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Outlet Obstruction: Diagnosis
and treatment 2008
Ferenc Jakab
Falk Symposium
2008. Budapest, May 2-3
Uzsoki Teaching Hospital, Surgery & Vascular Surgery
Budapest, Hungary
DEFINITON
The
OUTLET
OBSTRUCTION
SYNDROME encompasses all pelvic floor
abnormalities which are responsible for an
incomplete evacuation of fecal contents
from the rectum. OOS is related to
anatomic alterations / rectocele, enterocele
/ which may be associated with functional
disorders, such as paradoxical puborectalis
contraction
DEFINITON
OUTLET OBSTRUCTION SYNDROME is
associated
with
a
FAILURE
of
RELAXATION or even with a paradoxical
contraction of the puborectal muscle during
straining accentuating the flap-valve reaction
of the anorectal angle and resulting in an
obstruction to the onward passage of stool.
Ifinally resulting CONSTIPATION.
SIGNIFICANCE OF PUBORECTALIS
MUSCLE
Normal defecation:
puborectal muscle relaxes
rectoanal angle straightens
solid faces is getting to anal canal
The failure of puborectalis muscle to
relax alone leads to functional outlet
obstruction
PREVALENCE I.
The prevalence of constipation in adults
may be as high as 28% accounting for
more than 2.5 million outpatient medical
visits in the U.S. yearly.
DiPalma
PalmaJ.A.
J.A.Ann
AnnJ.J.Gastroenterol
Gastroenterol
Di
2001;96
96S140
S140
2001;
PREVALENCE II.
The
OUTLET
OBSTRUCTION
SYNDROME may
be observed in half
of
constipated
patients
D’HooreA:
A:Colorectal
ColorectalDis:
Dis:2003;
2003;5.280
5.280
D’Hoore
CAUSES OF CONSTIPATION
I.
Extrainestinal
1. Endocrine: hypercalcemia, hypocalemia
2. Metabolic: hypercalcemia, hypocalemia
3. Neurologic: Parkinson’s disease, multiple sclerosis, spinal
cord lesions, musculardystrophies, autonomic neuropathy
4. Rheumatologic: systemic sclerosis
5. Psychological: depression, eating disorders
6. Medications: narcotics, anticholinergics, antipsychotics,
calcium channel blockers, anti-Parkinson’s therapy,
anticonvulsants, tricyclic anticdepressants, iron, calcium,
aluminium antacids, sucralfate
AndromanakosNNetetal:
al:J.J.Gastroenterol.
Gastroenterol.Hepatol
Hepatol2006;
2006;21.
21.638
638
Andromanakos
CAUSES OF CONSTIPATION
II. Intestinal
A Colon
1. Functional: slow transit, irritable bowel syndrome
2. Organic: neoplasms, polyps, diverticulum disease, strictures,
aganglionosis
B Anorectum and pelvic floor
1. Megarectum
2. Neoplasms, polyps
3. Anal stenosis (after surgery, radiation or Crohn’s disease))
4. External compression
5. Aganglionosis
AndromanakosNNetetal:
al:J.J.Gastroenterol.
Gastroenterol.Hepatol
Hepatol2006;
2006;21.
21.638
638
Andromanakos
CAUSES OF CONSTIPATION
6. Internal rectal prolapse
7. Complete rectal prolapse
8. Mucosal rectal prolapse
9. Solitary rectal ulcer
10. Congenital or acquired internal anal
sphincter myopathy
11. Anismus
12. Descending perineum syndrome
13. Enterocele
14. Rectocele
AndromanakosNNetetal:
al:J.J.Gastroenterol.
Gastroenterol.
Andromanakos
Hepatol2006;
2006;21.
21.638
638
Hepatol
CAUSES OF OUTLET OBSTRUCTION
Functional causes
Anismus
Hirschprungs’disease
Chagas disease
Hereditary internal sphincter
myopathy
Central nervous lesions
Morphological causes
Rectocele
Enterocele
Rectal prolapse
Descending perineum
syndrome
Rectal tumors
Posttherapeutical stenosis
of the anorectum
TYPES OF CONSTIPATION
1. Slow transit colonic constipation
2. Outlet Obstruction
3.
1+2
DIAGNOSIS OF OUTLET OBSTRUCTION
- Physical examination
- Barium X ray defecography
- Colonic transit time test
- Anorectal manometry
- Balloon expulsion test
- Electromyography (EM)
- Dynamic MR imaging
- Endorectal, Endocanal US
PHYSICAL EXAMINATION
Physical examination
History
Perineal inspection
Digital examination (at rest,
squeeze, straining)
Abnormal
defecation
Petulous anus
Stool
Straining at stool
Fissure
Neoplasms
Digital maneuver
Prolapsing
hemorrhoids
Stenosis
Disimpaction
Scars
Anal sphincter tone
Skin irritation
Rectal prolapse
Perineal descent
Rectocele
Enterocele
BARIUM X RAY DEFECOGRAPHY
For documenting the extent
rectoanal intussusception:
Wexner’s classification
Marti’s classification
AndromanakosNNetetal:
al:
Andromanakos
Gastroenterol.Hepatol
Hepatol
J.J.Gastroenterol.
2006;21.
21.638
638
2006;
of
COLONIC TRANSIT STUDIES
This test estimates the colonic
function by in taking 20
radiopaque markers, or
isotopically labelled solid particles
Normal transit < 5 remaining
markers
Obstructive > 5 markers in
rectosigmoid
Slow > 5 markers throughout the
colon
Diagnosis of Chronic Constipation
ANORECTAL MANOMETRY
Manometry helps to detect motor and sensory
abnormalities of the anorectum during attempted
defecation.
Maximal Anal Resting Pressure (MARP)
Maximal Anal Squeezing Pressure (MASP)
Rectal Sensitivity Threshold Volume (RSTV)
Objective Recto Anal Inhibitory Reflex (RAIR)
Maximum Tolerable Volume (MTV)
BALLOON EXPULSION TEST
Balloon inflated with 50 – 100 cc of
saline should be expel from the
rectum.
Patients with pelvic outlet obstruction
are unable to expel the balloon.
BALLOON TOPOGRAPHY
The pressure of the cylindrical flexible
balloon placed into the anal canal and
rectum, filled with liquid radiopaque under
low pressure is controlled, the shape of the
balloon is visualized.
Failure of puborectalis muscle to relax and
the maintenance of anorectal angle can be
diagnosed.
ELECTROMYOGRAPHY (EM)
Tonic activity inhibition of the striated
pelvic floor muscles (including the
puborectalis muscle) is considered to
normally occur in straining and during
defecation
Rosato G. Complex Anorectal
Rosato G. Complex Anorectal
Disorders2005;
2005;153.
153.29.
29.
Disorders
DYNAMIC MR IMAGING
N.Bolog
BologJJGastroenterol
Gastroenterol2005.
2005.
N.
14.293-302
14.293-302
ENDORECTAL US
Zabar:Complex
ComplexAnorectal
Anorectal
P.P.Zabar:
Disorders2005;
2005;263.3
263.3
Disorders
DYNAMIC TRANSPERINEAL ULTRASOUND
Beer-GabelM
Metetal.:
al.:Dis
DisColon
ColonRectum
Rectum2002.
2002.45
45239
239
Beer-Gabel
CONSTIPATION OF ANORECTAL OUTLET
OBSTRUCTION
MEGARECTUM
Primary or secondary megarectum is a
disorder of the rectal sensation and a
high compliance.
CONSTIPATION OF ANORECTAL OUTLET
OBSTRUCTION
ANISMUS (Spastic pelvic floor
syndrome)
Failure of relaxation or paradoxical
contraction of puborectalis muscle
CONSTIPATION OF ANORECTAL OUTLET
OBSTRUCTION
HIRSCHSPRUNG DISEASE
The abscence of the rectoanal inhibitory reflex
leads to functional distal
obstruction.
CONSTIPATION OF ANORECTAL OUTLET
OBSTRUCTION
DESCENDING PERINEUM SYNDROME
The anterior rectal wall protrudes into the
anal canal, and the protrusive mucosa may
act as a plug of the anal canal.
CONSTIPATION OF ANORECTAL OUTLET
OBSTRUCTION
RECTAL PROLAPSE: The anal canal is
blocked from the protruding rectum
ENTEROCELE: anterior or posterior
enteroceles head to mechanical obstruction
of the rectum
RECTOCELE: Influence of regional forces
lead to stool into the rectocele rather than
take outlet of anal canal
MANAGEMENT / TREATMENT OF
Education
Fiber
diet
(bulk,
stimulating, osmotic)
Laxatives
Biofeedback training
Colhicin, Misoprostil,
Botulinum toxin
Surgical options
OOS
lubricating,
SLOGAN OF SURGICAL TREATMENT
FOR OOS 2008
„Surgery
should be
considered as a last
resort for constipated
patients.”
MANAGEMENT ALGORITHM FOR THE
PATIENT WITH CONSTIPATION
PRINCIPLES OF SURGICAL
INTERVENTIONS FOR OOS
™ proven the abscence of primary colonic
constipation
™ patients with impaired sphincter formation
should be excluded
™ surgery mainly for the repair or removal of
the specific anatomic defect
MANAGEMENT OF OOS
CAUSE OF FECAL
IMPACTION
Rectal neoplasm
Megarectum
Impaired rectal sensation
Hirschsprung disease
Anismus – or spastic pelvic
floor syndroma
+ slow colonic transit
OPTION
Surgery
STC + IRA
Total proctocolectomy + ileal pouch
Duhamel operation
Biofeedback training or
Electrical stimulation SNS
Pull – through procedure
Rectal or anorectal myectomy
Division of puborectalis muscle
Botilinum toxin A
Biofeedback training
Colectomy
B.Holzer:
Holzer:ASCRS
ASCRS2007.
2007.170
170
B.
V.Ripetti.
Ripetti.Surg.
Surg.2006;
2006;02.009
02.009
V.
MANAGEMENT OF OOS
CAUSE OF FECAL
IMPACTION
Rectocele
+ slow colonic transit
Descending perineum syndrome
+ denervation
Internal rectal prolapse
Complete rectal prolapse
OPTION
Simple repair
retropexy transabdominally
pelvic floor repair
Biofeedback therapy
Dilation, sphincterotomy
?
Transabdominal repair
Resection, pexy
Laparoscopic repair
Sutures, clips,
Mesh
SURGICAL OPTIONS
™ vaginal or perineal levator plasty
™ open rectopexies
™ laparoscopic rectopexies
™ laparoscopic resection, retropexy
™ transrectalis excision
™ stapler- assisted trans – anal surgery (double –
stapled)
™ antegrade colonic enema (Malone procedure)
™ STC with IRA (laparoscopic, hand assisted)
™ segmental resection
AugusteT.T.Gastroenterol
GastroenterolClin.
Clin.
Auguste
Biol.2006;
2006;30.659
30.659
Biol.
LONGTERM RESULTS OF STC with IRA
Author
Fan
Pikarsky
Athanasakis
FitzHarris
Year
2000
2001
2001
2003
N
24
30
4
112
Follow up
No
Succes
(years) megacolon
%
1.9
8.8
0.7
n.a.
24
30
4
112
87.5
83
100
93
CONCLUSION
¾ Conservative treatment options should
tried until they are exhausted.
¾Segmental resection may be a good
option
for
isolated
megasigmoid,
sigmoidocele, or recurrent sigmoid
volvulus.
CONCLUSION
¾ In general patients with GID should not
be offered any surgical options because of
their anticipated poor result.
¾ Moreover, patients with psychiatric
disorders should be actively discouraged
from resection, as they tend to have
poorer prognosis.
CONCLUSION
¾ Colectomy is not a treatment option for pain
and / or abdominal bloating.
¾ Surgical interventions are numerous, covering
wide range of interventions from endorectal
repair of rectocele through stapler assisted
transanal surgery to proctocolectomy with
restorative ileo- anal reservoir.
CONCLUSION
¾ The repair of specific anatomic defects are
indicated if the absence of primarily colonic
obstipation is proven.
¾ Moreover, patients with impaired sphincter
function should be exluded due to the high risk of
inducing definitive postoperative incontinence.
CONCLUSION
¾ The detailed surgical indications are hot
spots in 2008.
¾ The patholophysiology of outlet obstruction
syndrome is still far to be clearly understood,
for this reason surgery should be taken into
consideration if the patients is unresponsive to
conservative treatment.