Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception

The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders

AIM

Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process.

METHOD

Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up.

RESULTS

After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy.

CONCLUSION

The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Ventral Prosthesis Rectopexy for obstructed defaecation syndrome: a systematic review and meta-analysis

Obstructed Defecation Syndrome (ODS) is a rather complex entity concerning mainly females and causing primarily constipation. Surgical treatment in the form of Ventral Prosthesis Rectopexy (VPR) has been proposed and seems to have the best outcomes. However, the selection criteria of patients to undergo this kind of operation are not clear and the reported outcomes are mainly short-term and data on long-term outcomes is scarce. This study assesses new evidence on the efficacy of VPR for the treatment of ODS, specifically focusing on inclusion criteria for surgery and the long-term outcomes. A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VPR for ODS from 2000 to March 2020. No language restrictions were made. All studies on VPR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers. Fourteen studies including 963 patients were eligible for analysis. The immediate postoperative morbidity rate was 8.9%. A significant improvement in constipation symptoms was observed in the 12-month postoperative period for ODS (p < 0.0001). Current evidence shows that VPR offers symptomatic relief to the majority of patients with ODS, improving both constipation-like symptoms and faecal incontinence for at least 1-2 years postoperatively. Some studies report on functional results after longer follow-up, showing sustainable improvement, although in a lesser extent.

Posterior pelvic tilt is a risk factor for rectal prolapse: a propensity score matching analysis

BACKGROUND

There is little evidence about possible effects of pelvic anatomical characteristics on proctological complications. The aim of our study was to investigate the potential correlation between sagittal pelvic position and rectal prolapse.

METHODS

A study was conducted on a proctology patients and patients without any specific history of proctological disorders who were divided into two groups according to the presence or the absence of rectal prolapse. In all cases, the pelvic angle was measured with a pelvic goniometer and categorized as posterior (< 10°), neutral (10°-15°), and anterior (> 15°). To minimize effects of potential confounders in the analysis, 3:1 nearest neighbor propensity score matching (PSM) method was implemented using age, sex, and diagnose of rectal disorders as confounding variables.

RESULTS

Among the 143 screened patients, posterior tilt was more frequent in the 19 patients with rectal prolapse than in those without prolapse (42 vs. 18%; p = 0.027). This result was also confirmed in the post-PSM analysis (42 vs. 14%; p = 0.036) using 35 propensity score (PS)-matched controls compared with the rectal prolapse group. Posterior tilt was associated with an increased risk of prolapse in both the unmatched population (odds ratio = 3.37; p = 0.020) and PS-matched subset (odds ratio = 4.36; p = 0.028).

CONCLUSIONS

A posterior pelvic angle was more frequently associated with the diagnosis of rectal prolapse. In both the entire population and in the PS-matched subset, posterior tilt was a significant risk factor for rectal prolapse. The easy-to-do investigation of the pelvic angle can provide several benefits in terms of rectal prolapse prevention and more precise management of post-surgical prolapse recurrence.

Short term outcome of laparoscopic ventral mesh rectopexy for rectal and complex pelvic organ prolapse: case series

Objectives

Laparoscopic ventral mesh rectopexy (LVMR) is a technique gaining more recognition for the management of pelvic floor disorders, such as external rectal prolapse (ERP), high grade internal rectal prolapse (IRP) and rectocele. LVMR also allows correction of coexisted pelvic organ prolapse. This study aimed to evaluate the safety, efficacy and functional outcome of LVMR for rectal and complex pelvic organ prolapse.

Material and Methods

All patients who underwent LVMR from February 2014 to October 2017 were included into the study. The patients were evaluated preoperatively and three months postoperatively. Surgical complications and functional results in terms of fecal incontinence (measured with the Wexner Incontinence Score= WIS) and constipation (measured with the Wexner Constipation Score= WCS) were analyzed.

Results

Thirty (4 males) patients underwent LVMR. Seventeen (56.6%) patients had complex pelvic organ prolapse according to MRI findings. Median operative time and postoperative stay were 110 minutes and 4 days, respectively. No mesh-related complication and recurrence were observed. Before surgery, 21 (70%) patients had complained about symptoms of obstructed defecation. WCS decreased significantly from median 19 to 6 (p <0.001). Preoperative median WIS of 9 patients was 14 and went down to 6 postoperatively (p= 0.008). WCS significantly improved after LVMR in patients with symptomatic rectocele combined with enterocele or sigmoidocele (p= 0.005), and significant improvement was also observed in patients with symptomatic rectocele combined with gynecologic organ prolapse, preoperative median WCS was 18 and the postoperative value fell to 8 (p= 0.005).

Conclusion

LVMR is an effective surgical option for rectal and complex pelvic organ prolapse with short-term follow-up.