Laparoscopic ventral rectopexy: A viable option in procidentia with redundant sigmoid - An Indian perspective

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.

Natural Orifice Transanal Endoscopic Rectopexy for Complete Rectal Prolapse: Prospective Evolution of a New Technique and Short-term Outcomes

BACKGROUND

Endoluminal surgery for the management of rectal prolapse remains largely experimental.

OBJECTIVE

To evaluate the evolution and short-term outcomes of a new endoluminal technique for the management of complete rectal prolapse.

DESIGN

This was a prospective study.

SETTINGS

This study was conducted at a single tertiary care teaching center.

PATIENTS

A total of 29 patients were included. The first 12 patients underwent the procedure with our initial technique, and the last 17 patients were subjected to the new modified procedure. The follow-up duration was 3 years for the older technique and 26 months for the newer technique.

INTERVENTION

This technique involves: 1) ventral "suture" rectopexy: rectum is fixed anteriorly to the anterior abdominal wall using percutaneously placed sutures. 2) Posterior rectum is fixed to the sacral promontory using tackers through a submucosal tunnel.

MAIN OUTCOME MEASURES

Safety, recurrence, functional outcomes, morbidity, and mortality were the main outcome measures.

RESULTS

There were improvements in constipation and incontinence scores, anal manometric pressures, anorectal angle, anorectal descent, and quality of life postoperatively in both groups. In patients undergoing the modified procedure, there was a significant decrease in duration of surgery (220 ± 48.89 vs 110 ± 12.51 min), shortened hospital stay (4.6 ± 1.71 vs 2.6 ± 0.65 d), decreased recurrence (25% vs 5.8%), and complications (surgical-site infection and retrorectal abscess).

LIMITATIONS

Short follow-up, small sample size, and single-center study were the limitations.

CONCLUSION

This is a novel endoluminal technique for treating rectal prolapse obviating perirectal dissection, abdominal incisions, or a mesh. This can now be performed under complete endoscopic and fluoroscopic vision. It avoids general anesthesia and therefore can be an alternative for patients with comorbid conditions in whom the standard abdominal procedure may not be well tolerated. Larger randomized multicentric studies with longer follow-ups are warranted. See Video Abstract at http://links.lww.com/DCR/C59.

RECTOPEXIA ENDOSCPICA TRANSANAL POR ORIFICIO NATURAL PARA EL PROLAPSO RECTAL COMPLETO EVOLUCIN PROSPECTIVA DE UNA NUEVA TCNICA Y RESULTADOS A CORTO PLAZO

ANTECEDENTES:La cirugía endoluminal para el tratamiento del prolapso rectal ha permanecido en gran parte experimental.OBJETIVO:Este estudio tiene como objetivo evaluar la evolución y los resultados a corto plazo de una nueva técnica endoluminal para el manejo del prolapso rectal completo.DISEÑO:Estudio prospectivo.ÁMBITOS:Único centro docente de tercer nivel de atención.PACIENTES:Se incluyeron un total de 29 pacientes (19 hombres y 10 mujeres) con prolapso rectal completo. Los primeros 12 pacientes fueron sometidos al procedimiento con nuestra técnica anteriormente descrita y los últimos 17 pacientes fueron sometidos al nuevo procedimiento modificado. La duración del seguimiento es de 3 años para la técnica más antigua y de 26 meses para la técnica más nueva.INTERVENCIÓN:Esta técnica implica: A) Rectopexia de "sutura" ventral: el recto se fija anteriormente a la pared abdominal anterior mediante suturas colocadas percutáneamente. B) El recto posterior se fija al promontorio sacro mediante grapas a través de un túnel submucoso.PRINCIPALES MEDIDAS DE RESULTADO:Seguridad, recurrencia, resultados funcionales, morbilidad y mortalidad.RESULTADOS:Hubo mejorías en las puntuaciones de estreñimiento (ODS) e incontinencia (SMIS), presiones manométricas anales (reposo y contracción), ángulo anorrectal, descenso anorrectal y calidad de vida post operatoria en ambos grupos. En los pacientes sometidos al procedimiento modificado hubo una significativa disminución en la duración de la cirugía (220 + 48,89 vs 110 + 12,51 minutos), acortamiento de la estancia hospitalaria (4,6 + 1,71 vs 2,6 + 0,65 días), disminución de la recurrencia (25% vs 5,8%) y complicaciones (infecciónes del sitio quirúrgico y abscesos retrorrectales).LIMITACIONES:Seguimiento corto, tamaño de muestra pequeña, estudio de un solo centro.CONCLUSIÓNES:La rectopexia endoscópica transanal por orificio natural (NOTER) es una novedosa técnica endoluminal para el tratamiento del prolapso rectal que evita la disección perirrectal, las incisiones abdominales o la fijación de una malla. Este procedimiento puede realizar hoy día bajo visión completa endoscópica y fluoroscópica. Evita la anestesia general y, por lo tanto, puede ser una alternativa para pacientes con condiciones comórbidas donde el procedimiento abdominal estándar puede no ser bien tolerado. Se justifican estudios multicéntricos aleatorios más grandes con un seguimiento más prolongado para validar aún más esta nueva técnica. Consulte Video Resumen en http://links.lww.com/DCR/C59. (Traducción-Dr Osvaldo Gauto).

Transanal rectopexy for external rectal prolapse

PURPOSE

The surgical management of patients with full-thickness rectal prolapse (FTRP) continues to remain a challenge in the laparoscopic era. This study retrospectively assesses a cohort of patients undergoing a transanal suture sacro rectopexy supported by sclerosant injection into the presacral space under ultrasound guidance.

METHODS

Patients with FTRP underwent a sutured transrectal presacral fixation of 2/3 of the circumference of the rectum from the third sacral vertebra to the sacrococcygeal junction through a side-viewing operating proctoscope. The procedure was supplemented by ultrasound-guided injection into the retrorectal space of a 2 mL solution of sodium tetradecyl sulfate/polidocanol mixed with air. Patients were functionally assessed before and 6 months after surgery with the Agachan constipation score and the Pescatori incontinence score.

RESULTS

There were 36 adult patients (26 males; the range of age, 23-92 years). The mean operative time was 27 minutes (range, 23-50 minutes) with no recorded perioperative morbidity. The median follow-up was 66 months (range, 48-84 months) with 1 (2.8%) recurrence presenting 18 months after surgery. There were 19 patients (52.8%) who presented with incontinence before surgery with 17 out of 19 (89.5%) reporting improvement in their Pescatori score (P<0.001). No patient had worsening incontinence and there were no de novo incontinence cases. Constipation scores improved in 23 out of 36 patients (63.9%) with a mean score reduction difference of 7.91 (P=0.001).

CONCLUSION

Transanal sutured sacral rectopexy with supplemental presacral sclerosant injection is safe and effective in the management of FTRP with sustained improvement in bowel function.

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.

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.

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.