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Rectal Prolapse [keywords]
- Long-term Outcome of Stapled Transanal Rectal Resection (STARR) versus Stapled Hemorrhoidopexys (STH) for Grade III-IV Hemorrhoids: Preliminary Results. [JOURNAL ARTICLE]
- In Vivo 2014 11-12; 28(6):1171-1174.
Circular stapled transanal hemorrhoidopexy (STH) was first introduced by A. Longo for the correction of internal mucosal prolapse and obstructed defecation and in 1998, was proposed as alternative to conventional excisional hemorrhoidectomy. More recently, stapled transanal rectal resection (STARR) has gradually gained popularity, as the Longo procedure, in the treatment of hemorrhoids. The aim of our study was to evaluate the usefulness of STARR as alternative to STH in patients with grade III (n=218, 68.1%) and IV (n=102, 31.9%) hemorrhoids. A group of 320 consecutive patients (median age=51 years; range=16-85) underwent STH (n=281) or STARR (n=39) procedure. The rate of postoperative bleeding (53.8% vs. 74.4%, p<0.01) was significantly reduced in patients who underwent STARR procedure, which required a longer (45±22 vs. 26±11 min, p<0.01) operative time. There were no differences between groups with regard to use of painkillers, postoperative pain intensity, short- (three months) and long-term (one and three years) residual pain, soiling, incontinence and urgency. Patients treated with the STARR procedure had lower recurrence rate of hemorrhoids and a lower incidence of prolapse, both at one year (none vs. 1.4%, p=0.593 and 2.6% vs. 5.3%, p=0.396, respectively) and at two years (none vs. 6.8%, p=0.078 and none vs. 13.2%, p=0.012, respectively). The one-year (9.0±1.8 vs. 9.4±0.7, p=0.171) and two-year (9.6±0.8 vs. 9.1±1.7, p=0.072) general satisfaction was similar but higher in STARR patients than in the STH group. In conclusion, according to our preliminary results, the STARR procedure leads to a lower incidence of complications and recurrences and should be considered for patients with grade III or IV hemorrhoids previously selected for stapled hemorrhoidectomy, as a promising alternative to STH.
- Laparoscopic ventral mesh rectopexy for ODS - time for a critical appraisal. [JOURNAL ARTICLE]
- Colorectal Dis 2014 Nov 8.
Obstructed defaecation syndrome (ODS) is a symptom complex consisting of a sense of incomplete evacuation, prolonged straining and a persisting desire to defaecate. In patients with ODS structural abnormalities of the colorectum and the pelvic floor including rectal intussuception, rectocele, enterocele and prolapse of the middle pelvic compartment are nearly always present(1) . The aetiology and nature of rectal intussusception is debatable. This article is protected by copyright. All rights reserved.
- PELVIC FLOOR SYMPTOMS AND QUALITY OF LIFE ANALYSES IN WOMEN UNDERGOING SURGERY FOR RECTAL PROLPASE. [JOURNAL ARTICLE]
- World J Colorectal Surg 2013 Dec; 3(3)
Characterize pelvic floor symptom distress and impact, sexual function and quality of life in women who underwent rectal prolapse surgery.Subjects undergoing rectal prolapse surgery from 2004-2009 completed questionnaires including the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Prolapse/Urinary Incontinence Sexual Questionnaire. Baseline demographic, medical, and surgical characteristics were extracted by chart review. Demographic and clinic outcomes of women undergoing transperineal and abdominal approaches were compared. Wilcoxon rank-sum test was used for continuous variables and Fisher's exact test for categorical measures.45 were identified; two deceased at follow-up. 28/43 subjects (65.1%) responded to the questionnaires. Mean time from original procedure was 3.9 ± 3.1 years. No differences in median total Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and subscale scores, and Prolapse/Urinary Incontinence Sexual Questionnaire scores in women undergoing open rectopexy versus transperineal proctectomy were seen (all p>0.05). 26 (60%) participants answered the Prolapse/Urinary Incontinence Sexual Questionnaire, nine reported sexual activity within the last month. All underwent abdominal procedures.There are few colorectal or other pelvic floor symptoms after rectal prolapse repair. Robust prospective studies are needed to more fully characterize and understand issues associated with rectal prolapse surgery in women.
- Which operative repair is associated with a higher likelihood of reoperation after rectal prolapse repair? [Journal Article]
- Am Surg 2014 Nov; 80(11):1128-31.
The rate of reoperation after transabdominal as compared with transperineal repair for rectal prolapse is unknown. We evaluated all patients who underwent surgical treatment for rectal prolapse performed through transabdominal or transperineal repair from the trackable California Inpatient data files and Revisit Analyses during the time period of January 1, 2005, through December 31, 2007. We specifically evaluated rates of reoperation and stoma formation during the 36-month study period. A total of 3400 patient discharges with rectal prolapse from California during the 36-month study period was identified. Of this cohort, 1772 patients had one or more prolapse repairs. Procedures were more likely to be performed through a transabdominal (1035 [58%]) as compared with a transperineal approach (737 [42%]). There was no difference in reoperation for transabdominal (11%) as compared with transperineal procedures (11%; P = 0.9). However, a significantly larger proportion of patients underwent stoma formation after transabdominal (8%) as compared with transperineal repair (5%; P < 0.02). Time to reoperation was not significantly different for patients treated with transabdominal (295 ± 254 days) as compared with transperineal repair (271 ± 246 days; P = 0.6). In conclusion, the risk of reoperation is substantial for both transabdominal and transperineal procedures for rectal prolapse.
- Postprocessing of pelvic floor ultrasound data: How repeatable is it? [JOURNAL ARTICLE]
- Aust N Z J Obstet Gynaecol 2014 Oct 22.
Translabial 3D/4D pelvic floor ultrasound (PFUS) is increasingly used in the evaluation of pelvic floor disorders. Commonly, this involves the analysis of stored volume data sets by postprocessing. In this study, we aimed to assess the time requirement to reaching acceptable repeatability for commonly employed outcome measures in PFUS.Between 2010 and 2013, 20 individuals from 11 countries underwent training in postprocessing of PFUS volume data sets. They undertook test-retest series (n ≥ 20) between day 2 and day 15 of training. Outcome measures tested included levator hiatal area on Valsalva, descent of the bladder neck, bladder, uterus and rectal ampulla, and rectocele depth. After an initial training session of 10-20 cases, test-retest series were undertaken between the trainee and measurements obtained by the author or senior trainees.Trainees were obstetricians/gynaecologists in training (n = 4), obstetricians/gynaecologists or subspecialty trainees (n = 13), medical students (n = 1) and physiotherapists (n = 2). A total of 58 repeatability series were analysed, obtained between days 2 and 15 of training. When second or third retest series were necessary, there always was improvement in repeatability except for one series in one individual. Satisfactory repeatability (ICC > 0.7) was achieved by all trainees for all parameters required by them. Training lasted from 3 to 15 days, with means between 4 and 5.8 days.Postprocessing analysis of commonly used PFUS parameters can be taught to an acceptable standard within 1 week. Most commonly used ultrasound parameters obtained by postprocessing for prolapse assessment can be taught to an acceptable standard of repeatability within one week.
- Sacral colpopexy: long-term mesh complications requiring reoperation(s). [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Oct 17.
Sacral colpopexy (SC) is a classic procedure used for the surgical treatment of pelvic organ prolapse. Although the procedure boasts excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed.A retrospective monocentric study of patients who were operated on following a mesh complication after SC was conducted, at Lille University Hospital, between January 2007 and January 2013. Information relating to medical and surgical history, SC surgical technique, type of complication, and reoperation techniques was gathered.Twenty-seven patients required surgery for complications after SC. Nineteen patients were treated for vaginal mesh exposures (VME), four for intravesical mesh (including one with VME), one for ano-rectal dyschezia, one for spondylodiscitis with a VME, one for mesh infection, and one for vaginal fistula communicating with a collection in the ischio-coccygeal muscle. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years. The median operating time was 40 ± 95 min, and the length of hospital stay was 3.0 ± 3.0 days. Ten patients needed several interventions.This case series provides a description of surgical interventions for complications related to sacral colpopexy. These complications may be serious and occur years after the initial surgery.
- Case-matched series of a non-cross-linked biologic versus non-absorbable mesh in laparoscopic ventral rectopexy. [Journal Article]
- Int J Colorectal Dis 2014 Dec; 29(12):1477-83.
Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh.Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign®, Cook Medical) or polypropylene mesh.Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group.LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.
An 83-year-old woman underwent an elective perineal proctosigmoidectomy (Altemeier procedure) for a rectal prolapse. On postoperative day 1, the patient presented with impressive subcutaneous emphysema involving the chest, neck and face without any other symptoms. A CT scan showed free air in the retroperitoneum, the intraperitoneal cavity, the mediastinum and a subcutaneous emphysema of the neck and the face. Air was also found around the coloanal anastomosis and an anastomotic leak was proven by rectal contrast agent. In this situation, a rectoscopy followed by a laparoscopy were immediately performed. The leak could not be visualised. Peritoneal lavage and drainage, followed by protective sigmoidostomy were carried out. After surgery, the follow-up was uneventful except a persistent but asymptomatic leak with a presacral cavity. The coloanal dehiscence was later proven in rectoscopy. Although sutured, it is still present and colostomy closure will eventually be possible in a few months.
- Apex technique in the treatment of obstructed defecation syndrome associated with rectal intussusception and full rectal mucosa prolapse. [Journal Article]
- Dis Colon Rectum 2014 Nov; 57(11):1324-8.
The aim of the current study was to demonstrate the use of a modified stapling technique, called the apex technique, to treat rectal intussusception and full rectal mucosal prolapse. It was conducted as a retrospective study at 3 centers (2 in Brazil and 1 in Chile).The apex technique is performed by using a HEM/EEA-33 stapler. A pursestring suture is placed at the apex of the prolapse, on the 4 quadrants, independent of the distance to the dentate line. A second pursestring is then placed to define the band of rectal mucosa to be symmetrically resected.Outcome measures included width of the resected full-thickness rectal wall; the intensity of postoperative pain on a visual analog scale from 1 to 10; full mucosal prolapse and rectal intussusception assessed by physical examination, cinedefecography, or echodefecography; and change in the constipation scale.Forty-five patients (30 women/15 men; mean age, 59.5 years) with rectal intussusception and full mucosal prolapse were included. The median operative time was 17 (range, 15-30) minutes. Bleeding after stapler fire requiring manual suture occurred in 3 patients (6.7%); 25 (55.6%) patients reported having no postoperative pain. Hospital stay was 24 hours. The mean width of the resected rectal wall was 5.9 (range, 5.0-7.5) cm. Stricture at the staple line was seen in 4 patients, of whom 1 required dilation under anesthesia. The median follow-up time was 120 (range, 90-120) days. A small residual prolapse was identified in 6 (13.3%) patients. Imaging demonstrated complete disappearance of rectal intussusception in all patients, and the mean postoperative constipation score decreased from 13 (range, 8-15) to 5 (range, 3-7).The apex technique appears to be a safe, quickly performed, and low-cost method for the treatment of rectal intussusception. In this series, imaging examinations showed the disappearance of rectal intussusception, and a significant decrease in constipation score suggested improvement in functional outcomes.