Thursday, 11 February 2016
Southern Pelvic Floor Society
The Bristol Hotel
Present
J Randall (Bristol), T Dixon (Bristol), M Williamson (Bath), M Lamparelli (Dorchester), K Mabey (Bristol), L Griffin (Bristol), D Cotton (Bristol), E Jones-(Southampton), T Boorman (Exeter), J Hicks (Southampton), S Pilkington (Southampton), A Clarke (Poole), S Perring (Poole), C Overton (Bristol), P Hughes (Ethicon), E Smythe (Taunton), J Virjee (Bristol), L Thomas (Bristol), B Thomas (Bristol), M Feldman (Truro), W Faux (Truro), E Courtney (Bath), D Glancey (Cheltenham), M Ahmed (Poole), E Kirton (Bristol), A Bacon(Bristol), C Glasspool (Bristol)
Apologies: C Oppong (Plymouth), K Nugent (Southampton), P Durdey (Bristol)
JR introduced meeting. ML welcomed all to the meeting and gave a short history of the group; each of those present then introduced themselves briefly
Talks
Anterior resection syndrome
A background of the condition and its current management was outlined by David Cotton, senior fellow at UHB. Slides attached
-Roles of Biofeedback, SNS and PTNS outlined UHB service then described by Lucy Griffin, Clinical scientist at UHB- slides attached
In past treatment was based on excluding cancer recurrence and then simple reassurance
Newer practice includes Bowel management advice, biofeedback, rectal irrigation and ? SNS.
Baseline FI QoL score
Current results of 8 patients
Only 9 months of results thus far.
Questions: JV how long do you use peristeen?
Should all patients post op b given advice about pelvic floor exercises etc.
Brief experiences of all in the room canvassed with evidence of patchy practice
Some good and some bad
TD expressed his views about the difficulty with this condition
A level of expectation may be important
Pre-op teaching
Pre-op DXT
And also? Internal prolapse
Potential for studies of baseline practice, streamlining of process of management through the group.
All willing to support
Clinical cases
DG
Previous case under PD in UHB.
Previous hysterectomy
Pain as the main presenting feature
No signs of prolapse
Not helped by LAP VMR performed by PD. Presented back to DG with ongoing symptoms, increasing pain,
Now referred to GS in pelvic pain clinic.
GT patient of DG
Young
Labile emotional personality disorder
"There are issues"
Developed full thickness prolapse at age of 26 in absence of hypermobility
Underwent a posterior rectopexy at that stage
Developed ongoing symptoms
Proctogram showed animus
No improvement with Botox a
Then ongoing symptoms and underwent biological mesh VMR
Repeat proctogram shows recurrent enterocoele
Has the mesh detached?
Has it come free from the rectum?
For relook VMR
Discussions re next meeting:
Possibly Cheltenham DG
Then perhaps Plymouth.
TD
40 lady
Previous Forceps delivery
Rectal bleeding
Awaits 8/12 for Delormes
Ends up with a haemorrhoidectomy
Presents via Gynaecologist with ods symptoms
Treated conservatively
Then represents
Next consultant
Physiology urgency
Underwent an EAS repair and transperineal levatorplasty
Develops an internal prolapse
Now completely incontinent
With EAS disruption
Has an anal stenosis
Repeat USS shows disrupted sphincter
What to do?
Offered EUA and laparoscopy to assess
May need permanent stoma
Options are redo sphincter repair or VMR . Might need SNS.
2nd case
Lady born without bladder. At 6/12 underwent ureterosigmoidostomy
Later underwent new- bladder formation
Subsequently developed prolapse, better with operations.
Delivers a child normally.
Subsequently underwent a Fothergill operation.
Now has a large recurrent grade three cystocoele
What to do?
Advice to manage the same as a large cystocoele
Cf pessary, native tissue repair, mesh repair.
Consider laparoscopy first.
SP
42 lady from Jersey
Mucosal prolapse
4 yr hx of ods and bleeding
Mild learning difficulties, neurofibromas
Thick end rectal wall on scan. SRUS on histology
Proctogram small rectocoele, mucosal prolapse
Offered an APER by team on Jersey as thought to be cancer.
AC suggests an EUA
To assess rectum. All agreed that this is the way forward.
Lessons from TD on Rectopexy
If bulging perineum or lots of descent on proctogram consider the need for posterior fixation or something at the side.
This needs the use of cad at start of op.
If at initial laparoscopy, there is a floppy mesentery, also consider this as the need for a posterior support.
At time of op, needs a more distal dissection, lots lower than normally. Getting down to intersphincteric plane.
Uses a 20cm strip of Tileen mesh
Try to get the mesh lower, and flatter
Suture very low on the rectum, take sutures onto the levatorplasty, then 8 sutures onto the rectum and more sutures laterally to keep it flat.
Suggests performing a suture rectopexy posteriorly with an ethibond suture. Augmenting this onto the mesh with more ethibond.
Uses a v-lock suture to close the peritoneum.
Does not make any dissection anteriorly
Looks at the end with the cad to see if any laterally placed rar sutures are
This is effectively three operations at once
Has moved away from biological mesh as this is less likely to last.
In summary this is a more extensive procedure.
Moved away from using biological mesh as this does not have the longevity
Meeting closed 2145
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