Magnetic resonance follow-up protocol for patients after stapled transanal rectal resection for intussusception and rectocele

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1 Magnetic resonance follow-up protocol for patients after stapled transanal rectal resection for intussusception and rectocele Poster No.: C-2659 Congress: ECR 2013 Type: Scientific Exhibit Authors: S. Camisa, F. Calliada, I. Fulle, G. Ori Belometti; Pavia/IT Keywords: Pelvic floor dysfuntion, Defecography, MR, Pelvis DOI: /ecr2013/C-2659 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Purpose To define a clinical-mr imaging follow-up protocol for patients after "Stapled Transanal Rectal Resection" (STARR) for surgical correction of rectocele and rectal prolapse conditioning Obstructed Defecation Syndrome (ODS) [1]. This follow-up protocol involves patients 6-12 months after STARR surgery, and includes a first clinical approach, in order to investigate symptoms in post-operative period, and then an objective imaging evaluation by MR-defecography. In fact, if there are specific selection criteria for patients undergoing to STARR surgery, a monitoring post-operative protocol isn't yet approved. The presented follow-up, by comparing clinical symptoms and MRI features, notices in particular patients without correlation between reported symptoms and MRI, and patients with an early relapse of rectocele disease: for each type it is proposed a specific short and long-term monitoring. This protocol also emphasizes the role of MR-defecography, such as panoramic and multiplanar examination, in the assessment of pelvic floor dysfunctions [2]. Methods and Materials 31 patients, including 27 women (87.1%) and 4 men (12.9%) with mean age of 56 ± 12 years, are enrolled for a 6-12 months follow-up protocol after STARR surgery. Inclusion criteria: Patients years old; Patients who performed MR-defecography in our Institute of Radiology before STARR, with imaging diagnosis of rectocele and rectal prolapse. Exclusion criteria: Patients with contraindications to MR exam; Patients with a history of drug addiction, psychiatric disorders, dementia, or other reasons that may affect compliance during performing protocol; Patients with claustrophobia. After enrolled, one woman is excluded from the protocol because of a claustrophobia crisis, so our results refer to 30 patients (26 women +4 men). In order to standardize the follow-up monitoring and to quantify symptoms as constipation and incontinence, clinical evaluation is carried out by two score systems: Cleveland Clinic Constipation Score (CCCS) [3] and Wexner Continence Grading Scale (WCGS) [4]. Although not recent, these two score systems are easily usable by patients. Before performing MR defecography, it is necessary to distend rectal ampulla using ultrasonography gel (about 300 ml). Patients are evaluated by MR-defecography using 1.5 Tesla MRI system and surface multichannel coil "phased arrey" for signal reception. Page 2 of 15

3 MR-defecography consists of two phases: static and dynamic ones [5-6]. Static phase includes Turbo Spin Echo (TSE) T2-w sequences on axial and sagictal planes (Fig. 1) and a TSE T1-w sequence on coronal plane (Fig. 2). These rest sequences ensure a morphological study of puborectal and levator ani muscles and a functional assessment of anorectal angle. In the next dynamic phase True FISP sequences on sagictal plane are used, performed during squeezing (voluntary contraction of external anorectal sphincter) (Fig. 3) and during gel evacuation (Fig.4). Images for this section: Fig. 1: Fig.1: TSE T2-w static sequences on axial and sagictal planes Page 3 of 15

4 Fig. 2: Fig.2: TSE T1-w static sequence on coronal plane Page 4 of 15

5 Fig. 3: Fig.3: TSE T2-w static sequence on sagictal plane (A) and TRUE-FISP sequence on sagictal plane in squeezing: notice closure of anorectal angle (B) Page 5 of 15

6 Fig. 4: Fig.4: TSE T2-w static sequence on sagictal plane (A) and TRUE-FISP sequence on sagictal plane during gel evacuation: notice anterior rectocele (B) Page 6 of 15

7 Fig. 5: Fig.5: TSE T2-w static sequence on sagictal plane: notice gel evacuation at rest as part of fecal incontinence Page 7 of 15

8 Fig. 9: Fig.9: TRUE-FISP sequenze on sagictal plane during gel evacuation: notice descending perineum syndrome Page 8 of 15

9 Fig. 8: Fig.8: TRUE-FISP sequenze on sagictal plane during gel evacuation: notice evident enterocele Page 9 of 15

10 Fig. 7: Fig.7: TRUE-FISP sequenze on sagictal plane of two different patients during gel evacuation: notice rectal prolapse without enterocele or uro-genital prolapse Page 10 of 15

11 Fig. 6: Fig.6: TRUE-FISP sagictal sequenze during squeezing and gel evacuation: notice progressive closure of ano-rectal angle in case of dyssynergia Page 11 of 15

12 Fig. 10: Fig.10: TRUE-FISP sequence on sagictal palne during gel evacuation: notice anterior rectocele Page 12 of 15

13 Results Clinical scores results are as follows: Cleveland Clinic Constipation Score using a score of 15 as threshold value for the definition of "constipation": -12 patients score> 15; -18 patients score# 15. Wexner Continence Grading Scale using a score of 10 as threshold value for the definition of "incontinence": -10 patients score> 10; -20 patients score # 10. As concern MRI findings: Intussusception and Rectocele -in14 patients (47%), it is visible and measurable, at MR-defecography, relapse of rectocele, with or without rectal intussusception; -in 16 patients (53%), preexisting rectal prolapse/rectocele is no longer visible. Starting from the objective MRI findings, patients are classified as "negative", i.e. no recurrence of rectocele after surgery, and "positive", i.e. relapse of rectocele. According to CCCS scoring system, used to objectively quantify the severity of constipation, these two groups patients are further classified. In particular, patients who score >15 are considered "symptomatic", while patients who score #15 are defined "no symptomatic". By comparing MRI and CCCS, 4 classes of patients are created, defined respectively: -"negative no-symptomatic patients" or "true-negative ones": patients without evidence of rectocele or rectal prolapsed at MRI and who score #15 at CCCS; -"negative-symptomatic patients" or "false negative ones": while presenting clear absence of disease on MRI, these patients scored >15 at CCCS, with persistent constipation after surgery; -"positive-symptomatic patients" or "true-positive ones": patients with rectocele relapse disease at MRI and a CCCS score >15; -"positive no-symptomatic patients" or "false positive ones": patients with recurrent rectocele or rectal prolapse at MR-defecography, without constipation (CCCS score #15). For each category identified with this clinical-mri follow-up, it is defined a precise multidisciplinary and shot/long-term monitoring after STARR. "Negative no-symptomatic or true-negative patients" According protocol, it is possible to suggest to patients without constipation and without rectocele relapse at MR: -annual surgical examination; -annual MR-defecography, for 5 years; Page 13 of 15

14 -biofeedback rehabilitative therapy in case of fecal incontinence (Fig.5), corresponding to a score >10 on Wexner Continence Grading Scale. "Negative symptomatic or false negative patients" While presenting absence of recurrent rectocele disease at MR-defecography, these patients score >15 at CCCS and considered symptomatic for constipation. Differences between clinic and MRI suggest a more complex long-term monitoring, that may include: -annual MR-defecography, for 5 years; -biofeedback rehabilitative therapy in patients with fecal incontinence (score >10 at WCGS) and with dyssynergia of puborectal muscles (Fig.6) [7]; -gastroenterological consulting in order to determine the cause of persistent constipation (e.g. colonic transit constipation or irritable bowel syndrome), considering the success STARR surgery; -if necessary, psychological support. "Positive symptomatic or true positive patients" In patients whose MR-defecography evidences recurrent rectocele or rectal prolapse, and who report persistent constipation, with score >15 at CCCS, it is considered the possibility of reintervention: -STARR or other surgical operation to correct the anatomical alteration, generally in absence of enterocele and uro-genital prolapse, as demonstrated at MR-defecography (Fig.7-8); -combined surgery for rectocele, enterocele and uro-genital prolapse correction in patients with descending perineum syndrome (Fig.9). "Positive no-symptomatic or false positive patients" Although presenting recurrent rectocele disease at MRI (Fig.10), these patients are considered no-symptomatic, as reported score #15 at the CCCS. In such case, because of discrepancy between clinic and imaging features, a short-term monitoring is advisable. In fact there is the real risk that a silent rectocele is becoming evident conditioning ODS, therefore such patients are recommended: -MR-defecography every 6 months, -surgical examination every 6 months. Conclusion The presented follow-up protocol, comparing quantified MR-defecografy parameters and clinical assessment of patients by scoring systems, provides more objective approach to patient after STARR and introduces a standardized short and long term monitoring. Furthermore, the classification of patients in 4 categories allows to direct each patient to the most appropriate therapy, in the event of persistence of symptoms. Page 14 of 15

15 Pelvic compartment disorders necessitates a multidisciplinary approach, because each organic or functional alteration has important implications for static and dynamic pelvic functions [8]. In this sense, the present follow-up protocol provides a contribution in the right direction. References 1. Zhang B. et al., Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception. World J Gastroenterol. 2010; 16(20): Boyadzhyan L., Raman S., Raz S., Role of static and dynamic MR imaging in surgical pelvic floor dysfunction. RadioGraphics 2008; 28: Agachan F., Wexner SD et al., A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 1996; 39: Jorge JMN, Wexner SD, Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36: Healy JC et al., Dynamic RM imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement. AJR 1997; 169: Flusberg M. et al., Dynamic MR defecography: assessment of the usefulness of the defecation phase. AJR Am J Roentgenol. 2011; 196(4): W Heymen S. et al., Randomized controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergiatype constipation. Dis Colon Rectum 2007; 50: Rentsch M. et al., Dynamic magnetic resonance imaging defecography: a diagnostic alternative in the assessment of pelvic floor disorders in proctology. Dis Colon Rectum. 2001; 44(7): Personal Information -S. Camisa, MD - IRCCS Policlinico S.Matteo, Pavia - Università degli Studi di Pavia -F.Calliada, MD - IRCCS Policlinico S.Matteo, Pavia - -I. Fulle, MD - IRCCS Policlinico S.Matteo, Pavia - -G. Ori Belometti, MD - IRCCS Policlinico S.Matteo, Pavia - Università degli Studi di Pavia Page 15 of 15