Analysis of factors that indicated surgery in 400 patients submitted to a complete diagnostic workup for obstructed defecation syndrome and rectal prolapse using a supervised machine learning algorithm.

BACKGROUND: Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach. METHODS: This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested. RESULTS: A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001). CONCLUSIONS: Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared.

Testing in functional constipation-What's new and what works.

BACKGROUND: Constipation is among the most common symptoms prompting a consultation with a paediatric gastroenterologist. While most patients will respond to lifestyle and dietary changes and conventional therapy, some may require diagnostic studies. AIM: To review the diagnostics studies used to evaluate children with functional constipation. MATERIALS AND METHODS: There is no evidence to support the routine use of abdominal X-rays in the evaluation of paediatric constipation. Colon transit by radiopaque markers (ROM) should be indicated when medical history does not match clinical findings, to guide colon manometry (CM) performance and to discriminate between faecal incontinence from functional constipation and non-retentive faecal incontinence. Colon scintigraphy may be useful as an alternative to ROM. Lumbar spine MRI may be indicated to evaluate for spinal abnormalities. The role of defecography has not been properly evaluated in children. Anorectal manometry in children is indicated primarily to evaluate anal resting pressure, presence and quality of the recto-anal inhibitory reflex and simulated defecation manoeuvres. The CM is indicated to guide surgical interventions after failing medical therapy. CONCLUSIONS: The goal of these studies is to identify treatable causes of constipation. Most of these studies are designed to evaluate anatomy, transit and/or colon/rectum motility function and are primarily indicated in those who fail to respond to conventional therapy.

MR defecography in assessing stress urinary incontinence with or without symptomatic pelvic organ prolapse.

PURPOSE: Utilize magnetic resonance defecography (MRD) to analyze the primary pelvic floor dysfunctions in patients with stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP), and in SUI patients with asymptomatic POP. METHOD: We performed MRD in both SUI and POP subjects. As a primary analysis, the functional MR parameters were compared between the isolated POP and POP combined SUI groups. As a secondary analysis, the functional MR data were compared between the POP combined SUI and the SUI with asymptomatic POP (isolated SUI) groups. RESULTS: MRD noted the main characteristics of SUI combined moderate or severe POP, including the shorter closed urethra length (1.87 cm vs. 2.50 cm, p < 0.001), more prevalent urethral hypermobility (112.31° vs. 85.67°, p = 0.003), bladder neck funneling (48.28% vs. 20.51%, p = 0.020), lower position of vesicourethral junction (2.11 cm vs. 1.67 cm, p = 0.030), and more severe prolapse of the posterior bladder wall (6.26 cm vs. 4.35 cm, p = 0.008). The isolated SUI patients showed the shortest length of the closed urethra (1.56 cm vs. 1.87 cm, p = 0.029), a larger vesicourethral angle (153.80° vs. 107.58°, p < 0.001), the more positive bladder funneling (84.85% vs. 48.28%, p = 0.002) and a special urethral opening sign (45.45% vs. 3.45%, p < 0.001). CONCLUSIONS: Patients with SUI accompanying POP primarily exhibit excessive urethral mobility and a shortened urethral closure. SUI patients with asymptomatic POP mainly show dysfunction of the urethra and bladder neck, characterized by the opening of the urethra and bladder neck and a shortened urethral closure.

Diagnosis of Chronic Constipation.

Patients with chronic constipation (CC) usually complain of mild to severe symptoms, including hard or lumpy stools, straining, a sense of incomplete evacuation after a bowel movement, a feeling of anorectal blockage, the need for digital maneuver to assist defecation, or reduced stool frequency. In clinical practice, healthcare providers need to check for 'alarm features' indicative of a colonic malignancy, such as bloody stools, anemia, unexplained weight loss, or new-onset symptoms after 50 years of age. In the Seoul Consensus on the diagnosis and treatment of chronic constipation, the Bristol stool form scale, colonoscopy, and digital rectal examination are useful for objectively evaluating the symptoms and making a differential diagnosis of the secondary cause of constipation. If patients with CC improve to lifestyle modification or first-line therapies, the effort to determine the subtypes of CC is usually not considered. On the other hand, if conventional therapeutic strategies fail, diagnostic testing needs to be considered to distinguish between the different subtypes of functional constipation (normal-transit constipation, slow transit constipation, or defecatory disorder) because these subtypes of constipation have different therapeutic implications and a correct diagnosis is critical. In the Seoul consensus, physiological testing is recommended for patients with functional constipation who have failed to respond to treatment with available laxatives (for a minimum of 12 weeks and recommended a therapeutic regimen) or who are strongly suspected of having a defecatory disorder. The Seoul consensus contains statements of physiological testing, including balloon expulsion test, anorectal manometry, defecography, and colon transit time.

Radiographic Evaluation of Ileal Pouch Disorders: A Systematic Review.

BACKGROUND: Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI, contrasted pouchography, and defecography. OBJECTIVES: To perform a systematic review of the literature and describe applications of cross-sectional imaging, pouchography, defecography, and ultrasonography. DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on endoscopy in ileal pouches published between January 2003 and June 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION: Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included. MAIN OUTCOME MEASURES: Accuracy in characterization of ileal pouch disorders. RESULTS: CT is the test of choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). MRI of the pelvis is suitable for the assessment of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn's disease of the pouch. CT enterography and magnetic resonance enterography are useful in assessing intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for evaluating acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers. LIMITATIONS: This is a qualitative, not quantitative, review of mainly case series and case reports. CONCLUSIONS: Abdominopelvic imaging, along with clinical and endoscopic evaluation, is imperative for accurately assessing structural, inflammatory, functional, and neoplastic disorders. See video from symposium .

Volumetric segmentation analysis of the levator ani muscle using magnetic resonance imaging in pelvic floor function assessment

PURPOSE: In this case-control study, we aimed to evaluate how muscle volume affects pelvic floor function by analyzing the levator ani muscle (LAM) using volumetric segmentation in addition to standard magnetic resonance (MR) defecography assessments. METHODS: We enrolled 85 patients with varying degrees of pelvic floor dysfunction (PFD) and 85 age- and gender-matched controls in this retrospective study. All patients had MR defecography images, while all controls had pelvic MR images obtained for other reasons. Group comparisons were performed using independent samples t-tests and Mann-Whitney U tests. The receiver operating curve (ROC) was constructed to establish a cut-off value for a normal LAM volume. Interrater reliability was assessed by calculating the intraclass correlation coefficient. A P value of less than 0.05 was considered statistically significant. RESULTS: Volumetric measurements revealed that the control group had higher LAM volumes, and the ROC curve analysis indicated a cut-off value of 38934.3 mm3 with a sensitivity of 0.812 and specificity of 0.8 for PFD assessment using LAM volumetric measurement. Gender did not significantly affect LAM volume in the control group. CONCLUSION: Alongside the useful structural and functional information acquired from MR defecography images, volumetric analysis, and three-dimensional reconstructions of LAM may help to improve the accuracy of the diagnosis.

Pubococcygeal Line Versus H-line as MR Defecography Reference for Bladder Descent.

INTRODUCTION AND HYPOTHESIS: Magnetic resonance defecography imaging techniques have been used widely to study pelvic floor function and diagnose pelvic organ prolapse (POP). The aim of this study was to investigate the diagnostic accuracy of the H-line to detect bladder descent compared with the current landmark, the pubococcygeal line (PCL). METHODS: In this retrospective cohort study, patients who underwent MR defecography in our medical center and were diagnosed with moderate to severe cystocele by radiological measurements were recruited. One rest image and one maximum evacuation image for each subject were used for the following measurements: bladder base perpendicular distance from the genital hiatus (GH), indicative of clinically significant bladder descent, PCL as the current radiological reference line, and the H-line, or minimal levator hiatus line, indicative of pelvic floor muscle and connective tissue support. Subjects were categorized as having clinically significant cystocele if the "bladder base" reached within 1 cm or lower of the GH (stage II or higher cystocele). A comparison was performed to assess differences and predictive capabilities of the reference lines relative to the GH measure. RESULTS: Seventy subjects were included, 30 with clinically significant bladder descent based on distance to GH. Women with bladder descent were older (64.0 ± 11.8 vs 51.2 ± 15.6, p < 0.001), had increased parity (3 [1-7] vs 2 [0-5], p = 0.009), and had a bladder that descended lower than the H-line at rest (1.9 ± 0.5 vs 2.2 ± 0.4, p = 0.003) and evacuation (-2.4 ± 1.6 vs -0.7 ± 1.1, p < 0.001). Multivariate regression analysis confirmed that age, length of the H-line at evacuation, the perpendicular distances between the H-line and the lowest bladder point at rest, and the PCL to the lowest bladder point at evacuation significantly correlated with bladder descent. Receiver operating characteristic analysis was used to identify a measurement threshold to diagnose clinically significant cystocele for both measurements, bladder base to the H-line: -1.2 (80.0, 72.5) area under the curve (AUC) 0.82, and bladder base PCL: -3.3 (77.8, 79.5) AUC 0.86. CONCLUSION: Our data support the application of using the minimal levator hiatus plane and specifically the H-line as a reliable landmark to diagnose bladder descent using MR defecography imaging.

A new defecographic parameter for assessing rectal emptying / Um novo parâmetro defecográfico para avaliar o esvaziamento retal

ABSTRACT Purpose: To validate a new defecographic parameter to assess rectal empyting correlating the percentage of weight reduction of barium paste and the variation in the percentage of area reduction of rectum compared before and after defecation during cinedefecography. Method: Thirty-two consecutive female patients with dyschezia who had clinical indication for cinedefecography were selected. Their median age was 58 years old (18-78 years, mean = 55 years). During cinedefecography, we calculated the cross-sectional sagittal area of the rectum before and after defecation and, thus, the percentage of area reduction of the rectum. The percentage of weight reduction of barium paste was calculated after weighing the contrast injected into the rectum and the amount of contrast evacuated, in grams, using a scale. Finally, both percentages were compared and checked for a correlation between them. Pearson's correlation (r) and Student's t test were used for statistical analysis. Results: A correlation between evacuated barium paste and cross-sectional sagittal area of the rectum at the end of defecation was demonstrated (r = 0.668 and p < 0.0001). Conclusion: It is possible to estimate how much barium paste is evacuated based on the variations in cross-sectional sagittal area of the rectum before and after defecation, in cinedefecography.

RESUMO Objetivo: Validar um novo parâmetro defecográfico para avaliar o esvaziamento retal correlacionando o percentual de redução de peso da pasta baritada e a variação da porcentagem da redução da área do reto antes e depois da evacuação durante o exame de cinedefecografia. Métodos: Foram selecionadas 32 pacientes consecutivas do sexo feminino, portadoras de disquezia, com indicação clínica de investigação por cinedefecografia. A mediana de idade da amostra foi 58 anos (18-78 anos, média de 55 anos). Durante o exame de cinedefecografia, calcularam-se as áreas retais pela secção sagital antes e após a defecação e, assim, o percentual de redução da área retal. O percentual de redução do peso do contraste baritado foi calculado após medidas de peso do contraste injetado no reto e da quantidade de contraste evacuado, em gramas, utilizando uma balança. Por fim, os percentuais foram comparados e verificou-se se havia correlação entre eles. Para análise estatística, foram utilizados correlação de Pearson (r)eT este t de Student. Resultados: Foi observada correlação entre o contraste baritado evacuado e a área retal pela secção sagital ao final da evacuação (r = 0.668; p < 0.0001). Conclusões: É possível estimar o percentual de contraste baritado evacuado através da análise da variação da área retal pela secção sagital antes e após a evacuação, utilizando a cinedefecografia.

High Prevalence of Slow Transit Constipation in Patients With Gastroparesis

BACKGROUND/AIMS: Current evidence suggests the presence of motility or functional abnormalities in one area of the gastrointestinal tract increases the likelihood of abnormalities in others. However, the relationship of gastroparesis to chronic constipation (slow transit constipation and dyssynergic defecation) has been incompletely evaluated. METHODS: We retrospectively reviewed the records of all patients with chronic dyspeptic symptoms and constipation who underwent both a solid gastric emptying scintigraphy and a high-resolution anorectal manometry at our institution since January 2012. When available, X-ray defecography and radiopaque marker colonic transit studies were also reviewed. Based on the gastric emptying results, patients were classified as gastroparesis or dyspepsia with normal gastric emptying (control group). Differences in anorectal and colonic findings were then compared between groups. RESULTS: Two hundred and six patients met the inclusion criteria. Patients with gastroparesis had higher prevalence of slow transit constipation by radiopaque marker study compared to those with normal emptying (64.7% vs 28.1%, P = 0.013). Additionally, patients with gastroparesis had higher rates of rectocele (88.9% vs 60.0%, P = 0.008) and intussusception (44.4% vs 12.0%, P = 0.001) compared to patients with normal emptying. There was no difference in the rate of dyssynergic defecation between those with gastroparesis vs normal emptying (41.1% vs 42.1%, P = 0.880), and no differences in anorectal manometry findings. CONCLUSIONS: Patients with gastroparesis had a higher rate of slow transit constipation, but equal rates of dyssynergic defecation compared to patients with normal gastric emptying. These findings argue for investigation of possible delayed colonic transit in patients with gastroparesis and vice versa.

Laparoscopic Rectovaginal Septal Repair without Mesh for Anterior Rectocele

A rectocele with a weakened rectovaginal septum can be repaired with various surgical techniques. We performed laparoscopic posterior vaginal wall repair and rectovaginal septal reinforcement without mesh using a modified transperineal approach. A 63-year-old woman with outlet dysfunction constipation complained of lower pelvic pressure and sense of heaviness for 30 years. Initial defecography showed an anterior rectocele with a 45-mm anterior bulge and perineal descent. Laparoscopic procedures included peritoneal and rectovaginal septal dissection directed toward the perineal body, rectovaginal septal suturing, and peritoneal closure. The patient started a soft diet the following day and was discharged on the 5th postoperative day without any complications. The patient had no dyschezia or dyspareunia, and no problem with bowel function; 3-month follow-up defecography showed a decrease in bulging to 18 mm. Laparoscopic posterior vaginal wall and rectovaginal septal repair is safe and feasible for treatment of a rectocele, and enables early recovery.

Update on the Pathophysiology and Management of Anorectal Disorders

Anorectal disorders are common and present with overlapping symptoms. They include several disorders with both structural and functional dysfunction(s). Because symptoms alone are poor predictors of the underlying pathophysiology, a diagnosis should only be made after evaluating symptoms and physiologic and structural abnormalities. A detailed history, a thorough physical and digital rectal examination and a systematic evaluation with high resolution and/or high definition three-dimensional (3D) anorectal manometry, 3D anal ultrasonography, magnetic resonance defecography and neurophysiology tests are essential to correctly identify these conditions. These physiological and imaging tests play a key role in facilitating a precise diagnosis and in providing a better understanding of the pathophysiology and functional anatomy. In turn, this leads to better and more comprehensive management using medical, behavioral and surgical approaches. For example, patients presenting with difficult defecation may demonstrate dyssynergic defecation and will benefit from biofeedback therapy before considering surgical treatment of coexisting anomalies such as rectoceles or intussusception. Similarly, patients with significant rectal prolapse and pelvic floor dysfunction or patients with complex enteroceles and pelvic organ prolapse may benefit from combined behavioral and surgical approaches, including an open, laparoscopic, transabdominal or transanal, and/or robotic-assisted surgery. Here, we provide an update on the pathophysiology, diagnosis, and management of selected common anorectal disorders.

Application of Rectal Prolapse Constipation Balloon in Single Auxiliary Defecation / 中国医疗器械杂志

OBJECTIVE@#To explore the application value of rectal prolapse constipation balloon in single auxiliary defecation.@*METHODS@#Forty-one patients with moderate or severe rectocele were treated with a rectocele constipation balloon through the vagina. The defecography and VAS scores were compared before and after implantation.@*RESULTS@#There was a significant difference between the anorectal angle, rectocele, and VAS scores before and after intervention in defecography (<0.01).@*CONCLUSIONS@#A single assisted defecation of the rectocelicular constipation balloon is feasible.

Modified stapled transanal rectal resection combined with perioperative pelvic floor biofeedback therapy in the treatment of obstructed defecation syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical efficacy and safety of modified stapled transanal rectal resection (STARR) combined with perioperative pelvic floor biofeedback therapy (POPFBFT) in treating obstructed defecation syndrome (ODS).</p><p><b>METHODS</b>Thirty female ODS patients underwent modified STARR (resection and suture was performed in rectocele with one staple) combined with POPFBFT in Department of Colorectal and Anal Surgery, The First Hospital of Jilin university from October 2013 to March 2015. Before the modified STARR, patients received a course of POPFBFT (20 min/time, 2 times/d, 10 times as a course), and another 2 courses were carried out in clinic after discharge. Efficacy evaluation included general conditions of patients, morbidity of postoperative complication, overall subjective satisfaction (excellent: without any symptoms; good: 1 to 2 times of laxatives per month and without the need of any other auxiliary defecation; fairly good: more than 3 times of laxatives per month ; poor: with no improvement; excellent, good, fairly good are defined as effective), Longo ODS score (range 0 to 40 points, the higher the score, the more severe the symptoms), gastrointestinal quality of life index(GIQLI)(range 0 to 144 points, the lower the score, the more severe the symptoms), anorectal manometry and defecography examination. The follow-up lasted 12 months after operation (ended at April 2016).</p><p><b>RESULTS</b>Average age of 30 patients was 57(46 to 72) years and Longo ODS score of every patient was ≥9 before operation. The modified STARR was completed successfully in all the 30 patients with average operation time of 25 (18 to 34) min and average hospital stay of 6(4 to 9) d. Postoperative complications included pain(20%, 6/30), urinary retention (16.7%, 5/30), anorectal heaviness (6.7%, 2/30), and fecal urgency(26.7%, 8/30). Anaorectal heaviness and fecal urgency disappeared within 3 months. No severe complications, such as postoperative bleeding, infection, rectovaginal fistula, anastomotic dehiscence and anal incontinence were observed. The effective rate of overall subjective satisfaction was 93.3%(28/30) during the follow-up of 12 months. There was no significant difference in Longo ODS score between pre- POPFBFT and pre-operation (pre- POPFBFT: 32.95±3.22, pre-operation: 32.85±3.62, t=1.472, P=0.163). Compared with pre-POPFBFT, Longo ODS score at 1 week after operation decreased (t=4.306, P=0.000), moreover, score at 1 month after operation was lower than that at 1 week (13.05±7.49 vs. 15.00±7.17, t=7.322, P=0.000), while no significant differences were found among 1, 3, 6, 12 months after operation (F=2.111, P=0.107). Likewise, there was no significant difference in GIQLI score between pre-POPFBFT and pre-operation (pre-POPFBFT: 79.39±17.14, pre-operation: 76.65±17.56, t=1.735, P=0.096). Compared with the pre-POPFBFT, GIQLI score at 1 week after operation increased (t=4.714, P=0.000), moreover, GIQLI score at 1 month after operation was higher than that at 1 week (102.26±19.24 vs 91.31±21.35, t=5.628, P=0.000), while no significant differences were found among 1, 3, 6, 12 months after operation(F=1.211, P=0.313). In comparison with pre- POPFBFT, parameters of defecography examination at 12 months after operation showed obvious improvement: the rectocele decreased from (34.1±0.4) mm to (3.1±0.3) mm (t=6.847, P=0.000), anorectal angle during defecation increased from (123.8±6.7)degree to (134.7±8.5)degree, enlargement of anorectal angle during defecation increased from (29.1±3.5)degree to (37.1±5.3)degree, while no significant differences in descend of perineum, anorectal angles at rest as well as parameters of anorectal manometry were found (all P>0.05).</p><p><b>CONCLUSION</b>Modified STARR combined with POPFBFT is safe and effective for ODS patients.</p>

Clinical efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter in the treatment of puborectalis syndrome with high anal pressure / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter(IAS) in the treatment of puborectalis syndrome with high anal pressure.</p><p><b>METHODS</b>Twenty-five cases of puborectalis syndrome with high anal resting pressure in the preoperative examination received the operation of partial resection of puborectalis combined with mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o'clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ORB-16007695).</p><p><b>RESULTS</b>Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [(53.56±9.05) mmHg vs. (92.44±7.06) mmHg, (142.80±20.35) mmHg vs. (210.88±20.56) mmHg, respectively, both P=0.000]; anorectal angulation at resting state and forced defecation state increased significantly [(102.32±4.96)degree vs. (95.88±4.01)degree, (117.88±5.95)degree vs. (89.52±3.25)degree, respectively, both P=0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28±3.91, 7.40±3.64 and 8.04±4.74) was significantly lower than the preoperative score (16.00±3.69, all P<0.05), while the score was not significantly different among 3 time points after operation (P>0.05). Cleveland Clinic incontinence score was 0 at postoperative 6 and 12 months, and revealed 20 cases were effective among all the surgical patients(80%).</p><p><b>CONCLUSION</b>Partial resection of puborectalis combined with mutilation of internal anal sphincter can effectively reduce anal pressure and improve symptoms of outlet obstruction, which is an effective method in the treatment of puborectalis syndrome with high anal pressure.</p>

Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation / 대한소화기학회지

BACKGROUND/AIMS: Chronic constipation is a common gastrointestinal disorder diagnosed using Rome III criteria. Defecography is a radiographic method used to identify anatomic abnormalities of anorectum. The present study aimed to evaluate the defecographic findings in patients with severe idiopathic chronic constipation. METHODS: One hundred patients, who complained of severe idiopathic chronic constipation with abnormal balloon expulsion test, underwent defecography after injection of barium. An analysis of radiographs was performed by an expert radiologist for the diagnosis of descending perineum syndrome, rectocele, enterocele, rectal ulcer, rectal prolapse, fecal residue of post defecation, and etc. Then, they were compared between the two sexes. RESULTS: Normal defecography was only observed in two participants. Descending perineum syndrome was the most common abnormality (73.3%). The results showed that rectocele (80.8%) and descending perineum syndrome (69.2%) were most frequent in women. In males, descending perineum syndrome and rectal prolapse were more prevalent (87% and 43.5%, respectively). Compared with men, rectocele and rectal ulcer were more frequently observed in women (p<0.001, and p=0.04, respectively), while men were more affected by descending perineum syndrome (p=0.04). In total, women had a greater incidence of abnormal defecographic findings compared with men (p=0.02). CONCLUSIONS: Defecography can be performed to detect anatomic abnormalities in patients with severe idiopathic chronic constipation and abnormal balloon expulsion test. This technique can assist physicians in making the most suitable decision for surgical procedure.

Preliminary exploration on accurately preoperative evaluation of colonic lesions in slow transit constipation complicated with adult megacolon / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the application value of colonic transit test (CTT) combined with anorectal manometry (ARM), barium enema (BE) and defecography (DFG) in accurately evaluating colonic lesions of slow transit constipation complicated with adult megacolon.</p><p><b>METHODS</b>Clinical data of 47 above patients admitted between October 2007 and February 2015 in the People's Hospital of Hunan Province were analyzed retrospectively. All the patients were examined with≥2 times of CTT combined with ARM and BE, and 42 cases received additional DFG at the same time, to evaluate colonic lesions before operation. Operative biopsy pathology was used as the standard. The sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) of positioning in the ascending colon and caecum, transverse colon and descending colon were calculated, and the consistency was represented by Kappa test(Kappa value≥0.75 indicates good consistency, meanwhile higher Kappa value indicates better consistency). The Heikkinen score was used to evaluate defecation function at postoperative 6 months.</p><p><b>RESULTS</b>The age of 47 patients was from 18 to 56 years old. Compared with intraoperative findings and biopsy pathology, the diagnostic coincidence rate was 89.4% by CTT combined with BE and DFG positioning, which suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=12), transverse colon (n=26) and descending colon (n=9), while intraoperative findings and biopsy pathology suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=11), transverse colon (n=23) and descending colon (n=13). The sensitivity was 88.3%, specificity 93.5%, PPV 92.1%, NPV 94.9% and Kappa value was 0.827(P<0.001). Procedures performed included segmental colectomy (n=8), subtotal colectomy (n=29), total colectomy (n=10). There was no serious complication during and after operation. Defecatory function was excellent in 24 cases (60.0%), good in 10 (25.0%), and moderate in 6 (15.0%) evaluated by Heikkinen score at postoperative 6 months. A total of 40 patients were followed up from 1 to 7 years (median 3 years) and there was no long-term diarrhea and recurrence of constipation or giant colon after operation.</p><p><b>CONCLUSION</b>Preoperative detection of CTT combined with ARM, BE and DFG in patients with slow transit constipation complicated with adult megacolon can make a more precise assessment of the extent of colonic lesions in advance, which has a good clinical predictive value.</p>

Efficacy and safety of the Jinling procedure in the treatment of adult Hirschsprung disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the safety, efficacy and long-term outcomes of Jinling procedure in the treatment of adult Hirschsprung disease.</p><p><b>METHODS</b>Clinical and follow-up data of 125 patients with adult Hirschsprung disease undergoing Jinling procedure at the Department of General Surgery between January 2000 and January 2013 were summarized. All the patients were diagnosed by CT, barium enema, anorectal pressure detection and pathology examination. Abdominal symptoms, gastrointestinal quality of life index(GIQLI, the lower score, the worse quality of life), Wexner constipation score (higher score indicated worse symptom), defecography (evaluation included rectocele, mucosal prolapse, intramucosal intussusception, perineal prolapse) and other operative complications were compared before and after operation.</p><p><b>RESULTS</b>Among 125 patients, 69 were male and 56 were female with median age of (41.2±15.5) (18 to 75) years. The follow-up rates were 94.4%(118/125), 92.0%(115/125), 89.6%(112/125) and 88.0%(110/125) at postoperative months 1, 3, 6, and 12. Incidences of abdominal distension and abdominal pain were 100% and 82.4%(103/125) before operation, and were 7.3%(8/110) and 20.9%(23/110) at 12 months after surgery. Wexner score was significantly lower at postoperative months 1(8.7±2.9), 3 (7.2±2.8), 6(6.7±2.2) and 12(6.3±1.7) than that before operation (21.4±7.2) (P<0.01). GIQLI score was 51.6±11.9 before operation, though it decreased at 1 month (47.3±5.5)(P<0.05) after surgery, but increased significantly at postoperative months 3, 6, 12(68.9±8.0, 96.5±8.2, 103.2±8.6)(P<0.01). Abnormal rate of defecography was 70.4%(81/115), 48.2%(54/112) and 27.3%(30/110) at postoperative months 3, 6, 12, which was significantly lower than 91.2%(114/125) before operation (P<0.01). Morbidity of postoperative complication was 29.6%(37/125), including 5 cases of surgical site infection (4.0%), 2 of anastomotic bleeding (1.6%), 8 of anastomotic leakage (6.4%, one died of severe abdominal infection), 4 of urinary retention (3.2%), 3 of recurrent constipation (2.4%, without megacolon relapse), 11 of bowel obstruction (8.8%), 2 of anastomotic stricture(1.6%) and 2 of refractory staphylococcus aureus enteritis (1.6%, diagnosed by stool smear and culture, and both died finally).</p><p><b>CONCLUSION</b>Jinling procedure is a safe and effective surgical procedure for adult Hirschsprung's disease.</p>

Efficacy observation of partial stapled transanal rectal resection combined with Bresler procedure in the treatment of rectocele and internal rectal intussusception / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy of partial stapled transanal rectal resection (part-STARR) combined with Bresler procedure in the treatment of obstructed defecation syndrome (ODS) associated with rectocele and internal rectal intussusception(IRI), and compare with STARR.</p><p><b>METHODS</b>A randomized controlled study from January 2013 to December 2014 was undertaken. Sixty female patients with ODS caused by rectocele and IRI were prospectively enrolled and randomly divided into trial group (29 cases) receiving part-STARR combined with Bresler procedure, and control group (31 cases) undergoing STARR only. For patients in trial group, two thirds of posterior rectal wall were stapled with STARR methods and one third of anterior with Bresler procedure, while for those in control group, only STARR was performed. Intra-operational status, postoperative complications, Wexner constipation score and patient satisfaction 3 months and 6 months after operation, and rectocele defecography 6 months after operation were compared between the two groups.</p><p><b>RESULTS</b>The average operation time of trial group was longer than that of control group [(31.2±5.4) minutes vs. (28.7±4.0) minutes, t=2.127, P=0.038]. There were no significant differences in intra-operative blood loss, postoperative hospital stay and complications(pain, postoperative bleeding, rectovaginal fistula, feeling of tenesmus and swelling) between the two methods(all P>0.05). There were no significant differences in the Wexner score of constipation between the two groups before operation and 3 months after operation (6.72±1.19 vs. 7.32±1.25, t=-1.896, P=0.063), while the Wexner score of trial group was significantly lower 6 months after operation (6.90±1.42 vs. 7.74±1.26, t=-2.463, P=0.018). Patient satisfaction between two groups was not significantly different 3 months after operation(χ(2)=5.743, P=0.125), while trial group had better satisfaction 6 months after operation[93.1%(27/29) vs. 67.7%(21/31), χ(2)=8.247, P=0.041]. There was no difference in depth of rectocele on defecography between the two groups before operation, while rectocele was significantly improved 6 months after operation [(0.7±0.2) cm vs. (0.9±0.2) cm, t=2.527, P=0.014].</p><p><b>CONCLUSION</b>Partial STARR combined with Bresler procedure in the treatment of ODS associated with rectocele and IRI has better efficacy than STARR only.</p>

Diagnosis and Treatment of Dyssynergic Defecation

Dyssynergic defecation is common and affects up to one half of patients with chronic constipation. This acquired behavioral problem is due to the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. A detailed history, prospective stool diaries, and a careful digital rectal examination will not only identify the nature of bowel dysfunction, but also raise the index of suspicion for this evacuation disorder. Anorectal physiology tests and balloon expulsion test are essential for a diagnosis. Newer techniques such as high-resolution manometry and magnetic resonance defecography can provide mechanistic insights. Recently, randomized controlled trials have shown that biofeedback therapy is more effective than laxatives and other modalities, both in the short term and long term, without side effects. Also, symptom improvements correlated with changes in underlying pathophysiology. Biofeedback therapy has been recommended as the first-line of treatment for dyssynergic defecation. Here, we provide an overview of the burden of illness and pathophysiology of dyssynergic defecation, and how to diagnose and treat this condition with biofeedback therapy.

Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus

PURPOSE: Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. METHODS: Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). CONCLUSION: Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.