Laparoscopic ventral mesh rectopexy vs Delorme's operation in management of complete rectal prolapse: a prospective randomized study

Statistical Fragility in Minimally Invasive Colorectal Surgery Studies: A Review of Randomized Trials

Purpose: The P value has been used as a statistical tool in randomized controlled trials (RCTs) to establish significance but does not provide information on the robustness of a study when used alone. The fragility index (FI) provides a supplemental approach for demonstrating robustness in RCTs that report dichotomous outcomes. This study aims to determine the statistical fragility of RCTs that compare minimally invasive techniques with open techniques in managing benign and malignant colorectal diseases. Methods: Dichotomous outcomes of minimally invasive surgery versus open surgery in RCTs from 2000 to 2023 were assessed. The overall FI and fragility quotient (FQ) of each study were calculated. Results: Of the 1377 screened studies, 50 met the inclusion criteria. In total, 820 outcomes were recorded with 747 outcomes reported as not significant (P ≥ .05) and 73 as significant (P < .05). The overall FI for all studies including all outcomes was 5 (interquartile range [IQR] 4-7) with a FQ of 0.031 (IQR 0.014-0.062). Of the 50 RCTs, 6 (12%) reported a loss to follow-up that was greater than the overall FI of 5. Conclusions: As RCTs are judged increasingly beyond just the P value, practicing colorectal surgeons will benefit from using and interpreting the FI, FQ, and the P value of studies both in analyzing future RCTs and in determining whether or not to make a change in their clinical practice if there is an efficiently true discovery.

Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity.

METHODS

A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023.

RESULTS

Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups.

CONCLUSION

LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

Could robotic-assisted surgery reduce mesh-related complications after ventral mesh rectopexy? Experience of a tertiary centre and systematic review of the literature

AIM

The development of robotic assistance has made dissection and suturing in the deep pelvis much easier. The augmented quality of the images and the articulation of the robotic arms have also enabled a more precise dissection. The aim of this study is to present the data on robotic-assisted ventral mesh rectopexy procedures in a university hospital and examine the literature in terms of mesh erosion.

METHOD

The electronic databases Pubmed, Embase and Cochrane were searched. Studies from January 2004 until January 2023 in the English language were included. Studies which included fewer than 10 patients were excluded. Laparoscopic or robotic-assisted ventral mesh rectopexies were included. Mesh erosion rates following laparoscopic or robotic-assisted ventral mesh rectopexies were measured.

RESULTS

Overall, the systematic review presents 5911 patients from 43 studies who underwent laparoscopic ventral mesh rectopexy compared with 746 patients treated with robotic-assisted ventral mesh rectopexy from six studies and our centre. Mesh erosion was rare in both groups; however, the prevalence was greater in the laparoscopy group (0.90% vs. 0.27%).

CONCLUSION

The mesh erosion rates are very low with robotic-assisted ventral mesh rectopexy. For precise results, more studies and experience in robotic surgery are required.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis

BACKGROUND

Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse.

METHODS

A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis.

RESULTS

Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches.

CONCLUSIONS

A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

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.

Comparison of four surgical approaches for rectal prolapse: multicentre randomized clinical trial

BACKGROUND

Several different procedures have been described for surgical treatment of rectal prolapse and consensus on the optimal approach has not been reached. The Swedish Rectal Prolapse Trial was performed with the aim to compare the outcomes after the most common surgical approaches to rectal prolapse.

METHOD

A multicentre randomized trial was conducted from 2000 to 2009. Patients were randomized between a perineal or an abdominal approach for correction of rectal prolapse (randomization A) if eligible for any procedures. Patients considered unsuitable for random allocation were only included in randomizations B or C. Patients in randomization B (perineal group) were randomized to Delorme's or Altemeier's procedures and those in randomization C (abdominal group) to suture rectopexy or resection rectopexy. Primary outcomes were bowel function and quality of life, measured using Wexner incontinence score and RAND-36, and secondary outcomes were complications and recurrence at 3 years.

RESULTS

During the study period, 134 patients were randomized: 18 in randomization A group, 80 in randomization B group and 54 in randomization C group; of these, 122 patients underwent surgery. Mean follow-up was 2.6 years. Improvements in Wexner and RAND-36 scores were seen but with no significant difference between the groups. Health change scores were significantly improved from baseline up to 1 year after surgery (P < 0.001). At 3 years, recurrence rates were two of seven patients for abdominal versus five of eight patients for perineal approach (P = 0.315), 18 of 31 patients (58 per cent) for Delorme's versus 15 of 30 patients (50 per cent) for Altemeier's (P = 0.611) and four of 19 patients (21 per cent) for suture rectopexy versus two of 21 patients (10 per cent) for resection rectopexy (P = 0.398). There were no significant differences regarding postoperative complications.

CONCLUSION

For all procedures, significant improvements from baseline in health change scores were noted after surgery. Recurrence rates were higher than previously reported. Registration number: NCT04893642 (http://www.clinicaltrials.gov).

Trends in the surgical management of rectal prolapse: An Asian experience

BACKGROUND

Posterior compartment pelvic floor prolapse (PCPFP) leads to anatomical distortion and functional impairment. Definitive management involves surgery. Ventral mesh rectopexy (VMR) has gained increasing popularity in the West as it emerges as a durable approach. Existing literature and evidence on safety and efficacy of PCPFP surgery in the Asian population remains sparse. Our study aims to review our institution's experience in surgery for PCPFP.

METHODS

All cases of PCPFP surgery in Singapore General Hospital between 2014 to 2019 were studied.

RESULTS

Eighty-three patients had surgery performed for PCPFP, with the majority (83%) in the last 3 years. Median age was 63 years and 92% were female. Most patients (64%) had obstructive defecation symptoms, while the remaining had fecal incontinence, rectal bleeding, or anal discomfort. Main anatomical indication for surgery was external rectal prolapse (48%). Other indications were rectocele and/or rectal intussusception. The majority (66%) had abdominal rectopexy, while 28 underwent Delorme's procedure. Forty-five of the 50 VMRs were minimally invasive. Patients undergoing rectopexy were observed to be younger. Median length of stay was 3 days. Nine patients had early operative complications of which ileus was most common. Median length of follow-up was 12 months. The majority (93%) had initial symptom satisfaction. Eleven patients had anatomical recurrence with a median length of 9 months to development. There was no significant difference in outcomes between abdominal vs perineal approach, or laparoscopic vs robotic VMR.

CONCLUSION

Surgery for PCPFP has gained acceptance in our Asian institution with good symptom improvement, alongside low morbidity and recurrence.

OUP accepted manuscript

Background

External rectal prolapse (ERP) is a debilitating condition in which surgery plays an important role. The aim of this study was to evaluate the outcomes of abdominal approaches (AA) and perineal approaches (PA) to ERP.

Methods

This was a PRISMA-compliant systematic review with meta-analysis. Studies published between 1990 and 2021 were retrieved. The primary endpoint was recurrence at the last available follow-up. Secondary endpoints included factors associated with recurrence and function. All studies were assessed for bias using the Newcastle–Ottawa Scale and Cochrane tool.

Results

Fifteen studies involving 1611 patients (AA = 817; PA = 794) treated for ERP were included, three of which were randomized controlled trials (RCTs; 114 patients (AA = 54; PA = 60)). Duration of follow-up ranged from 12 to 82 months. Recurrence in non-randomized studies was 7.7 per cent in AA versus 20.1 per cent in PA (odds ratio (OR) 0.29, 95 per cent confidence interval (c.i.) 0.17 to 0.50; P < 0.001, I² = 45 per cent). In RCTs, there was no significant difference (9.8 per cent versus 16.3 per cent, AA versus PA (OR 0.82, 95 per cent c.i. 0.29 to 2.37; P = 0.72, I² = 0.0 per cent)). Age at surgery and duration of follow-up were risk factors for recurrence. Following AA, the recurrence rates were 10.1 per cent and 6.2 per cent in patients aged 65 years and older and less than 65 years of age, respectively (effect size [e.s.] 7.7, 95 per cent c.i. 4.5 to 11.5). Following PA, rates were 27 per cent and 16.3 per cent (e.s. 20.1, 95 per cent c.i. 13 to 28.2). Extending follow-up to at least 40 months increased the likelihood of recurrence. The median duration of hospital stay was 4.9 days after PA versus 7.2 days after AA. Overall, incontinence was less likely after AA (OR 0.32), but constipation occurred more frequently (OR 1.68). Most studies were retrospective, and several outcomes from RCTs were not consistent with those observed in non-RCTs.

Conclusion

The overall risk of recurrence of ERP appears to be higher with PA versus AA. Incontinence is less frequent after AA but at the cost of increased constipation. Age at surgery and duration of follow-up are associated with increased risk of recurrence, which warrants adequate reporting of future studies on this topic.

A comparative study on the surgical options for male rectal prolapse

Purpose:

Rectal prolapse is known to be a rare condition in males compared to females. This study aimed to analyse the frequency of male rectal prolapse and compare the results of different surgical approaches performed at a single centre.

Patients and Methods:

The authors included patients who underwent surgical treatment for rectal prolapse from March 2016 to February 2021. The proportion of males, mean age and recurrence rates were calculated. Patients were divided into two groups, transanal approach and laparoscopic abdominal approach group, to identify the para-operative parameters including functional tests.

Results:

A total of 56 males, comprising 23.7% (56/236) of all patients. The mean age was 60.8 years, with a recurrence rate of 7 cases (12.5%) during 7.2 months of follow-up. Forty patients underwent transanal procedures, and fifteen underwent laparoscopic abdominal procedures. The mean operative time was longer in the laparoscopic group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003), and intra-operative bleeding was greater in the transanal group (12.4 vs. 3.4 ml, P < 0.001). Full-layer prolapse (36.8 vs. 81.2% P = 0.003) and longer length (5.6 vs. 7.8 cm, P = 0.048) were more common in laparoscopic group. Time to feeding resumption was shorter after the transanal group (1.2 vs. 1.7 days, P = 0.028). There was no difference between the groups in terms of post-operative complications and recurrence rates. Both Wexner's constipation and incontinence scores showed significant improvement postoperatively.

Conclusion:

The frequency of male rectal prolapse was 23.7%, and perioperative factors differed between transanal and abdominal approaches, but recurrence rates and functional test results did not differ significantly.

Clinical outcomes of surgical management for recurrent rectal prolapse: a multicenter retrospective study

Purpose

Methods

Results

Conclusion

Mesh-related complications and recurrence after ventral mesh rectopexy with synthetic versus biologic mesh: a systematic review and meta-analysis

Background

Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material.

Methods

A systematic search of the electronic databases of PubMed, Embase and Cochrane was performed (from inception until September 2020). Studies evaluating patients who underwent VMR with synthetic or biologic mesh were eligible. The MINORS score was used for quality assessment.

Results

Thirty-two studies were eligible after qualitative assessment. Eleven studies reported on mesh-related complications including 4001 patients treated with synthetic mesh and 762 treated with biologic mesh. The incidence of mesh-related complications ranged between 0 and 2.4% after synthetic versus 0–0.7% after biologic VMR. Synthetic mesh studies showed a pooled incidence of mesh-related complications of 1.0% (95% CI 0.5–1.7). Data of biologic mesh studies could not be pooled. Twenty-nine studies reported on the risk of recurrence in 2371 synthetic mesh patients and 602 biologic mesh patients. The risk of recurrence varied between 1.1 and 18.8% for synthetic VMR versus 0–15.4% for biologic VMR. Cumulative incidence of recurrence was found to be 6.1% (95% CI 4.3–8.1) and 5.8% (95% CI 2.9–9.6), respectively. The clinical and statistical heterogeneity was high.

Conclusions

No definitive conclusions on preferred mesh type can be made due to the quality of the included studies with high heterogeneity amongst them.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

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.

Longer Prolapsed Rectum Length Increases Recurrence Risk After Delorme's Procedure

Purpose

Risk factors for recurrence of rectal prolapse after surgery remain unclear. Delorme’s procedure is often selected for relatively small-sized rectal prolapse, but there are few reports discussing the association between prolapsed rectum length and prolapse recurrence after Delorme’s procedure. We hypothesized that patients with longer rectal prolapses are at a higher risk of recurrence after Delorme’s procedure.

Methods

The study population comprised patients with rectal prolapse who underwent Delorme’s procedure between January 2014 and December 2019 at Tokyo Yamate Medical Center. We extracted data on patient age, sex, body mass index, previous history of anal surgery, previous history of surgery for rectal prolapse, and length of prolapse, to identify risk factors for prolapse recurrence.

Results

Altogether, 96 patients were eligible for analysis. The median length of the prolapsed rectum was 3.0 cm (range, 1.0–6.6 cm). Twenty-four patients (25.0%) experienced recurrence after Delorme’s procedure after a median of 7.5 months (interquartile range, 3.2–20.9 months). Multivariate analysis revealed that longer prolapsed rectum length increased the risk of recurrence after Delorme’s procedure (hazard ratio, 6.28; 95% confidence interval, 1.83–21.50; P<0.001).

Conclusion

The length of the prolapsed rectum should be measured before Delorme’s procedure for rectal prolapse, because length is associated with a risk of recurrence after the surgery.

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.

Meta-analysis of laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete rectal prolapse

OBJECTIVES

To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse.

METHODS

We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures.

RESULTS

We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR (n=160) or LPSR (n=147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P=0.009) but longer procedure time (MD: 23.93, P<0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: -1.02, P=0.50), CCCS (MD: -1.54, P=0.47), surgical site infection (OR: 1.48, P=0.71), and length of hospital stay (MD: -1.54, P=0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis.

CONCLUSIONS

LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

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

Background

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

Methods

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

Results

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

Conclusion

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

Epidemiological trends in surgery for rectal prolapse in England 2001-2012: an adult hospital population-based study

AIM

To analyse trends in admission and surgery for rectal prolapse in adults in England between 2001 and 2012 as well as prolapse reoperation rates.

METHOD

Analysis of data derived from a comparative longitudinal population-based cohort study using Hospital Episode Statistics (HES).

RESULTS

During the study period, a total of 25 238 adults, of median age 73 [interquartile range (IQR: 58-83] years, underwent a total of 29 379 operations for rectal prolapse (mean: 2662 per annum). The female to male ratio of this group of patients was 7:1. Median length of hospital stay was 3 (IQR: 1-7) days with an overall in-hospital mortality rate of 0.9%. Total number of admissions (4950 in 2001/2002 vs 8927 in 2011/2012) and of patients undergoing prolapse surgery (2230 in 2001/2002 vs 2808 in 2011/2012) significantly increased over the study period (P < 0.001 for trends). The overall increase in prolapse surgery (of 33% overall and of 44% for elective procedures) was dwarfed by an increase in popularity of laparoscopic surgery (of 15-fold). Overall prolapse reoperation rate was 12.7%. The lowest recurrence rate was observed for elective open resection (9.1%) but this had the highest mortality (1.9%). Laparoscopic and perineal fixations were also associated with low reoperation rates (< 11%) and the lowest mortality rates, of 0.3%, when these procedures were elective. These data refute a trend towards subspecialization (by surgeon or hospital) during the study period.

CONCLUSION

Admissions for rectal prolapse increased in England between 2001 and 2012, together with increases in rectal prolapse surgery. Surgical decision making has changed over this period and may be reflected in outcome.

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.

Modified Stapled Transanal Rectal Resection Procedure for Limited Rectal Prolapse: A Viable Alternative to the Delorme Operation

Purpose. The optimal surgical approach for full-thickness rectal prolapse (FTRP) remains controversial. In China, patients with limited FTRP (<5 cm in length) are usually managed by perineal surgery. We retrospectively assessed the outcome of Delorme's procedure and compared it with modified stapled transanal rectal resection (STARR). Methods. The study was conducted in 2 public tertiary referral centers in China with modified STARR or Delorme's procedure performed by experienced surgeons. Outcomes assessed recurrence, operative times, blood loss, complications, length of hospital stay, and continence and constipation scoring. Results. Between December 2012 and May 2019, 65 patients were assessed, including 48 with modified STARR (group 1) and 17 with Delorme's procedure (group 2). The median follow-up was 22 months (range, 3-86 months). The mean operative time for group 1 was 37.4 ± 17.5 minutes vs 74.3 ± 30.6 minutes for group 2 (P < .001). The blood loss for group 1 was significantly lower than that for group 2 (17.4 ± 15.9 mL vs 27.8 ± 16.7 mL, respectively; P = .028). There was no significant difference between groups in recurrence (group 1 18.8% vs group 2 23.5%; P = .944) with no effect of operation type. Both procedures showed improvement in constipation and continence scoring with a similar impact. Conclusions. Modified STARR and the Delorme operation are comparable in managing limited FTRP with superior results in operative time and blood loss for STARR.

Laparoscopic Pelvic Organ Prolapse Suspension (Pops) Versus Laparoscopic Ventral Mesh Rectopexy for Treatment of Rectal Prolapse: Prospective Cohort Study

BACKGROUND

This study aimed to compare ventral mesh rectopexy (VMR) and pelvic organ prolapse suspension surgery (POPS) in management of patients presenting with rectal prolapse.

METHODS

Our study was a prospective cohort trial in which 120 female patients with complete rectal prolapse were included, 60 patients had had VMR and the other 60 had had POPS as a surgical management for complete rectal prolapse. Results had been compared 6 months postoperatively regarding operative time, postoperative pain, hospital stay, complications of surgery including recurrence of the rectal prolapse, the efficacy of each operation in treatment of rectal prolapse and associated symptoms.

RESULTS

The patients were assessed 6 months postoperatively. There was no significant statistical difference regarding hospital stay and postoperative pain. Operative time was significantly shorter in POPS in comparison with VMR (P value < 0.05). VMR showed slight improvement regarding constipation and continence scores; however, this was statistically significant. VMR showed less complications compared to POPS. Complications with rectopexy happened only with 4 patients compared to 24 patients in POPS groups, 2 cases of recurrence in rectopexy group compared to 6 cases of recurrence in POPS.

CONCLUSION

POPS is comparable to VMR in management of rectal prolapse and in improving the ODS symptoms. Thus, POPS can be used as easier, faster option to treat rectal prolapse in selected patients.

Perineal rectosigmoidectomy for rectal prolapse-the preferred procedure for the unfit elderly patient? 10 years experience from a UK tertiary centre

BACKGROUND

Rectal prolapse is a disease presentation with a prevalence of about 1%, mainly affecting older women. It usually presents with symptoms of rectal mass, rectal bleeding, fecal incontinence or constipation, with patients frequently feeling socially isolated as a result. Perineal rectosigmoidectomy is associated with lesser morbidity and mortality than the abdominal procedure, but with a much higher recurrence rate. Therefore, this technique is mainly suitable for the frail elderly patient. Specific outcomes in an elderly population have been described in only a few studies. We evaluated the morbidity, mortality, recurrence rate and functional results after this procedure related to age.

METHODS

All patients who underwent a perineal rectosigmoidectomy over a 10-year period in two tertiary referral centers were included in the study. American Society of Anesthesiology (ASA) grade, pre- and postoperative symptoms, pathology-reported post-fixation specimen length, length of in-patient stay, 30-day morbidity/mortality, and recurrence were measured.

RESULTS

A total of 45 patients underwent a perineal rectosigmoidectomy. Forty-three (95%) were female, with a median age of 82.0 years (IQR 70.5-86.5), ASA grade III and median follow-up of 20 months (range 8.5-45.5 months). Half of the cohort was over 80 years old. Significant symptomatic relief was achieved, predominantly the resolution of rectal mass (8.9% vs. 60.0% preoperatively), fecal incontinence (15.6% vs. 46.7%) and constipation (4.4% vs. 26.7%). The median length of stay was 6 days, while morbidity occurred in 14 patients (31.1%) and recurrence occurred in 6 patients (13%). There were no deaths within 30 days of the procedure and outcomes were comparable in the < 80 and ≥ 80 age group.

CONCLUSIONS

Perineal rectosigmoidectomy is safe for older patients with greater comorbidities resulting in good functional results and is associated with low morbidity and mortality.

Long-term outcomes of surgical management of rectal prolapse

BACKGROUND

Various surgical options for rectal prolapse are available but none have been shown to be clearly superior. The aims of this study were to investigate the long-term recurrence rate of a variety of surgical approaches, their associated morbidities and the types of reoperation used to treat recurrence.

METHODS

A retrospective analysis was performed of all cases of rectal prolapse surgery within one colorectal surgical unit between January 2000 and June 2017. Abdominal approaches consisted of rectopexy (RP) and resection rectopexy (RRP); perineal approaches included perineal rectosigmoidectomy (PR) and Delorme's repair (DR). Complications were graded according to the Clavien-Dindo classification. The median follow-up was 4.5 years (interquartile range 1.5-10.1, maximum 16.5). Statistical analysis was performed using Kaplan-Meier to determine recurrence rates.

RESULTS

A total of 157 patients were included in the study. The numbers for each procedure were: DR (n = 55), RRP (n = 44), RP (n = 38) and PR (n = 20). The majority were females (94%). The perineal group were significantly older than the abdominal group (80 versus 67 years, P = 0.0001). At 5 years, the recurrence rates were 52%, 30%, 5% and 3% for DR, PR, RP and RRP, respectively. Morbidity was highest in PR (20%) followed by RRP (18%), RP (16%) and DR (7%) (n.s.). The overall morbidity rates for perineal group and abdominal group were 10.7% and 17.1%, respectively (n.s.).

CONCLUSION

Abdominal approaches have a significantly lower recurrence rate at 5 years but tend to be associated with higher morbidity.

Outcome of laparoscopic ventral mesh rectopexy for full-thickness external rectal prolapse: a systematic review, meta-analysis, and meta-regression analysis of the predictors for recurrence

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) has proved effective in the treatment of internal and external rectal prolapse. The present meta-analysis aimed to determine the predictive factors of recurrence of full-thickness external rectal prolapse after LVMR.

METHODS

An organized, systematic search of electronic databases including PubMed/Medline, Embase, Scopus, and Cochran library was conducted in adherence to PRISMA guidelines. Studies that reported the outcome of LVMR in patients with full-thickness external rectal prolapse were included according to predefined criteria. A meta-regression analysis and sub-group meta-analyses were performed to recognize the patient and technical factors that were associated with higher recurrence rates.

RESULTS

Seventeen studies comprising 1242 patients of a median age of 60 years were included. The median operation time was 122.3 min. Conversion to open surgery was required in 22 (1.8%) patients. The weighted mean complication rate across the studies was 12.4% (95% CI 8.4-16.4) and the weighted mean rate of recurrence of full-thickness external rectal prolapse was 2.8% (95% CI 1.4-4.3). The median follow-up duration was 23 months. Male gender (SE = 0.018, p = 0.008) and length of the mesh (SE = - 0.007, p = 0.025) were significantly associated with full-thickness recurrence of rectal prolapse. The weighted mean rates of improvement in fecal incontinence and constipation after LVMR were 79.3% and 71%, respectively.

CONCLUSION

LVMR is an effective and safe option in treatment of full-thickness external rectal prolapse with low recurrence and complication rates. Male patients and length of the mesh may potentially have a significant impact on recurrence of rectal prolapse after LVMR.

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.

Massive chronic irreducible rectal prolapse successfully treated with Altemeier's procedure

The guideline for the treatment of rectal prolapse recommends that surgeons select appropriate surgical procedures individually based on each patient's overall status. However, in cases of irreducible or incarcerated rectal prolapse, surgical options are quite limited. Here we present a case of an elderly woman with massive chronic irreducible rectal prolapse. An 87-year-old woman presented to our hospital with a complaint of massive rectal prolapse. The prolapsed rectum was over 20 cm long, and completely irreducible. She underwent perineal rectosigmoidectomy with levatorplasty known as Altemeier's procedure. More than 30 cm of rectosigmoid colon was resected. After the operation, rectal prolapse was resolved completely. Her postoperative course was uneventful, and her quality of life and bowel movements improved. She has since been healthy without recurrence for over 2 years. Altemeier's procedure is applicable even in cases of irreducible rectal prolapse and features acceptable safety and a satisfactory outcome.

Post-surgical fecal incontinence

The primary endpoint of this work was to understand the pathophysiology of fecal incontinence manifested after rectal and anal surgery. A retrospective cohort study with negative colonoscopy patients was created and 169 postoperative incontinent patients were analyzed (114 women and 55 men: mean age 58.9 ± 6.3): clinical evaluation, endoanal ultrasound and anorectal manometry reports were scanned. The duration of incontinence was very long, with a mean of 21.7 months. The mean number of bowel movements/week was 18.2 ± 7.2. Urge incontinence was present in 82.2% of patients, mixed with passive incontinence in 44 patients. Patients' Fecal Incontinence Severity Index (FISI) score was 27.0 ± 6.6. Operated patients had significantly lower anal resting pressure (P < 0.01) than controls while patients with colo-anal anastomosis and those who underwent Delorme operation had lowest values (P < 0.01). Maximal tolerated volume and rectal compliance were significantly impaired in operated patients with rectum involvement (colo-anal anastomosis, Delorme, restorative procto-colectomy and STARR). External anal sphincter (EAS) defects were present in 33.1% of all patients and internal anal sphincter (IAS) was damaged in 44.3%: a combined lesion of anal sphincters was detected in 39 patients (23.0%). A positive correlation was found between patients' FISI score and thickness of both sphincters (EAS: ρ_{s =} 73; IAS: ρ_s = 81). Malfunctioning continence factors may induce fecal incontinence involving each time, in a different way, the volumetric capacity and/or the motility of the rectum, the perception of the fecal bolus and anal sphincter contraction.