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

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

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

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

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

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

Adult sigmoid intussusception resembling rectal prolapse:A case report

BACKGROUND Rectal prolapse arises from benign etiology.When symptoms of internal intussusception mirror those of rectal prolapse,a misdiagnosis is possible,especially under limited clinical presentation.It is crucial to recognize and differentiate rectal prolapse from internal intussusception because the two diagnoses have different prognoses.Here,we describe a case of adult sigmoid intussusception presenting as rectal prolapse.CASE SUMMARY A 64-year-old woman with no known medical history visited a gastrointestinal outpatient department due to hard bloody stool defecation for 1 wk followed by constipation for 3 d.Colonoscopy revealed a huge polypoid ulcerated tumor at the sigmoid colon with lumen stenosis.The patient was admitted due to postprocedural dull abdominal pain.Due to failed colonoscopy reduction and stent insertion,the patient underwent sigmoid colon resection with primary end-to-end anastomosis,with the transverse colostomy pathological report showing adenocarcinoma,pT3N0M0.She recovered well from the operation and was discharged with regular outpatient clinic follow-up.CONCLUSION Presentation and manifestation of sigmoid intussusception may resemble that of rectal prolapse,necessitating careful observation due to distinct prognostic implications.

Advancing the predictive accuracy of PNTML in rectal prolapse:An ongoing quest

Fecal incontinence is a common symptom among patients with rectal prolapse.Pudendal nerve terminal motor latency(PNTML)testing can serve as a reference indicator for predicting the outcomes of rectal prolapse surgery,thereby assisting surgeons in formulating more appropriate surgical plans.The direct correlation between preoperative PNTML testing results and postoperative fecal incontinence in patients with rectal prolapse remains a contentious issue,necessitating further clarification.Thus,we analyze the existing publications from both clinical and statistical perspectives to comprehensively evaluate the accuracy of preoperative PNTML testing in rectal prolapse and provide some feasible statistical solutions.

Modified Gant procedure for treatment of internal rectal prolapse in elderly women

BACKGROUND Although rectal prolapse is not a life-threatening condition,it can cause defecation disorders,anal incontinence,sensory abnormalities,and other problems that can seriously affect quality of life.AIM To study the efficacy of the modified Gant procedure for elderly women with internal rectal prolapse.METHODS Sixty-three elderly female patients with internal rectal prolapse underwent the modified Gant procedure.The preoperative and postoperative anal symptoms,Patient Assessment of Constipation Quality of Life(PAC-QOL),Wexner incontinence score,incontinence quality of life score,and complications(massive hemorrhage,infection,anorectal stenosis,and anorectal fistula)were compared.RESULTS The improvement rates of postoperative symptoms were defecation disorders(84.5%),anal distention(69.6%),defecation sensation(81.4%),frequent defecation(88.7%),and anal incontinence(42.9%)(P<0.05).All dimensions and total scores of the PAC-QOL after the procedure were lower than those before the operation(P<0.05).The postoperative anal incontinence score and Wexner score were significantly lower than those before the procedure(P<0.05).The quality of life and total scores of postoperative anal incontinence were significantly higher than those before the procedure(P<0.05).There were no serious complications and no deaths.CONCLUSION The modified Gant procedure has significant advantages in the treatment of elderly women with internal rectal prolapse.

Obseruation on the morphological changes of pelvic floor and theirclinical significance during internal rectal prolapse with defeco pelvicography

In order to distinguish rectal rnucosal prolapse (RMP) from full thickness rectal intassusception(FTRI ). 66 patients with internal rectal prolapse and 36 normal controls were studied with defecopelvicography. Anorectal angle,level of pelvic floor and other indices were measured. It was found that 41patients with RMP had no changes of the peritoneal cul-de-sac of pelvic floor and 25 patients with FTRI hadabnormal descent of the peritoneal cul-de-sac of pelvic floor. which formed the internal herniated sac of therectal wall. It is believed that defeco-pelvicography is a reliable method to distinguish RMP from FTRI,anddemonstrate coexistent internal herniated sac of the rectal wall. Our findings are helpful to plan proper management of internal rectal prolapse.

Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results

AIM:To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.METHODS:MEDLINE, Pub Med, EMBASE, and other relevant database were searched to identify studies.Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.RESULTS:Twelve non-randomized case series studies with 574 patients were included in the review.No surgical mortality was described.Conversion was needed in 17 cases(2.9%), most often due to difficult adhesiolysis.Twenty eight patients(4.8%) presented with major complications.Seven(1.2%) mesh-related complications were reported.Most frequent complications were urinary tract infection and urinary retention.Mean recurrence rate was 4.7% with a median follow-up of 23 mo.Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%.Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages.Evaluation of functional score was disparate between studies.CONCLUSION:Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.

Perineal rectosigmoidectomy for gangrenous rectal prolapse

Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse.Even more rarely,it becomes strangulated,necessitating emergency surgery.We describe an extremely rare case of incarcerated acute rectal prolapse,without a relevant previous history or symptoms of predisposing pathology.The patient underwent emergency perineal proctosigmoidectomy,the Altemeier operation,combined with diverting loop sigmoid colostomy.The postoperative course was quite uneventful with an excellent final result after colostomy closure.The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual case scenario of bowel incarceration.

What operation for recurrent rectal prolapse after previous Delorme's procedure? A practical reality

AIM: To report our experience with perineal repair(Delorme's procedure) of rectal prolapse with particular focus on treatment of the recurrence.METHODS: Clinical records of 40 patients who underwent Delorme's procedure between 2003 and 2014 were reviewed to obtain the following data: Gender; duration of symptoms, length of prolapse, operation time, ASA grade, length of post-operative stay, procedure-related complications, development and treatment of recurrent prolapse. Analysis of post-operative complications, rate and time of recurrence and factors influencing the choice of the procedure for recurrent disease was conducted. Continuous variables were expressed as the median with interquartile range(IQR). Statistical analysis was carried out using the Fisher exact test.RESULTS: Median age at the time of surgery was 76 years(IQR: 71-81.5) and there were 38 females and 2 males. The median duration of symptoms was 6 mo(IQR: 3.5-12) and majority of patients presented electively whereas four patients presented in the emergency department with irreducible rectal prolapse. The median length of prolapse was 5 cm(IQR: 5-7), median operative time was 100 min(IQR: 85-120) and median post-operative stay was 4 d(IQR: 3-6). Approximately16% of the patients suffered minor complications such as- urinary retention, delayed defaecation and infected haematoma. One patient died constituting postoperative mortality of 2.5%. Median follow-up was 6.5 mo(IQR: 2.15-16). Overall recurrence rate was 28%(n = 12). Recurrence rate for patients undergoing an urgent Delorme's procedure who presented as an emergency was higher(75.0%) compared to those treated electively(20.5%), P value 0.034. Median time interval from surgery to the development of recurrence was 16 mo(IQR: 5-30). There were three patients who developed an early recurrence, within two weeks of the initial procedure. The management of the recurrent prolapse was as follows: No further intervention(n = 1), repeat Delorme's procedure(n = 3), Altemeier's procedure(n = 5) and rectopexy with faecal diversion(n = 3). One patient was lost during follow up.CONCLUSION: Delorme's procedure is a suitable treatment for rectal prolapse due to low morbidity and mortality and acceptable rate of recurrence. The management of the recurrent rectal prolapse is often restricted to the pelvic approach by the same patientrelated factors that influenced the choice of the initial operation, i.e., Delorme's procedure. Early recurrence developing within days or weeks often represents a technical failure and may require abdominal rectopexy with faecal diversion.

Delorme's operation plus sphincteroplasty for complete rectal prolapse associated with traumatic fecal incontinence

Rectal prolapse associated with traumatic fecal incontinence is a rare clinical combination. This study was designed to assess Delorme＇s operation with sphincteroplasty as a surgical management of this combination in terms of recurrence and improvement of fecal incontinence. In this prospective study, we enrolled patients suffering from short, full-thickness rectal prolapse associated with traumatic fecal incontinence who had been admitted to Alexandria Main University Hospital during the period of May 2010-January 2013. Preoperative data including cause of trauma, duration of symptoms, results of anal manometry, and degree of fecal incontinence using Wexner score were collected from all patients. Delorme＇s procedure with overlap sphincteroplasty was done in all patients. Recurrence of prolapse and improvement of fecal incontinence were assessed after 1, 3, 6 and 12 months. The study included 13 patients aged （32±8.7） years, 9 females and 4 males. Cause of sphincteric injury included previous anal surgery in 7 patients and normal labor in 6 patients. Duration between sphinctefic injury and operation was （8.08±2.47） months. Preoperative Wexner＇s mean score was 16.07±3.4. Early postoperative complications included superficial wound infection （69.2%）, minor wound dehiscence （61.5%）, and postoperative bleeding （7.6%）. Recurrence was detected in 1 patient at 6 month follow-up. Wexner＇s score showed significant improvement for all patients after 6 months （4.00±2.04）. In conclusion, combination of Delorme＇s procedure and sphincteroplasty for treatment of patients with short complete rectal prolapse associated with traumatic fecal incontinence is a safe, effective surgical management with satisfactory results regarding anatomical and functional outcomes.

RELATIONSHIP BETWEEN INTERNAL ANAL SPHINCTER FUNCTION AND LENGTH OF REMAINING RECTUM AFTER RESECTING RECTAL CARCINOMA

Objective: To study the relationship between internal anal sphincter function and length of remaining rectum after resecting rectal carcinoma. Methods: Preoperatively, 21 patients were evaluated via patients' clinical date, including anal resting pressure (resting pressure) assay. Six months postoperatively, repeated manometric studies and clinical evaluations were performed to assess the level of continence . The formula use for calculating post operative resting pressure is as follows: postoperative resting pressure=0.42×preoperative resting pressure+1.56×length of remaining recturm+12.37(R 2=0.58; P <0.01).Degree of continence was graded based on severity of the dysfunction and grade of the continence score. Results: It was demonstrated the patients with low postoperative resting pressures (<4.0 Kpa) had incontinence, and those with high postoperative resting pressures (>4.7 Kpa) were continent. There were significant correlations between length of the remaining rectum and ratio of the decrease in maximum resting pressure (postoperative/preoperative maximum resting pressure;r=0.62; P <0.01). Conclusion: Continence of rectum is influenced by maximum resting pressure of function of the internal anal sphincter, length of remaining rectum is shorter, the more damage to the internal anal sphincter. It is able to foretell stool incontinence by using the postoperative resting pressure formula, and to determine the length of the remaining rectum.

Treatment of rectal prolapse in children with cow milk injection sclerotherapy:30-year experience

AIM:To evaluate the role and our experience of injecti-on sclerotherapy with cow milk in the treatment of rectal prolapse in children. METHODS:In the last 30 years (1976-2006) we made 100 injections of sclerotherapy with cow milk in 86 chil-dren. In this study we included children who failed to respond to conservative treatment and we perform ope-rative treatment. RESULTS:In our study we included 86 children and in all of the patients we perform cow milk injection sclerot-herapy. In 95.3% (82 children) of patients sclerotherapy was successful. In 4 (4.7%) patients we had recurrent rectal prolapse where we performed operative treatment. Below 4 years we had 62 children (72%) and 24 older children (28%). In children who needed operative trea-tment we performed Thiersch operation and without any complications. CONCLUSION:Injection sclerotherapy with cow milk for treatment rectal prolapse in children is a simple and effective treatment for rectal prolapse with minimal com-plications.

Laparoscopic ventral mesh rectopexy for complete rectal prolapse: A retrospective study evaluating outcomes in North Indian population

AIM: To analyze the outcomes of laparoscopic ventral mesh rectopexy in the management of complete rectal prolapse(CRP) in North Indian patients with inherent bulky and redundant colon. METHODS: The study was conducted at a tertiary health care center of North India. Between January 2010 and October 2014, 15 patients who underwent laparoscopic ventral mesh repair for CRP, were evaluated in the present study. Perioperative outcomes, improvement in bowel dysfunction or appearance of new complications were documented from the hospital records maintained prospectively. RESULTS: Fifteen patients(9 female) with a median age of 50 years(range, 15-68) were included in the study. The median operative time was 200 min(range, 180-350 min) and the median post-operative stay was 4 d(range, 3-21 d). No operative mortality occurred. One patient with inadvertent small bowel injury required laparotomy on post-operative day 2. At a median follow-up of 22 mo(range, 4-54 mo), no prolapse recurrence was reported. No mesh-related complication was encountered. Wexner constipation score improved significantly from the preoperative value of 17(range, 5-24) to 6(range, 0-23)(P < 0.001) and the fecal incontinence severity index score from 24(range, 0-53)to 2(range, 0-53)(P = 0.007). No de novo constipation or fecal incontinence was recorded during the followup. On personal conversation, all patients expressed satisfaction with the outcome of their treatment. CONCLUSION: Our experience indicates that laparoscopic ventral mesh rectopexy is an effective surgical option for CRP in North Indian patients having a bulky redundant colon.

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential,full-thickness protrusion of the rectum through the anus.It is a rare condition,and only affects 0.5%of the general population.Multiple treatment modalities have been described,which have changed significantly over time.Particularly in the last decade,laparoscopic and robotic surgical approaches with different mobilization techniques,combined with medical therapies,have been widely implemented.Because patients have presented with a wide range of complaints(ranging from abdominal discomfort to incomplete bowel evacuation,mucus discharge,constipation,diarrhea,and fecal incontinence),understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure.It is crucial to assess these additional symptoms and their severities using preoperative scoring systems.Additionally,radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders.However,there is no consensus on or standardization of the optimal extent of dissection,type of procedure,and materials used for rectal fixation;this makes providing maximum benefits to patients with minimal complications difficult.Even recent publications and systematic reviews have not recommended the most appropriate treatment options.This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

Isolated rectal diverticulum complicating with rectal prolapse and outlet obstruction: Case report

The occurrence of rectal diverticula is very rare, with only sporadic reports in the literature since 1911. Symptomatic rectal diverticula are encountered even less frequently.Treatments of these complicated events range from conservative treatments to major surgical interventions.We present a hitherto unreported occurrence of isolated rectal diverticulum complicated with rectal prolapse and outlet obstruction. Delorme's procedure resulted in subsidence of symptoms and resolution of the diverticulum. It provides a minimal invasive surgical technique to successfully address the reported malady.

Complete rectal prolapse in young Egyptian males: Is schistosomiasis really condemned?

AIM To investigate the assumption that schistosomiasis is the main cause of rectal prolapse in young Egyptian males. METHODS Twenty-one male patients between ages of 18 and 50 years with complete rectal prolapse were included in the study out of a total 29 patients with rectal prolapse admitted for surgery at Colorectal Surgery Unit, Ain Shams University hospitals between the period of January 2011 and April 2014. Patients were asked to fill out a specifically designed questionnaire about duration of the prolapse, different bowel symptoms and any past or present history of schistosomiasis. Patients also underwent flexible sigmoidoscopy and four quadrant midrectal biopsies documenting any gross or microscopic rectal pathology. Data from questionnaire and pathology results were analyzed and patients were categorized according to their socioeconomic class.RESULTS Twelve patients(57%) never contracted schistosomiasis and were never susceptible to the disease, nine patients(43%) had history of the disease but were properly treated. None of the patients had gross rectal polypsand none of the patients had active schistosomiasis on histopathological examination. Fifteen patients(71%) had early onset prolapse that started in childhood, majority before the age of 5 years. Thirteen patients(62%) were habitual strainers, and four of them(19%) had straining dating since early childhood. Four patients(19%) stated that prolapse followed a period of straining that ranged between 8 mo and 2 years. Nine patients(43%) in the present study came from the low social class, 10 patients(48%) came from the working class and 2 patients(9%) came from the low middle social class. CONCLUSION Schistosomiasis should not be considered the main cause of rectal prolapse among young Egyptian males. Childhood prolapse that continues through adult life is likely involved. Childhood prolapse probably results from malnutrition, recurrent parasitic infections and diarrhea that induce straining and prolapse, all are common in lower socioeconomic classes.

Rectal prolapse: Diagnosis and clinical management

The exact cause of rectal prolapse is not well addressed,but it is often associated with long standing constipation,advanced age,chronic obstructive pulmonary disease and some neurological disorders.Rectal prolapse is usually only a symptom,which needs a focus on discovery of the underlying pathology or disorder.Three different clinical presentations are often combined and called rectal prolapse.Rectal prolapse can be divided into full thickness rectal prolapse where the entire rectum protrudes beyond the anus,mucosal prolapse where only the rectal mucosa (not the entire wall) prolapses,and internal intussuception wherein the rectum collapses but does not exit the anus.Although constipation and straining may contribute to the development of rectal prolapse,simply correcting these problems may not improve the prolapse once it has developed.There are many different approaches to surgical correction of rectal prolapse.

Perineal rectosigmoidectomy for strangled rectal prolapse:A case report

Strangled rectal prolapse, the rare disease, is a proctological emergency. Its management is controversial. When it is not reducible and signs of ischemia are present, the Altemeierperineal rectosigmoidectomy remains the best treatment. This study aimed to report our experience on the management of strangled rectal prolapse about 1 case in a 45-year-old man, a holder of a rectal prolapse for 2 years. On admission, he had strangled prolapse for 24 hours with edema. After a vain attempt of manual reduction and installation of necrosis after 48 hours, he had an Altemeier rectosigmo?dectomy. The postoperative course was uneventful and the patient was discharged on the 6th postoperative day. The results were very good, after one year follow-up.

Strangulated Transanal Evisceration of Small Bowel Complicating Rectal Prolapse of the Child: An Observation of the University Hospital Center of Parakou, Benin

Transanal intestinal evisceration is an extremely rare and dramatic digestive surgical emergency. The cases reported in the literature are few and concern much more elderly patients. We report the case of a 3-year-old boy admitted in very general poor condition to the emergency department, late for transanal evisceration complicating rectal prolapse that the parents tried to reduce. The fatal outcome of this case is probably related to strangulation and delay in consultation. We learn from this that parents should avoid inopportune prolapse reduction and early consultation.