Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse

Long-term Outcomes After Minimally Invasive Ventral Rectopexy for Rectal Prolapse Using Biological Graft Prosthesis: A 15-Year Retrospective Cohort Study

BACKGROUND

Minimally invasive ventral rectopexy has widely become the preferred prolapse procedure. However, there have been recent concerns regarding the safety of permanent synthetic mesh in the pelvis. Biological grafts have also been commonly used as an alternative prosthesis, but data on their safety and the longevity of the prolapse repair have been lacking.

OBJECTIVE

To assess the short- and long-term safety and efficacy of biological grafts in minimally invasive ventral rectopexy.

DESIGN

Retrospective cohort study using data from a prospectively collected database.

SETTINGS

Single surgeon at a single tertiary hospital in Australia.

PATIENTS

There were 366 patients with minimum 6-month follow-up undergoing minimally invasive ventral rectopexy using a biological graft between January 1, 2008, and October 5, 2023.

MAIN OUTCOME MEASURES

Overall recurrence, complications, and functional outcomes.

RESULTS

A total of 57 patients (15.6%) experienced a recurrence during the study period, with a median follow-up time of 35.5 months (range, 6-183 months). Of these, 17 (4.6%) were full-thickness recurrence. The Kaplan-Meier estimates of the overall 1-, 3-, and 5-year recurrence rates were 2.0%, 6.0%, and 16.0%, respectively. There was no statistically significant difference in recurrence for patients who presented with a full-thickness prolapse compared to those with other indications (16.8% vs 14.2%, p = 0.29). Overall, there were a total of 34 complications that occurred in 29 patients (7.9%). Nineteen patients (5.2%) required a return to theater. There was no reported graft-related complication or long-term pelvic pain. Ninety-eight percent of patients had symptomatic improvement and were satisfied with their outcome.

LIMITATIONS

Retrospective study and generalizability of the results from single surgeon experience. Late recurrences may have been missed.

CONCLUSIONS

Minimally invasive ventral rectopexy using a biological graft is both safe and effective, offering acceptable short- and long-term recurrence rates and overall complications with no graft-related morbidity. See Video Abstract .

RESULTADOS A LARGO PLAZO DESPUS DE LA RECTOPEXIA VENTRAL MNIMAMENTE INVASIVA PARA EL PROLAPSO RECTAL UTILIZANDO PRTESIS DE INJERTO BIOLGICO UN ESTUDIO DE COHORTE RETROSPECTIVO DE AOS

ANTECEDENTES:La rectopexia ventral mínimamente invasiva se ha convertido en gran medida, como el procedimiento preferido para el prolapso. Sin embargo, recientemente ha habido inquietudes con respecto a la seguridad de la malla sintética permanente en la pelvis. Los injertos biológicos también se han utilizado comúnmente como prótesis alterna, pero faltan datos sobre su seguridad y la longevidad de la reparación del prolapso.OBJETIVO:Evaluar la seguridad y eficacia a corto y largo plazo de los injertos biológicos en la rectopexia ventral mínimamente invasiva.DISEÑO:Estudio de cohorte retrospectivo que utiliza datos de una base de datos recopilada prospectivamente.AJUSTE:Un cirujano de hospital terciario en Australia.PACIENTES:366 pacientes con un mínimo de 6 meses de seguimiento sometidos a una rectopexia ventral mínimamente invasiva utilizando un injerto biológico entre el 1 de enero de 2008 y el 5 de octubre de 2023.PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia general, complicaciones y resultados funcionales.RESULTADOS:Un total de 57 pacientes (15,6 %, n = 57) presentaron una recurrencia durante el período de estudio, con un tiempo de seguimiento medio de 35,5 meses (rango, de 6 a 183 meses). De estos, 17 (4,6 %) fueron recurrencias de espesor total. Las estimaciones de Kaplan-Meier de las tasas generales de recurrencia a 1, 3 y 5 años fueron del 2,0 %, 6,0 % y 16,0 %, respectivamente. No hubo una diferencia estadísticamente significativa en la recurrencia para los pacientes que presentaron un prolapso de espesor total en comparación con aquellos con otras indicaciones (16,8 % frente a 14,2 %, p = 0,29). En general, hubo un total de 34 complicaciones que ocurrieron en 29 (7,9 %) pacientes. 19 pacientes (5,2 %) necesitaron regresar al quirófano. No hubo complicaciones relacionadas con el injerto o dolor pélvico a largo plazo. El 98% de los pacientes presentaron una mejoría sintomática y se mostraron satisfechos con el resultado.LIMITACIONES:Estudio retrospectivo y generalización de los resultados a partir de la experiencia de un solo cirujano. Es posible que se hayan pasado inadvertidas las recurrencias tardías.CONCLUSIONES:La rectopexia ventral mínimamente invasiva con un injerto biológico es segura y eficaz, y ofrece tasas de recurrencia aceptables a corto y largo plazo y complicaciones generales sin morbilidad relacionada con el injerto. (Traducción - Dr. Fidel Ruiz Healy ).

Trends for the Surgical Management of Rectal Prolapse in the Elderly: A Contemporary Analysis of the National Quality Improvement Program

BACKGROUND

Traditionally, the management of rectal prolapse in the elderly involved a perineal approach to repair. However, management paradigms have evolved, and the use of the transabdominal approach may be as safe as the perineal approach in elderly patients.

OBJECTIVE

To provide a contemporary analysis of early postoperative outcomes and trends in the surgical management of rectal prolapse.

DESIGN

This was a retrospective review of a large multicenter database.

SETTING

The National Surgical Quality Improvement Program captured data from 702 participating sites.

PATIENTS

All patients aged 70 years or older who underwent surgical repair of rectal prolapse from 2005 to 2022 were included for review.

INTERVENTION

Surgical approach used to treat prolapse is defined as open transabdominal, minimally invasive transabdominal, and perineal.

MAIN OUTCOME MEASURES

Temporal trends in the surgical approach used to treat rectal prolapse and rates of 30-day major and minor complications.

RESULTS

A total of 9664 patients were analyzed who underwent rectal prolapse repair via perineal (72%), minimally invasive (19%), or open approach (9%). Surgical trends demonstrated the proportion of open approaches decreased from a high of 16.5% to 8.1% and that of perineal approaches decreased from 92.9% to 67.0%. In contrast, the proportion of minimally invasive procedures increased from 0.0% to 24.9%. There were no differences in major complication rates among the 3 approaches, but a higher mortality rate was seen for the perineal approach (1.7%) than for the minimally invasive approach (0.5%), and a higher minor complication rate was seen for open (11.1%) than for minimally invasive (5.8%) and perineal (6.0%) approaches.

LIMITATIONS

This was a retrospective database study with limited details regarding surgical procedures and no long-term follow-up data beyond 30 days.

CONCLUSIONS

The minimally invasive approach appears to be the safest repair method and has gained significant popularity in recent years among the elderly population. However, the perineal approach remains the most commonly used approach despite evolving trends. See Video Abstract.

TENDENCIAS EN EL TRATAMIENTO QUIRRGICO DEL PROLAPSO RECTAL EN ANCIANOS UN ANLISIS CONTEMPORNEO DEL PROGRAMA NACIONAL DE MEJORA DE LA CALIDAD

ANTECEDENTES:Tradicionalmente, el tratamiento del prolapso rectal en los ancianos implicaba un abordaje perineal para la reparación. Sin embargo, los paradigmas de tratamiento han evolucionado, y el uso del abordaje transabdominal puede ser tan seguro como el perineal en los ancianos.OBJETIVO:Proporcionar un análisis contemporáneo de los resultados postoperatorios tempranos y las tendencias en el tratamiento quirúrgico del prolapso rectal.DISEÑO:Se trata de una revisión retrospectiva de una gran base de datos multicéntrica.ENTORNO CLINICO:El Programa Nacional de Mejora de la Calidad Quirúrgica recopiló datos de 702 centros participantes.PACIENTES:Se incluyeron para la revisión todos los pacientes ≥ 70 años de edad que se sometieron a reparación quirúrgica de prolapso rectal entre 2005 y 2022.INTERVENCIÓN:Abordaje quirúrgico utilizado para tratar el prolapso, definido como transabdominal abierto, transabdominal mínimamente invasivo y perineal.MEDIDAS DE RESULTADO PRINCIPALES:Tendencias temporales en el abordaje quirúrgico utilizado para tratar el prolapso rectal y tasas de complicaciones mayores y menores a 30 días.RESULTADOS:Se analizó un total de 9.664 pacientes sometidos a reparación de prolapso rectal mediante abordaje perineal (72%), mínimamente invasivo (19%) o abierto (9%). Las tendencias quirúrgicas demostraron que la proporción de abordaje abierto utilizado disminuyó de un máximo del 16,5% al 8,1%, y el abordaje perineal disminuyó del 92,9% al 67,0%. En cambio, la proporción de procedimientos mínimamente invasivos aumentó del 0,0% al 24,9%. No hubo diferencias en las tasas de complicaciones mayores entre los 3 abordajes, pero se observó una mayor tasa de mortalidad en el abordaje perineal (1,7%) que en el mínimamente invasivo (0,5%), y una mayor tasa de complicaciones menores en el abierto (11,1%) que en el mínimamente invasivo (5,8%) y el perineal (6,0%).LIMITACIONES:Este fue un estudio retrospectivo de base de datos con detalles limitados con respecto a los procedimientos quirúrgicos y sin datos de seguimiento a largo plazo más allá de 30 días.CONCLUSIONES:El abordaje mínimamente invasivo parece ser la reparación más segura y ha ganado una popularidad significativa en los últimos años en la población anciana. Sin embargo, el abordaje perineal sigue siendo el más utilizado a pesar de la evolución de las tendencias. (Traducción- Dr. Francisco M. Abarca-Rendon).

The Predictive Risk Factor of Postoperative Recurrence Following Altemeier's and Delorme's Procedures for Full-thickness Rectal Prolapse: An Analysis of 127 Japanese Patients in a Single Institution

Objectives

We aimed to identify risk factors for postoperative recurrence (PR) after Altemeier's and Delorme's procedures for full-thickness rectal prolapse (FTRP).

Methods

We enrolled 127 patients who underwent Altemeier's and Delorme's procedures for FTRP between April 2008 and September 2021. We divided the 127 patients into recurrence and non-recurrence groups and conducted univariate and multivariate analyses. We used six independent variables: age, body mass index (BMI), history of surgical repair for FTRP, coexistence of prolapse in other organs, poor fixation of the rectum on defecography before surgery, length of the prolapsed rectum, and type of surgical procedure (Altemeier's or Delorme's procedures).

Results

PR developed in 51 (40.1%) patients during a mean follow-up period of 453 (range, 9-3616) days. Comparing the recurrence group (n=51) with the non-recurrence group (n=76), significant difference was observed regarding the coexistence of prolapse in other organs (p=0.017) in the univariate analysis. In the multivariate analysis, significant differences were observed in BMI (OR 1.18, 95% CI 1.030-1.350, p=0.020), coexistence of prolapse in other organs (OR 3.38, 95% CI 1.200-9.500, p=0.021), length of the prolapsed rectum (OR 1.030, 95% CI 1.010-1.060, p=0.015), poor fixity of the rectum on defecography (OR 0.332, 95% CI 0.129-0.852, p=0.022), and surgical procedures (OR 0.192, 95% CI 0.064-0.573, p=0.003).

Conclusions

The study suggested that increasing BMI, coexistence of prolapse in other organs, length of the prolapsed rectum, poor fixation of the rectum on defecography before surgery, and types of surgical procedure might be risk factors of PR after perineal surgery for FTRP.

A network meta-analysis of surgical treatments of complete rectal prolapse

PURPOSE

Surgical treatment of complete rectal prolapse can be undertaken via an abdominal or a perineal approach. The present network meta-analysis aimed to compare the outcomes of different abdominal and perineal procedures for rectal prolapse in terms of recurrence, complications, and improvement in fecal incontinence (FI).

METHODS

A PRISMA-compliant systematic review of PubMed, Scopus, and Web of Science was conducted. Randomized clinical trials comparing two or more procedures for the treatment of complete rectal prolapse were included. The risk of bias was assessed using the ROB-2 tool. The main outcomes were recurrence of full-thickness rectal prolapse, complications, operation time, and improvement in FI.

RESULTS

Nine randomized controlled trials with 728 patients were included. The follow-up ranged between 12 and 47 months. Posterior mesh rectopexy had significantly lower odds of recurrence than did the Altemeier procedure (logOR, - 12.75;  95% credible intervals, - 40.91, - 1.75), Delorme procedure (- 13.10; - 41.26, - 2.09), resection rectopexy (- 11.98; - 41.36, - 0.19), sponge rectopexy (- 13.19; - 42.87, - 0.54), and sutured rectopexy (- 13.12; - 42.58, - 1.50), but similar odds to ventral mesh rectopexy (- 12.09; - 41.7, 0.03). Differences among the procedures in complications, operation time, and improvement in FI were not significant.

CONCLUSIONS

Posterior mesh rectopexy ranked best with the lowest recurrence while perineal procedures ranked worst with the highest recurrence rates.

A comparative study between transanal and transabdominal approaches in treatment of complete rectal prolapse

Formulating clear guidelines for the most reliable treatment methods for complete rectal prolapse appears challenging. The authors designed this study to compare the results according to the approaches for female complete rectal prolapse and to suggest a more effective method. The transanal and abdominal groups showed differences in operating time, hospital stay, and recurrence rate. However, both groups demonstrated improvement in postoperative functional evaluation.

PURPOSE

There is a wide variety of surgical methods to treat rectal prolapse; however, to date, no clear agreement exists regarding the most effective surgical method. This study was designed to compare the results according to the surgical approach for complete rectal prolapse in women.

METHODS

This study was conducted from March 2016 to February 2021 on female patients with rectal prolapse who underwent surgery. First, all patients were classified into mucosal and complete layer groups to confirm the difference in results between the two groups, and only complete layer prolapse patients were divided into transanal and abdominal approaches to compare parameters and functional outcomes in each group.

RESULTS

A total of 180 patients were included, with an average age of 71.7 years and 102 complete prolapses. The complete layer group was found to have more abdominal access, longer operating time, and higher recurrence rates compared to the mucosal layer group. (p<0.001) When targeting only the complete layer patients, there were 65 patients with the transanal and 37 with the abdominal (laparoscopic) approaches. The abdominal approach group had a longer operating time and hospital stay (p<0.001, respectively) and lower recurrence rate than the transanal group (transanal vs. abdominal, 38% vs. 10.8%, p=0.003), while the Wexner constipation and incontinence scores showed improved results in both groups.

CONCLUSION

Although operating time and hospitalization period were shorter in the transanal group, laparoscopic abdominal surgery is a procedure that can reduce the recurrent rate for complete rectal prolapse.

Comparison of abdominal and perineal approach for recurrent rectal prolapse

Purpose

Rectal prolapse is a benign disease in which the rectum protrudes below the anus. Although many studies have been reported on the treatment of primary rectal prolapse for many years, there is a lack of treatment or clinical research results on recurrent rectal prolapse. This study aimed to evaluate the outcomes of surgical approaches for recurrent rectal prolapse.

Methods

We studied patients who underwent surgical treatment for recurrent rectal prolapse disease from March 2016 to February 2021. We analyzed the previous operation methods in patients with recurrent rectal prolapse, as well as the operation time, complication rate, hospital stay, and re-recurrence rates in the perineal and abdominal approach groups.

Results

Out of a total of 239 patients, 41 patients who underwent surgery for recurrent rectal prolapse were retrospectively enrolled. Recurrent rectal prolapses were surgically treated either by the perineal approach (n = 25, 61.0%) or by the abdominal approach (n = 16, 39.0%). The operation times were significantly longer in the abdominal approach than in the perineal approach (98.44 minutes vs. 58.00 minutes, P = 0.001). Hospital stay was significantly longer in the abdominal approach than in the perineal approach (9.19 days vs. 6.00 days, P = 0.012). Re-recurrence rate after repeat repair was not significantly different between the 2 groups (P = 0.777).

Conclusion

Although the perineal approach shortened the operation time and hospital stay, there were no significant differences between the 2 groups in postoperative complications and re-recurrence rate. Both approaches can be good surgical options for the treatment of recurrent rectal prolapse.

Perioperative Supplemental Oxygen and Postoperative Copeptin Concentrations in Cardiac-Risk Patients Undergoing Major Abdominal Surgery-A Secondary Analysis of a Randomized Clinical Trial

Noncardiac surgery is associated with hemodynamic perturbations, fluid shifts and hypoxic events, causing stress responses. Copeptin is used to assess endogenous stress and predict myocardial injury. Myocardial injury is common after noncardiac surgery, and is often caused by myocardial oxygen demand-and-supply mismatch. In this secondary analysis, we included 173 patients at risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. Patients were randomly assigned to receive 80% or 30% oxygen throughout surgery and the first two postoperative hours. We evaluated the effect of supplemental oxygen on postoperative Copeptin concentrations. Copeptin concentrations were measured preoperatively, within two hours after surgery, on the first and third postoperative days. In total, 85 patients received 0.8 FiO2, and 88 patients received 0.3 FiO2. There was no significant difference in postoperative Copeptin concentrations between both study groups (p = 0.446). Copeptin increased significantly within two hours after surgery, compared with baseline in the overall study population (estimated effect: −241.7 pmol·L−1; 95% CI −264.4, −219.1; p < 0.001). Supplemental oxygen did not significantly attenuate postoperative Copeptin release. Copeptin concentrations showed a more immediate postoperative increase compared with previously established biomarkers. Nevertheless, Copeptin concentrations did not surpass Troponin T in early determination of patients at risk for developing myocardial injury after noncardiac surgery.

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.

Update on Robotic Rectal Prolapse Treatment

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

Surgical Techniques for Rectal Prolapse

Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes.

A meta-epidemiological study of bias in randomized clinical trials of open and laparoscopic surgery

BACKGROUND

Blinding, random sequence generation, and allocation concealment are established strategies to minimize bias in RCTs. Meta-epidemiological studies of drug trials have demonstrated exaggerated treatment effects in RCTs where such methods were not employed. As blinding is more difficult in surgical trials it is important to determine whether this applies to them. The study aimed to investigate this using systematic meta-epidemiological methods.

METHOD

The Cochrane Database of Systematic Reviews was searched for systematic reviews of RCTs that compared laparoscopic and open abdominal surgical procedures. Each review was then scrutinized to determine whether at least one of the included trials was blinded. Eligible reviews were updated and individual RCTs retrieved. Extracted data included the primary outcomes of interest (length of stay and complications), secondary outcomes and a risk of bias assessment. A multistep meta-regression analysis was then performed to obtain an overall difference in the reported outcome differences between trials that employed each bias-minimization strategy, and those that did not.

RESULTS

Some 316 RCTs were included, reporting on eight different procedures. Patient-blinded RCTs reported a smaller difference in length of stay between laparoscopic and open groups (difference of standardized mean differences -0·36 (95 per cent c.i. -0·73 to 0·00)) and complications (ratio of odds ratios 0·76 (95 per cent c.i. 0·61 to 0·93)). Blinding of postoperative carers and outcome assessors had similar effects.

CONCLUSION

Lack of blinding significantly altered the treatment effect estimates of RCTs comparing laparoscopic and open surgery. Blinding should be implemented in surgical RCTs where possible to avoid systematic bias.

Laparoscopic Sutureless Rectopexy Using a Fixation Device for Complete Rectal Prolapse

BACKGROUND

Complete rectal prolapse (CRP) commonly affects the daily life of older people and has no established operative treatment approach. We describe our simple method of laparoscopic, sutureless rectopexy, involving rectal mobilization (along with its peritoneum bilaterally) and fixation to the sacral promontory using a fixation device. We also present an analysis of short-term outcomes in patients treated using this procedure.

MATERIALS AND METHODS

We retrospectively evaluated 62 patients with CRP, who underwent a laparoscopic rectopexy via tack fixation, between 2004 and 2017. The peritoneum was widely attached near the site of peritoneal reflection, as in rectal cancer surgery. The hypogastric nerve was carefully detached from the front of the sacrum. Keeping the nerve intact, we lifted and mobilized the dissected rectum cranially towards the promontory, and the rectal peritoneum was affixed to the sacrum by applying 2 to 3 fixed tacks bilaterally, using a fixation device.

RESULTS

The median age of the study group was 80 (10 to 91) years. All procedures were successful without serious intraoperative complications; only 1 patient required conversion to open surgery. Median values for operative duration, intraoperative blood loss, and postoperative period of hospitalization were 177 (125 to 441) minutes, 5 (0 to 275) mL, and 7 (3 to 17) days, respectively. Only 6 (9.7%) patients experienced recurrence during the follow-up period.

CONCLUSION

Laparoscopic tacking rectopexy performed using a fixation device for repairing CRP is a simple, safe, and sutureless procedure with no severe complications or mortality.

Laparoscopic Versus Open Rectopexy for Rectal Prolapse: A Randomized Controlled Trial

Introduction

Most of the patients with rectal prolapse complain of fecal incontinence followed by constipation. Surgery is the only definitive treatment option for rectal prolapse. There are two approaches: either transanal/perineal or transabdominal. The abdominal procedures can be done in the open laparotomy method or laparoscopically. Suture rectopexy is a very old and popular method of treating rectal prolapse. Nowadays, rectopexy by laparoscopic approach is considered the gold standard treatment for rectal prolapse. The study has been conducted to compare both the procedures and their outcomes in terms of conditions associated with rectal prolapse.

Methods

All consecutive patients with full-thickness rectal prolapse who had attended the surgery outpatient department were included in the study. The patients had undergone either open suture rectopexy or laparoscopic rectopexy after randomization. Assessment of postoperative pain, mean days of hospital stay, constipation, and incontinence score along with operative time, recurrence within six months of follow-up, and time to resume bowel activity were done. The patients were followed up for 18 months at regular intervals.

Results

A total of 58 patients were included in the study: 27 in the open group and 31 in the laparoscopic group. The operative time was 102 minutes versus 129 minutes (p=0.0001) in the open and laparoscopic groups, respectively. The laparoscopic group had an earlier resumption of bowel activity (3.1 days vs. 1.4 days [p=0.0001]); fewer days of hospital stay (6.8 days vs. 2.5 days [p=0.0001]), less postoperative pain (mean visual analogue scale score for pain on postoperative day one 4.0 versus 3.1 [p=0.0035] and on postoperative day two 3.8 versus 2.2 [p=0.0001]). There was no significant difference in postoperative constipation score and incontinence score between the two groups.

Conclusion

Laparoscopic rectopexy results in lesser postoperative pain, lesser hospital stay, and better patient satisfaction than open rectopexy.

Surgical management of the rectocele - An update

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

Three years prospective clinical and radiologic follow-up of laparoscopic sacrocolpoperineopexy

BACKGROUND

When Rectocele is part of a complex pelvic organ prolapse, a full repair is recommended. The aim of this study was to evaluate the clinical and radiological results after laparoscopic surgery in patients with symptomatic rectocele and III/IV stage vaginal vault prolapse METHODS: This is a prospective cohort study of women with symptomatic rectoceles and middle compartment prolapse operated on between 2013 and 2015, who underwent a laparoscopic sacrocolpoperineopexy with synthetic Y mesh attached to puborectalis muscles, the anterior and posterior vagina wall and the sacrum. The clinical outcomes measured were symptoms of prolapse, obstructive defecation syndrome and quality of life. Radiological outcomes were distance of the vaginal vault below pubococcigeal line and depth of rectovaginal wall protrusion in dynamic pelvic resonance.

RESULTS

33 patients were included. 32 of them remained asymptomatic after a three years follow-up. Significant differences were shown in the obstructed defecation score and quality of life after 6, 12 and 36 months compared to preoperatively. No differences were identified when the postoperative results were compared. Significant differences were shown in preoperative vaginal vault prolapse (3.2 cms ± 0.8 SD below the pubococcigeal Line) and rectocele size, compared with 1 and 3 years after surgery. There were no significant differences in vaginal vault prolapse when compared after 1 and 3 years. When rectocele size after 1 and 3 years was compared, significant differences were shown, but only one clinical recurrence (3%) was identified after a mean follow-up of 47 months.

CONCLUSIONS

Laparoscopic sacrocolpoperineopexy in patients with symptomatic rectocele and III/IV vaginal vault prolapse solves the constipation and obstructed defecation with an excellent quality of life and low clinical recurrences. Radiological deterioration, especially in rectocele size, was identified in the mid-term follow-up without clinical significance.

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

Abdominal versus Perineal Approach for Treatment of Rectal Prolapse: Comparable Safety in a Propensity-matched Cohort

Abdominal operations for rectal prolapse are associated with lower recurrence rates than perineal procedures but presumed higher morbidity. Therefore, perineal procedures are recommended for patients deemed unfit for abdominal repair. Consequently, bias confounds retrospective comparisons of the two approaches. To clarify the impact of operative approach on outcomes, we analyzed abdominal and perineal procedures in a propensity score-matched analysis. We selected patients undergoing surgery for rectal prolapse from the American College of Surgeons National Surgical Quality Improvement Program data set from 2005 to 2010. We grouped procedures as abdominal or perineal. We identified preoperative variables predictive of complications and regressed against operative approach. The resulting propensity score was used to select a matched cohort with similar clinical risk. We identified 2188 patients (848 abdominal [38.8%]; 1340 perineal [61.2%]). Patients undergoing the perineal approach had higher rates of most risk variables. Propensity matching resulted in 563 matched pairs (1126 patients) with similar clinical risk. In this matched cohort, no significant difference was found in the rate of any complication between the operative approaches; mortality was 0.9 per cent in each group ( P = 1.0). Relative risk for major morbidity after abdominal approach was 1.39 (95% confidence interval, 0.92 to 2.10; P = 0.15). Although many patients with rectal prolapse are high risk for abdominal surgery, our study indicates that many patients treated by perineal repair could be safely treated with a more durable operation.

Usefulness of laparoscopic posterior rectopexy for complete rectal prolapse: A cohort study

BACKGROUND

Transabdominal rectopexy for complete rectal prolapse reportedly yields more definitive results than transperineal surgery. Recently, minimally invasive laparoscopic rectopexy has become a popular treatment option for patients with rectal prolapse. Herein, we describe our surgical procedure for correction of rectal prolapse. We further aimed to perform a comparative assessment between perioperative outcomes achieved with open and laparoscopic applications of this technique.

MATERIALS AND METHODS

In this cohort study, 65 patients underwent posterior rectopexy (laparoscopic, 50; open, 15) between April 2008 and December 2015. The basic procedure consisted of posterior rectopexy using mesh fixation (modified Wells' method). We assessed and compared perioperative outcomes (duration of surgery and hospitalization, complication rates, blood-loss, degree of fecal incontinence) of laparoscopic and open rectopexy. Furthermore, pre- and post-operative urinary incontinence was measured (using pad test, questionnaire) and compared to determine the effects of the procedure on pelvic organ function. A p-value <0.05 indicated statistical significance.

RESULTS

The mean operative time of the laparoscopic and open procedures was 127 and 83.6 min, respectively. The amount of blood-loss was negligible and 77 (range, 18-200) g with the laparoscopic and open approaches, respectively. The mean duration of hospitalization was 4.2 and 7.2 days for the former and latter procedures, respectively (p < 0.05). Rectal prolapse and fecal incontinence (evaluated using Wexner's score) diminished in all patients. Urinary incontinence also decreased postoperatively. There were no recurrences of rectal prolapse.

CONCLUSION

Laparoscopic rectopexy can be safely performed in older patients to achieve early postoperative ambulation and significantly shorten the hospital-stay. It may therefore be considered an effective treatment for complete rectal prolapse and urinary dysfunction.

Ventral rectopexy with biological mesh for recurrent disorders of the posterior pelvic organ compartment

PURPOSE

Recurrent prolapse of the posterior pelvic organ compartment presents a management challenge, with the best surgical procedure remaining unclear. We present functional outcome and patient satisfaction after laparoscopic and robotic ventral mesh rectopexy (VMR) with biological mesh in patients with recurrence.

METHODS

We analyzed data from 30 patients with recurrent posterior pelvic organ prolapse who underwent VMR with biological mesh from August 2012 to January 2018. Data included patient demographics and intra- and postoperative findings; functional outcome as assessed by Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), and Cleveland Clinic Incontinence Score (CCIS); and patient satisfaction.

RESULTS

CCCS, CCIS, and ODS were significantly improved at 6-12 months postoperatively and at last follow-up. Patient satisfaction (visual analog scale [VAS] 6.7 [0 to 10]), subjective symptoms (+ 3.4 [scale - 5 to + 5]), and quality of life improvement (+ 3.0 [scale from - 5 to + 5]) were high at last follow-up. The rates of morbidity and major complications were 13% and 3%, respectively. There were no mesh-related complications or deaths. Difference in type of previous surgery (abdominal or transanal/perineal) had no significant effect on results.

CONCLUSIONS

VMR with biological mesh is a safe and effective option for patients with recurrent posterior pelvic organ prolapse. It reduces functional symptoms, has a low complication rate, and promotes patient satisfaction.

Rectal-prolapse repair in men is safe, but outcomes are not well understood

Introduction

Rectal prolapse is a condition that occurs infrequently in men and there is little literature guiding treatment in this population. The purpose of this study was to evaluate the surgical approach and outcomes of rectal-prolapse repair in men.

Methods

A retrospective multicenter review was conducted of consecutive men who underwent rectal-prolapse repair between 2004 and 2014. Surgical approaches and outcomes, including erectile function and fecal continence, were evaluated.

Results

During the study period, 58 men underwent rectal-prolapse repair and the mean age of repair was 52.7 ± 24.1 years. The mean follow-up was 13.2 months (range, 0.5–117 months). The majority of patients underwent endoscopic evaluation (78%), but few patients underwent anal manometry (16%), defecography (9%) or ultrasound (3%). Ten patients (17%) underwent biofeedback/pelvic-floor physical therapy prior to repair. Nineteen patients (33%) underwent a perineal approach (most were perineal proctosigmoidectomy). Thirty-nine patients (67%) underwent repair using an abdominal approach (all were suture rectopexy) and, of these, 77% were completed using a minimally invasive technique. The overall complication rate was 26% including urinary retention (16%), which was more common in patients undergoing the perineal approach (32% vs. 8%, P = 0.028), urinary-tract infection (7%) and wound infection (3%). The overall recurrence rate was 9%, with no difference between abdominal and perineal approaches. Information on sexual function was missing in the majority of patients  both before and after surgery (76% and 78%, respectively).

Conclusion

 Rectal-prolapse repair in men is safe and has a low recurrence rate; however, sexual function was poorly recorded across all institutions. Further studies are needed to evaluate to best approach to and functional outcomes of rectal-prolapse repair in men.

Clinical Outcome and Surgical Technique of Laparoscopic Posterior Rectopexy Using the Mesh With Anti-adhesion Coating

We herein present an innovative technique of laparoscopic posterior mesh rectopexy (LPMR) for full-thickness rectal prolapse and report the clinical outcomes in our institution. Ten consecutive patients who were treated with our latest LPMR technique using mesh with an anti-adhesion coating from June 2014 to May 2017 were retrospectively analyzed. All patients were women with a mean age of 63.6 years (range, 39 to 82 y). The median operative time and blood loss volume were 197.5 minutes (range, 156 to 285 min) and 0 mL (range, 0 to 152 mL), respectively. No perioperative complications occurred, including surgical site infection, pneumonia, urinary dysfunction, and intestinal obstruction. The median follow-up duration was 768 days (range, 396 to 1150 d). During the follow-up, the cumulative incidence of full-thickness rectal prolapse and any mesh-related complications was 0. It may be possible to eliminate retroperitoneal closure using a mesh with an anti-adhesion coating. Our LPMR technique appears safe and acceptable.

Getting to the bottom of treatment of rectal prolapse in the elderly: Analysis of the National Surgical Quality Improvement Program (NSQIP)

BACKGROUND

Many approaches to treat rectal prolapse exists, yet little is known regarding their safety in the elderly.

METHOD

NSQIP (2008-2014) was queried to identify patients ≥ 70 years who underwent open rectopexy (OR), laparoscopic rectopexy (LR) and perineal rectosigmoidectomy (PR). Patients were selected using NSQIP's estimated probability of morbidity of ≥50^th percentile. Outcomes were 30-day mortality and a composite: mortality, septic shock and organ space abscess and fascial dehiscence.

RESULTS

Overall, 1361 patients underwent OR(18%), LR(15%) and PR(67%) with no difference in outcomes among 3 approaches. After adjustment of other factors, the composite was associated with PR [OR 2.5, CI 1.1, 5.7] and not with older age [OR 1.3, (CI) 0.7, 2.4]. From 2008 to 2014, LR increased from 11% to 19%; and PR decreased from 75% to 72%.

CONCLUSIONS

All 3 surgical approaches carry low morbidity among the sick, elderly. PR remains the predominant approach nationally. A paradigm shift accepting the safety of abdominal approaches is needed. There should also be less focus on age in the decision-making process of surgical treatment.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Laparoscopic Ventral Mesh Rectopexy: Functional Outcomes after Surgery

Aims  Rectal prolapse is a debilitating and unpleasant condition adversely affecting the quality of life. Laparoscopic ventral mesh rectopexy (LVMR) is recognized as one of the treatment options. The aim of this study was to evaluate the functional outcomes after a standardized LVMR.

Methods  A cohort of patients who underwent LVMR from 2011 to 2015 were contacted and asked to fill questionnaires about their symptoms before and after the surgery. Three questionnaires based on measurement of Wexner fecal incontinence (WFI), obstructive defecation syndrome (ODS), and Birmingham Bowel and Urinary Symptom (BBUS) scores were used to assess the changes in postoperative functional outcomes. Some additional questions were also added to further assess bowel dysfunction.

Results  There were 58 female patients with a mean age of 62.74 ± 15.20 (26–86) years in this cohort. About 70% of the patients participated in the study and returned the filled questionnaires. There was a significant overall improvement across all three scores (WFI: p  = 0.001, ODS: p  = 0.001, and BBUS: p  = 0.001). Some individual components in the scoring systems did not improve to patient's satisfaction. No perioperative complication or conversion to an open procedure was reported in this study. Three recurrences were seen in the redo cases.

Conclusion  LVMR is a promising way of dealing with rectal prolapse. A careful patient selection, appropriate preoperative workup, and a meticulous surgical technique undoubtedly transform the postoperative outcomes.

Trends in the treatment of rectal prolapse: a population analysis

PURPOSE

Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI).

METHODS

This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive.

RESULTS

There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p < 0.001), with no change in the mean age of patients over time (p = 0.229). The application of a laparoscopic approach increased over time (p = 0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1 ± 17.3 versus 75.2 ± 15.5 years, p < 0.001) despite having a similar Charlson Comorbidity Index (p = 0.097). The mortality rate for elective repair was 0.2%.

CONCLUSIONS

Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme's procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Ventral rectopexy with biological mesh: short-term functional results

PURPOSE

Ventral mesh rectopexy (VMR) is an established, minimally invasive, nerve-sparing procedure for the treatment of various symptomatic morphological changes in the posterior pelvic compartment. We present the short-term functional outcome and patient satisfaction after laparoscopic and robotic VMR with biological mesh.

METHODS

We analyzed data from 123 patients who underwent laparoscopic ventral mesh rectopexy (LVMR) or robotic ventral mesh rectopexy (RVMR) from August 2012 to January 2017. Included in these data were patient demographics, intra- and postoperative findings, Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), Cleveland Clinic Incontinence Score (CCIS), and patient satisfaction as measured by visual analog scale (0-10).

RESULTS

Improvements in CCCS, CCIS, and ODS were statistically significant at 6 and 12 months (p < 0.001). Patient satisfaction was excellent at 6 and 12 months (8.2/10 and 8.3/10, respectively). The overall complication rate was 14%, with a major complication rate of 2%. No mesh-related complications were observed. The need for surgical re-intervention because of relapse, symptom persistence or recurrence, or new symptoms was 3%. Outcome appears to be similar between LVMR and RVMR.

CONCLUSIONS

Both LVMR and RVMR with biological mesh are safe and effective in reducing symptoms, as measured by CCCS, CCIS, and ODS, and patient satisfaction is high.

Robotic Rectopexy for Rectal Prolapse in Pediatric Patients

Rectal prolapse is the protrusion of the rectum out of the anus. Surgical correction can be accomplished via open and minimally invasive abdominal approaches, as well as from the perineum. Robotic rectopexy is an option for minimally invasive treatment of rectal prolapse. There are no studies that have established the efficacy of robotic rectopexy for rectal prolapse in the pediatric population. The aim of this study was to review the experience of robotic rectopexy at a single institution. This is a retrospective review of our pediatric robotic rectopexy experience from 2012 to 2015. Information was obtained from chart review of both operative notes and clinic visits. Four pediatric patients underwent a robotic rectopexy for rectal prolapse from 2012 to 2015. Three patients were male and one was female. The mean age was 15.5 years (range 13–17). Two patients had rectal prolapse with chronic constipation. One patient had rectal prolapse from Ehlers Danlos syndrome, and the last had rectal prolapse after imperforate anus repair as an infant. Three patients received a bowel preparation. Three patients were completed robotically, and one patient required conversion to an open procedure. The average postoperative length of stay was 3.25 days (range 2–4). There were no episodes of recurrent prolapse. Two patients had improvement in constipation, one had no improvement, and one had no documented change. Average postoperative follow-up was 11.5 months (range 3–29). This study was a review of one institution's experience with pediatric robotic rectopexy. With short-term follow-up, there was no recurrence of prolapse. Robotic rectopexy provided a safe, reliable, and short-term resolution of rectal prolapse in pediatric patients.

Knot free technique for Laparoscopic Ventral Mesh Rectopexy

AIM

The aim of our study was to describe and assess a new method of mesh fixation using clips in Laparoscopic Ventral Mesh Rectopexy (VMR). This technique avoids knots while suturing in pelvis and saves time.

METHOD

A systematic search of the literature (PUBMED, EMBASE) was done to find out alternate ways to fix the mesh over the anterior surface of rectum. This technique has not been used before. We performed five operations using this technique. Indication for surgery was full thickness rectal prolapse in all of them. Majority of patients were female (four) and one was male with age range of 32-69 years. Two patients had previous abdominal surgery. Laparoscopic access included four ports and 30° scope in all cases. Biological mesh was used in 4 cases and synthetic in remaining one. Instead of using normal intra-corporeal or extra-corporeal suturing, a novel technique was used to secure the Ethibond 2/0 suture using endo clip. The mesh fixation to sacral promontory was done with tacker.

RESULTS

These patients were prospectively followed up to assess the effectiveness of repair and to assess for the recurrence. The median follow up so far is 8 months (range 5-11). None of the patients had any major complication. No patient has reported recurrence either.

CONCLUSION

Our study with limitations of small group and relatively shorter follow up has proven to be a safe technique. This technique has a potential of replacing intra or extracorporeal knot with endo clips and requires less time compared to conventional suturing. It also advantage of having a minimal learning curve.

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.

The use of laparoscopic rectopexy to manage rectal prolapse with Pseudo-Meigs' syndrome in a 64-year-old female: a case report

We report a rare case of rectal prolapse with Pseudo‐Meigs’ syndrome in which laparoscopic bilateral oophorectomy and rectopexy were performed simultaneously and resulted in improved quality of life due to the loss of ascites and the repair of rectal prolapse. Laparoscopic surgery is feasible for rectal prolapse with Pseudo‐Meigs’ syndrome.

Incidence and surgical treatment of synthetic mesh-related infectious complications after laparoscopic ventral rectopexy

BACKGROUND

Prosthetic-related infection and erosion occurring after a laparoscopic ventral rectopexy (LVR) are rare complications, and their importance is often underestimated. The aim of this study was to compare the incidence rate and surgical management of these complications in LVR patients with polyester (PE) or polypropylene (PP) prostheses.

METHODS

From January 2004 to June 2012, 149 patients underwent LVR with PE and 176 underwent LVR with PP. Surgical management and rate of infectious and erosive prosthesis-related complications, depending on the type of prosthesis, were described and compared. Functional results after complications were assessed.

RESULTS

Five patients from the PE prosthesis group (3.3 %), compared with two patients from the PP prosthesis group (1.1 %), experienced prosthesis-related infection or erosion (p = 0.16). The rate of erosion alone was 3.3 % in patients with a PE prosthesis, and 0.55 % in patients with a PP prosthesis (p = 0.06). The average time until clinical diagnosis of a prosthesis-related complication was identical for both groups: 31 months (range 3-62 months). All patients underwent surgical removal of the prosthesis: For the five patients from the PE group, complete removal was performed by laparoscopy associated with a transanal procedure. For the two patients in the PP mesh group, laparoscopy was ineffective in removing the mesh which was partially removed through a subsequent transanal procedure. None of the patients had a protective stoma, and in all patients the complication had resolved 12 months after removal. Only one patient had worsening functional symptoms (fecal incontinence) after prosthesis removal.

CONCLUSIONS

When a prosthesis-related infection or erosion occurs, treatment consists in the surgical removal of the prosthesis by laparoscopy/and/or a transanal procedure. Functional symptoms do not routinely recur after prosthesis removal.

Day case robotic ventral rectopexy compared with day case laparoscopic ventral rectopexy: a prospective study

BACKGROUND

Ventral rectopexy to the promontory has become one of the most strongly advocated surgical treatments for patients with full-thickness rectal prolapse and deep enterocele. Despite its challenges, laparoscopic ventral rectopexy with or without robotic assistance for selected patients can be performed with relatively minimal patient trauma thus creating the potential for same-day discharge. The aim of this prospective case-controlled study was to assess the feasibility, safety, and cost of day case robotic ventral rectopexy compared with routine day case laparoscopic ventral rectopexy.

METHODS

Between February 28, 2014 and March 3, 2015, 20 consecutive patients underwent day case laparoscopic ventral rectopexy for total rectal prolapse or deep enterocele at Michallon University Hospital, Grenoble. Patients were selected for day case surgery on the basis of motivation, favorable social circumstances, and general fitness. One out of every two patients underwent the robotic procedure (n = 10). Demographics, technical results, and costs were compared between both groups.

RESULTS

Patients from both groups were comparable in terms of demographics and technical results. Patients operated on with the robot had significantly less pain (p = 0.045). Robotic rectopexy was associated with longer median operative time (94 vs 52.5 min, p < 0.001) and higher costs (9088 vs 3729 euros per procedure, p < 0.001) than laparoscopic rectopexy.

CONCLUSIONS

Day case robotic ventral rectopexy is feasible and safe, but results in longer operative time and higher costs than classical laparoscopic ventral rectopexy for full-thickness rectal prolapse and enterocele.

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.

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

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

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 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.

[Current evidence for laparoscopic surgery of colonic cancer]

BACKGROUND

The development of modern videoendoscopy enables surgeons to perform laparoscopic resection of colonic cancer.

AIM

This manuscript evaluated the literature concerning clinically relevant differences in the short and long-term course after laparoscopic or conventional resection of colonic cancer.

METHODS

An investigation of meta-analyses from randomized controlled clinical trials comparing laparoscopic and conventional surgery for colonic cancer was carried out.

RESULTS

The incidence of intraoperative complications was higher during laparoscopic surgery, the duration of surgery was increased and blood loss was less when compared to open surgery. Overall morbidity and the incidence of surgical complications were decreased after laparoscopic surgery. General morbidity and mortality were not different after laparoscopic or open resection of colonic cancer. Duration of hospital stay was shorter but was also associated with the type of perioperative care (i.e. traditional or enhanced recovery). Following minimally invasive or conventional resection, the incidence of tumor recurrence (local and distant) and the duration of survival (overall and disease-free) showed no differences. Wound implantations were rare after both operative techniques but with a tendency to occur more often after laparoscopic than open resection.

CONCLUSION

Laparoscopic resection of colonic cancer has clinically relevant short-term benefits for the patients and long-term results are not different from open colectomy. However, most of the patients included in randomized controlled trials underwent right or left colectomy and sigmoid or rectosigmoid resections. Data with a high level of evidence concerning carcinomas of the flexures or the transverse colon do not exist. Suitable patients with colonic cancer should undergo laparoscopic resection by experienced surgeons.

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

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

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

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

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

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

Exploiting the critical perioperative period to improve long-term cancer outcomes

Evidence suggests that the perioperative period and the excision of the primary tumour can promote the development of metastases—the main cause of cancer-related mortality. This Review first presents the assertion that the perioperative timeframe is pivotal in determining long-term cancer outcomes, disproportionally to its short duration (days to weeks). We then analyse the various aspects of surgery, and their consequent paracrine and neuroendocrine responses, which could facilitate the metastatic process by directly affecting malignant tissues, and/or through indirect pathways, such as immunological perturbations. We address the influences of surgery-related anxiety and stress, nutritional status, anaesthetics and analgesics, hypothermia, blood transfusion, tissue damage, and levels of sex hormones, and point at some as probable deleterious factors. Through understanding these processes and reviewing empirical evidence, we provide suggestions for potential new perioperative approaches and interventions aimed at attenuating deleterious processes and ultimately improving treatment outcomes. Specifically, we highlight excess perioperative release of catecholamines and prostaglandins as key deleterious mediators of surgery, and we recommend blockade of these responses during the perioperative period, as well as other low-risk, low-cost interventions. The measures described in this Review could transform the perioperative timeframe from a prominent facilitator of metastatic progression, to a window of opportunity for arresting and/or eliminating residual disease, potentially improving long-term survival rates in patients with cancer.