Laparoscopic ventral rectopexy for internal rectal prolapse: short‐term functional results

Objective Over the last 15 years, posterior rectopexy, which causes rectal autonomic denervation, was discredited for internal rectal prolapse because of poor results. The condition became medical, managed largely by biofeedback. We aimed to audit the short‐term functional results of autonomic nerve‐sparing laparoscopic ventral rectopexy (LVR) for internal rectal prolapse. Method Prospectively collected data on LVR for internal rectal prolapse were analysed. End‐points were changes in bowel function (Wexner Constipation Score and Fecal Incontinence Severity Index) at 3 and 12 months. Analysis was performed using Mann–Whitney U‐test for unpaired data and Wilcoxon signed rank test for paired data (two‐sided p‐test). Functional outcomes were compared with those achieved previously for external rectal prolapse (ERP). Results Seventy‐five patients underwent LVR (median age 58, range 25–88 years, median follow up was 12 months). Mortality (0%), major (0%) and minor morbidity (4%) were acceptably low. Median length of stay was 2 days. Preoperative constipation (median Wexner score 12) and faecal incontinence (median FISI score 28) improved significantly at 3 months (Wexner 4, FISI 8, both P < 0.0001) and 12 months (Wexner 5, FISI 8, both P < 0.0001). No patient had worse function. Functional outcomes were similar to those for ERP. Conclusion Laparoscopic ventral rectopexy for internal rectal prolapse improves symptoms of obstructed defaecation and faecal incontinence in the short‐term. This establishes proof of concept for a nerve‐sparing surgical treatment for internal rectal prolapse.     

Surgery for occult rectal prolapse

OBJECTIVE: An 'occult' rectal prolapse may be diagnosed during investigation of altered bowel habit. It has been suggested that the outcome of surgery for these patients may be associated with results that are inferior to those achieved in patients with overt rectal prolapse. This study compares the results of surgery for 'occult' and overt rectal prolapse in terms of mortality, morbidity and change in bowel habit. PATIENTS AND METHODS: A retrospective review was undertaken of consecutive patients undergoing surgery for rectal prolapse during the decade 1988-98. Resection rectopexy was the treatment of choice except in patients with faecal incontinence who underwent sutured rectopexy. Those patients who were unfit for an abdominal operation were offered a perineal procedure. Outcome measures were mortality, morbidity, prolapse recurrence, constipation and faecal incontinence. Data were retrieved from case note review, clinical assessment, telephone consultation or postal questionnaire. RESULTS: Rectal prolapse surgery was undertaken in 69 patients with an overt prolapse and 74 patients with an 'occult' prolapse. Patients in the 'occult' prolapse group were significantly younger than those with overt prolapse (P = 0.0002). There were significantly more perineal procedures in the overt prolapse group compared with the 'occult' prolapse group (54% vs 5%, P = 0.0001). There were no deaths within 28 days of surgery. Major surgical complications occurred in 5 patients (3.5%). Seven patients (10%) experienced recurrent prolapse. Rectal prolapse surgery reduced the incidence of St. Mark's grade 4 faecal incontinence from 38% to 19% in the overt prolapse group (P = 0.023) and from 49% to 22% in the 'occult' prolapse group (P < 0.001). Following surgery the incidence of constipation increased in the 'occult' group from 39% to 50% but decreased in the overt prolapse group from 42% to 35%. CONCLUSIONS: Surgery for an 'occult' rectal prolapse is unlikely to benefit patients whose principle symptom is constipation. Approximately half of those patients whose 'occult' rectal prolapse is associated with faecal incontinence will have their bowel habit improved by prolapse surgery.     

The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra‐anal rectal intussusception

Aim Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra‐anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients. Method Forty consecutive patients with incontinence and intra‐anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded. Results The mean CCI scores were 13.2 (=/?4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as ‘cured’ in 26 (65%), ‘improved’ in 13 (32.5%) and ‘unchanged’ in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow‐up of 38 months. Conclusion Intra‐anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.     

Transsacral rectopexy for recurrent complete rectal prolapse

The aim of this study was to examine the functional outcome of transsacral rectopexy performed with Dexon mesh for recurrent complete rectal prolapse. Anorectal function was assessed by anorectal manometry and defecography, before and from 1 year after surgery in five patients who were followed up for 1–3 years. The fecal incontinence score recovered from a preoperative mean score of 3.8 to a postoperative mean score of 1.2, and constipation was improved in four patients (80%). The straining anorectal angle (S-ARA), measured by defecography, improved from a preoperative value of 120.6°±6.9° to a postoperative value of 98.5°±3.5° (P<0.05), and the perineal descent (PD) improved from a preoperative value of 16.2±2.5 cm to a postoperative value of 8.1±1.3 cm (P<0.05). The maximal resting pressure (MRP) increased from a preoperative value of 20.5±3.7 cmH₂O to a postoperative value of 40.5±4.8 cmH₂O (P<0.05). These findings indicate that transsacral rectopexy with Dexon mesh can achieve good control of recurrent complete rectal prolapse.     

Closed rectopexy with transanal resection for complete rectal prolapse in adults

Many techniques have been described for repair of complete rectal prolapse in adults. The results of abdominal approaches are superior to those of perineal approaches, but they carry the risks of major abdominal surgery. Twenty-seven patients (15 females and 12 males) were included in this study, with a mean age of 46 years. Nine of these patients had fecal incontinence. The operation can be performed under spinal or general anesthesia. The operation involves transanal resection of the redundant part of the rectum followed by rectopexy through small postanal incisions. The mean follow-up period was 24 months. One patient developed infection in one stab incision 6 months after the operation. Two patients had hematoma formation, which were managed conservatively. During the 2-year period of follow-up, no recurrence was observed in any of our patients. Fecal incontinence improved in the nine incontinent patients. The technique is simple, easy, and less invasive with good results and less morbidity and is not associated with serious complications.     

Systematic review on ventral rectopexy for rectal prolapse and intussusception

Objective This systematic review assesses the effectiveness of ventral rectopexy (VR) surgery for treatment of rectal prolapse (RP) and rectal intussusception (RI) in adults. Method MEDLINE, EMBASE, Scopus and other relevant databases were searched to identify studies. Randomized controlled trials or nonrandomized studies with more than 10 patients receiving ventral mesh rectopexy surgery were considered for the review. Results Twelve nonrandomized case series studies with 728 patients in total are included in the review. Seven studies used the Orr‐Loygue procedure (VR with posterior rectal mobilization to the pelvic floor) and five studies used VR without posterior rectal mobilization. Overall weighted mean percentage decrease in faecal incontinence (FI) rate was 45%. The weighted mean percentage decrease in constipation rate was 24%. Weighted mean recurrence rate was 3.4%. Conclusions There are limitations in published literature on VR. The available data indicate that VR has low recurrence and improves FI in patients suffering from these conditions. There is a greater reduction in postoperative constipation if VR is used without posterior rectal mobilization.     

Incontinence in full‐thickness rectal prolapse: low level of improvement after laparoscopic rectopexy

Aim The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse. Method Eighty‐five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self‐administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery. Results After a mean follow‐up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (?3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients’ average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P < 0.0001) were significantly higher in patients suffering from postoperative incontinence. Conclusion Despite some continence improvement in two‐thirds of patients who underwent surgery for rectal prolapse, the level of improvement remained low in more than half of the patients.     

SEPSIS AFTER IVALON SPONGE RECTOPEXY AN UNUSUAL CASE

A case with an unusual presentation of sepsis after Ivalon sponge rectopexy is reported. A strong index of suspicion is important for correct diagnosis. Early removal of infected sponge allows quick resolution of the sepsis without recurrent prolapse.     

腹腔镜直肠缝线固定术:一种治疗完全性直肠脱垂的简便有效术式

【摘要】〓目的〓探讨腹腔镜直肠缝线固定术治疗完全性直肠脱垂的临床效果。方法〓对我院2010年1月至2014年1月采用腹腔镜直肠缝线固定术治疗的36例完全性直肠脱垂病例进行观察,并与同期采用腹腔镜直肠补片固定术治疗的16例同病种病例进行对照。结果〓采用直肠缝线固定术的平均手术时间明显短于直肠补片固定术(110±13 min vs 120±9 min,P<0.05),而且住院费用也较低(16227±845元 vs 19143±1163元,P<0.05)。两组在平均术中出血量、平均术后肛门恢复排气时间、平均术后住院时间方面相比均无统计学差异。两组患者均无术后早期并发症。中位随访时间26个月,两组患者在术后1月和术后1年的直肠脱垂复发率、Wexner便秘评分、胃肠生活质量指标GIQLI均无显著性差异(P>0.05)。结论〓腹腔镜直肠缝线固定术对治疗完全性直肠脱垂具有手术创伤小、恢复快、住院时间短、费用低等优点,而近期和远期随访均具有满意的效果。     

Open vs laparoscopic repair of full‐thickness rectal prolapse: a re‐meta‐analysis

Objective A re‐meta‐analysis of available data within the published literature comparing laparoscopic rectopexy (LR) with open repair (OR). Method We searched MEDLINE, EMBASE, CINAHL, PubMed and the Cochrane databases from January 1990 to October 2008. We searched the following MESH terms: ‘laparoscopy’, ‘prolapse’ and ‘rectal prolapse’. We used the following text words: ‘rectopexy’, ‘haemorrhoids’, ‘minimally invasive’ and ‘keyhole surgery’. The bibliography of selected trials and a Cochrane review was scrutinized and relevant references obtained. Selected trials were analysed to conduct a meta‐analysis. Results Twelve comparative studies on 688 patients qualified for the review. There were 330 patients in LR group and 358 in the OR group. LR takes longer to perform compared with OR. This difference was statistically significant [random effects model: standardized mean difference (SMD) 1.63, 95% CI (1.14–2.12), z = 6.56, P < 0.001]. There was a significant reduction in hospital stay between LR vs OR [random effects model: SMD ?1.75, 95% CI (?2.45 to ?1.05), z = ?4.90, P < 0.001]. There was no statistical difference relating to morbidity, constipation, incontinence or mortality between the two groups. Conclusion laparoscopic rectopexy is a safe and effective modality and is comparable to OR, however, there is still a paucity of randomized controlled trials within the literature regarding this subject. Until these trials are conducted, we would advise caution in deriving absolute conclusions.     

Laparoscopic ventral mesh rectopexy for complete rectal prolapse: A retrospective study evaluating outcomes in North Indian population

AIM: To analyze the outcomes of laparoscopic ventral mesh rectopexy in the management of complete rectal prolapse(CRP) in North Indian patients with inherent bulky and redundant colon. METHODS: The study was conducted at a tertiary health care center of North India. Between January 2010 and October 2014, 15 patients who underwent laparoscopic ventral mesh repair for CRP, were evaluated in the present study. Perioperative outcomes, improvement in bowel dysfunction or appearance of new complications were documented from the hospital records maintained prospectively. RESULTS: Fifteen patients(9 female) with a median age of 50 years(range, 15-68) were included in the study. The median operative time was 200 min(range, 180-350 min) and the median post-operative stay was 4 d(range, 3-21 d). No operative mortality occurred. One patient with inadvertent small bowel injury required laparotomy on post-operative day 2. At a median follow-up of 22 mo(range, 4-54 mo), no prolapse recurrence was reported. No mesh-related complication was encountered. Wexner constipation score improved significantly from the preoperative value of 17(range, 5-24) to 6(range, 0-23)(P < 0.001) and the fecal incontinence severity index score from 24(range, 0-53)to 2(range, 0-53)(P = 0.007). No de novo constipation or fecal incontinence was recorded during the followup. On personal conversation, all patients expressed satisfaction with the outcome of their treatment. CONCLUSION: Our experience indicates that laparoscopic ventral mesh rectopexy is an effective surgical option for CRP in North Indian patients having a bulky redundant colon.