Transanal rectal resection: an initial experience of 20 cases.

AIM: Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique. METHOD: From June 2013 to September 2014, 20 selected patients underwent transanal rectal resection for various malignant and benign low rectal pathologies. All patients with rectal cancer were discussed at a multidisciplinary team meeting. Data were entered into a prospective managed international database. RESULTS: Of the 20 patients (14 male), seventeen (85%) had rectal cancer lying at a median distance of 2 cm (range 0-7) from the anorectal junction. The operations performed included LAR (16). Abdominoperineal excision (2) and completion proctectomy (2), all of which were performed by a minimally invasive approach with three conversions. The mean operation time was 315.3 min. There were six postoperative complications of which two (10%) were Clavien-Dindo Grade IIIb (pelvic haematoma and a late contained anastomotic leakage). The median length of stay was 7 days. The TME specimen was intact in 94.1% of cancer cases. The mean number of harvested lymph nodes was 23.2. There was only one positive circumferential resection margin (tumour deposit; R1 rate 5.9%). One patient developed a distant recurrence (median follow-up 10 months, range 6-21). CONCLUSION: TaTME was safe in this small series of patients. It is especially attractive in patients with a narrow and irradiated pelvis and a tumour in the lower third of the rectum. TaTME is technically demanding, but the good outcomes should prompt randomized studies and prospective registration of all taTME cases in an international registry.

The treatment of all MRI-defined low rectal cancers in a single expert centre over a 5-year period: is there room for improvement?

AIM: Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition. METHOD: A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database. RESULTS: One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response. CONCLUSION: In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers.

A two-centre experience of transanal total mesorectal excision.

AIM: Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two-centre experience of this technique, focusing on the short-term and oncological outcome. METHOD: From May 2013 to May 2015, 40 selected patients with histologically proven rectal adenocarcinoma underwent TaTME in two institutions and were prospectively entered on an online international registry. RESULTS: Forty patients (80% men, mean body mass index 27.4 kg/m2 ) requiring TME underwent TaTME. Procedures included low anterior resection (n = 31), abdominoperineal excision (n = 7) and proctocolectomy (n = 2). A minimally invasive approach was attempted in all cases, with three conversions. The mean operation time was 368 min and 16 patients (40%) had a synchronous abdominal and transanal approach. There was no mortality and 16 postoperative complications occurred, of which 68.8% were minor. The median length of stay was 7.5 (3-92) days. A complete or near-complete TME specimen was delivered in 39 (97.5%) cases with a mean number of 20 lymph nodes harvested. R0 resection was achieved in 38 (95%) patients. After a median follow-up of 10.7 months, there were no local recurrences and six (15%) patients had developed distant metastases. CONCLUSION: TaTME appears to be feasible, safe and reproducible, without compromising the oncological principles of rectal cancer surgery. It is an attractive option for patients for whom laparoscopy is likely to be particularly difficult. These encouraging results should encourage larger studies with assessment of long-term function and the oncological outcome.

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.

Histological and mechanical differences in the skin of patients with rectal prolapse.

INTRODUCTION: It is still an enigma that some patients develop rectal prolapse whilst others with similar risk factors do not. Biomechanical assessment of the skin may provide further insight into the aetiology of this complex condition. Elastin fibres are an abundant and integral part of many extracellular matrices and are especially critical for providing the property of elastic recoil to tissues. The significance of elastin fibres is clearly reflected by the numerous human conditions in which a skin phenotype occurs as a result of elastin fibre abnormalities. METHOD: Between January and June 2013, skin specimens were obtained prospectively during surgery on 20 patients with rectal prolapse and 21 patients without prolapse undergoing surgery for other indications. Expression levels of elastin in the skin were measured by Orcein staining, and Image J. Tensile tests were performed using the Zwick Roell device, with custom ceramic clamps. For statistical analysis, Student's t test was used. RESULTS: Histological analysis of prolapse vs control showed percentage dermal elastin fibres of 9 vs 5.8 % (p = 0.001) in males and 6.5 vs 5.3 % (p = 0.05) in females. Patients with more severe prolapse (external) had a significantly (p = 0.05) higher percentage dermal elastin fibres 6.9 vs 6.1 % than internal prolapse. Young's modulus of patients with prolapse was lower in males (3.3 vs 2.8, p = 0.05) and females (3.1 vs 2.7, p = 0.05). CONCLUSION: Patients with prolapse have a higher concentration of elastin fibres in the skin, and these differences are quantitatively demonstrated through mechanical testing. This suggests that the aetiology may be a result of a dysfunction of elastin fibre assembly.

Laparoscopic rectopexy is feasible and safe in the emergency admission setting.

AIM: External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse. METHOD: A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed. RESULTS: Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse. CONCLUSION: Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities.

Expression of fibulin-5 in the skin of patients with rectal prolapse.

AIM: Components of connective tissue other than collagen have been found to be involved in patients with rectal prolapse. The organization of elastic fibres differs between controls and subsets of patients with rectal prolapse, and their importance for maintaining the structural and functional integrity of the pelvic floor has been demonstrated in transgenic mice, with animals which have a null mutation in fibulin-5 (Fbln5(i/i)) developing prolapse. This study aimed to compare fibulin-5 expression in the skin of patients with and without rectal prolapse. METHOD: Between January 2013 and February 2014, skin specimens were obtained during surgery from 20 patients with rectal prolapse and from 21 without prolapse undergoing surgery for other indications. Fibroblasts from the skin were cultured and the level of fibulin-5 expression was determined on cultured fibroblasts, isolated from these specimens by quantitative real-time polymerase chain reaction. Immunohistochemistry was performed on fixed tissue specimens to assess fibulin-5 expression. RESULTS: Fibulin-5 mRNA expression and fibulin-5 staining intensity were significantly lower in young male patients with rectal prolapse compared with age-matched controls [fibulin-5 mean ± SD mRNA relative units, 1.1 ± 0.41 vs 0.53 ± 0.22, P = 0.001; intensity score, median (range), 2 (0-3) vs 1 (0-3), P = 0.05]. There were no significant differences in the expression of fibulin-5 in women with rectal prolapse compared with controls. CONCLUSION: Fibulin-5 may be implicated in the aetiology of rectal prolapse in a subgroup of young male patients.

Laparoscopic ventral rectopexy is effective for solitary rectal ulcer syndrome when associated with rectal prolapse.

AIM: Solitary rectal ulcer syndrome (SRUS) is uncommon and its management is controversial. The aim of this study was to evaluate the outcome of patients with SRUS who underwent laparoscopic ventral rectopexy (LVR). METHOD: A review was performed of a prospective database at the Oxford Pelvic Floor Centre to identify patients between 2004 and 2012 with a histological diagnosis of SRUS. All were initially treated conservatively and surgical treatment was indicated only for patients with significant symptoms after failed conservative management. The primary end-point was healing of the ulcer. Secondary end-points included changes in the Wexner Constipation Score and Faecal Incontinence Severity Index (FISI). RESULTS: Thirty-six patients with SRUS were identified (31 women), with a median age of 44 (15­81) years. The commonest symptoms were rectal bleeding (75%) and obstructed defaecation (64%). The underlying anatomical diagnosis was internal rectal prolapse (n = 20), external rectal prolapse (n = 14) or anismus (n = 2). Twenty-nine patients underwent LVR and one a stapled transanal rectal resection (STARR) procedure. Nine (30%) required a further operation, six required posterior STARR for persistent SRUS and two a per-anal stricturoplasty for a narrowing at the healed SRUS site. Healing of the SRU was seen in 27 (90%) of the 30 patients and was associated with significant improvements in Wexner and FISI scores at a 3-year follow-up. CONCLUSION: Almost all cases of SRUS in the present series were associated with rectal prolapse. LVR resulted in successful healing of the SRUS with good function in almost all patients, but a significant number will require further surgery such as STARR for persistent obstructed defaecation.

Incision-less reversal of Hartmann's procedure.

After taking down the colostomy in a patient who has previously undergone a Hartmann's operation, it is possible to restore bowel continuity using the single-port technique via the colostomy site itself. This study presents our experience of this approach using the glove port and standard laparoscopic instrumentation. Between October 2010 and October 2013, 14 patients [median age 62 years (range 42-83 years); median body mass index 25.2 kg/m(2) (range 22.7-34.9) kg/m(2)] underwent attempted single-port (via colostomy site) reversal of Hartmann's. All but one patient had had a laparotomy for their primary surgery. The glove port was used with a camera and two working ports. Additional remote access was needed in 3 (21 %) patients [1 × 5 mm port (two patients); 2 × 5-mm ports ; 2 × 5-mm ports and Pfannenstiel]. Median operative time was 150 min (range 75-270 min). Mortality was nil. One patient required reoperation and a stoma. Median hospital stay was 5 days (range 2-36 days). Glove port reversal of Hartmann's is technically possible, though challenging if extensive adhesions are present. Outcomes are variable. Further studies will be needed to assess whether this is a safe technique.

Temporary sacral neuromodulation under local anaesthesia using new anatomical reference points.

BACKGROUND: Prior to implantation of an expensive sacral nerve stimulator, a 'screening phase' is undertaken. This report examines the feasibility of temporary sacral neuromodulation under local anaesthesia in an outpatient setting. We report on our technique, results and patient satisfaction. METHODS: Percutaneous nerve evaluation was performed in 184 patients using a new set of reference points and local anaesthesia to guide insertion of a test wire without the need for fluoroscopy in an outpatient setting. Three bony landmarks were used: tip of the coccyx, sacro-coccygeal joint and posterior superior iliac spine. The technical success was defined as stimulation in the perineal/anal area at amperages <6 mAmp. A consecutive cohort of 24 patients was asked to grade their pain and satisfaction regarding the procedure. RESULTS: Successful placement of the test wire was accomplished in 171 patients (93 %). Twelve patients required placement under fluoroscopy due to lack of sensation during stimulation (N = 7) procedural pain (N = 4) or failure to identify S3 or S4 (N = 2). There were two lead infections, one lead dislocation and one lead fracture. 22 of 24 patients (92 %) would recommend the procedure under local anaesthesia to other patients. CONCLUSIONS: Temporary sacral neuromodulation can be reliably performed in a more practical, less expensive outpatient setting under local anaesthesia without adversely influencing test outcome.

Local recurrence after stenting for obstructing left-sided colonic cancer.

BACKGROUND: Self-expanding metallic stents (SEMS) may be used in acute obstructing left-sided colonic cancers to avoid high-risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long-term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection. METHODS: A consecutive prospective cohort of patients admitted with obstructing left-sided colonic cancer between 2006 and 2012 was analysed. The decision to stent as a bridge to surgery or to perform emergency surgery was made by the on-call consultant colorectal surgeon in conjunction with a consultant interventional radiologist; when appropriate, they performed the stent procedure together. Primary outcomes were local and distant recurrence, and overall survival. Secondary outcomes were postoperative complications, in-hospital mortality, proportion of procedures undertaken laparoscopically, and anastomosis and stoma rates. RESULTS: In total, 105 patients with obstructing left-sided colonic cancer were treated with curative intent; 62 were treated with SEMS as a bridge to surgery and 43 had emergency resection. In patients aged 75 years or less, stenting and delayed surgery was associated with a higher local recurrence rate compared with emergency surgery at the end of follow-up (32 versus 8 per cent; P = 0·038). This did not translate into a significant difference in overall survival. CONCLUSION: SEMS was associated with an increased local recurrence rate.

What are the symptoms of internal rectal prolapse?

AIM: Although high-grade internal rectal prolapse is believed to cause functional symptoms such as obstructed defaecation, little has been published on the exact distribution and frequency of symptoms. The aim of this study was to identify the most common symptoms of patients with high-grade internal rectal prolapse. METHOD: Patients were diagnosed with high-grade prolapse (grade 3 and 4) on proctography using the Oxford Rectal Prolapse Grade. Information from a prospectively collected database was supplemented by a retrospective case note review. RESULTS: Eighty eight patients (94% of them women) were included for analysis. Faecal incontinence (56%) was the most common symptom at presentation. Symptoms related to obstructed defaecation syndrome were the next most common, including incomplete evacuation (45%), straining (34%), digital assistance (34%) and repetitive toilet visits (33%). CONCLUSION: A variety of symptoms may be caused by high-grade internal rectal prolapse Although symptoms of obstructed defaecation were frequent, urge faecal incontinence was the most common.

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.

Impact of slow transit constipation on the outcome of laparoscopic ventral rectopexy for obstructed defaecation associated with high grade internal rectal prolapse.

AIM: Limited literature exists on whether slow colonic transit adversely influences the results of outlet obstruction surgery. We compared the functional results of laparoscopic ventral rectopexy (LVR) for obstructed defaecation secondary to high grade internal rectal prolapse in patients with normal and slow colonic transit. METHOD: Consecutive patients suffering from obstructed defaecation associated with an internal rectal prolapse, who underwent an LVR between 2007 and 2011, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and colonic transit studies. Symptoms were assessed preoperatively and at 12 months after operation using a standardized questionnaire incorporating the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire, the Fecal Incontinence Severity Index (FISI), the Patient Assessment of Constipation Quality of Life (PAC-QOL) scale and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: In all, 151 patients underwent LVR, 109 with normal and 42 with slow colonic transit. Preoperatively there was no significant difference between the two groups in age, sex, PAC-SYM score or FISI score. The PAC-SYM and FISI scores were significantly reduced in both groups at 12 months (P < 0.001). When comparing the change from baseline of PAC-SYM between patients with and without slow transit constipation, a significant difference was observed (P = 0.030) with changes of 58% and 40%. Quality of life (GIQLI and PAC-QOL) was equally improved in both groups. Quality of life improvement was less in patients with right colonic stasis. CONCLUSION: Slow colonic transit has no adverse impact on function and quality of life after LVR for obstructed defaecation due to high grade internal rectal prolapse.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded.

AIM: Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus. METHOD: Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5. RESULTS: Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%. CONCLUSION: Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.

Long-term follow-up after anterior sphincter repair: influence of age on functional outcome.

AIM: Anterior sphincter repair has been advocated for women with anterior sphincter defects and faecal incontinence. There have been a number of reports of deterioration in functional outcome from anal sphincter repair over the long-term and of inferior outcomes in older patients. This study set out to examine these issues in a specialist tertiary referral unit. METHOD: Patients having a sphincter repair were identified from a prospectively collected database. The information within the database was expanded by the use of a postal questionnaire and structured review of the case notes. The questionnaire incorporated commonly used validated scoring systems as well as subjective questions. RESULTS: One hundred and thirteen patients were identified, of whom 66 (58%) responded. Of these patients, four had incomplete medical notes, leaving 62 (55%) with both returned questionnaires and complete medical notes. Forty-eight (72%) patients reported subjective initial improvement in their symptoms, though only 37 (56%) believed themselves improved at long-term follow-up (median 8.8 years; range 1.1-13.6 years). Incontinence and quality of life scores mirrored these patients' subjective responses. The median age of those patients reporting a subjective improvement at long-term follow-up was 38, compared with 56 in those who thought they were not improved (P < 0.001). CONCLUSIONS: Outcome from anal sphincter repair deteriorates with time. Subjective outcome is worse in older patients who additionally tend to have worse incontinence scores and quality of life measures.

A contraction response of the internal anal sphincter to Botulinum toxin: does low-pressure chronic anal fissure have a different pathophysiology?

AIM: A subset of low-pressure fissures is not associated with typical internal anal sphincter hypertonia and may involve a different pathophysiological mechanism. We aimed to assess the manometric response of the internal anal sphincter to botulinum toxin in low-pressure fissures compared to high-pressure fissures. METHOD: Twenty five units of botulinum toxin (Botox(TM)) were injected directly into the internal anal sphincter. Maximum resting pressure (MRP) and maximum squeeze increment (MSI) were documented at baseline and four weeks after injection. RESULTS: Nine (31%) of 29 patients had a low-pressure fissure. Those with an anterior fissure had a significantly lower median baseline MRP than those with a posterior fissure (66 vs 83 mmHg, P = 0.009). Significantly more patients with low-pressure fissures developed a contraction or no response (78%vs 30%, difference 48%, 95% CI 14-82%, P = 0.006). Those developing a contraction response had a lower mean baseline MRP than those developing a relaxation response (56 vs 86 mmHg, difference 30 mmHg, 95% CI 17-43%, P < 0.001). CONCLUSION: Botulinum toxin appears to have an atypical contraction effect on the internal anal sphincter in low-pressure (usually anterior) fissures. This may be accounted for by blockade of acetylcholine released at parasympathetic nerve terminals and the sympathetic ganglion (relaxation). Low pressure fissures may be physiologically different from high-pressure fissures.

The relationship between internal rectal prolapse and internal anal sphincter function.

AIM: Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function. METHOD: Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed. RESULTS: A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP. CONCLUSION: This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone.