Efficacy Of Bresler Procedure Combined With PPH In The Treatment Of Rectocele Patients With Obstructed Defecation:a Prospective Clinical Study

BackgroundThe rectocele (RC), a herniation of the anterior rectal wall into the posterior vagina, occurs in approximately20%of adult females, and is closely associated with obstructed defecation syndrome (ODS). RC patients with obstructed defecation usually experience a spectrum of symptoms including difficult evacuation, excessive straining during defecation, prolonged time to defecate, frequent sensation of defecation, sensation of incomplete evacuation, anal and perineal pressure and pain, and the use of digital assistance or enema to aid defecation etc. RC is one of the most common anatomical and physiological abnormalities of ODS in females. For now, the etiology and pathogenesis of RC have not been fully clarified, but most investigators consider that RC could be induced by birth trauma, the increase of long-term abdominal pressure, declined estrogen level, abnormal collagen metabolism, congenital or genetic defects and pudendal nerve injury. The symptoms of about30%of RC patients may be relieved after conservative treatments, including diet adjustment, medications and biofeedback, however, the majority are with poor outcomes. Because RC rarely exists alone and is always accompanied with other pelvic floor disorders, together with the lack of understanding of its etiology and pathogenesis, the effect of surgical treatment is usually difficult to fully satisfy the patients, which makes surgical treatment a last resort after unsuccessful conservative therapy. To date, a variety of surgical methods have been proposed for treating RC with obstructed defecation. According to the differences of surgical approaches, they can be divided into transanal, transvaginal, transperineal and transabdominal approaches. Each approach has its own advantages and disadvantages. However, none of them is widely adopted as an optimal approach. With the advantages of a wide visual field exposure, operating conveniently, other concomitant anorectal diseases could be treated simultaneously, good therapeutic outcomes and less complications, transanal approach has been widely adopted by most of colorectal surgeons. In recent years, with the development of stapling techniques, they have been widely applied in the rectocele surgical repair, such as transanal rectocele repair using endoscopic linear cutter (Bresler procedure), procedure for prolapse and hemorrhoids (PPH), and stapled transanal rectal resection (STARR). They have the advantages of little trauma, simple operative procedures, less pain, quick recovery and good effect, and have been widely popularized and applied in clinic currently, nevertheless, we have also observed some complications and recurrence rate for these treatments. Bresler procedure performs longitudinal linear resection, whereas the PPH and STARR perform transversal circular resection of the loose and weak rectal mucosa, submucosal and muscular layers tissue of the anterior rectal wall so as to reinfore the support of the anterior rectal wall, restore the normal physiological anatomy, correct the rectal volume and compliance, and lower the rectal sensation threshold. Whether we can combine the linear resection and circular resection, namely combine Bresler procedure and PPH to perform a RC repair transanally, so as to obtain a better therapeutic effect, however, we haven’t found related literature reports. For this purpose, a prospective clinical study was performed for transanal rectocele repair by the combination of Bresler procedure and PPH, then the efficacy and safety according to the changes of depth of rectocele in defecography, ODS score, CSS score, CRQOL score and the incidence of complications were evaluated and compared with those of Bresler procedure, PPH, and STARR, respectively. Study Objective To evaluate the efficacy and safety of transanal rectocele repair by Bresler procedure combined with PPH in the treatment of rectocele patients with obstructed defecation, and to further confirm the efficacy and safety of a single Bresler procedure, PPH and STARR in the treatment of rectocele patients with obstructed defecation.Study MethodsA prospective clinical study was applied in Yantai Yuhuangding Hospital from November2011to December2012. A total of112subjects with symptomatic rectocele were enrolled and randomly divided into four groups according to the ages and different operative methods, including26cases of Bresler procedure group (Group B),30cases of PPH (Group P),28cases of STARR (Group S), and28cases of Bresler procedure combined with PPH (Group B+P), then the follow-up was performed at2months and12months after surgery. The operative time, intraoperative blood loss, length of hospital stay, costs, and perioperative and postoperative complications at2months and12months were recorded respectively for each patient, In addition, the depth of rectocele in defecography, ODS score, CSS and CRQOL score were also recorded respectively before surgery and2and12months after surgery. All data were statistically analyzed between groups and within group to evaluate the efficacy and safety of four surgical approaches.Results1. The age, history of disease, experience in vaginal delivery, concomitant internal rectal intussusceptions, concomitant internal hemorrhoids, concomitant stricture of anus, the depth of rectocele in defecography, ODS score, CSS and CRQOL score in four groups have no significant difference (P>0.05).2. The average operative time was shorter and the intraoperative blood loss was less in Group B+P than those in Group S, nevertheless, there was no statistical difference between the two groups (P>0.05). Compared with Group B and Group P respectively, there was longer average operative time in Group B+P (P<0.05), and more average intraoperative blood loss in Group B+P, but there was no statistical difference between Group B+P and Group P (P>0.05). There was no significant difference in the average length of hospital stay among the four groups (P>0.05). The average costs in those groups ranked as followed:Group B+P> Group B> Group S> Group P, and there were significant differences between each two groups (P<0.01).3. Compared with the baseline, the depth of rectocele in defecography, ODS score, CSS and CRQOL score in all groups at2months and12months after surgery decreased significantly, among which, the Group B+P and Group S showed better outcomes, even Group B+P slightly better. There was no statistically difference between Group B+P and Group S, or between Group B and Group P at2months and12months after surgery (P>0.05), indicating a similar therapeutic effect between Group B+P and Group S, and between Group B and Group P; There was significant difference when comparing Group B+P with Group B and Group P respectively, and comparing Group S with Group B and Group P, respectively (P<0.05), suggesting that Group B+P and Group S have better efficacy. There were significant differences of the depth of rectocele in defecography, ODS score, CSS and CRQOL score at2months and12months after surgery when comparing with the baseline within each group (P<0.05). At12-month’s follow-up after surgery, the above results showed slight aggravation when compared with those at2-month’s follow-up, implying that the surgical therapeutic effect may slightly decrease with time, however, there was no statistically difference (P>0.05)4. There was no significant difference of the incidence of perioperative complications and postoperative complications at perioperative period and2-month follow-up after surgery in Group B+P when comparing with Group S, Group P and Group B, respectively (P>0.05). However, the complications in Group B were the lowest. Nevertheless, the incidence of complications of the four groups at12months after surgery was significantly decreased, but there was no statistically different (P>0.05). No serious complications occurred during perioperative and postoperative follow-up period in all groups. Conclusions1. Bresler procedure combined with PPH is a safe and effective approach in the treatment of rectocele with obstructed defecation. 2. The efficacy of Bresler procedure combined with PPH in the treatment of rectocele with obstructed defecation is nearly equal to or even better than STARR, and is significantly superior to Bresler procedure and PPH. It has the most stable therapeutic effect during the period of follow-up. Compared with Group S, Group P and Group B respectively, the short and mid-term incidence of complications did not show significant difference. No serious complications were observed during perioperative and postoperative follow-up period.3. The concomitant internal rectal intussusception and/or internal hemorrhoids can be relieved or removed simultaneously when treating rectocele with obstructed defecation by PPH, STARR or Bresler procedure combined with PPH. However, the Bresler procedure could only relieve or eliminate the concomitant internal rectal intussusception, but not relieve or remove the concomitant internal hemorrhoids.4. Bresler procedure, PPH, STARR and Bresler procedure combined with PPH have such advantages of simple operative procedures, little trauma, shorter hospital stay, less pain, few complications, higher safety and efficacy. All of them are recommended as the optional surgical methods in the treatment of rectocele with obstructed defecation. But the efficacy of them was slightly decreased with follow-up time.5. The Bresler procedure combined with PPH in the treatment of rectocele with obstructed defecation has been applied in very few cases, and within a relatively shorter time, its long-term therapeutic effect should be evaluated by large-sample multicenter randomized controlled trials, as well as longer follow-up periods. Besides, this approach needed two different staplers with a relatively higher cost, which may restrict its promotion and application in a certain degree.