J Korean Med Assoc.  2006 Oct;49(10):939-950. 10.5124/jkma.2006.49.10.939.

Surgical Management of Obstructed Defecation

• Park UC

• KMID: 2064973
• DOI: http://doi.org/10.5124/jkma.2006.49.10.939

Abstract

There are three groups of patients with constipating symptoms; those with obstructed defecation, slow transit constipation, or both. The treatment of obstructed defecation (pelvic outlet obstruction) is often challenging because the underlying disorders are diverse with a wide range of and clinical symptoms. The underlying anatomical and pathophysiological changes in patients with obstructed defecation are complex and often poorly understood. As a consequence, many medical, surgical, and behavioral approaches have been described, with no single panacea. For successful outcomes, preoperative physiologic testing is mandatory to differentiate between obstructed defecation caused by pelvic outlet obstruction and slow transit constipation. Obstructed defecatory disorders can distress patients both socially and psychologically and greatly impair their quality of life. For the great majority of patients, dietary adjustment with an increased fiber and liquid supplement can resolve the symptoms. The surgical approach depends upon the etiology, severity of symptoms, and operative risks. In a small group of patients with a rectocele or a third degree sigmoidocele, surgical intervention yields a high success rate. Division or resection of the puborectalis muscle is not recommended. In patients with a mixed pattern of slow transit colon and pelvic outlet obstruction, surgical intervention alone is often not successful; these patients can experience better outcomes by conservative treatment of pelvic outlet obstruction, followed by a colectomy. Stapled transanal rectal resection has recently become a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential damage to the structures located in front of the anterior rectal wall. The laparoscopic approach can shorten the hospital stay with good outcomes and is well tolerated in elderly patients with rectal prolapse. Despite the progress in modern surgery, the choice of the surgical procedure of pelvic outlet obstruction is still controversial. Preoperative counseling of all patients undergoing surgery is of extreme importance, in particular to explain the evolving nature of pelvic floor dysfunction and the possible need for further reconstructive surgery. To identify patients who will benefit from surgery for obstructed defecation, a careful selection of candidate patients remains the crucial issue in the diagnostic assessment. Surgical intervention should be limited only to the patients with identifiable, surgically correctable causes of outlet obstruction. This review gives an overview of surgical treatment options in patients with obstructed defecation.

Keyword

Obstructed defecation; Pelvic outlet obstruction; Surgery

MeSH Terms

Aged
Colectomy
Colon
Constipation
Counseling
Defecation*
Humans
Length of Stay
Pelvic Floor
Quality of Life
Rectal Prolapse
Rectocele

Figure

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  Figure 1 Illustration of rectocele reveals a sac-like projection of the anterior rectum

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  Figure 2 Illustration of cinedefecography showing progression of internal intussusception. Findings suggestive of preprolapse include funnel-shaped confuguration of the rectum and the formation of a "ring pocket"

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  Figure 3 Left: Full thickness rectal prolapse (note concentric folds). Right: Rectal mucosal prolapse (note radial folds)

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  Figure 4 Defecographic verification of severe rectal prolapse (arrows)

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  Figure 5 Defecography demonstrates a third degree sigmoidocele in patient with pelvic outlet obstruction (black arrow). The contrast material is also in the lower rectum showing rectocele (white arrow) Sig.: sigmoid colon, RC: rectocele

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  Figure 6 STARR (stapled trans-anal rectal resection) procedure. The operation was carried out by circular stapled prolapsectomy in the treatment of rectal internal mucosal prolapse(23)

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  Figure 7 Laparoscopic rectopexy for patient with total rectal prolapse (by courtesy of the korean laparoscopic colorectal surgery study group, 2006)

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