Rectal prolapse: which surgical option is appropriate?

Sigmoido-rectal intussusception anastomosis in the Altemeier procedure for complete rectal prolapse: preliminary results of a new technique

Purpose

Our research introduces an innovative surgical approach, combining the Altemeier Procedure with Sigmoido-rectal Intussusception Anastomosis, effectively reducing recurrence, minimizing complications, and improving postoperative anal function in rectal prolapse patients.

Materials and methods

This retrospective study, conducted at tertiary referral hospitals including Shandong University of Traditional Chinese Medicine's Affiliated Hospital, Linyi People's Hospital, and Pingyi People's Hospital, examined data from patients undergoing conventional Altemeier surgery or Altemeier combined with Sigmoido-rectal Intussusception Anastomosis. Analyzing hospitalization and follow-up data from January 2009 to December 2022, the study focused on prolapse recurrence, complications, and anal function as primary outcome indicators across these three study centers.

Results

In the study, both groups had an average follow-up of (12.5 ± 2.41) months, and only two traditional group patients experienced mortality. Recurrence rates significantly differed, with 26.47% in the traditional group and 1.54% in the modified group (P < 0.001). The modified group showed no perioperative anastomotic dehiscence, contrasting with a 13.24% occurrence in the conventional group (P = 0.003). Primary complications in the modified group included anastomotic hemorrhage, with rates of 17.65% and 6.15% in the traditional and modified groups, respectively (P = 0.077). At 12 months postoperatively, both groups improved in anal manometry parameters and the Wexner anal incontinence score. Resting pressure was significantly lower in the traditional group (32.50 ± 1.76 mmHg) than the modified group (33.24 ± 2.06 mmHg) (P = 0.027), while the extrusion pressure was higher in the modified group (64.78 ± 1.55 mmHg) than the traditional group (62.85 ± 2.30 mmHg) (P < 0.001). The Wexner anal incontinence score was significantly lower in the modified group (2.69 ± 1.65) than the traditional group (3.69 ± 1.58, P = 0.001).

Conclusion

This retrospective study affirms that adding Sigmoido-rectal Intussusception Anastomosis to the Altemeier procedure reduces recurrence and complications. While both approaches enhance postoperative anal function in complete rectal prolapse patients, the combined method, particularly with Sigmoido-rectal Intussusception Anastomosis, proves more effective.

Comparison of four surgical approaches for rectal prolapse: multicentre randomized clinical trial

BACKGROUND

Several different procedures have been described for surgical treatment of rectal prolapse and consensus on the optimal approach has not been reached. The Swedish Rectal Prolapse Trial was performed with the aim to compare the outcomes after the most common surgical approaches to rectal prolapse.

METHOD

A multicentre randomized trial was conducted from 2000 to 2009. Patients were randomized between a perineal or an abdominal approach for correction of rectal prolapse (randomization A) if eligible for any procedures. Patients considered unsuitable for random allocation were only included in randomizations B or C. Patients in randomization B (perineal group) were randomized to Delorme's or Altemeier's procedures and those in randomization C (abdominal group) to suture rectopexy or resection rectopexy. Primary outcomes were bowel function and quality of life, measured using Wexner incontinence score and RAND-36, and secondary outcomes were complications and recurrence at 3 years.

RESULTS

During the study period, 134 patients were randomized: 18 in randomization A group, 80 in randomization B group and 54 in randomization C group; of these, 122 patients underwent surgery. Mean follow-up was 2.6 years. Improvements in Wexner and RAND-36 scores were seen but with no significant difference between the groups. Health change scores were significantly improved from baseline up to 1 year after surgery (P < 0.001). At 3 years, recurrence rates were two of seven patients for abdominal versus five of eight patients for perineal approach (P = 0.315), 18 of 31 patients (58 per cent) for Delorme's versus 15 of 30 patients (50 per cent) for Altemeier's (P = 0.611) and four of 19 patients (21 per cent) for suture rectopexy versus two of 21 patients (10 per cent) for resection rectopexy (P = 0.398). There were no significant differences regarding postoperative complications.

CONCLUSION

For all procedures, significant improvements from baseline in health change scores were noted after surgery. Recurrence rates were higher than previously reported. Registration number: NCT04893642 (http://www.clinicaltrials.gov).

Meta-analysis of laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete rectal prolapse

OBJECTIVES

To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse.

METHODS

We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures.

RESULTS

We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR (n=160) or LPSR (n=147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P=0.009) but longer procedure time (MD: 23.93, P<0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: -1.02, P=0.50), CCCS (MD: -1.54, P=0.47), surgical site infection (OR: 1.48, P=0.71), and length of hospital stay (MD: -1.54, P=0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis.

CONCLUSIONS

LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

What is the recommended procedure for recurrent rectal prolapse? A retrospective cohort study in a single Japanese institution

Purpose

The choice of surgical procedure for rectal prolapse (RP) is challenging because of the high recurrence and morbidity rates. We aimed to clarify whether laparoscopic suture rectopexy (lap-rectopexy) is suitable for Japanese patients with recurrent RP.

Methods

We retrospectively evaluated 77 recurrent RP patients who had been treated on average 1.5 times between June 2008 and April 2016. Forty-one patients underwent lap-rectopexy and 36 underwent perineal procedures. We compared surgical outcomes and recurrence rate following surgery between the two groups. The multivariable logistic regression analysis was performed to determine risk factors of recurrent RP.

Results

In patients’ characteristics, significant differences were observed in the type of anesthesia (p < 0.01) and length of recurrent RP (p = 0.030). The mean operative time was significantly longer in the lap-rectopexy group (p < 0.001). Blood loss, length of hospitalization, and postoperative complications were similar. The recurrence rate was significantly lower in the lap-rectopexy group (17.1% vs. 38.9%, p = 0.032). Multivariate analysis showed that only the laparoscopic approach was significantly associated with a low recurrence following surgery (odds ratio 0.273, 95% CI − 2.568 to − 0.032).

Conclusion

Lap-rectopexy is recommended for recurrent RP because its low recurrence rate and safety profile are similar to those of perineal procedures.

Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: Follow-up in the Indian population

Context:

Obstructive defecation syndrome (ODS) is a poorly understood cause of constipation. In selected patients not responding to conservative management, surgical options may be offered. Laparoscopic ventral mesh rectopexy (LVMR) is another surgical option which gained popularity in the past decade.

Aim:

This study aims to identify the efficacy of LVMR in the Indian population.

Setting and Design:

It is a retrospective analysis of prospectively collected data of patients who underwent LVMR from January 2015 to January 2017 at a tertiary centre in India.

Subjects and Methods:

Thirty patients fulfilled the inclusion criteria. Patients were periodically followed for 2 years. Pre- and post-operative modified Longo's ODS scores were recorded and compared. Furthermore, other complications were noted and evaluated.

Statistical Analysis Used:

Relevant statistical tests were used to analyse the collected data.

Results:

Thirty patients (28 females, 2 males, mean age: 52.4 years) underwent LVMR for ODS due to anatomical abnormality like rectorectal intussusceptions (RRIs) (36.7%), rectocele (13.3%), or combined RRI with rectocele (50%). The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% at 12-month follow-up and 93.2% fall on 2-year follow-up. The mean operative time was 115 min and the average hospital stay of patients who underwent LVMR was 3.26 days.

Conclusion:

LVMR is a safe surgical procedure with minimal complications and good functional results for ODS patients due to rectal anatomical abnormality. Further larger studies are required to decide the best treatment modality for ODS.

Functional Outcome after Laparoscopic Posterior Sutured Rectopexy Versus Ventral Mesh Rectopexy for Rectal Prolapse: Six-year Follow-up of a Double-blind, Randomized Single-center Study

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) for rectal prolapse has been implemented to reduce postoperative bowel symptoms. The preoperative-to-postoperative change in a double-blinded, randomized study comparing it to laparoscopic posterior sutured rectopexy (LPSR) found no significant difference between the two procedures after one year. The aim of this study was to investigate the long-term functional outcomes.

METHODS

From November 2006-January 2014, 75 patients were randomized to LVMR (n = 37) or LPSR (n = 38). In March 2017, questionnaires containing constipation symptom score (PAC-SYM), quality of life score (PAC-QoL), obstructed defecation score (ODS), Cleveland clinic constipation and incontinence scores (CCCS, CCIS) were mailed to all the patients included in the RCT. Prolapse recurrences and mesh complications were recorded.

FINDING

Sixty-nine patients were available for long-term follow-up. Questionnaires were completed by 64 patients (94.4%). The median follow-up was 6.1 years. The total PAC-QoL was significantly lower in the LVMR group 0.26 (0.14-0.83) compared to the LPSR group 0.93(0.32-1.61)(P = 0.008). The total PAC-SYM was significantly lower in the LVMR group 0.5 (0.21-0.87) compared to the LPSR group 1.0 (0.5-1.5)(P = 0.031). Except for CCIS, the ODS and the CCCS significantly favored the LVMR group at six years (P = 0.011 & 0.017). Only three(8.82%) patients in the LVMR group developed recurrence compared to seven(23.33%) in the LPSR group (P = 0.111).

INTERPRETATION

The long-term functional outcome after LVMR is superior to that after LPSR. Larger multicenter studies are warranted.

FUNDING

None.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up

AIM

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome.

METHOD

This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included.

RESULTS

Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence.

CONCLUSIONS

Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse

External and internal rectal prolapse with their affiliated rectocele and enterocele, are associated with debilitating symptoms such as obstructed defecation, pelvic pain and faecal incontinence. Since perineal procedures are associated with a higher recurrence rate, an abdominal approach is commonly preferred. Despite the description of greater than three hundred different procedures, thus far no clear superiority of one surgical technique has been demonstrated. Ventral mesh rectopexy (VMR) is a relatively new and promising technique to correct rectal prolapse. In contrast to the abdominal procedures of past decades, VMR avoids posterolateral rectal mobilisation and thereby minimizes the risk of postoperative constipation. Because of a perceived acceptable recurrence rate, good functional results and low mesh-related morbidity in the short to medium term, VMR has been popularized in the past decade. Laparoscopic or robotic-assisted VMR is now being progressively performed internationally and several articles and guidelines propose the procedure as the treatment of choice for rectal prolapse. In this article, an outline of the current status of laparoscopic and robotic ventral mesh rectopexy for the treatment of internal and external rectal prolapse is presented.

Delorme's operation plus sphincteroplasty for complete rectal prolapse associated with traumatic fecal incontinence

Rectal prolapse associated with traumatic fecal incontinence is a rare clinical combination. This study was designed to assess Delorme's operation with sphincteroplasty as a surgical management of this combination in terms of recurrence and improvement of fecal incontinence. In this prospective study, we enrolled patients suffering from short, full-thickness rectal prolapse associated with traumatic fecal incontinence who had been admitted to Alexandria Main University Hospital during the period of May 2010–January 2013. Preoperative data including cause of trauma, duration of symptoms, results of anal manometry, and degree of fecal incontinence using Wexner score were collected from all patients. Delorme's procedure with overlap sphincteroplasty was done in all patients. Recurrence of prolapse and improvement of fecal incontinence were assessed after 1, 3, 6 and 12 months. The study included 13 patients aged (32±8.7) years, 9 females and 4 males. Cause of sphincteric injury included previous anal surgery in 7 patients and normal labor in 6 patients. Duration between sphincteric injury and operation was (8.08±2.47) months. Preoperative Wexner's mean score was 16.07±3.4. Early postoperative complications included superficial wound infection (69.2%), minor wound dehiscence (61.5%), and postoperative bleeding (7.6%). Recurrence was detected in 1 patient at 6 month follow-up. Wexner's score showed significant improvement for all patients after 6 months (4.00±2.04). In conclusion, combination of Delorme's procedure and sphincteroplasty for treatment of patients with short complete rectal prolapse associated with traumatic fecal incontinence is a safe, effective surgical management with satisfactory results regarding anatomical and functional outcomes.

Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results

AIM: To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.

METHODS: MEDLINE, PubMed, EMBASE, and other relevant database were searched to identify studies. Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.

RESULTS: Twelve non-randomized case series studies with 574 patients were included in the review. No surgical mortality was described. Conversion was needed in 17 cases (2.9%), most often due to difficult adhesiolysis. Twenty eight patients (4.8%) presented with major complications. Seven (1.2%) mesh-related complications were reported. Most frequent complications were urinary tract infection and urinary retention. Mean recurrence rate was 4.7% with a median follow-up of 23 mo. Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%. Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages. Evaluation of functional score was disparate between studies.

CONCLUSION: Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.

The role of synthetic and biologic materials in the treatment of pelvic organ prolapse

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

Internal Delorme's procedure for rectal outlet obstruction

AIM

The outcome of the internal Delorme's procedure (IDP) for obstructed defaecation was assessed.

METHOD

From October 2001 to March 2009, 167 patients with obstructed defaecation associated with rectal intussusception were operated on. Patients were selected on the basis of validated constipation and continence scores, clinical examination and defaecography. Seventy-six patients were treated by the IDP alone and 91 patients were treated by the IDP with a levatorplasty. Before surgery and after a mean ± SD follow up of 3.0 ± 1.5 years, patients were assessed using the Cleveland Clinic Incontinence and Constipation Score (CCIS and CCCS), the Obstructed Defecation Score (ODS), faecal urgency and the Patient Assessment of Constipation Quality of Life (PAC-QoL) questionnaire.

RESULTS

Seventeen (10.2%) patients developed a postoperative complication including fissure-in-ano (4.2%), proctalgia (3.0%), suture-line dehiscence with stenosis (1.8%) and Clostridium difficile colitis (1.2%). Faecal urgency changed from 22% to 17.6% (P = 0.754). Tenesmus fell from 53.9% to 17.1% (P < 0.001). The CCCS and the ODS fell by 50% or more in 82.6% and 73.7% of the patients, respectively. The CCIS did not worsen significantly in patients who remained incontinent, and 45.7% of the previously incontinent patients regained normal continence. The CCCS decreased from 11 to 3 (P < 0.001) in the patients treated by the IDP and from 12 to 3 (P < 0.001) in the patients treated by the IDP with levatorplasty. The overall recurrence rate was 5.4%. The PAC-QoL showed a reduction of anxiety/depression and of physical and psychological discomfort (P < 0.001).

CONCLUSION

The IDP is an effective and safe option for rectal outlet obstruction caused by rectal intussusception with excellent function and patient satisfaction.

Dynamic MRI (dMRI) as a guide to therapy in children and adolescents with persistent full thickness rectal prolapse: a single centre review

INTRODUCTION

Full thickness rectal prolapse (FTRP) tends to be self-limiting in children and is usually managed expectantly. However, it may persist and therefore requires surgical correction. There is no consensus upon operative management, and no one procedure has uniformly good outcomes. The aim of this study was to determine whether pre-operative diagnostic dMRI findings might help identify the operative approach best suited to the anatomical abnormality of the individual child.

METHODS

A retrospective review of ten children with persistent FTRP who had been evaluated pre-operatively with dMRI between 2002 and 2010 was performed. In this preliminary work, MRI findings were not used to direct surgical management. Data collected included: age at presentation, underlying medical conditions, timing and findings of dMRI (specifically, descent of rectum from pubococcygeal (PC) line on straining), timing and type of surgery, surgical outcomes, and length of follow-up.

RESULTS

Ten children (two female) with a median age of 11 years 2 months (range 8-15 years) with FTRP refractory to conservative treatment underwent diagnostic pre-operative dMRI. Median perineal descent from PC line on straining during dMRI was 3.5 cm (range 1-4 cm). Three of the seven children with severe descent initially underwent a Delorme's procedure, and all required surgical revision. Five with severe descent and one with moderate descent achieved a cure following rectopexy. Two patients with mild descent underwent a Delorme's procedure. One achieved a cure, and the other developed recurrence. Of the ten patients, seven had no prolapse at the last clinic review, and three have persisting symptoms. Median follow-up was 3.5 years (range 1-6).

CONCLUSION

The findings from this small study favour rectal suspension techniques for surgical management of moderate to severe perineal descent on dMRI. Delorme's procedure should only be applied to those with mild descent. Pre-operative dMRI assessment may have a potential role in guiding surgical intervention for children. However, future prospective studies will be required to confirm this assertion.

Discontinuous suture ligation and injection for the treatment of rectal mucosal prolapse

AIM: To evaluate the effectiveness and safety of discontinuous suture ligation and injection in the treatment of rectal mucosal prolapse.

METHODS: Thirty-two patients with rectal mucosal prolapse were treated by discontinuous suture ligation from January 2009 to December 2011. The incidence of preoperative and postoperative symptoms was compared. Symptomatic relief was also scored and compared.

RESULTS: The average operative time was 52 min. The average visual analogue scale pain score was 3.5 points in the first 3 dafter operation. The mean follow-up period was 11 mo after surgery, and no recurrence or anal incontinence occurred. Postoperatively, the incidence of symptoms declined significantly, the obstructive defecation scored decreased by 84%, and the scores for all the other symptoms were reduced by > 70% (all P < 0.05).

CONCLUSION: Discontinuous suture ligation and injection is a simple, less invasive, and less painful treatment for rectal mucosal prolapse with fewer complications and more satisfactory short-term effect.

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.

DeloRes trial: study protocol for a randomized trial comparing two standardized surgical approaches in rectal prolapse - Delorme's procedure versus resection rectopexy

Background

More than 100 surgical approaches to treat rectal prolapse have been described. These can be done through the perineum or transabdominally. Delorme’s procedure is the most frequently used perineal, resection rectopexy the most commonly used abdominal procedure. Recurrences seem more common after perineal compared to abdominal techniques, but the latter may carry a higher risk of peri- and postoperative morbidity and mortality.

Methods/Design

DeloRes is a randomized, controlled, observer-blinded multicenter trial with two parallel groups. Patients with a full-thickness rectal prolapse (third degree prolapse), considered eligible for both operative methods are included. The primary outcome is time to recurrence of full-thickness rectal prolapse during the 24 months following primary surgery. Secondary endpoints are time to and incidence of recurrence of full-thickness rectal prolapse during the 5-year follow-up, duration of surgery, morbidity, hospital stay, quality of life, constipation, and fecal incontinence. A meta-analysis was done on the basis of the available data on recurrence rates from 17 publications comprising 1,140 patients. Based on the results of a meta-analysis it is assumed that the recurrence rate after 2 years is 20% for Delorme’s procedure and 5% for resection rectopexy. Considering a rate of lost to follow-up without recurrence of 30% a total of 130 patients (2 x 65 patients) was calculated as an adequate sample size to assure a power of 80% for the confirmatory analysis.

Discussion

The DeloRes Trial will clarify which procedure results in a smaller recurrence rate but also give information on how morbidity and functional results compare.

Trial registration

German Clinical Trial Number DRKS00000482

Outcome analysis of elderly patients undergoing laparoscopic resection rectopexy for rectal prolapse

PURPOSE

For treatment of rectal prolapse, abdominal approaches are generally offered to younger patients, whereas perineal, less invasive procedures are considered more beneficial in the elderly. The aim of this study was to analyze whether laparoscopic resection rectopexy (LRR) is suitable for older patients.

PATIENTS/METHODS

Patients who received LRR for rectal prolapse were selected from a prospective laparoscopic colorectal surgery database. Perioperative and long-term outcome were compared between patients <75 years old (group A) and ≥75 years old (group B).

RESULTS

Of 154 patients, 111 were in group A and 43 in group B. There was one conversion that occurred in group B. Overall mortality rate was 1.3% (n = 2). Both patients were in group B (group B, 4.7%; p = 0.079). Differences in major and minor complications between the groups were not significant. Rates of improvement for incontinence were 62.7% (group A) and 66.7% (group B; p = 0.716); for constipation, the rates were 78.9% (group A) and 73.3% (group B; p = 0.832). All recurrences occurred in group A (n = 10; overall, 10.3%; group A, 13%). After exclusion of patients who had previously received perineal prolapse surgery, recurrence rate was 3.3% overall (group A, 4.3%).

CONCLUSIONS

This study supports the benefits of LRR for rectal prolapse in elderly patients. Age per se is not a contraindication for LRR. Elderly patients encounter complications slightly more frequently (although not statistically significant) than younger patients. Therefore, a very careful patient selection in the elderly is of paramount importance. However, the long-term outcome does not seem to differ between younger and elderly patients.

Trans-obturator colonic suspension during Altemeier's operation for full-thickness rectal prolapse: preliminary results with a new technique

AIM

With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed.

METHOD

Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure.

RESULTS

There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies.

CONCLUSION

The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrence.

Results in the long-term course after stapled transanal rectal resection (STARR)

PURPOSE

Stapled transanal rectal resection (STARR) has recently been recommended for patients with obstructed defecation caused by rectocele and rectal wall intussusception. Our study investigates the long-term results and predictive factors for outcome.

METHODS

Between November 2002 and February 2007, 80 patients (69 females) were operated on using the STARR procedure and included in the following study. Symptoms were defined according to the ROME II criteria. Preoperative assessment included clinical examination, colonoscopy, video defecography, and dynamic MRI. Preoperatively and during follow-up visits, we evaluated the Cleveland Constipation Score (CCS) to rate the severity of outlet obstruction and the Wexner Incontinence Score to rate anal incontinence. Patients were asked to judge the outcome of the operation as improved or poor/dissatisfied. We performed a univariate analysis for 11 patient- and disease-related factors to detect an association with outcome.

RESULTS

The median follow-up was 39 months (range 20-78). Major postoperative complications (one staple line insufficiency, one urosepsis, one prolonged urinary dysfunction with indwelling catheter) were found in 3.8%. The result after STARR procedure was a success in the long-term follow-up in 62 patients (77.5%), although the improvement did not persist in 15 patients (18.7%). The mean value of the CCS decreased significantly from 9.3 before surgery to 4.6 after 2 years and increased again slightly to 6.5 after 4-6 years. The Median Wexner Incontinence Score was 3.3 at baseline, but rose significantly to 6.0. However, a third of patients who reported deteriorated continence developed the symptoms 1-4 years after surgery. Of the factors investigated for the prediction of outcome, we could only identify the number of pelvic floor changes in defecography or dynamic MRI as being associated with the success of the operation.

CONCLUSION

Our study indicates that STARR is a safe procedure. A significant improvement of symptoms is to be expected, but this improvement may deteriorate with time. Patients' satisfaction is also associated with the occurrence of urge to defecate or incontinence. It remains difficult to predict outcome.

How to do it--laparoscopic resection rectopexy

INTRODUCTION

A variety of surgical strategies have been suggested and many surgical techniques, both abdominal and perineal, have been introduced for treatment of rectal prolapse. All these techniques and approaches are based on the attempt to restore the normal anatomy and physiologic function.

METHODS

In 1992, Berman et al. published the first laparoscopically performed rectopexy. Meanwhile, many different minimally invasive procedures have been described. Throughout the past century, more than 100 different surgical techniques have been introduced to treat patients with rectal prolapse. Unfortunately, there is still lack of one generally accepted standard technique for the surgical treatment of rectal prolapse.

RESULTS AND DISCUSSION

Our current data strongly supports laparoscopic resection rectopexy to be a safe, fast, and very effective procedure to improve function in patients with rectal prolapse. More evaluations of long-term outcome are needed that focus on each particular laparoscopic procedure to adequately compare different techniques. The indication to perform a laparoscopic resection rectopexy in patients with a previous perineal procedure and a recurrent prolapse should be stated critically because these patients seem to have a high risk to develop yet another recurrence.

Surgical treatment of rectal prolapse

Rectal prolapse is defined as a protrusion of the rectum beyond the anus. Although rectal prolapse was recognized as early as 1500 BC, the optimal surgical procedure is still debated. The varied operative procedures available for treating rectal prolapsed can be confusing. The aim of treatment is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. In elderly and high-risk patients, perineal approaches, such as Delorme's operation and Altemeier's operation, have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Abdominal operations involve dissection and fixation of the rectum and may include a rectosigmoid resection. From the late twentieth century, the laparoscopic procedure has been applied to the treatment of rectal prolapse. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis with or without rectopexy. The choice of surgery depends on the status of the patient and the surgeon's preference.

Laparoscopic resection rectopexy for rectal prolapse: a single-center study during 16 years

BACKGROUND

Many different techniques to treat rectal prolapse have been introduced. Laparoscopic resection rectopexy has been shown to entail benefits regarding both perioperative results and short-term outcome, whereas data for long-term outcome are scarce.

METHODS

Between 1993 and 2008, all laparoscopic resection rectopexies for rectal prolapse II° or III° were selected from a prospective laparoscopic colorectal surgery database. We analyzed demographic, perioperative, and follow-up results. We defined two periods (1993-2000 and 2001-2008) for comparison of data. Long-term follow-up was obtained by sending questionnaires to all patients. Evaluation included constipation, incontinence, and recurrence of prolapse.

RESULTS

Between January 1993 and November 2008, we performed 152 laparoscopic resection rectopexies for rectal prolapse. Median age was 64.1 years (± 14.6). Conversion rate was 0.7% (1), mean operation time was 204 (± 65.3) min, and was significantly shorter in the second period compared with the first (P < 0.0001). Mortality was 0.7% (n = 1). Complication rates were 4% (n = 6; major) and 19.2% (n = 29; minor), respectively. Mean length of hospital stay was 11.3 (± 6.4) days and was significantly shorter in the second period compared with the first period (P < 0.0001). Mean time of follow-up was 47.7 (± 41.6) months. Improvement or complete elimination of constipation was stated by 81.3% (65), and improvement or elimination of incontinence was stated by 67.3% (72). Overall recurrence rate was 11.1% (n = 10) with a rate of 5.6% (n = 5) for a 5-year period. Of those patients with previous perineal surgery for rectal prolapse, 53.8% (7/13) experienced recurrent prolapse after laparoscopic resection rectopexy in contrast to 3.9% (3/77) of patients without previous perineal prolapse surgery (P < 0.0001).

CONCLUSIONS

Our data support the benefits of laparoscopic resection rectopexy for rectal prolapse regarding both perioperative results and long-term functional outcome. Preceding perineal or open abdominal operations have an impact on recurrence after laparoscopic resection rectopexy.

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.

Robot-assisted vs. conventional laparoscopic rectopexy for rectal prolapse: a comparative study on costs and time

PURPOSE

Laparoscopic rectopexy has become one of the most advocated treatments for full-thickness rectal prolapse, offering good functional results compared with open surgery and resulting in less postoperative pain and faster convalescence. However, laparoscopic rectopexy can be technically demanding. Once having mastered dexterity, with robotic assistance, laparoscopic rectopexy can be performed faster. Moreover, it shortens the learning curve in simple laparoscopic tasks. This may lead to faster and safer laparoscopic surgery. Robot-assisted rectopexy has been proven safe and feasible; however, until now, no study has been performed comparing costs and time consumption in conventional laparoscopic rectopexy vs. robot-assisted rectopexy.

METHODS

Our first 14 cases of robot-assisted laparoscopic rectopexy were reviewed and compared with 19 patients who underwent conventional laparoscopic rectopexy in the same period.

RESULTS

Robot-assisted laparoscopic rectopexy did not show more complications. However, the average operating time was 39 minutes longer, and costs were euro 557.29 (or: dollars 745.09) higher.

CONCLUSION

Robot-assisted laparoscopic rectopexy is a safe and feasible procedure but results in increased time and higher costs than conventional laparoscopy.

Mesh invasion of the rectum: an unusual late complication of rectal prolapse repair

Various surgical techniques have been described for repair of rectal prolapse; however, there is no agreement on a standard treatment method. In the Ripstein procedure, the rectum is fixed to the sacrum with a piece of mesh material. We describe the case of a patient who had undergone a Ripstein procedure to address rectal prolapse 6 years before admission to our clinic. His complaints were anal discomfort, abdominal discomfort, and tenesmus of 2 years duration. Rectoscopy and abdominal computed tomography (CT) revealed that the mesh had penetrated the rectal wall and was located within the rectal lumen 7-8 cm from the anal verge. Once the mesh was endoscopically, and the patient's symptoms resolved completely. Various complications of mesh implantation for rectal prolapse repair have been documented, but rectal wall penetration has not been reported to date. This report presents our case of this unusual complication and reviews the relevant literature.

Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients

INTRODUCTION

Laparoscopic rectopexy for complete rectal prolapse offers short-term advantages compared with operations performed by laparotomy. The aim of this prospective study was to report technical and functional outcome after laparoscopic rectopexy to the promontory in consecutive patients operated on by a single surgeon.

PATIENTS AND METHODS

From May 1996 to July 2004, 54 consecutive patients (47 women), median age 53 years (range: 16-84 years), underwent laparoscopic rectopexy to the promontory for complete rectal prolapse. Preoperative evaluation included physical examination, dynamic videoproctography and, in patients with constipation, colonic transit time (with radiopaque markers). Postoperative evaluation included the same examinations and a simple global quality-of-life questionnaire.

RESULTS

Conversion to laparotomy was required for three patients during the learning curve. Median duration of operation was 157 minutes (range: 50-370). There was no mortality and morbidity was 5.5% (brachial plexus palsy in two patients and urinary tract infection in one). Median hospital stay was 3.5 days (range: 1-11). There were 4 recurrences (7.4%). Functional outcome at 12 months showed the presence of constipation in 20.3% of patients (persistence in eight and de novo in three) and the presence of outlet obstruction in 25.9% of patients (persistence in six and de novo in eight). Anal continence improved in 72.4% of the 29 patients who complained of this symptom. The global quality-of-life questionnaire showed a satisfactory result in 96% of patients.

CONCLUSION

Laparoscopic rectopexy to the promontory is a safe and efficient procedure to treat complete rectal prolapse; morbidity is low. Functional outcome is at least equivalent to that obtained with open procedures in terms of continence, constipation and outlet obstruction.

The current role of imaging techniques in faecal incontinence

Faecal incontinence is a common multifactorial disorder. Major causes of faecal incontinence are related to vaginal delivery and prior anorectal surgery. In addition to medical history and physical examination, several anorectal functional tests and imaging techniques can be used to assess the underlying pathophysiology and to guide treatment planning in faecal incontinent patients. Anorectal functional tests provide functional information, but the potential strength comes from combining test results. Imaging techniques, including defecography, endoanal sonography, and magnetic resonance (MR) imaging, provide structural information about the anorectal region with a direct clinical impact. The major role of imaging techniques in faecal incontinence is visualising the structural and functional integrity of the anal sphincter complex. Both two-dimensional endoanal sonography and endoanal MR imaging are accurate tools to depict anal sphincter defects. The major advantage of endoanal MR imaging is the accurate demonstration of external anal sphincter atrophy. Recent studies have suggested that external phased array MR imaging and three-dimensional endoanal sonography are also valuable tools in the diagnostic work up of faecal incontinence. Decisions about the preferred technique will mainly be determined by availability and local expertise. This article demonstrates the current role of tests, predominantly imaging tests, in the diagnostic work up of faecal incontinence.

Impact of new technologies on the clinical and functional outcome of Altemeier's procedure: a randomized, controlled trial

PURPOSE

A randomized study was performed to assess whether new technologies offer advantages over the conventional technique on the clinical and functional outcome of patients with full-thickness rectal prolapse and fecal incontinence, submitted to Altemeier's procedure with levatorplasty.

METHODS

Between January 1999 and December 2003, 58 patients (55 females; mean age, 70.9 +/- 11.3 years) with full-thickness rectal prolapse were evaluated with continence score, colonoscopy, anorectal manometry, anal electromyography, and sacral reflex latency; 40 of them were selected and randomly assigned to two groups: 20 patients (Group 1; 19 females, 73.4 +/- 10.4 years) were submitted to a conventional operation with monopolar electrocautery and handsewn anastomosis, and 20 (Group 2; 18 females, 71.5 +/- 12.2 years) using harmonic scalpel and circular stapler. Patients were followed up with clinical examination, anorectal manometry, and anal electromyography, with mean follow-up 29.3 +/- 8.5 and 27.5 +/- 9.2 months in Groups 1 and 2, respectively.

RESULTS

Operative time, blood loss, and hospital stay were significantly reduced in Group 2 (P < 0.001), whereas no differences were found in pain score, time to return to normal activity, morbidity, and mortality. Complications were two (10 percent) stenosis in Group 1. Fecal continence score significantly improved in both groups (P < 0.01), whereas anorectal manometry and neurophysiologic data were not significantly modified by the operation. Recurrence rates were 15 and 10 percent in Groups 1 and 2, respectively (P= not significant).

CONCLUSIONS

The clinical and functional long-term results of perineal rectosigmoidectomy with levatorplasty are not influenced by surgical instruments and type of coloanal anastomosis. The clinical relevance of the short-term results in high-risk patients should be specifically investigated.

[Rectal prolapse. Abdominal or perineal approach? Current situation]

Rectal prolapse is a major challenge for the surgeon who has to resolve the anatomical problem and the functional disturbances in the same procedure. Abdominal procedures are the most appropriate in young patients, and the most common technique is rectopexia with or without resection. The use of mesh or sutures provides the same results and the choice depends on the surgeon's preference. Laparoscopic surgery has been demonstrated to have similar efficacy to conventional surgery and may become the option of the future. The perineal approach is the best option in elderly patients and in those with associated morbidity; the Delorme technique is simple to carry out, but rectosigmoidectomy provides better results.

[Obstructed defecation]

Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.