Enterocele Reduction in the Prone Position: New Horizons for Safer Stapled Transanal Rectal Resections

The presence of enterocele may interfere with the surgical approach for obstructed defecation syndrome (ODS) as it may represent a contraindication to stapled transanal rectal resection (STARR), and tactics to overcome this problem have been debated. A change in the patient's position during surgery may be a means to overcome an enterocele. We sought to determine whether an enterocele could be completely reduced when the patient is placed in the prone position during fluoroscopic defecography (FD).

Patients of a Colon and Rectal Surgery Residency Program undergoing FD for any condition from August 2012 to May 2016 were enrolled. For participants with an enterocele documented during FD, projections in the prone position were also obtained. Data regarding sex, age, pelvic floor laxity, rectocele, intussusception, sigmoidocele, enterocele and its reduction in the prone position were recorded for all participants. Enterocele reduction was analyzed by Fisher's exact test.

A total of 101 patients were enrolled and an enterocele was found in 63 (62.3%). Among the patients with an enterocele, in 48 (76.2%) it was completely reduced when the patient was placed in the prone position (p-value = 0.000195; 95% CI 63.79 - 86.02).

Complete enterocele reduction in the prone position during FD was highly statistically significant. This finding may safely eliminate enterocele as a contraindication to STARR. These results suggest that a projection in the prone position should be added to the standard sequence obtained during FD for patients who may be eligible for a transanal surgical approach. Validation studies are needed to assess whether this change can lead to lower enterocele-related complications in STARR.