Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome: a cause for optimism?

Efficacy of surgical treatments for the management of solitary rectal ulcer syndrome: a network meta-analysis

AIM

Solitary rectal ulcer syndrome (SRUS) is a benign and poorly understood disorder with complex management. Typical symptoms include straining during defaecation, rectal bleeding, tenesmus, mucoid secretion, anal pain and a sense of incomplete evacuation. Diagnosis is based on characteristic clinical symptoms and endoscopic/histological findings. Several treatments have been reported in the literature with variable ulcer healing rates. This study aimed to evaluate the efficacy of different treatments for SRUS.

MATERIALS AND METHODS

A systematic review and network meta-analysis were performed according to the PRISMA guidelines. Studies in English, French and Spanish languages were included. Papers written in other languages were excluded. Other exclusion criteria were reviews, case reports or clinical series enrolling less than five patients, study duplications, no clinical data of interest and no article available. A systematic literature search was conducted from January 2000 to March 2024 using the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus. The biases of the studies were assessed using the Newcastle-Ottawa scale or the Jadad scale when appropriate. Types of treatment and their efficacy for the cure of SRUS were collected and critically assessed. The study's primary outcome was to estimate the rate of patients with ulcer healing.

RESULTS

A total of 22 studies with 911 patients (men 361, women 550) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimates of treatment efficacy revealed that surgery showed the highest ulcer healing rate (70.5%; 95% CI 0.57-0.83). Surgery was superior in the cure of ulcers with respect to medical therapies and biofeedback (OR 0.09 and OR 0.14).

CONCLUSION

Solitary rectal ulcer syndrome is a challenging clinical entity to manage. Proficient results have been reported with the surgical approach, suggesting its positive role in cases refractory to medical and biofeedback therapy. Further studies in homogeneous populations are required to evaluate the efficacy of surgery in this setting. (PROSPERO registration number CRD42022331422).

Could robotic-assisted surgery reduce mesh-related complications after ventral mesh rectopexy? Experience of a tertiary centre and systematic review of the literature

AIM

The development of robotic assistance has made dissection and suturing in the deep pelvis much easier. The augmented quality of the images and the articulation of the robotic arms have also enabled a more precise dissection. The aim of this study is to present the data on robotic-assisted ventral mesh rectopexy procedures in a university hospital and examine the literature in terms of mesh erosion.

METHOD

The electronic databases Pubmed, Embase and Cochrane were searched. Studies from January 2004 until January 2023 in the English language were included. Studies which included fewer than 10 patients were excluded. Laparoscopic or robotic-assisted ventral mesh rectopexies were included. Mesh erosion rates following laparoscopic or robotic-assisted ventral mesh rectopexies were measured.

RESULTS

Overall, the systematic review presents 5911 patients from 43 studies who underwent laparoscopic ventral mesh rectopexy compared with 746 patients treated with robotic-assisted ventral mesh rectopexy from six studies and our centre. Mesh erosion was rare in both groups; however, the prevalence was greater in the laparoscopy group (0.90% vs. 0.27%).

CONCLUSION

The mesh erosion rates are very low with robotic-assisted ventral mesh rectopexy. For precise results, more studies and experience in robotic surgery are required.

Solitary Rectal Ulcer Syndrome in Patients Presenting With Lower Gastrointestinal Bleeding: A Tertiary-Care Hospital Experience

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is a benign rectal condition associated with defecation disorder that has multifactor pathologies and variable findings on presentation, endoscopy, and histopathology. A diagnostic dilemma with an overlap of differentials and step-wise management that starts with conservative therapies and goes up to repeated surgeries in case of failure of the conservative approach.

OBJECTIVE

This study aims to observe clinical, endoscopic, and histological features of SRUS in patients presenting with lower gastrointestinal bleeding.

MATERIAL AND METHODS

The study was conducted at the Department of Gastroenterology, Medical Teaching Institute, Lady Reading Hospital Peshawar from October 2018 to April 2020. After written informed consent, 257 patients (149 males and 108 females) from ages 15 to 70 who presented with lower GI bleeding were included via non-probability convenient sampling. Sociodemographic details were recorded in a pre-designed proforma. A colonoscopy was performed with the Colonoscope CF200 Z, Olympus Tokyo, Japan, and findings were noted. Suspected lesions were magnified, dyed with 0.2% indigo carmine, biopsied from the middle and edges of the ulcer, and sent for histopathology. All data were recorded and analyzed in SPSS-20. The mean with SD was calculated for quantitative variables, and frequency and percentages were calculated for qualitative variables. The chi-square test was used to check the significance, and a p-value of <0.05 was considered statistically significant.

RESULTS

SRUS was found in 17 (6.6%) patients with lower GI bleeding, with a male predominance of 57% (n=11). Perirectal bleeding, constipation, mucous discharge, abdominal pain, and anemia were common clinical findings. Solitary lesions, ulceration, and anterior rectum location were the most common endoscopy findings. Obliterated lamina propria with collagen, ulceration, crypt distortion, and inflammatory infiltrates were common histopathological findings.

CONCLUSION

SRUS is a benign defecation disorder commonly presenting with lower GI bleeding, constipation, straining, and abdominal pain. It needs a stepwise approach with conservative management, medical management, biofeedback, and surgeries as a last resort.

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation

Background

The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods

The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results

Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions

With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration

ISRCTN Registry (ISRCTN11747152).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02633-w.

Mesh-related complications and recurrence after ventral mesh rectopexy with synthetic versus biologic mesh: a systematic review and meta-analysis

BACKGROUND

Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material.

METHODS

A systematic search of the electronic databases of PubMed, Embase and Cochrane was performed (from inception until September 2020). Studies evaluating patients who underwent VMR with synthetic or biologic mesh were eligible. The MINORS score was used for quality assessment.

RESULTS

Thirty-two studies were eligible after qualitative assessment. Eleven studies reported on mesh-related complications including 4001 patients treated with synthetic mesh and 762 treated with biologic mesh. The incidence of mesh-related complications ranged between 0 and 2.4% after synthetic versus 0-0.7% after biologic VMR. Synthetic mesh studies showed a pooled incidence of mesh-related complications of 1.0% (95% CI 0.5-1.7). Data of biologic mesh studies could not be pooled. Twenty-nine studies reported on the risk of recurrence in 2371 synthetic mesh patients and 602 biologic mesh patients. The risk of recurrence varied between 1.1 and 18.8% for synthetic VMR versus 0-15.4% for biologic VMR. Cumulative incidence of recurrence was found to be 6.1% (95% CI 4.3-8.1) and 5.8% (95% CI 2.9-9.6), respectively. The clinical and statistical heterogeneity was high.

CONCLUSIONS

No definitive conclusions on preferred mesh type can be made due to the quality of the included studies with high heterogeneity amongst them.

Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs

Background

Chronic constipation affects 1–2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery.

Objectives

(1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up.

Design

The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3).

Setting

Specialist hospital centres across England, with a mix of urban and rural referral bases.

Participants

The main inclusion criteria were as follows: age 18–70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology’s constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions.

Interventions

CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (n = 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (n = 68); and group 3 – standardised radiophysiological investigations-guided treatment (n = 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1, n = 30) or high-volume (group 2, n = 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (n = 9) and after 12 weeks’ (n = 10) and after 24 weeks’ (n = 9) waiting time (allocation ratio 1 : 1 : 1, respectively).

Main outcome measures

The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis.

Results

A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately –0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (–0.03 points, 95% confidence interval –0.33 to 0.27 points; p = 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval –0.11 to 0.55 points; p = 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year gain; p = 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference –0.37 points, 95% confidence interval –0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference –£8, 95% confidence interval –£240 to £221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (–1.09 points, 95% confidence interval –1.76 to –0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (£5012, 95% confidence interval £4446 to £5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval –0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of £115,512 per quality-adjusted life-year.

Conclusions

Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life.

Limitations

All three trials significantly under-recruited [CapaCiTY trial 1, n = 182 (target 394); CapaCiTY trial 2, n = 65 (target 300); and CapaCiTY trial 3, n = 28 (target 114)]. The numbers analysed were further limited by loss before primary outcome.

Trial registration

Current Controlled Trials ISRCTN11791740, ISRCTN11093872 and ISRCTN11747152.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.

Solitary Rectal Ulcer Syndrome: A Narrative Review

Solitary rectal ulcer syndrome is a multifactorial pathology, which entails a variety of clinical, histologic and endoscopic aspects that needs step-wise logical approach for management especially in relapsing refractory cases. Apart from the diagnostic dilemma that may be faced due to similarities of presentation with inflammatory bowel diseases or colorectal neoplastic lesions, the syndrome also overlaps with dyssynergic defecation syndrome, health anxiety disorder, obsessive compulsive disorder, and latent mucosal rectal prolapse, a systematic composite treatment modality including psychological, pharmacological, physiological and possibly surgical interventions are sometimes essential. Selecting appropriate treatment in this condition not only affects clinical outcome but also patients’ experience and further stigma of SRUS life-long. In this review, we will discuss the detailed pathophysiology, diagnostic and therapeutic approaches in dealing with solitary rectal ulcer syndrome.

Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature

Introduction and hypothesis

The use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery.

Methods

A prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up).

Results

Ninety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%).

Conclusions

The long-term rate of mesh erosion following an abdominally placed synthetic graft is low.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-03990-1) contains supplementary material, which is available to authorized users

A systematic review and meta-analysis of the efficacy of medical treatments for the management of solitary rectal ulcer syndrome

BACKGROUND/AIM

Solitary rectal ulcer syndrome (SRUS) is a benign, poorly understood disorder that is difficult to manage. Medical interventions such as sucralfate, sulfasalzine, human fibrin, and a high fibre diet are reported as the first line of treatment. The aim of this study is to perform a systematic review and meta-analysis of the efficacy of medical treatments for SRUS.

MATERIALS AND METHODS

Databases including PubMed, Cochrane, and Embase were searched for randomised clinical trials (RCT) and observational studies that evaluated medical treatments for SRUS. Two authors independently performed selection of eligible studies based on eligiblity criteria. Data extraction from potentially eligible studies was carried out according to predefined data collection methods. Medical treatments, including sucralfate, sulfasalzine, human fibrin, a high fibre diet, and psyllium powder as a single or combination therapy were compared to placebo alone or combined with other treatments. The primary outcome was the proportion of patients with ulcer remission; this was presented as pooled prevalence (PP) with a 95% confidence interval (CI). The I² value and Q statistic test were used to test for heterogeneity. In the presence of heterogeneity, a random-effects model was applied.

RESULTS

A total of 9 studies with 216 patients (males = 118, females = 98) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimate of treatment efficacy revealed that, of the patients receiving medical treatment, 57% had resolution of their ulcers (PP 0.57; 95% CI; 0.41 to 0.73). Statistically significant heterogeneity was observed (I² = 63%; τ2 = 0.64, P= <0.01). The scarcity of RCTs comparing medical treatments with other interventions was a major limitation.

CONCLUSIONS

The majority of patients receiving medical treatment for the management of SRUS experience resolution of their ulcers.

A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018?

PURPOSE

To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy.

METHOD

A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed.

RESULTS

A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary.

CONCLUSIONS

The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed.

Stepped-wedge randomised trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation: study protocol for a randomized controlled trial

Background

Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence.

Methods

An individual level, stepped-wedge randomised trial has been designed to allow observer-blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) pre-operative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates.

Discussion

An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks).

Trial registration

ISRCTN registry, ISRCTN11747152. Registered on 30 September 2015. The trial was prospectively registered (first patient enrolled on 21 March 2016).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2456-3) contains supplementary material, which is available to authorized users.

Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension)

AIM

To assess the outcomes of rectal suspension procedures (forms of rectopexy) in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Eighteen articles were identified, providing data on outcomes in 1238 patients. All studies reported only on laparoscopic approaches. Length of procedures ranged between 1.5 to 3.5 h, and length of stay between 4 to 5 days. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 5-15%, with mesh complications accounting for 0.5% of patients overall. No mortality was reported after any procedures in a total of 1044 patients. Although inconsistently reported, good or satisfactory outcome occurred in 83% (74-91%) of patients; 86% (20-97%) of patients reported improvements in constipation after laparoscopic ventral mesh rectopexy (LVMR). About 2-7% of patients developed anatomical recurrence. Patient selection was inconsistently documented. As most common indication, high grade rectal intussusception was corrected in 80-100% of cases after robotic or LVMR. Healing of prolapse-associated solitary rectal ulcer syndrome occurred in around 80% of patients after LVMR.

CONCLUSION

Evidence supporting rectal suspension procedures is currently derived from poor quality studies. Methodologically robust trials are needed to inform future clinical decision making.

Abdominal Approaches to Rectal Prolapse

Rectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient-most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or imaging demonstrating the prolapse, and evaluating for other causes of pelvic floor dysfunction. Multiple surgical repairs are available, but treatment must be individualized based on patient symptoms and the presence or absence of constipation or other pelvic floor disorders. Mesh repairs have shown promising results, but carry the added risks of mesh erosion, infection, and mesh migration. The optimal repair has not been clearly demonstrated at this time.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse

External and internal rectal prolapse with their affiliated rectocele and enterocele, are associated with debilitating symptoms such as obstructed defecation, pelvic pain and faecal incontinence. Since perineal procedures are associated with a higher recurrence rate, an abdominal approach is commonly preferred. Despite the description of greater than three hundred different procedures, thus far no clear superiority of one surgical technique has been demonstrated. Ventral mesh rectopexy (VMR) is a relatively new and promising technique to correct rectal prolapse. In contrast to the abdominal procedures of past decades, VMR avoids posterolateral rectal mobilisation and thereby minimizes the risk of postoperative constipation. Because of a perceived acceptable recurrence rate, good functional results and low mesh-related morbidity in the short to medium term, VMR has been popularized in the past decade. Laparoscopic or robotic-assisted VMR is now being progressively performed internationally and several articles and guidelines propose the procedure as the treatment of choice for rectal prolapse. In this article, an outline of the current status of laparoscopic and robotic ventral mesh rectopexy for the treatment of internal and external rectal prolapse is presented.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review

AIM

Laparoscopic ventral rectopexy (VR) with the use of prosthesis has been advocated for both overt rectal prolapse (ORP) and obstructed defaecation syndrome (ODS). The present study reviews the short-term and functional results of laparoscopic VR.

METHOD

A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VR for ORP, ODS and other anatomical abnormalities of the pelvic floor from 2004 until February 2013. No language restrictions were made. All studies on VR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, recurrence of ORP, recurrence of anatomical disorder, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers.

RESULTS

Twenty-three studies including 1460 patients were eligible for analysis. The conversion rate ranged from 0 to 14.3%. No mortality was reported. The immediate postoperative morbidity rate was 8.6%. Length of stay ranged from 1 to 7 days. A significant improvement in constipation and incontinence symptoms was observed in the postoperative period for both ORP and ODS (chi-square test, P < 0.0001).

CONCLUSION

Laparoscopic VR is a safe and effective procedure for ORP and ODS. Longer follow-up is required, and studies comparing VR with standard rectopexy and stapled transanal rectal resection are not yet available.

Laparoscopic ventral rectopexy is effective for solitary rectal ulcer syndrome when associated with rectal prolapse

AIM

Solitary rectal ulcer syndrome (SRUS) is uncommon and its management is controversial. The aim of this study was to evaluate the outcome of patients with SRUS who underwent laparoscopic ventral rectopexy (LVR).

METHOD

A review was performed of a prospective database at the Oxford Pelvic Floor Centre to identify patients between 2004 and 2012 with a histological diagnosis of SRUS. All were initially treated conservatively and surgical treatment was indicated only for patients with significant symptoms after failed conservative management. The primary end-point was healing of the ulcer. Secondary end-points included changes in the Wexner Constipation Score and Faecal Incontinence Severity Index (FISI).

RESULTS

Thirty-six patients with SRUS were identified (31 women), with a median age of 44 (15–81) years. The commonest symptoms were rectal bleeding (75%) and obstructed defaecation (64%). The underlying anatomical diagnosis was internal rectal prolapse (n = 20), external rectal prolapse (n = 14) or anismus (n = 2). Twenty-nine patients underwent LVR and one a stapled transanal rectal resection (STARR) procedure. Nine (30%) required a further operation, six required posterior STARR for persistent SRUS and two a per-anal stricturoplasty for a narrowing at the healed SRUS site. Healing of the SRU was seen in 27 (90%) of the 30 patients and was associated with significant improvements in Wexner and FISI scores at a 3-year follow-up.

CONCLUSION

Almost all cases of SRUS in the present series were associated with rectal prolapse. LVR resulted in successful healing of the SRUS with good function in almost all patients, but a significant number will require further surgery such as STARR for persistent obstructed defaecation.

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive 'revolution' of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.

Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis and treatment strategies

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disease, characterized by a combination of symptoms, clinical findings and histological abnormalities. Ulcers are only found in 40% of the patients; 20% of the patients have a solitary ulcer, and the rest of the lesions vary in shape and size, from hyperemic mucosa to broad-based polypoid. Men and women are affected equally, with a small predominance in women. SRUS has also been described in children and in the geriatric population. Clinical features include rectal bleeding, copious mucus discharge, prolonged excessive straining, perineal and abdominal pain, feeling of incomplete defecation, constipation, and rarely, rectal prolapse. This disease has well-described histopathological features such as obliteration of the lamina propria by fibrosis and smooth muscle fibers extending from a thickened muscularis mucosa to the lumen. Diffuse collage deposition in the lamina propria and abnormal smooth muscle fiber extensions are sensitive markers for differentiating SRUS from other conditions. However, the etiology remains obscure, and the condition is frequently associated with pelvic floor disorders. SRUS is difficult to treat, and various treatment strategies have been advocated, ranging from conservative management to a variety of surgical procedures. The aim of the present review is to summarize the clinical features, pathophysiology, diagnostic methods and treatment strategies associated with SRUS.