Lomas-Cooperman technique for rectal prolapse in the elderly patient.

BACKGROUND: A variety of surgical procedures is used to correct complete rectal prolapse (RP). We analysed the immediate and long-term results of the Lomas-Cooperman technique in the management of symptomatic RP in elderly patients with severe concomitant diseases. METHODS: Across a 13-year period, all patients with RP having undergone surgery with this procedure were retrospectively evaluated. The technique consisted in placing a triply folded piece of polypropylene mesh encircling the anal canal through a perineal approach. RESULTS: A total of 22 patients (20 female) with a mean age of 84 years (range, 72-93 years) with severe concomitant pathologies were assessed. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky score was 50%, ranging between 40% and 60%. All patients were operated on under regional anaesthesia without incidents. Mean operative time was 35 min(range, 20-60 min) and mean hospital stay was 4.5 days (range, 2-17 days). The most common immediate postoperative complication was urinary tract infection, found in 18% of the cases. Mean follow-up was 32 months (range, 4-84 months). During follow-up, 4 cases (18%) of mesh exteriorisation were detected, requiring mesh trimming at the outpatient clinic. Rectal prolapse recurred in 2 patients; one of them was managed with a new cerclage reaching a satisfactory outcome. Thus, by intention-to-treat basis, the recurrence rate was 4.5%. Constipation was resolved in three out of 4 patients, but in 18% of the cases late faecal impact was recorded. Mean preoperative incontinence score improved from 5.1+/-0.62 to 3.4+/-1.61 (p<0.0001) after surgery. CONCLUSION: Anal cerclage with the Lomas-Cooperman technique constitutes a simple and reproducible surgical technique with an acceptable morbidity and recurrence rate in high-risk elderly patients with RP.

Posterior pelvic exenteration for primary rectal cancer.

BACKGROUND: Indications for and the prognosis of posterior pelvic exenteration (PPE) in rectal cancer patients are not clearly defined. The aim of this study was to analyse the indications, complications and long-term results of PPE in patients with primary rectal cancer. METHODS: A retrospective review included patient demographics, tumour and treatment variables, and morbidity, recurrence, and survival statistics. These results were compared with a group of female patients who underwent standard resection for primary rectal cancer in the same period (non PPE group). RESULTS: The series included 30 women with an average age of 56.7 years (range 22-78). Tumour location was recorded in three cases in the upper rectum, 13 cases in the medium rectum and 14 cases in the lower rectum. A sphincter-preserving procedure was performed in 70% of the patients. Mean operative time was 4.2 h (range 2-7.5 h). Overall major morbidity rate in this series was 50% and mean hospital stay was 19.7 days (range 9-60 days). There was no hospital mortality. Pathological reports showed direct invasion of uterus, vagina or rectovaginal septum in 19 cases, involvement of perirectal tissue in 25 cases and positive lymph nodes in 18 cases. Comparison between PPE and non PPE groups showed no differences in mean tumour diameter, histological grade and tumour stage, but patients in the first group were younger. Although low tumours were seen more frequently in the PPE group (P = 0.003), the rate of sphincter-preserving procedure was comparable in both groups. Operative time was longer (P = 0.04) and morbidity was higher (P = 0.0058) in the PPE group. Local recurrence with or without distant metastases for the whole series was 30%. Five-year survival rate for patients who underwent curative resections (TNM I-III) was 48% in the PPE group vs 62% in the non PPE group (P = 0.09). CONCLUSIONS: In the present series, PPE prolonged operative time, increased postoperative complications and showed a trend toward poor prognosis in recurrence and survival. However, PPE offers the only hope for cure to patients with a primary rectal cancer that is adherent or invades reproductive organs.