obstructed defecation syndrome: diagnosis & surgical treatment
TRANSCRIPT
Obstructed Defecation Syndrome: Diagnosis & Surgical Treatment
By
Dr Ashwin PorwalConsultant Procto-Surgeon
Apollo Jehangir Hospital
Poona Hospital &
Inamdar Hospital
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in1
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in2
Obstructed Defecation Syndrome (ODS)
Constipation due to difficulty in passing stools once it has reached rectum as a result of RectorectalIntussusception (Internal Rectal Prolapse) or Rectocele
ODS has been shown to be the result of an abnormal function of the muscles involved in defecation or an anatomical abnormality of the pelvic organs
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in3
Prevalence of ConstipationConstipation prevalence in the general population is
estimated at around 5-15% .
reports suggesting significantly higher levels in the elderly, especially above the age of 65.
reports of females being affected more then males, male to female ratio of 1: 2.2.
ODS is estimated to be prevalent in 7% of the adult population and is judged to be the cause of one third of all cases of constipation
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in4
1)Failure of conservative treatment for ODS
2)Underlying structural abnormality like Rectocele & Recto-Rectal Intussuception on MRI Defecography
NICE guidelines for STARR surgery for ODS
Efficacy of STARR in ODS
In multiple studies reviewed by NICE , It was observed that there was significant improvement in pre operative constipation symptoms at a mean follow up of 2 years.Post op Defecography also demonstrated correction of rectocele and intussuception in one study .Quality of life following STARR was assessed in few studies , excellent or good outcome was reported by 70-80% of the patients.
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in5
Rectocele in females – A Rectovaginal Defect
• A rectocele is an out pouching of the anterior rectal wall and posterior vaginal wall into the lumen of the vagina
Definition
• high rectoceles due to stretching or disruption of the upper third of the vaginal wall and uterosacral ligaments
• mid level rectocelesmost common and are associated with loss of pelvic floor support
• low-level rectoceles can be caused by obstetric trauma
Gradation
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in6
Rectocele: Prevalence
Prevalence in young nulliparous women : 12%
• Source: Australia & NZ Journal of Obst & Gynec.2005 Oct;45(5):391-4
Prevalence in multiparous women
with uterus : 18.6 % without uterus : 18.3%
• Source: American Journal of Obst & Gynec
Prevalence of Rectocele in male patients who have a history ofchronic constipation and are symptomatic for ODS is as high as 60% inmy routine clinical observation
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in7
Rectocele & ODS
Symptoms of Rectocele include:
– Pain or pressure in the vagina
– Pain during sexual intercourse
– Pain or pressure in the rectum
– Feeling of tissue bulging out of vagina
– Constipation: ODS (Obstructed Defecation Syndrome)
• Difficult passage of stool
• Needing to apply pressure on vagina to pass stool
• Feelings of incomplete stool passage
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in8
• Colonoscopy to rule out tumours + IBD
• Conservative treatment with laxatives /enemas / diet failed
Before patient sees
surgeon
• Patient history
• Dr Longo’s Score (ODS Score) assessment
• Incontinence / Urogenital assessment to rule out other complications
• Quality of life / Patient motivation assessment
Patient sees the surgeon
– Patient Interview
• Perineal Examination
• Proctoscopy resting / straining
• Urogenital Examination
Clinical Examination
• Conventional Defecography / MRI Defecography
• Anal-manometry and Endo-anal ultrasound – only if incontinence or suspicion of sphincter damage – otherwise not mandatory
• Colon transit – suspicion of slow bowel movement
Clinical Evaluation
Diagnostic Approach for ODS
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in9
Patients of ODS: Symptoms and Signs
• Pain at defecation• Haemorrhoidal prolapse (!) • Extended time at the toilet• Perineal pain / discomfort when standing• Use of laxatives or enemas• Fecal Incontinence• Extreme straining to defecate• Feeling of incomplete evacuation• Fragmented defecation• Vaginal, Perineal or Rectal digitation
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in10
History Taking for Constipation
Obstructive
• Excessive Straining
• Poor response to Laxatives over a period of time
• Either 2-3 visits/day or 2-3 visits in a week to toilet
• Inadequate Defecation
• Feeling of stools obstructed in Rectum
• Rectal and or Vaginal Digitationfor Evacuation
Functional / IBS
• Straining + -
• No feeling of stools obstructed in rectum
• Usually responds to laxatives
• Inadequate Defecation +
• Multiple visits to toilet +
• Usually no history of digitation
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in11
Defecography
• Salient phases of Conventional / MRI Defecography Image captured
– During rest with filled anal bulb
– During maximum contraction of anal sphincter and pelvic floor muscles
– During straining without evacuation
– During evacuation
– During rest when evacuation is completed
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in12
Surgical Treatment for ODS –Stapled Transanal Rectal Resection(STARR)
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in13
Treatment for ODS
STARR (Stapled Transanal Rectal Resection)
• Transanal resection of the lower rectum
• Full thickness resection of the anterior rectum wall by stapler after longitudinal stitches at 10, 12 and 2 o‘clock positions. Similar approach at the posterior wall with stitches at 4, 6 and 8 o‘clock positions.
• Suturing of the overlaping dog ears at 3 and 9 o‘clock positions.
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in14
Conclusion
STARR is a safe and effective procedure to treat ODS (Obstructd Defecation Syndrome)
The surgery needs only 24hrs of hospitalisation & patient can resume his routine work from 3rd day
The key to success is patient selection
Problem could be the cost involved
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in15
Thank You!
12/3/2014Copyright@ 2014 Healing Hands Clinic
www.healinghandsclinic.co.in16