A. R. Dixon

Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete

Aim  Perineal approaches are considered to be the ‘gold standard’ in treating elderly patients with external rectal prolapse (ERP) because morbidity and mortality with perineal approaches are lower compared with transabdominal approaches. Higher recurrence rates and poorer function are tolerated as a compromise. The aim of the present study was to assess the safety of laparoscopic ventral rectopexy (LVR) in elderly patients, compared with perineal approaches.

Consensus on ventral rectopexy: report of a panel of experts

Ventral rectopexy (VR) has gained in popularity amongst colorectal surgeons as an operation that addresses functional bowel symptoms by correcting anatomical abnormalities in patients with internal (rectal intussusception) and external rectal prolapse. The operation includes fixation of a synthetic or biological implant to the ventral rectum and vaginal vault. There is current concern over the fixation of any material placed transvaginally or paravaginally in pelvic organ prolapse surgery because of the risks of erosion and sepsis [1]. Concerns have also been expressed regarding patient selection for VR, choice of material, operative technique and a lack of high-level evidence. In order to address these concerns, two Consensus Conferences were held, the first on 25 September 2012 at the Austria Trend Hotel, Vienna, Austria and the second on 17 May 2013 at St John’s College, Oxford, UK to develop a consensus opinion from expert colorectal surgeons with a subspeciality of pelvic floor practice and experience of performing VR. Most had performed 100 or more ventral rectopexies.

The evolution of analgesia in an 'accelerated' recovery programme for resectional laparoscopic colorectal surgery with anastomosis.

Objective  The study set out to analyse the outcomes of an evolving accelerated recovery programme after laparoscopic colorectal resection (LCR).

Medium-term results of stapled transanal rectal resection (STARR) for obstructed defecation and symptomatic rectal-anal intussusception

Aim  Stapled transanal rectal resection (STARR) is an increasingly accepted treatment for obstructed defaecation syndrome (ODS) associated with internal rectal prolapse (IRP) and rectocoele. The aim of this study is to evaluate the medium to long‐term outcomes of STARR for ODS.

A multicenter collaboration to assess the safety of laparoscopic ventral rectopexy

BACKGROUND: Concerns have been raised regarding the potential risk of mesh complications after laparoscopic ventral rectopexy. OBJECTIVE: This study aimed to determine the risk of mesh and nonmesh morbidity after laparoscopic ventral rectopexy and to compare the safety of synthetic meshes with biological grafts. DESIGN: This was a retrospective review. SETTINGS: The study used data collated from prospective pelvic floor databases in 5 centers (3 in the United Kingdom, 1 in Australia, and 1 in Italy). PATIENTS: All of the patients undergoing laparoscopic ventral rectopexy over a 14-year period (1999–2013) at these centers were included in the study. MAIN OUTCOME MEASURES: The primary outcome was mesh morbidity, classified as vaginal erosion, rectal erosion, rectovaginal fistula, or perineal erosion. Secondary outcomes were nonmesh morbidity. RESULTS: A total of 2203 patients underwent surgery; 1764 (80.1%) used synthetic mesh and 439 (19.9%) used biological grafts. There were 2 postoperative deaths (0.1%). Forty-five patients (2.0%) had mesh erosion, including 20 vaginal, 17 rectal, 7 rectovaginal fistula, and 1 perineal. Twenty-three patients (51.1%) required treatment for minor erosion morbidity (local excision of stitch/exposed mesh), and 18 patients (40.0%) were treated for major erosion morbidity (12 laparoscopic mesh removal, 3 mesh removal plus colostomy, and 3 anterior resection). Erosion occurred in 2.4% of synthetic meshes and 0.7% of biological meshes. The median time to erosion was 23 months. Nonmesh complications occurred in 11.1% of patients. LIMITATIONS: This was a retrospective study including patients with minimal follow-up. The study was unable to determine whether patients will develop future erosions, currently have asymptomatic erosions, or have been treated in other institutions for erosions. CONCLUSIONS: Laparoscopic ventral rectopexy is a safe operation. Mesh erosion rates are 2% and occasionally require resectional surgery that might be reduced by the use of biological graft. An international ventral mesh registry is recommended to monitor mesh problems and to assess whether type of mesh has any impact on functional outcomes or the need for revisional surgery for nonerosion problems.

Emergency laparoscopic surgery for complicated diverticular disease.

Objective  The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease.

Laparoscopic surgery for recurrent ileocolic Crohn's disease is as safe and effective as primary resection.

Aim  The safety and short‐term outcome of laparoscopic surgery for recurrent ileocolic Crohn’s disease was compared with the outcome following primary resection.

Stapled transanal rectal resection for obstructed defecation: a cautionary tale.

PURPOSE: This prospective study was designed to assess the efficacy and safety of a novel technique in treating outlet obstruction syndrome using a transanal double-stapling procedure. METHODS: Two hundred thirty patients (187 female) with obstructed defecation underwent stapled transanal rectal resection over a six-year period with follow-up at 2, 6, and 12 months, then yearly; median follow-up was 24 (range, 12–68) months. All failed conservative measures. Patients with slow transit constipation and puborectalis dyssynergia were excluded. RESULTS: Operating time was short (median, 35 (range, 20–95) minutes), with 159 (69%) performed as day cases (outpatient). Major complications were seen in 16 (7%); there were no deaths. Twelve (5%) patients reported severe postoperative pain. Immediate postoperative fecal urgency was reported by 107 (46%) patients, but persisted at six months in only 26 (11%). Three (1%) developed recurrent rectal prolapse. Nearly all incontinent patients (98%) reported an improvement, with a median Wexner score reduction of 5 points (P < 0.0001). Constipation improved in 77% of patients. Seventy-seven percent of patients were “very glad” they had the operation, and 86% “recommended” stapled transanal rectal resection to a friend. CONCLUSION: Stapled transanal rectal resection can be performed on a day-case basis with high levels of patient satisfaction. Incontinence and constipation are improved. However, significant morbidity occurs in 7% of patients, and urgency of defecation persists beyond six months in 11%.

Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome: a cause for optimism?

The treatment of solitary rectal ulcer syndrome (SRUS) is notoriously difficult. Laparoscopic ventral mesh rectopexy (LVMR) is a nonresectional technique for patients with full thickness external rectal prolapse and internal prolapse with obstructed defaecation syndrome (ODS), features associated in the pathogenesis of SRUS. Our aim was to assess the short‐ and long‐term efficacy of LVMR in treating SRUS.

The role of laparoscopic surgery for the management of acute large bowel obstruction.

Aim  The aim of this study was to analyse the outcome of laparoscopic management of large bowel obstruction (LBO).