What the radiologist needs to know!

Transcription

1 What the radiologist needs to know! Clare Molyneux Sam Treadway Sathi Sukumar Wal Baraza Abhiram Sharma Karen Telford University Hospital of South Manchester Manchester UK

2 Introduction Indications Investigations Procedure Normal post-operative appearance (Cunningham et al, 2013) Complications (Early & Delayed)

3 Laparoscopic Ventral Rectopexy (LVR) is commonly used in the treatment of rectal prolapse. Concerns have been raised about the potential risk of mesh complications after LVR. Both synthetic and biological meshes have been used as grafts. Radiological imaging can be used pre-operatively to identify patient suitable for LVR. Postoperatively radiological imaging can assess normal placement of mesh, potential complications and therefore guide future management. Complications could present acutely or years later.

4 LVR is indicated in patients with: Overt rectal prolapse (Extra anal prolapse) High grade internal rectal prolapse/intussusception Rectal prolapse with middle compartment prolapse Patients presenting with rectal prolapse may report symptoms of: Obstructive defecation syndrome (ODS) (difficulty evacuating or emptying rectum) Tenesmus (sensation of incomplete evacuation) Faecal incontinence (Involuntary loss of faeces) (Franceschilli, L. et al, 2015)

5 Rectal Prolapse can be graded using the Oxford Prolapse Grade (Collison et al, 2009) using images obtained through defecating proctography.

6 Rectal examination Examination under anaesthetic Defecating proctography Can identify: Overt rectal prolapse Intussusception Rectocele Involuntary loss of faeces Perineal descent Non-relaxation of puborectalis

7 Can be performed under fluoroscopy or with dynamic Magnetic Resonance (MR) imaging Defecatory phases essential 37% rectocele, 40% enterocele, 28% intussusecption only found in defecatory phase imaging (Flusberg et al, 2011)

8 Fluoroscopic DP MR Proctography Availability Cheap Assessment is physiological sitting position Superior rectal emptying and therefore increased sensitivity to detect abnormalities of the rectum But Radiation Exposure Limited assessment of posterior compartment Global assessment of all compartments of pelvis Excellent contrast resolution for soft tissues Cross sectional & multiplanar imaging Allows accurate measurements of organ prolapse But Lower sensitivity of diagnosing intussusception Performed supine position Costly (Foti et al., 2013; Kelvin et al., 1999; Pilkington et al., 2012)

9 Indication Symptomatic Grade III, Grade IV Rectal Intussusception Grade V or overt rectal prolapse Concomitant middle compartment prolapse Relative Contraindications Previous CVA Previous abdominal surgery with unfavourable adhesions

10 Fluoroscopic defecating proctography showing patient with intra-anal intussusception( )& rectocele( )

11 A B Fluoroscopic Imaging of patient showing Intra anal intussuseption (A) shown extending into overt rectal prolapse in (B) during defaecatory phase of proctogram.

12 A B MR proctographic imaging of a patient at rest (A) and during defaecation(b). Note three compartment prolapse with cystocele ( ), uterine descent ( )and rectocele ( ). Note also the presence of intrarectal mucosal prolapse during the defaecatory phase. Pubo-Coccygeal line ( ).

13 (PFMMedical, 2015)

14 (Cook Medical, 2015)

15 Patient position - Reverse Trendelenberg Urinary catheter, IV Abs, VTE Prophylaxis 3 laparoscopic ports used Sacral promontory exposure Division of pelvic peritoneum from sacral promontory to right rectovaginal plane Rectovaginal plane dissected to pelvic floor Mesh secured to anterior rectal wall with soluble sutures Mesh stapled to sacral promontory (tension free) Peritoneum closed over mesh

16 MR images of normal placement of mesh following LVR

17 Our centre, University Hospital of South Manchester has a specialist pelvic floor service. As well as complications we have experienced with our own patients, we receive tertiary referrals from other centers for patients with LVR/mesh complications. Complex patients are discussed at a monthly pelvic floor multidisciplinary team.

18 Mesh Related Non-Mesh Related Early Infection Rectal perforation Early Bleeding Delayed Mesh Erosion 2.4% synthetic mesh, 0.7% biological mesh Median time to erosion 23 months (Evans et al, 2015) Vaginal erosion Rectal erosion Rectovaginal fistula Perineal Erosion Recurrence of prolapse Delayed Small Bowel Obstruction Adhesional or internal hernia Recurrence of prolapse

19 A (A)Early Post-operative complication. Large Pelvic Haematoma ( ). B (B)Resolving haematoma ( ) No sepsis No fistula Full resolution of symptoms at 6/12 FU ( )represents the mesh

20 A B Patient presented to ER following LVR at another hospital, with symptoms of increasing abdominal pain and distension since surgery. CT imaging 4 weeks post-lvr. (A) Showing dilated oedematous obstructed closed loop of small bowel( ). (B) Demonstrating adhesional obstruction close to the mesh insertion site at sacral promontory ( ).(C) Highlighting the mesh fixation site( ) to the sacrum. Note the reactive ascites. C

21 A B C A C MR images in axial (A), sagittal (B) and coronal plane (C) showing the site B of recto-vaginal fistula ( ) secondary to mesh erosion and extrusion. ( ) represents the gas filled vagina, ( ) represents the rectum.

22 Complications Recto-vaginal Fistula after mesh Erosion & Extrusion Images represent the extruded mesh.

23 A B Rest (A) and Defecatory phase (B) during dynamic MR Proctography showing formation of intra rectal prolapse ( ), cystocele( )and rectocele( ). Note the presence of perineal descent in A & B. Patient had a previous LVR at another center and presented to UHSM with recurrence of obstructive defecation symptoms. Pubo-Coccygeal line ( ).

24 A B A B C A B MR Proctography in a different patient showing patient at rest (A) and during defecatory phase (B). Note 3 compartment descent in (B). (C) Coronal image shows detached mesh ( ) in the right side of the pelvis. Pubo-Coccygeal line ( ). D

25 A B MR Images (A) Axial &(B) Coronal showing detachment of mesh in a patient 10 months post-lvr. Note the loose end of mesh tethered to the small bowel ( ).

26 A B C MR images (A)(B)&(C) showing a patient who has undergone LVR presenting with low take off recurrent, symptomatic mucosal prolapse ( )below mesh attachment to the rectum. Note normal placement of the mesh( ).

27 Laparoscopic Ventral Rectopexy (LVR) is commonly used in the treatment of rectal prolapse Laparoscopic Ventral Rectopexy is safe. However, there are risks from using mesh in the pelvis. Mesh complications occur in 2% of cases. Mesh complications may occur early or late.

28 Radiological Imaging with proctography is essential in the assessment of patients pre-operatively MR imaging is most useful in assessing post-operative complications. Dynamic MR proctography is essential in patients presenting with recurrent prolapse after surgery.

29 COLLINSON, R., CUNNINGHAM, C., D'COSTA, H. & LINDSEY, I Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study. Colorectal Dis, 11, COOK MEDICAL Cook Medical [Online]. [Accessed 12/01/2016. CUNNINGHAM, C., JONES, O. & LINDSEY, I Laparoscopic Ventral Rectopexy. In: CENTRE, O. P. F. (ed.). EVANS, C., STEVENSON, A. R., SILERI, P., MERCER-JONES, M. A., DIXON, A. R., CUNNINGHAM, C., JONES, O. M. & LINDSEY, I A Multicenter Collaboration to Assess the Safety of Laparoscopic Ventral Rectopexy. Dis Colon Rectum, 58, FLUSBERG, M., SAHNI, V. A., ERTURK, S. M. & MORTELE, K. J Dynamic MR defecography: assessment of the usefulness of the defecation phase. AJR Am J Roentgenol, 196, W FOTI, P. V., FARINA, R., RIVA, G., CORONELLA, M., FISICHELLA, E., PALMUCCI, S., RACALBUTO, A., POLITI, G. & ETTORRE, G. C Pelvic floor imaging: comparison between magnetic resonance imaging and conventional defecography in studying outlet obstruction syndrome. Radiologia Medica, 118, FRANCESCHILLI, L., VARVARAS, D., CAPUANO, I., CIANGOLA, C. I., GIORGI, F., BOEHM, G., GASPARI, A. L. & SILERI, P Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases. Techniques in Coloproctology, 19, KELVIN, F. M., HALE, D. S., MAGLINTE, D. D. T., PATTEN, B. J. & BENSON, J. T Female pelvic organ prolapse: Diagnostic contribution of dynamic cystoproctography and comparison with physical examination. American Journal of Roentgenology, 173, PFMMEDICAL Titanized Mesh Implants,TiLENE Mesh [Online]. [Accessed 12/01/2016.