The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders.

AIM: Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process. METHOD: Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up. RESULTS: After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy. CONCLUSION: The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Anal Sphincter Length as Determined by 3-Dimensional Endoanal Ultrasound and Anal Manometry: A Study in Healthy Nulliparous Women.

OBJECTIVES: The normal female external anal sphincter (EAS) is shorter anteriorly than laterally and posteriorly. Furthermore, the thickness of the very proximal part of the circular EAS is thinner than 50% of the lateral and posterior EAS thickness. The extent of these features is not fully explored. The aim of this prospective study was to assess the normal anal sphincter with 3-dimensional (3D) endoanal ultrasound (EAUS) and to relate 3D EAUS length measurements to sphincter length determined by anal manometry. METHODS: Healthy premenopausal nulliparous women underwent anal manometry and 3D EAUS examinations. Two experienced colorectal surgeons independently assessed all scans, blinded to any patient data. RESULTS: A total of 43 women were included. Four scans were incomplete and excluded from the analysis. Interobserver agreement was fair to very good for the various length measurements. The mean length from the distal border of the puborectal muscle to the very proximal border of the anterior EAS (the anterior gap) was 4.4 (95% confidence interval, 3.9-4.9) mm, whereas the length to the level where the anterior EAS thickness was at least 50% of the lateral and posterior EAS thickness was 7.2 (95% confidence interval, 6.5-7.9) mm. Manometric sphincter length at rest did not correlate with any 3D EAUS length measurements. CONCLUSIONS: In the normal anterior female anal canal, the EAS is not present or appears with less than 50% of the thickness of the lateral and posterior EAS for the first 7.2 mm below the distal border of the puborectal muscle.

Pelvic mesh in colorectal pelvic floor surgery-implications of recent developments.

The use of mesh prostheses in pelvic surgery is under significant scrutiny. There are justifiable concerns around the transvaginal use of mesh products for POP surgery. The latter part of 2017 saw the announcement of wide-ranging regulatory actions relating to transvaginal mesh products, by the Therapeutic Goods Administration in Australia and subsequently Medsafe in New Zealand. In colorectal surgery, pelvic mesh is predominantly used in the treatment of rectal prolapse, with ventral mesh rectopexy (VMR) becoming popularised in recent years. The available evidence suggests that despite the current mesh controversy, VMR is an acceptable procedure, with functional advantages over other colorectal prolapse procedures. With only short-term outcome data available however, comparative studies and longer follow-up are required to answer the question of long-term mesh safety. In the meantime, there are areas where surgical practice can be optimised, in particular around reporting, training and patient education. The aims of this paper are to summarise the current status of pelvic floor mesh surgery and examine how this will impact colorectal pelvic floor surgery.

'How I do it': TEM for tumors of the rectum.

INTRODUCTION: Transanal endoscopic microsurgery (TEM) has an established role in the management of benign rectal tumors. It also has an expanding role in the management of malignant tumors, which is more demanding for the clinician. It requires accurate histological and radiological assessment and draws on an expert understanding of the nature of local recurrence, metastasis, and the place of adjuvant therapies. DISCUSSION: A multidisciplinary approach is recommended. This paper discusses our institutional approach to TEM for benign and malignant tumors and covers some of the current management controversies.