[Obstructed defecation]

[Intraoperative pitfalls and complications in defecation disorders and rectal prolapse]

BACKGROUND

No generally accepted gold standard exists for the operative therapy of rectal prolapse in its variety of manifestations. Existing evidence suggests that an individualized choice of procedure provides the best result for each single patient. Knowledge of possible pitfalls and intraoperative management of complications in frequently applied procedures are important prerequisites for reliable treatment of affected patients.

MATERIAL AND METHODS

A consecutive series of 233 patients (June 2011-May 2016) with individualized choice of operative procedure in patients with rectal prolapse and rectocele based on an algorithm for a clinical treatment pathway and stapled hemorrhoidopexy were included. Intraoperative pitfalls and complications and their management (iPCM) were prospectively documented and analyzed.

RESULTS

The iPCM could be classified into three different categories: group I: iPCM was immediately noted and intraoperatively treated with no impact on the further clinical course (n = 20), group II: iPCM was successfully treated conservatively within a short time after the procedure (n = 9) and group III: iPCM required surgical revision (n = 5).

CONCLUSION

Individualized treatment of rectal prolapse and rectocele requires a broad spectrum of methods in specialized coloproctology units. A clinical treatment pathway facilitates the optimal choice of procedure. Overall the complication rates during surgical treatment of transanal rectal prolapse are low; however, available operative procedures hold specific risks and knowledge of these risks helps to avoid them. Once complications occur, measures demonstrated in this study lead to normal clinical courses in the majority of cases.

Obstructive defecation syndrome: 19 years of experience with laparoscopic resection rectopexy

BACKGROUND

In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS.

METHODS

Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed.

RESULTS

The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively.

CONCLUSIONS

LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

Conversion in transanal stapling techniques for haemorrhoids and anorectal prolapse

AIM

It was the aim of this single-surgeon series to assess the role of conversion in transanal stapling to techniques and to identify potential factors predictive of conversion.

METHOD

The details of all consecutive patients who were planned for a stapled approach were prospectively recorded in a PC database. Stapling techniques (PPH03, PPH01 and ContourTranstar) were indicated for haemorrhoidal disease and internal rectal prolapse. 'Conversion' from a stapled approach was defined as an unplanned change of the surgical method to a nonstapled, traditional technique, related to indication, anatomy and technical factors. The primary outcomes were whether the procedure was performed using a stapling device only, or whether the procedure was converted. Logistic regression analysis was performed to evaluate multiple variables as potential risk factors for conversion.

RESULTS

In a 2-year period (May 2006-May 2008), 258 patients met the inclusion criteria and underwent transanal surgery scheduled as a stapled approach. In these 258 patients, 246 procedures were completed as a stapled procedure [that stapled haemorrhoidopexy, n = 148; stapled mucosectomy, n = 52; stapled transanal rectal resection (STARR) with PPH01, n = 38; and STARR with ContourTranstar, n = 8], giving a completion rate of 95.4%. However, 12 procedures were converted to conventional surgery (including traditional haemorrhoidectomy and the Delorme procedure), giving a conversion rate of 4.6%. The reasons for conversion were related to anatomy and to clinical findings (nonreducible haemorrhoidal prolapse), to new clinical findings not detected preoperatively (proctitis, anal fistula) and to a technical inability to insert the circular anal dilatator because of a deep anal canal. Neither univariate nor multivariate analysis identified any factor to be specifically associated with the risk of conversion.

CONCLUSION

In the era of transanal stapling procedures for haemorrhoids and anorectal prolapse, the majority of procedures can be performed using stapled techniques if strict criteria of indication and patient selection are respected. However, the current study identified a 4.6% conversion rate to traditional treatment, which has an impact on informed consent and requires the surgeon to be familiar with conventional anorectal procedures.

Assessing the safety, effectiveness, and quality of life after the STARR procedure for obstructed defecation: results of the German STARR registry

BACKGROUND

Internal rectal prolapse and rectocele are frequent clinical findings in patients with obstructed defecation syndrome (ODS). However, there is still no evidence whether stapled transanal rectal resection (STARR) provides a safe and effective surgical option. Therefore, the German STARR registry was initiated to assess safety, effectiveness, and quality of life.

METHODS

The German STARR registry was designed as an interventional, prospective, multicenter audit. Primary outcomes include safety (morbidity and adverse events), effectiveness (ODS, symptom severity, and incontinence scores), and quality of life (PAC-QoL and EQ-5D) documented at baseline and at 6 and 12 months. Statistical evaluation was performed by an independent research organization of clinical epidemiology.

RESULTS

Complete data of 379 patients (78% females, mean age 57.8 years) were entered into the registry database. Mean operative time was 40 min, mean hospitalization was 5.5 days. A total of 103 complications and adverse events were reported in 80 patients (21.1%) including staple line complications (minor bleeding, infection, or partial dehiscence; 7.1%), major bleeding (2.9%), and postsurgical stenosis (2.1%). Comparisons of ODS and symptom severity scores (SSS) demonstrated a significant reduction in ODS score between baseline (mean 11.14) and 6 months (mean 6.43), which was maintained at 12 months (mean 6.45), and SSS at preoperative and at 6- and 12-month follow-up (13.02 vs. 7.34 vs. 6.59; paired t test, p < 0.001). Significant reduction in ODS symptoms was matched by an improvement in quality of life as judged by symptom-specific PAC-QoL and generic ED-5Q (utility and visual analog scale) scores and was not associated with an impairment of incontinence score following STARR (p > 0.05). However, 11 patients (2.9%) showed de novo incontinence, and new-onset symptoms of fecal urgency were observed in 25.3% of patients.

CONCLUSION

These data indicate that STARR is a safe and effective procedure. However, conclusions are limited due to the selection and reporting bias of a registry. The problem of fecal urgency needs cautious reassessment.

Patient Mood and Neuropsychological Outcome After Laparoscopic and Conventional Colectomy

The study was designed to compare patients after laparoscopic and conventional colectomy with regard to early postoperative mood, cognitive function, and neurocognitive variables S100β and neuron-specific enolase (NSE). Forty-five laparoscopic and 25 open colectomies were enrolled into the prospective study. Outcome measurements were positive and negative postoperative mood (BSKE), neuropsychological tests (Trail-Making Test; word reproduction; Stroop Test), and serum biochemical parameters (S100β; NSE). Following laparoscopic procedure, patients described significantly better positive mood ( P < .05), tended to require less time in the Trail-Making Test and Stroop Test, and had lower postoperative serum concentrations of S100β compared to conventional colectomy patients ( P < .01). The current results revealed several group differences, which, in their entirety, seem to represent a more beneficial outcome after laparoscopic colonic surgery.

[Vaginal prolapse and rectal obstruction. Treated with a vaginal vault mesh colpo suspension and laparoscopic resection rectopexy]

BACKGROUND

Stool outlet obstruction with incomplete or complete rectal prolapse combined with vaginal vault prolapse is a severe form of pelvic floor insufficiency. Combining laparoscopic resection rectopexy with a vaginal vault mesh colpo suspension is a possible way of correcting this defect.

METHOD

The safety of the combination was evaluated in 18 patients.

RESULTS

The procedure was performed successfully with no complications in 16 of the 18 patients. One patient suffered intraoperative rectal injury and therefore received no polypropylene mesh, and one showed intraoperative bleeding requiring transfusion. No secondary surgery was required. Hospital stay lasted an average of 11.4 days (range 8-20) and the urinary catheters could be removed after an average of 4.3 days (range 2-10). No urinary disturbances were noted at the time of hospital release. Short-term mild fever appeared in 28% of cases (5/18). There were two urinary tract infections. No disturbance in healing and no anastomotic insufficiency were observed. The duration of postoperative antibiotic therapy averaged 3 days (range 0-8).

CONCLUSION

The combination of laparoscopic resection rectopexy with a vaginal vault mesh colpo suspension might be safe. The close contact between the mesh and anastomosis might induce no increase in insufficiency. Long-term outcome must still be evaluated.