Resection rectopexy for rectal prolapse

Background: Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse. Methods: Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment included anorectal manometry, defecography, and measurement of large-bowel transit. Results: The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze pressures and rectal compliance increased significantly in both groups of patients (p= 0.007, p= 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p= 0.007). In addition, sampling events were observed more commonly (p= 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in four of them after rectopexy (two LAP and two OPEN). Conclusions: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained with both procedures. Received: 16 February 1998/Accepted: 2 September 1998     

Laparoscopic repair of rectal prolapse

Background: There have been few large series that have focused on the feasibility of the laparoscopic approach for rectal prolapse. This single-institution study prospectively examines the surgical outcome and changes in symptoms and bowel function following the laparoscopic repair of rectal prolapse. Methods: In a selected group of 34 patients (total prolapse, 28; intussusception, six), 17 patients underwent laparoscopic-assisted resection rectopexy and 17 patients received a laparoscopic sutured rectopexy. Preoperative and postoperative evaluation at 3, 6, and 12 months included assessment of the severity of anal incontinence, constipation, changes in constipation-related symptoms, and colonic transit time. Results: Median operation time was 255 min (range, 180–360) in the resection rectopexy group and 150 min (range, 90–295) in the rectopexy alone group. Median postoperative hospital stay was 5 days (range, 3–15) and median time off work was 14 days (range, 12–21) in both groups. There were no deaths. Postoperative morbidity was 24%. Incontinence improved significantly regardless of which method was used. The main determinant of constipation was excessive straining at defecation. Constipation was cured in 70% of the patients in the rectopexy group and 64% in the resection rectopexy group. Symptoms of difficult evacuation improved, but the changes were significant only after resection rectopexy. Two patients (7%) developed recurrent total prolapse during a median follow-up of 2 years (range 12–60 months). Conclusions: Laparoscopic-sutured rectopexy and laparoscopic-assisted resection rectopexy are feasible and carry an acceptable morbidity rate. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are alleviated. Received: 30 April 1999/Accepted: 8 July 1999/Online publication: 22 May 2000     

Laparoscopic-assisted abdominoperineal resection in the prone position

With the introduction of laparoscopic-assisted abdominoperineal resection (LAPR), the traditional Lloyd-Davies position with the Mayo two-team combined approach is being adapted. The Lloyd-Davies position allows two teams of surgeons to work simultaneously, minimizing operating time. The conditions required for laparoscopy restrict a simultaneous procedure. Since LAPR is typically performed as a two-stage procedure, we introduce an alternative position which facilitates the perineal dissection. We review the results and technique of LAPR in the prone position in three patients who were suitable candidates for this procedure. Three patients underwent LAPR. No operative or postoperative complications were encountered and the procedures were in keeping with oncologic principles of resection. Total anesthesia times were less than 3.5 h for these initial patients. No hemodynamic problems were encountered due to the choice of patient positioning. The prone jackknife position greatly increases visualization of deep structures, reduces blood loss, enhances dissection, and reduces the technical demands of the laparoscopic portion of the procedure. Received: 23 October 1995/Accepted: 5 August 1996     

Stapled laparoscopic rectopexy for rectal prolapse

The widespread success of laparoscopic cholecystectomy has led to the development of a wide range of laparoscopic surgical procedures. Procedures for treating rectal prolapse (Procidentia) may constitute some of the best applications for colorectal laparoscopic techniques. A technique of laparoscopic rectopexy performed using the endo-stapler is described. Twenty-nine consecutive patients have undergone laparoscopic rectopexy. The median age was 71 years (52–89), and male:female ratio was 27:2. One procedure had to be converted to open due to ventilatory difficulties. The mean operative time was 95 minutes (50–190). The mean hospital stay was 5 days (4–15). There was no mortality in this series. Morbidity included incisional hernia through a port hole (n=1), extraperitoneal haematoma (n=1), and urinary tract infection with retention (n=1). In conclusion, laparoscopic abdominal rectopexy is a safe and effective technique in the management of rectal prolapse.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, 18–19 April 1994     

Early experience with laparoscopic abdominoperineal resection

Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients. Received: 23 April 1996/Accepted: 8 July 1996     

15-Year experience in the treatment of rectal prolapse in children

Background

Rectal prolapse is a common and usually self-limited condition in children. Several surgical techniques have been advocated for refractory prolapse. We reviewed our experience with treatment and the outcome of refractory rectal prolapse.

Methods

Retrospective review was conducted on patients undergoing surgery for rectal prolapse from January 1993 to March 2009. Patients with imperforate anus/cloacal abnormalities, Hirschsprung disease, spina bifida, or prior pull-through were excluded.

Results

Twenty patients underwent 23 procedures for rectal prolapse. There were 10 posterior sagittal rectopexies, 6 transabdominal rectopexies, 5 laparoscopic rectopexies, 1 hypertonic saline injection, and 1 anal cerclage. The mean duration of symptoms was 1.6 years (range, 1-10 years). The mean age at operation was 6.8 years (range, 4 months-19 years), with a 5:1 male predominance. There was no operative or perioperative mortality. Median length of follow-up was 7.2 months; 2 patients were lost to follow-up.The overall recurrence rate was 35%. All recurrences followed posterior sagittal rectopexies, which had a 70% recurrence rate. Four patients required reoperation, all done transabdominally (2 open and 2 laparoscopically). None of the 3 remaining patients with mild recurrences required reoperation.

Conclusions

A variety of options for management of refractory rectal prolapse in children exist. Laparoscopic rectopexy seems to be safe and a comparatively successful option in these children.     

Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children

Background The repair of choice for persistent rectal prolapse (PRP) in children is disputed. Laparoscopic suture rectopexy (LSRP) is effective in adults, but its usefulness in pediatric PRP is unknown. We compared LSRP with posterosagittal rectopexy (PSRP). Methods Sixteen children, with a median age of 6.5 years (range, 0.8–16.8) and duration of symptoms of 2.8 years (range, 0.5–10.2), underwent surgery for PRP. Eight (1991–2000) had PSRP, and eight (2002–2005) had LSRP. Three patients with LSRP were healthy; the others had mental retardation and epilepsy (n = 1), cerebral palsy (n = 1), Aspeger’s syndrome (n = 1), meningomyelocele (n = 1), and bladder extrophy (n = 1). Preoperative cologram (n = 6), sigmoideoscopy (n = 3), and anorectal manometry (n = 2) were normal in patients with LSRP. In LSRP, the rectum was mobilized and sutured to the sacral periosteum. Results Median operation time for LSRP was 80 min (range, 62–90) and for PSRP 40 min (range, 25–70) (p < 0.05); median hospital time was 6 days (range, 3–8) for LSRP and 6 days (range, 3–9) for PSRP (not significant). Six patients with LSRP had a median follow-up of 13 months (range, 4–24). None have had recurrences, and two patients (33%) require laxatives. Of the patients with PSRP, two (25%) had recurrence and underwent abdominal rectopexy with sigmoid resection. Conclusion Medium-term results indicate that LSPR is effective in pediatric PRP. Constipation is the only postoperative problem in a significant proportion of patients.     

Laparoscopic-assisted colonoscopic polypectomy

Background: The majority of colonic polyps found at endoscopy are suitable for diathermy snare excision via colonoscope. Due to location or size, some are deemed unsafe to treat in this manner and therefore require colectomy. This study describes the technique and early results of a laparoscopic-assisted colonoscopic polypectomy technique that can be used to manage such polyps and thereby avoid laparotomy and colectomy. Methods: Colonoscopy with simultaneous laparoscopy was utilized to locate the site of the polyp. The colon was mobilized, if required, and the polyp resected by electrosurgical snare via the colonoscope while the serosal aspect of the colon was monitored laparoscopically. Results: The technique has been tried successfully in six patients. Three polyps were in the cecum and three were within the left colon. The size of the polyps ranged from 3 to 7 cm. All polyps were benign on histological examination. The patients were discharged on the day following the procedure. There were no complications. Conclusions: The combination of laparoscopy with colonoscopic resection of a select group of large polyps represents a safe alternative to colonic resection. Received: 18 March 1998/Accepted: 7 May 1998     

Surgery for occult rectal prolapse

OBJECTIVE: An 'occult' rectal prolapse may be diagnosed during investigation of altered bowel habit. It has been suggested that the outcome of surgery for these patients may be associated with results that are inferior to those achieved in patients with overt rectal prolapse. This study compares the results of surgery for 'occult' and overt rectal prolapse in terms of mortality, morbidity and change in bowel habit. PATIENTS AND METHODS: A retrospective review was undertaken of consecutive patients undergoing surgery for rectal prolapse during the decade 1988-98. Resection rectopexy was the treatment of choice except in patients with faecal incontinence who underwent sutured rectopexy. Those patients who were unfit for an abdominal operation were offered a perineal procedure. Outcome measures were mortality, morbidity, prolapse recurrence, constipation and faecal incontinence. Data were retrieved from case note review, clinical assessment, telephone consultation or postal questionnaire. RESULTS: Rectal prolapse surgery was undertaken in 69 patients with an overt prolapse and 74 patients with an 'occult' prolapse. Patients in the 'occult' prolapse group were significantly younger than those with overt prolapse (P = 0.0002). There were significantly more perineal procedures in the overt prolapse group compared with the 'occult' prolapse group (54% vs 5%, P = 0.0001). There were no deaths within 28 days of surgery. Major surgical complications occurred in 5 patients (3.5%). Seven patients (10%) experienced recurrent prolapse. Rectal prolapse surgery reduced the incidence of St. Mark's grade 4 faecal incontinence from 38% to 19% in the overt prolapse group (P = 0.023) and from 49% to 22% in the 'occult' prolapse group (P < 0.001). Following surgery the incidence of constipation increased in the 'occult' group from 39% to 50% but decreased in the overt prolapse group from 42% to 35%. CONCLUSIONS: Surgery for an 'occult' rectal prolapse is unlikely to benefit patients whose principle symptom is constipation. Approximately half of those patients whose 'occult' rectal prolapse is associated with faecal incontinence will have their bowel habit improved by prolapse surgery.     

Laparoscopic-assisted colon surgery by abdominal wall lifting with newly developed lifting bars

Background: The aim of the study is to evaluate the efficacy of laparoscopic-assisted colon surgery by lifting the abdominal wall with newly developed lifting bars. Methods: We have made and used two kinds of lifting bars: type I and type T. Two I-type lifting bars are used in transverse colectomy and right hemicolectomy. One I-type lifting bar and one T-type bar are used in sigmoid colectomy and low anterior resection. After the intestine is dissected and the mesenterium is treated under laparoscopy, a small laparotomy wound about 4 to 6 cm long is made, and the intestine is pulled out of the body for extracorporeal anastomosis. Results: The mean operating time was 153.8 ± 51.9 min, and no particular complications were noted. Conclusions: Since postoperative pain is mild and postoperative recovery is rapid, this method is considered to be an effective surgical procedure. Received: 18 March 1996/Accepted: 12 December 1996     

直肠脱垂的外科治疗进展

直肠脱垂是一种较少见的疾病,一直以来吸引着许多外科医师对其进行研究.目前治疗直肠脱垂的手术有50多种,其中大部分都是几种基本治疗模式的变形,而且依赖于医师对患者解剖上的把握.目前多种疗法综合治疗成为治疗直肠脱垂较为理想的方式.     

Long-term outcome after laparoscopic and open surgery for rectal prolapse

Background Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited. Methods Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey. Results A total of 111 patients (age, 56.8 ± 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17). Conclusions The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Application of rectal stents for palliation of obstructing rectosigmoid cancer

Background: The rationale of palliative endoscopic treatment is to avoid a colostomy in patients with advanced disease and limited life expectancy. This study was conducted to evaluate the role of endoscopic stent implantation for palliation of obstructing rectal cancer. Methods: Overall, 19 patients (aged 47–87 years) with nonresectable or metastatic rectal cancer were treated by stent insertion after laser recanalization or dilation. Three types of stents, i.e., plastic tubes (n= 8), self-expanding mesh stents (n= 6), and endocoil stents (n= 5), were used to maintain luminal patency. Results: Endoscopic stent implantation was successfully performed in all 19 patients. Long-term luminal patency and satisfactory bowel function were achieved in 16 of 19 patients (84%). After a median follow-up of 6 months, eight of the patients have died and eight are still alive without evidence of recurrent obstruction. Dislocation of the endoprosthesis occurred in two of eight plastic tubes and one of five mesh stents. Recurrent obstruction due to tumor ingrowth was only observed in patients treated with self-expanding mesh stents (n= 2). In spite of reinsertion and laser therapy a colostomy was required in three of 19 patients. There was no evidence of treatment failure in five patients who received endocoil stents. None of the patients experienced serious complications related to the endoscopic procedure. Conclusions: Endoscopic stent implantation seems to be a safe and efficient palliative approach to selected patients with obstructing rectal cancer. Currently, self-expanding coil stents are superior to other devices because of lower risk of dislocation and tumor ingrowth. Received: 10 May 1996/Accepted: 11 November 1996     

腹腔镜腹会阴联合切除术治疗低位直肠癌疗效评价

目的前瞻性评估腹腔镜直肠癌腹会阴联合切除术的临床优劣性。方法将2003年7月至2006年4月收治的低位直肠癌患者随机分为两组，37例行腹腔镜腹会阴联合切除术（腹腔镜组），另37例常规开腹行腹会阴联合切除术（开腹组）；比较两组的手术时间、清除淋巴结数目和腹部出血量、术后排气时间、起床活动时间、住院时间、并发症发生率和复发转移率及卫生经济学情况。结果腹腔镜全组患者均顺利完成手术，无中转开腹者；手术时间两组比较差异无统计学意义（P〉0．05），但前10例手术时间比开腹组长（P〈0．01）；腹部出血量少于开腹组（P〈0．01）．但前10例较开腹组多（P〈0．01）；术后肛门排气时间两组差异无统计学意义（P〉0．05）；起床活动时间腹腔镜组早于开腹组（P〈0．01）；住院时间长短两组无差异，但腹腔镜会阴闭合较开腹组早：腹腔镜组腹部创口相关并发症明显少于开腹组（P〈O．05）；两组的清除淋巴结枚数、局部复发及远处早期复发率差异无统计学意义（P〉0．05）；手术费用腹腔镜组明显高于开腹组，但医疗总费用两组差异无统计学意义（P〉0．05）。结论腹腔镜直肠癌腹会阴联合切除术不仅创口小、术中出血少、与腹部创口相关并发症少、术后恢复快，且其手术时间、医疗总费用和肿瘤根治性与开腹手术无差异。     

直肠乙状结肠部分切除联合直肠固定术治疗成人完全型直肠脱垂

目的 探讨成人完全型直肠脱垂采用直肠乙状结肠部分切除联合直肠固定术的手术疗效.方法 2006-2011年,收治的6例成人完全型直肠脱垂患者,采用直肠乙状结肠部分切除联合直肠固定术进行手术治疗.结果 6例患者全部治愈,术后平均住院时间为13.7 d,随访3～61个月,无复发病例.结论 直肠乙状结肠部分切除联合直肠固定术治...     

Sclerotherapy for the management of rectal prolapse in children

Purpose

Rectal prolapse is a commonly occurring and usually self-limited process in children. Surgical management is indicated for failures of conservative management. However, the optimal approach is unknown. The purpose of this study is to determine the efficacy of sclerotherapy for the management of rectal prolapse.

Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients

The authors propose a new laparoscopic technique for correction of rectal prolapse. The unique feature of this technique is that it avoids any posterolateral dissection of the rectum. The mesh is sutured to the anterior aspect of the rectum to inhibit intussusception. The technique was applied in 109 consecutive patients to correct total rectal prolapse. Conversion was needed for four patients. No postoperative mortality or major morbidity occurred. Minor morbidity was noted for 7% of the patients, and a recurrence rate of 3.66% was observed. Because this technique limited the dissection and the subsequent risk of autonomic nerve damage, a cure comparable with that resulting from classical mesh rectopexy can be anticipated.     

Overt rectal prolapse following repair of stage IV vaginal vault prolapse

Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.