1. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry EXternal Pelvic REctal SuSpension Using Permacol Implant The ‘Express’ Procedure P Giordano ACOI 2005

2. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Rectal intussusception (RI) Definition full-thickness descent of the rectal wall Mellgren et al., 1994 Felt-Bersma & Cuesta, 2001 Recto-rectal Recto-anal

3. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Commonly diagnosed at evacuation proctography

4. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Surgical treatment of Rectal Intussusception Abdominal approach Perineal approach

5. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry 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. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry 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. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry 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 Recal Intussusception Obstructed Rectocoele

8. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Treatment of Rectocoele 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 } The conventional approach is to consider rectocoele as merely a weakness in the rectovaginal septum

9. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry EXternal Pelvic REctal SuSpension The ‘Express’ procedure NS Williams, LS Dvorkin, P Giordano et al. Br J Surg 2005;92:598-604 Aim To develop a minimally invasive perineal procedure to correct RI + rectocoele Using an acellular porcine collagen implant (Permacol™)

10. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Patient Selection 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

11. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry 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. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Transversus perineii retracted upwards Anterior rectal wall Puborectalis Operative details

13. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry

14. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry

15. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry

16. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Results of the ‘Express’ procedure

17. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Demographics N = 17 (13 F) Median age 47 years (20 – 67) Median follow-up 12 months (6 - 20) 13 (all F) had concomitant rectocoele repair

18. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Morbidity

19. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Morbidity Vaginal perforation (n = 2) Anterior rectal wall perforation (n = 3) 1 sepsis and subsequent stoma

20. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Functional outcome: clinical symptom score PRE-OP median (range) POST-OP median (range) P value * Prolapse11 (0 - 17) 4 (0 - 11)0.0004 Evacuation 11 (3 - 15)6 (1 - 13)0.002 Incontinence 6 (0 - 16)5 (0 - 14)0.3 * Wilcoxon signed rank test (n=15)

21. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Functional outcome: quality of life score PRE-OP median (range) POST-OP median (range) P value * Prolapse7 (0 - 14)2 (0 - 8)0.001 Evacuation10 (0 - 18)5 (0 - 16)0.009 Incontinence5 (0 - 16)3 (0 - 13)0.147 * Wilcoxon signed rank test (n=15)

22. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Anatomical outcome: RI 6 normal

23. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Anatomical outcome: rectocoele (n = 11) 8 = normal 3 = persistent

24. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Conclusion The “Express” procedure is a safe and effective surgical option for rectal intussusception and rectocoele in patients with evacuatory symptoms

25. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Defecation should be natural

26. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Rectal intussusception and Rectocoele Point of ‘take-off’ ARJ

27. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Aids to evacuation PRE-OPPOST-OP Laxatives63 Rectal Preparations 34 Rectal irrigation 21

28. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry SRUS 6 months after surgery, ulcers had healed in both patients

29. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry 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. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Anorectal physiological investigation

31. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Functional outcome vs. proctographic findings There were no significant differences in functional outcome scores between those with and those without postoperative intussuscepta

32. Centre of Academic Surgery Barts and The London Queen Mary’s School of Medicine and Dentistry Evacuatory dynamics