Current Concepts in Management of Outlet Obstruction A. Infantino, R. Bellomo, F. Galanti, L. Pisegna Cerone Outlet constipation is often characterized by dis- ical defects should always be considered. abling symptoms consisting of the strenuous Incidences of 33% of occult rectal prolapse, 1.7% effort to expel stools, a feeling of incomplete of sigmoidocele, and 10% of anismus have been evacuation, rectal tenesmus and a repeated call defecographically demonstrated after a clinical to toilet, digitations, and the necessity of enemas diagnosis of rectocele and obstructed defecation and/or suppositories [1]. It is related to multiple [4]. This is very important because of the subse- alterations, variously associated and in different quent different approaches: conservative for degrees, of the organs of the pelvis and per- anismus or surgical intervention for other condi- ineum: rectocele, rectal occult-mucosal or full- tions. thickness prolapse, and enterocele. Synchronous anatomic alterations in the urogynecological sector can also be found: uterine, vaginal, and Rectal Intussusception bladder prolapses [2]. A unique pathophysiolog- ic theory has been suggested but not yet demon- Rectal intussusception is often difficult to diag- strated [3]. As a consequence of the variability of nose. Radiological findings that can be indicative the affected organs, great difficulty in reaching a of rectal intussusception can be found also in diagnosis exists, and the management and treat- healthy people [5, 6]. Even the interpretation of ment of outlet constipation is, to date, far from radiological images is still a controversial issue being standardized. [4, 7–10]. There is open discussion as to whether magnetic resonance imaging (MRI) can add more information than cystocolpodefecography Clinical Conditions [9, 10], which remains the most useful and sim- plest test. Rectocele Rectocele is the most common anatomical alter- Enterocele ation that can be evidentiated through inspec- tion at straining and combined digital rectal and Enterocele has been found by Mellgren et al. [11] vaginal examinations. The presence of a recto- in 19% of 2,816 defecographies, but it can be visu- cele, however, often does not represent by itself alized at a high rate at straining [12, 13]. By itself, it the cause of the symptoms of obstructed defeca- does not necessarily impair defecation [14]; how- tion. In fact, only when it is larger than 3 cm, ever, the presence of the sigma in the dislocated when barium is entrapped after defecographic Douglas pouch can be a cause of compression of evacuation, in the absence of anismus, can it be the rectum at straining [15]. In any case, when a considered a cause of outlet obstruction. The surgical approach for obstructed defecation has association between rectocele and other anatom- been chosen, enterocele must be treated. 404 Benign Anorectal Diseases Solitary Rectal Ulcer quence, an initial conservative approach has been encouraged: high-fiber diet, biofeedback, and In patients with obstructed defecation, a solitary rehabilitation of the pelvic floor muscles can help rectal ulcer can be diagnosed at a rate ranging to reduce symptoms of outlet obstruction [19, 20]. from 6% to 39%. The symptoms improve signifi- cantly after behavioral therapy consisting of biofeedback and attempts to discourage the use of Rectocele laxatives, enemas, and suppositories. The success rate correlates to an increase of rectal mucosal When it has been demonstrated that the predom- blood flow as a consequence of improved activity inant alteration is the rectocele, repair of the ante- of extrinsic innervations of the rectum [16]. rior rectal wall through the different approaches Growing attention has been paid to the psy- described (transvaginal, perineal, or transanal) chological aspect [17]. Fifty patients (eight with should be performed. We believe that transanal slow-transit constipation, 36 with obstructed techniques are to be chosen for simultaneous defecation, and six with mixed symptoms) were repair of exuberant mucosal or full-thickness rec- given biofeedback training: 70% found biofeed- tal wall [21]. The simplest operation is the back helpful, and 62% improved, irrespective of transanal suture of the anterior rectal wall [22], the type of constipation. The results were related with satisfactory results in more than 80% of to psychological state rather than anorectal tests patients [23]. Depending on the size and in [17]. It has been demonstrated that in patients absence of a large rectal intussusception, Sarles with functional intestinal disorders, modification operation may be carried out and combined with of mucosal blood flow depends on the psycholog- an anterior levatorplasty in case of contextual ical state and autonomic innervations [18]. presence of fecal incontinence [24]. Improvement of mucosal blood flow could be sec- Taking into consideration new technologies, ondary to both a better psychological equilibrium rectocele and rectal occult mucosal prolapse may and better autonomic nerve stimulation. be also resected with a GIA stapled with satisfacto- ry short-term results [25]. Transanal stapled pro- lapsectomy and anterior levatorplasty have been Management of Obstructed successfully carried out in a small series with short Defecation follow-up [26]. The stapled transanal rectal resec- tion (STARR) for the treatment of symptomatic Treatment of outlet obstruction is often disap- rectocele was presented in 2002 [27]. After 3 pointing, and many authors reported no encour- months, 30% of patients had no complaints, 40% aging results after surgery [19, 20]. As a conse- had only one to two episodes per month of a b Section X • Current Concepts in Management of Outlet Obstruction 405 c d e f g h Fig. X.1. A 43-year-old woman with obstructed defecation and digital evacuation. Defecography confirmed the presence of a large rectocele associated to a posterior mucosal rectal prolapse (a). Stapler transanal rectal resection (STARR) procedure was performed. Three series of suture were passed through the anterior rectal wall at a distance of 5 cm from the dentate line (b). Anterior rectal bulging (c). The 33-mm circular stapler (PPH-01, Ethicon EndoSurgery) was then introduced for the anterior rec- tal resection (d). Similarly, two series of sutures were passed through the posterior rectal wall (e). Posterior rectal mucosal pro- lapse (f). The stapler was introduced for the second time for the posterior rectal resection (g). At the end of the operation, the rectum appeared unobstructed (h) obstructed defecation, 13.3% had evacuation only obstruction; however. 4/25 (16%) patients were using laxatives, and 16.6% were unchanged [27]. complicated by the urge to defecate [28]. In a mul- Afterward, a double stapler technique (Fig. X.1) was ticenter study, 90 patients with rectocele and rectal proposed and compared with STARR plus levator- intussusception were treated by performing the plasty: the results were encouraging on outlet same technique. Symptoms of obstructed defeca- 406 Benign Anorectal Diseases tion improved in 90% of patients, but 17.8% of lapse [35, 36]. Among 20 operated patients, after a patients were complicated with fecal urgency, and follow-up of at least 6 months, only 8.3% (1/12) 8.9% complained of incontinence to flatus [29]. In reported fecal incontinence, and 5% of patients a recent paper, preliminary results on seven with preoperative constipation still complained of patients appeared to be promising after treatment outlet obstruction. The negative predictive preop- with the double stapler procedure [30]. erative data were proximal internal prolapse with Nevertheless, some reports have published dis- rectosacral separation at defecography, chronic appointing results for the STARR procedure diarrhea, fecal incontinence, and major perineal [31–34]. Anismus and neuroticism were related to descent (>9 cm on straining) [35]. The Delorme severe postoperative pain and recurrent obstruct- procedure for the treatment of rectal outlet ed defecation [31]. In another report from four obstruction can be carried out with minimal mor- Italian centers [32], after performing the STARR bidity and short hospital stay, with good function- technique in 65 patients with obstructed defeca- al results and overall patient satisfaction above tion, more than 60% were still on laxatives after 1- 75% [36]. These are the conclusions of a study on year follow-up. Further studies are needed to clar- 34 patients complaining of outlet obstruction con- ify the usefulness and the proper indications of firmed by defecography. Twenty-six patients the STARR procedure [33] because the diffusion of (76.4%) reported good to excellent overall result the technique is, to date, not justified by the crite- after the Delorme procedure, and eight (23.6%) ria of evidence-based medicine [34]. reported fair to poor results. Symptomatic improvement was observed in 89.7% of patients who had incomplete evacuation and in 88.5% of Rectal Prolapse patients with constipation [37]. Our unpublished results demonstrated that in 27 patients selected Perineal Approach on the basis of the criteria reported in Table X.1 (STARR procedure is not included, as it is awaiting Positive results have been reported by using the scientific placing, which makes valid the most Delorme technique for the treatment of rectal pro- appropriate indication [34]), all symptoms signifi- Table X.1. Selection criteria for the choice of surgery in patients with outlet constipation after failure of conser-