvico em pacientes com evacuação obstruída permanece ainda controverso. OBJETIVO: Determinar a influência da idade, tipo de parto e paridade na prevalência de disfunções do assoalho pélvico posterior em mulheres com evacuação obstruída. MÉTODOS: Quatrocentas e sessenta e nove mulheres com evacuação obstruída foram avaliadas, retrospectivamente, utilizando ultrassonografia tridimensional dinâmica para quantificar disfunções do assoalho pélvico posterior (retocele grau II ou III, intussuscepção retal, anismus e entero/sigmoidocele grau III) e presença de lesão esfincteriana. As pacientes foram agrupadas de acordo com a idade (<50 anos e >50 anos) e estratificadas por tipo de parto e paridade em grupo I (<50 anos): incluindo 218 pacientes (75 nulíparas, 64 com partos vaginais e 79 apenas com operações cesarianas) e grupo II (>50 anos): incluindo 251 pacientes (60 nulíparas, 148 com partos vaginais e 43 apenas com cesarianas). Além disso, as pacientes foram estratificadas por número de partos vaginais em nulíparas (n = 135), com um parto vaginal (n = 46) e com mais de um parto vaginal (n = 166). RESULTADOS: Retocele, intussuscepção, associação de intussuscepção e retocele e lesão esfinceriana foram mais prevalentes no grupo II (P = 0,0432, P = 0,0028, P = 0,0178, P = 0,0001). Não houve diferença significante na prevalência de retocele, intussuscepção ou anismus em relação ao tipo de parto e paridade, em cada faixa etária. Êntero/sigmoidocele foi mais prevalente em pacientes com parto vaginal no grupo I e em nulíparas e com parto vaginal no grupo II. Nenhuma correlação foi encontrada entre prevalência de retocele e número de partos vaginais. CONCLUSÃO: A idade superior a 50 anos está associada a maior prevalência de retocele, intussuscepção e lesão esfincteriana, no entanto, a paridade e o tipo de parto não se correlacionam com a prevalência de intussuscepção, retocele e anismus em mulheres com evacuação obstruída.

Prolapsed uterus with huge rectocele and omentocele following cervical amputation: a rare and unusual case presentation.

Pelvic organ prolapse is a common condition whose incidence is increasing. Many cases of prolapse of the posterior vaginal wall occur along with other pelvic support defects. Pelvic surgeons who treat rectocele must have an excellent understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship between anatomy and function. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and faecal incontinence are some of the symptoms that have been described in patients with rectocele.

Defecography in patients with anorectal disorders: a study in 27 cases.

Defecography of twenty-seven cases of anorectal disorders with an age range from 22 to 86 years, were evaluated from June 1989 to February 1999. There were 24 patients with constipation, 2 patients with incomplete defecation and mucous bloody stool in one case. The defecographic results were analyzed regarding the following 1) anorectal angle, defined both at rest and straining 2) abnormalities of the rectal configuration during straining, including rectocele, intussusception, infolding and ulceration. 3) pelvic floor descent. The results showed abnormal anorectal angle 5 cases, rectocele 15 cases, intussusception of the rectal wall 3 cases, infolding 11 cases, ulceration 7 cases and anal canal constriction 1 case. Consequently, the patients with anorectal disorders were found to have a variety of rectal abnormalities in which the defecography would be the imaging tool in demonstrating them.