RESUMO
The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.
Assuntos
Doenças Retais , Humanos , Doenças Retais/fisiopatologia , Doenças Retais/terapia , Doenças Retais/etiologia , Doenças Retais/diagnóstico , Doenças do Colo/terapia , Doenças do Colo/fisiopatologia , Doenças do Colo/etiologia , Comportamento Sexual/fisiologia , Doenças do Ânus/terapia , Doenças do Ânus/fisiopatologia , Doenças do Ânus/etiologia , Doenças do Ânus/diagnóstico , Prazer/fisiologia , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Fisiológicas/terapia , Disfunções Sexuais Fisiológicas/fisiopatologiaRESUMO
BACKGROUND: Low anterior resection syndrome has a negative impact on quality of life. Intestinal irrigation is a method of lavage consisting of a scheduled evacuation. OBJECTIVE: This study aims to evaluate functional and quality-of-life outcomes in patients with low anterior resection syndrome after transanal irrigation using a colostomy irrigation system. DESIGN: This was a prospective case series. SETTINGS: This study presents a single-center experience at a tertiary oncological center in an upper-middle-income country. PATIENTS: Patients classified as having minor or major low anterior resection syndrome 12 months after their operation were selected. INTERVENTIONS: Transanal irrigation was performed using an ostomy irrigation kit. Questionnaires assessing patients' bowel function (low anterior resection syndrome and Wexner score) and quality of life (Short Form-36 questionnaire) were applied before and after treatment. MAIN OUTCOME MEASURES: The primary outcomes were low anterior resection syndrome score and quality-of-life improvement after a 12-month treatment. RESULTS: Of the 22 patients included, 20 had major and 2 had minor low anterior resection syndrome, with a median score of 39, especially high rates of incontinence for liquid stool (21; 95.5%), clustering (21; 95.5%), and urgency (17; 77.3%). All patients successfully completed the 3-day training, and there were no complications during the treatment. After the 12-month period, the median score was 8, with 90% of the patients classified as having "no syndrome" and great improvement in all domains of this score. The most improved quality-of-life sections were patient vitality (p = 0.025) and physical (p = 0.002), social (p = 0.001), and emotional aspects (p = 0.001). LIMITATIONS: The study was limited by its small sample size and the limited follow-up period. CONCLUSIONS: This study presents a safe implementation protocol of an ostomy irrigation device for transanal irrigation. It also adds to the literature that transanal irrigation is a safe, effective, and easily implemented procedure for patients with low anterior resection syndrome with a significant improvement in quality of life. See Video Abstract at http://links.lww.com/DCR/B563.ESTUDIO DE FACTIBILIDAD DE LA IRRIGACIÓN TRANSANAL UTILIZANDO EL SISTEMA DE IRRIGACIÓN PARA COLOSTOMÍA EN PACIENTES CON SÍNDROME DE RESECCIÓN ANTERIOR BAJAANTECEDENTES:El síndrome de resección anterior baja tiene un impacto negativo en la calidad de vida de los pacientes. La irrigación intestinal es un método de lavado que consiste en evacuaciones programadas.OBJETIVOS:Evaluar los resultados de la funcionalidad e impacto en la calidad de vida de los pacientes con síndrome de resección anterior y baja posterior a la irrigación transanal utilizando un sistema de irrigación de colostomía.DISEÑO:Es estudio prospectivo de una serie de casos.ESCENARIO:En este estudio se muestra la experiencia de un centro oncológico de tercer nivel en un país en vías de desarrollo.PACIENTES:Aquellos clasificados como síndrome con afección en menor o mayor grado doce meses después de la cirugía.METODO:Se efectuó irrigación transanal utilizando un equipo de irrigación de estomas. Se aplicaron cuestionarios para valorar la función intestinal de los pacientes (síndrome de resección anterior baja y la escala de Wexner) y para calidad de vida (Cuestionario Corto-36) antes y después del tratamiento.EVALUACION DE LOS RESULTADOS PRINCIPALES:Los principales resultados se obtuvieron de la escala del síndrome de resección baja y la mejoría en la calidad vida doce meses después de tratamiento.RESULTADOS:De los veintidós pacientes incluidos, veinte presentaron manifestaciones mayores del síndrome de resección baja y dos, manifestaciones menores. Con una media de treinta y nueve, se encontraron, especialmente, altos índices de incontinencia a líquidos (21; 95'5%) hiperdefecación "clustering" (21; 95'5%) y urgencia (17; 77'3%). Todos los pacientes completaron en forma satisfactoria el entrenamiento de tres días sin presentarse complicaciones durante el tratamiento. Al término del mes doce la media fue de ocho, con el 90% de los pacientes clasificados como "sin síndrome" y se observó una mejoría substancial en todos los puntos de la evaluación. Las secciones de calidad de vida que mostraron una mejoría significativa fueron: la vitalidad del paciente (p = 0'025), física (p = 0'002), social (p = 0'001) y emocional (p = 0'001).LIMITACIONES:El tamaño de la muestra es pequeño y el tiempo de seguimiento corto.CONCLUSIONES:Este estudio muestra la implementación de un protocolo seguro para la irrigación de estomas mediante un dispositivo transanal. Además contribuye con el concepto en la literatura de que la seguridad de la irrigación transanal es seguro, efectivo y facilmente reproducible para pacientes con síndrome de resección anterior baja con una mejoría significativa en la calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B563. (Traducción-Dr. Miguel Esquivel-Herrera).
Assuntos
Catéteres , Intestino Grosso/fisiopatologia , Complicações Pós-Operatórias , Protectomia/efeitos adversos , Qualidade de Vida , Doenças Retais , Neoplasias Retais/cirurgia , Irrigação Terapêutica , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Terapia Neoadjuvante/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/psicologia , Complicações Pós-Operatórias/terapia , Protectomia/métodos , Doenças Retais/etiologia , Doenças Retais/fisiopatologia , Doenças Retais/psicologia , Doenças Retais/terapia , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/radioterapia , Estudos Retrospectivos , Irrigação Terapêutica/instrumentação , Irrigação Terapêutica/métodos , Resultado do TratamentoRESUMO
Constipation of anorectal outlet obstruction may be caused by mechanical or functional causes. This complication is a debilitating disease that needs proper and timely treatment. Many studies have shown that there is a direct link between constipation and intestinal cancer. One of the most effective ways to prevent or diagnose intestinal cancer is through genetic studies. Evaluation of people's polymorphism shows how much they are at risk for cancer. Therefore, in this study, the GSTM1 gene polymorphism was evaluated in patients with constipation of anorectal outlet obstruction to assess better and manage this disease and investigate the possibility of anorectal cancer in these people. In this regard, 40 people with constipation of anorectal outlet obstruction were compared with 40 healthy people. In the case group (patients), in addition to demographic and clinical evaluations, the anorectal manometric test was used to diagnose the pathology of the disease. Results showed that out of 40 patients with constipation of anorectal outlet obstruction, 5 cases (12.5%) had megarectum, 7 cases (17.5%) had anismus, 10 cases (25%) had Hirschsprung's disease, 5 cases (12.5%) had descending perineum syndrome, 6 cases (15%) had rectal prolapse, 4 cases (10%) had enterocele, and 3 cases (7.5%) were with rectocele. Also, the results of GSTM1 gene deletion polymorphism showed that patients with constipation of anorectal outlet obstruction were almost two times more exposed to the null genotype than the control group (P <0.04). Therefore, in people with both constipation of anorectal outlet obstruction and null genotype (i.e., deletion in the GSTM1 gene), because they do not have glutathione-S transferase, they appear to be at higher risk for anorectal cancer than healthy people with the same genotype.
Assuntos
Doenças do Ânus/genética , Constipação Intestinal/genética , Glutationa Transferase/genética , Obstrução Intestinal/genética , Polimorfismo Genético , Doenças Retais/genética , Adulto , Doenças do Ânus/fisiopatologia , Doenças do Ânus/terapia , Neoplasias do Ânus/genética , Neoplasias do Ânus/fisiopatologia , Constipação Intestinal/fisiopatologia , Constipação Intestinal/terapia , Feminino , Frequência do Gene , Genótipo , Humanos , Obstrução Intestinal/fisiopatologia , Obstrução Intestinal/terapia , Masculino , Doenças Retais/fisiopatologia , Doenças Retais/terapia , Neoplasias Retais/genética , Neoplasias Retais/fisiopatologia , Fatores de RiscoRESUMO
BACKGROUND: Barium defecography can assess structural and functional abnormalities in patients with chronic constipation. OBJECTIVE: The purpose of this study was to determine the prevalence of individual and overlapping defecographic findings in this setting. DESIGN: This was a cross-sectional study. SETTINGS: The study was conducted at a university hospital tertiary GI physiology department. PATIENTS: Consecutive examinations of 827 consecutive patients presenting over a 30-month period with well-defined symptom severity (≥12 points on the Cleveland Clinic Constipation score) were included. Systematic evaluation of images with results stratified by sex is described. MAIN OUTCOME MEASURES: Six individual functional or anatomic (intussusception, rectocele, enterocele, megarectum, excessive dynamic perineal descent) defecographic observations were defined a priori, thus permitting 26 possible combinations of findings (ie, 63 abnormal types + 1 normal). RESULTS: Patients with constipation (mean symptom score = 19) were predominantly female (88%), with median age of 49 years (range, 17-98 y) . All 6 individual radiologic findings were identified with a total of 43 combinations found in the cohort; the 14 most prevalent of these accounted for >85% of patients. Only 136 patients (16.4%) had a normal defecography (34.3% males vs 13.9% females; p < 0.0001). Overall, 612 patients (74.0%) had structural (n = 508 (61.4%)) or functional (n=104 (12.6%)) abnormalities in isolation, with 79 (9.6%) others exhibiting combinations of both. Functional abnormalities in isolation were more common in males compared with females (22.5% vs11.2%; p = 0.025) as opposed to structural abnormalities (57.8% vs 85.7%; p < 0.0001). Expulsion time was longer in females compared with males (110 s (60-120 s) vs 90 s (60-120 s); p = 0.049). LIMITATIONS: The study was limited by its lack of multiorgan opacification. CONCLUSIONS: These results provide a contemporary atlas of defecographic findings in constipation. Several individual structural and functional features have been systematically classified, with overlap greater than previously acknowledged and profound differences among sexes that carry implications for tailoring management. See Video Abstract at http://links.lww.com/DCR/B552. CARACTERIZACIN SISTEMTICA DE ANOMALAS DEFECOGRFICAS EN UNA SERIE CONSECUTIVA DE PACIENTES CON ESTREIMIENTO CRNICO: ANTECEDENTES:La defecografía con bario puede evaluar anomalías estructurales y funcionales en pacientes con estreñimiento crónico.OBJETIVO:Determinar la prevalencia de hallazgos defecográficos individuales y superpuestos en este entorno.DISEÑO:Transversal.ENTORNO CLINICO:Hospital Universitario de tercer nivel, departamento de fisiología gastrointestinal.PACIENTES:Exploraciones consecutivas de 827 pacientes consecutivos que se presentaron durante un período de 30 meses con una gravedad de los síntomas bien definida (≥12 puntos en la escala de estreñimiento de la Cleveland Clinic): evaluación sistemática de imágenes con resultados estratificados por sexo.PRINCIPALES MEDIDAS DE VALORACION:Se definieron a priori seis observaciones defecográficas individuales, funcionales o anatómicas (intususcepción, rectocele, enterocele, megarecto, descenso perineal dinámico excesivo), lo que permitió 26 combinaciones posibles de hallazgos (es decir, 63 tipos anormales + 1 normal).RESULTADOS:Los pacientes con estreñimiento (puntuación media de síntomas, 19) eran predominantemente mujeres (88%) con una edad mediana de 49 (17-98) años. Se identificaron 6 hallazgos radiológicos individuales con un total de 43 combinaciones encontradas en la cohorte; los 14 más predominantes de éstos representaron >85% de los pacientes.Solo 136 (16,4%) pacientes tuvieron una defecografía normal (34,3% hombres vs. 13,9% mujeres; P < 0,0001). En general, 612 (74,0%) pacientes tenían anomalías estructurales (n = 508 [61,4%]) o funcionales (n = 104 [12,6%]) de forma aislada, y otros 79 (9,6%) presentaban combinaciones de ambas. Las anomalías funcionales aisladas fueron más comunes en los hombres en comparación con las mujeres (22,5% vs. 11,2%, P = 0,025) en comparación con las anomalías estructurales (57,8 vs. 85,7%, P < 0,0001). El tiempo de expulsión fue mayor en las mujeres en comparación con los hombres (110 [60-120] vs. 90 [60-120] segundos; P = 0,049).LIMITACIONES:Falta de opacificación multiorgánica.CONCLUSIONES:Estos resultados proporcionan un atlas contemporáneo de hallazgos defecográficos en estreñimiento. Varias características individuales, estructurales y funcionales; se han clasificado sistemáticamente, con una superposición mayor que la reconocida anteriormente y con grandes diferencias entre los sexos que tienen implicaciones para adaptar su tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B552.
Assuntos
Constipação Intestinal/diagnóstico por imagem , Constipação Intestinal/etiologia , Defecação/fisiologia , Obstrução Intestinal/diagnóstico por imagem , Doenças Retais/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Constipação Intestinal/fisiopatologia , Estudos Transversais , Defecografia , Feminino , Humanos , Obstrução Intestinal/complicações , Obstrução Intestinal/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doenças Retais/complicações , Doenças Retais/fisiopatologia , Adulto JovemRESUMO
To identify factors associated with early deviation and delayed discharge within an Enhanced Recovery after Surgery (ERAS) pathway. This is a retrospective review of prospectively collected data of consecutive patients who underwent laparoscopic or open colorectal surgery and managed with a standardized ERAS pathway between April 2015 and October 2018. ERAS items were assessed within 48 h after surgery. Patients with early complications were excluded. The influence of factors on length of stay was calculated by univariate and multivariate analysis. A binary logistic regression was used to model a predicting score. Seven hundred and thirty-three patients met the inclusion criteria. Multivariate analysis showed that age ≥ 75 years (P = 0.02), ASA score ≥ 3 (P = 0.03), open surgery or conversion to open (P = 0.001), non-compliance with the intra-operative balanced fluid therapy (P = 0.049), failure to early removal of the urinary catheter (P = 0.001), to discontinue IV fluid (P = 0.02) and to early mobilization (P = 0.001) were independently associated with ERAS failure. The generated score had a specificity of 84% and a positive predictive value of 72%. Patients who would have a length of stay longer than the median for each surgical procedure were properly identified (Area under ROC Curve = 0.753, P < 0.001). The delayed discharge could be predicted at 48 h from the intervention. The ability of the model to weight the specific role of each statistically significant variable might be a useful tool to identify the most frail patients.
Assuntos
Colo/cirurgia , Doenças do Colo/cirurgia , Recuperação Pós-Cirúrgica Melhorada , Laparoscopia/métodos , Doenças Retais/cirurgia , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/fisiopatologia , Feminino , Fragilidade , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Doenças Retais/fisiopatologia , Estudos Retrospectivos , Falha de Tratamento , Adulto JovemRESUMO
BACKGROUND: Little is known about the pathophysiological mechanisms of solitary rectal ulcer syndrome (SRUS). AIMS: We aim to identify the different phenotypes, taking into account complaints, anatomy and anorectal physiology. METHODS: Complaints, endoscopy results, and physiology data of patients with histologically proven SRUS were collected and analysed. The associated anorectal diseases were faecal incontinence and obstructed defecation. The clinical aspects of SRUS were compared, and factors associated with anorectal diseases were identified. RESULTS: Overall, 102 consecutive patients were included. The predominant lesion was a rectal ulcer (66%), and inflammation of the rectal wall was present in 42% of patients. Abnormal rectal capacities and/or rectal perception was observed in more than half. Nearly half (52%) of the patients met the criteria for obstructed defecation and they tended to more frequently have psychiatric disease (66.7%â¯vs 33.3%; p=0.07). Patients with faecal incontinence (17%) reported more self-perception of anal procidentia (p=0.01) and were more likely to have inflammation of the rectal wall (p=0.02), high-grade internal rectal procidentia (p=0.06) and anal hypotonia (p=0.004); their maximum tolerable volume was lower (p=0.004). CONCLUSION: The characteristics of patients with SRUS suggest different phenotypes. This may be a way to develop a comprehensive treatment strategy.
Assuntos
Doenças Retais/fisiopatologia , Úlcera/fisiopatologia , Adulto , Idoso , Canal Anal/fisiopatologia , Constipação Intestinal/fisiopatologia , Incontinência Fecal/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fenótipo , Doenças Retais/diagnóstico , Prolapso Retal/fisiopatologia , Estudos Retrospectivos , Síndrome , Úlcera/diagnósticoRESUMO
BACKGROUND: There is wide variation in the clinical use of diagnostic tools for children with chronic constipation and functional/structural fecal incontinence (CCFSFI). Anorectal manometry (ARM) is a well-recognized technique to assess the function of the anorectum. PURPOSE: Our aim was to perform an up-to-date review on ARM in pediatric patients with CCFSFI, with specific focus on the indication of use and protocol. Variation of its use in pediatrics will be explored. METHODS: A systematic search was conducted for empirical studies utilizing ARM with a pediatric sample. A keyword search of literature published in English before July 2018 was conducted and updated to October 2019. Data on demographics, clinical information, study aims, ARM parameters and use of sedation/anesthesia were collected. KEY RESULTS: A total of 227 studies were included in this systematic review. The age of study participants at the time of ARM ranged from birth to 18 years. ARM was most commonly used in patients with organic conditions (65%) compared to functional constipation (41%). In almost half [108/227 (48%)] of the studies, ARM was performed awake. The ARM parameters most frequently assessed were the rectoanal inhibitory reflex, which was evaluated in 198/227 studies (87%) and the anal resting pressure [166/227 studies (73%)]. CONCLUSIONS AND INFERENCES: This systematic review has highlighted the vast variation of ARM use within pediatrics and the need to strive toward standardization and use of consensus guidelines. We anticipate this will further advance our understanding of the pathophysiological mechanisms involved in children with defecation disorders.
Assuntos
Canal Anal/fisiopatologia , Constipação Intestinal/fisiopatologia , Incontinência Fecal/fisiopatologia , Manometria/métodos , Doenças Retais/fisiopatologia , Reto/fisiopatologia , Adolescente , Criança , Pré-Escolar , Constipação Intestinal/diagnóstico , Defecação/fisiologia , Pesquisa Empírica , Incontinência Fecal/diagnóstico , Humanos , Lactente , Recém-Nascido , Pediatria/métodos , Doenças Retais/diagnósticoRESUMO
CASE SUMMARY: A 31-year-old woman with a history of endometriosis was referred to the outpatient colorectal surgery office for evaluation of rectal bleeding. Colonoscopy was recommended because of the ongoing symptoms, and a polyp was discovered in the colon (). Pathology was consistent with endometriosis (). The patient was previously scheduled for laparoscopic endometriosis resection and underwent laparoscopic colon resection at the same time. She recovered and continued to do well postoperatively with no additional signs of rectal bleeding.
Assuntos
Pólipos do Colo/diagnóstico , Endometriose , Hemorragia , Laparoscopia/métodos , Protectomia/métodos , Doenças Retais , Adulto , Biópsia/métodos , Dissecação/métodos , Endometriose/complicações , Endometriose/diagnóstico , Endometriose/cirurgia , Feminino , Hemorragia/diagnóstico , Hemorragia/etiologia , Hemorragia/cirurgia , Humanos , Doenças Retais/patologia , Doenças Retais/fisiopatologia , Doenças Retais/cirurgia , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal dysfunction. Regrettably, the utility of the most established and widely employed investigations for such measurement (anorectal manometry (ARM), rectal sensory testing and the balloon expulsion test) has been limited by wide variations in clinical practice. RECENT FINDINGS: This article summarizes the recently published International Anorectal Physiology Working Group (IAPWG) consensus and London Classification of anorectal disorders, together with relevant allied literature, to provide guidance on the indications for, equipment, protocol, measurement definitions and results interpretation for ARM, rectal sensory testing and the balloon expulsion test. The London Classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.
Assuntos
Canal Anal/fisiologia , Doenças do Ânus/classificação , Doenças do Ânus/fisiopatologia , Manometria , Doenças Retais/classificação , Doenças Retais/fisiopatologia , Humanos , Manometria/instrumentação , Terminologia como AssuntoRESUMO
BACKGROUND: Outlet obstruction constipation accounts for about 30% of chronic constipation (CC) cases in a referral practice. AIMS: To assess the proportion of patients with CC diagnosed with descending perineum syndrome (DPS) by a single gastroenterologist and to compare clinical, radiological, and associated features in DPS compared to patients with constipation. METHODS: We conducted a review of records of 300 consecutive patients evaluated for constipation by a single gastroenterologist from 2007 to 2019, including medical, surgical, and obstetrics history, digital rectal examination, anorectal manometry, defecation proctography (available in 15/23 with DPS), treatment, and follow-up. DPS was defined as > 3 cm descent of anorectal junction on imaging or estimated perineal descent on rectal examination. Logistic regression with univariate and multivariate analysis compared factors associated with DPS to non-DPS patients. RESULTS: Twenty-three out of 300 (7.7%, all female) patients had DPS; these patients were older, had more births [including more vaginal deliveries (84.2% vs. 31.2% in non-DPS, p < 0.001)], more instrumental or traumatic vaginal deliveries, more hysterectomies, more rectoceles on proctography (86.7% vs. 28.6% non-DPS, p = 0.014), lower squeeze anal sphincter pressures (p < 0.001), and lower rectal sensation (p = 0.075) than non-DPS. On univariate logistic regression, history of vaginal delivery, hysterectomy, and Ehlers-Danlos syndrome increased the odds of developing DPS. Vaginal delivery was confirmed as a risk factor on multivariate analysis. CONCLUSIONS: DPS accounts for almost 10% of tertiary referral patients presenting with constipation. DPS is associated with age, female gender, and number of vaginal (especially traumatic) deliveries.
Assuntos
Constipação Intestinal , Complicações do Trabalho de Parto , Períneo , História Reprodutiva , Procedimentos Cirúrgicos Operatórios , Constipação Intestinal/diagnóstico , Constipação Intestinal/etiologia , Constipação Intestinal/fisiopatologia , Defecografia/estatística & dados numéricos , Exame Retal Digital/estatística & dados numéricos , Feminino , Gastroenterologia/métodos , Humanos , Masculino , Manometria/estatística & dados numéricos , Anamnese/estatística & dados numéricos , Pessoa de Meia-Idade , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/fisiopatologia , Períneo/diagnóstico por imagem , Períneo/patologia , Períneo/fisiopatologia , Gravidez , Doenças Retais/complicações , Doenças Retais/diagnóstico , Doenças Retais/fisiopatologia , Encaminhamento e Consulta/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricosRESUMO
Colorectal surgery is a major therapeutic approach for various colorectal diseases. Surgery and perioperative management, such as fasting, mechanical bowel preparation, and antibiotics use, have an impact on the composition and function of gut microbiome. Abnormal microbiome reconstruction may lead to multiple complications, including infection, gastrointestinal dysfunction, anastomotic leak and disease recurrence. The aim of this review is to elucidate the roles and mechanisms of perioperative interventions of colorectal surgery on gut microbiome, which may provide a novel insight into the microbe-based therapies in the perioperative period of colorectal surgery.
Assuntos
Doenças do Colo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Microbioma Gastrointestinal/fisiologia , Assistência Perioperatória/efeitos adversos , Doenças Retais/cirurgia , Fístula Anastomótica , Doenças do Colo/microbiologia , Doenças do Colo/fisiopatologia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Humanos , Assistência Perioperatória/métodos , Doenças Retais/microbiologia , Doenças Retais/fisiopatologiaRESUMO
PURPOSE OF REVIEW: Functional anorectal pain syndromes are a neglected yet often disabling clinical entity resulting in significant economic and psychological burden to the patient. The aim of this review is to update the practicing gastroenterologist/coloproctologist on the diagnosis and management of these complicated disorders. RECENT FINDINGS: The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings. Chronic proctalgia is thought to be secondary to paradoxical pelvic floor contraction in many patients and biofeedback to improve the defecation effort has proven effective for over 90% in the short term. Unfortunately, management of proctalgia fugax remains challenging and treatment outcomes modest at best. A number of therapies to relax the pelvic floor may be employed to improve symptoms in functional anorectal pain syndromes; however, only biofeedback to improve defaecatory dynamics in patients with levator ani syndrome has proven effectiveness in a randomized setting. Further investigation of treatment approaches in proctalgia fugax is required.
Assuntos
Canal Anal/anormalidades , Doenças do Ânus , Dor Crônica , Doenças Musculares , Dor , Dor Pélvica , Doenças do Ânus/complicações , Doenças do Ânus/diagnóstico , Doenças do Ânus/terapia , Biorretroalimentação Psicológica , Toxinas Botulínicas Tipo A/administração & dosagem , Dor Crônica/etiologia , Dor Crônica/fisiopatologia , Dor Crônica/terapia , Terapia por Estimulação Elétrica , Humanos , Injeções Intramusculares , Doenças Musculares/complicações , Doenças Musculares/diagnóstico , Doenças Musculares/terapia , Dor/complicações , Dor/diagnóstico , Diafragma da Pelve/fisiopatologia , Dor Pélvica/etiologia , Dor Pélvica/fisiopatologia , Dor Pélvica/terapia , Doenças Retais/complicações , Doenças Retais/fisiopatologia , Doenças Retais/terapiaRESUMO
INTRODUCTION: The aim of our study is to describe MRI appearance of a posterior rectal pouch (PRP) for patients managed for low rectal endometriosis by large full-thickness disc excision and to assess its relationship with postoperative functional digestive symptoms. MATERIAL AND METHODS: Single center retrospective study including patients managed by low/mid rectal disc excision using a semi-circular stapler (the Rouen technique) from June 2009 to October 2016. Intraoperative findings and data provided by standardized gastrointestinal self-questionnaires (GIQLI, KESS, Wexner and Bristol), before and 1 year after the surgery, were prospectively recorded. Postoperative pelvic MRI were reviewed and PRP was assessed in three planes and its volume was estimated on a 3D T2 weighted sequence. RESULTS: Eighteen patients were included in the study. All patients had postoperative PRP while none of them presented with rectal stenosis. The mean (± SD) volume of the PRP was estimated at 66 ± 32 mL. The mean antero-posterior diameter was 56 mm ± 22 mm, mean height at 44 mm ± 15 mm and mean width at 46 mm ± 11 mm. No positive correlation between the volume of the PRP and the GIQLI questionnaire was found at one year after surgery (r = -0.24, 95%CI -0.51-0.69, p = 0.44). CONCLUSION: Large disc excision of low and mid rectum leads to a posterior rectal pouch, with no significant impact on postoperative functional digestive outcomes, but it is not followed by bowel stenosis.
Assuntos
Doenças do Sistema Digestório/epidemiologia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Endometriose/cirurgia , Complicações Pós-Operatórias/patologia , Doenças Retais/cirurgia , Reto/patologia , Endometriose/patologia , Endometriose/fisiopatologia , Feminino , França , Humanos , Imageamento por Ressonância Magnética , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Doenças Retais/patologia , Doenças Retais/fisiopatologia , Retocele/epidemiologia , Retocele/patologia , Reto/cirurgia , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND: Opioid use has reached epidemic proportions. In contrast to the known effect of opioids on gut transit, the effect on rectal sensorimotor function has not been comprehensively investigated. METHODS: Cross-sectional (hypothesis-generating) study of anorectal physiology studies in 2754 adult patients referred to a tertiary unit (2004-2016) for investigation of functional constipation (defined by "derived" Rome IV core criteria). Statistical associations between opioid usage, symptoms, and anorectal physiological variables were investigated. Opioids were sub-classified as prescriptions for mild-moderate or moderate-severe pain. KEY RESULTS: A total of 2354 patients (85.5%) were classified as non-opioid users, 162 (5.9%) as opioid users for mild-moderate pain, and 238 (8.6%) for moderate-severe pain. Opioids for moderate-severe pain were associated with increased symptomatic severity (Cleveland Clinic constipation score 18.5 vs 15.1; mean difference 2.9 [95%-CI 2.3-3.6]; P < .001), rectal hyposensitivity (odds ratio 1.74 [95%-CI 1.23-2.46]; P = .002), functional evacuation disorders (odds ratio 1.73 [95%-CI 1.28-2.34]; P < .001), and delayed whole-gut transit (odds ratio 1.68 [95%-CI 1.19-2.37]; P = .003). Differences in anorectal variables between opioid users for mild-moderate pain and non-opioid users were not statistically significant. Hierarchical opioid use (non vs mild-moderate vs moderate-severe) was associated with decreasing proportions of patients with no physiological abnormality on testing (40.2% vs 38.1% vs 29.2%) and increasing proportions with both delayed whole-gut transit and rectal sensorimotor dysfunction (16.6% vs 17.5% vs 28.5%). CONCLUSIONS AND INFERENCES: Opioid use is over-represented in patients referred for investigation of constipation. Opioids for moderate-severe pain are associated with rectal sensorimotor abnormalities. Further studies are required to determine whether this association indicates causation.
Assuntos
Analgésicos Opioides/efeitos adversos , Constipação Induzida por Opioides/epidemiologia , Constipação Induzida por Opioides/fisiopatologia , Doenças Retais/induzido quimicamente , Doenças Retais/epidemiologia , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Constipação Induzida por Opioides/complicações , Dor/tratamento farmacológico , Dor/epidemiologia , Doenças Retais/fisiopatologia , Reto/fisiopatologiaRESUMO
INTRODUCTION: Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms. MATERIAL AND METHODS: We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea. RESULTS: Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group. CONCLUSIONS: Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.
Assuntos
Colo/patologia , Doenças do Colo/patologia , Doenças do Colo/cirurgia , Endometriose/cirurgia , Doenças Retais/cirurgia , Doenças do Colo Sigmoide/cirurgia , Adulto , Doenças do Colo/fisiopatologia , Constipação Intestinal , Diarreia , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Dor , Doenças Retais/patologia , Doenças Retais/fisiopatologia , Estudos Retrospectivos , Doenças do Colo Sigmoide/patologia , Doenças do Colo Sigmoide/fisiopatologia , Resultado do TratamentoRESUMO
Recto-vaginal (RVF) and recto-urethral (RUF) fistulas are infrequent but disabling conditions that severely affect patients' quality of life. Considering the high recurrence rate after conservative approaches, the best surgical treatment is still challenging. The aim of this study was to evaluate the outcome of graciloplasty to treat patients with complex RVF or RUF, and to investigate its effect on the quality of life. Fourteen patients with RVF and RUF who underwent graciloplasty between 2003 and 2017 were retrospectively enrolled. The main outcome was the healing rate of fistulas. Postoperative patients satisfaction was evaluated administering the Clinical Patient Grading Assessment Scale (CPGAS), SF-36 questionnaires and Changes in Sexual Functioning (CSF) questionnaires. The Wexner score was calculated in case of preoperative faecal incontinence. RVF and RUF were iatrogenic in 11 patients and due to Crohn's disease in 3 cases. After 1 year of follow-up (IQR 10-14 months), the success rate of the procedure was 78%. Out of three patients with RVF due to Crohn's disease, two healed after the procedure. Six months after surgery, all eight SF-36 domains significantly improved except for "body pain"; CSF score significantly increased from 35.5 (IQR 31-38.7) to 44 (IQR 37.7-48.5); CPGAS score improved from a median value of 0 (IQR 0-0) to 4 (IQR 3.2-4). The Wexner score was calculated only in 5 patients with preoperative faecal incontinence and it significantly decreased from a median value of 12 (IQR 11-14) to 5 (IQR 4-5). Graciloplasty could be considered as a first option treatment for complex or recurrent RVF and RUF. It shows a good healing rate even in case of unfavourable factors like Crohn's disease.
Assuntos
Fístula/fisiopatologia , Fístula/cirurgia , Qualidade de Vida , Recuperação de Função Fisiológica , Doenças Retais/fisiopatologia , Doenças Retais/cirurgia , Doenças Uretrais/fisiopatologia , Doenças Uretrais/cirurgia , Fístula Urinária/fisiopatologia , Fístula Urinária/cirurgia , Procedimentos Cirúrgicos Urogenitais/métodos , Doenças Vaginais/fisiopatologia , Doenças Vaginais/cirurgia , Feminino , Humanos , Masculino , Satisfação do Paciente , Inquéritos e Questionários , Resultado do TratamentoRESUMO
OBJECTIVE: To explore whether operation can change the elasticity of levator ani in deep infiltrating endometriosis (DIE) with operation and pharmacotherapy using transperineal elastography. METHODS: Total thirty-four patients who were diagnosed as DIE were included in the study. Transperineal elastography were performed in all cases preoperatively and postoperatively. The levator ani was evaluated by means of the scoring system and strain ratio (SR) values on maximal Valsalva and quiescent condition, respectively. RESULTS: On quiescent condition, the preoperative mean elastography scores and SR of the levator ani were statistically significantly higher than the postoperative ones in both shaving technique group and segmental colorectal resection group. And on maximal Valsalva, the preoperative mean elastography scores and SR of the levator ani were statistically significantly lower than the postoperative ones in both groups. After surgery and 6 cycles of GnRHa therapy, the mean elastography score and SR of the levator ani were statistically significantly lower than before GnRHa therapy in shaving technique group on quiescent condition. And on maximal Valsalva, the mean elastography score and SR were statistically higher than before GnRHa therapy. However, in segmental colorectal resection group, the differences were not observed before and following 6 cycles of GnRHa therapy. CONCLUSION: The elasticity of levator ani of DIE was changed by both shaving technique and segmental colorectal resection. And transperineal elastography could access the alterations.
Assuntos
Doenças do Colo/cirurgia , Técnicas de Imagem por Elasticidade/métodos , Endometriose/cirurgia , Diafragma da Pelve/fisiopatologia , Doenças Retais/cirurgia , Adulto , Doenças do Colo/fisiopatologia , Elasticidade , Endometriose/fisiopatologia , Feminino , Humanos , Período Pós-Operatório , Doenças Retais/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Pamoato de Triptorrelina/uso terapêuticoRESUMO
INTRODUCTION: The conventional video colpo-cysto entero defecography describing the morpho- functional imaging features, physiological and pathological of the recto-anal region and pelvic floor . It represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions. MATERIALS AND METHODS: Between January 2010 to January 2013 88 patients underwent STARR procedure for obstructed defecation syndrome (ODS) caused by single rectocele or internal rectal intussusception. We retrospectively analyzed the collected data,in particular we reviewed the defecography results before surgery. RESULTS: At defecography imaging , 30 patients (34 %) had an anal canal opening between 0 and 5 seconds, 44 (50 %) between 6 and 10 seconds and 14 patients (16 %) over 10 seconds at defecography imaging. The defecography showed an enterocele in 30 patients (34 %) The enterocele was functional in 25 (28,4 %) and stable in 5 (5,6 %) patients. 53 patients have a II° rectocele (60,2 %) and 35 patients a III° rectocele (39,7 %). The average preoperative ODS score was 14 . The average ODS score revaluated at 1 year was 3.1, 4.3 at 3 years an 6,4 after 5 years. The improvement of the ODS score was lower in the subgroup of patients presenting a slow opening of the anal canal (> 10 sec): 7.5 at one year, 9.1 at 3 years and 11 after 5 years follow-up. Also in the subgroup of patients with stable enterocele (5,6 %) the improvement was less evident: 6.7 at 1 year, 8 at 3 years and 9.7 after 5 years follow-up. DISCUSSION AND CONCLUSION: We have observed that a coexistence of a long opening time of the anal canal and / or the presence of a stable enterocele are factors that significantly reduce the effectiveness of the surgery leading over time to ODS score values close to those present before surgery. In the fisrt case we suggest a pre and post-operative perineal physiotherapy, in the second case a Dougla's platsy KEY WORDS: Defecography, Obstructed defecation syndrome, Rectocele, Recto-anal prolapse.
Assuntos
Defecografia , Intussuscepção/cirurgia , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Doenças Retais/cirurgia , Idoso , Canal Anal/diagnóstico por imagem , Canal Anal/fisiopatologia , Feminino , Seguimentos , Humanos , Intussuscepção/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Prognóstico , Recuperação de Função Fisiológica , Doenças Retais/diagnóstico por imagem , Doenças Retais/fisiopatologia , Retocele/diagnóstico por imagem , Retocele/fisiopatologia , Retocele/cirurgia , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Gravação em VídeoRESUMO
OBJECTIVES: The impact of opioids on anorectal function is poorly understood but potentially relevant to the pathogenesis of opioid-induced constipation (OIC). To evaluate anorectal function testing (AFT) characteristics, symptom burden, and quality of life in chronically constipated patients prescribed an opioid (OIC) in comparison with constipated patients who are not on an opioid (NOIC). METHODS: Retrospective analysis of prospectively collected data on 3,452 (OIC = 588 and NOIC = 2,864) chronically constipated patients (Rome 3) who completed AFT. AFT variables included anal sphincter pressure and response during simulated defecation, balloon expulsion test (BET), and rectal sensation. Dyssynergic defecation (DD) was defined as an inability to relax the anal sphincter during simulated defecation and an abnormal BET. Patients completed Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. RESULTS: The mean age of the study cohort was 49 years. Most patients were women (82%) and whites (83%). Patients with OIC were older than NOIC patients (50.7 vs 48.3, P = 0.001). OIC patients were significantly more likely to have DD (28.6% vs 21.4%, P < 0.001), an abnormal simulated defecation response on anorectal manometry (59% vs 43.8%, P < 0.001), and an abnormal BET (48% vs 42.5%, P = 0.02) than NOIC patients. OIC patients reported more severe constipation symptoms (P < 0.02) and worse quality of life (P < 0.05) than NOIC patients. DISCUSSION: Chronically constipated patients who use opioids are more likely to have DD and more severe constipation symptoms than NOIC.