Comparison of dynamic magnetic resonance defaecography with rectal contrast and conventional defaecography for posterior pelvic floor compartment prolapse.

AIM: This study compared the diagnostic capabilities of dynamic magnetic resonance defaecography (D-MRI) with conventional defaecography (CD, reference standard) in patients with symptoms of prolapse of the posterior compartment of the pelvic floor. METHOD: Forty-five consecutive patients underwent CD and D-MRI. Outcome measures were the presence or absence of rectocele, enterocele, intussusception, rectal prolapse and the descent of the anorectal junction on straining, measured in millimetres. Cohen's Kappa, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the positive and negative likelihood ratio of D-MRI were compared with CD. Cohen's Kappa and Pearson's correlation coefficient were calculated and regression analysis was performed to determine inter-observer agreement. RESULTS: Forty-one patients were available for analysis. D-MRI underreported rectocele formation with a difference in prevalence (CD 77.8% vs D-MRI 55.6%), mean protrusion (26.4 vs 22.7 mm, P = 0.039) and 11 false negative results, giving a low sensitivity of 0.62 and a NPV of 0.31. For the diagnosis of enterocele, D-MRI was inferior to CD, with five false negative results, giving a low sensitivity of 0.17 and high specificity (1.0) and PPV (1.0). Nine false positive intussusceptions were seen on D-MRI with only two missed. CONCLUSION: The accuracy of D-MRI for diagnosing rectocele and enterocele is less than that of CD. D-MRI, however, appears superior to CD in identifying intussusception. D-MRI and CD are complementary imaging techniques in the evaluation of patients with symptoms of prolapse of the posterior compartment.

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy.

PURPOSE: To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR. METHODS: All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan-Meier estimates were calculated for recurrences. RESULTS: A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6-30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2-58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0-53.9) for ERP recurrence and 24.4 % (95 % CI 9.1-39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates. CONCLUSION: High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse.

BACKGROUND: Laparoscopic resection rectopexy (LRR) and laparoscopic ventral rectopexy (LVR) are favored for the treatment for rectal prolapse (RP) in the USA and Europe, respectively. This study aims to compare these two surgical techniques. METHODS: All patients who underwent LRR because of RP between January 2000 and January 2012 at Cleveland Clinic Florida (Weston, FL, USA) were identified, and all relevant characteristics were entered in a database. This same analysis was also conducted for all patients who underwent LVR in the Meander Medical Center (Amersfoort, the Netherlands) between January 2004 and January 2012. These two cohorts were retrospectively compared with regard to complications, functional results and recurrence. RESULTS: Twenty-eight patients (all female, mean age 50.1 years) were included in the LRR cohort at a mean follow-up of 57 (range 2-140; standard deviation (SD) ± 41.2) months. The LVR group consisted of 40 patients (36 females and 4 males) with a mean age of 67.0 years and a mean follow-up of 42 (range 2-82; SD ± 23.8) months. A significant reduction in constipation was observed in both cohorts after surgery: 57 versus 21% after LRR and 55 versus 23% after LVR (both P < 0.05). The incidence of incontinence also significantly decreased in both groups: 15% after LVR (55% before surgery) and 4% after LRR (61 % before surgery). Direct comparison of these two techniques showed a trend to significance (P = 0.09). Significantly, more complications occurred after LRR (n = 9: 1 major, 8 minor) then after LVR (n = 3: 2 major, 1 minor) (P < 0.05). CONCLUSIONS: Both LVR and LRR are effective for the treatment for RP. Although both techniques offer significant improvements in functional symptoms, continence may be better after LRR. However, LRR also had a higher complication rate then did LVR.

Impact of rectopexy on sexual function: a cohort analysis.

PURPOSE: Laparoscopic ventral rectopexy (LVR) is an established surgical technique for the treatment of both rectal prolapse and symptomatic rectoceles. It is, however, not known whether LVR influences sexual function (SF). The aim of this study was, therefore, to determine the impact of this procedure on the SF of patients. METHODS: All female patients after LVR procedure in a single institution were identified and were sent a questionnaire concerning SF. This addressed sexual activity, satisfaction, preoperative SF, and the impact of surgery on SF. Furthermore, the PISQ-12 validated sexual functioning questionnaire was sent to all female patients. RESULTS: A total of 217 patients were sent a questionnaire. These patients underwent LVR for rectal prolapse, symptomatic rectocele, or enterocele between 2004 and 2011. Mean age was 62 years (range 22-89). Mean follow-up was 30 months (range 5-83). Response rate was 64 % (139 patients). The number of sexual active patients dropped from 71 to 54 % after surgery. The number of patients being satisfied with their SF remained relatively equal; 91 % of patients before and 85 % of patients after surgery. Forty-three percent of patients stated that the LVR procedure did not influence their sexual function, in 16 % of patients, the procedure positively influenced their SF, and in 13 % of respondents, SF decreased after surgery. The mean PISQ-12 score postoperatively was 34 out of 48. CONCLUSIONS: The impact of LVR on SF of patients seems limited in this cross-sectional study in a large cohort of patients.

Laparoscopic ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of 245 consecutive patients.

AIM: This retrospective study aimed to determine functional results of laparoscopic ventral rectopexy (LVR) for rectal prolapse (RP) and symptomatic rectoceles in a large cohort of patients. METHOD: All patients treated between 2004 and 2011 were identified. Relevant patient characteristics were gathered. A questionnaire concerning disease-related symptoms as well as the Cleveland Clinic Incontinence Score (CCIS) and Cleveland Clinic Constipation Score (CCCS) was sent to all patients. RESULTS: A total of 245 patients underwent operation. Twelve patients (5%) died during follow-up and were excluded. The remaining patients (224 women, nine men) were sent a questionnaire. Indications for LVR were external RP (n = 36), internal RP or symptomatic rectocele (n = 157) or a combination of symptomatic rectocele and enterocele (n = 40). Mean age and follow-up were 62 years (range 22-89) and 30 months (range 5-83), respectively. Response rate was 64% (150 patients). The complication rate was 4.6% (11 complications). A significant reduction in symptoms of constipation or obstructed defaecation syndrome was reported (53% of patients before vs 19% after surgery, P < 0.001). Mean CCCS during follow-up was 8.1 points (range 0-23, SD ± 4.3). Incontinence was reported in 138 (59%) of the patients before surgery and in 32 (14%) of the patients after surgery, indicating a significant reduction (P < 0.001). Mean CCIS was 6.7 (range 0-19, SD ± 5.2) after surgery. CONCLUSION: A significant reduction of incontinence and constipation or obstructed defaecation syndrome after LVR was observed in this large retrospective study. LVR therefore appears a suitable treatment for RP and rectocele with and without associated enterocele.

Evaluation and surgical treatment of rectal prolapse: an international survey.

AIM: Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP. METHOD: A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail. RESULTS: In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients. CONCLUSION: The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.

Early complications after stoma formation: a prospective cohort study in 100 patients with 1-year follow-up.

PURPOSE: This study aims to provide an overview of all complications that may occur after construction of an ileostomy or colostomy (loop or end) in daily practice. METHODS: Between July 2007 and April 2008, all adult patients who underwent any type of intestinal stoma formation were asked to participate in this prospective cohort study. All relevant patient characteristics were gathered.Patients were evaluated for complications eight times in a1-year postoperative period. Enterostomal therapy nurses scored complications on specially designed forms. RESULTS: One hundred patients were included; two patients were lost before initial follow-up (FU). During FU, 21% of the patients deceased, and 15% were lost, physically unable to visit the outpatient clinic or withdrew from FU. In 37% of the patients, bowel continuity was restored. Only 26% of the patients were able to complete FU. Overall, 82% of all the patients had one or more stoma-related complications. Most common complications were skin irritation (55%), fixation problems (46%) and leakage (40%). Superficial necrosis,bleeding and retraction occurred in 20%, 14% and 9% of patients, respectively. More stoma related complications were found in stoma's on inappropriate locations. CONCLUSIONS: In this heterogenic patient population with formation of different stoma types, a high complication rate was detected.