Surgery for rectal prolapse: Orr-Loygue ventral rectopexy with limited dissection prevents postoperative-induced constipation without increasing recurrence

The Current Evidence and How-To on Combined Sacrocolpopexy and Rectopexy

INTRODUCTION AND HYPOTHESIS

Multicompartment prolapse is a complex pelvic floor condition that can involve coordination of both urogynecologists and colorectal surgeons.

METHODS

Concomitant sacrocolpopexy and ventral rectopexy is a safe and effective approach to treating this condition.

RESULTS

The combined procedure has high rates of patient satisfaction and symptom improvement, including defecatory dysfunction, sexual health, and overall increased quality of life.

CONCLUSION

Concomitant sacrocolpopexy with ventral rectopexy is safe and improves overall outcomes.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

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.

Laparoscopic low anterior resection for rectal cancer with rectal prolapse: a case report

BACKGROUND

Rectal cancer with rectal prolapse is rare, described by only a few case reports. Recently, laparoscopic surgery has become standard procedure for either rectal cancer or rectal prolapse. However, the use of laparoscopic low anterior resection for rectal cancer with rectal prolapse has not been reported.

CASE PRESENTATION

A 63-year-old Japanese woman suffered from rectal prolapse, with a mass and rectal bleeding for 2 years. An examination revealed complete rectal prolapse and the presence of a soft tumor, 7 cm in diameter; the distance from the anal verge to the tumor was 5 cm. Colonoscopy demonstrated a large villous tumor in the lower rectum, which was diagnosed as adenocarcinoma on biopsy. We performed laparoscopic low anterior resection using the prolapsing technique without rectopexy. The distal surgical margin was more than 1.5 cm from the tumor. There were no major perioperative complications. Twelve months after surgery, our patient is doing well with no evidence of recurrence of either the rectal prolapse or the cancer, and she has not suffered from either fecal incontinence or constipation.

CONCLUSIONS

Laparoscopic low anterior resection without rectopexy can be an appropriate surgical procedure for rectal cancer with rectal prolapse. The prolapsing technique is useful in selected patients.

Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) has become a well-established treatment for symptomatic high-grade internal rectal prolapse. The aim of this study was to identify proctographic criteria predictive of a successful outcome.

METHODS

One hundred and twenty consecutive patients were evaluated from a prospectively maintained pelvic floor database. Pre- and post-operative functional results were assessed with the Wexner constipation score (WCS) and Fecal Incontinence Severity Index (FISI). Proctogram criteria were analyzed against functional results. These included grade of intussusception, presence of enterocele, rectocele, excessive perineal descent and the orientation of the rectal axis at rest (vertical vs. horizontal).

RESULTS

Ninety-one patients completed both pre- and post-operative follow-up questionnaires. Median pre-operative WCS was 14 (range 10-17), and median FISI was 20 (range 0-61), with 28 patients (31%) having a FISI above 30. The presence of an enterocele was associated with more frequent complete resolution of obstructed defecation (70 vs. 52%, p = 0.02) and fecal incontinence symptoms (71 vs. 38%, p = 0.01) after LVMR. Patients with a more horizontal rectum at rest pre-operatively had significantly less resolution of symptoms post-operatively (p = 0.03).

CONCLUSIONS

These data show that proctographic findings can help predict functional outcomes after LVMR. Presence of an enterocele and a vertical axis of the rectum at rest may be associated with a better resolution of symptoms.

Laparoscopic Ventral Rectopexy Versus Laparoscopic Wells Rectopexy for Complete Rectal Prolapse: Long-Term Results

BACKGROUND

There is no agreement about which laparoscopic rectopexy technique is best for treating complete rectal prolapse. Purpose was to compare functional outcome, the recurrence rate, and quality of life in patients treated with laparoscopic ventral rectopexy (LVR) versus the laparoscopic Wells rectopexy (LWR) for complete rectal prolapse.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database of consecutive patients who presented with complete rectal prolapse. Patients were divided into two cohorts: first one had LVR and the other one had LWR. Exclusion criteria were previous major abdominal surgery, slow transit constipation, Hirschsprung's disease, inflammatory bowel disease, pregnancy, and patients on drugs that cause constipation. Patients were assessed preoperatively by clinical examination to evaluate constipation using the Wexner constipation scale (WCS), incontinence using the Wexner incontinence score (WIS), and quality of life using the gastrointestinal quality of life index (GIQOL). The primary outcome measures were disappearance of prolapse and recurrences. Secondary outcome parameters were operative time, complications, length of hospital stay, effect on perineal descent, functional outcome (constipation and continence), and quality of life.

RESULTS

A total of 74 patients (mean age of 55 years) with complete rectal prolapse had LVR (n = 41) and LWR (n = 33). Sixty (81%) patients were females. Operative time was significantly longer in LVR (122 minutes versus 105 minutes; P = .001). Also, length of stay was significantly longer in LVR (4.5 days versus 3.7 days; P = .04). Recurrences were reported in 1 patient in each group. Perineal descent improved >50% in defecogram 6 months postoperatively in 79% in LVR versus 21% in LWR. In LVR, mean WCS decreased from 11.3 to 5.1 postoperatively (P < .0001), while in LWR it decreased from 8.9 to 6.9 (P = .11). Mean WIS decreased in LVR from 5.9 to 3.8, P = .01, while in LWR, it decreased from 6.6 to 2.8; P = .001. GIQOL improved from 74.4 to 124.9 in LVR and from 79.3 to 112.6 in LWR. The change in both groups was statistically significant (P = .0001).

CONCLUSIONS

In this study, both LVR and LWR successfully and safely corrected the prolapse and prevented recurrence in patients after long-term follow-up. Operative time and hospital length of stay are significantly shorter in LWR. High incontinence scores and age >70 are potential predictors of bad continence postoperatively. LVR appears to be more suitable for patients with a high constipation score and abnormal perineal descent.

Ventral mesh rectopexy versus conventional suture technique: a single-institutional experience

AIMS

Anterior mesh rectopexy is a novel surgical technique for the treatment of complete rectal prolapse, a common disorder in female elderly patients. Aim of the study was to evaluate functional outcomes after ventral mesh rectopexy and conventional suture rectopexy.

PATIENTS AND METHODS

Forty patients have been enrolled in this prospective study. Patients were divided into two groups: 20 patients (group A) had a conventional suture rectopexy with a standard technique and 20 patients (group B) underwent an anterior mesh rectopexy. Each patient had a clinic and defecographic diagnosis of full-thickness rectal prolapse, which was further investigated with manometry and clinical questionnaires (Wexner Constipation and Incontinence Score, Rome III criteria). Postoperative outcomes were evaluated through clinical questionnaires, a rigid rectosigmoidoscopy and a defecography, 1 year after surgery.

RESULTS

Preoperative Wexner constipation score was greater than 15 in all the patients (21 in group A and 22 in group B); median postoperative score was 15 in group A and 11 in group B, and the difference was significant. Median preoperative incontinence score was 11 in group A and 12 in group B; median postoperative score was 9 in group A and 6 in group B. Three patients experienced recurrence in group A and only 1 patient in group B.

CONCLUSION

Ventral mesh rectopexy is feasible, safe and effective for the treatment of full-thickness rectal prolapse in a well-fit geriatric population. Better functional results have been achieved compared with conventional suture technique with a trend toward a lower recurrence rate.

Evolution of male rectal prolapse surgery and initial experience of robotic rectopexy in men

Laparoscopic ventral mesh rectopexy (LVMR) has proven benefit in the treatment of external rectal prolapse and symptomatic internal rectal prolapse in women. However, there is a recurrence rate of 4-50% depending on indication. Some of this recurrence is attributable to persistent lateral and posterior prolapses. Modifications of LVMR (modified Orr-Loygue rectopexies) describe an additional narrow posterior rectal mesh fixed to the mesorectal fat, which is inherently insecure. Additional complications in men include sexual dysfunction caused by nerve damage from the ventral rectal dissection. There is one case series in men, published by a surgeon with an unusually large practice, showing LVMR to have a good success rate with low rates of sexual dysfunction. Other series have contained small numbers of men, but subgroup analysis to determine success and complication rates is not possible. Robotic surgery is more precise than laparoscopic surgery, allows stereotactic vision, and has a stable platform. We have developed a robotic modified Orr-Loygue rectopexy in an attempt to deal with the persistent components of posterior rectal prolapse by placing a mesh posteriorly through a narrow dissection and securing the mesh to the distal rectal muscle tube. Mesh-to-muscle fixation is more secure than mesh-to-mesorectal fat fixation. The robotic platform also improves the accuracy of ventral dissection and reduces the risk of sexual dysfunction in men. Our initial results indicate that robotic modified Orr-Loygue rectopexy is a safe and feasible option for rectal prolapse in men, with no more complications or recurrences than the best published outcomes for LVMR.

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.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Surgical management of rectal prolapse: The role of robotic surgery

The robotic technique as a safe approach in treatment of rectal prolapse has been widely reported during the last decade. Although there is limited clinical data regarding the benefits of robotic surgery, the safety of robotic surgery in rectal prolapse treatment has been cited by several authors. Also, the robotic approach helps overcome some of the laparoscopic approach challenges with purported advantages including improved visualization, more precise dissection, easier suturing, accurate identification of anatomic structures and fewer conversions to open surgery which can facilitate the conduct of technically challenging cases. These advantages can make robotic surgery ideally suited for minimally invasive ventral rectopexy. Currently, with greater surgeon experience in robotic surgery, the length of the procedure and the recurrence rate with the robotic approach are decreasing and short term outcomes for robotic rectal prolapse seem on par with laparoscopic and open techniques in recent studies. However, the high cost of robotic procedures is still an important issue. The benefits of a robotic approach must be weighed against the higher cost. More research is needed to better understand if the increased cost is justified by an improvement in outcomes. Also, published articles comparing long term outcomes of the robotic approach with other approaches are very limited at this time and further clinical trials are indicated to affirm the role of robotic surgery in the treatment of rectal prolapse.

Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review

AIM

Laparoscopic ventral rectopexy (VR) with the use of prosthesis has been advocated for both overt rectal prolapse (ORP) and obstructed defaecation syndrome (ODS). The present study reviews the short-term and functional results of laparoscopic VR.

METHOD

A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VR for ORP, ODS and other anatomical abnormalities of the pelvic floor from 2004 until February 2013. No language restrictions were made. All studies on VR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, recurrence of ORP, recurrence of anatomical disorder, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers.

RESULTS

Twenty-three studies including 1460 patients were eligible for analysis. The conversion rate ranged from 0 to 14.3%. No mortality was reported. The immediate postoperative morbidity rate was 8.6%. Length of stay ranged from 1 to 7 days. A significant improvement in constipation and incontinence symptoms was observed in the postoperative period for both ORP and ODS (chi-square test, P < 0.0001).

CONCLUSION

Laparoscopic VR is a safe and effective procedure for ORP and ODS. Longer follow-up is required, and studies comparing VR with standard rectopexy and stapled transanal rectal resection are not yet available.

Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defaecation syndrome and/or faecal incontinence. Very few reports exist on the use of biologic mesh for LVR. The aim of our study was to report the complication and recurrence rate of our first 100 cases of LVR for symptomatic internal rectal prolapse and/or rectocele using a porcine dermal collagen mesh.

METHODS

Prospectively collected data on LVR for internal rectal prolapse were analysed. Surgical complications and functional results in terms of faecal incontinence (measured with the Faecal Incontinence Severity Index = FISI) and constipation (measured with the Wexner Constipation Score = WCS) at 3, 6 and 12 months were analysed. It was considered an improvement if FISI or WCS scores were reduced by at least 25 % and a cure if the FISI score decreased to <10 and the WCS decreased to <5.

RESULTS

Between April 2009 and April 2013, 100 consecutive female patients (mean age 63 years, range 24-88 years) underwent LVR. All patients had internal rectal prolapse (grade III [n = 25] and grade IV [n = 75] according to the Oxford classification) and rectocele. Mean operative time was 85 ± 40 min. Conversion rate to open technique was 1 %. There was no post-operative mortality. Overall 16 patients (16 %) experienced 18 complications, including rectal perforation (n = 1), small bowel obstruction (n = 2), urinary tract infection (n = 8), subcutaneous emphysema (n = 3), wound haematoma (n = 2), long lasting sacral pain (n = 1) and incisional hernia (1). Median post-operative length of stay was 2 days. Ninety-eight out of 100 patients completed follow-up. At the end of follow-up, the mean FISI score improved from 8.4 (±4.0 standard deviation (SD) p = 0.003) to 3.3 ± 2.3 SD (p = 0.04). Incontinence improved in 37 out of 43 patients (86 %), and 31 patients (72 %) were cured. Similarly, the mean WCS score improved from 18.4 ± 11.6 SD to 5.4 ± 4.1 SD (p = 0.04). Constipation improved in 82 out of 89 patients (92 %), and 70 patients (79 %) were cured. No worsening of continence status, constipation or sexual function was observed. Fourteen patients (14 %) experienced persistence or recurrence of prolapse.

CONCLUSIONS

LVR using biologic mesh is a safe and effective procedure for improving symptoms of obstructed defaecation and faecal incontinence in patients with internal rectal prolapse associated with rectocele.

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive 'revolution' of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Modified laparoscopic ventral mesh rectopexy

We present a modified laparoscopic ventral mesh rectopexy procedure using biological mesh and bilateral anterior mesh fixation. The rectopexy is anterior with a minimal posterior mobilization. The rectum is symmetrically suspended to the sacral promontory through a mesorectal window.

Conservative treatment of intrarectal mesh migration after ventral laparoscopic rectopexy for rectal prolapse

OBJECTIVE

Ventral rectopexy is a validated treatment for rectal prolapse with a low morbidity rate but a risk of intrarectal mesh migration. The purpose of this study was to report the results of local transanal mesh excision for intrarectal mesh migration after ventral rectopexy.

METHODS

Between January 2004 and March 2011, 312 patients underwent laparoscopic ventral rectopexy in two hospitals. Six patients were treated for intrarectal mesh migration.

RESULTS

Delay between ventral rectopexy and the onset of symptoms was 53 months (4-124 months). All patients have symptoms. Imaging revealed a pelvic abscess in two cases. Intrarectal mesh migration was confirmed by anorectoscopy or clinical examination. Five patients were only treated by local transanal partial mesh excision, and one required a colostomy. Morbidity and mortality were zero. The median hospitalization time was 5 days (3-8 days). After a median postoperative follow-up period of 9 months (1-40 months), one recurrence was observed 2 months after surgery.

CONCLUSION

Local transanal mesh excision for intrarectal mesh migration after laparoscopic ventral rectopexy is a feasible conservative treatment. This simple treatment produced a cure of the pelvic inflammation and closure of the fistula without compromising a more aggressive secondary treatment which was not necessary in our series.

[Transabdominal procedures for functional bowel diseases]

Incontinence and constipation can occur in cases of pelvic floor dysfunction. Purely morphological changes without severe clinical symptoms are not an indication for surgery. Abdominal operations can be classified into procedures with dorsal (with or without bowel resection and with or without mesh implantation) and procedures with ventral rectopexy (with mesh). With respect to constipation and incontinence suture rectopexy alone is inferior to all other procedures. Dorsal and ventral mesh rectopexy and resection rectopexy are all comparable with respect to improvement of incontinence. Ventral rectopexy without dorsal mobilization and resection rectopexy are superior to mesh rectopexy with respect to constipation. Due to poor evidential status treatment is carried out from a pragmatic viewpoint.

Mesh-free Ventral Rectopexy for Women with Complete Rectal and Uterovaginal Prolapse

Background:

Mesh rectopexy may be associated with infective complications, erosion into the vagina or rectum, and disintegration or dislodgement. A mesh-free rectopexy will avoid these complications. Objective of the study was to perform mesh-free ventral rectopexy and assess its safety and effectiveness.

Materials and Methods:

Nine women with complete rectal and uterovaginal prolapse were treated with total abdominal hysterectomy, closure of the vaginal vault, extirpation of the pouch of Douglas and suture of anterior rectal wall to the posterior vaginal wall (ventral suture rectopexy). The ventral suture rectopexy was achieved by three pairs of interrupted silk sutures, 2.5 cm above each other, and the first pair very close to the pelvic floor. This composite structure (anterior rectal wall and posterior vaginal wall), sits astride the perineal body. Intussusception and subsequent prolapse of the sutured rectum and vaginal wall is prevented. Vaginal vault prolapse was prevented by the suture of each round ligament of the uterus to the corresponding lateral vaginal fornix. No mesh was used.

Results:

Nine multiparous women aged between 52 and 70 years had the procedure. The mean operative time was 135 minutes (range 110-220). The follow-up period was between 29 months and 7 years. Full continence was restored in all patients within eight weeks of the operation. Bowel habit returned to once daily in four patients and once every other day in the remaining five patients, within thirteen weeks of surgery. One patient had intermittent mucus discharge per rectum for six months. This stopped without a specific treatment. There has been no known recurrence in these nine patients. One patient developed wound infection as a complication. There was no mortality. All the patients are now asymptomatic.

Conclusion:

Ventral suture rectopexy is a safe and effective treatment for complete rectal prolapse in a selected group of patients.

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.

Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: short- and long-term follow-up

BACKGROUND

There are multiple procedures to treat full-thickness rectal prolapse. No consensus exists as to the best surgical option. All procedures have a significant recurrence rate.

OBJECTIVE

The aim of this study was to report short- and long-term technical results following laparoscopic removal of the Douglas pouch peritoneum and anterior rectopexy in patients with total rectal prolapse.

DESIGN

This study is a prospective evaluation of consecutive patients.

SETTINGS

This investigation was conducted at a single academic colorectal unit.

PATIENTS

Between May 1996 and June 2009, 175 consecutive patients (17 males) with a mean age of 58 years (range, 16-94) were operated on.

INTERVENTION

The Douglas pouch peritoneum was excised, 2 synthetic meshes were fixated to the anterior part of the lower rectum with five 4-mm staples and to the promontory with 3 spiked chromium staples, and the peritoneum was closed over the meshes to isolate them from the abdominal cavity.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, 12, and then annually. Mortality, morbidity, and recurrence were analyzed. Median follow-up was 74 months (range, 24-181). Recurrence rate was calculated according to the Kaplan-Meier method.

RESULTS

: There was no mortality. Morbidity (5.1%) consisted in temporary brachial plexus palsy in 2 cases, urinary infection in 3 cases, ureteral lesion in 1 patient having had a previous bone graft on the promontory for spondylolisthesis (JJ catheter), and perforation of the small bowel because of adhesions (laparoscopic suture) in 1 case. One patient presented with a rectal erosion at month 9 (transanal removal of the mesh). Two patients presented with a recurrence of the rectal prolapse at months 6 and 24 (recurrence rate of 3% at 5 years) that was treated with anal artificial sphincter in one and redo operation in the other.

CONCLUSION

Laparoscopic removal of the Douglas pouch peritoneum and rectopexy to the promontory is a safe and efficient procedure to treat full-thickness rectal prolapse.

Laparoscopic ventral rectopexy for internal rectal prolapse using biological mesh: postoperative and short-term functional results

BACKGROUND

Laparoscopic ventral mesh rectopexy is a novel procedure to correct internal and external rectal prolapse. Several authors have shown that this approach is safe and improves obstructive defaecation symptoms and faecal incontinence, without inducing new-onset constipation, possible after posterior rectopexy. Over the last decade, as for other procedures, biological meshes are used to correct pelvic floor disorders. Literature data are scant. In this study, we present our experience with this procedure using biological mesh.

PATIENTS AND METHODS

Prospectively collected data on laparoscopic ventral mesh rectopexy for internal rectal prolapse were analysed. All patients underwent preoperative evaluation with defaecating proctography and/or pelvic dynamic MRI, full colonoscopy, anal physiology studies and endo-anal ultrasound. End-points were to evaluate surgical complications and functional results of this technique such as changes in bowel function (Wexner Constipation Score and Faecal Incontinence Severity Index) at 3 and 6 months. Analysis was performed using Mann-Whitney U test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p test).

RESULTS

Thirty-four consecutive patients underwent laparoscopic ventral mesh rectopexy (median age 59, range 25-78 years, mean follow-up was 12 months). Twenty-eight patients (82%) had a constipation score ≥ 5, while 14 (41%) a FISI score ≥ 10. Nine patients (26%) had mixed obstructed defaecation and faecal incontinence. One patient required conversion to open (3%). Median length of stay was 2 days. Overall complication rate was 23.5%. Preoperative constipation (median Wexner score 15) and faecal incontinence (median FISI score 12) improved significantly at 3 months (Wexner 5, FISI 5, both p < 0.001). Two patients experienced prolapse persistence or recurrence. No patients had function worsening or complained of sexual dysfunction.

CONCLUSIONS

Laparoscopic ventral mesh rectopexy using biological mesh for internal rectal prolapse is safe and effective in ameliorating symptoms of obstructed defaecation and faecal incontinence.

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.

Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature

BACKGROUND

Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there are few long-term follow-up and functional outcome data available. Using meta-analysis techniques, this study was designed to evaluate long-term results of open and laparoscopic abdominal procedures to treat full-thickness rectal prolapse in adults.

METHODS

A literature review was performed using the National Library of Medicine's PubMed database. All articles on abdominal rectopexy patients with a follow-up longer than 16 months were considered. The primary end point was recurrence of rectal prolapse, and the secondary end points were improvement in incontinence and constipation. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.

RESULTS

Eight comparative studies, consisting of a total of 467 patients (275 open and 192 laparoscopic), were included. Analysis of the data suggested that there is no significant difference in recurrence, incontinence and constipation improvement between laparoscopic abdominal rectopexy and open abdominal rectopexy. Considering non-comparative trials, the event rate for recurrence was similar in open and laparoscopic suture rectopexy studies and in open and laparoscopic mesh rectopexy trials. Improvement in constipation after the intervention was not statistically significant except for open mesh repair; postoperative improvement in incontinence was statistically significant after laparoscopic procedures and open mesh rectopexy.

CONCLUSIONS

Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regard to recurrence, incontinence and constipation. However, large-scale randomized trials, with comparative, strong methodology, are still needed to identify outcome measures accurately.

The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra-anal rectal intussusception

AIM

Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra-anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients.

METHOD

Forty consecutive patients with incontinence and intra-anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded.

RESULTS

The mean CCI scores were 13.2 (=/-4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as 'cured' in 26 (65%), 'improved' in 13 (32.5%) and 'unchanged' in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow-up of 38 months.

CONCLUSION

Intra-anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.

Surgical treatment for constipation in children and adults

Functional constipation is one of the most common gastrointestinal disorders. In both children and adults, most patients are managed conservatively with good results. In this review, we focus on the surgical approach to constipation. Patients who lack the capacity to consistently have voluntary bowel movements may need mechanical emptying of the colon through an enema program; for them, surgery to allow for antegrade enemas, (via the appendix or using a button device) is useful. Those patients with severe constipation not responsive to intense medical treatment may be candidates for other surgical interventions, such as resection of the dysfunctional colonic segment (rectosigmoid or whole colon), or plication, -pexy, and STARR techniques for evacuatory disorders secondary to obstructive anatomical features. Permanent stomas are an option of last resort.

Common transabdominal surgical options for rectal prolapse

Rectal prolapse is a troublesome anorectal disorder. Surgical procedures for rectal prolapse contain transabdominal and transperineal approaches. There are hundreds of transabdominal procedures currently available for treatment of the disease, such as Ripstein procedure, Wells procedure, Orr procedure, Nigro procedure, anterior resection, Frykman-Goldberg procedure, and Roscoe Graham procedure. Laparoscopic repair represents the latest advance in surgical treatment of rectal prolapse. As each procedure has its strength and weakness, personalized selection of appropriate procedure can greatly improve surgical outcome. Individualized diagnosis and treatment plan may represent a new direction for transabdominal surgical treatment of rectal prolapse.

Systematic review on ventral rectopexy for rectal prolapse and intussusception

OBJECTIVE

This systematic review assesses the effectiveness of ventral rectopexy (VR) surgery for treatment of rectal prolapse (RP) and rectal intussusception (RI) in adults. Method MEDLINE, EMBASE, Scopus and other relevant databases were searched to identify studies. Randomized controlled trials or nonrandomized studies with more than 10 patients receiving ventral mesh rectopexy surgery were considered for the review.

RESULTS

Twelve nonrandomized case series studies with 728 patients in total are included in the review. Seven studies used the Orr-Loygue procedure (VR with posterior rectal mobilization to the pelvic floor) and five studies used VR without posterior rectal mobilization. Overall weighted mean percentage decrease in faecal incontinence (FI) rate was 45%. The weighted mean percentage decrease in constipation rate was 24%. Weighted mean recurrence rate was 3.4%.

CONCLUSIONS

There are limitations in published literature on VR. The available data indicate that VR has low recurrence and improves FI in patients suffering from these conditions. There is a greater reduction in postoperative constipation if VR is used without posterior rectal mobilization.

A new technique for suture rectopexy without resection for rectal prolapse

BACKGROUND

We surmised that if rectopexy was performed without dissection of the lateral rectal stalks in patients with full-thickness rectal prolapse and normal preoperative transit, sigmoid resection may not be required. This study evaluated a new approach to abdominal suture rectopexy for rectal prolapse.

METHODS

A total of 81 patients (57 male, 24 female; median age 37 years, range 5-82 years) with rectal prolapse were assessed by clinical examination, anal manometry (maximum resting pressure, MRP, and squeeze pressure, MSP) and radioopaque marker transit studies. Of the 81 patients, 70 with normal preoperative transit underwent suture fixation alone, without resection, performed under spinal anaesthesia, through a 7-cm transverse left lower quadrant incision gaining access to the presacral space via a left pararectal "window", preserving the lateral stalks.

RESULTS

Average surgical time was 50 min, mortality was zero, and morbidity was 9% (three patients with wound infection, four with urinary retention). Anal incontinence improved in 43 of 53 patients (81%, p=0.001). MRP and MSP had improved at 3 months after surgery: MRP from a mean of 27.6+/-1.4 mmHg (range 2-30 mmHg) before surgery to 32.5+/-2.21 mmHg (2-60 mmHg) after surgery (p=0.008); MSP from 69.25+/-6.4 mmHg (8-153 mmHg) before surgery to 79+/-4.77 mmHg (35-157 mmHg) after surgery (p=0.001).. Transit was unchanged in 18 of 20 patients (90%) who were evaluated before and after surgery; none was constipated after surgery. At 56 months, prolapse had recurred in five patients (7%).

CONCLUSION

Abdominal suture rectopexy with a left pararectal approach without sigmoid resection in those with normal preoperative transit resulted in an improvement in anal incontinence and satisfactory long-term control of prolapse. The operation did not alter transit and did not result in significant constipation.

Overt rectal prolapse and fecal incontinence

PURPOSE

Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging.

METHODS

Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 +/- 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed.

RESULTS

The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49-13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68-48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018).

CONCLUSIONS

In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.