Long-term functional outcomes after laparoscopic and open rectopexy for the treatment of rectal prolapse

Diagnostic accuracy of intraoperative pelvic autonomic nerve monitoring during rectal surgery: a systematic review

PURPOSE

Anorectal and urogenital dysfunctions are common after rectal surgery and have a significant impact on quality of life. Intraoperative pelvic autonomic nerve monitoring (pIONM) has been proposed as a tool to identify patients at risk of these functional sequelae. This systematic review aims to evaluate the diagnostic accuracy of pIONM in detecting anorectal and urogenital dysfunction following rectal surgery.

METHODS

A systematic review of articles published since 1990 was conducted using MEDLINE, Embase, CINAHL, Google Scholar, Scopus, and Web of Science. Studies describing pIONM for rectal surgery and reporting anorectal or urogenital functional outcomes were included. The risk of bias was assessed using the QUADS-2 tool. The diagnostic accuracy of pIONM was established with pooled sensitivity and specificity alongside summary receiver-operating characteristic curves.

RESULTS

Twenty studies including 686 patients undergoing pIONM were identified, with seven of these studies including a control group. There was heterogeneity in the pIONM technique and reported outcome measures used. Results from five studies indicate pIONM may be able to predict postoperative anorectal (sensitivity 1.00 [95% CI 0.03-1.00], specificity 0.98 [0.91-0.99]) and urinary (sensitivity 1.00 [95% CI 0.03-1.00], specificity 0.99 [0.92-0.99]) dysfunction.

CONCLUSIONS

This review identifies the diagnostic accuracy of pIONM in detecting postoperative anorectal and urogenital dysfunction following rectal surgery. Further research is necessary before pIONM can be routinely used in clinical practice.

PROSPERO REGISTRATION DETAILS

CRD42022313934.

Mesh-associated complications in minimally invasive ventral mesh rectopexy: a systematic review

BACKGROUND

Ventral mesh rectopexy (laparoscopic and robotic) is a common and well established treatment of rectal prolapse. Although described as safe and effective, complications, especially mesh-associated ones are often mentioned. Additionally, there is no consensus regarding the mesh type and fixation method as well as the materials used for this purpose. The aim of this systematic review was to identify the total amount of complications and of those the mesh-associated ones.

METHODS

Pubmed, Web of Science and Cochrane Central Register were screened for complications in general and in detail regarding the mesh(es) and a systematic review was performed.

RESULTS

Following qualitative evaluation, 40 studies were identified for further investigation. Across 6269 patients, complications were found in 9.2% (622 patients). Mesh-related complications were described in 1.4% (88 patients) of which 64.8% were erosions, 11.4% fistulas and 13.6% mesh releases. The complication rate according to the different materials were low with 1% in biological and synthetic meshes and 1.8% in not further described or mixed mesh type. Non-absorbable material to fixate the mesh was most frequently used to fixate the mesh.

CONCLUSION

Laparoscopic ventral mesh rectopexy is a safe operation with a low-complication rate, regardless of mesh type.

Easy modified wells method for rectal prolapse with using bilayer mesh

BACKGROUND

In recent years, many laparoscopic procedures have been reported for the treatment of rectal prolapse, and the Wells method is safe and has relatively good results for rectal prolapse, which is common in the elderly. In this report, we have developed a simpler method to perform the Wells method.

METHODS

In our procedures, easy modified Wells method is performed laparoscopically, but the use of a bilayer mesh makes it easier to perform without the need to suture the retroperitoneum. We performed the method for six cases. All patients are female and average age is 86 ± 4.6. Max length of rectal prolapse is 3 cm-7 cm.

RESULTS

The median operative time was 191 ± 26 min. No recurrent rectal prolapse was encountered during follow-up period. The average defecation frequency per week before surgery was 5.3 ± 1.9 and after surgery was 3.7 ± 2.1.

CONCLUSION

Easy modified Wells method can be performed with safety and without difficulty. This method has shown acceptable results in recurrence rates and defecation frequency after surgery.

Autologous Fascia Lata for Combined Sacrocolpopexy and Rectopexy

ABSTRACT

We present a case series and video of our technique using autologous fascia lata for combined sacrocolpopexy and rectopexy, with or without resection.

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.

Suture rectopexy versus ventral mesh rectopexy for complete full-thickness rectal prolapse and intussusception: systematic review and meta-analysis

Background

This systematic review and meta-analysis aimed to compare recurrence rates of rectal prolapse following ventral mesh rectopexy (VMR) and suture rectopexy (SR).

Methods

MEDLINE, Embase, and the Cochrane Library were searched for studies reporting on the recurrence rates of complete rectal prolapse (CRP) or intussusception (IS) after SR and VMR. Results were pooled and procedures compared; a subgroup analysis was performed comparing patients with CRP and IS who underwent VMR using biological versus synthetic meshes. A meta-analysis of studies comparing SR and VMR was undertaken. The Methodological Items for Non-Randomized Studies score, the Newcastle–Ottawa Scale, and the Cochrane Collaboration tool were used to assess the quality of studies.

Results

Twenty-two studies with 976 patients were included in the SR group and 31 studies with 1605 patients in the VMR group; among these studies, five were eligible for meta-analysis. Overall, in patients with CRP, the recurrence rate was 8.6 per cent after SR and 3.7 per cent after VMR (P < 0.001). However, in patients with IS treated using VMR, the recurrence rate was 9.7 per cent. Recurrence rates after VMR did not differ with use of biological or synthetic mesh in patients treated for CRP (4.1 versus 3.6 per cent; P = 0.789) and or IS (11.4 versus 11.0 per cent; P = 0.902). Results from the meta-analysis showed high heterogeneity, and the difference in recurrence rates between SR and VMR groups was not statistically significant (P = 0.76).

Conclusion

Although the systematic review showed a higher recurrence rate after SR than VMR for treatment of CRP, this result was not confirmed by meta-analysis. Therefore, robust RCTs comparing SR and biological VMR are required.

Simplified Laparoscopic Suture Rectopexy for Idiopathic Rectal Prolapse In Children: Technique and Results

BACKGROUND

Laparoscopic suture rectopexy is safe and effective treatment option for pediatric rectal prolapse. We performed this study to compare the outcome of modified laparoscopic suture rectopexy (MLSR) versus Classical Laparoscopic suture rectopexy (CLSR).

MATERIAL AND METHODS

The study was conducted between June 2015 to May 2019 including all the patients with persistent rectal prolapse who underwent surgery managed by either MLSR (Group A) or CLSR (Group B). The groups were compared for constipation, operative time, blood loss, length of stay, postoperative complications.

RESULTS

19 patients from MLSR and 22 patients from CLSR were evaluated. The mean operative time in MLSR group was 41.5 ± 6.2 min which was significantly lesser than CLSR group with a mean operative time of 78.6 ± 14.2 (p = 0.001). The blood loss was also less in MLSR group compared to CLSR group (p = 0.013). At three months of follow up, the constipation was less in MLSR group compared to CLSR group (p = 0.041).

CONCLUSION

The modification makes the procedure technically easy, minimizes the chances of complications and retaining all the advantages of suture rectopexy.

LEVEL OF EVIDENCE

Level II.

Motor Evoked Potential Recordings from the Urethral Sphincter Muscles (USMEPs) during Spine Surgeries

Bowel and bladder function are at risk during tumor resection of the conus, cauda equina, and nerve roots. This study demonstrates the ability to acquire transcranial electrical motor evoked potentials (TCeMEPs) from the urethral sphincter muscles (USMEPs) by utilizing a urethral catheter with an embedded electrode. A retrospective analysis of intraoperative neurophysiological monitoring (IONM) data from nine intradural tumors, four tethered cord releases, and two spinal stenosis procedures was performed (n = 15). The cohort included seven females and eight males (median age: 38.91 years). A catheter with embedded urethral electrodes was used for recording TCeMEPs and spontaneous electromyograph (s-EMG) from the external urethral sphincter (EUS). USMEPs were obtained in 14 patients (93%). The reliability of TCeMEP from the external anal sphincter (EAS) was variable across all patients. In patient 7, the TCeMEP recordings from the urethral sphincter were not present before incision; however, following the resection of the tumor, the USMEP recordings were obtained and remained stable for the remainder of the procedure. Patient 7 had subsequent improvement in bladder function postoperatively. Patient 4 exhibited a 50% increase in the amplitude of the USMEP following tumor resection and exhibited improved bladder function as well postoperatively. In this small series, we were able to acquire consistent and reliable MEPs when recorded from the urethral sphincters. More study is needed to establish a better understanding of the value added by this modality. USMEPs can be attempted in surgeries that put the function of the pelvic floor at risk.

Intraoperative Triggered Electromyography Recordings from the External Urethral Sphincter Muscles During Spine Surgeries

Introduction: Bowel and bladder function are at risk during tumor resection and other surgeries of the conus, cauda equina, and nerve roots. This study demonstrates the ability to acquire triggered electromyography (t-EMG) from the external urethral sphincter (EUS) muscles by utilizing a urethral catheter with an electrode attached.

Methods: A retrospective analysis of neurophysiological monitoring data from two medical centers was performed. Seven intradural tumors and three tethered cord release surgeries that used urethral sphincter electrodes to record t-EMG were included in the analysis. The patients consisted of five females and five males with ages ranging from eight months to 67 years (median: 49 years). Our neuromonitoring paradigm included upper and lower extremity somatosensory evoked potentials (SSEPs) and transcranial electrical motor evoked potentials (TCeMEPs), as well as spontaneous and triggered electromyography (EMG) from the external anal sphincter (EAS), EUS muscles and lower extremity muscles bilaterally. A catheter with urethral electrodes attached was used for recording spontaneous electromyography (s-EMG), t-EMG, and TCeMEPs from the skeletal muscle of the EUS. Train of four (TOF) was also recorded from the abductor hallucis muscle as well for monitoring the level of muscle relaxant.

Results: We were able to successfully record t-EMG responses from the EUS muscles in all patients (100%). It is worthy to note that only one patient presented preoperatively with bladder incontinence, urgency, and frequency. Almost immediately in the postoperative phase, the patient’s frequency and urgency improved, and the bladder function normalized within two weeks of having the tumor removed.

Conclusions: In this small series, we were able to acquire t-EMG in 100% of patients when recorded from the EUS using a urethral catheter with electrodes built into it. T-EMGs can be attempted in surgeries that put the function of the pelvic floor at risk. More study is needed to establish better statistical methods, better modality efficacy, and a better understanding of intraoperative countermeasures that may be employed when an alert is encountered to prevent impending neurological sequelae.

Retrospective case-matched study between reduced port laparoscopic rectopexy and conventional laparoscopic rectopexy for rectal prolapse

Introduction:

Reduced port laparoscopic Well's procedure (RPLWP) is a novel technique used to overcome the limitations of single-incision laparoscopic surgery. The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic Well's procedure (CLWP) and to investigate the learning curve of RPLWP.

Patients and Methods:

From January 2006 to March 2017, a retrospective review of a prospectively maintained laparoscopic surgery database was performed to identify patients had undergone CLWP and RPLWP. From these patients, each of 10 cases were manually matched for age, sex, body mass index. From January 2006 to March 2015, CLWP was used for all procedures whereas, from April 2015, RPLWP was routinely performed as a standard procedure for rectal prolapse.

Results:

No significant differences were observed between the two groups in terms of operating time, blood loss, intraoperative complications, and conversion to CLWP or open rectopexy. Based on the postoperative outcomes, the hospital stay was significantly shorter in the RPLWP group. The estimated learning curve for RPLWP was fitted and defined as y = 278.47^e-0.064x with R²= 0.838; therefore, a significant decrease in operative time was observed by using the more advanced surgical procedure.

Conclusions:

RPLWP is an effective, safe, minimally invasive procedural alternative to CLWP with no disadvantage for patients when a skilled surgeon performs it.

Robotic ventral rectopexy: Initial experience in an Indian tertiary health-care centre and review of literature

BACKGROUND

Minimally invasive ventral rectopexy is a well-described technique for management of rectal prolapse. Robotic system has proven its advantage for surgeries in the pelvis. Applying this technique, ventral rectopexy can be done more precisely with minimal recurrence. With growing experience, the operative duration and cost of robotic ventral rectopexy can be reduced with better outcome. Few case studies have been described in literature with no study from Indian subcontinent. We describe a series of eight cases of robotic ventral rectopexy done for rectal prolapse in a tertiary health-care centre of India.

METHODS

A total of 8 patients were operated for complete rectal prolapse during the period from August 2015 to April 2016. da Vinci Si robotic surgical system was used with prolene or permacol mesh for ventral rectopexy. All patients were prospectively followed for a period minimum of 3 months. Pre- and intra-operative findings were recorded along with post-operative outcome.

RESULTS

Out of eight patients, prolene mesh was used in five patients and permacol mesh (porcine collagen) in three patients. Mean operative time (console time) was 177 min and mean total time was 218 min. Mean blood loss was 23.7 ml. Functional outcome was satisfactory in all patients. There was no significant complication in any patient with mean hospital stay of 2.2 days. With average follow-up of 8.8 months, no patient had recurrence.

CONCLUSION

Robotic ventral rectopexy is a safe technique for rectal prolapse with excellent result in terms of functional outcome, recurrence and complications. With experience, the duration and cost can be comparable to laparoscopic technique.

Future of Minimally Invasive Colorectal Surgery

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

Recurrence of rectal prolapse following rectopexy: a pooled analysis of 532 patients

AIM

The study was designed to address the unanswered question of the influence of the extent of rectal mobilization, the type of rectal fixation and the surgical access (open vs laparoscopic) on recurrence rates following abdominal surgery for full-thickness rectal prolapse (FTRP).

METHOD

Individual patient data were pooled and data merging was performed following comparison of variable definitions to ensure similarity in definitions. Recurrence after rectopexy was defined as the presence of FTRP on physical examination. The impact of categorical factors on recurrence was assessed using Fisher's exact and the chi-squared tests. Recurrence-free survival curves were generated for patients and differences in time to recurrence were compared using the log rank test. Factors passing univariate screening with a P value < 0.1 were included in a multivariate model.

RESULTS

After data matching and merging, 532 patients were included. The duration of follow-up ranged from 12 to 235 months. There were 46 (8.6%) recurrences at a median follow-up of 60 months. Mean age was 53.6 ± 17 years, 359 (67.5%) were female, the mean length of external prolapse was 6.3 ± 4 cm, and previous abdominal surgery had taken place in 33.7%. Four variables were identified on initial univariate screening as being related to recurrence. They included a history of incontinence (P = 0.09), constipation (P = 0.018), the extent of rectal mobilization (P = 0.004) and the role of sigmoid resection (P = 0.057). Using multivariate analysis, only the degree of mobilization was independently associated with recurrence (P = 0.026).

CONCLUSION

Circumferential rectal mobilization during rectopexy was associated with a decreased long-term recurrence rate. The type of rectal fixation and the type of surgical access did not influence recurrence.

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy

Purpose

To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR.

Methods

All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences.

Results

A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates.

Conclusion

High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

Surgery for complete (full-thickness) rectal prolapse in adults

BACKGROUND

Complete (full-thickness) rectal prolapse is a lifestyle-altering disability that commonly affects older people. The range of surgical methods available to correct the underlying pelvic floor defects in full-thickness rectal prolapse reflects the lack of consensus regarding the best operation.

OBJECTIVES

To assess the effects of different surgical repairs for complete (full-thickness) rectal prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register up to 3 February 2015; it contains trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) as well as trials identified through handsearches of journals and conference proceedings. We also searched EMBASE and EMBASE Classic (1947 to February 2015) and PubMed (January 1950 to December 2014), and we specifically handsearched theBritish Journal of Surgery (January 1995 to June 2014), Diseases of the Colon and Rectum (January 1995 to June 2014) and Colorectal Diseases (January 2000 to June 2014), as well as the proceedings of the Association of Coloproctology meetings (January 2000 to December 2014). Finally, we handsearched reference lists of all relevant articles to identify additional trials.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of surgery for managing full-thickness rectal prolapse in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The four primary outcome measures were the number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, number of patients with faecal incontinence and number of patients with constipation.

MAIN RESULTS

We included 15 RCTs involving 1007 participants in this third review update. One trial compared abdominal with perineal approaches to surgery, three trials compared fixation methods, three trials looked at the effects of lateral ligament division, one trial compared techniques of rectosigmoidectomy, two trials compared laparoscopic with open surgery, and two trials compared resection with no resection rectopexy. One new trial compared rectopexy versus rectal mobilisation only (no rectopexy), performed with either open or laparoscopic surgery. One new trial compared different techniques used in perineal surgery, and another included three comparisons: abdominal versus perineal surgery, resection versus no resection rectopexy in abdominal surgery and different techniques used in perineal surgery.The heterogeneity of the trial objectives, interventions and outcomes made analysis difficult. Many review objectives were covered by only one or two studies with small numbers of participants. Given these caveats, there is insufficient data to say which of the abdominal and perineal approaches are most effective. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation. Laparoscopic rectopexy was associated with fewer postoperative complications and shorter hospital stay than open rectopexy. Bowel resection during rectopexy was associated with lower rates of constipation. Recurrence of full-thickness prolapse was greater for mobilisation of the rectum only compared with rectopexy. There were no differences in quality of life for patients who underwent the different kinds of prolapse surgery.

AUTHORS' CONCLUSIONS

The lack of high quality evidence on different techniques, together with the small sample size of included trials and their methodological weaknesses, severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Longer follow-up with current studies and larger rigorous trials are needed to improve the evidence base and to define the optimum surgical treatment for full-thickness rectal prolapse.

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 ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results

AIM

We report the clinical and anal manometric results of elderly patients treated with laparoscopic ventral rectopexy (LVR) for full-thickness rectal prolapse.

METHOD

From March 2009 to June 2012, patients were consecutively included. A modified laparoscopic Orr-Loygue procedure with posterior mobilisation was used. The patients were evaluated preoperatively, 2 months postoperatively and after 1 year. We registered Wexner incontinence scores and laxative uses by a questionnaire and performed simple anal manometry.

RESULTS

A total of 46 patients underwent operation, all women. The median age was 83 years (range 34-99), median prolapse size was 8 cm (range 2-15), and 30 % had previous prolapse surgery. The median operative time was 135 min (range 90-215), and the median length of stay was 2 days (range 1-14). The 30-day morbidity rate was 15 %, and there were two (4 %) deaths within 30 days. There was a significant reduction in incontinence scores after 2 months and 1 year. The anal resting pressures improved from 10 cm H(2)O slightly to 16 cm H(2)O after 2 months, significantly, and still significant after 1 year at 13 cm H(2)O. There were no changes in the use of laxatives. The median follow-up time was 1.5 years (range 0.5-3), and there were two prolapse recurrences (4 %) in this period.

CONCLUSIONS

Laparoscopic ventral rectopexy with posterior mobilisation seems to be effective and relatively well tolerated, although not without mortality in elderly debilitated patients. It improves incontinence. With increased life-year expectance, these patients may benefit from a lower risk of recurrence compared with perineal procedures.

Ten-year follow up after laparoscopic suture rectopexy for full-thickness rectal prolapse

AIM

Studies have shown that recurrence rates of full-thickness rectal prolapse (FTRP) 5 years after surgery can quadruple at 10 years. This study aimed to evaluate the impact of laparoscopic suture rectopexy for FTRP on recurrence rates and functional outcome at a median follow up of 10 years.

METHOD

Prospectively collected data for patients who underwent laparoscopic suture rectopexy for FTRP between 1993 and 2006 were analysed. Laparoscopic rectopexy consisted of circumferential mobilization of the rectum down to the levator followed by suture suspension to promontory. Patients with preexisting constipation or who were unfit for general anaesthesia were not included. Incontinence, quality of life and constipation were assessed by validated scores. Recurrence-free curves were generated using the Kaplan-Meier method.

RESULTS

One hundred and seventy-nine patients with a median age of 62 (15-93) years including 174 women and five men underwent laparoscopic suture rectopexy. There was no mortality. The 30-day complication rate was 4% (partial transection of the left ureter, pneumonia, urinary tract infection, urinary retention, superficial surgical site infection). Data on 172 patients (96%) were available at follow up. There were 10 recurrences of FTRP at 5-year follow up giving a crude recurrence rate of 6%. The actuarial 10-year recurrence rate was 20% (95% CI, 10.8-20.1). Follow-up continence (P < 0.0001) and quality of life were better than preoperatively: lifestyle (P < 0.001), coping (P < 0.001), self-perception (P < 0.005), embarrassment (P < 0.06). Constipation was unchanged.

CONCLUSION

Laparoscopic suture rectopexy led to few complications, a recurrence rate of 20%, improved continence and quality of life with no worsening of constipation at 10 years.

Laparoscopic rectopexy for rectal prolapse to reduce surgical-site infections and length of stay

BACKGROUND

Rectal prolapse is commonly seen in patients with significant co-morbidities. Multiple approaches have been described, including the use of laparoscopy. The purpose of this study was to determine if laparoscopic approaches for repair of rectal prolapse are associated with less short-term morbidity than open approaches.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent laparoscopic or open rectopexy (R) or sigmoid resection and rectopexy (SR + R) between 2005 and 2008. Co-morbidities analyzed included diabetes, body mass index, chronic obstructive pulmonary disease, hypertension, cardiac (history of congestive heart failure, myocardial infarction, peripheral vascular disease, previous percutaneous cardiac intervention or surgery), and neurologic disorder (history of transient ischemic attack or cerebrovascular accident). Postoperative complications analyzed included surgical-site infections (SSIs), pneumonia, reintubation, pulmonary embolus, stroke, myocardial infarction, and sepsis. The χ (2) or t test/ANOVA were used to assess significance for categoric and continuous variables, respectively. Logistic regression analysis was used to determine risk factors for morbidity after rectal prolapse repair.

RESULTS

Altogether, 685 patients underwent surgical treatment of rectal prolapse. Most patients underwent open SR + R (open: 247 SR + R, 193 R; laparoscopic: 161 SR + R, 84 R). All patients had similar co-morbidity profiles. Patients undergoing laparoscopic R were significantly older (mean age 61.4 years) than those in the other three groups (p = 0.04). Operating time ranged from 128 min (open R) to 185 min (laparoscopic SR + R; p < 0.001). Open SR + R and open R were associated with significantly more morbidity than laparoscopic SR + R and R [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.22-0.83, p = 0.01]. Comparing all four procedures, there was a trend to decreased overall morbidity with laparoscopic R, but without statistical significance (OR 0.31, 95 % CI 0.07-1.40, p = 0.13). Length of hospital stay (LOS) and SSI rates were significantly lower with laparoscopic R than with the other three procedures.

CONCLUSIONS

Patients who undergo laparoscopic rectopexy have a shorter LOS and lower SSI rate than patients who undergo other abdominal procedures for repair of rectal prolapse. Further study is necessary to determine the long-term outcomes from laparoscopic rectopexy, but in high-risk patients the laparoscopic approach can decrease perioperative risk.

Laparoscopic neuromapping in pelvic surgery: scopes of application

BACKGROUND

New developments in intraoperative electrophysiological neuromonitoring for conventional surgery are providing further insights into functional neuroanatomy and nerve-sparing in the minor pelvis. The aim of this study was to open up potential scopes of application in laparoscopy.

METHODS

Ten patients with different indications for surgery (presacral tumor excision, n = 2; resection rectopexy. n = 2; low anterior rectal resection, n = 2; proctocolectomy. n = 2; abdomino-perineal excision of the rectum, n = 2) were investigated prospectively. The pelvic autonomic nerves were bilaterally mapped by laparoscopic electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Stimulation results were compared to patients' anorectal and urogenital functional outcome.

RESULTS

In all the operations laparoscopic neuromapping (LNM) was technically feasible. Laparoscopy enabled excellent visibility of pelvic neural structures for simple and differentiated electric stimulation. In all cases LNM resulted in significantly evoked electromyographic potentials and intravesical pressure rises. The technique facilitated electrophysiological determination of functional neuroanatomical topography in the minor pelvis. The stimulation results were suitable to confirm laparoscopic nerve-sparing and compatible with patients' anorectal and urogenital functional outcome.

CONCLUSIONS

LNM is technically feasible and opens up a new dimension for verification of functional nerve integrity. Further developments and investigations are mandatory to evaluate its role for laparoscopic nerve-sparing procedures.

Hand-assisted laparoscopic suture rectopexy for complete rectal prolapse complicated by a solitary ulcer and obstructed defecation: a case report and review of the literature

Introduction

Solitary rectal ulcer syndrome is a condition in which an ulcer occurs in the rectum. There is evidence that solitary rectal ulcer syndrome is associated with rectal prolapse either overt or occult and that stopping complete rectal prolapse may lead to rapid healing of the solitary rectal ulcer. A huge variety of operative techniques have been described in the literature to correct this condition. We present the case of a patient who underwent hand-assisted laparoscopic suture rectopexy for complete rectal prolapse complicated by a solitary ulcer and obstructed defecation.

Case presentation

A 32-year-old Caucasian woman presented to our institute complaining of having had difficulty with her bowel movements, a rectal prolapse and pain in the anal area for one and a half years. She was checked in hospital for suspected rectal carcinoma, however, the examination revealed rectal ulceration. A diagnosis of complete rectal prolapse complicated by a solitary ulcer and obstructed defecation was established. The symptoms persisted so a hand-assisted laparoscopic suture rectopexy was performed. After six months of follow-up, her bowel movements had improved, she was experiencing no pain and the rectal ulcer had healed.

Conclusion

A hand-assisted laparoscopic suture rectopexy is a feasible and safe surgical treatment of rectal prolapse with solitary rectal ulcer syndrome, providing complete recovery for patients with solitary rectal ulcer syndrome.

Incontinence in full-thickness rectal prolapse: low level of improvement after laparoscopic rectopexy

AIM

The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse.

METHOD

Eighty-five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self-administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery.

RESULTS

After a mean follow-up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (-3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients' average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P < 0.0001) were significantly higher in patients suffering from postoperative incontinence.

CONCLUSION

Despite some continence improvement in two-thirds of patients who underwent surgery for rectal prolapse, the level of improvement remained low in more than half of the patients.

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.

Is the abdominal repair of rectal prolapse safer than perineal repair in the highest risk patients? An NSQIP analysis

BACKGROUND

Although the perineal approach in the surgical management of rectal prolapse has a higher recurrence, it is the accepted approach for higher-risk patients because of its lower morbidity.

OBJECTIVE

The aim of this study was to determine outcomes of abdominal versus perineal approaches to rectal prolapse repair. DESIGN SETTINGS: A retrospective study was performed comparing outcomes of patients undergoing different types of surgical approaches (open abdominal, laparoscopic, perineal) for rectal prolapse.

PATIENTS

The American College of Surgeons National Surgical Quality Improvement Participant User Data Files (2008-2009) were queried for patients undergoing adult, elective procedures for rectal prolapse.

MAIN OUTCOME MEASURES

Univariate analysis and multivariate logistic regression were performed to look at age, ASA classification, procedure type, and resultant mortality rate.

RESULTS

One thousand four hundred sixty-nine patients meeting our criteria were identified. Older patients (age>80) and higher-risk patients (ASA classifications 3 and 4) were significantly associated with the selection of the perineal approach. The overall mortality rate was 0.5%. The mortality rate for all perineal procedures was 0.9% in comparison with 0.13% for all abdominal operations (p = 0.033). The mortality rate for the highest-risk groups (ASA 3 and 4) for perineal procedures was 1.3% in comparison with 0.35% in the abdominal procedure group; the relative risk for mortality was 4 times greater in the perineal procedure group than in the abdominal procedure group.

LIMITATIONS

The retrospective design and standardized outcomes measured use administrative-level data and prevent the assessment of procedure-specific outcomes.

CONCLUSIONS

Hospital mortality for the surgical repair of rectal prolapse is uncommon. The decision to choose the abdominal approach for the repair of rectal prolapse may not be as prohibitive as previously thought for higher-risk patients. Because of the broad range of functionality within each ASA classification, the operation offered should always be individualized, and patient selection is the most important factor.

Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients

AIM

Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence.

METHOD

The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate.

RESULTS

Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years.

CONCLUSION

The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

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.

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.

Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele

AIM

Laparoscopic ventral mesh rectopexy, previously described for external rectal prolapse, was evaluated for symptomatic complex rectocoele.

METHOD

From January 2004 to December 2008, 84 (50.9%) patients (mean age 64 ± 5 years) underwent laparoscopic ventral mesh rectopexy for symptomatic complex rectocoele, confirmed preoperatively on dynamic defaecography, with 26 (31%) patients having a concurrent cystocoele. The operative technique was standardized, and those with cystocoele underwent bladder mesh suspension during the same procedure. Prospectively collected data were analysed for preoperative symptoms, operative and functional results [constipation, faecal incontinence (FI), dyspareunia and satisfaction score].

RESULTS

The conversion rate was 3.6% and perioperative morbidity 4.8% with no mortality. At a median follow up of 29 (4-59) months, there was a significant decrease in vaginal discomfort (86-20%) and obstructed defaecation symptoms (83-46%), P < 0.001. There was no significant change in FI (20-16%), no worsening of preoperative symptoms or new complaints of constipation, dyspareunia or FI. Overall, 88% of patients reported an improvement in overall well-being.

CONCLUSION

Laparoscopic ventral mesh rectopexy is a safe and effective method for treating symptomatic complex rectocoele.

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.

Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients

BACKGROUND

The balance between abdominal and perineal approaches for rectal prolapse is always the higher morbidity but better outcome in the former setting. Therefore, perineal approaches have been preferred for the treatment of full-thickness rectal prolapse (FTRP) in elderly patients. However, laparoscopic rectopexy with or without resection also may be used for elderly patients and may confer the same benefits.

PURPOSE

The objective of this study was to evaluate safety and efficacy of laparoscopic rectopexy compared with perineal rectosigmoidectomy for FTRP in elderly patients.

METHODS

Between July 2000 and June 2009, eight consecutive patients (8 women; mean age, 71 (range, 65-77) years) with FTRP underwent laparoscopic rectopexy (LAP group). During the same period, 143 patients underwent perineal rectosigmoidectomy (PRS group). A total of 123 patients were selected who underwent perineal rectosigmoidectomy (117 women; mean age, 80.7 (range, 66-98) years).

RESULTS

Three patients (37.5%) in the LAP group and 29 patients (23.6%) in the PRS group had undergone previous operations for rectal prolapse. The mean follow-up periods were 6.9 months and 12.8 months, respectively. In the LAP group, operative time was longer (166.5 vs. 73.5 minutes; p > 0.05) and bleeding loss was more (101.7 vs. 31.6; p < 0.05), whereas the length of hospitalization was same between the two groups (5.4 vs. 5.3 days; p > 0.05). Postoperative complications included an incisional hernia in the LAP group (12.5%) and urinary retention (4.8%), anastomotic disruption (2.4%), urinary tract infection (1.6%), and atelectasis (1.6%) in the PRS group (13.8%). Recurrences were 1 (12.5%) in the LAP group and 14 (11.4%) in the PRS group.

CONCLUSIONS

Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with FTRP but results in increased operative time.

Robotic versus laparoscopic rectopexy for complex rectocele: a prospective comparison of short-term outcomes

PURPOSE

The role of robotic assistance in pelvic floor prolapse surgery is debatable. This study aims to report our early experience of robotic-assisted ventral mesh rectopexy in the treatment of complex rectocele and to compare this with the laparoscopic approach in terms of safety and short-term postoperative outcomes.

METHODS

We analyzed a cohort of 63 consecutive patients operated on for complex rectocele from March 2008 to December 2009. A complex rectocele was defined as a rectocele that had one or more of the following features: larger than 3 cm in diameter, associated with an enterocele or internal rectal prolapse. The patients underwent either the robotic procedure or laparoscopic procedure, based only on the availability of the robotic system. Procedures involved either a single-mesh fixation for posterior-compartment prolapse (concurrent rectocele and enterocele) or a double-mesh fixation for a concurrent anterior compartment prolapse (with cystocele). A transvaginal tape was inserted at the same surgery in patients with urinary incontinence.

RESULTS

All patients were female; 40 underwent the laparoscopic procedure and 23 underwent the robotic procedure. Both groups were similar in age (mean, 59 ± 13 vs 61 ± 11; P = .440), ASA status, and previous abdominal surgery, respectively. Patients undergoing the robotic procedure had a significantly higher body mass index (mean, 27 ± 4 vs 24 ± 4; P = .03), more frequent double-mesh implantation (17/23 vs 14/40; P = .003), and longer operative time (mean, 221 ± 39 min vs 162 ± 60 min; P = .0001). Patients undergoing a laparoscopic procedure had slightly more blood loss (mean, 45 ± 91mL vs 6 ± 23 mL, P = .05). The number of transvaginal-tape procedures performed (6/40 vs 3/23, P > .999), conversion rate (10% vs 5%; P = .747), and duration of hospitalization were similar (mean, 5 ± 2 d vs 5 ± 1.6 d; P = .872). There were no mortalities or recurrences at the 6-month postoperative review.

CONCLUSION

In our experience, the robotic approach for the treatment of complex rectocele is as safe as the laparoscopic approach, with favorable short-term results.

Open vs laparoscopic repair of full-thickness rectal prolapse: a re-meta-analysis

OBJECTIVE

A re-meta-analysis of available data within the published literature comparing laparoscopic rectopexy (LR) with open repair (OR).

METHOD

We searched MEDLINE, EMBASE, CINAHL, PubMed and the Cochrane databases from January 1990 to October 2008. We searched the following MESH terms: 'laparoscopy', 'prolapse' and 'rectal prolapse'. We used the following text words: 'rectopexy', 'haemorrhoids', 'minimally invasive' and 'keyhole surgery'. The bibliography of selected trials and a Cochrane review was scrutinized and relevant references obtained. Selected trials were analysed to conduct a meta-analysis.

RESULTS

Twelve comparative studies on 688 patients qualified for the review. There were 330 patients in LR group and 358 in the OR group. LR takes longer to perform compared with OR. This difference was statistically significant [random effects model: standardized mean difference (SMD) 1.63, 95% CI (1.14-2.12), z = 6.56, P < 0.001]. There was a significant reduction in hospital stay between LR vs OR [random effects model: SMD -1.75, 95% CI (-2.45 to -1.05), z = -4.90, P < 0.001]. There was no statistical difference relating to morbidity, constipation, incontinence or mortality between the two groups.

CONCLUSION

Laparoscopic rectopexy is a safe and effective modality and is comparable to OR, however, there is still a paucity of randomized controlled trials within the literature regarding this subject. Until these trials are conducted, we would advise caution in deriving absolute conclusions.

The Long-term Clinical Efficacy of Biofeedback Therapy for Patients With Constipation or Fecal Incontinence

BACKGROUND/AIMS

There has been a controversy regarding the usefulness of biofeedback therapy for functional constipation or fecal incontinence. This study was performed to investigate the long-term clinical efficacy of biofeedback therapy.

METHODS

Sixty-four patients with constipation or fecal incontinence received biofeedback therapy for 4 weeks. Symptom improvements were evaluated immediately after the completion of biofeedback therapy and during the follow-up period of about 12 to 64 months.

RESULTS

Twenty-five patients in the constipation group [mean age of 52.1 years, 16 men (64.0%)] received 6.2 sessions of biofeedback therapy. Improvement of constipation after the completion of biofeedback therapy was as follows: major response (or improvement) in 3 patients (12.0%), fair in 6 (24.0%), minor in 11 (44.0%) and none in 5 (20.0%). Among 9 patients who showed major or fair improvement, 8 patients (88.9%) maintained the symptom improvement through the long term follow-up periods. Thirty-nine patients in the fecal incontinence group [59.7 years old, 15 men (38.5%)] received 6.8 sessions of biofeedback therapy. Improvement of incontinence after the completion of biofeedback therapy was as follows: major improvement in 6 patients (15.4%), fair in 14 (35.9%), minor in 14 (35.9%), and none in 5 (12.8%). All 11 patients with major or fair improvement maintained the symptom improvement to the end of follow-up periods.

CONCLUSIONS

Symptom improvements after biofeedback therapy were disappointing in both the constipation and incontinence group. However, when the symptom improvements were classified as major or fair, the improvements continued for at least a year.

Transvaginal sacrospinous rectopexy: initial clinical experience

BACKGROUND

There is a wide range of surgical procedures available to treat rectal prolapse that differ in approach as well as in principle. The current perineal approaches available involve mucosal or full thickness resection. There are currently no accepted procedures combining rectal fixation without resection using the perineal approach. We present our initial report of transvaginal sacrospinous rectopexy for the treatment of rectal prolapse.

METHODS

A longitudinal incision was made in the posterior wall of the vagina. The rectum and sacrospinous ligament were identified. Two sutures were placed in the sacrospinous ligament and brought through a piece of Surgisis mesh previously anchored to the anterior surface of the rectum. This was performed bilaterally. These sutures were tied to complete the rectal suspension, and the posterior wall of the vagina was closed.

RESULTS

Transvaginal sacrospinous rectopexy was performed in all seven cases. In the first two cases, a Delorme procedure was performed concurrently. Two patients had rubber band ligation for symptomatic internal hemorrhoids, one patient had a sphincter plication, and one patient had an anal encirclement procedure with Surgisis. Six of the seven patients had concomitant urologic procedures. The average operative time was 163 min, and the average blood loss was 107 mL. None of the cases required conversion to an open procedure. There was one full thickness recurrence at 18 weeks.

CONCLUSION

Transvaginal sacrospinous rectopexy is a safe, minimally invasive, technically feasible technique for the treatment of rectal prolapse.

Laparoscopic management of persistent complete rectal prolapse in children

BACKGROUND

Rectal prolapse is a relatively common condition in children. The multiplicity of surgical approaches used for rectal prolapse indicates that there is no single approach universally accepted and applicable to all cases. The laparoscopic approach promises to become the criterion standard for the management of full-thickness rectal prolapse in children. The aim of this study was to review our experience over the last 5 years and to evaluate the results that can be achieved by using laparoscopy in management of complete rectal prolapse in children.

PATIENTS AND METHODS

Forty patients presented with complete rectal prolapse and fecal incontinence grades (3-4) according to Rintala scale (37 secondary to prolapse and 3 neuropathic) had been operated upon laparoscopically from August 2003 to August 2008. They were subjected to clinical examination, investigations, pre- and postoperative electromyogram activities for external sphincter, puborectalis, and pelvic floor muscles. The pathophysiologic changes for each case was identified and dealt with laparoscopically (laparoscopic suture rectopexy, laparoscopic mesh rectopexy, laparoscopic resection rectopexy, and laparoscopic levatorplasty).

RESULTS

Among the 40 children with complete rectal prolapse, 22 were males and 18 females. Their median age was 9 years (range, 4-14 years). All cases (n = 40) showed a redundant rectosigmoid junction. Additional laxity of the pelvic floor was present in 32, rectoanal intussusception in 27, anterior wall rectoanal intussusception in 3, and rectosacral hernia in 5 cases. All procedures were completed laparoscopically. The median duration of surgery was 60 minutes (range, 50-70 minutes) for suture rectopexy, 90 minutes (range, 60-110 minutes) for mesh rectopexy, 110 minutes (range, 95-160 minutes) for resection rectopexy, and 120 minutes (range, 100-150 minutes) for laparoscopic levatorplasty. No intraoperative complications occurred in this study. Median postoperative hospitalization was 3 days (range, 2-5 days). Electromyogram studies showed statistically significant improvement during rest, minimal volition, and squeezing in all cases except those children with spina bifida and meningomyelocele. The only complications were postoperative constipation and external colonic fistula. Significant improvement of the continence score was achieved in all cases. The average follow-up time was 36 months. There were no recurrences.

CONCLUSION

The use of laparoscopy in the management of complete rectal prolapse is safe, effective, and associated with improved functional outcome. It saved the patients multiple operations and is associated with minimal postoperative pain and short hospital stay.

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.

Laparoscopy for benign colorectal diseases

The applicability of laparoscopy to many complex intraabdominal colorectal procedures continues to expand, and has been shown to be feasible and safe in experienced hands. Data are available on the elderly, rectal prolapse, diverticulitis, Hartman's takedown, small bowel obstruction, Crohn's disease, and ulcerative colitis. Clinically relevant advantages have been clearly demonstrated in selected patient populations. Laparoscopic surgery for benign colorectal disease should be considered in patients suitable for this approach to an abdominal operation.