EXternal Pelvic REctal SuSpension Using Permacol Implant The ‘Express’ Procedure

1. EXternal Pelvic REctal SuSpension Using Permacol Implant The ‘Express’ Procedure P Giordano ACOI 2005

2. Rectal intussusception (RI) • Definition • full-thickness descent of the rectal wall • Mellgren et al., 1994 • Felt-Bersma & Cuesta, 2001 • Recto-rectal • Recto-anal

3. Commonly diagnosed at evacuation proctography

4. Surgical treatment of Rectal Intussusception • Abdominal approach • Perineal approach

5. Abdominal procedures • Abdominal rectopexy is the preferred technique • full rectal mobilisation • potential morbidity • high rate of post-operative constipation • variable results • anatomy vs. symptoms Schultz et al., 1996 Schultz et al., 2000 Johansson et al., 1985

6. Perineal procedures • Intra-rectal Délorme’s • rectal mucosectomy / vertical plication of the rectal wall • technically demanding • low morbidity • functional results • 60 - 70% improved evacuatory symptoms • faecal continence improved in minority • recurrence unknown Berman et al., 1985, 1990, Sielezneff et al., 1999, Liberman et al., 2000

7. Intussusception and Rectocoele • RI and rectocoele frequently co-exist • Choi et al., 2001 • RI often seen to block rectocoele • Rectopexy fails to deal with a co-existent rectocoele Rectocoele Obstructed Rectocoele Recal Intussusception

8. Treatment of Rectocoele } The conventional approach is to consider rectocoele as merely a weakness in the rectovaginal septum • Trans-anal / trans-vaginal / STARR • Trans-perineal mesh repair procedures • Functional outcome • 40% to 90% success rate • Kenton et al., 1999 • Lopez et al., 2001 • Recurrence rate • up to 50% • Tjandra et al., 2001

9. EXternal Pelvic REctal SuSpensionThe ‘Express’ procedureNSWilliams, LS Dvorkin, P Giordano et al. Br J Surg 2005;92:598-604Aim • To develop a minimally invasive perineal procedure to correct RI + rectocoele • Using an acellular porcine collagen implant (Permacol™)

10. Inclusion Criteria: Circumferential / full-thickness RI Symptoms consistent with physiological findings Failed maximal conservative therapy Rectocoele > 2 cm and retains neo-stool Exclusion Criteria: Organic disease Delayed colonic transit Rectal hyposensitivity Overt rectal prolapse <18 years old Patient Selection

11. Clinical and physiological assessment • Clinical symptom questionnaires • GIQOL Index • SF36-v2 • Intussusception symptom score • Comprehensive anorectal physiological investigation • stationary pull-through manometry • rectal sensory thresholds • PNTML • EAUS • evacuation proctography • Post-operative assessment at 6 months

12. Operative details Transversus perineii retracted upwards Anterior rectal wall Puborectalis

16. Results of the ‘Express’ procedure

17. Demographics • N = 17 (13 F) • Median age 47 years (20 – 67) • Median follow-up 12months (6 - 20) • 13 (all F) had concomitant rectocoele repair

18. Morbidity

19. Morbidity • Vaginal perforation (n = 2) • Anterior rectal wall perforation (n = 3) • 1 sepsis and subsequent stoma

20. Functional outcome: clinical symptom score * Wilcoxon signed rank test (n=15)

21. Functional outcome: quality of life score * Wilcoxon signed rank test (n=15)

22. Anatomical outcome: RI 6 normal

23. Anatomical outcome: rectocoele(n = 11) 8 = normal 3 = persistent

24. Conclusion • The “Express” procedure is a safe and effective surgical option for rectal intussusception and rectocoele in patients with evacuatory symptoms

25. Defecation should be natural

26. Rectal intussusception and Rectocoele Point of ‘take-off’ ARJ

27. Aids to evacuation

28. SRUS • 6 months after surgery, ulcers had healed in both patients

29. Faecal incontinence • Preoperatively • Faecal incontinence: 5 (29%) • Faecal urgency: 2 • Passive leakage of mucus: 2 • Postoperatively • 1 became fully continent and 1 developed PFL • Faecal urgency unchanged • Passive leakage of mucus resolved in 1 patient

30. Anorectal physiological investigation

31. Functional outcome vs. proctographic findings • There were no significant differences in functional outcome scores between those with and those without postoperative intussuscepta

32. Evacuatory dynamics