Therapeutic effects of the TST36 stapler on rectocele combined with internal rectal prolapse.

BACKGROUND: The most common causes of outlet obstructive constipation (OOC) are rectocele and internal rectal prolapse. The surgical methods for OOC are diverse and difficult, and the postoperative complications and recurrence rate are high, which results in both physical and mental pain in patients. With the continuous deepening of the surgeon's concept of minimally invasive surgery and continuous in-depth research on the mechanism of OOC, the treatment concepts and surgical methods are continuously improved. AIM: To determine the efficacy of the TST36 stapler in the treatment of rectocele combined with internal rectal prolapse. METHODS: From January 2017 to July 2019, 49 female patients with rectocele and internal rectal prolapse who met the inclusion criteria were selected for treatment using the TST36 stapler. RESULTS: Forty-five patients were cured, 4 patients improved, and the cure rate was 92%. The postoperative obstructed defecation syndrome score, the defecation frequency score, time/straining intensity, and sensation of incomplete evacuation were significantly decreased compared with these parameters before treatment, and the differences were statistically significant (P < 0.05). The postoperative anal canal resting pressure and maximum squeeze pressure in patients decreased compared with before treatment, and the differences were statistically significant (P < 0.05). The initial and maximum defecation thresholds after surgery were significantly lower than those before treatment, and the differences were statistically significant (P < 0.05). The postoperative ratings of rectocele, resting phase, and defecation phase in these patients were significantly decreased compared with those before treatment, and the differences were statistically significant (P < 0.05). CONCLUSION: The TST36 stapler is safe and effective in treating rectocele combined with internal rectal prolapse and is worth promoting in clinical work.

Anatomo-functional outcomes of the laparoscopic Frykman-Goldberg procedure for rectal prolapse in a tertiary referral centre.

Rectal prolapse is a common disorder that represents a burden for patients due to the associated symptoms that may include both incontinence and constipation. Currently, a huge variation in techniques exist. The aim of this study was to evaluate the anatomo-functional results of the laparoscopic Frykman-Goldberg procedure (LFGP) for the treatment of both internal (IRP) and complete rectal prolapse (CRP). Between July 2004 and October 2019, 45 patients with IRP and CRP underwent a LFGP. The Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Syndrome Score (ODSS) and Vaizey Score (VS) were assessed preoperatively, 3 months before the procedure, 12 months after the procedures and at the final follow-up visit. The patients' mean age was 51.4 ± 17.9 (15-93) years, and the mean follow-up was 9.24 ± 4.57 (1.6-16.3) years. The VS, CCCS and ODSS significantly improved (p = 0.008; p < 0.001; p < 0.001) from median preoperative values of 3, 20 and 18 to 2, 6 and 5, respectively. Furthermore, the improvements in scores during follow-up remained constant and significant over time when considering the two groups separately (time effect for ODSS p < 0.001, for VS p = 0.026, for CCCS p < 0.001) and when the patients were divided by age (< 40, 41-60 and > 60; p < 0.001). The overall complication rate was 8.9% (4/45), and no intraoperative complications or anastomotic leakage occurred. Conversion to the open approach was not necessary in any case. The overall success rate was 97.7%, and only one recurrence in the IRP group occurred after 14 months. LRGP can be considered a safe, effective and long-lasting procedure in young patients with IRP or CRP, a history of ODS and a redundant sigmoid colon.

A step-by-step approach to endorectal proctopexy (ERPP): how we do it.

There are many surgical treatments aimed at correcting internal mucosal prolapse and rectocele associated with obstructed defecation syndrome (ODS). Perineal procedures can be considered as first options in young men in whom an abdominal approach poses risks of sexual dysfunction and in selected women with isolated posterior compartment prolapse who failed conservative treatment. About 20 years ago, we described endorectal proctopexy (ERPP) also known as internal Delorme procedure. The aim of the present study was to describe, with attention to technical details and the aid of a video, the different steps of ERPP for the treatment of ODS. A retrospective analysis of our last 100 cases confirms our initial good results. Complications included suture line dehiscence with consequent stricture in four patients (4%). Bleeding occurred in four (4%) patients and was conservatively treated. Transient anal continence impairment consisting of urgency and soiling occurred in 12 (12%) and 6 (6%) patients, respectively. At 6-month follow-up the Cleveland Clinic Constipation Score and ODS score improved from a median preoperative value of 18.9 and 18.5 to 5 and 5, respectively (p < 0.0001). The mean follow-up was 36.05 ± 13.3 (range 12-58) months and anatomical recurrence rate was 6 (%). Due to its excellent safety profile and the ability to tailor the procedure to different disease presentations, we think that ERPP should be part of the basic armamentarium of all colorectal surgeons operating on the pelvic floor.

Clinical efficacy of integral theory-guided laparoscopic integral pelvic floor/ligament repair in the treatment of internal rectal prolapse in females.

BACKGROUND: Internal rectal prolapse (IRP) is one of the most common causes of obstructive constipation. The incidence of IRP in women is approximately three times that in men. IRP is mainly treated by surgery, which can be divided into two categories: Abdominal procedures and perineal procedures. This study offers a better procedure for the treatment of IRP. AIM: To compare the clinical efficacy of laparoscopic integral pelvic floor/ligament repair (IPFLR) combined with a procedure for prolapse and hemorrhoids (PPH) and the laparoscopic IPFLR alone in the treatment of IRP in women. METHODS: This study collected the clinical data of 130 female patients with IRP who underwent surgery from January 2012 to October 2014. The patients were divided into groups A and B. Group A had 63 patients who underwent laparoscopic IPFLR alone, and group B had 67 patients who underwent the laparoscopic IPFLR combined with PPH. The degree of internal rectal prolapse (DIRP), Wexner constipation scale (WCS) score, Wexner incontinence scale (WIS) score, and Gastrointestinal Quality of Life Index (GIQLI) score were compared between groups and within groups before surgery and 6 mo and 2 years after surgery. RESULTS: All laparoscopic surgeries were successful. The general information, number of bowel movements before surgery, DIRP, GIQLI score, WIS score, and WCS score before surgery were not significantly different between the two groups (all P > 0.05). The WCS score, WIS score, GIQLI score, and DIRP in each group 6 mo, and 2 years after surgery were significantly better than before surgery (P < 0.001). In group A, the DIRP and WCS score gradually improved from 6 mo to 2 years after surgery (P < 0.001), and the GIQLI score progressively improved from 6 mo to 2 years after surgery (P < 0.05). In group B, the DIRP, WCS score and WIS score significantly improved from 6 mo to 2 years after surgery (P < 0.05), and the GIQLI score 2 years after surgery was significantly higher than that 6 mo after surgery (P < 0.05). The WCS score, WIS score, GIQLI score, and DIRP of group B were significantly better than those of group A 6 mo and 2 years after surgery (all P < 0.001, Bonferroni) except DIRP at 2 years after surgery. There was a significant difference in the recurrence rate of IRP between the two groups 6 mo after surgery (P = 0.011). There was no significant difference in postoperative grade I-III complications between the two groups (P = 0.822). CONCLUSION: Integral theory-guided laparoscopic IPFLR combined with PPH has a higher cure rate and a better clinical efficacy than laparoscopic IPFLR alone.

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome: An alternative option for selected patients.

BACKGROUND: Abdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique for ODS are very limited. AIM: To evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS. METHODS: Consecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department. Patient demographics, perioperative surgical results, and postoperative follow-up outcomes were collected and analyzed. Long-term follow-up was evaluated with standardized questionnaires. The severity of symptoms was assessed by the objective Wexner Constipation Score (WCS) and ODS Score. The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score. Functional outcome was compared pre- and post-operatively for each patient. The primary outcomes were determined by the improvement in symptoms and quality of life. Secondary outcome measures were operating time, postoperative length of stay, morbidity and mortality, improvement of pelvic floor structure, and patient satisfaction. RESULTS: Four patients underwent robotic-assisted surgery, and two patients underwent a laparoscopic-assisted procedure. The mean operating time for the robotic approach was 243 min (range 160-300 min), and the mean operating time for the laparoscopic approach was 230 min (range 220-240 min). The mean postoperative length of stay was 8.2 d (range 6-12 d). There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection and anastomosis leakage occurred. Six patients were followed up for 36 mo. The WCS, ODS, and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively (P < 0.05). The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication. CONCLUSION: Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS. However, comprehensive preoperative evaluation and careful patient selection are essential.

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

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence. METHODS: An individual level, stepped-wedge randomised trial has been designed to allow observer-blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) pre-operative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates. DISCUSSION: An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks). TRIAL REGISTRATION: ISRCTN registry, ISRCTN11747152 . Registered on 30 September 2015. The trial was prospectively registered (first patient enrolled on 21 March 2016).

Abdominal rectopexy for the treatment of internal rectal prolapse: a systematic review and meta-analysis.

AIM: Internal rectal prolapse (IRP) is a unique functional disorder that presents with a wide spectrum of clinical symptoms, including constipation and/or faecal incontinence (FI). The present review aims to analyse the results of trials evaluating the role of abdominal rectopexy in the treatment of IRP with regard to regarding functional and technical outcomes. METHOD: A systematic review of the literature for the role of abdominal rectopexy in patients with IRP was conducted. PubMed/Medline, Embase and the Cochrane Central Register of Controlled Trials were searched for published and unpublished studies from January 2000 to December 2015. RESULTS: We reviewed 14 studies including 1301 patients (1180 women) of a median age of 59 years. The weighted mean rates of improvement of obstructed defaecation (OD) and FI across the studies were 73.9% and 60.2%, respectively. Twelve studies reported clinical recurrence in 84 (6.9%) patients. The weighted mean recurrence rate of IRP among the studies was 5.8% (95% CI: 4.2-7.5). Two hundred and thirty complications were reported with a weighted mean complication rate of 15%. Resection rectopexy had lower recurrence rates than did ventral rectopexy, whereas ventral rectopexy achieved better symptomatic improvement, a shorter operative time and a lower complication rate. CONCLUSION: Abdominal rectopexy for IRP attained satisfactory results with improvement of OD and, to a lesser extent, FI, a low incidence of recurrence and an acceptable morbidity rate. Although ventral rectopexy was associated with higher recurrence rates, lower complication rates and better improvement of bowel symptoms than resection rectopexy, these findings cannot be confirmed owing to the limitations of this review.

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

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

A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'.

PURPOSE: The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up. METHODS: From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded. RESULTS: The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up. CONCLUSIONS: The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.

Current surgical treatment of obstructed defecation among selected European opinion leaders in pelvic floor surgery.

BACKGROUND: The aim of this study was to perform a survey on the surgical management of obstructed defecation (OD) across advocated selected coloproctological experts across Europe. METHODS: Surgeons from 42 centers of coloproctology in Europe were asked to complete a questionnaire, including seven questions about their past and present operative treatment strategy for patients with OD. RESULTS: The questionnaire was completed by 32 experts of pelvic floor surgery in 13 European countries. All but one indicated that they consider surgical treatment for OD. Seventy-four percent of these have been using transanal stapled rectal resection (STARR) and 96 % transabdominal rectopexy. While only 65 %, who have begun performing STARR are still using transanal resection, the technique is still being used by all surgeons performing abdominal procedures. Rectopexy only, STARR only, or both approaches are offered by 52, 3, and 45 % of surgeons, respectively. CONCLUSIONS: The use of STARR in the treatment of OD is decreasing among European opinion leaders in the field of pelvic floor surgery, while the application of transabdominal procedures continues.

Trans-anal endoscopic microsurgery for internal rectal prolapse.

Internal rectal prolapse can lead to obstructed defecation, faecal incontinence and pain. In treatment of frail or technically difficult patients, a perineal approach is often used, such as a Delorme's or a STARR. However, in case of very high take-off prolapse, these procedures are challenging if not unsuitable. We present trans-anal endoscopic microsurgery as surgical option for management of this uncommon type of rectal prolapse in specific cases.

High-grade internal rectal prolapse: Does it explain so-called "idiopathic" faecal incontinence?

BACKGROUND: Faecal incontinence is a multifactorial disorder, with multiple treatment options. The role of internal rectal prolapse in the aetiology of faecal incontinence is debated. Recent data has shown the importance of high-grade internal rectal prolapse in case of faecal incontinence. We aimed to determine the incidence and relevance of internal rectal prolapse in patients with faecal incontinence without an anal sphincter defect. METHODS: Patient data, collected in a prospective pelvic floor database, were assessed. All females with moderate to severe pure faecal incontinence, without obstructed defecation and sphincter muscle defects, were included. Data on defecation proctography, anorectal physiology and incontinence scores were analysed. RESULTS: Of 2082 females in the database, 174 fitted the inclusion criteria. High-grade internal rectal prolapse was found in 49% of patients and was associated predominantly with urge faecal incontinence. Passive faecal incontinence was more common in low-grade compared to high-grade internal rectal prolapse patients. Maximum resting pressure was lower in older patients and in patients with high-grade compared to low-grade internal rectal prolapse. Internal rectal prolapse grade was not significantly correlated with faecal incontinence severity score. CONCLUSION: High-grade internal rectal prolapse is common in female patients suffering particularly urge faecal incontinence, without anal sphincter lesions. Defecation proctography should be routine in the work up of faecal incontinence.

Procedure for prolapse and hemorrhoids vs traditional surgery for outlet obstructive constipation.

AIM: To compare the clinical efficacies of two surgical procedures for hemorrhoid rectal prolapse with outlet obstruction-induced constipation. METHODS: One hundred eight inpatients who underwent surgery for outlet obstructive constipation caused by internal rectal prolapse and circumferential hemorrhoids at the First Affiliated Hospital of Xinjiang Medical University from June 2012 to June 2013 were prospectively included in the study. The patients with rectal prolapse hemorrhoids with outlet obstruction-induced constipation were randomly divided into two groups to undergo either a procedure for prolapse and hemorrhoids (PPH) (n = 54) or conventional surgery (n = 54; control group). Short-term (operative time, postoperative hospital stay, postoperative urinary retention, postoperative perianal edema, and postoperative pain) and long-term (postoperative anal stenosis, postoperative sensory anal incontinence, postoperative recurrence, and postoperative difficulty in defecation) clinical effects were compared between the two groups. The short- and long-term efficacies of the two procedures were determined. RESULTS: In terms of short-term clinical effects, operative time and postoperative hospital stay were significantly shorter in the PPH group than in the control group (24.36 ± 5.16 min vs 44.27 ± 6.57 min, 2.1 ± 1.4 d vs 3.6 ± 2.3 d, both P < 0.01). The incidence of postoperative urinary retention was higher in the PPH group than in the control group, but the difference was not statistically significant (48.15% vs 37.04%). The incidence of perianal edema was significantly lower in the PPH group (11.11% vs 42.60%, P < 0.05). The visual analogue scale scores at 24 h after surgery, first defecation, and one week after surgery were significantly lower in the PPH group (2.9 ± 0.9 vs 8.3 ± 1.1, 2.0 ± 0.5 vs 6.5 ± 0.8, and 1.7 ± 0.5 vs 5.0 ± 0.7, respectively, all P < 0.01). With regard to long-term clinical effects, the incidence of anal stenosis was lower in the PPH group than in the control group, but the difference was not significant (1.85% vs 5.56%). The incidence of sensory anal incontinence was significantly lower in the PPH group (3.70% vs 12.96%, P < 0.05). The incidences of recurrent internal rectal prolapse and difficulty in defecation were lower in the PPH group than in the control group, but the differences were not significant (11.11% vs 16.67% and 12.96% vs 24.07%, respectively). CONCLUSION: PPH is superior to the traditional surgery in the management of outlet obstructive constipation caused by internal rectal prolapse with circumferential hemorrhoids.

Does the presence of a high grade internal rectal prolapse affect the outcome of pelvic floor retraining in patients with faecal incontinence or obstructed defaecation?

AIM: Pelvic floor retraining is considered first-line treatment for patients with faecal incontinence or obstructed defaecation. There are at present no data on the effect of a high grade internal rectal prolapse on outcomes of pelvic floor retraining. The current study aimed to assess this influence. METHOD: In all, 120 consecutive patients were offered pelvic floor retraining. The predominant symptom was faecal incontinence in 56 patients (47%) and obstructed defaecation in 64 patients (53%). Patients were assessed before and after therapy using the Fecal Incontinence Severity Index (FISI), the Patient Assessment of Constipation Symptoms (PAC-SYM) score and the Gastrointestinal Quality of Life Index (GIQLI). Defaecography and anorectal manometry were performed in all patients before pelvic floor retraining. RESULTS: A high grade internal rectal prolapse was observed in 42 patients (35%). In patients with faecal incontinence without a high grade internal rectal prolapse, the FISI score decreased from 36 to 27 (P < 0.01). The FISI score did not change (32 vs 32; P = 0.93) in patients with a high grade internal rectal prolapse. The PAC-SYM score improved significantly (24 vs 19; P = 0.01) in patients with obstructed defaecation without a high grade rectal prolapse compared with no significant change (26 vs 25; P = 0.21) in patients with a high grade rectal prolapse. Quality of life (GIQLI) improved only in patients without a high grade internal rectal prolapse. CONCLUSION: Pelvic floor retraining may be useful in patients with defaecation disorders not associated with a high grade internal rectal prolapse. Patients with a high grade internal rectal prolapse may be considered for surgery from the outset.