Control Of Prolapse Research Articles

Office-Based Procedures in the Management of Hemorrhoidal Disease: Rubber Band Ligation versus Sclerotherapy – Systematic Review and Meta-Analysis

Introduction: The most frequently used office-based procedures in hemorrhoidal disease (HD) are rubber band ligation (RBL) and sclerotherapy. Few studies have been published comparing the various types of instrumental therapy. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of sclerotherapy and RBL. Methods: Three online databases were searched. Efficacy (control of symptoms, prolapse, bleeding and pain, patients’ satisfaction, and disease recurrence) and safety (complications, such as pain and bleeding) were the assessed outcomes. Pooled relative risks (RR) were computed for each outcome using a random-effects model, and heterogeneity was assessed by Cochran’s Q test and I2. Results: Six RCTs and three cohort studies were included. Control of prolapse and bleeding was significantly higher with RBL (93.1% RBL vs. 66.4% sclerotherapy, RR 1.34, 95% CI 1.12–1.60 and 89.1% RBL vs. 78.7% SCL, RR 1.17, 95% CI 1.02–1.34, respectively). Both techniques had similar results in terms of pain relief, overall control of symptoms, and risk of recurrence at 3 months. Although patient satisfaction was significantly higher with RBL (77.8% RBL vs. 46.7% sclerotherapy, RR 1.59, 95% CI 1.01–2.50), post-procedural pain was significantly higher with this technique (24% RBL vs. 14% sclerotherapy, RR 1.74, 95% CI 1.32–2.28). There was no significant difference regarding post-procedure bleeding (11.1% RBL vs. 8.7% sclerotherapy, RR 1.29, 95% CI 0.86–1.94). In the subgroup analysis, according to the HD grade, post-procedure pain was higher with RBL only in HD grade II (vs. HD grade I–III). Conclusions: RBL performs better than sclerotherapy in controlling HD symptoms, specifically prolapse and bleeding, although post-procedural pain is a frequent complication. Recurrence is similar with both procedures. While waiting for the publication of results with sclerotherapy with new sclerosants, RBL remains the office-based treatment of choice in HD.

Trans-abdominal Combined Posterior, Lateral and Anterior Fixation of Rectum for Complete Prolapse: a Novel Procedure

Rectal prolapse is not uncommon. There is no foolproof method to prevent recurrence. This novel method is likely to show new insight. Patients with completely prolapsed rectum and with normal colonic transit and those found fit in ASA grades I and II were included. A lower midline incision was used for open trans-abdominal rectopexy. Only posterior mobilisation was performed. A prolene mesh was placed on the dissected sacral surface. The rectal wall was fixed on either side of the sacral periosteum at promontory with a prolene suture along with the mesh. The lateral and anterior walls were plicated without any dissection obliterating the recto-vaginal/vesical pouch. There were 30 patients including 27 males studied from 2004 to 2012. The mean age was 32.35 years (SD 11.67). Two were paraplegics and three patients had recurrent case of prolapse. The median operation time and blood loss were 55 min and 50 ml respectively. There were no mortalities and one superficial wound sepsis by MRSA. Anal incontinence subsided and none of them were constipated after resumption of normal diet. One case, a paraplegic with recurrent prolapse had a recurrence of mucosal prolapse during the median follow-up of 66 months. Posterior rectal dissection with prolene mesh, anterior and lateral placating fixation without dissection in cases with normal colonic transit resulted in good control of prolapse without any constipation and reduction of the mucous discharge.

Evaluation of Transanal Hemorrhoidal Dearterialization as a Minimally Invasive Therapeutic Approach to Hemorrhoids

Transanal hemorrhoidal dearterialization is an innovative technique to treat hemorrhoids using a specially designed proctoscope for Doppler-guided transanal ligation of hemorrhoidal arteries. We analyzed results of experience at a single-institution with this transanal hemorrhoidal dearterialization device. Overall, 170 patients were submitted to transanal hemorrhoidal dearterialization during the period July 2005 through October 2008. The operation consisted of hemorrhoidal dearterialization (of 6 arteries) in all patients, with major mucosal/submucosal pexy in 56 patients (32.9%). The first consecutive 11 patients (6.4%) were treated under general/spinal anesthesia, the remaining 159 (93.6%) by sedation with propofol, supported by analgesia with remifentanil. Following transanal hemorrhoidal dearterialization surgery, patients were regularly evaluated at 2 weeks, 1 and 3 months, and once a year after operation. The mean age of the 170 patients was 47.3 +/- 13.0 years; 102 (60%) were men. Hemorrhoidal disease was grade II in 13 (7.6%); grade III in 141 (82.7%), and grade IV in 16 (9.6%). Postoperative bleeding requiring surgical hemostasis occurred in 2 cases (1.2%). Mean follow-up was 11.5 +/- 12 (range, 1-41) months. Hemorrhoidal thrombosis occurred in 4 patients (2.3%), chronic pain and fecal incontinence in none. Hemorrhoidal prolapse was reported at follow-up by 50 patients (29.5%), but prolapse was confirmed only in 18 (10.5%) and was mild; some patients reporting prolapse were found to have skin tags. Overall, long-term control of bleeding was obtained in 159 patients (93.5%) and control of prolapse in 152 (89.5%). Recurrence of hemorrhoidal disease requiring surgery was found in 7 patients (4.1%). Transanal hemorrhoidal dearterialization appears to be a very effective minimally invasive option to treat hemorrhoids and can be performed in a day-surgery setting. Future controlled trials comparing transanal hemorrhoidal dearterialization with other procedures will show the real potential of transanal hemorrhoidal dearterialization and define adequate indications for this approach.

A new technique for suture rectopexy without resection for rectal prolapse

We surmised that if rectopexy was performed without dissection of the lateral rectal stalks in patients with full-thickness rectal prolapse and normal preoperative transit, sigmoid resection may not be required. This study evaluated a new approach to abdominal suture rectopexy for rectal prolapse. A total of 81 patients (57 male, 24 female; median age 37 years, range 5-82 years) with rectal prolapse were assessed by clinical examination, anal manometry (maximum resting pressure, MRP, and squeeze pressure, MSP) and radioopaque marker transit studies. Of the 81 patients, 70 with normal preoperative transit underwent suture fixation alone, without resection, performed under spinal anaesthesia, through a 7-cm transverse left lower quadrant incision gaining access to the presacral space via a left pararectal "window", preserving the lateral stalks. Average surgical time was 50 min, mortality was zero, and morbidity was 9% (three patients with wound infection, four with urinary retention). Anal incontinence improved in 43 of 53 patients (81%, p=0.001). MRP and MSP had improved at 3 months after surgery: MRP from a mean of 27.6+/-1.4 mmHg (range 2-30 mmHg) before surgery to 32.5+/-2.21 mmHg (2-60 mmHg) after surgery (p=0.008); MSP from 69.25+/-6.4 mmHg (8-153 mmHg) before surgery to 79+/-4.77 mmHg (35-157 mmHg) after surgery (p=0.001).. Transit was unchanged in 18 of 20 patients (90%) who were evaluated before and after surgery; none was constipated after surgery. At 56 months, prolapse had recurred in five patients (7%). Abdominal suture rectopexy with a left pararectal approach without sigmoid resection in those with normal preoperative transit resulted in an improvement in anal incontinence and satisfactory long-term control of prolapse. The operation did not alter transit and did not result in significant constipation.

Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy

Objective:Unlike excisional haemorrhoidectomy, stapled anopexy (SA), which does not involve radical excision, has theoretical advantages, thus offering potential patient benefits. We compared the clinical efficacy, safety and patient acceptability of...

Sutured posterior abdominal rectopexy with sigmoidectomy compared with Marlex® rectopexy for rectal prolapse

Two treatment policies for rectal prolapse were prospectively assessed between April 1986 and January 1989. Sixteen patients had a Marlex mesh posterior rectopexy alone and 13 underwent a sigmoidectomy combined with a sutured posterior rectopexy. Preoperative and post-operative assessment included manometry, a saline infusion test and video-proctography. Hospital stay, control of prolapse and complications were comparable in both groups. Restoration of continence occurred in nine of the 12 incontinent patients after Marlex rectopexy, compared with six of nine after sutured rectopexy and sigmoidectomy. Constipation persisted in three patients who were constipated before operation and in four of 13 who had previously normal bowel habits became constipated after Marlex rectopexy; constipation persisted in one of five previously constipated patients while none with previously normal bowel habits became constipated after sutured rectopexy and sigmoidectomy. Sigmoidectomy combined with sutured rectopexy was safe and as efficient as Marlex rectopexy in prolapse control and improvement of continence; significantly fewer patients were constipated (one of 13) after sigmoidectomy than following rectopexy alone (seven of 16). A randomized trial now seems justified.

Late results of silicone rubber perianal suture for rectal prolapse.

Twenty-one patients were reviewed five to 12 years after silicone rubber perianal suture for rectal prolapse. Sixteen patients (76 percent) were continent with control of prolapse and two patients (9 percent) suffered only from occasional prolapse or incontinence. Rebanding for silicone cutout or fracture was required in four patients and a second rebanding operation was needed in two. Silicone rubber perianal suture for rectal prolapse stands the test of time and might be recommended for more widespread use in younger patients.

RECTAL PROLAPSE

One hundred and twenty-seven patients with complete rectal prolapse have been reviewed. The condition occurred more commonly in females than males (105 to 22), and at an older age in females (mean age 55 years compared with 40 years for males). Although the diagnosis is usually obvious, the importance of recognizing occult prolapse is stressed, especially in association with benign rectal ulcer, localized proctitis and colitis cystica profunda. Examination of the patient in the squatting position may assit in showing occult prolapse. Associated incontinence occurred in 33 patients (26%). Since 1971 the policy of this Unit has been to perform a Ripstein repair for complete rectal prolapse wherever possible. One hundred and two Ripstein repairs have not been performed. A minimum follow-up period of two years is available for 53 patients, of whom 50 (94%) have had their prolapse cured. Control of prolapse usually improves continence; however, seven (13%) remained incontinent despite surgery. The Ripstein repair is strongly advocated as the most effective operation for cure of complete rectal prolapse.