Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review.

BACKGROUND: Chronic idiopathic constipation (CIC) is a substantial problem in pediatric and adult patients with similar symptoms and workup; however, surgical management of these populations differs. We systematically reviewed the trends and outcomes in the surgical management of CIC in pediatric and adult populations. METHODS: A literature search was performed using Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov between January 1, 1995 and June 26, 2020. Clinical trials and retrospective and prospective studies of patients of any age with a diagnosis of CIC with data of at least 1 outcome of interest were selected. The interventions included surgical resection for constipation or antegrade continence enema (ACE) procedures. The outcome measures included bowel movement frequency, abdominal pain, laxative use, satisfaction, complications, and reinterventions. RESULTS: Adult patients were most likely to undergo resection (94%), whereas pediatric patients were more likely to undergo ACE procedures (96%) as their primary surgery. Both ACE procedures and resections were noted to improve symptoms of CIC; however, ACE procedures were associated with higher complication and reintervention rates. CONCLUSION: Surgical management of CIC in pediatric and adult patients differs with pediatric patients receiving ACE procedures and adults undergoing resections. The evaluation of resections and long-term ACE data in pediatric patients should be performed to inform patients and physicians whether an ACE is an appropriate procedure despite high complication and reintervention rates or whether resections should be considered as an initial approach for CIC.

Comparing the short-term clinical outcomes and therapeutic effects of different colectomies in patients with refractory slow-transit constipation in eastern countries: a network meta-analysis.

Surgical treatment has been widely used in patients with refractory slow transit constipation (RSTC). The aim of this network meta-analysis (NMA) was to compare the effects of different colectomies on short-term postoperative complications and quality of life in patients with RSTC. Electronic literature searches were performed in the PubMed, Web of Science, EMBASE, WANFANG DATA, and Cochrane Central Register of controlled trials databases and were searched up to December 2022. Selected to compare the short-term clinical outcomes and quality of life of the treatment of RSTC. A random-effects Bayesian NMA was conducted to assess and rank the effectiveness of different surgical modalities. This study included a total of six non-randomized controlled trials involving 336 subjects. It was found that subtotal colectomy with cecorectal anastomosis (CRA) demonstrated superior effectiveness in several aspects, including reduced hospital stay (MD 0.06; 95% CI [0.02, 1.96]), shorter operative time (MD 4.75; 95% CI [0.28, 14.07]), lower constipation index (MD 0.61; 95% CI [0.04, 1.71]), improved quality of life (MD 4.42; 95% CI [0.48, 4.42]). Additionally, in terms of short-term clinical outcomes, subtotal colectomy with ileosigmoidal anastomosis (SC-ISA) procedure ranked the highest in reducing small bowel obstruction (OR 0.24; 95% CI [0.02, 0.49]), alleviating abdominal pain (OR 0.53; 95% CI [0.05, 1.14]), minimizing abdominal distension (OR 0.33; 95% CI [0.02, 0.65]), and reducing incision infection rates (OR 0.17; 95% CI [0.01, 0.33]). Furthermore, SC-ISA ranked as the best approach in terms of patient satisfaction (OR 0.66; 95% CI [0.02, 1.46]). Based on our research findings, we recommend that CRA be considered as the preferred treatment approach for patients diagnosed with RSTC.

Mental health disorders as a risk factor in young patients with rectal prolapse.

BACKGROUND: Rectal prolapse (RP) typically presents in the elderly, though it can present in younger patients lacking traditional risk factors. The current study compares medical and mental health history, presentation, and outcomes for young and older patients with RP. METHODS: This is a single-center retrospective review of patients who underwent abdominal repair of RP between 2005 and 2019. Individuals were dichotomized into two groups based on age greater or less than 40 years. RESULTS: Of 156 patients, 25 were < 40. Younger patients had higher rates of diagnosed mental health disorders (80% vs 41%, p < 0.001), more likely to take SSRIs (p = .02), SNRIs (p = .021), anxiolytics (p = 0.033), and antipsychotics (p < 0.001). Younger patients had lower preoperative incontinence but higher constipation. Both groups had low rates of recurrence (9.1% vs 11.6%, p = 0.73). CONCLUSIONS: Young patients with RP present with higher concomitant mental health diagnoses and represent unique risk factors characterized by chronic straining compared to pelvic floor laxity.

Ventral mesh rectopexy. Does a descending perineum impact functional results and quality of life?

PURPOSE: The impact of perineal descent (PD) on functional outcome and quality of life after ventral mesh rectopexy (VMR) is unknown. The purpose of this study was to analyze the effect of PD on the functional outcome and quality of life (QOL) after VMR. METHODS: A retrospective analysis was performed on fifty-five patients who underwent robotic VMR between 2018 and 2021. Pre and postoperative data along with radiological studies were gathered from a prospectively maintained database. The Cleveland Clinic Constipation score (CCCS), the Rome IV criteria and the 36-Item Short-Form Health Survey (SF-36), were used to measure functional results and QOL. RESULTS: All 55 patients (mean age 57.8 years) were female. Most patients had radiological findings of severe PD (n = 31) as opposed to mild/moderate PD (n = 24). CCCS significantly improved at 3 months and 1 year post-VMR (mean difference = -4.4 and -5.4 respectively, p < 0.001) with no significant difference between the two groups. The percentage of functional constipation Rome IV criteria only showed an improved outcome at 3 months for severe PD and at 1 year for mild/moderate PD (difference = -58.1% and -54.2% respectively, p < 0.05). Only the SF-36 subscale bodily pain significantly improved in the mild/moderate PD group (mean difference = 16.7, p = 0.002) 3 months post-VMR which subsided after one year (mean difference = 5.5, p = 0.068). CONCLUSION: Severe PD may impact the functional outcome of constipation without an evident effect on QOL after VMR. The results, however, remain inconclusive and further research is warranted.

Endoscopic retrieval of migrated Foley catheter: A clinical case series.

Use of Foley catheter in patients with ileostomy, for the decompression of large bowel distal to stoma or for the administration of large bowel enema through colostomy, either to treat constipation or for bowel preparation prior to colonoscopy, is a common practice. Accidental migration of catheter during bowel irrigation through stoma can take place if it is not secured externally to the skin. We present 2 such cases with intra-colonic migration of Foley catheter that occurred during bowel irrigation and were retrieved endoscopically. To our knowledge, this is the first case report of endoscopic removal of Foley catheter that migrated internally through the stoma.

Logistic analysis of the recurrence of laparoscopic percutaneous extraperitoneal repair of pediatric inguinal hernia: A report of 486 cases.

BACKGROUND: Although the laparoscopic treatment of pediatric inguinal hernia (PIH) has more benefits than traditional surgery, it is difficult to completely avoid the problem of recurrence. The aim of this study was to use a logistic regression model to investigate the causes of recurrence after laparoscopic percutaneous extraperitoneal repair (LPER) of PIH. PATIENTS AND METHODS: From June 2017 to December 2021, 486 cases of PIH were performed using LPER in our department. We utilized a two-port approach to implement LPER for PIH. All cases were followed up and the recurrent cases were recorded in detail. We used a logistic regression model to analyze the clinical data in order to find the reasons for recurrence. RESULTS: We completed 486 cases with an internal inguinal ostium high ligation using laparoscopic surgery without conversion. Patients were followed for 10-29 months with an average of 18.2 months and 8 cases had recurrent ipsilateral hernia, including 4 recurrent cases in 89 cases (4.49%) using absorbable suture, 1 in 7 cases (14.29%) with internal inguinal ostium larger than 25 mm, 2 in 26 cases (7.69%) with BMI greater than 21, 2 in 41 cases (4.88%) with postoperative chronic constipation. The total recurrence rate was 1.65%. A foreign body reaction occurred in 2 cases, there were no complications such as scrotal hematoma, trocar umbilical hernia and testicular atrophy, and no deaths in this study. Univariate logistic regression analysis showed that patient BMI, ligation suture, diameter of the internal inguinal ostium and postoperative chronic constipation were significant variables (P values 0.093, 0.027, 0.060 and 0.081). The multivariate logistic regression analysis showed that the ligation suture and the diameter of the internal inguinal ostium were the main risk factors for postoperative recurrence, the odds ratio (OR) value were 5.374 and 2.801, the P values 0.018 and 0.046, and the 95% CI were 2.513-11.642 and 1.134-9.125. The area under ROC curve (AUC) for the logistic regression model was 0.735 (the 95% CI 0.677-0.801, P < 0.01). CONCLUSION: An LPER for PIH is a safe and effective operation, but there still remains a small probability of recurrence. In order to reduce the recurrence rate of LPER, we should improve surgical skills, choose an appropriate ligature and avoid using LPER for a huge internal inguinal ostium (especially over 25 mm). It is appropriate to be converted to open surgery for the patients with a very wide internal inguinal ostium.

Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): The Sydney partial thickness discoid excision technique.

BACKGROUND: Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. AIM: This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. MATERIALS AND METHODS: Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. RESULTS: Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). CONCLUSION: This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.

Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective.

INTRODUCTION: Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception worldwide. The aim of this study is to report our experience and long time consequences and to offer a new medico-legal perspective. MATERIALS AND METHODS: We retrospective review medical charts of patients treated between 2006 and 2021 â€‹b â€‹y the same team directed by the same senior surgeon. We consider major complications and long time sequelaeses as main object for the discussion. Inclusion and exclusion criteria were created. IRB approved the study. After revision a medico-legal perspective was done based on major complications. RESULTS: During the study period 1726 patients, ages between 18 and 71 years old, were treated with 1280 STARR procedures and 446 "Longo" [was stopped on 2012]; all procedures were performed by the senior surgeon and visited by the team at the same control visit at 7days, 30 days and 12 and 18 months after surgery. All patients had 100 â€‹% compliance at 30 days, while 85 â€‹% had long time visit (more than 18 months). During the study period 6 â€‹% (104 subjects) of patients had minor complications while 1 patient (42 â€‹yrs female) reported total fecal incontinence after 18 months (0,05 â€‹%). This patient had mental disorder treated with drugs unknown before surgery and long time mental disorder after surgery. We focused on this last case to discuss long time complication DISCUSSION: This survey reports some interesting clinical data; respect to standard complications minor complications such as pain, bleeding and anal discomfort represent less than 10 â€‹% of procedures that is a good results in this perineal surgery. For those working with rectal mucosal prolapse, obstructed defecation syndrome, rectocele or rectal intussusception is essential to distinguish these diagnosis to have a good counselling with patient before surgery (at least 1 month before). It is essential to check these patients with a close follow-up especially after surgery, to avoid any other mental discomfort related to fecal incontinence; long time fecal incontinence, without anatomical disorders as our case, could be associated and related to drugs consumption or mental disorder, or perineal insensitivity due to surgical procedure. In conclusion it is essential to have good clinical practice to suggest STARR procedure, having idea about different diseases, different surgical approaches and different long time complications.

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery.

PURPOSE: Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery. METHODS: A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time. RESULTS: Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001). CONCLUSION: SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

[Chinese surgical diagnosis and treatment consensus on slow transit constipation (2023 edition)].

In recent years, advancements have been made in both basic and surgical research of slow-transit constipation (STC). However, compelling references for surgeons in the clinical practice of STC have been lacking, particularly on preoperative evaluation and the choice of surgical procedures. In order to further standardize the diagnosis, assessment and surgical management of STC, Chinese Medical Doctor Association Anorectal Doctor Branch and its Functional Diseases Committee selected relevant experts in the field of STC surgery in China to form the Editorial and Review Committee of the Expert Consensus on Diagnosis, Evaluation and Surgical Management of STC in China. By meticulously reviewing relevant literature from both domestic and international sources and integrating the clinical expertise of the panel of experts, the committee has formulated 20 recommendations. These recommendations aim to establish standardized processes for surgical diagnosis and treatment of STC, ultimately elevating the overall diagnostic and therapeutic standards for STC across China.

Laparoscopic modified mesh rectopexy: medium-term results of a novel approach for external rectal prolapse.

AIM: Rectal prolapse is a common and significantly debilitating condition. Surgical correction is usually required. The two most common abdominal approaches are ventral mesh rectopexy and posterior suture rectopexy. Both may be complicated, respectively, by either mesh-related complications or significant postoperative constipation. We report the outcome of a novel rectopexy operation which combines aspects of both the aforementioned approaches, for the treatment of external rectal prolapse (ERP). METHOD: The technique involves laparoscopic partial posterior-lateral rectal mobilization of the rectum with posterior suture fixation to the sacral promontory and placement of an absorbable mesh in the rectovaginal space. Data were collected on postoperative complications, prolapse recurrence, mesh-related complications and the assessment of quality of life. RESULTS: Eighty patients underwent a modified mesh rectopexy for ERP. Seventy-seven were women. The median age was 67.5 years. Almost a third had undergone a previous rectal prolapse repair. Recurrences were seen in 11 (13.8%). No mesh-related complications were seen. Eleven patients reported postoperative constipation. CONCLUSION: The laparoscopic modified mesh rectopexy may be a safe and effective operation for the treatment of ERP.

Laparoscopic ventral mesh rectopexy vs. transperineal mesh repair for obstructed defecation syndrome associated with rectocele: comparison of selectively distributed patients.

PURPOSE: Obstructed defecation syndrome represents 50-60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes. METHODS: This study is a retrospective review of 131 female patients who were diagnosed with obstructed defecation syndrome, attributed to rectocele with or without rectal intussusception, enterocele, hysterocele or cystocele, and who underwent either laparoscopic ventral mesh rectopexy or transperineal mesh repair. Patients were evaluated for surgical outcomes based on the operative time, the length of hospital stay, operative complications, using prospectively designed charts. Functional outcome was assessed by using the Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool. RESULTS: Fifty-one patients diagnosed with complex rectocele underwent laparoscopic ventral mesh rectopexy, and 80 patients diagnosed with simple rectocele underwent transperineal mesh repair. Mean age was found to be 50.35 ± 13.51 years, and mean parity 2.14 ± 1.47. Obstructed defecation symptoms significantly improved in both study groups, as measured by the Colorectal Anal Distress Inventory, Constipation Severity Instrument and Patient Assessment of Constipation-Symptoms scores. Minor postoperative complications including wound dehiscence (n = 3) and wound infection (n = 2) occurred in the transperineal mesh repair group. CONCLUSION: Laparoscopic ventral mesh rectopexy and transperineal mesh repair are efficient and comparable techniques in terms of improvement in constipation symptoms related to obstructed defecation syndrome. A selective distribution of patients with or without multicompartmental prolapse to one of the treatment arms might be the preferred strategy.

[A Surgical Case of Currarino Syndrome with Syringomyelia].

Currarino syndrome is characterized by a triad of anorectal malformations, sacral defects, and presacral masses. Although it is not extremely rare, this report presents a surgical case of Currarino syndrome with syringomyelia and discusses related literature. The patient is a girl, aged 2 years and 2 months, who presented with marked constipation, chronic cystitis, and lower limb weakness. After examining the patient through magnetic resonance imaging, we diagnosed her with rectal compression due to meningocele and syringomyelia. The base of the meningocele was detached, and the spinal cord was untethered. One week after surgery, her lower limb weakness and constipation improved. Following up on symptoms and performing imaging is essential to determine a treatment plan for Currarino syndrome. (Received 28 February, 2023; Accepted 22 March, 2023; Published 1 August, 2023).

The impact of antegrade continence enemas on bladder function in patients with neurogenic bladder and bowel.

INTRODUCTION: In neurologically intact children with constipation and lower urinary tract symptoms, treatment of constipation frequently results in improved or resolved lower urinary tract symptoms. The impact of treatment of constipation on bladder function in children with a neurogenic bowel and bladder is not well studied. The objective of this study was to evaluate the impact of antegrade continence enemas (ACE) via Chait tube on urodynamic study (UDS) parameters and urinary continence in patients with neurogenic bowel and bladder (NGB). We hypothesized that following ACE some patients would demonstrate improved UDS parameters and improved urinary continence. MATERIALS AND METHODS: A review of patients with NGB who underwent a cecostomy was performed. Inclusion criteria required UDS within 12 months before and after Chait tube placement and no change in clean intermittent catheterization or anticholinergic medications. UDS parameters assessed included bladder capacity, bladder compliance, and bladder stability. In addition, the frequency of antegrade continence enemas and encopresis were reviewed as was the frequency of UTIs before and after the surgery. RESULTS: 8 children met inclusion criteria, including 5 girls and 3 boys, with a mean (range) age of 8.5 years (5-13). All children were on clean intermittent catheterization and 7 were on anticholinergic medications. The patients demonstrated a significant improvement in constipation and encopresis (p < 0.05). All but 1 patient had resolution of encopresis, and 6 of 7 patients who had constipation before ACE management had a resolution of constipation. 2 patients (25%) developed urinary continence (i.e., dry between CIC), and 2 others had improvement in continence. 3, 2, and 2 patients had urodynamic improvement in bladder capacity, compliance, or stability, respectively. However, no significant improvement in urinary incontinence or UDS parameters was demonstrated for the group overall. DISCUSSION: Our data demonstrate that some children with neurogenic bowel and bladder will have improvement in continence and UDS parameters following the initiation of ACE. Despite significant improvement in constipation and encopresis, the frequency of bladder improvement in this population appears less than that reported in neurologically intact children following treatment of constipation. Confirmatory studies with a larger number of children are needed. However, since constipation appears to negatively impact bladder function in some children with neurogenic bowel and bladder, it is reasonable to try to eliminate significant constipation in these patients before increasing pharmaceutical management of their neurogenic bladder.

Evaluating the risk factors for the development of benign disorders of defaecation: a surgical perspective.

PURPOSE: There remains uncertainty as to which risk factors are important for the development of defaecatory problems as a result of heterogeneity of published evidence. Understanding the impact of risk factors may be important in selecting targets for disease prevention or reversal. The aim of this study was to identify and evaluate risk factors for faecal incontinence and chronic constipation. METHODS: Risk factors for chronic constipation and faecal incontinence were long-listed from scientific literature, then anonymously evaluated (by 50 predominantly colorectal surgical experts from the UK Pelvic Floor Society) using a Delphi technique. Each risk factor was rated as independent, a co-factor, or not a risk factor. Independent risk factors were rated between 1 (not important) and 10 (critically important) with mean (± standard deviation) calculated. RESULTS: Thirty-eight risk factors for chronic constipation were evaluated. Eighteen were classed as independent and 16 as co-factors. Opioid analgesia (7.87 ± 2.05), eating disorders (7.80 ± 1.72), and history of abuse (7.70 ± 1.89) were scored as most important independent risk factors. Female sex (6.60 ± 2.02) was considered an independent risk factor but increasing age was rated a co-factor. Thirty-three risk factors for faecal incontinence were evaluated. Twenty were classed as independent and eight as co-factors. Third- or fourth-degree tear (8.88 ± 1.57), instrumental delivery (8.47 ± 1.58), and grand multiparity (8.00 ± 1.63) were rated most important. Increasing age (7.41 ± 2.14) and female sex (7.58 ± 2.05) were both considered independent risk factors. CONCLUSIONS: Several risk factors for chronic constipation and faecal incontinence were selected by Delphi approach. These factors will feed forward into Bayesian models of disease prediction that combine data and expert knowledge.

Constipation After Elective Laparoscopy for Benign Gynecological Indications-A Prospective Observational Study.

STUDY OBJECTIVE: Discover the rate of post-operative constipation in participants undergoing elective laparoscopy for benign gynecological indications DESIGN: Prospective observational study SETTING: Single site, tertiary level gynecology unit with a focus on pelvic pain and endometriosis. PATIENTS: Recruited participants were patients of the institution over the age of 18 who had planned to undergo an elective laparoscopy for benign gynecological indications prior to enrolment in the study. Participants were excluded if they were not English speaking, had a chronic bowel condition (with the exception of irritable bowel syndrome), were planned to have bowel surgery, hysterectomy, or converted to laparotomy. INTERVENTION: In this prospective study, participants completed 3 consecutive surveys. One prior to surgery, one a week post-surgery, and a third 3 months post-surgery. The surveys collected data regarding the participant's bowel habits, pain relief used, laxatives used, and the distress or bother caused by their bowels. MEASUREMENT AND MAIN RESULTS: Constipation was defined by a modified ROME IV criteria. Opiate use and laxative use were defined by patient-reported tablet counts. The level of distress was measured as a continuously variable scale from 0 to 100. Variables adjusted for included subject's demographics, pre-operative constipation, indication for surgery, duration of surgery, estimated blood loss, opiate use (preoperative, peri-operative, and post-operative), laxative use, and length of stay. A total of 153 participants were recruited, of which 103 completed both the pre-operative and post-operative survey. Post-operative constipation was present in 70% of participants. The mean length of time to first bowel motion was 3 days, with 32% of participants having their first bowel motion after the third post-operative day. The level of bother caused by their bowel habit was higher in the constipation group compared to those without constipation. Post-operatively opiates were used in 84.9% of participants, and laxatives were used in 47.1%. Visits to the general practitioner for constipation occurred in 5.8% of participants. CONCLUSION: Post-operative constipation is common and bothersome in participants who undergo elective laparoscopy for benign gynecological indications. Analysis of individual variables failed to identify any factors that influenced the rate of constipation.

Long-Term outcomes of cecostomy tube insertion for patients with bowel dysfunction: A retrospective review.

BACKGROUND: Constipation is common in the pediatric population and in severe forms it can lead to debilitating fecal incontinence which has a significant impact on quality of life. Cecostomy tube insertion is a procedural option for cases refractory to medical management, however there is limited data investigating the long-term success and complication rate. METHODS: A retrospective review was performed evaluating patients at our centre undergoing cecostomy tube (CT) insertion between 2002 and 2018. The primary outcomes of the study were the rate of fecal continence at 1-year, and the incidence of unplanned exchanges prior to annual scheduled exchange. Secondary outcomes include the frequency of anaesthetic requirements and length of hospital stay. Descriptive statistics, t-test, and chi-square analysis was performed where appropriate using SPSS v25. RESULTS: Of 41 patients, the average age at the time of initial insertion was 9.9 years with the average length of stay in hospital being 3.47 days. The most common etiology of bowel dysfunction was spina bifida, which was present in 48.8% (n = 20) of patients. Fecal continence was achieved in 90% (n = 37) of patients at 1 year and the average rate of cecostomy tube exchange was 1.3/year with an average of 3.6 general anaesthetics being required by patients and the average age of no longer requiring one being 14.9 years. DISCUSSION: Analysis of patients undergoing cecostomy tube insertion at our centre has further supported the use of cecostomy tubes as a safe and effective option for management of fecal incontinence refractory to medical management. However, a number of limitations exist in this study including its retrospective design and failure to investigate changes in quality of life using validated questionnaires. Additionally, while our research provides greater insight to practitioners and patients what degree of care and types of complications or issues they may encounter with an indwelling tube over the long-term, our single-cohort design limits any conclusions that could be made regarding optimal management strategies for overflow fecal incontinence through direct comparison with other management strategies. CONCLUSIONS: CT insertion is a safe and effective method for managing fecal incontinence due to constipation in the pediatric population, however, unplanned exchange of tube due to malfunction, mechanical breakage, or dislodgment occurs frequently and may impact quality of life and independence. LEVEL OF EVIDENCE: IV.

Robotic-assisted rectosigmoid resection rectopexy with natural orifice specimen extraction (NOSE): technical notes, short-term results, and functional outcome.

PURPOSE: Rectosigmoid resection rectopexy has been established as an effective therapy for obstructive defecation syndrome. The addition of the NOSE-technique provides an even less invasive approach avoiding minilaparotomy, but can be technically challenging. Application of a robotic platform has been proposed to facilitate the specimen extraction and fashioning of the intracorporeal anastomosis and has been proven to be effective in left-sided colectomies. METHODS: After establishing laparoscopic rectosigmoid-resection-rectopexy with NOSE, we modified our technique by addition of the robotic platform. Whenever robotic capacity was available, elective patients scheduled for rectosigmoid resection rectopexy for obstructive defecation syndrome were operated robotically assisted. Demographic and intraoperative data were prospectively collected. Follow up was assessed using the Wexner constipation score, Wexner incontinence score, and Altomare ODS score. RESULTS: The NOSE-RRR technique was completed in all 31 patients. The mean operative time was 166 min (range 67-230). No conversion was required. The median hospital stay was 5 days (range 3-28). Four patients had minor complications (Clavien I). Two patients were reoperated (Clavien IIIb). Functional scores improved significantly postoperatively. Mean Wexner incontinence score was 7.1 preoperatively, 6.9 after 1 month, and decreased significantly to 3.93 after 3 months (p < 0.001). Mean Altomare ODS score was 17.47 preoperatively and 6.93/5.03 after 1/3 months (p < 0.001). Wexner constipation score (12.83) also showed a significant improvement after 1/3 months (6.97/6.67; p < 0.001). CONCLUSION: NOSE-RRR can be performed safely with a low rate of manageable complications. The technique provides a significant improvement for ODS-Symptoms.

Preoperative predictors of success after transvaginal rectocoele repair.

PURPOSE: Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment. METHODS: Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up. RESULTS: 115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure. CONCLUSION: Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.