Full-thickness External Rectal Prolapse Research Articles

Altemeier procedure for surgical treatment of full thickness external rectal prolapse (with video).

Altemeier procedure for surgical treatment of full thickness external rectal prolapse (with video).

Laparoscopic approach to recurrence following multiple surgeries for external rectal prolapse: a case report

IntroductionThe optimal procedure for recurrent external rectal prolapse remains unclear, particularly in laparoscopic approach. In addition, pelvic organ prolapse (POP) is sometimes concomitant with rectal prolapse. We present a case who underwent laparoscopic procedure for the recurrence of full-thickness external rectal prolapse coexisting POP.Case presentationAn 81-year-old parous female had a 10-cm full-thickness external rectal prolapse following the two operations: the first was perineal recto-sigmoidectomy and the second was laparoscopic posterior mesh rectopexy. Imaging study revealed that the recurrent rectal prolapse was concomitant with both cystocele and exposed vagina, what we call POP. We planned and successfully performed laparoscopic ventral mesh rectopexy (LVMR) with laparoscopic sacrocolpopexy (LSC) using self-cut meshes without any perioperative complication.ConclusionThis is the first report of LVMR and LSC for recurrent rectal prolapse with POP following the perineal recto-sigmoidectomy and laparoscopic posterior mesh rectopexy. Even for recurrent rectal prolapse with POP, our experience suggests that LVMR and LSC could be utilized.

Outcome of laparoscopic ventral mesh rectopexy for full-thickness external rectal prolapse: a systematic review, meta-analysis, and meta-regression analysis of the predictors for recurrence.

Laparoscopic ventral mesh rectopexy (LVMR) has proved effective in the treatment of internal and external rectal prolapse. The present meta-analysis aimed to determine the predictive factors of recurrence of full-thickness external rectal prolapse after LVMR. An organized, systematic search of electronic databases including PubMed/Medline, Embase, Scopus, and Cochran library was conducted in adherence to PRISMA guidelines. Studies that reported the outcome of LVMR in patients with full-thickness external rectal prolapse were included according to predefined criteria. A meta-regression analysis and sub-group meta-analyses were performed to recognize the patient and technical factors that were associated with higher recurrence rates. Seventeen studies comprising 1242 patients of a median age of 60years were included. The median operation time was 122.3min. Conversion to open surgery was required in 22 (1.8%) patients. The weighted mean complication rate across the studies was 12.4% (95% CI 8.4-16.4) and the weighted mean rate of recurrence of full-thickness external rectal prolapse was 2.8% (95% CI 1.4-4.3). The median follow-up duration was 23months. Male gender (SE = 0.018, p = 0.008) and length of the mesh (SE = - 0.007, p = 0.025) were significantly associated with full-thickness recurrence of rectal prolapse. The weighted mean rates of improvement in fecal incontinence and constipation after LVMR were 79.3% and 71%, respectively. LVMR is an effective and safe option in treatment of full-thickness external rectal prolapse with low recurrence and complication rates. Male patients and length of the mesh may potentially have a significant impact on recurrence of rectal prolapse after LVMR.

Result Evaluation between Laparoscopic Anterior and Posterior Mesh Rectopexy in Complete Rectal Prolapse

Background: The prospectively and retrospective collected databases for identifying outcome in patients of 20 or more years of age with full thickness external rectal prolapse (ERP) treated by laparoscopic ventral rectopexy. Primary end-points were age, and mortality, morbidity, length of hospital stay and recurrence. Aim of the study: Evaluation of the comparative result between anterior and posterior mesh rectopexy and better method of rectopexy. Patient and methods Twenty-four adult patients with complete rectal prolapse underwent operative treatment for the prolapse between January 2016 and December 2018. The diagnosis of rectal prolapse was made clinically and confirmed by defecation proctography. Patients underwent pre-operative colonoscopy or flexible sigmoidoscopy to exclude organic disease. Data on gender, age, mortality, morbidity, length of stay and recurrence were prospectively collected on an institutionally approved electronic database. Non-parametric data were described as median and range, while parametric data were presented as average and standard deviation. Results: 24 patients of median age 38 (20-52 years old). Patients underwent laparoscopic ventral rectopexy. There was no mortality and 10 (13%) patients had complications. At a median follow up of 8 (2 – 12) months, two (3%) patients developed a recurrent full thickness prolapse. Conclusions: Abdominal procedures are generally better for young fit patients. The results of all abdominal procedures are comparable. Suture and mesh rectopexy are still popular with many surgeons. The choice depends on the surgeon’s experience and preference. Similarly, the procedure may be done through a laparoscope. Laparoscopic ventral or dorsal rectopexy is safe to treat full-thickness ERP. Morbidity, mortality, and hospital stay are comparable with published rates with a tenfold lower recurrence.

Result Evaluation between Laparoscopic Anterior and Posterior Mesh Rectopexy in Complete Rectal Prolapse

Background: The prospectively and retrospective collected databases for identifying outcome in patients of 20 or more years of age with full thickness external rectal prolapse (ERP) treated by laparoscopic ventral rectopexy. Primary end-points were age, and mortality, morbidity, length of hospital stay and recurrence. Aim of the study: Evaluation of the comparative result between anterior and posterior mesh rectopexy and better method of rectopexy. Patient and methods Twenty-four adult patients with complete rectal prolapse underwent operative treatment for the prolapse between January 2016 and December 2018. The diagnosis of rectal prolapse was made clinically and confirmed by defecation proctography. Patients underwent pre-operative colonoscopy or flexible sigmoidoscopy to exclude organic disease. Data on gender, age, mortality, morbidity, length of stay and recurrence were prospectively collected on an institutionally approved electronic database. Non-parametric data were described as median and range, while parametric data were presented as average and standard deviation. Results: 24 patients of median age 38 (20-52 years old). Patients underwent laparoscopic ventral rectopexy. There was no mortality and 10 (13%) patients had complications. At a median follow up of 8 (2 – 12) months, two (3%) patients developed a recurrent full thickness prolapse. Conclusions: Abdominal procedures are generally better for young fit patients. The results of all abdominal procedures are comparable. Suture and mesh rectopexy are still popular with many surgeons. The choice depends on the surgeon’s experience and preference. Similarly, the procedure may be done through a laparoscope. Laparoscopic ventral or dorsal rectopexy is safe to treat full-thickness ERP. Morbidity, mortality, and hospital stay are comparable with published rates with a tenfold lower recurrence.

Should we offer ventral rectopexy to patients with recurrent external rectal prolapse?

For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described. The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs. This study is a prospective cohort study. IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015. Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method. A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases wereopen, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p=0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5years (p=0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7months (p=0.03). VR is a better option for patients undergoing primary rectal prolapse repair.

Perineal stapled prolapse resection (PSPR) in elderly patients for external rectal prolapse: early experience

Full-thickness rectal prolapse in frail elderly patients is often treated by a perineal approach with considerable attendant morbidity. We report our preliminary results of the perineal stapled prolapse resection (PSPR) technique for resection of full-thickness external rectal prolapse using a new reloadable Contour(®) Transtar™ stapler (Ethicon Endo-Surgery) device. Fourteen elderly high-risk patients with an external prolapse up to 10 cm in length were treated between April 2010 and October 2011, and operative factors, outcome and recurrence rates were assessed. There were no intraoperative difficulties and no perioperative morbidity. The median operating time was 35 min (range 25-45 min) with a median hospital stay of 3 days (range 3-5 days). Four patients developed early recurrence over a median follow-up of 32 months (range 25-41 months). PSPR is safer, faster and easier to perform than other conventional perineal prolapse procedures and is suitable for elderly, high-risk patients for whom an abdominal approach under general anesthesia is not advisable.

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

The treatment of solitary rectal ulcer syndrome (SRUS) is notoriously difficult. Laparoscopic ventral mesh rectopexy (LVMR) is a nonresectional technique for patients with full thickness external rectal prolapse and internal prolapse with obstructed defaecation syndrome (ODS), features associated in the pathogenesis of SRUS. Our aim was to assess the short- and long-term efficacy of LVMR in treating SRUS. Forty-eight patients with SRUS who underwent LVMR over a 15-year period (December 1996 to July 2012) were identified from a prospectively maintained electronic database. Forty-eight patients, 38 (79%) women, median age 43 (18-80) years, median body mass index 26 (21-40) kg/m(2) underwent LVMR for SRUS after initial biofeedback. The median follow-up was 33 months (95% CI 31-55, range 1-186 months); 52% were followed for more than 3 years and 13 (27%) for more than 5 years. Five (10%) had relapsed following a response to stapled transanal rectal resection (STARR; 10 additional patients have had a continued response to STARR). Eleven (23%) had intermittent reducible external prolapse. Epithelial ulcer healing was reported in all patients at 3 months. The ODS scores improved by 68% (P < 0.0001) and quality of life (QoL; Birmingham Bowel and Urinary Symptoms Questionnaire-22) scores improved by 45% (P < 0.0001). There was a significant improvement in bowel visual analogue scale (VAS) scores at 3 and 12 months (P = 0.0007). Sustained improvement in QoL and VAS scores was maintained at 2 years and continued in the 52% followed up for between 3 and 15 years. There were four (8%) symptomatic ODS recurrences: posterior rectal wall prolapse successfully treated by STARR (3) and one symptom free for 2 years following a temporary loop ileostomy. There were two recurrences (4%). LVMR appears to provide a sustained improvement in QoL, VAS and patient satisfaction in patients with SRUS. Morbidity, recurrence and safety profiles are low.

Laparoscopic ventral rectopexy: a prospective long-term evaluation of functional results and quality of life

Laparoscopic ventral rectopexy for rectal prolapse combines the advantages of a minimally invasive approach with the low recurrence rate observed after abdominal procedures. To date, only a few long-term functional studies and no quality of life assessment are available. The aim of this study was to assess long-term functional outcomes and quality of life after laparoscopic ventral rectopexy. Between January 2007 and December 2008, patients who underwent laparoscopic ventral rectopexy for full-thickness external rectal prolapse and/or rectocele were prospectively included. Fecal incontinence and constipation were scored (Wexner score and Rome II criteria). Quality of life was assessed using the gastrointestinal quality of life form (GIQLI). Thirty-three patients were included and 30 (91 %) completed all the questionnaires. There was no morbidity or mortality. The mean length of hospital stay was 5 ± 1 days (range 3-7 days). After a mean follow-up of 42 ± 7 months (range 32-52 months), recurrence of rectocele was observed in two patients (6 %). At the end of follow-up, constipation was improved in 13/18 patients (72 %) and two patients (7 %) presented de novo constipation. The patients' Wexner score improved between preoperative status and end of follow-up (12 ± 7 vs. 4 ± 3, p = 0.002). Compared to the preoperative score, quality of life significantly improved over time: 77 ± 21 preoperatively versus 107 ± 17 at 1 year versus 109 ± 18 at the end of follow-up (p < 0.001). This prospective study showed that laparoscopic ventral rectopexy was associated with excellent postoperative outcomes and a low long-term recurrence rate. Long-term functional results were excellent in terms of continence, with significant improvement of quality of life and without worsening constipation.

Perineal Stapled Prolapse Resection for Complete External Rectal Prolapse: Preliminary Experience and Literature Review

Purpose: Perineal stapled prolapse resection (PSP) for external rectal prolapse is a new surgical technique. Methods: Between April 2009 and January 2011, 5 female patients (mean age, 67 years; range, 53–76) underwent PSP for full-thickness external rectal prolapse. Patients were placed in a slight Trendelenburg position to free the pouch of Douglas from any deep enterocele. Laparoscopic control of the PSP procedure was performed to avoid injury to the bowel in one patient with anorexia. The prolapse was completely resected continuously counterclockwise using a curved Contour® Transtar™ stapler placed parallel to the dentate line. After completion of resection, the neorectum fell back into place spontaneously. Results: Mean operating time was 56 min (range, 40–90). No intraoperative or postoperative complications occurred. No recurrence appeared. The mean hospital stay was 4 days (range, 3–6); the mean follow-up was 6.5 months (range, 2–15). The mean Wexner fecal incontinence score was 9.2 before and 4.6 at 3 months after surgery (p = 0.010); the mean obstructed defecation syndrome score decreased from 16 to 4.75 (p < 0.001). Conclusions: PSP is an easy, fast and safe procedure. Early functional results are good. Long-term results and recurrence rates need to be investigated further.

Enterocoele is a marker of severe pelvic floor weakness

The aim was to evaluate the relationship between the presence of an enterocoele and grade of rectal prolapse (RP). Defaecating proctograms of consecutive patients presenting to the Oxford Pelvic Floor Clinic between January 2004 and November 2008 were analysed. Patients were included if they had full thickness internal (grades 1-4 prolapse) or external RP (grade 5 prolapse). All those included were analysed with regards to the presence of an enterocoele. Three hundred and seventy-one patients [322 (87%) women and 49 (23%) men] were found to have a degree of RP. One out of eight (12.5%) patients with grade 1 RP, 10/42 (18.5%) with grade 2 RP, 34/125 (27%) with grade 3 RP, 62/135 (46%) with grade 4 RP and 23/49 (47%) with grade 5 full thickness external RP had an enterocoele present. This was a statistically significant trend (Pearson chi(2) test P < 0.0002). There was a significantly higher proportion of enterocoeles in women [125/322 (39%) than in men (5/49 (10%)] (P < 0.0001) and a higher likelihood of having an enterocoele with advancing age (P < 0.0001). Within the study, there was no significant difference in the proportion of nulliparous and parous women with enterocoeles (P = 0.8); there were a significantly higher proportion of enterocoeles in hysterectomized women (P = 0.015). Enterocoele is increasingly seen with advancing RP severity. This suggests that the two findings are part of the same pelvic floor process. These data support the hypothesis that enterocoele is a marker of severe pelvic floor weakness. Enterocoele is seen more frequently in females particularly after hysterectomy.

Modified perineal stapled rectal resection with contour transtar for full‐thickness rectal prolapse

We report a modified technique of perineal proctectomy using a new reloadable curved cutter stapler, the Contour Transtar (Ethicon Endo-Surgery), to treat full-thickness external rectal prolapse. Between May and July 2008 three female patients were treated. All had a full-thickness external rectal prolapse up to 10 cm in length. The prolapse was initially divided by a linear cutter in anterior and posterior flaps, and resection of the prolapse was performed with a Contour Transtar stapler. There was no mortality or early or late morbidity. Follow-up was 2-4 months. All patients had a bowel movement within 3 days of the operation, oral feeding started immediately and the hospital stay was 5 days in all cases. All patients reported an improvement of constipation and continence. Our procedure may be indicated for full-thickness prolapse with a rectal protrusion up to 10 cm, as it allows a simple resection without any mobilization or dissection of the rectum. The technique is safe, easier and faster to perform than conventional perineal rectosigmoidectomy.

Management of Recurrent Rectal Prolapse: Surgical Approach Influences Outcome

Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse. From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients. Mean interval to their first recurrence was 33 (range, 1-168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1-82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01). The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach.