Tailoring surgery for obstructed defecation syndrome to the 'iceberg diagram': Long-term results.

BACKGROUND: Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results. METHODS: Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated. RESULTS: Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured. CONCLUSION: The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.

Rectal perforation during defecography: extraluminal barium impaction removed by TEM (Transanal Endoscopic Microsurgery).

AIM: Defecography is the standard diagnostic technique for the diagnosis of functional disorders of the posterior pelvic compartment. However it has some limits as radiation exposure, low-contrast resolution, some degrees of embarrassment and discomfort for the patients. Furthermore it often fails to directly visualize the changes that affect the pararectal space. Here we present a never described case of rectal perforation after defecography with barium impaction removed by TEM (Transanal Endoscopic Microsurgery). CASE REPORT: We present a case of a 50 years old woman with extraluminal barium impaction due to perforation occurred during defecography. Both pelvic MR and endoanal ultrasound confirmed the presence of the extramural rectal mass below rectal mucosa. It was completely and safely removed using transanal endoscopic microsurgery (TEM). RESULTS: The barium impaction has been radically removed using transanal endoscopic microsurgery. The post-operative period was uneventful and the patient was discharged 3 days after the operation. She is asymptomatic after 6 months from surgery. CONCLUSION: Defecography is not completely safe and its use must be indicated only in selected cases. When a patient has complications during or after this investigation he must be referred to a specialistic centre where a tailored treatment can be performed. It is mandatory that the indication for defecography and other diagnostic functional investigations is given by a colorectal specialist KEY WORD: Barium Impaction, Defecography, Rectal Perforation, TEM (Transanal Endoscopic Microsurgery).

Vaginal opacification during defecography: direction of vaginal migration aids in diagnosis of pelvic floor pathology.

BACKGROUND: To determine whether direction of vaginal displacement during defecography aids in diagnosing pelvic floor pathology. METHODS: Ninety patients underwent defecography over a 2-year period. Each study was retrospectively reviewed by three radiologists who recorded whether the vagina was displaced cephalad, caudad, or nondisplaced in relation to the urogenital hiatus. This information was then correlated with radiologic diagnosis rendered for the study. RESULTS: Of the 26 patients with normal defecograms, 19 (73%; p < 0. 001) demonstrated no vaginal displacement during the procedure. Comparatively, 10 (83%; p < 0.001) of the 12 patients with cystoceles showed caudad vaginal displacement, and no patients with cystoceles showed cephalad displacement of the vagina. Of the 17 patients with rectoceles, 10 (58%) showed cephalad displacement, one (6%) showed caudad displacement, and six (35%) patients showed no vaginal displacement. Thirteen (46%) of 28 patients with enteroceles showed cephalad vaginal displacement, nine (32%) showed no vaginal displacement, and six (21%) demonstrated caudad displacement. CONCLUSIONS: Caudad displacement of the opacified vagina suggests the presence of a cystocele. Cephalad vaginal displacement is suggestive of the presence of an enterocele or rectocele.