Rectal prolapse: a historical perspective

Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature

Introduction and hypothesis

The use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery.

Methods

A prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up).

Results

Ninety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%).

Conclusions

The long-term rate of mesh erosion following an abdominally placed synthetic graft is low.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-03990-1) contains supplementary material, which is available to authorized users

Transanal endorectal approach for the treatment of idiopathic rectal prolapse in children: Experience with the modified Delorme's procedure

BACKGROUND

Persistent or recurrent idiopathic rectal prolapse in children requires surgical intervention. Several techniques have been used to repair this problem. However, recurrence and complications continue to be a challenge in the management of this condition. Here we report our experience in using the modified Delorme's procedure to treat such patients.

METHODS

We conducted a retrospective observational study of patients with idiopathic rectal prolapse who underwent the modified Delorme's procedure during 2013-2017. We analyzed the clinical characteristics of the patients and the recurrence and complication rates during a follow-up of 15-68 months.

RESULTS

We included 14 patients. The age at operation ranged from 2 to 17 years, and the length of the prolapse was 3-15 cm. There were no intraoperative or postoperative complications. All patients achieved postoperative fecal control, and there were no recurrences.

CONCLUSION

The modified Delorme's procedure was effective for the treatment of idiopathic rectal prolapse. There were no recurrences or complications. Because it is a perineal technique, the procedure avoids the risk of nerve injury that exists for transabdominal methods.

Resection Rectopexy is Still an Acceptable Operation for Rectal Prolapse

The aim of this study was to compare resection rectopexy (RR) with ventral mesh rectopexy (VMR). This institutional review board–approved retrospective study compared patients with rectal prolapse, who underwent RR or VMR from 2009 to 2016. The primary end point was the comparison of complications and prolapse recurrence rates. Seventy-nine RR and 108 VMR patients qualified. Using propensity score matching, the two groups were not significantly different (P = 0.818). There were no differences regarding gender (female 103 vs 72; P = 0.4) and age (59.3 vs 53.9; P = 0.054). Patients in the VMR group had a greater body mass index (25.5 vs 22.9; P = 0.001) and poorer physical status (American Society of Anesthesiologists 3 57.4% vs 41.8%; P = 0.04). The VMR group had more: robotic approaches (69.4% vs 8.9%; P < 0.001), concomitant urogynecological procedures (63 vs 19; P < 0.001), and longer operative time (269 vs 206 minutes; P < 0.001) but a reduced length of stay (2 vs 5 days; P < 0.001). The median follow-up (16 vs 26 months; P = 0.125) and the median time of recurrence (14 vs 38 months; P = 0.163) were similar. No differences were observed for complications or recurrence (10.2% vs 10.1%; P = 0.43). We failed to identify superiority based on surgical technique.

Surgical options for full-thickness rectal prolapse: current status and institutional choice

Full-thickness rectal prolapse (FTRP) is generally believed to result from a sliding hernia through a pelvic fascial defect, or from rectal intussusception. The currently accepted cause is a pelvic floor disorder. Surgery is the only definitive treatment, although the ideal therapeutic option for FTRP has not been determined. Auffret reported the first FTRP surgery using a perineal approach in 1882, and rectopexy using conventional laparotomy was first described by Sudeck in 1922. Laparoscopy was first used by Bermann in 1992, and laparoscopic surgery is now used worldwide; robotic surgery was first described by Munz in 2004. Postoperative morbidity, mortality, and recurrence rates with FTRP surgery are an active research area and in this article we review previously documented surgeries and discuss the best approach for FTRP. We also introduce our institution's laparoscopic surgical technique for FTRP (laparoscopic rectopexy with posterior wrap and peritoneal closure). Therapeutic decisions must be individualized to each patient, while the surgeon's experience must also be considered.

British Surgeon Frederick Salmon (1796-1868) and His "Trans-Fixing Pins and Excision" Surgical Procedure for the "Rectum Prolapsus"

Frederick Salmon was born in Bath. From his early career, he was fond of surgery, mostly interested in proctology. He had been specialized in London at St Bartholomew's Hospital. He was the founder of "The Infirmary for the Relief of the Poor Afflicted with Fistula and Other Disease of the Rectum," and the writer of one of the most important surgical treatises, the " Practical Observations on Prolapsus of the Rectum." In this book, Salmon described an innovative operation for procidentia, based on the principle "trans-fixing pins and excision." Although his work was too significant for the era, he was almost completely neglected by historians, most probably due to his clash with his fellow surgeons, who had been considered by him as scientifically inadequate in anorectal diseases.

Thiersch Procedure for Rectal Prolapse: Experiences From a Single Institution

The Thiersch procedure is a simple and safe surgical management option for rectal prolapse. Herein, experiences—the perioperative factor, functional outcome, recurrence, and complications—from a single institution are reported. Medical records were reviewed to identify patients diagnosed with rectal prolapse, and only patients who underwent the Thiersch procedure. The clinical presentations, perioperative findings, complications, recurrences, and long-term functional outcomes were collated. Twenty-four patients underwent the Thiersch procedure for rectal prolapse between 1995 and 2014. The mean operative time was 55.5 ± 25.6 minutes and postoperative wound pain was minor. The major complications were urine retention (29.2%) and wound infection (16.7%). All patients experienced symptom improvement after the operation and recovered their anal tone. Although the Thiersch procedure entails certain recurrence and infection rates, it provides improved functional outcomes and low perioperative risks.

A novel technique for correction of total rectal prolapse: Endoscopic-assisted percutaneous rectopexy with the aid of the EndoLifter

INTRODUCTION AND AIMS

Rectal prolapse is common in the elderly, having an incidence of 1% in patients over 65years of age. The aim of this study was to evaluate the safety and feasibility of a new endoluminal procedure for attaching the previously mobilized rectum to the anterior abdominal wall using an endoscopic fixation device.

MATERIALS AND METHODS

The study is a single-arm phasei experimental trial. Under general anesthesia, total rectal prolapse was surgically reproduced in five pigs. Transanal endoscopic reduction of the rectal prolapse was performed. The best site for transillumination of the abdominal wall, suitable for rectopexy, was identified. The EndoLifter was used to approximate the anterior wall of the proximal rectum to the anterior abdominal wall. Two percutaneous rectopexies were performed by puncture with the Loop FixtureII Gastropexy Kit^® at the preset site of transillumination. After the percutaneous rectopexies, rectoscopy and exploratory laparotomy were performed. Finally, the animals were euthanized.

RESULTS

The mean procedure time was 16min (11-21) and the mean length of the mobilized specimen was 4.32cm (range 2.9-5.65cm). A total of 10 fixations were performed with a technical success rate of 100%. There was no evidence of postoperative rectal prolapse in any of the animals. The EndoLifter facilitated the process by allowing the mucosa to be held and manipulated during the repair.

CONCLUSIONS

Endoscopic-assisted percutaneous rectopexy is a safe and feasible endoluminal procedure for fixation of the rectum to the anterior abdominal wall in experimental animals.

A novel percutaneous technique for treating complete rectal prolapse in adults

PURPOSE

To evaluate a new technique for treating complete rectal prolapse in adults that combines injection sclerotherapy with anal encirclement.

METHODS

From 2008 to 2012, 20 patients were treated using combined perirectal injection sclerotherapy with anal encirclement. The primary outcome was recurrent full-thickness/mucosal rectal prolapse.

RESULTS

The mean age of the patients was 39 years. The mean operating time was 17 minutes. Patients had short hospital stays (range = 2-4 days) and rapid recovery with no serious postoperative complications. After a mean follow-up of 22 months, recurrence occurred in 9 patients, and was complete in 6 cases and mucosal in 3 patients. Recurrent mucosal prolapse was treated with a mucosectomy, while recurrent complete rectal prolapse was treated with an open rectopexy with mesh.

CONCLUSION

The combination of perirectal sclerotherapy and anal encirclement for treating complete rectal prolapse in adults is a simple and safe procedure with reasonable outcome. These findings call for confirmatory trials in larger series.

Longitudinal plication--a surgical strategy for complete rectal prolapse management

BACKGROUND

Rectal prolapse is a known problem since antiquity and the cause is not fully understood. Despite the presence of more than 100 lines of treatment, none of them is ideal.

METHODS

Between the years of (2005-2011), thirty patients with full-thickness rectal prolapse were operated upon. Age ranged between (2-65 years) with a mean of 21.5 year. Male to female ratio was (2:1). Each prolapsed rectum was repaired with longitudinal plication (LP) at two or three points accordingly using braded polyglycolic acid - absorbable 1.0 suture material. Plications started by inserting a stitch at the most proximal part of the prolapse, followed by successive similar transverse stiches continuing in a spiral fashion till the mucocutaneous junction. We used three LP in adults and two in children. All of the patients where operated upon as a day-case procedure and discharged 6 hours after the operation.

RESULTS

In this series of patients, twenty-nine of them had complete recovery from the prolapse. Only one patient had recurrence 2 years after the operation, and the same procedure was applied successfully with uneventful post-operative period. Although twenty-three patients had fecal Incontinence, twenty-one of them regained continence after operation.

CONCLUSIONS

This method is an easy perineal procedure, with fewer complications. It can be performed for all age groups, in an ordinary surgical unit, by an expert anorectal surgeon. We found that our procedure is simple, safe and less invasive.

Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation and surgical treatment of rectal prolapse: an international survey

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Morphological alterations of the enteric nervous system in young male patients with rectal prolapse

OBJECTIVES

The pathogenesis of rectal prolapse (RP) defined by a circumferential, full-thickness invagination of the rectal wall into the anal canal is controversial. RP is normally encountered in elderly women and attributed to several etiological factors (e.g., advanced age, pudendal nerve injury, laxity of supporting ligaments). RP affecting young male patients is unlikely to be explained by these factors and may be due to a rectal motility disorder. Therefore, the enteric nervous system (ENS) as key regulator of intestinal motility was evaluated by a systematic morphometric analysis.

PATIENTS AND METHODS

Full-thickness rectosigmoid specimens obtained from young male patients with symptomatic RP (n = 5) and male controls (n = 15) were processed for conventional histology and immunohistochemistry using anti-HuC/D as pan-neuronal marker. Enteric ganglia, nerve and glial cells were quantified separately in the myenteric (MP) and submucosal plexus (SMP).

RESULTS

Compared to controls, patients with RP showed significantly (p < 0.05) increased mean ganglionic area both in MP and SMP, increased mean neuronal content of submucosal ganglia, and nearly threefold higher frequency of submucosal ganglia containing ≥7 neurons.

CONCLUSION

The morphometric analysis reveals distinct quantitative alterations of the ENS in young male patients with RP mainly characterized by submucosal hyperganglionosis similar to histopathological features described in intestinal neuronal dysplasia. The data give evidence that RP in this unusual subgroup is associated with morphological changes of enteric ganglia which may contribute to the development of RP and complement established etiological concepts.

Perineal rectosigmoidectomy for gangrenous rectal prolapse

Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse. Even more rarely, it becomes strangulated, necessitating emergency surgery. We describe an extremely rare case of incarcerated acute rectal prolapse, without a relevant previous history or symptoms of predisposing pathology. The patient underwent emergency perineal proctosigmoidectomy, the Altemeier operation, combined with diverting loop sigmoid colostomy. The postoperative course was quite uneventful with an excellent final result after colostomy closure. The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual case scenario of bowel incarceration.