Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach

Abdominal versus perineal approach for external rectal prolapse: systematic review with meta-analysis

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.

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.

Laparoscopic Sutureless Rectopexy Using a Fixation Device for Complete Rectal Prolapse

BACKGROUND

Complete rectal prolapse (CRP) commonly affects the daily life of older people and has no established operative treatment approach. We describe our simple method of laparoscopic, sutureless rectopexy, involving rectal mobilization (along with its peritoneum bilaterally) and fixation to the sacral promontory using a fixation device. We also present an analysis of short-term outcomes in patients treated using this procedure.

MATERIALS AND METHODS

We retrospectively evaluated 62 patients with CRP, who underwent a laparoscopic rectopexy via tack fixation, between 2004 and 2017. The peritoneum was widely attached near the site of peritoneal reflection, as in rectal cancer surgery. The hypogastric nerve was carefully detached from the front of the sacrum. Keeping the nerve intact, we lifted and mobilized the dissected rectum cranially towards the promontory, and the rectal peritoneum was affixed to the sacrum by applying 2 to 3 fixed tacks bilaterally, using a fixation device.

RESULTS

The median age of the study group was 80 (10 to 91) years. All procedures were successful without serious intraoperative complications; only 1 patient required conversion to open surgery. Median values for operative duration, intraoperative blood loss, and postoperative period of hospitalization were 177 (125 to 441) minutes, 5 (0 to 275) mL, and 7 (3 to 17) days, respectively. Only 6 (9.7%) patients experienced recurrence during the follow-up period.

CONCLUSION

Laparoscopic tacking rectopexy performed using a fixation device for repairing CRP is a simple, safe, and sutureless procedure with no severe complications or 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.

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.

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.

METHODS

Prospective case series of patients undergoing LPR between 2013 and 2017. Full laparoscopic mobilization of the rectum was performed from the sacral promontory to the pelvic floor. 'Wings' of the lateral mesorectal peritoneum left attached to the rectum are then fixed to the sacral promontory using ProTack™. Demographics, associated conditions, previous procedures for FTRP, follow up time, length of stay (LOS), short and long term complications and clinical improvement were assessed.

RESULTS

Seven consecutive patients with FTRP underwent LPR. The mean age was 9 years old (2-17) with a male to female ratio of 6:1. Median LOS was 1 day (1-2 days). Median follow up time was 17 months (10-38 months). All patients had complete resolution of symptoms within the follow up period.

CONCLUSIONS

LPR is a simple, safe and effective procedure showing promising results in children. It negates the risks associated with the use of mesh and has the potential to avoid the higher risk of failure associated with suture rectopexy. It is important to ensure patients receive adequate analgesia and management of postoperative constipation.

Laparoscopic Posterolateral Rectopexy for the Treatment of Patients With a Full Thickness Rectal Prolapse: Experience With 63 Patients and Short-term Outcomes

Purpose

Although numerous procedures have been proposed for the treatment of patients with a rectal prolapse, the most effective operation has not yet been established. Minimal rectal mobilization can prevent constipation; however, it is associated with increased recurrence rates. We describe our novel method for a laparoscopic posterolateral rectopexy, which includes rectal mobilization with a posterior-right unilateral dissection, suture fixation to the sacral promontory with a polypropylene mesh (Optilene), and a mesorectal fascia propria that is as wide as possible. The present report describes our novel method and assesses the short-term outcomes of patients.

Methods

Between June 2014 and June 2017, 63 patients (28 males and 35 females) with a full-thickness rectal prolapse underwent a laparoscopic posterolateral (LPL) rectopexy. We retrospectively analyzed the clinical characteristics and postoperative complications in those patients. The outcome of surgery was determined by evaluating the answers on fecal incontinence questionnaires, the results of anal manometry preoperatively and 3 months postoperatively, the patients’ satisfaction scores (0–10), and the occurrence of constipation.

Results

No recurrence was reported during follow-up (3.26 months), and 3 patients reported postoperative complications (wound infection, postoperative sepsis, which was successfully treated with conservative management, and retrograde ejaculation). Compared to the preoperative baseline, fecal incontinence at three months postoperatively showed an overall improvement. The mean patient satisfaction score was 9.55 ± 0.10, and 8 patients complained of persistent constipation.

Conclusion

LPL rectopexy is a safe, effective method showing good functional outcomes by providing firm, solid fixation for patients with a full-thickness rectal prolapse.

Optimizing Treatment for Rectal Prolapse

Rectal prolapse is associated with debilitating symptoms and leads to both functional impairment and anatomic distortion. Symptoms include rectal bulge, mucous drainage, bleeding, incontinence, constipation, tenesmus, as well as discomfort, pressure, and pain. The only cure is surgical. The optimal surgical repair is not yet defined though laparoscopic rectopexy with mesh is emerging as a more durable approach. The chosen approach should be individually tailored, taking into account factors such as presence of pelvic floor defects and coexistence of vaginal prolapse, severe constipation, surgical fitness, and whether the patient has had a previous prolapse procedure. Consideration of a multidisciplinary approach is critical in patients with concomitant vaginal prolapse. Surgeons must weigh their familiarity with each approach and should have in their armamentarium both perineal and abdominal approaches. Previous barriers to abdominal procedures, such as age and comorbidities, are waning as minimally invasive approaches have gained acceptance. Laparoscopic ventral rectopexy is one such approach offering relatively low morbidity, low recurrence rates, and good functional improvement. However, proficiency with this procedure may require advanced training. Robotic rectopexy is another burgeoning approach which facilitates suturing in the pelvis. Successful rectal prolapse surgeries improve function and have low recurrence rates, though it is important to note that correcting the prolapse does not assure functional improvement.

Single port laparoscopic mesh rectopexy

Introduction

Traditionally, laparoscopic mesh rectopexy is performed with four ports, in an attempt to improve cosmetic results. Following laparoscopic mesh rectopexy there is a new operative technique called single-port laparoscopic mesh rectopexy.

Aim

To evaluate the single-port laparoscopic mesh rectopexy technique in control of rectal prolapse and the cosmesis and body image issues of this technique.

Material and methods

The study was conducted in El Fayoum University Hospital between July 2013 and November 2014 in elective surgery for symptomatic rectal prolapse with single-port laparoscopic mesh rectopexy on 10 patients.

Results

The study included 10 patients: 3 (30%) males and 7 (70%) females. Their ages ranged between 19 years and 60 years (mean: 40.3 ±6 years), and they all underwent laparoscopic mesh rectopexy. There were no conversions to open technique, nor injuries to the rectum or bowel, and there were no mortalities. Mean operative time was 120 min (range: 90–150 min), and mean hospital stay was 2 days (range: 1–3 days). Preoperatively, incontinence was seen in 5 (50%) patients and constipation in 4 (40%). Postoperatively, improvement in these symptoms was seen in 3 (60%) patients for incontinence and in 3 (75%) for constipation. Follow-up was done for 6 months and no recurrence was found with better cosmetic appearance for all patients.

Conclusions

Single-port laparoscopic mesh rectopexy is a safe procedure with good results as regards operative time, improvement in bowel function, morbidity, cost, and recurrence, and with better cosmetic appearance.

Rectal Prolapse in Women-Outcomes of Perineal and Abdominal Approaches

The aim of the study was to assess the clinical and functional results of surgical treatment of female patients with rectal prolapse. In the period of 2003-2010, the group of 86 female patients (mean age of 67 ± 10) underwent surgery due to rectal prolapse. The group of 24 patients (27.9 %) suffered from mild anal incontinence. They were operated on with open sutured rectopexy (18 pts), Altemeier (45 pts) and Delorme procedure (23 pts). Prior to surgery and after operation, clinical and function results were obtained. The follow-up period amounted to 32 ± 11 months. In perineal approaches, we found mortality in one patient (1.4 %, Delorme) and anastomotic leak in four patients (5.9 %). The recurrence rate in the perineal group was 11.8 % (eight patients). We noted one recurrence in the rectopexy group (5.6 %). The Altemeier procedure revealed the most significant impact on the function of the anal sphincter muscles and resting pressures (42 ± 7 vs 53 ± 9 cm H2O; p = 0.0082). If anterior levatoroplasty was added, the benefits referred also to squeeze pressures (41 ± 8 vs 58 ± 9 cm H2O; p = 0.006 and 42 ± 10 vs 56 ± 9 cm H2O; p = 0.01). In the treatment of rectal prolapse, there is still no consensus about the operation of choice. Selection of the appropriate method should be based on clinical findings and patients' comorbidities to obtain maximal benefits and minimize the postoperative risk and failures.

The role of synthetic and biologic materials in the treatment of pelvic organ prolapse

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

Perineal Stapled Prolapse Resection

Perineal stapled prolapse resection is a new technique for external rectal prolapse introduced in 2007. We have done stapled perineal resection for 12 patients with full thickness rectal prolapse between January 2010 and April 2012. Elderly patients with comorbidities and young patients who want to avoid risk of nerve damage, with rectal prolapse up to 8-10 cms were included prospectively for perineal stapled rectal prolapse resection. Functional outcome, complications, operating time, and hospital stay were assessed in all patients. Perineal stapled prolapse resection was performed without major complications in a median operating time of 45 (range, 40-90) min and median Hospital stay was 3 days (3 to 11 days). Preoperative severe fecal incontinence and constipation improved postoperatively in 90 and 66 % of the patients, respectively, and there was no incidence of de novo onset or worsening of constipation in any of the patient. One patient developed small extra peritoneal collection which was managed by conservative treatment. No other complications occurred. At median follow-up of 36 months, all patients were well and showed no early recurrence of prolapse. Perineal stapled rectal prolapse resection is a new surgical procedure for external rectal prolapse, which is safe, easy, and quick to perform.

Laparoscopic ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results

AIM

We report the clinical and anal manometric results of elderly patients treated with laparoscopic ventral rectopexy (LVR) for full-thickness rectal prolapse.

METHOD

From March 2009 to June 2012, patients were consecutively included. A modified laparoscopic Orr-Loygue procedure with posterior mobilisation was used. The patients were evaluated preoperatively, 2 months postoperatively and after 1 year. We registered Wexner incontinence scores and laxative uses by a questionnaire and performed simple anal manometry.

RESULTS

A total of 46 patients underwent operation, all women. The median age was 83 years (range 34-99), median prolapse size was 8 cm (range 2-15), and 30 % had previous prolapse surgery. The median operative time was 135 min (range 90-215), and the median length of stay was 2 days (range 1-14). The 30-day morbidity rate was 15 %, and there were two (4 %) deaths within 30 days. There was a significant reduction in incontinence scores after 2 months and 1 year. The anal resting pressures improved from 10 cm H(2)O slightly to 16 cm H(2)O after 2 months, significantly, and still significant after 1 year at 13 cm H(2)O. There were no changes in the use of laxatives. The median follow-up time was 1.5 years (range 0.5-3), and there were two prolapse recurrences (4 %) in this period.

CONCLUSIONS

Laparoscopic ventral rectopexy with posterior mobilisation seems to be effective and relatively well tolerated, although not without mortality in elderly debilitated patients. It improves incontinence. With increased life-year expectance, these patients may benefit from a lower risk of recurrence compared with perineal procedures.

Laparoscopic Rectopexy for Rectal Prolapse: Will it be the Gold Standard?

A review of the current literature is presented regarding the surgical management of full thickness rectal prolapse, comparing laparoscopic rectopexy with open abdominal operations and perineal procedures. Outcome measures include length of stay, short- and long-term outcomes and financial burdens. Current evidence suggests that laparoscopic rectopexy as treatment for full thickness rectal prolapse is a safe alternative to the other options.

A single centre comparative study of laparoscopic mesh rectopexy versus suture rectopexy

AIM:

The aim of our study is to compare the results of laparoscopic mesh vs. suture rectopexy.

MATERIALS AND METHODS:

In this retrospective study, 70 patients including both male and female of age ranging between 20 years and 65 years (mean 42.5 yrs) were subjected to laparoscopic rectopexy during the period between March 2007 and June 2012, of which 38 patients underwent laparoscopic mesh rectopexy and 32 patients laparoscopic suture rectopexy. These patients were followed up for a mean period of 12 months assessing first bowel movement, hospital stay, duration of surgery, faecal incontinence, constipation, recurrence and morbidity.

RESULTS:

Duration of surgery was 100.8 ± 12.4 minutes in laparoscopic suture rectopexy and 120 ± 10.8 min in laparoscopic mesh rectopexy. Postoperatively, the mean time for the first bowel movement was 38 hrs and 40 hrs, respectively, for suture and mesh rectopexy. Mean hospital stay was five (range: 4-7) days. There was no significant postoperative complication except for one port site infection in mesh rectopexy group. Patients who had varying degree of incontinence preoperatively showed improvement after surgery. Eleven out of 18 (61.1%) patients who underwent laparoscopic suture rectopexy as compared to nine of 19 (47.3%) patients who underwent laparoscopic mesh rectopexy improved as regards constipation after surgery.

CONCLUSION:

There were no significant difference in both groups who underwent surgery except for patients undergoing suture rectopexy had better symptomatic improvement of continence and constipation. Also, cost of mesh used in laparoscopic mesh rectopexy is absent in lap suture rectopexy group. To conclude that laparoscopic suture rectopexy is a safe and feasible procedure and have comparable results as regards operative time, morbidity, bowel function, cost and recurrence or even slightly better results than mesh rectopexy.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature

BACKGROUND

Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there are few long-term follow-up and functional outcome data available. Using meta-analysis techniques, this study was designed to evaluate long-term results of open and laparoscopic abdominal procedures to treat full-thickness rectal prolapse in adults.

METHODS

A literature review was performed using the National Library of Medicine's PubMed database. All articles on abdominal rectopexy patients with a follow-up longer than 16 months were considered. The primary end point was recurrence of rectal prolapse, and the secondary end points were improvement in incontinence and constipation. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.

RESULTS

Eight comparative studies, consisting of a total of 467 patients (275 open and 192 laparoscopic), were included. Analysis of the data suggested that there is no significant difference in recurrence, incontinence and constipation improvement between laparoscopic abdominal rectopexy and open abdominal rectopexy. Considering non-comparative trials, the event rate for recurrence was similar in open and laparoscopic suture rectopexy studies and in open and laparoscopic mesh rectopexy trials. Improvement in constipation after the intervention was not statistically significant except for open mesh repair; postoperative improvement in incontinence was statistically significant after laparoscopic procedures and open mesh rectopexy.

CONCLUSIONS

Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regard to recurrence, incontinence and constipation. However, large-scale randomized trials, with comparative, strong methodology, are still needed to identify outcome measures accurately.

Rectal prolapse: review according to the personal experience

The aim of treatment of rectal prolapse is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. Faced with a multitude of options, the choice of an optimal treatment is difficult. It is best tailored to patient and surgeon. Numerous procedures have been described and are generally categorized into perineal or abdominal approaches. In general, an abdominal procedure has associated with lower recurrence and better functional outcome than perineal procedures. The widespread success of laparoscopic surgery has led to the development of laparoscopic procedures in the treatment of complete rectal prolapse. In Korea, there has been a trend toward offering perineal procedures because of the high incidence of rectal prolapse in young males and its being a lesser procedure. Delorme-Thiersch procedure has appeal as a lesser procedure for patients of any age or risk category, especially for elderly low-risk patients, patients with constipation or evacuation difficulties, young males, and patients with symptomatic hemorrhoids or mucosal prolapse. Laparoscopic suture rectopexy is recommended for either low-risk female patients or patients who are concerned with postoperative aggravation of their incontinence.

Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients

BACKGROUND

The balance between abdominal and perineal approaches for rectal prolapse is always the higher morbidity but better outcome in the former setting. Therefore, perineal approaches have been preferred for the treatment of full-thickness rectal prolapse (FTRP) in elderly patients. However, laparoscopic rectopexy with or without resection also may be used for elderly patients and may confer the same benefits.

PURPOSE

The objective of this study was to evaluate safety and efficacy of laparoscopic rectopexy compared with perineal rectosigmoidectomy for FTRP in elderly patients.

METHODS

Between July 2000 and June 2009, eight consecutive patients (8 women; mean age, 71 (range, 65-77) years) with FTRP underwent laparoscopic rectopexy (LAP group). During the same period, 143 patients underwent perineal rectosigmoidectomy (PRS group). A total of 123 patients were selected who underwent perineal rectosigmoidectomy (117 women; mean age, 80.7 (range, 66-98) years).

RESULTS

Three patients (37.5%) in the LAP group and 29 patients (23.6%) in the PRS group had undergone previous operations for rectal prolapse. The mean follow-up periods were 6.9 months and 12.8 months, respectively. In the LAP group, operative time was longer (166.5 vs. 73.5 minutes; p > 0.05) and bleeding loss was more (101.7 vs. 31.6; p < 0.05), whereas the length of hospitalization was same between the two groups (5.4 vs. 5.3 days; p > 0.05). Postoperative complications included an incisional hernia in the LAP group (12.5%) and urinary retention (4.8%), anastomotic disruption (2.4%), urinary tract infection (1.6%), and atelectasis (1.6%) in the PRS group (13.8%). Recurrences were 1 (12.5%) in the LAP group and 14 (11.4%) in the PRS group.

CONCLUSIONS

Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with FTRP but results in increased operative time.

Surgical treatment of rectal prolapse

Rectal prolapse is defined as a protrusion of the rectum beyond the anus. Although rectal prolapse was recognized as early as 1500 BC, the optimal surgical procedure is still debated. The varied operative procedures available for treating rectal prolapsed can be confusing. The aim of treatment is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. In elderly and high-risk patients, perineal approaches, such as Delorme's operation and Altemeier's operation, have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Abdominal operations involve dissection and fixation of the rectum and may include a rectosigmoid resection. From the late twentieth century, the laparoscopic procedure has been applied to the treatment of rectal prolapse. 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 choice of surgery depends on the status of the patient and the surgeon's preference.

No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial

BACKGROUND

No randomized controlled trial has compared no rectopexy with rectopexy for external full-thickness rectal prolapse.

OBJECTIVE

This study was performed to test the hypothesis that recurrence rates following no rectopexy are not inferior to those following rectopexy for full-thickness rectal prolapse.

DESIGN

This was a multicenter randomized controlled trial. Eligible patients were randomly assigned to no rectopexy or rectopexy. The end point was recurrence rates defined as the presence of external full-thickness rectal prolapse after surgery. A prerandomized controlled trial meta-analysis suggested a sample size of 251 patients based on a 15% expected difference in the 5-year cumulative recurrence rate. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively. Data were presented as median (range).

SETTING

This study was conducted in 41 tertiary centers in 21 countries.

PATIENTS

Patients with prior surgery for rectal prolapse or pelvic floor descent were not included.

INTERVENTIONS

The no-rectopexy arm was defined as abdominal surgery with rectal mobilization only. The rectopexy arm was defined as abdominal surgery with mobilization and rectopexy. Sigmoid resection was not randomized and was added in the presence of constipation.

MAIN OUTCOME MEASURES

Two hundred fifty-two patients with external full-thickness rectal prolapse were randomly assigned to undergo no rectopexy or rectopexy in 41 centers. All patients but one underwent the allocated intervention. One hundred sixteen no-rectopexy patients were comparable to 136 rectopexy patients for age (P = .21), body mass index (P = .61), ASA grade (P = .29), and previous abdominal surgery (P = .935), but not for sex (P = .013) and external full-thickness rectal prolapse length (8 (1-25) cm vs 5 (1-20) cm, P = .026). Sigmoid resection was performed more frequently in the no-rectopexy arm (P < .001). There was no significant difference in complication rates (11% vs 17.9%; P = .139). The mortality rate was 0.8%. The loss of patients to 5-year follow-up was 10.3%. Actuarial analysis demonstrated a significant difference in 5-year recurrence rates between study arms (8.6% vs 1.5%) (log-rank, P = .003).

LIMITATIONS

Limitations were the high proportion of male patients, randomization timing, the lack of standardization for rectopexy technique, and the 10% loss to follow-up.

CONCLUSIONS

Recurrence rates following no rectopexy are inferior to those following rectopexy for external full-thickness rectal prolapse.

Abdominal approaches for rectal prolapse

The management of full-thickness rectal prolapse involves surgical intervention in the majority of cases. Many procedures have been described employing both perineal and abdominal approaches. Abdominal procedures result in more durable repair of the prolapse; however, the procedures require general anesthesia and are reserved for younger healthier patients. Laparoscopy has been utilized in the treatment of rectal prolapse since its introduction for colorectal procedures; recent studies have found equivalent long-term results and short-term outcomes.

Posterior sagittal approach for mesh rectopexy as a management of complete rectal in adults

OBJECTIVES

The aim of this study was to evaluate prospectively the functional outcome of posterior sagittal rectopexy with prolene mesh for rectal prolapse in young adults.

PATIENTS AND METHODS

The study was carried out on 32 patients, 21 were males (65.63%) presented with complete rectal prolapse with a mean age of 36.7 +/- (range, 28-45) years. All patients were subjected to preoperative colonoscopy, clinical assessment, and anorectal manometry, dynamic magnetic resonance defecography before and after posterior sagittal rectopexy with prolene mesh. Anal incontinence and constipation were evaluated using a Wexner scale and Cleveland clinic constipation score, respectively. The patients were followed for a mean of 18.7 +/- 6.4 months.

RESULTS

Fecal incontinence score recovered from 11.1 +/- 4.3 to 4.38 +/- 6.7, and constipation was improved in 13 out of 15 cases (86.57%). Straining anorectal angle (S-ARA) by MRI defecography improved from 127.2 +/- 5.9 degrees of 93.5 +/- 4.5 degrees (P < 0.05), perineal descent (PD) improved from 15.9 +/- 3.1 cm to 7.3 +/- 1.5 cm (P < 0.05). Maximal resting pressure (MRP) increased from 19.8 +/- 4.7 cm H(2)O to 43.5 +/- 3.9 cm H(2)O (P < 0.05). No mortality occurred, single case of recurrence of prolapse (3.22%), mucosal prolapse in two patients (6.44%), and mild wound infection in three patients (9.38%).

CONCLUSION

These findings indicate that posterior sagittal rectopexy with prolene mesh in adults with rectal prolapse is an effective technique, with excellent functional results and without major morbidities, but still long-term results are awaited.

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.

Functional outcome after perineal stapled prolapse resection for external rectal prolapse

Background

A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up.

Methods

From December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour^® Transtar™ stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores.

Results

32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (P < 0.0001). No new incidence of constipation was reported.

Conclusions

The PSP is an elegant, fast and safe procedure, with good functional results.

Trial registration

ISRCTN68491191

Haemorrhoids, rectal prolapse, anal fissure, peri-anal fistulae and sexually transmitted diseases

Anorectal disorders like haemorrhoids, rectal prolapse, anal fissures, peri-anal fistulae and sexually transmitted diseases are bothersome benign conditions that warrant special attention. They, however, can all be diagnosed by inspection or proctoscopy (sexually transmitted proctitis). Constipation can play an underlying role in haemorrhoids, rectal prolapse and anal fissures, and it is important to treat these conditions in order to avoid recurrences. Haemorrhoids and anal fissures are generally treated conservatively and surgery is seldom required. Rectal prolapse and cryptoglandular peri-anal fistulae are treated surgically. In a recurrent peri-anal fistula, the fistular tract needs to be visualised with anal ultrasound or magnetic resonance imaging (MRI). There are different techniques available for this evaluation, and care must be taken not to damage the anal sphincter. Peri-anal fistulae in Crohn's disease are treated conservatively and surgery is only required in cases with abscesses. Sexually transmitted proctitis needs to be adequately recognised and treated according to the infectious agent.

Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*

OBJECTIVE

Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period.

METHOD

Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months).

RESULTS

Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05).

CONCLUSION

Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.

Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.

Robot-assisted laparoscopic rectovaginopexy for rectal prolapse: a prospective cohort study on feasibility and safety

Robotic systems may be particularly supportive for procedures requiring careful pelvic dissection and suturing in the Douglas pouch, as in surgery for rectal prolapse. Studies reporting robot-assisted laparoscopic rectovaginopexy for rectal prolapse, however, are scarce. This prospective cohort study evaluated the outcome of this technique up to one year after surgery. From January 2005 to June 2006, 15 consecutive patients with a rectal prolapse, either with or without a concomitant rectocele or enterocele, underwent robot-assisted laparoscopic rectovaginopexy with support of the da Vinci robotic system. A prospective cohort study was performed on operating times, blood loss, intra-operative and post-operative complications, and outcome at a minimum of one year after surgery. Median age at time of operation was 62 years (33-72) and median body mass index 24.9 (20.9-33.9). Median robot set-up time was 10 min (3-15) and median skin-to-skin operating time was 160 min (120-180). No conversions to open surgery were necessary. No in-hospital complications occurred and there was no mortality. Median hospital stay was four days (2-9). During one year follow-up, two patients needed surgical reintervention. One patient was operated for recurrent enterocele and rectocele one week after surgery. In another patient an incisional hernia at the camera port occurred three months after surgery. At one year after surgery, 87% of patients claimed to be satisfied with their postoperative result. Robot-assisted laparoscopic rectovaginopexy proved to be an effective technique with favourable outcomes in most patients in this prospective series. The operating team experienced the support of the robotic system as beneficial, especially during the dissection of the rectovaginal plane and suturing in the Douglas pouch.

Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse. A prospective study

BACKGROUND

Laparoscopic rectopexy offers the advantages of the open transabdominal approach while decreasing the surgical comorbidity. The aim of this prospective study was to assess the clinical and functional outcome of laparoscopic Wells procedure for full-thickness rectal prolapse.

METHODS

Between 1999 and 2005, 77 patients underwent laparoscopic modified Wells procedure for full-thickness rectal prolapse. The patients were evaluated postoperatively for resolution of their prolapse and functional outcome, as well as for their satisfaction level regarding the procedure.

RESULTS

Laparoscopy was successful in all but one case. There were no major intra- or postoperative complications and the mean hospital stay was 4.9 days. Approximately half of the patients had some degree of fecal incontinence preoperatively. At long-term follow up, 89 percent experienced alleviation of symptoms. Constipation was improved in 36% of cases. Eighteen percent of the patients suffered a new onset of constipation. Recurrent prolapse was observed in one patient. Ninety percent of the patients were satisfied at long-term follow-up.

CONCLUSION

The laparoscopic Wells procedure for rectal prolapse had good functional results, a low recurrence rate and proved to be a feasible and safe procedure. Postoperative constipation remains a problem, which should be solved.

Rectal prolapse

INTRODUCTION

Rectal prolapse, or procidentia, is defined as a protrusion of the rectum beyond the anus. It commonly occurs at the extremes of age. Rectal prolapse frequently coexists with other pelvic floor disorders, and patients have symptoms associated with combined rectal and genital prolapse. Few patients, a lack of randomized trials and difficulties in the interpretation of studies of anorectal physiology have made the understanding of this disorder difficult.

METHODS OF TREATMENT

Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation, whereas in patients with concurrent genital and rectal prolapse, an interdisciplinary surgical approach is required. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms. Numerous surgical procedures have been suggested to treat rectal prolapse. They are generally classified as abdominal or perineal according to the route of access. However, the controversy as to which operation is appropriate cannot be answered definitively, as the extent of a standardized diagnostic assessment and the types of surgical procedures have not been identified in published series.

LITERATURE REVIEW

This review encompasses rectal prolapse, including aetiology, symptoms and treatment. The English-language literature about rectal prolapse was identified using Medline, and additional cited works not detected in the initial search were obtained. Articles reporting on prospective and retrospective comparisons and case reports were included.

Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients

INTRODUCTION

Laparoscopic rectopexy for complete rectal prolapse offers short-term advantages compared with operations performed by laparotomy. The aim of this prospective study was to report technical and functional outcome after laparoscopic rectopexy to the promontory in consecutive patients operated on by a single surgeon.

PATIENTS AND METHODS

From May 1996 to July 2004, 54 consecutive patients (47 women), median age 53 years (range: 16-84 years), underwent laparoscopic rectopexy to the promontory for complete rectal prolapse. Preoperative evaluation included physical examination, dynamic videoproctography and, in patients with constipation, colonic transit time (with radiopaque markers). Postoperative evaluation included the same examinations and a simple global quality-of-life questionnaire.

RESULTS

Conversion to laparotomy was required for three patients during the learning curve. Median duration of operation was 157 minutes (range: 50-370). There was no mortality and morbidity was 5.5% (brachial plexus palsy in two patients and urinary tract infection in one). Median hospital stay was 3.5 days (range: 1-11). There were 4 recurrences (7.4%). Functional outcome at 12 months showed the presence of constipation in 20.3% of patients (persistence in eight and de novo in three) and the presence of outlet obstruction in 25.9% of patients (persistence in six and de novo in eight). Anal continence improved in 72.4% of the 29 patients who complained of this symptom. The global quality-of-life questionnaire showed a satisfactory result in 96% of patients.

CONCLUSION

Laparoscopic rectopexy to the promontory is a safe and efficient procedure to treat complete rectal prolapse; morbidity is low. Functional outcome is at least equivalent to that obtained with open procedures in terms of continence, constipation and outlet obstruction.

How accurate are published recurrence rates after rectal prolapse surgery? A meta-analysis of individual patient data

BACKGROUND

The literature shows wide variations of recurrence rates (RRs) after abdominal surgery for rectal prolapse. The aim of this meta-analysis was to evaluate the accuracy of published RRs.

METHODS

An electronic search was performed with no restrictions. Inclusion criterion was abdominal surgery in at least 10 adults with follow-up evaluation of any length of time. Two reviewers screened 1669 references. A total of 190 investigators were asked to provide individual patient data that should be the same used at the time their reports were written. The RR was estimated by actuarial analysis. Investigators were asked for comments on results.

RESULTS

Individual patient data from 6 reports published with 273 patients (186 women, 87 men) with a median age of 54 years (range, 18-88 y) were available. Abdominal surgery included mobilization with pexy (88%), with additional resection (7%), or mobilization only (5%). There were 16 recurrences at a median follow-up period of 3.94 years (range, .05-15.11 y). The effect of age (hazard ratio [HR], 2.010; P = .3443), sex (HR, 2.070; P = .4260), surgical technique (HR, .743; P = .7669), and publication (HR, 1.014; P = .8747) on RR was not significant. Two publications reported a RR of 0. In another report, the published and estimated RRs of 15% did not differ. Published RRs differed from estimated RRs in 3 reports (2.5% vs 4%; 7% vs 54%; and 9.6% vs 36%). The pooled odds ratios of 6 reports revealed a borderline significant difference between the published and estimated RRs (P = .066).

CONCLUSIONS

Published RRs differed by as much as 47% from the RRs estimated by actuarial analysis depending on event definition and how the data were censored.

Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients

BACKGROUND

We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki.

METHODS

Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV.

RESULTS

The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good.

CONCLUSIONS

Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study

BACKGROUND

Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited.

METHODS

Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey.

RESULTS

A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to 10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17).

CONCLUSIONS

The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Long-term results of Delorme's procedure and Orr-Loygue rectopexy to treat complete rectal prolapse

PURPOSE

The aim of this study was to assess long-term outcome of Orr-Loygue rectopexy and Delorme's procedures in total rectal prolapse management.

METHODS

Data were collected retrospectively from 1978 to 2001. Statistical analysis was performed by chi-squared test and Student's t -test.

RESULTS

One hundred nine patients underwent either a Orr-Loygue rectopexy (49 patients) or a Delorme's procedure (60 patients). Mean follow-up was 88 (range, 1-300) months. In the rectopexy group, the overall complication rate and the recurrence rate were 33 percent and 4 percent, respectively. In patients with preoperative constipation, this symptom was improved or completely resolved in 33 percent and worsened in 58 percent postoperatively. Seventy-three percent of patients with preoperative incontinence were continent or had continence improvement postoperatively. In Delorme's group, overall complication and recurrence rates were 15 percent and 23 percent, respectively. Mortality was 7 percent. In patients with preoperative constipation, this symptom was improved or completely resolved in 54 percent and worsened in 12.5 percent of patients postoperatively. Forty-two percent of patients with preoperative incontinence were continent or had continence improvement postoperatively.

CONCLUSIONS

In this study, Orr-Loygue rectopexy had a lower long-term recurrence rate. However, this surgical procedure is associated with a higher complication rate. We believe that Delorme's procedure is still a valuable option in selected patients with postoperative minimal morbidity but higher recurrence rate.

Abdominal rectopexy for complete rectal prolapse: preliminary results of a new technique

PURPOSE

Although the technique for the surgical repair of rectal prolapse has advanced over the years, no ideal procedure has been found. We aim to test a new surgical procedure for abdominal rectopexy that uses the greater omentum to support the rectum below the rectopexy, to reconstruct the anorectal angle and dispense with the need for synthetic mesh, thus reducing the risk of infection.

METHODS

A series of ten patients, all young and medically fit, underwent repair surgery for rectal prolapse with the new rectopexy technique. Some patients had concomitant sigmoidectomy. Preoperative and postoperative assessment included a clinical examination, anal manometry and defecography.

RESULTS

Follow-up lasted a mean of 56.4 months. None of the patients had recurrent rectal prolapse or infection. Postoperative assessment at 24 months disclosed significant improvements in all the bowel and sphincter variables assessed. The 8 patients who had severe incontinence preoperatively had notably improved and 4 were fully continent, 3 moderately incontinent, and only 1 patient had persistently high levels of incontinence. In only 1 patient who initially had severe incontinence, continence completely regressed and severe constipation developed. Maximal basal pressure values increased significantly after surgery (p=0.0025), although they increased slightly less evidently in patients in whom marked incontinence persisted at postoperative follow-up. Maximal voluntary contraction pressure also increased significantly after surgery (p=0.0054), although the values changed less than those for basal pressure. During rest, squeeze and straining, and in all the patients who regained continence, even those who recovered it only partly, surgery substantially reduced the anorectal angle. The reduction during rest was statistically significant (p=0.0062).

CONCLUSIONS

The rectopexy technique we tested in patients with rectal prolapse avoids the need for synthetic mesh, and provides good results in terms of bowel and sphincter function, without infection or recurrence.

Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse

BACKGROUND

Postoperative constipation is a common problem with most mesh suspension techniques used to correct rectal prolapse. Autonomic denervation of the rectum subsequent to its complete mobilization has been suggested as a contributory factor. The aim of this study was to assess the long-term outcome of patients who underwent a novel, autonomic nerve-sparing, laparoscopic technique for rectal prolapse.

METHODS

Between 1995 and 1999, 42 patients had laparoscopic ventral rectopexy for total rectal prolapse. The long-term results after a median follow-up of 61 (range 29-98) months were analysed.

RESULTS

There were no major postoperative complications. Late recurrence occurred in two patients. In 28 of 31 patients with incontinence there was a significant improvement in continence. Symptoms of obstructed defaecation resolved in 16 of 19 patients. During follow-up, new onset of mild obstructed defaecation was noted in only two patients. Symptoms suggestive of slow-transit colonic obstipation were not induced.

CONCLUSION

Laparoscopic ventral rectopexy is an effective technique for the correction of rectal prolapse and appears to avoid severe postoperative constipation. The ventral position of the prosthesis may explain the beneficial effect on symptoms of obstructed defaecation.

Anal sphincter tears in patients with rectal prolapse and faecal incontinence

OBJECTIVE

Faecal incontinence often persists after surgery for rectal prolapse. Multiple mechanisms have been proposed as responsible, however, anal sphincter integrity has only been studied in a handful of cases. This study assesses the incidence of ultrasound detected anal sphincter tears in patients with rectal prolapse and faecal incontinence.

METHODS

Retrospective search of medical records at Flinders Medical Centre over a 7-year period to identify patients with full thickness rectal prolapse and faecal incontinence who had undergone endosonographical imaging of the anal sphincter complex. Anal manometry and pudendal nerve terminal motor latency studies were also included.

RESULTS

Twenty-one patients were identified (1 male, 20 female) of median age 67.5 years. Fifteen (71%) subjects had an abnormality in the anal sphincter complex on endoanal ultrasound. Of these, the defects in 4 (19%) patients were isolated to the internal sphincter, 3 (14%) to the external sphincter and in the remaining 8 (38%) subjects, defects were found in both internal and external sphincters. The degree of sphincteric defect was variable but at least 6 (29%) of the study group had full-length external sphincter tears. In the 19 patients studied, anal manometry revealed reduced basal and squeeze pressures in the majority. Delayed pudendal nerve terminal motor latency was evident in 9 of 18 patients studied.

CONCLUSION

Anal sphincter tears are common in patients presenting with rectal prolapse and faecal incontinence. The faecal incontinence associated with prolapse appears to be multifactorial in aetiology. Anal sphincter defects are likely to contribute to persistent faecal incontinence or recurrence following rectal prolapse. Endoanal ultrasound derived knowledge of anal sphincter injury may guide surgical management in problematic cases.

Rectal prolapse: a possibly underrecognized complication of anorexia nervosa amenable to surgical correction

OBJECTIVE

Rectal prolapse is a complication of anorexia nervosa (AN) that may be more common than previously recorded experience would suggest.

METHOD

In this report we document, for the first time, the association of (AN) and rectal prolapse in a series of three patients seen in the past three years. An extensive review of the literature using Medline over the period from 1966 to Jan 2000 failed to reveal any previous example of this association.

RESULTS AND CONCLUSION

The finding could have significant health care implications if confirmed. It would suggest that patients with either the psychiatric or surgical problem may not be receiving the appropriate complementary referrals: psychiatrist to surgeon and vice versa. The importance of recognition of this association in anorectic patients is the availability of effective surgical therapy.

General geriatrics and gastroenterology: constipation and faecal incontinence

The incidence of constipation increases with age but no consistent changes of colonic or anorectal motility have been shown in elderly people. Instead, neurological diseases, constipating drugs, bedriddenness and weak straining ability may explain this increased prevalence of constipation. The amount of dietary fibre in the diet may be reduced because of poor chewing ability. Parkinson's disease is accompanied by both slow colonic transit and impaired relaxation of the anal sphincter. Drug-induced constipation is particularly likely with anti-parkinsonism drugs (either anti-cholinergic or dopaminergic) and also with tricyclic anti-depressants, opiates, iron, anti-convulsants and aluminium- or calcium-containing antacids. The prevalence of faecal incontinence is also increased in elderly people. About half of frail bedridden institutionalized patients are incontinent. Anal sphincter pressures tend to be lower, but variables of sensitivity are not. In bedridden people faecal impaction may occur. The ensuing rectal distension leads to relaxation of the internal sphincter and hence to faecal soiling. The condition is often overlooked though correct diagnosis is rather simple, being made with a digital rectal examination.

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.

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.