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Pesikhani MD, Hosseini RS, Ghanbarpour S, Ghashghaee S, Jelodarian P, Kazemi M, Eftekhar T, Ghanbari Z. Assessment of manometric results following posterior pericervical repair or level I to III surgical procedures. J Med Life 2023; 16:1740-1744. [PMID: 38585533 PMCID: PMC10994622 DOI: 10.25122/jml-2022-0357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/20/2023] [Indexed: 04/09/2024] Open
Abstract
Constipation and obstructive bowel disorders are the most common symptoms of prolapse and posterior defects. Prolapse and obstructive defecation disorders are treated using various surgical techniques to repair posterior defects. This study aimed to evaluate the manometry results of patients before and after reconstructive surgery of the posterior compartment. This retrospective cohort study included 40 women with defecation disorders referred to the Imam Khomeini Hospital Complex, an academic center affiliated with Tehran University of Medical Sciences, Tehran, Iran, from 2020 to 2021. Data were collected through medical records and a checklist developed by the researcher before and after surgery. All analyses were performed using SPSS software (version 26), with significance at p<0.05. Forty women with a mean age of 49.47±9.66 years participated in this study. The manometry results showed significant differences in patients before and after surgery in parameters such as maximum resting pressure, push test, constipation, straining during defecation, finger support necessity, sensation of incomplete defecation, dyspareunia, and husband's sexual satisfaction (p<0.001). In addition, all patients had a grade 2 or higher posterior compartment prolapse, which improved in all cases after surgery (p<0.0001). Patients' symptoms significantly improved during the 12-month follow-up after DeLancey level 3 to 1 surgery. This type of surgery proved to be an effective surgical intervention without significant complications in the short-term follow-up.
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Affiliation(s)
- Maryam Deldar Pesikhani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihane Sadat Hosseini
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sanam Ghanbarpour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sanaz Ghashghaee
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parivash Jelodarian
- Department of Obstetrics and Gynecology, Fertility Infertility and Perinatology Research Center, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Kazemi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Eftekhar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zinat Ghanbari
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Ferrari L, Cuinas K, Hainsworth A, Darakhshan A, Schizas A, Kelleher C, Williams AB. Preoperative predictors of success after transvaginal rectocoele repair. Tech Coloproctol 2023; 27:859-866. [PMID: 37212926 DOI: 10.1007/s10151-023-02822-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 05/04/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment. METHODS Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up. RESULTS 115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure. CONCLUSION Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.
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Affiliation(s)
- Linda Ferrari
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK.
| | - Karina Cuinas
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Alison Hainsworth
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Amir Darakhshan
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Alexis Schizas
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Cornelius Kelleher
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Andrew Brian Williams
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
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Bharucha AE, Knowles CH. Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era. Neurogastroenterol Motil 2022; 34:e14453. [PMID: 36102693 PMCID: PMC9887546 DOI: 10.1111/nmo.14453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/06/2022] [Accepted: 08/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. PURPOSE We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles H Knowles
- Blizard Institute (Knowles), Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
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Ferrari L, Cuinas K, Hainsworth A, Darakhshan A, Schizas A, Kelleher C, Williams AB. Transvaginal rectocoele repair for the surgical treatment of a "symptomatic" rectocoele when conservative measures fail: A 12 year experience of 215 patients. Neurogastroenterol Motil 2022; 34:e14343. [PMID: 35246914 DOI: 10.1111/nmo.14343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 01/30/2022] [Accepted: 02/15/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Conservative measures are first-line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery. METHODS We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in-hospital and 30 days post-operative complications and pre- and post-operative symptoms. KEY RESULTS The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in-hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow-up was 12.7 months (SD 13.9, range 1.4-71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS-related symptoms improved in 58% of cases. CONCLUSIONS & INFERENCES The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms.
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Affiliation(s)
- Linda Ferrari
- Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Karina Cuinas
- Guy's and St Thomas NHS Foundation Trust, London, UK
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Picciariello A, Rinaldi M, Grossi U, Trompetto M, Graziano G, Altomare DF, Gallo G. Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2022; 26:963-971. [PMID: 36104607 DOI: 10.1007/s10151-022-02705-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022]
Abstract
Abstract
Background
Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers.
Methods
Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient’s anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario.
Results
Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10–20 (54%) to 21–50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function.
Conclusions
The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.
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Matsumoto M, Misawa N, Tsuda M, Manabe N, Kessoku T, Tamai N, Kawamoto A, Sugama J, Tanaka H, Kato M, Haruma K, Sanada H, Nakajima A. Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography. Diagnostics (Basel) 2022; 12:diagnostics12020300. [PMID: 35204390 PMCID: PMC8871156 DOI: 10.3390/diagnostics12020300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/15/2022] [Indexed: 12/12/2022] Open
Abstract
Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient’s colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.
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Affiliation(s)
- Masaru Matsumoto
- School of Nursing, Ishikawa Prefectural Nursing University, 1-1 Gakuendai, Kahoku 929-1210, Japan;
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
| | - Noboru Misawa
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
| | - Momoko Tsuda
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, 18-16 Kawahara-cho, Hakodate 041-8512, Japan; (M.T.); (M.K.)
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan; (N.M.); (K.H.)
| | - Takaomi Kessoku
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
- Department of Palliative Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Nao Tamai
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsuo Kawamoto
- Division of Ultrasound and Department of Diagnostic Imaging, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan;
| | - Junko Sugama
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan;
| | - Hideko Tanaka
- School of Nursing, College of Nursing and Nutrition, Shukutoku University, 673 Nitona-cho, Chuo-ku, Chiba City 260-8703, Japan;
| | - Mototsugu Kato
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, 18-16 Kawahara-cho, Hakodate 041-8512, Japan; (M.T.); (M.K.)
| | - Ken Haruma
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan; (N.M.); (K.H.)
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
- Correspondence: ; Tel.: +81-45-787-2640
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Knowles CH, Booth L, Brown SR, Cross S, Eldridge S, Emmett C, Grossi U, Jordan M, Lacy-Colson J, Mason J, McLaughlin J, Moss-Morris R, Norton C, Scott SM, Stevens N, Taheri S, Yiannakou Y. Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background
Chronic constipation affects 1–2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery.
Objectives
(1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up.
Design
The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3).
Setting
Specialist hospital centres across England, with a mix of urban and rural referral bases.
Participants
The main inclusion criteria were as follows: age 18–70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology’s constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions.
Interventions
CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (n = 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (n = 68); and group 3 – standardised radiophysiological investigations-guided treatment (n = 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1, n = 30) or high-volume (group 2, n = 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (n = 9) and after 12 weeks’ (n = 10) and after 24 weeks’ (n = 9) waiting time (allocation ratio 1 : 1 : 1, respectively).
Main outcome measures
The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis.
Results
A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately –0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (–0.03 points, 95% confidence interval –0.33 to 0.27 points; p = 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval –0.11 to 0.55 points; p = 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year gain; p = 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference –0.37 points, 95% confidence interval –0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference –£8, 95% confidence interval –£240 to £221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (–1.09 points, 95% confidence interval –1.76 to –0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (£5012, 95% confidence interval £4446 to £5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval –0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of £115,512 per quality-adjusted life-year.
Conclusions
Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life.
Limitations
All three trials significantly under-recruited [CapaCiTY trial 1, n = 182 (target 394); CapaCiTY trial 2, n = 65 (target 300); and CapaCiTY trial 3, n = 28 (target 114)]. The numbers analysed were further limited by loss before primary outcome.
Trial registration
Current Controlled Trials ISRCTN11791740, ISRCTN11093872 and ISRCTN11747152.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Charles H Knowles
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Steve R Brown
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Samantha Cross
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Ugo Grossi
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mary Jordan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jon Lacy-Colson
- Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Christine Norton
- Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - S Mark Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shiva Taheri
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yan Yiannakou
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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Corsetti M, Brown S, Chiarioni G, Dimidi E, Dudding T, Emmanuel A, Fox M, Ford AC, Giordano P, Grossi U, Henderson M, Knowles CH, O'Connell PR, Quigley EMM, Simren M, Spiller R, Whelan K, Whitehead WE, Williams AB, Scott SM. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 2: Conservative, behavioural, medical and surgical treatment. Neurogastroenterol Motil 2021; 33:e14070. [PMID: 33522079 DOI: 10.1111/nmo.14070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/05/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects quality of life of patients and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted to the investigation and management of constipation was published (Neurogastroenterol Motil 2009;21(Suppl 2):1). In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held. The faculty members of this symposium were invited to write two reviews to present a collective synthesis of talks presented and discussions held during this meeting. The first review addresses epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. PURPOSE The present is the second of these reviews, providing contemporary perspectives and clinical challenges regarding behavioral, conservative, medical, and surgical treatments for patients presenting with constipation. It includes a management algorithm to guide clinical practice.
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Affiliation(s)
- Maura Corsetti
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Medicine, University of Nottingham and Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Steven Brown
- Department of Surgery, University of Sheffield, Sheffield, UK
| | - Giuseppe Chiarioni
- Division of Gastroenterology, University of Verona, AOUI Verona, Verona, Italy.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | | | | | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Pasquale Giordano
- Department of Colorectal Surgery, Barts health NHS Trust, London, UK
| | - Ugo Grossi
- Tertiary Referral Pelvic Floor and Incontinence Centre, Regional Hospital Treviso, University of Padua, Padua, Italy
| | - Michelle Henderson
- Durham Bowel Dysfunction Service, Old Trust Headquarters, University Hospital of North Durham, Durham, UK
| | - Charles H Knowles
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - P Ronan O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Eamonn M M Quigley
- Lynda K and David M Center for Gastrointestinal Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Magnus Simren
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robin Spiller
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Medicine, University of Nottingham and Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - William E Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - S Mark Scott
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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10
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Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology 2020; 158:1232-1249.e3. [PMID: 31945360 PMCID: PMC7573977 DOI: 10.1053/j.gastro.2019.12.034] [Citation(s) in RCA: 224] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Abstract
With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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11
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Serra J, Pohl D, Azpiroz F, Chiarioni G, Ducrotté P, Gourcerol G, Hungin APS, Layer P, Mendive JM, Pfeifer J, Rogler G, Scott SM, Simrén M, Whorwell P. European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterol Motil 2020; 32:e13762. [PMID: 31756783 DOI: 10.1111/nmo.13762] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.
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Affiliation(s)
- Jordi Serra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - Daniel Pohl
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy.,UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Philippe Ducrotté
- Department of Gastroenterology, UMR INSERM 1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - A Pali S Hungin
- General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
| | - Juan-Manuel Mendive
- Sant Adrià de Besòs (Barcelona) Catalan Institut of Health (ICS), La Mina Primary Health Care Centre, Badalona, Spain
| | - Johann Pfeifer
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Rogler
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - S Mark Scott
- Neurogastroenterology Group, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts, UK.,The London School of Medicine & Dentistry, Queen Mary University London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Whorwell
- Division of Diabetes, Endocrinology & Gastroenterology, Neurogastroenterology Unit, Wythenshawe Hospital, University of Manchester, Manchester, UK
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12
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Tsunoda A, Takahashi T, Kusanagi H. Transanal repair of rectocele: prospective assessment of functional outcome and quality of life. Colorectal Dis 2020; 22:178-186. [PMID: 31454453 DOI: 10.1111/codi.14833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023]
Abstract
AIM This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments. METHOD Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation. RESULTS Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement. CONCLUSION Transanal repair for rectocele improves constipation and constipation-specific QOL.
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Affiliation(s)
- A Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - T Takahashi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - H Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa City, Chiba, Japan
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13
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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14
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Recalled stapler device, high complication rate, non validated scoring system and misquote from the STARR surgeons. Tech Coloproctol 2019; 23:1017-1018. [PMID: 31452016 DOI: 10.1007/s10151-019-02068-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/14/2019] [Indexed: 12/13/2022]
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15
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Vollstedt A, Meeks W, Triaca V. Robotic sacrocolpopexy for the management of pelvic organ prolapse: quality of life outcomes. Ther Adv Urol 2019; 11:1756287219868593. [PMID: 31447937 PMCID: PMC6689921 DOI: 10.1177/1756287219868593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 07/15/2019] [Indexed: 12/05/2022] Open
Abstract
Background: Our aim was to investigate longer-term surgical and quality of life (QOL) outcomes in a cohort of women undergoing robotic-assisted laparoscopic sacrocolpopexy (RALS) for pelvic organ prolapse (POP). Methods: We performed a retrospective cohort study at a single institution of female patients undergoing RALS with and without concomitant robotic-assisted laparoscopic hysterectomy, urethral sling, and rectocele repair. Scores from the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) surveys were used to evaluate QOL outcomes. Clinical improvement was defined by a decrease in a patient’s PFDI and PFIQ postoperative score by ⩾70%. Results: Clinical improvement was seen in 62.6% by the PFIQ and in 64% by the PFDI survey. Younger patient age (OR 0.92, p = 0.011) and worse preoperative American Urological Association (AUA) Quality of Life score (OR 1.42, p = 0.046) were associated with clinical improvement. Within the PFIQ, 35.6% of patients saw clinical improvement with their bowel symptoms, compared with bladder (54.1%, p < 0.001) and prolapse (45.6%, p = 0.053) symptoms. Within the PFDI, 45.5% of patients reached clinical improvement with their bowel symptoms, compared with bladder (56.7%, p = 0.035) and prolapse (62.6%, p < 0.001) symptoms. Of the patients who had a rectocele repair, 46.3% reached clinical improvement in their CRADI-8 score, and 51% saw clinical improvement in the bowel portion of the PDFI. Conclusions: Significantly fewer patients reached clinical improvement within the portions of the surveys that focus on bowel symptoms, compared with symptoms related to urination and POP. Of those that had a concomitant rectocele repair, approximately half reached clinical improvement with their bowel symptoms.
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Affiliation(s)
- Annah Vollstedt
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - William Meeks
- Department of Data Management and Statistical Analysis, American Urological Association, Linthicum, MD, USA
| | - Veronica Triaca
- Concord Hospital Center for Urologic Care, Geisel School of Medicine at Dartmouth, NH, USA
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16
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Kim NY, Kim DH, Pickhardt PJ, Carchman EH, Wald A, Robbins JB. Defecography: An Overview of Technique, Interpretation, and Impact on Patient Care. Gastroenterol Clin North Am 2018; 47:553-568. [PMID: 30115437 DOI: 10.1016/j.gtc.2018.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pelvic floor and defecatory dysfunction are common in the female patient population. When combined with physical examination, barium defecography allows for accurate and expanded assessment of the underlying pathology and helps to guide future intervention. Understanding the imaging findings of barium defecography in the spectrum of pathology of the anorectum and pelvic floor allows one to appropriately triage and treat patients presenting with defecatory dysfunction.
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Affiliation(s)
- Nathan Y Kim
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - David H Kim
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Evie H Carchman
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Arnold Wald
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
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17
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Wilkinson-Smith V, Bharucha AE, Emmanuel A, Knowles C, Yiannakou Y, Corsetti M. When all seems lost: management of refractory constipation-Surgery, rectal irrigation, percutaneous endoscopic colostomy, and more. Neurogastroenterol Motil 2018; 30:e13352. [PMID: 29700961 DOI: 10.1111/nmo.13352] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/12/2018] [Indexed: 12/13/2022]
Abstract
While the pharmacological armamentarium for chronic constipation has expanded over the past few years, a substantial proportion of constipated patients do not respond to these medications. This review summarizes the pharmacological and behavioral options for managing constipation and details the management of refractory constipation. Refractory constipation is defined as an inadequate improvement in constipation symptoms evaluated with an objective scale despite adequate therapy (ie, pharmacological and/or behavioral) that is based on the underlying pathophysiology of constipation. Minimally invasive (ie, rectal irrigation and percutaneous endoscopic colostomy) and surgical therapies are used to manage refractory constipation. This review appraises these options, and in particular, percutaneous endoscopic colostomy, which as detailed by an article in this issue, is a less invasive option for managing refractory constipation than surgery. While these options benefit some patients, the evidence of the risk: benefit profile for these therapies is limited.
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Affiliation(s)
- V Wilkinson-Smith
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - A E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - A Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK
| | - C Knowles
- Blizard Institute, Barts & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Y Yiannakou
- University Hospital of North Durham, Durham, UK
| | - M Corsetti
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
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