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

Does Concomitant Pelvic Organ Prolapse Repair at the Time of Rectopexy Impact Rectal Prolapse Recurrence Rates? A Retrospective Review of the Prospectively Collected Pelvic Floor Disorders Consortium Quality Improvement Database Pilot

BACKGROUND

Pelvic organ prolapse is reported in 30% of women presenting with rectal prolapse. Combined repair is a viable option to avoid the need for future pelvic floor interventions. However, the added impact of adding a modicum of middle compartment suspension by closing the pouch of Douglas during a rectal prolapse repair has not been studied.

OBJECTIVE

The study aimed to assess the impact of middle compartment suspension on the durability of rectal prolapse repair. We also aimed to determine whether adding some form of pouch of Douglas closure to achieve middle compartment suspension leads to any improvements in the rates or severity of postoperative constipation or in the rates or severity of postoperative fecal incontinence.

DESIGN

This study was a retrospective analysis of a multicenter prospective database.

SETTING

Data were analyzed from the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery database. Deidentified surgeons at more than 20 sites (75% academic, 81% high volume) self-reported patient demographics, previous repairs, symptoms of fecal incontinence and obstructed defecation, and operative details, including addition of concomitant gynecologic repairs, use of mesh, posterior or ventral dissection, and sigmoidectomy.

PATIENTS

Patients were included who underwent abdominal repair for rectal prolapse.

INTERVENTIONS

Abdominal rectopexy procedures with and without middle compartment suspension were compared. Middle compartment suspension was defined as excision and closure of the pouch of Douglas with some degree of colpopexy or culdoplasty.

MAIN OUTCOME MEASURES

The primary outcome of prolapse recurrence and secondary outcomes of incontinence and constipation were calculated via univariate and multivariable regression by comparing those who underwent rectopexy with and without middle compartment suspension.

RESULTS

Of the 198 patients (98% female, age 60.2 ± 15.6 years) who underwent abdominal repairs (59% robotic), 138 patients (70%) underwent some concomitant middle compartment suspension. Patients who had an added middle compartment suspension seemed to have lower early rectal prolapse recurrences. On multivariable regression to control for age, previous repairs, and the use of mesh, addition of some form of pouch of Douglas repair was associated with a decrease in short-term recurrences.

LIMITATIONS

Our data need to be interpreted cautiously. Future studies are critically needed to further explore this observation, with an a priori, prospective definition of middle compartment suspension, validated measurement of concomitant pathology, and longer follow-up.

CONCLUSION

Our results suggest that some middle compartment suspension at the time of rectal prolapse repair may improve short-term durability of rectal prolapse repair. See Video Abstract at http://links.lww.com/DCR/C30 .

LA REPARACIN CONCOMITANTE DEL PROLAPSO DE RGANOS PLVICOS EN EL MOMENTO DE LA RECTOPEXIA AFECTA LAS TASAS DE RECURRENCIA DEL PROLAPSO RECTAL UNA REVISIN RETROSPECTIVA DE UNA BASE DE DATOS RECOPILADA PROSPECTIVAMENTE DEL CONSORCIO SOBRE LA MEJORA DE LA CALIDAD DE TRASTORNOS DEL PISO PLVICO

ANTECEDENTES:El prolapso de órganos pélvicos se informa en el 30 % de las mujeres que presentan prolapso rectal y la reparación combinada es una opción viable para evitar la necesidad de futuras intervenciones del suelo pélvico. Sin embargo, no se ha estudiado el impacto adicional de agregar un mínimo de suspensión del compartimento medio cerrando el fonde de saco de Douglas durante una reparación de prolapso rectal.OBJETIVO:Nuestro objetivo fue evaluar el impacto de la suspensión del compartimento medio con respecto a la durabilidad de la reparación del prolapso rectal. Quisimos de igual manera determinar si el agregado de algún tipo de cierre del fondo de saco de Douglas para lograr la suspensión del compartimento medio conduce a alguna mejora en las tasas o la gravedad del estreñimiento posoperatorio así como en las tasas o la gravedad de la incontinencia fecal posoperatoria.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.ESCENARIO:Base de datos Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement. Cirujanos no identificados en >20 sitios (75% académicos, 81% de alto volumen) datos demográficos de pacientes auto informados, reparaciones previas, síntomas de incontinencia fecal y defecación obstruida, y detalles quirúrgicos, incluida la suma de reparaciones ginecológicas concomitantes, uso de malla, disección anterior o posterior y sigmoidectomía.INTERVENCIONES:Se compararon los procedimientos de rectopexia abdominal con y sin suspensión del compartimento medio). La suspensión del compartimento medio se definió como la escisión y cierre del fondo de saco de Douglas con algún grado de colpopexia o culdoplastia.RESULTADOS:El resultado principal de la recurrencia del prolapso y los resultados secundarios de incontinencia y estreñimiento se calcularon mediante regresión uni y multivariable al comparar los que fueron sometidos a rectopexia con y sin suspensión del compartimento medio.PACIENTES:Pacientes sometidos a reparación abdominal por prolapso rectal.RESULTADOS:De los 198 pacientes (98% mujeres, edad 60,2 ± 15,6 años) sometidas a reparaciones abdominales (59% robótica), 138 (70%) fueron sometidas igualmente y de manera concomitante a alguna suspensión del compartimento medio. Los pacientes a los que se les añadió una suspensión del compartimento medio parecían tener menores recurrencias tempranas del prolapso rectal y, en la regresión multivariable para controlar la edad, las reparaciones previas y el uso de malla, la adición de alguna forma de reparación del fondo de saco de Douglas se asoció con una disminución de las recurrencias a corto plazo.LIMITACIONES:Nuestros datos deben interpretarse con cautela. Se necesitan de manera critica, estudios futuros para explorar más a fondo esta observación, con una definición prospectiva a priori de la suspensión del compartimento medio, una medición validada de la patología concomitante y un seguimiento más prolongado.CONCLUSIONES:Nuestros resultados sugieren que alguna suspensión del compartimento medio en el momento de la reparación del prolapso rectal puede mejorar la durabilidad a corto plazo de la reparación del prolapso rectal. Consulte Video Resumen en http://links.lww.com/DCR/C30 . (Traducción-Dr. Osvaldo Gauto ).

A quantitative study to explore functional outcomes following laparoscopic ventral mesh rectopexy for rectal prolapse

INTRODUCTION

Rectal prolapse is a life-altering problem and laparoscopic ventral mesh rectopexy (LVMR) is emerging as the surgical intervention of choice. However, the literature is ambiguous on its effect on bowel function and sparse as regards bladder and sexual function. This study assesses short-term functional outcomes following LVMR.

MATERIALS AND METHODS

This quantitative retrospective study with a pretest-post-test design included 130 adults who had undergone LVMR from October 2010 to December 2018 in a tertiary centre. Analysis with paired-samples t-test and Wilcoxon matched pairs test was done using SPSS (v26).

RESULTS

The median age was 58 years (interquartile range, 48-74 years); 123 (94.6%) were female. The median length of stay was two days (interquartile range, 1-2 days). A total of 104 (80%) sets of medical notes were reviewed. One patient had recurrence of rectal prolapse. Synthetic mesh was used in 24 patients (23.1%) and biological mesh in 80 (76.9%). One patient had extrusion of a synthetic mesh and required surgery; 31(23.8%) completed the Electronic Patient Assessment Questionnaire for Pelvic Floor. Overall, the improvement in bladder function was not statistically significant (p = 0.670). A statistically significant improvement was seen for all bowel symptoms (p = 0.002) excluding constipation (p = 0.295). Irritable bowel symptoms associated with rectal prolapse improved significantly following LVMR (p = 0.001). Vaginal prolapse (p < 0.0005), dyspareunia (p = 0.001) and bowel symptoms affecting sexual intercourse (p = 0.01) improved, but improvement in overall sexual function was not statistically significant (p = 0.081).

CONCLUSIONS

LVMR improves bowel function overall, although it can worsen constipation. It has the potential to improve sexual function but makes negligible difference to bladder function.

Transvaginal sacrospinous ligament suture rectopexy for obstructed defecation symptoms: 1-year outcomes

Introduction and hypothesis

The current study was aimed at investigating the safety, efficiency, and durability of transvaginal sacrospinous ligament suture rectopexy in women with obstructed defecation symptoms (ODS) and significant rectal hypermobility/folding.

Methods

This was a prospective case series study performed during December 2018 to July 2020. Women presenting to our center with pelvic organ prolapse electing for surgical treatment were screened for ODS utilizing the PFDI-20 questionnaire. Patients were eligible for inclusion if they reported OD symptoms accompanying >50% of bowel movements (BMs), BM frequency ≥3 per week, stool type 3 or 4 based on the Bristol stool chart, absence of dyssynergic Valsalva, and dynamic ultrasound indicating a rectal compression ratio >25%. Patients underwent transvaginal sacrospinous ligament rectopexy and were followed up at 2 and 12 months postoperatively.

Results

A total of 20 patients underwent the procedure and completed the follow-up. Statistically significant improvements were observed in all OD symptoms and subjective improvement (94.7% ± 13.4 and 90.6% ± 18) at 2 and 12 months after the surgery respectively. Mean rectal compression ratio, detected via ultrasound, improved from 45.5% ± 18.4 preoperatively to 9.2% ± 13.7 at 2 months (p < 0.0001) and 19.6% ± 14.4 at 12 months (p < 0.0012). Surgical failure, defined as combined subjective (ODS >50% of bowel movements) and anatomical failure (rectal compression ratio >25%), occurred in 2 patients.

Conclusion

Transvaginal sacrospinous ligament suture rectopexy was safe, feasible, and effectively treated ODS within this cohort of women undergoing POP surgery with rectal hypermobility confirmed by dynamic ultrasound.

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.

[Robot assisted Frykman-Goldberg procedure. Case report]

BACKGROUND

Rectal prolapse is defined as the protrusion of the rectal wall through the anal canal; with a prevalence of less than 0.5%. The most frequent symptoms include pain, incomplete defecation sensation with blood and mucus, fecal incontinence and/or constipation. The surgical approach can be perineal or abdominal with the tendency for minimal invasion. Robot-assisted procedures are a novel option that offer technique advantages over open or laparoscopic approaches.

CASE REPORT

67 year-old female, who presented with rectal prolapse, posterior to an episode of constipation, that required manual reduction, associated with transanal hemorrhage during defecation and occasional fecal incontinence. A RMI defecography was performed that reported complete rectal and uterine prolapse, and cystocele. A robotic assisted Frykman-Goldberg procedure wass performed.

DISCUSSION

There are more than 100 surgical procedures for rectal prolapse treatment. We report the first robot assisted procedure in Mexico. Robotic assisted surgery has the same safety rate as laparoscopic surgery, with the advantages of better instrument mobility, no human hand tremor, better vision, and access to complicated and narrow areas.

CONCLUSION

Robotic surgery as the surgical treatment is a feasible, safe and effective option, there is no difference in recurrence and function compared with laparoscopy. It facilitates the technique, improves nerve preservation and bleeding. Further clinical, prospective and randomized studies to compare the different minimal invasive approaches, their functional and long term results for this pathology are needed.

Learning curves and surgical outcomes for proctored adoption of laparoscopic ventral mesh rectopexy: cumulative sum curve analysis

BACKGROUND

Laparoscopic ventral mesh rectopexy (VMR) is an effective and well-recognised treatment for symptoms of obstructive defecation in the context of rectal prolapse and recto-rectal intussusception. However, due to the technical complexity of VMR, a significant learning curve has been previously described. This paper examines the effect of proctored adoption of VMR on learning curves, operative times, and outcomes.

METHODS

A retrospective database analysis of two district general hospitals was conducted, with inclusion of all cases performed by two surgeons since first adoption of the procedure in 2007-2015. Operative time, length of stay, and in-hospital complications were evaluated, with learning curves assessed using cumulative sum curves.

RESULTS

Three hundred and eleven patients underwent VMR during the study period and were included for analysis. Patients were near-equally distributed between surgeons (surgeon A: n = 151, surgeon B, n = 160) with no significant differences between gender, age, or ASA grade. In-hospital morbidity was 3.2 %, with 0 % mortality. Cumulative sum curve analysis suggested a change point of between 25 and 30 cases based on operative times and length of stay and was similar between both surgeons. No significant change point was seen for morbidity or mortality.

CONCLUSION

VMR is an effective and safe treatment for rectal prolapse. Surgeons in this study were proctored during the adoption process by another surgeon experienced in VMR; this may contribute to increased safety and abbreviated learning curve. In the context of proctored adoption, this study estimates a learning curve of 25-30 cases, without detrimental impact on patient outcomes.

[Complications after rectal prolapse surgery]

Major complications only rarely occur after rectal prolapse surgery. Generally, the spectrum of possible complications should always be considered depending on the selected surgical procedure. Minor complications in all techniques have been described in up to 36 %. The commonest complication is bleeding with 2-5 %, urinary tract infections and wound infections. Finally, the risk of recurrence must be considered, which shows substantial differences (4-40 %); therefore, no operation technique can be given preference based solely on the risk of recurrence. Therapy decisions are always more individualized and must take the personal environment of the patient as well as the experience of the surgeon into consideration.

Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy: An Observational Study of 919 Consecutive Patients

OBJECTIVE

This multicenter study aims to assess long-term functional outcome, early and late (mesh-related) complications, and recurrences after laparoscopic ventral mesh rectopexy (LVR) for rectal prolapse syndromes in a large cohort of consecutive patients.

BACKGROUND

Long-term outcome data for prolapse repair are rare. A high incidence of mesh-related problems has been noted after transvaginal approaches using nonresorbable meshes.

METHODS

All patients treated with LVR at the Meander Medical Centre, Amersfoort, the Netherlands and the University Hospital Leuven, Belgium between January 1999 and March 2013 were enrolled in this study. All data were retrieved from a prospectively maintained database. Kaplan-Meier estimates were calculated for recurrences and mesh-related problems.

RESULTS

919 consecutive patients (869 women; 50 men) underwent LVR. A 10-year recurrence rate of 8.2% (95% confidence interval, 3.7-12.7) for external rectal prolapse repair was noted. Mesh-related complications were recorded in 18 patients (4.6%), of which mesh erosion to the vagina occurred in 7 patients (1.3%). In 5 of these patients, LVR was combined with a perineotomy. Both rates of fecal incontinence and obstructed defecation decreased significantly (P < 0.0001) after LVR compared to the preoperative incidence (11.1% vs 37.5% for incontinence and 15.6% vs 54.0% for constipation).

CONCLUSIONS

LVR is safe and effective for the treatment of different rectal prolapse syndromes. Long-term recurrence rates are in line with classic types of mesh rectopexy and occurrence of mesh-related complications is rare.

Laparoscopic surgery for rectal prolapse and pelvic floor disorders

Pelvic floor disorders are different dysfunctions of gynaecological, urinary or anorectal organs, which can present as incontinence, outlet-obstruction and organ prolapse or as a combination of these symptoms. Pelvic floor disorders affect a substantial amount of people, predominantly women. Transabdominal procedures play a major role in the treatment of these disorders. With the development of new techniques established open procedures are now increasingly performed laparoscopically. Operation techniques consist of various rectopexies with suture, staples or meshes eventually combined with sigmoid resection. The different approaches need to be measured by their operative and functional outcome and their recurrence rates. Although these operations are performed frequently a comparison and evaluation of the different methods is difficult, as most of the used outcome measures in the available studies have not been standardised and data from randomised studies comparing these outcome measures directly are lacking. Therefore evidence based guidelines do not exist. Currently the laparoscopic approach with ventral mesh rectopexy or resection rectopexy is the two most commonly used techniques. Observational and retrospective studies show good functional results, a low rate of complications and a low recurrence rate. As high quality evidence is missing, an individualized approach is recommend for every patient considering age, individual health status and the underlying morphological and functional disorders.

Laparoscopic posterior mesh rectopexy for rectal prolapse is a safe procedure in older patients: A prospective follow-up study

BACKGROUND AND AIMS

The aim of this study is to examine the clinical and functional outcome of laparoscopic posterior rectopexy in a consecutive series of adult patients with full-thickness rectal prolapse.

MATERIAL AND METHODS

Preoperative data on demography, life-style practices, medication, comorbidity, and previous surgery for rectal prolapse were ascertained from patient charts. Information on operative procedure, and pre- and postoperative complications were recorded. Short- and long-term follow-up were done after a median of 60 days and 2 years after surgery.

RESULTS

Between 1 February 2009 to 1 June 2012, 81 laparoscopic posterior rectopexies were done. Male-to-female ratio was 4:77, median age 73 [57-80.5] years and median ASA Grade 2. Conversion to open surgery was done in 6.2%, the median operating time was 82 min [66 - 102] and median length of hospital stay was 2 days [2-5.7]. Minor and major complications were seen in 5.3% and 14.8%, respectively. The 30-day mortality rate was 1.2%. Constipation or incontinence improved or disappeared in 65.2% and 74.4%, respectively. The cumulated recurrence rate was 11.1% after a median observation time of 2 years.

CONCLUSION

Laparoscopic posterior rectopexy is a safe and well-tolerated procedure in older patients and can be done with acceptable complications and recurrence rates and short hospital stays. Laparoscopic posterior rectopexy seems to improve bowel function in many patients.

Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse

BACKGROUND

Laparoscopic resection rectopexy (LRR) and laparoscopic ventral rectopexy (LVR) are favored for the treatment for rectal prolapse (RP) in the USA and Europe, respectively. This study aims to compare these two surgical techniques.

METHODS

All patients who underwent LRR because of RP between January 2000 and January 2012 at Cleveland Clinic Florida (Weston, FL, USA) were identified, and all relevant characteristics were entered in a database. This same analysis was also conducted for all patients who underwent LVR in the Meander Medical Center (Amersfoort, the Netherlands) between January 2004 and January 2012. These two cohorts were retrospectively compared with regard to complications, functional results and recurrence.

RESULTS

Twenty-eight patients (all female, mean age 50.1 years) were included in the LRR cohort at a mean follow-up of 57 (range 2-140; standard deviation (SD) ± 41.2) months. The LVR group consisted of 40 patients (36 females and 4 males) with a mean age of 67.0 years and a mean follow-up of 42 (range 2-82; SD ± 23.8) months. A significant reduction in constipation was observed in both cohorts after surgery: 57 versus 21% after LRR and 55 versus 23% after LVR (both P < 0.05). The incidence of incontinence also significantly decreased in both groups: 15% after LVR (55% before surgery) and 4% after LRR (61 % before surgery). Direct comparison of these two techniques showed a trend to significance (P = 0.09). Significantly, more complications occurred after LRR (n = 9: 1 major, 8 minor) then after LVR (n = 3: 2 major, 1 minor) (P < 0.05).

CONCLUSIONS

Both LVR and LRR are effective for the treatment for RP. Although both techniques offer significant improvements in functional symptoms, continence may be better after LRR. However, LRR also had a higher complication rate then did LVR.

[Pelvic floor disorders from the surgeon's viewpoint]

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

Resection rectopexy--laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results

PURPOSE

Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping.

METHODS

Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up.

RESULTS

Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1-18) to 1 (range 0-3) at follow-up (p = 0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5-17) to 3 (range 1-7; p = 0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed.

CONCLUSIONS

Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.

Evaluation and surgical treatment of rectal prolapse: an international survey

AIM

Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP.

METHOD

A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail.

RESULTS

In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients.

CONCLUSION

The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.

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.

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.

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.