Biological materials in colorectal surgery: current applications and potential for the future

Laparoscopic Rectopexy with Urinary Bladder Xenograft Reinforcement

BACKGROUND AND OBJECTIVES

Rectal prolapse is often repaired laparoscopically, frequently with the use of reinforcement material. Both synthetic and biologically derived materials reduce recurrence rate compared to primary suture repair. Synthetic mesh introduces potential complications such as mesh erosion, fibrosis, and infection. Urinary bladder matrix (UBM) represents a biologically derived material for reinforcement of rectal prolapse repair with the potential to improve durability without risks of synthetic materials. The objective of the study is to evaluate the effectiveness, durability, and functional result of laparoscopic rectopexy using urinary bladder matrix xenograft reinforcement at three years follow up.

METHODS

The 20 cases presented describe rectal prolapse repair by means of laparoscopic rectopexy with presacral UBM reinforcement. Patients were followed up for an average of 3 years and assessed with interviews, physical examination, manometry, and the fecal incontinence severity index (FISI).

RESULTS

Each repair was completed laparoscopically. UBM exhibited favorable handling characteristics when sutured to the sacrum and the lateral rectal walls. One patient underwent laparoscopic drainage of a postoperative abscess; no other complications occurred. In 3 years of follow-up, there have been no full-thickness recurrences, erosions, reoperations, or long-term complications. Two patients exhibited a small degree of mucosal prolapse on follow-up physical examination that did not require surgery. Three-year FISI scores averaged 8 (range, 0-33 of a possible 61), indicating low fecal incontinence symptomatology. Follow-up anorectal manometry was performed in 9 patients, showing mixed results.

CONCLUSION

Surgeons may safely use laparoscopic rectopexy with UBM reinforcement for repair of rectal prolapses. In this series, repairs with UBM grafts have been durable at 3-year follow-up and may be an alternative to synthetic mesh reinforcement of rectal prolapse repairs. Future studies may compare the advantages and cost-effectiveness of reinforcement materials for rectal prolapse repair.

Repair of a coccygeal hernia with a biological mesh

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We present a case of coccygeal hernation after coccygectomy.

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Hernia repair was performed with a biological mesh via an direct approach.

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Only 8 other cases could be identified in literature.

Coccygeal herniation after coccygectomy is rare. Little is known about the management of this complication. We present a case of a 44 year old women with a coccygeal herniation 7 years after coccygectomy. She was treated two times for an infected pilonidal sinus with incision and drainage. After the last incision and drainage she had complaints of a painful swelling in the sacral area and difficulty with evacuation of her stools. A defaecography showed a coccygeal herniation. An additional MRI of the pelvic region showed a defect with a diameter of approximately 38 mm. We performed a hernia repair with a biological mesh (Strattice™ surgical mesh, LifeCell Corporation USA) via a sacral approach. Her recovery was complicated by a small wound dehiscence without clinical signs of infection. The sacral wound healed per secundam. Her complaints had completely disappeared. A defaecography 2 months after surgery showed no residual herniation. To our knowledge, it is the first reported case of a coccygeal hernia repair with a biological Strattice™ surgical mesh.

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.

Chemotherapy-induced enterocutaneous fistula after perineal hernia repair using a biological mesh: a case report

This is the first reported case of an enterocutaneous fistula as a late complication to reconstruction of the pelvic floor with a Permacol™ mesh after a perineal hernia. A 70-year-old man had a reconstruction of the pelvic floor with a biological mesh because of a perineal hernia after laparoscopic abdominoperineal resection. Nine months after the perineal hernia operation, the patient had multiple metastases in both lungs and liver. The patient underwent chemotherapy, including bevacizumab, irinotecan, calcium folinate, and fluorouracil. Six weeks into chemotherapy, the patient developed signs of sepsis and complained of pain from the right buttock. Ultrasound examination revealed an abscess, which was drained, guided by ultrasound. A computed tomography scan showed a subcutaneous abscess cavity located in the right buttock with communication to the small bowel. Operative findings confirmed a perineal fistula from the distal ileum to perineum. A resection of the small bowel with primary anastomosis was performed. The postoperative course was complicated by fluid and electrolyte disturbances, but the patient was stabilized and finally discharged to a hospice for terminal care after 28 days of hospital stay. It seems that hernia repairs with biological meshes have lower erosion and infection rates compared with synthetic meshes, and so far, evidence suggests that biological grafts are safe and effective in the treatment of pelvic floor reconstruction. There have been no reports of enteric fistulas after pelvic reconstruction with biological meshes. However, the development of intestinal fistulas after chemotherapy with bevacizumab has been described in the literature. Our case report supports this association between bevacizumab and fistula formation among rectal cancer patients, as symptoms of a fistula started only 6 weeks into bevacizumab treatment but approximately 12 months after the perineal hernia operation, even after pelvic reconstruction using a biological mesh and without local recurrence.