Persistent Prolapse Research Articles

Clinical Outcomes after Mitral Valve Surgery in Failed MitraClip Procedures.

We retrospectively evaluated in-hospital and overall outcome of patients who received mitral valve replacement (MVR) after failed MitraClip procedure. A total of 26 out of 740 patients received MVR after treatment with MitraClip between June 2010 and December 2020. We analyzed in-hospital mortality and overall mortality during the median follow-up period of 72 days after MVR. The median age in the entire cohort was 77.5 years. In-hospital mortality was 15.4% (n = 4) and the overall mortality during the follow-up period was 27% (n = 7). The median time between the MitraClip procedure and surgery was 34.5 days. The main reasons for surgery were mitral stenosis (23.1%), persistent prolapse of the mitral valve leaflets (42.3%), and persistent tethering of the mitral valve leaflets (34.6%). At the time of surgery all of the patients presented with New York Heart Association 3 and above. The underlying mitral valve pathology was mainly secondary 61.5% (n = 16). Median left ventricular end-diastolic diameter was 60 mm. Preoperative ejection fraction was 40% and above in 73% of the cohort. In addition to the mitral valve procedure, 57.7% of patients received either concomitant tricuspid annuloplasty, aortic valve surgery, ascending aortic replacement, or coronary artery bypass grafting. The need for MVR for failed MitraClip repair is low and the results are acceptable. However, remaining options for reconstruction are usually limited and MVR is often needed. Anticipating success or failure according to the underlying pathology more than according to concomitant risk factors should form the basis in decision making for the treatment modality of first choice.

Efficacy and safety of anal encirclement combining the Leeds-Keio artificial ligament with injection sclerotherapy using aluminum potassium sulfate and tannic acid in the management of rectal prolapse: a single-center observational study.

Perineal procedures are an important surgical option for frail and high-risk patients with rectal prolapse. This study aimed to evaluate the efficacy and safety of combined therapy using injection sclerotherapy, with aluminum potassium sulfate and tannic acid (ALTA), and the Thiersch procedure, using the Leeds-Keio ligament (ALTA-Thiersch). This study included 106 consecutive patients (mean age, 81.2 years) who underwent ALTA-Thiersch for rectal prolapse. The procedure was performed under caudal epidural anesthesia. ALTA was injected into the submucosa from the tip of the prolapsed rectum down to the dentate line, circumferentially, at 20 to 40 locations. The ligament tape was placed outside the external sphincter muscle and at an approximate depth of 2 cm into the middle anal canal. Of 106 patients, rectal prolapse was cured shortly after surgery in 105 patients. An additional tape was inserted in 1 patient who had persistent prolapse. Postoperative complications were observed in 27 patients (25.5%). Fecal impaction occurred in 12 patients; however, since it was temporary, no tape removal was required. Of the 12 cases in which the tape was infected or exposed, 11 required tape removal. There were 18 cases of recurrence at a mean follow-up of 22.1 months. Cumulative recurrence rates at 3 and 5 years were 21.3% and 38.6%, respectively. ALTA-Thiersch is a simple and safe procedure for rectal prolapse, having reasonable outcomes. The use of the Leeds-Keio ligament for anal encircling can help compensate for the disadvantages of the Thiersch operation.

Posterior sagittal rectopexy in the management of persistent and recurrent complete rectal prolapse in children

Aim The aim of this study was to evaluate the clinical and functional results of posterior sagittal rectopexy (PSR) in children with persistent and recurrent rectal prolapse. Patients and methods All patients with recurrent rectal prolapse after injection sclerotherapy or previous anal cerclage and patients with prolonged persistent prolapse needing surgery were subjected to PSR. Follow-up extended in the outpatient clinic for 6 months, and the patients were observed for any change in bowel habits, continence, and postoperative complication (incontinence and bleeding). Results This study included 12 patients with persistent rectal prolapse not responding to conservative treatment for 1 year and eight patients with recurrent rectal prolapse. Their ages at the operation ranged from 3 to 10 years. The mean operative time was 60 min (range, 40–80 min). Early postoperative complications include wound infection in four cases, which responded to antibiotics and daily dressings, and four patients with temporary constipation responding to laxatives and regulation of diet habits. Recurrence occurred in one patient in the form of partial mucosal prolapse. Conclusion PSR is a safe and effective procedure for persistent and recurrent rectal prolapse in children with excellent clinical and functional results.

Prolapse Recurrence after Transvaginal Mesh Removal

We determined the rate of pelvic organ prolapse recurrence after transvaginal mesh removal. Following institutional review board approval a longitudinally collected database of women undergoing transvaginal mesh removal for complications after transvaginal mesh placement with at least 1 year minimum followup was queried for pelvic organ prolapse recurrence. Recurrent prolapse was defined as greater than stage 1 on examination or the need for reoperation at the site of transvaginal mesh removal. Outcome measures were based on POP-Q (Pelvic Organ Prolapse Quantification System) at the last visit. Patients were grouped into 3 groups, including group 1--recurrent prolapse in the same compartment as transvaginal mesh removal, 2--persistent prolapse and 3--prolapse in a compartment different than transvaginal mesh removal. Of 73 women 52 met study inclusion criteria from 2007 to 2013, including 73% who presented with multiple indications for transvaginal mesh removal. The mean interval between insertion and removal was 45 months (range 10 to 165). Overall mean followup after transvaginal mesh removal was 30 months (range 12 to 84). In group 1 (recurrent prolapse) the rate was 15% (6 of 40 patients). Four women underwent surgery for recurrent prolapse at a mean 7 of months (range 5 to 10). Two patients elected observation. The rate of persistent prolapse (group 2) was 23% (12 of 52 patients). Three women underwent prolapse reoperation at a mean of 10 months (range 8 to 12). In group 3 (de novo/different compartment prolapse) the rate was 6% (3 of 52 patients). One woman underwent surgical repair at 52 months. At a mean 2.5-year followup 62% of patients (32 of 52) did not have recurrent or persistent prolapse after transvaginal mesh removal and 85% (44 of 52) did not undergo any further procedure for prolapse. Specifically for pelvic organ prolapse in the same compartment as transvaginal mesh removal 12% of patients had recurrence, of whom 8% underwent prolapse repair.

Longo procedure (Stapled hemorrhoidopexy): Indications, results

There is now sufficient data in the literature to compare pedicularhemorroidectomy (Milligan and Morgan, Ferguson), the reference operation, to the Longo procedure (stapledhemorrhoidopexy) (SH). SH is easy to perform, is associated with less pain and allows early return to normal activities. Not withstanding a higher risk of recurrence and some degree of procidentia, the long-term level of patient satisfaction is high after SH. Strict patient selection is necessary: patients should have reversible prolapse, normal anal caliber, and absence of large tags. This procedure is not recommended for stageIV disease. In case of persistent prolapse or hemorrhoidal recurrence after SH, elastic band ligation should be preferred.

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: Surgical Technique and Outcomes at a Single High-volume Institution

BackgroundPelvic organ prolapse (POP) represents a common female pelvic floor disorder that has a serious impact on quality of life. Several types of procedures with different surgical approaches have been described to correct these defects, but the optimal management is still debated. ObjectiveTo describe our surgical technique of robot-assisted sacrocolpopexy (RASC) for POP and to assess its safety and long-term outcomes. Design, setting, and participantsA retrospective review of the medical records of 95 consecutive patients who underwent RASC for POP at our centre from April 2006 to December 2011 was performed. Surgical procedureRASC with use of polypropylene meshes was performed in all cases using a standardised technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. Outcome measurements and statistical analysisClinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes of RASC were assessed. A descriptive statistical analysis was performed. Results and limitationsMedian operative time was 101min. No conversion to open surgery was needed. One vaginal and two bladder injuries occurred and were repaired intraoperatively. Only one Clavien grade 3 postoperative complication was observed (bowel obstruction treated laparoscopically). At a median follow-up of 34 mo, persistent POP was observed in four cases (4.2%). One mesh erosion occurred and required robot-assisted removal of the mesh. Ten (10.5%) patients complained de novo urgency after RASC, which resolved in the first few weeks after surgery. No significant de novo bowel or sexual symptoms were reported. ConclusionsOur technique of RASC for correction of POP is safe and effective, with limited risk of complications and good long-term results in the treatment of all types of POP. The robotic surgical system facilitates precise and accurate placement of the meshes with short operative time, thereby favouring wider diffusion of minimally invasive treatment of POP. Patient summaryWe studied the treatment of patients with vaginal prolapse by using a robot-assisted surgical technique to fix the vaginal wall with a synthetic mesh. This technique was found to be safe and effective, with limited risk of complications and good long-term results.

Evaluation of Doppler-guided hemorrhoidal artery ligation in the management of symptomatic hemorrhoids

Background: We evaluated the results of the Doppler-guided hemorrhoidal artery ligation procedure in the management of symptomatic hemorrhoids to determine its effectiveness, safety, short and long term outcome. Patients and methods: Between January 2007 and December 2008, fifty consecutive patients with symptomatic hemorrhoids were treated by Doppler-guided hemorrhoidal artery ligation method. All patients were treated in insurance hospital in Riyad, KSA and Palestinian hospital, Cairo, Egypt. Postoperative pain was measured with visual analog scale (1-10). Patients were followed up at intervals of one week, 1, 3, 6 and 12 months postoperatively. At every postoperative follow up visit, wound healing was observed and any complication was reported. Results: Thirty five patients had their operations performed under general anesthesia. The operative time ranged between 19-45 minutes (mean 32± 3.6 minutes). The mean postoperative pain score was 6.1 ± 1.3 in the first postoperative day. The complications rate was low and the most common long term complication was persistent prolapse in three patients (6%). Conclusion: Doppler-guided hemorrhoidal artery ligation procedure in the management of symptomatic hemorrhoids is safe, effective and is associated with minimal long term complications. The procedure can be done on an out-patient basis

Letter to the editor on the article “Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results”

Dear Editor: We refer to the article entitled “Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results” published in December 2009.While we congratulate the authors on publishing their results of a randomized controlled trial on what is a new and exciting treatment modality for haemorrhoidal disease, we would like to share our thoughts on the subject. The authors set out to compare Procedure for Prolapsed Haemorrhoids (PPH) with Transanal Haemorrhoidal Dearterialisation (THD) with regards to post-operative complications and short-term results. They used “resolved pre-operative symptoms with no need for further treatment” as a primary end-point. We feel that this is not objective enough. For grade III and IV haemorrhoids, one of the main symptoms would be that of prolapse. Here, the authors have not quantified the nature of prolapse nor investigated the extent of resolution of the pre-operative prolapse after surgery. Further, it appears that there is only one patient in the PPH arm with grade IV haemorrhoids, compared with four patients in the THD arm. Could the observed difference in persistent prolapse between the two arms at 6 weeks be due to this? Overall, the small sample size suggests that the study may be inadequately powered to show a true difference between the two treatment modalities. It would have been helpful to include information on power calculations. With respect to the technical details of surgery, it was unclear how exactly THD was performed. It would also be helpful if the authors clarified whether three-, fouror six-point ligation was performed. In addition, was a plicating stitch or anopexy routinely performed in all cases? Finally, we wish to point out that this study did not look specifically into the costs and learning curve for performing both procedures. As such, the last statement that THD is “more easily learned and less costly” remains to be proven. In our ongoing study of 140 patients who had undergone THD, we have found persistent prolapse at 6 weeks in 19.2% of patients with grade III piles. This compares with 22.2% of patients in the current study who complained of persistent prolapse at 6 weeks. The authors mentioned that, in their PPH arm, only 11.1% had persistent prolapse. There appears to be twice the risk of persistent prolapse if grade III or IV haemorrhoids were operated on using THD instead of PPH. Based on the results reported in this study, perhaps we should only recommend THD for haemorrhoidal bleeding and not prolapse at this point in time.

Arytenoid prolapse: A source of obstruction following laryngotracheoplasty

Objective Arytenoid prolapse is a potential source of upper airway obstruction following laryngotracheoplasty, and may be difficult to identify. We explored the incidence, clinical features, etiology, and surgical approach to patients with arytenoid prolapse following laryngotracheoplasty. Study Design Case series with chart review. Subjects and Methods The charts of 93 patients diagnosed with arytenoid prolapse following laryngotracheoplasty from 1981 to 2007 were reviewed. Results The incidence was 5.7 percent (93/1634). Forty-nine patients had unilateral prolapse; 44 had bilateral prolapse. Average time from laryngotracheoplasty to presentation was 36.8 months. Common symptoms were dyspnea on exertion, tracheostomy dependence, and sleep-disordered breathing. Fifty-four patients (58%) required surgical intervention, with arytenoid reduction performed in 45 patients. Nine underwent reduction during revision laryngotracheoplasty or cricotracheal resection. Fourteen patients required a second procedure for persistent prolapse. Thirty-nine (42%) required no intervention. Symptom resolution or decannulation was achieved in all patients in whom prolapse was the source of obstruction. Statistically significant differences were found when anterior vs posterior graft utilization was compared. Conclusions Arytenoid prolapse is a cause of airway obstruction following laryngotracheoplasty. Subtle airway complaints and decannulation failures are common features. Both endoscopic and open procedures can successfully treat arytenoid prolapse. Potential etiologies are discussed.

Arytenoid Prolapse following Laryngotracheoplasty

Objective Dynamic arytenoid prolapse (AP) is a potential and often late source of upper airway obstruction in children following laryngotrachoplasty (LTP). Reasons for this occurrence remain unclear. We examined the incidence and clinical features of AP in patients following LTP to explore the etiology and optimal surgical approach to this problem. Methods Retrospective database and chart review of children diagnosed with AP after LTP at a pediatric tertiary care institution from 1981–2007. Results 120 patients with no history of AP were diagnosed with AP following LTP (incidence 7.3% = 120/1634). 63 patients had unilateral prolapse, while 57 had bilateral AP. Average time from LTP to presentation was 44 months. Common symptoms were dyspnea on exertion, tracheostomy-dependence, and sleep-disordered breathing. Posterior cricoid interventions and revision LTP were most frequently associated with postoperative AP. 64% (n=77) of patients required surgical intervention. Endoscopic arytenoid reduction (AR) was performed in 54 patients, while 13 underwent AR during revision LTP. 2 patients underwent AR with cordotomy. Tracheostomy was performed with AR in another 2 patients. 28 patients required a second procedure for persistent prolapse. 36%(n=42) of patients did not require surgery. Airway complaints were relieved, or tracheostomy decannulation was achieved, in all patients after AR in which AP was the source of obstruction (avg. f/u=34.4mos). Conclusions Dynamic AP is a notable cause of airway obstruction following LTP. Subtle airway complaints and decannulation failures are common clinical features. Both endoscopic and open AR procedures are successful in relieving AP. Potential etiology for AP after LTP is discussed.

Retrospective multicentre study of the new minimally invasive mesh repair devices for pelvic organ prolapse

To assess the complications and short-term outcomes of prolapse repair mesh devices used in the management of female pelvic organ prolapse (POP). Retrospective cohort study. Multicentre study involving a tertiary referral urogynaecology unit and two district general hospitals. 329 women who underwent surgical management of prolapse with various prolapse repair mesh devices in the period between January 2005 and December 2006. Women were identified from theatre records. An independent clinician performed a case notes review during the period March to May 2007. Complication rates and the short-term cure at 3-month follow-up (defined as </=stage I prolapse on the POP-Q or Baden Walker scoring systems). A total of 289 women were included: 219 (76%) used the Gynecare prolapse repair mesh devices, while 70 women (24%) used the American Medical Systems prolapse repair mesh devices. Operative complications included: bladder injury (1.6%), rectal injury (1.1%) and two women with serious vascular injuries. Postoperative complications included: buttock pain (5.2%), vaginal erosion (10%), one woman with bladder erosion and two women (0.7%) with serious infection, leading to necrotising fasciitis in one woman. Short-term cure rates in different groups varied from 94 to 100%, depending on vaginal compartment and device used. In total 15 women (5%) had persistent prolapse at 3-month follow up. The new prolapse repair mesh devices demonstrate excellent short-term cure and low morbidity rates. However, some complications are serious and require highly specialised management. Rigorous evaluation by means of independent, controlled studies is urgently required.