Gastroenterological options in faecal incontinence.

Faecal incontinence may be due to a trauma, a rectal prolapse, or a neurological disorder. Obstetric trauma: If the sphincter has been severed, direct repair is indicated. In the case of neurological damage, plication of the levators can provide significant improvement; while the post-anal repair has become popular, anterior sphincter plication and levatorplasty, provide equivalent results. Rectal prolapse: Full thickness rectal prolapse is frequently associated with incontinence. Two categories of operations have been described: local operative procedures (Delorme's plicature, perineal resection) provide poor results in term of restoration of continence and should be reserved to unfit and elderly patients; abdominal operations combine an extensive rectal mobilisation and they differ by the type of fixation. The Ripstein operation (fixation to the promontory by an encircling sling of non absorbable mesh) has long been popular in the United States, but is followed by severe constipation. In the simple suture rectopexy, the rectum is fixed to the pelvic floor and the presacral fascia by non absorbable procedures. In the Ivalon sponge rectoprexy, a polyvinyl alcohol mesh in secured between the sacrum and the rectum, and provides a dense fibrous reaction. In the antero-posterior Marlex rectopexy, a sheet of Marlex mesh is fixed posteriorly to the rectum, and a sling is interposed anteriorly in order to support the anterior wall. In the resection rectopexy, a sigmoid resection in added to the rectal fixation in order to suppress the redundant sigmoid which is responsible for the constipation frequently following rectopexy. Results of abdominal rectopexy are satisfactory in terms of recurrence and restoration of continence.(ABSTRACT TRUNCATED AT 250 WORDS)     

Posterior rectopexy in total rectal prolapse-

STUDY AIM: The aim of this retrospective study was to report the results of posterior Orr-Loygue rectopexy in 55 patients operated on for rectal prolapse. PATIENTS AND METHOD: From 1986 to 1997, 114 patients were operated on for rectal prolapse and 55 had an Orr-Loygue operation. There were 47 women and 8 men (mean age: 55 years). Twenty-five patients (45%) had fecal incontinence, 26 (47%) described preoperative 'constipation'. The procedure was performed under general anesthesia, through laparotomy in 51 patients, through laparoscopy in 4 patients. Resection of sigmoid colon was associated to rectopexy in four patients. RESULTS: Mortality rate was 0 and morbidity rate 12%. Mean hospital stay duration was 13.5 days. Mean follow-up was 63 months and at the end of the study, four patients (7%) had recurrence, 5/25 patients had still incontinence; 55% of the patients had unchanged postoperative bowel function, 22% described improvement (including the four patients with resection-rectopexy) but 38% (21/55) suffered from postoperative 'constipation'. The rate of 'constipation' induced or majored by rectopexy was 22% but the functional trouble described appeared often complex. CONCLUSION: Posterior Orr-Loygue rectopexy is the operation recommended for patients in good general condition, especially if fecal incontinence is associated. In the course of the procedure, preservation of pelvic nerves and hypogastric plexus, and positioning of the strips not too tight between the anterolateral rectal walls and promontory must be emphasized. Posterior Orr-Loygue rectopexy is contraindicated when general anesthesis is too risky and when bowel dysfunction and/or rectal exoneration dysfunction are present.     

腹腔镜直肠悬吊固定术治疗直肠重度脱垂

目的探讨腹腔镜直肠悬吊固定术治疗直肠脱垂的临床应用价值。方法1998年3月至2007年2月,对4例完全性直肠脱垂患者进行了腹腔镜直肠悬吊固定术。1例采用缝合固定法,将直肠后壁分离、提高,用丝线缝闭直肠前陷凹,并将直肠后壁悬吊固定于骶骨岬前筋膜上,再将乙状结肠缝合固定在左侧腰大肌筋膜。3例采用网片固定法,将直肠游离到肛提肌水平,用1张6cm×9cm的T字型聚丙烯网片置于直肠后方,网片下缘在肛提肌水平环绕直肠,在直肠前方用丝线缝合网片和直肠浆肌层,再将网片上端在直肠后用疝修补钉夹固定于骶骨岬前筋膜,缝合关闭盆底腹膜。再将乙状结肠缝合固定在左侧腰大肌筋膜。结果4例患者手术均顺利,无中转开腹者。手术时间92.5(80-100)min,出血量6.5(5～10)ml。无并发症发生。术后尿失禁和肛门失禁的症状缓解,术后随访2个月至3年均未见复发与便秘出现。结论腹腔镜下行腹腔镜直肠悬吊固定术创伤小、恢复快和安全有效。     

Laparoscopic Protack™ rectopexy: Early experience of a novel technique for full thickness rectal prolapse in children

Background/purpose

To review our early experience of laparoscopic ProTack? rectopexy (LPR) in the management of full thickness rectal prolapse (FTRP) in children.

Surgery of genital prolapse using the abdominal approach. Experience of the surgery and gynecology department at the Salpêtrière Hospital

Excellent results lasting for at least 10 years were obtained in a series of 316 cases of genital prolapse operated upon through an abdominal approach in the Broca Center, Paris. Major sling-type operations, the source of multiple particularly urinary complications, have now been replaced by surgery usually involving a combination of the following: fixation to the promontory through the anterior ligament, an inter-vesicogenital Tergal triangle, a posterior perineorrhaphy, and sometimes an inter-rectovaginal triangle and/or a rectopexy. Rare septic complications resulted from opening of a viscus with subsequent spondylodiscitis requiring removal of the prosthesis. Acute intestinal obstruction is now rarely observed as a result of performing a subtotal hysterectomy, which enables effective peritonization to be conducted. The use of prosthetic material appears to provide durable anatomical results of good quality.     

Functional results two years after laparoscopic rectopexy

BACKGROUND: Rectopexy is one of the accepted treatment options for full-thickness rectal prolapse, but the details of the technique remain controversial. This unit has adopted a laparoscopic approach as an alternative to open surgery, and has used three techniques: mesh, suture, and resection. This retrospective study compares the long-term outcome.METHODS: From 1993 to 1995, 14 patients underwent a laparoscopic posterior mesh rectopexy. From 1996 to 1999, 34 patients underwent laparoscopic suture rectopexy with (n = 18) or without sigmoid resection (n = 16). RESULTS: There was no postoperative mortality, and morbidity was similar in the three groups, ranging from 11 to 19%. The mean follow-up was 47, 24, and 20 months for mesh, suture, and resection rectopexy, respectively. During follow-up, 1 patient in each group developed mucosal prolapse. There was no difference between the three groups for incontinence rate, which improved in more than 75% of patients who had impaired continence preoperatively. Postoperative constipation was observed in 2 patients (11%) after resection rectopexy, in 10 (62%) after suture rectopexy (P < 0.01 versus resection), and in 9 (64%) after mesh rectopexy (P < 0.01 versus resection). CONCLUSIONS: Our results show that the addition of sigmoid resection to laparoscopic rectopexy is safe and could contribute to reduce the risk of severe constipation after operation. Laparoscopic mesh rectopexy confers no advantage over the sutured technique, which we now use as our fixation method of choice.     

腹腔镜辅助下盆底腹膜带直肠悬吊术治疗儿童完全性直肠脱垂

目的探讨腹腔镜腹膜带直肠悬吊术治疗儿童完全性直肠脱垂的可行性及临床效果。方法2004年8月～2008年10月,对6例完全性直肠脱垂（年龄2～6岁,平均3.5岁）,在腹腔镜下利用直肠周围盆腔增厚松弛的腹膜,切取成两条＂L＂形带蒂腹膜条,折叠缝合固定于游离的直肠两侧壁,然后缝合在骶骨岬前的筋膜上悬吊直肠,最后将盆腔腹膜切缘缝合于直肠前壁包埋腹膜带并紧缩盆底。结果6例手术均获成功。手术时间95～210min,（120±24）min。术中出血〈10ml。术后随访6～54个月,平均28个月,均无脱垂复发,排便功能正常。结论腹腔镜下腹膜带直肠悬吊术治疗儿童完全性直肠脱垂效果良好,具有创伤小、恢复快、复发率低等优点,是一种具有较高临床应用价值的新术式。     

Ventral rectopexy for rectal procidentia

The main objective of this section is a detailed review of the new approach to rectal procidentia: minimally invasive nerve-sparing ventral rectopexy, laparoscopic ventral rectopexy (LVR), robotic ventral rectopexy (RVR), and its contextual relevance in the surgical treatment of rectal and pelvic organ prolapse. A brief review of rectal prolapse is offered outlining the main perineal and abdominal surgical approaches to its treatment. Further details regarding LVR and its effectiveness in treatment of pelvic organ prolapse, fecal incontinence, and constipation will be reviewed as it applies to external rectal prolapse (ERP) and internal rectal prolapse (IRP). Details regarding the implications of the type of mesh used and complication profile will be covered.     

It’s the procedure not the patient: the operative approach is independently associated with an increased risk of complications after rectal prolapse repair

Aim This study compares 30‐day outcomes following rectal prolapse repair, examining potential surgical and patient factors associated with perioperative complications. Method Using the NSQIP database, patients with rectal prolapse were categorized by surgical approach to repair (perineal or abdominal) and abdominal cases were further subdivided by procedure (resection compared with rectopexy alone). Univariate and multivariate analyses compared major and minor complication rates between the groups. Results Of 1275 patients, the perineal group (n = 706, 55%) was older, with more comorbidity, than those undergoing an abdominal procedure. There were fewer minor (odd ratio (OR) = 0.35; 95% confidence interval (CI), 0.20–0.60; P = 0.0038) and major complications (OR = 0.46; 95% CI, 0.31–0.80; P = 0.0038) in the perineal compared with the abdominal cohort. There was a significant increase in major complications amongst patients undergoing a resection compared with rectopexy only (OR = 2.15; 95% CI, 1.10–4.41; P = 0.0299). There was no difference in major complications between abdominal rectopexy and a perineal approach, but the latter had a lower chance of minor complications (OR = 0.47; 95% CI, 0.24–0.94; P = 0.0287). Conclusion A perineal approach is safer than an abdominal approach to the treatment of rectal prolapse. Regarding an abdominal operation, rectopexy has fewer major complications than resection.     

Rectal prolapse

Rectal prolapse and rectal intussuception correspond to two stages of the same disease. Rectal prolapse is unusual but requires surgical treatment. Abdominal rectopexy is the most effective procedure but increases the risk of postoperative constipation. This risk decreases when the lateral sides are not touched during rectal dissection. The Delorme procedure is associated with a higher rate of recurrence and must be reserved for patients presenting a high risk of postoperative complications. Rectal intussuception is more frequent and is pathological only when arising in the anal sphincter. Rectal intussuception may lead to solitary rectal ulcer and has in this case to be treated by rectopexy. Rectal intussuception involvement in terminal constipation is not yet proved. Internal mucosectomy seems to be the best treatment for terminal constipation.     

Mesh fistulation into the rectum after laparoscopic ventral mesh rectopexy

INTRODUCTION

Laparoscopic ventral mesh rectopexy (LVMR) is an effective method of management of functional disorders of the rectum including symptomatic rectal intussusception, and obstructed defaecation. Despite the technical demands of the procedure and common use of foreign body (mesh), the incidence of mesh related severe complications of the rectum is very low.

PRESENTATION OF CASE

A 63 year old woman presented with recurrent pelvic sepsis following a mesh rectopexy. Investigations revealed fistulation of the mesh into the rectum. She was treated with an anterior resection.

DISCUSSION

The intraoperative findings and management of the complication are described. Risk factors for mesh attrition and fistulation are also discussed.

CONCLUSION

Chronic sepsis may lead to ‘late’ fistulation after mesh rectopexy.     

Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction

Objective Whilst trans‐abdominal fixation +/? resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve‐sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor. Method A prospective database was used to audit our 7‐year experience of this technique. The recto‐vaginal septum was mobilized anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral promontory. Patients were assessed with questionnaires and Cleveland Clinic scores. Results Eighty patients, six males, median age 59 years (range 31–90) underwent laparoscopic prolapse surgery between Jan 1997 and Dec 2005; 55% had full thickness prolapse and 46% rectal anal intussusception. Five had a solitary rectal ulcer. A total of 58% had undergone previous surgery; hysterectomy 33%, posterior colporrhaphy 15%, posterior rectopexy 6%, Delorme's rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2–17) and 31% reported symptoms of obstructed defecation; seven had slow transit constipation and underwent resection. The median operative time was 125 min (range 50–210) with one conversion. Median time to diet was 12 h and median length of stay 3 days (1–12). No patient has developed recurrent full thickness prolapse at a median follow‐up of 54 months (30–96). Incontinence improved in 39 of 43 patients (91%); median post‐operative Wexner score 1 (0–9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence. Conclusion Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium‐term, it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.     

The optimal strategy for proximal mesh fixation during laparoscopic ventral rectopexy for rectal prolapse: an ex vivo study

Background

Laparoscopic ventral rectopexy (LVR) is an established technique for the treatment of rectal prolapse. Several techniques and devices can be used for proximal mesh fixation on the sacral promontory during this procedure. The aim of this study was to compare the fixation strength of a recently introduced screw for mesh fixation on the promontory during LVR with two other frequently used techniques.

Methods

An ex vivo experimental model using a porcine spinal column was designed to measure the strength of proximal mesh fixation. In a laparoscopic box trainer, a polypropylene mesh was anchored on the spinal column using three different fixation methods, i.e., the Protack 5-mm tacker device, Ethibond Excel 2-0 stitches, and the Karl Storz screw. Subsequently, increasing traction was applied to the mesh. This traction was applied at a standardized angle as determined by measuring the mean angle between the site of distal mesh fixation on the rectum and a line straight through the sacral promontory on 12 random dynamic MR scans of the pelvic floor after the LVR procedure. The applied force was measured at the moment that the fixation broke, using a calibrated electronic Newton meter. All fixation methods were tested ten times.

Results

The mean angle, as measured on the MR scans, was 100°. The mean disruption force, which led to a break of the proximal mesh fixation, was 58?N for the three Protack tacks, 55?N for the two stitches, and 70?N for the new screw. The use of a screw therefore led to a significantly stronger fixation compared to the use of stitches (p?≤?0.05). No significant difference was determined between the tacks and the screw fixation and between the tacks and the stitches fixation.

Conclusion

The new screw for proximal mesh fixation during LVR procedures offers similar fixation strength when compared to tacks. The use of one screw for proximal mesh fixation is therefore a reasonable alternative to the use of several tacks or sutures.     

Laparoscopic suture rectopexy for full-thickness anorectal prolapse in children: an effective outpatient procedure

Background/Purpose

Our approach to full-thickness anorectal prolapse has transitioned to laparoscopic suture rectopexy (LSRP). The purpose of this study was to describe the indications, technique, and postoperative outcomes for LSRP.

Methods

Rectopexy was performed using 3 or 4 laparoscopic ports. Redundant rectum was retracted from the pelvis, and the posterior rectal wall was secured to the sacral promontory using 3 permanent sutures.

Results

Nineteen children (7 girls) underwent LSRP from March 2003 to January 2008. Mean age was 6.2 ± 3.6 years. Three patients had prior perineal operations: 2 sacrococcygeal teratoma resections and 1 pull-through for Hirschsprung disease. One patient had cystic fibrosis, and another had Prader-Willi syndrome. The remaining children had either chronic constipation or idiopathic prolapse. All patients were treated preoperatively with laxatives. Two patients received antegrade continent enemas. Length of stay was 1 ± 0.8 days, with only the first 5 patients admitted to the hospital. The patient with Prader-Willi syndrome had a full-thickness recurrence (5%) owing to obsessive-compulsive behavior. Partial mucosal prolapse occurred in 2 patients. There were no other complications.

Conclusions

Laparoscopic suture rectopexy is an effective minimally invasive method to treat full-thickness rectal prolapse in children from various etiologies. It can be performed as an outpatient procedure with minimal morbidity and low recurrence rate (5%).     

Management of rectal prolapse: the role of laparoscopic approaches

Rectal prolapse is a lifestyle-altering disability which has been treated with over 100 surgical options. The specific goals of surgical management of full thickness rectal prolapse are to minimize the operative risk in this typically elderly population, eradicate the external prolapse of the rectum, improve continence, improve bowel function, and reduce the risk of recurrence. The theoretical advantages of a laparoscopic approach are to couple reductions in surgical morbidity and good post-operative outcome. Studies which compare the same laparoscopic and open surgical approach for rectal prolapse have demonstrated that laparoscopy confers benefits related to postoperative pain, length of hospital stay, and return of bowel function. Virtually every type of open transabdominal surgical approach to rectal prolapse has been laparoscopically accomplished. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis, with or without rectopexy. The growing body of literature supports the concept that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with full thickness rectal prolapse.     

Rectal prolapse in adults--causes, diagnostic, treatment

Despite progress in modern surgery, the choice of the surgical procedure of rectal prolapse is regarded with controversy. Selection criteria between the abdominal or perineal approach or between rectopexy and resection rectopexy are not yet proven. This article gives a review of the literature about rectal prolapse and an analysis of the outcome of posterior rectopexy and resection rectopexy--partly conventionally and partly laparoscopically--in 25 patients with rectal prolapse III degrees and IV degrees. All except for one patient were examined during a mean follow-up of 5.5 (3.1) years for the rectopexy group and 2.1 (0.7) years for the resection rectopexy group. Recurrence occurred in one patient in each group respectively. There was no significant difference concerning the continence function (p = 0.32) and constipation (p = 0.36) between both groups. No mesh-related complications such as infection, fistula or rectum stenosis were observed. According to the review of the literature and our data, we believe that the choice of the operative procedure for rectal prolapse should be based on individual criteria. Fit patients should be offered laparoscopic procedures such as resection rectopexy and rectopexy without colonic resection.     

The long-term results of polyvinyl alcohol (Ivalon) sponge for rectal prolapse in young patients

The long-term outcome of Ivalon sponge rectopexy for rectal prolapse in a group of young patients was reviewed. Thirty-two patients under the age of 40 underwent Ivalon sponge rectopexy between 1961 and 1975 with no mortality and one early complication. Twenty-five patients (9 men; 16 women) aged 13-39 years (median 28 years) at the time of operation were interviewed and examined in the Out-Patient Department between 5 and 20 years (median 10 years) after the operation. Five (20 per cent) had developed recurrence which occurred at 1, 1, 5, 6 and 9 years. There was no significant change in bowel habit postoperatively, with the exception of 3 patients with diarrhoea who reverted to normal. There was some disturbance in faecal continence pre-operatively in 20 patients, of whom 15 (75 per cent) were improved by rectopexy. All patients had normal urinary and sexual function, and there was no disturbance of menstruation in females following rectopexy. Three men who wished to have children were successful. Three of six women who attempted to conceive post-operatively had normal pregnancies and deliveries. The three women who failed to do so had already been investigated for infertility before the operation. No patient developed pelvic malignancy.     

Repair of rectal prolapse by rectosacral suture fixation

In 46 patients with complete rectal prolapse a simple method of rectopexy was used, fixing the mobilized rectum to the sacrum with sutures. In 17 cases the rectopexy was supplemented with levator sutures. The patients' age range was 20-87 years and follow-up was 6 months to 17 years. There was no associated mortality and almost no morbidity. Prolapse recurred in two cases, in one of them due to incomplete fixation because of a congenital pelvic deformity. Rectopexy with sutures seemed to give results as good as the Teflon mesh and Ivalon sponge methods in regard to recurrence rate, while avoiding the complication risks associated with insertion of foreign material.     

Transabdominelle Verfahren bei funktionellen Darmerkrankungen

Incontinence and constipation can occur in cases of pelvic floor dysfunction. Purely morphological changes without severe clinical symptoms are not an indication for surgery. Abdominal operations can be classified into procedures with dorsal (with or without bowel resection and with or without mesh implantation) and procedures with ventral rectopexy (with mesh). With respect to constipation and incontinence suture rectopexy alone is inferior to all other procedures. Dorsal and ventral mesh rectopexy and resection rectopexy are all comparable with respect to improvement of incontinence. Ventral rectopexy without dorsal mobilization and resection rectopexy are superior to mesh rectopexy with respect to constipation. Due to poor evidential status treatment is carried out from a pragmatic viewpoint.