Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defaecation syndrome and/or faecal incontinence. Very few reports exist on the use of biologic mesh for LVR. The aim of our study was to report the complication and recurrence rate of our first 100 cases of LVR for symptomatic internal rectal prolapse and/or rectocele using a porcine dermal collagen mesh. METHODS: Prospectively collected data on LVR for internal rectal prolapse were analysed. Surgical complications and functional results in terms of faecal incontinence (measured with the Faecal Incontinence Severity Index = FISI) and constipation (measured with the Wexner Constipation Score = WCS) at 3, 6 and 12 months were analysed. It was considered an improvement if FISI or WCS scores were reduced by at least 25 % and a cure if the FISI score decreased to <10 and the WCS decreased to <5. RESULTS: Between April 2009 and April 2013, 100 consecutive female patients (mean age 63 years, range 24-88 years) underwent LVR. All patients had internal rectal prolapse (grade III [n = 25] and grade IV [n = 75] according to the Oxford classification) and rectocele. Mean operative time was 85 ± 40 min. Conversion rate to open technique was 1 %. There was no post-operative mortality. Overall 16 patients (16 %) experienced 18 complications, including rectal perforation (n = 1), small bowel obstruction (n = 2), urinary tract infection (n = 8), subcutaneous emphysema (n = 3), wound haematoma (n = 2), long lasting sacral pain (n = 1) and incisional hernia (1). Median post-operative length of stay was 2 days. Ninety-eight out of 100 patients completed follow-up. At the end of follow-up, the mean FISI score improved from 8.4 (±4.0 standard deviation (SD) p = 0.003) to 3.3 ± 2.3 SD (p = 0.04). Incontinence improved in 37 out of 43 patients (86 %), and 31 patients (72 %) were cured. Similarly, the mean WCS score improved from 18.4 ± 11.6 SD to 5.4 ± 4.1 SD (p = 0.04). Constipation improved in 82 out of 89 patients (92 %), and 70 patients (79 %) were cured. No worsening of continence status, constipation or sexual function was observed. Fourteen patients (14 %) experienced persistence or recurrence of prolapse. CONCLUSIONS: LVR using biologic mesh is a safe and effective procedure for improving symptoms of obstructed defaecation and faecal incontinence in patients with internal rectal prolapse associated with rectocele.

Pathological classification of DCIS and planning of therapeutic management.

BACKGROUND: Ductal intraepitelial neoplasia (DIN) represents a spectrum of disease that may progress from usual hyperplasia to ductal carcinoma in situ (DCIS) grade 3. The aim of the study was to asses the correlation between the DIN classification and the surgical treatment including sentinel lymph node biopsy (SLNB). PATIENTS AND METHODS: In this retrospective study, 229 patients with DIN had undergone conservative or radical surgical treatment and SLNB in cases of DIN1C-DIN3. RESULTS: Breast conservative surgery was the definitive treatment in 80% of the cases. The H&E evaluation of excised sentinel nodes was negative for metastatic disease; nevertheless the immunohistochemical (IHC) evaluation revealed the presence of metastatic cells in 6 patients (3.7%). CONCLUSION: In cases of DIN lesions SLNB is not indicated. The only reason SLNB should be considered is when there is an evidence of invasive foci at definitive histology or when radical mastectomy is proposed.