Recurrent Rectal Prolapse Research Articles

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy.

PurposeTo describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR.MethodsAll consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences.ResultsA total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates.ConclusionHigh-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

What operation for recurrent rectal prolapse after previous Delorme's procedure? A practical reality.

To report our experience with perineal repair (Delorme's procedure) of rectal prolapse with particular focus on treatment of the recurrence. Clinical records of 40 patients who underwent Delorme's procedure between 2003 and 2014 were reviewed to obtain the following data: Gender; duration of symptoms, length of prolapse, operation time, ASA grade, length of post-operative stay, procedure-related complications, development and treatment of recurrent prolapse. Analysis of post-operative complications, rate and time of recurrence and factors influencing the choice of the procedure for recurrent disease was conducted. Continuous variables were expressed as the median with interquartile range (IQR). Statistical analysis was carried out using the Fisher exact test. Median age at the time of surgery was 76 years (IQR: 71-81.5) and there were 38 females and 2 males. The median duration of symptoms was 6 mo (IQR: 3.5-12) and majority of patients presented electively whereas four patients presented in the emergency department with irreducible rectal prolapse. The median length of prolapse was 5 cm (IQR: 5-7), median operative time was 100 min (IQR: 85-120) and median post-operative stay was 4 d (IQR: 3-6). Approximately 16% of the patients suffered minor complications such as - urinary retention, delayed defaecation and infected haematoma. One patient died constituting post-operative mortality of 2.5%. Median follow-up was 6.5 mo (IQR: 2.15-16). Overall recurrence rate was 28% (n = 12). Recurrence rate for patients undergoing an urgent Delorme's procedure who presented as an emergency was higher (75.0%) compared to those treated electively (20.5%), P value 0.034. Median time interval from surgery to the development of recurrence was 16 mo (IQR: 5-30). There were three patients who developed an early recurrence, within two weeks of the initial procedure. The management of the recurrent prolapse was as follows: No further intervention (n = 1), repeat Delorme's procedure (n = 3), Altemeier's procedure (n = 5) and rectopexy with faecal diversion (n = 3). One patient was lost during follow up. Delorme's procedure is a suitable treatment for rectal prolapse due to low morbidity and mortality and acceptable rate of recurrence. The management of the recurrent rectal prolapse is often restricted to the pelvic approach by the same patient-related factors that influenced the choice of the initial operation, i.e., Delorme's procedure. Early recurrence developing within days or weeks often represents a technical failure and may require abdominal rectopexy with faecal diversion.

Surgery for complete (full-thickness) rectal prolapse in adults.

Complete (full-thickness) rectal prolapse is a lifestyle-altering disability that commonly affects older people. The range of surgical methods available to correct the underlying pelvic floor defects in full-thickness rectal prolapse reflects the lack of consensus regarding the best operation. To assess the effects of different surgical repairs for complete (full-thickness) rectal prolapse. We searched the Cochrane Incontinence Group Specialised Register up to 3 February 2015; it contains trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) as well as trials identified through handsearches of journals and conference proceedings. We also searched EMBASE and EMBASE Classic (1947 to February 2015) and PubMed (January 1950 to December 2014), and we specifically handsearched theBritish Journal of Surgery (January 1995 to June 2014), Diseases of the Colon and Rectum (January 1995 to June 2014) and Colorectal Diseases (January 2000 to June 2014), as well as the proceedings of the Association of Coloproctology meetings (January 2000 to December 2014). Finally, we handsearched reference lists of all relevant articles to identify additional trials. All randomised controlled trials (RCTs) of surgery for managing full-thickness rectal prolapse in adults. Two reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The four primary outcome measures were the number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, number of patients with faecal incontinence and number of patients with constipation. We included 15 RCTs involving 1007 participants in this third review update. One trial compared abdominal with perineal approaches to surgery, three trials compared fixation methods, three trials looked at the effects of lateral ligament division, one trial compared techniques of rectosigmoidectomy, two trials compared laparoscopic with open surgery, and two trials compared resection with no resection rectopexy. One new trial compared rectopexy versus rectal mobilisation only (no rectopexy), performed with either open or laparoscopic surgery. One new trial compared different techniques used in perineal surgery, and another included three comparisons: abdominal versus perineal surgery, resection versus no resection rectopexy in abdominal surgery and different techniques used in perineal surgery.The heterogeneity of the trial objectives, interventions and outcomes made analysis difficult. Many review objectives were covered by only one or two studies with small numbers of participants. Given these caveats, there is insufficient data to say which of the abdominal and perineal approaches are most effective. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation. Laparoscopic rectopexy was associated with fewer postoperative complications and shorter hospital stay than open rectopexy. Bowel resection during rectopexy was associated with lower rates of constipation. Recurrence of full-thickness prolapse was greater for mobilisation of the rectum only compared with rectopexy. There were no differences in quality of life for patients who underwent the different kinds of prolapse surgery. The lack of high quality evidence on different techniques, together with the small sample size of included trials and their methodological weaknesses, severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Longer follow-up with current studies and larger rigorous trials are needed to improve the evidence base and to define the optimum surgical treatment for full-thickness rectal prolapse.

Reoperative surgery for recurrent rectal prolapse

Up to 30% of patients who underwent surgical treatment for rectal prolapse will experience a recurrence. The presentation and evaluation of recurrent rectal prolapse is similar to that of primary rectal prolapse. The options for surgical treatment are the same as those for primary disease, and similarly, there is no widely accepted gold standard. Several factors are considered when choosing an approach, such as the patient׳s previous surgical history, age, functional status, and comorbid pelvic floor disorders such as fecal incontinence and constipation. Abdominal and perineal approaches have been described. The ideal procedure for each patient is that which has the longest durability and best functional outcome while minimizing surgical morbidity. Future prospective studies that critically evaluate outcomes are needed to guide procedure choice.

A systematic review of the literature on the surgical management of recurrent rectal prolapse.

There are no available guidelines to support surgical decision-making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence-based treatment algorithm. PubMed and MEDLINE databases were searched for all clinical studies involving patients who underwent surgery for recurrent rectal prolapse between 1950 and 2014. The primary outcome measure was the recurrence rate after abdominal or perineal surgery for recurrent rectal prolapse. Secondary outcomes included morbidity, mortality and quality of life data where available. There were no randomized controlled studies comparing the success rates of abdominal or perineal surgery for recurrent rectal prolapse. Most studies were heterogeneous, of low quality (level IV) and involved small numbers of patients. The follow-up of 144 patients included in the studies undergoing perineal surgery ranged from 8.8 to 81 months, with recurrence rates varying from 0% to 50%. Morbidity ranged from 0% to 17% with no mortality reported. Limited data on quality of life following the Altemeier procedure were available. The follow-up for 158 patients included in the studies who underwent abdominal surgery ranged from 0 to 23 years, during which recurrence rates varied from 0% to 15%. Morbidity rates ranged from 0% to 32% with 4% mortality. No quality of life data were available for patients undergoing abdominal surgery. This systematic review was unable to develop a treatment algorithm for recurrent rectal prolapse due to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Larger high-quality studies are necessary to guide practice in this difficult area.

Intrarectal migration of mesh following Rectopexy: Case series and review of literature

IntroductionMesh rectopexy for complete rectal prolapse is associated with complications such as fecal impaction, constipation and rarely recurrence. Mesh erosion following rectopexy is rare. We report three such cases managed successfully in our unit. Presentation of casesAll three patients presented with constipation. In addition, one patient had sense of incomplete evacuation and another had protrusion of mesh through anal canal with recurrence of rectal prolapse. There was a delayed presentation in one patient at 15 years after initial surgery, while other two presented at 2years and 5 years following rectopexy. Diagnosis was made by either per rectal examination or sigmoidoscopy. Two patients underwent trans abdominal removal of mesh along with anterior resection of rectum. In one patient, mesh was removed by transanal approach and sutured rectopexy was added to tackle the recurrent prolapse. All patients are symptom free on follow up with no recurrence of prolapse. DiscussionMesh erosion following rectopexy has multifactorial aetiology with diverse presentation. It is important to recognise this significantly morbid complication as it amenable to surgical correction. Management depends up on the location of erosion, the severity of mesh protrusion into rectal lumen and the degree of fibrosis around the area of mesh. ConclusionThe management of mesh erosion following rectopexy should be individualized. Although it is complex, acceptable functional outcome and quality of life can be achieved with proper treatment.

PTH-265 Outcomes of redo rectopexy with and without resection for recurrent rectal prolapse: are the results comparable to the primary surgery?

<h3>Introduction</h3> The surgical approach to recurrent full-thickness rectal prolapse is more complicated than for primary full thickness rectal prolapse. However, it has not been reported that redo rectopexy for recurrent full thickness rectal prolapse is as safe and feasible as primary rectopexy. This study evaluated the safety and efficacy of redo rectopexy with and without resection for recurrent full thickness rectal prolapse. <h3>Method</h3> After IRB approval, 144 consecutive patients [138 females; mean age 57 (range, 16–83) years] with primary [n = 112; 108 females, mean age 56 (range, 16–80) years] or recurrent [n = 32; 30 females, mean age 58 (29–83) years] rectal prolapse who underwent rectopexy with and without resection between May 2000 and April 2014 were identified from a prospective database. Perioperative outcomes and reoperation rate due to recurrence were compared between the two groups. <h3>Results</h3> Both groups had comparable demographics, BMI, ASA scores, type of surgical approach, and comorbidities. Patients with primary rectopexy had a higher percentage of resected colon (60.7%) than did those with redo rectopexy (28.1%; <i>p = 0</i>.001). Patients had open (75 vs. 25), hand-assisted (3 vs. 1) and laparoscopic (34 vs. 6) surgery in the primary vs. redo rectopexy groups, respectively (p = 0.213). Intraoperative blood loss and length of postoperative stay were similar in both groups. The most common complication was ileus (n = 15). There was no significant difference in the postoperative complication rate (primary rectopexy 30.6% vs. redo rectopexy 37.5%; <i>p = 0</i>.521). The reoperation rate due to recurrence was significantly higher in redo rectopexy vs. primary rectopexy (12.5% vs. 1.8%; <i>p = 0</i>.022). The mean interval from primary surgery to reoperation for recurrence was 17.0 (range, 2.5–40.5) months for the redo rectopexy group and 46.8 (range, 30.0–63.7) months for the primary rectopexy. Functional data were not available. <h3>Conclusion</h3> Redo rectopexy with and without resection can be performed as safely as primary rectopexy in patients with full-thickness rectal prolapse. However, the re-reoperation rate due to recurrence of rectal prolapse is higher in redo rectopexy. <h3>Disclosure of interest</h3> None Declared.

PWE-392 Need for further surgery after delormes procedure for rectal prolapse in elderly patients

<h3>Introduction</h3> Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly females. Delormes procedure is often the preferred operative option for high risk elderly patients due to its minimal invasive nature and minimal postoperative morbidity. A recent randomised control trial looking at the different operative procedure for rectal prolapse has quoted rectal prolapse recurrence after Delormes procedure as high as 46% at 5 years. Whether that high recurrence rates correlates with the need of further surgery is not known. We aimed to analyse rectal prolapse recurrence and further surgery rates for patients undergoing Delormes procedure in our institution. <h3>Method</h3> All consecutive adult patients undergoing Delormes procedure between April, 2000 – December, 2014 at the University Hospitals of Leicester NHS Trust were reviewed. This was a retrospective study. Patients were analysed for mode of surgery, 30 day post-operative mortality, post-operative length of hospital stay, clinically detected recurrence and further rectal prolapse surgery. <h3>Results</h3> 109 patients (median age = 79 years, female n = 102, male n = 7) underwent Delormes procedure over the 14 years. Ninety nine (91%) patients had planned surgery and ten (9%) patients had an urgent operation after being admitted via emergency admission route. Median follow up for all the patients was 4 years and 69 patients were alive at the time of analysis. 30 day post-operative mortality was 2.75% and median length of hospital stay after surgery was 4.5 days. 15 (13.7%) patients had a clinically detected rectal prolapse recurrence during the follow up period, 12 (11%) underwent further surgery for their rectal prolapse (redo Delormes n = 4, Altemeier–s procedure n = 5, abdominal rectopexy n = 3) and 3 patients did not undergo further surgery. <h3>Conclusion</h3> Delormes procedure remains safe and an effective procedure to treat rectal prolapse in elderly patients as clinically significant recurrence rates are low. <h3>Disclosure of interest</h3> None Declared.

PWE-384 Comparison of functional outcomes after laparoscopic ventral mesh rectopexy and resection rectopexy

Introduction Laparoscopic ventral mesh rectopexy (LVMR) repairs rectal prolapse and rectocoele by an autonomic nerve-sparing rectal dissection, using mesh reinforcement. The aim of this retrospective series was to assess functional outcomes of laparoscopic VMR and compare with an historical control group having had open resection rectopexy. Method Between 2012 and 2015, 64 patients had LVMR for rectal prolapse, functional obstructed defaecation (FOD) caused by rectocoele and/or faecal incontinence (FI). 31 out of 64 patients underwent preoperative imaging by MRI defaecating proctogram. Biological mesh was used in 51 out of 64 (80%) patients. We reviewed electronic patient records for outcomes and telephoned patients for further review of symptoms after surgery. Follow-up ranged from 1–33 months, median 12 months. Outcomes were also analysed in 68 patients who had open resection rectopexy between 1999 and 2009 (range 5–14 years, median 8 years). Results The conversion rate to open VMR was 7 out of 64 (11%) patients, due to adhesions from previous surgery. In this series of laparoscopic VMR, a total of 4 out of 64 patients required re-intervention, 2 for complications and 2 for technical failure (ie. early recurrent rectal prolapse and rectocoele). At 5 months there were no infections, fistulae or pain complications. In all patients with FI (n = 32), there was improvement in symptoms at initial follow-up. FOD resolved in 43 out of 44 patients. Outcomes from open resection rectopexy include FI (11 patients), constipation (8), FOD due to rectocoele (7), adhesional small bowel obstruction (7, of which 3 required laparotomy), uterovaginal prolapse (6), recurrent rectal prolapse (4) and incisional hernia (1). Conclusion Laparoscopic VMR is an effective technique for repairing rectocoele, rectal prolapse, and tricompartmental pelvic floor decent. It has a low complication rate with high resolution of symptoms at early follow-up (median 12 months). The longer term follow-up for open resection rectopexy suggested a higher level of recurrent prolapse, FI and FOD. Longer follow-up data on laparoscopic VMR patients is underway. This series of laparoscopic VMR repair for rectal prolapse and/or rectocoele has demonstrated early improvement in functional outcome overall and when compared with historical open resection rectopexy operations. Disclosure of interest None Declared. References D9Hoore A, Penninckx F. Laparoscopic ventral recto (colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc. 2006;20:1919–1923 D9Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004;91:1500–1505

Postoperative complications after reconstructive surgery for cloacal malformations: a systematic review.

The repair of cloacal malformations is most often performed using a posterior sagittal anorecto-vagino-urethroplasty (PSARVUP) or total urogenital mobilization (TUM) with or without laparotomy. The aim of this study was to systematically review the frequency and type of postoperative complication seen after cloacal repair as reported in the literature. A systematic literature search was conducted according to preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA). Eight records were eligible for this study which were qualitatively analyzed according to the Rangel score. Overall complication rates reported in included studies ranged from 0 to 57 %. After meta-analysis of data, postoperative complications were seen in 99 of 327 patients (30 %). The most common reported complications were recurrent or persistent fistula (n = 29, 10 %) and rectal prolapse (n = 27, 10 %). In the PSARVUP group, the complication rate was 40 % and in the TUM group 30 % (p = 0.205). This systematic review shows that postoperative complications after cloacal repair are seen in 30 % of the patients. The complication rates after PSARVUP and TUM were not significantly different. Standardization in reporting of surgical complications would inform further development of surgical approaches. Other techniques aiming to lower postoperative complication rates may also deserve consideration.

Rectal prolapse in children: a study of 71 cases.

IntroductionProlapse of the rectum is the herniation of the rectum through the anus, which may be categorised as mucosal or complete.AimTo evaluate the clinical manifestation, treatment, and surgical complications of children with rectal prolapse over a 6-year period.Material and methodsThis study was carried out on children aged < 14 years who were admitted or referred for rectal prolapse that failed to respond after medical treatment in Imam Khomeini and Abouzar Children's Hospital. Duration of the study was 6 years starting in March 2002. These cases were referred after failure of medical and conservative treatment. Age, sex, clinical manifestation, and type of procedure were recorded. Analysis was done using SPSS version 11.0 (SPSS Inc, Chicago, IL, USA). The χ2 test was used for comparison.ResultsSeventy-one cases were included in this study. Of these cases, 50 (70.4%) were male and 21 (29.6%) were female (p < 0.0001). Mean age of cases was 4.97 ±3.42 years (range: 2 days to 13 years). Of the male cases, 38% were in the age range of 3–6 years. In female cases, 57.1% were in the range of 1.5–3 years. Of all 71 cases, injection sclerotherapy was done for 50 (70.43%) for the first time. Twenty-one cases had history of injection sclerotherapy and 16 (22.53%) were treated by perineal surgery, and 5 (7.04%) had abdominal surgery. One case experienced recurrent rectal prolapse (1.40%) following injection sclerotherapy.ConclusionsIn girls, more than half of the cases were in the age range 1.5–3 years. Among male cases, 38% were in the age range of 1.5–3 years. The results of treatment of rectal prolapse in our hospitals was similar to that seen in developed countries.

Laparoscopic modified Orr-Loygue mesh rectopexy for rectal prolapse in children

AimWe present an operating technique inspired from the Orr-Loygue mesh rectopexy adapted for laparoscopy, and detail the technical steps that differ from laparoscopic posterior suture rectopexy more commonly described in the paediatric literature. MethodWe present a retrospective study of all children who underwent a modified Orr-Loygue procedure for recurrent complete rectal prolapse from 1999 to 2012 after failure of conservative treatment. Pathological conditions, technical details of the procedure (excision of the Douglas pouch, use of a prerectal non-absorbable mesh to suspend the rectum to the presacral fascia and promontory avoiding any tension on the rectal wall) and postoperative results were reviewed. ResultsEight patients were included, median age 6.5years (range, 2–17). Median symptoms duration before surgery was 14months (range, 6–24). Four patients presented with associated pathological conditions: 1 neurological impairment (Williams–Beuren syndrome), 1 severe malnutrition (mental anorexia), 1 solitary rectal ulcer with frequent bleeding, 1 syringomyelic cavity in the spinal cord. All procedures were completed laparoscopically with a median operative time of 98minutes (range, 80–125). Median hospital stay was 3.5days (range, 2–5). No postoperative constipation or recurrence was reported during the median follow-up period of 6years (range 2–13). ConclusionThe laparoscopic modified Orr-Loygue mesh rectopexy is a simple operating technique, reproducible and efficient as surgical treatment of nonresolving recurrent complete rectal prolapse in children. To avoid postoperative constipation, it is important to perform a tension-free rectopexy which can be achieved by the use of a mesh to simply suspend and not “fix” the redundant rectosigmoid. Nonetheless, a greater number of patients as well as colorectal electromyography or anorectal manometry would be necessary to prove the absence of postoperative deleterious functional disorder.

Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse.

Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients. A password-protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient-reported outcome measures were evaluated. Sixty-eight men of median age 35years and body mass index 26kg/m(2) underwent LVMR for external rectal prolapse (18) or Grade III-V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled 'chronic idiopathic pelvic pain' and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow-up was 42 (IQR 26-61) months. CCIS score improved from 4 (IQR 0-8) to 0 (IQR 0-0) (P<0.001) and the ODS score from 18.5 (IQR 16-22) to 6 (IQR 5-8) (P<0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ-22) at 3months (P=0.000). The QoL and the VAS for bowel symptoms were maintained at 4years. At the last follow-up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse. LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

A novel percutaneous technique for treating complete rectal prolapse in adults.

To evaluate a new technique for treating complete rectal prolapse in adults that combines injection sclerotherapy with anal encirclement. From 2008 to 2012, 20 patients were treated using combined perirectal injection sclerotherapy with anal encirclement. The primary outcome was recurrent full-thickness/mucosal rectal prolapse. The mean age of the patients was 39 years. The mean operating time was 17 minutes. Patients had short hospital stays (range = 2-4 days) and rapid recovery with no serious postoperative complications. After a mean follow-up of 22 months, recurrence occurred in 9 patients, and was complete in 6 cases and mucosal in 3 patients. Recurrent mucosal prolapse was treated with a mucosectomy, while recurrent complete rectal prolapse was treated with an open rectopexy with mesh. The combination of perirectal sclerotherapy and anal encirclement for treating complete rectal prolapse in adults is a simple and safe procedure with reasonable outcome. These findings call for confirmatory trials in larger series.

Rectopexy for paediatric rectal prolapse: good outcomes but not without postoperative problems.

Rectopexy is a simple treatment of persisting complete rectal prolapse (RP) or related functional disorders in children. The results of rectopexy have been encouraging with few complications. We describe the postoperative complications and outcome of rectopexy in our institution from 2002 to 2013. Ethical committee accepted the study. Hospital records of 27 successive patients (16 males), median age 7.2 (range 2.8-17) years, who underwent rectopexy (25 laparoscopic, 2 open) were reviewed. Indication for rectopexy included RP (n = 24), solitary rectal ulcer with enterocele (n = 2) and rectocele (n = 1). Nine patients (39 %) were healthy. In the remaining 14 patients, RP was secondary to anorectal malformation (n = 2), bladder exstrophy (n = 1), sacrococcygeal teratoma (n = 1) and myelomeningocele (n = 1) or associated with mental retardation (n = 8) and Asperger's syndrome (n = 1). Five (18 %) patients had constipation. Unexpected postoperative events and complications were rated by Clavien-Dindo classification (Grades I-V). Seventeen (61 %) patients had postoperative complications (Grade I n = 5, II n = 2 and III n = 7). Readmission was required in 11 (41 %) and reoperation, endoscopy or other surgical procedure in 9 (33 %) patients. Complications included severe faecal obstruction (n = 2), constipation (n = 3), faecal soiling (n = 1) urinary retention (n = 2), enuresis (n = 1), infection (n = 2), residual mucosal prolapse (n = 5), discomfort at defecation (n = 1) and recurrent RP (n = 2). Reoperations included sigmoid resection with re-rectopexy (n = 1), resection of mucosal prolapse (n = 1), suprapubic urinary catheter (n = 2), evacuation of faecal impaction (n = 2), colonoscopy (n = 3), appendicostomy for antegrade continence enema (n = 1). Mental retardation or behavioural disorder increased the risk of postoperative faecal obstruction and constipation RR = 84 (95 % CI 4.3-1600), p = 0.0035. After median follow-up of 4.1 (range 0.6-11) years RP or related condition was cured in 26 patients. Constipation and faecal soiling require management in a total of seven patients. Long-term results of rectopexy were good. Postoperative complications from mild to moderate grade were unexpectedly frequent. Preoperative neurobehavioural disorder and constipation increase the risk of postoperative problems and should be mentioned in patient counselling.

Sacrocolpopexy With Rectopexy for Pelvic Floor Prolapse Improves Bowel Function and Quality of Life

Sacrocolpopexy with rectopexy is advocated for combined rectal and vaginal prolapse, but limited outcome data have been reported. The purpose of this study was to evaluate the indications and outcomes of sacrocolpopexy and rectopexy by comparing pre- and postoperative function and quality of life. A retrospective review of prospectively collected data was performed of all patients undergoing sacrocolpopexy and rectopexy at our institution from 2004 to 2011. Preoperatively, all patients underwent physiology testing and completed 4 validated questionnaires assessing bowel symptom severity and associated quality of life. Patients completed the same questionnaires in 2012. A total of 110 women (median age, 55 years; range, 28-88) underwent a sacrocolpopexy and rectopexy, 33 with concomitant hysterectomy. All patients had rectal prolapse (n = 96) or rectal intussusception (n = 14), and each also had either enterocele (n = 86) or vaginal prolapse (n = 48). Rectal prolapse with enterocele was the most common presentation (n = 75). Previous surgery included rectal prolapse repair (21%) and hysterectomy (57%). Complications included presacral bleeding (n = 2), ureteral injury (n = 2), wound infection (n = 8), and pulmonary embolism (n = 2). There were no mortalities. Fifty-two patients completed the follow-up questionnaires, with a median follow-up of 29 (range, 4-90) months, and preoperative surveys were available in 30 of these patients. Preoperatively, 93% reported constipation; 82% reported resolution or improvement postoperatively. Constipation severity, measured with the Patient Assessment of Constipation Symptom Questionnaire, demonstrated improvement (1.86-1.17; p < 0.001). Fecal incontinence severity scores (Fecal Incontinence Severity Index) improved (39-24; p < 0.01), and 82% of incontinent patients reported cure or improvement. Quality-of-life scores also improved significantly. No patient developed recurrent rectal prolapse. This was a retrospective review, and the response rate to questionnaires was limited. Sacrocolpopexy and rectopexy for combined middle and posterior compartment prolapse is a safe procedure, with low risk for recurrence, and improves bowel function and quality of life in most patients.

Early experience with robotic rectopexy

The introduction of robotics in colorectal surgery has been gaining increasing acceptance. However, experience remains still limited for pelvic floor disorders. We report herein our first cases of fully robotic rectopexy and promontofixation for rectal prolapse. From October 2011 to June 2012, five female patients underwent a robotic rectopexy at our institution. The patients were selected according to their primary pathology and their medical history for this preliminary experience. Four of them presented a rectal prolapse associated or not with a vaginal prolapse and the last patient presented a recurrent rectal prolapse 5 years after a laparoscopic repair. The study was approved by our local ethics committee. The robot da Vinci Si (Intuitive Surgical Inc, Sunnyvale, CA) was used with a 4-port setting in all cases. The mean operative time was 170 minutes (range: 120-270). There was no conversion. The blood loss was minimal. One patient presented a retrorectal hematoma, treated conservatively with success. There was no other complication. The mean hospital stay was 3.6 days (range: 2-7). At 2 months, there was neither recurrence nor readmission. In comparison with the laparoscopic approach, there were no statistically significant differences. Robotic rectopexy and promontofixation are feasible and safe. The outcomes are encouraging, but functional results and long-term outcomes are required to evaluate the exact role of robotics for rectal prolapse.

Use of negative contrast computed tomography for diagnosis of a colonic duplication in a dog

A 24-week-old dog was presented with recurrent rectal prolapse because of colonic duplication. Colonic duplication is an extremely uncommon congenital abnormality, with only six cases reported in veterinary medicine, one diagnosed at necropsy and five after barium enema, colonoscopy, abdominal ultrasound, exploratory laparotomy either alone or in combination. In this case, these techniques failed to identify the abnormality and diagnosis was ultimately achieved via negative contrast computed tomography. The evaluation generated by the computed tomography images allowed a refined surgical approach. To the authors' knowledge, negative contrast computed tomography has not yet been reported in the veterinary literature to diagnose gastrointestinal pathologies. Colonic duplication in this case was treated by removal of the intercolonic septum via colotomy.

Su1604 Outcomes for Robotic-Assisted Rectopexy With or Without Sigmoid Colon Resection for Rectal Prolapse

Purpose : Our experience in robotic-assisted rectopexy with sigmoid colon resection (RAR+SR) or without sigmoid colon resection (RAR) was reviewed to determine if there was a significant difference in intra-operative or postoperative outcomes. Methods : We retrospectively reviewed 26 patients that underwent robotic-assisted rectopexy for rectal prolapse from 2006 to 2012. Rectopexy is performed with primary suture pexy and without mesh. Continuous variables were analyzed by t-test, while Fisher's exact test was applied for categorical data. Results : Twenty-two patients underwent RAR and 4 patients underwent RAR+SR. The average age for study participants was 56 years (range 21-78 years) and consisted of 4 men and 22 women. Recurrent rectal prolapse occurred in 2 patients at 3 and 30 months after surgery in the RAR group and no recurrence occurred in the RAR+SR group (p=1.00). The duration of surgery for RAR was 211 minutes versus 309 minutes for RAR+SR (p,0.001, CI 60.8 135.4). Intra-operative blood loss for RAR was 97.8mL compared to 87.5mL for RAR+SR (p=0.924, CI -77.4 89.7). Conversion to open procedure occurred twice with RAR and once with RAR+SR (p=0.407). Length of hospitalization averaged 3 days for RAR and 4 days for RAR+SR (p=0.196, CI -0.2 2.2). The mean follow up was 127 days (range 1-72 months). Eight of 10 patients with preoperative constipation subjectively noted improvement with RAR versus 1 of 2 patients with RAR+SR (p=0.455). Six of 10 patients with preoperative fecal incontinence had subjectively improved symptoms with RAR versus 1 of 2 patients with RAR+SR (p=1.00). Six patients in the RAR group experienced a postoperative complication (over-sedation, corneal abrasion, atrial flutter, pulmonary edema, pelvic hematoma, ileus) versus 1 complication (urinary retention) after RAR+SR (p=0.924). There were no mortalities and no complications requiring operative intervention. Conclusions : The majority of patients underwent RAR and outcomes for RAR versus RAR+SR were not significantly different in this series with the exception of increased operative time for RAR+SR. The recurrence rate was 8% and the complication rate was 27% with the majority of complications being minor complications.

Su1605 Anastomotic Leak Following Anterior Resection for Rectal Cancer: Does the Presence of a Defunctioning Stoma Reduce the Burden of a Leak ?

Purpose : Our experience in robotic-assisted rectopexy with sigmoid colon resection (RAR+SR) or without sigmoid colon resection (RAR) was reviewed to determine if there was a significant difference in intra-operative or postoperative outcomes. Methods : We retrospectively reviewed 26 patients that underwent robotic-assisted rectopexy for rectal prolapse from 2006 to 2012. Rectopexy is performed with primary suture pexy and without mesh. Continuous variables were analyzed by t-test, while Fisher's exact test was applied for categorical data. Results : Twenty-two patients underwent RAR and 4 patients underwent RAR+SR. The average age for study participants was 56 years (range 21-78 years) and consisted of 4 men and 22 women. Recurrent rectal prolapse occurred in 2 patients at 3 and 30 months after surgery in the RAR group and no recurrence occurred in the RAR+SR group (p=1.00). The duration of surgery for RAR was 211 minutes versus 309 minutes for RAR+SR (p,0.001, CI 60.8 135.4). Intra-operative blood loss for RAR was 97.8mL compared to 87.5mL for RAR+SR (p=0.924, CI -77.4 89.7). Conversion to open procedure occurred twice with RAR and once with RAR+SR (p=0.407). Length of hospitalization averaged 3 days for RAR and 4 days for RAR+SR (p=0.196, CI -0.2 2.2). The mean follow up was 127 days (range 1-72 months). Eight of 10 patients with preoperative constipation subjectively noted improvement with RAR versus 1 of 2 patients with RAR+SR (p=0.455). Six of 10 patients with preoperative fecal incontinence had subjectively improved symptoms with RAR versus 1 of 2 patients with RAR+SR (p=1.00). Six patients in the RAR group experienced a postoperative complication (over-sedation, corneal abrasion, atrial flutter, pulmonary edema, pelvic hematoma, ileus) versus 1 complication (urinary retention) after RAR+SR (p=0.924). There were no mortalities and no complications requiring operative intervention. Conclusions : The majority of patients underwent RAR and outcomes for RAR versus RAR+SR were not significantly different in this series with the exception of increased operative time for RAR+SR. The recurrence rate was 8% and the complication rate was 27% with the majority of complications being minor complications.